Chapter 48: PrepU - Nursing Assessment: Sensorineural Function

A client has been referred to an ophthalmologist for suspected macular degeneration. The nurse knows to prepare what test for the physician to give the client? 1- Ishihara polychromatic plates 2- Visual field 3- Amsler grid 4- Slit lamp

3

Which of the following is the main refracting surface of the eye? 1- Cornea 2- Iris 3- Pupil 4- Conjunctiva

1

The nurse is caring for a client with chronic migraines who is prescribed medication. What drug-related instructions should the nurse give the client? 1- Take medication just before going to bed at night. 2- Take medication only when migraine is intense. 3- Take medication as soon as symptoms of the migraine begin. 4- Take medication only during the morning when it's calm and quiet.

3

The nurse is performing an assessment of the visual fields for a patient with glaucoma. When assessing the visual fields in acute glaucoma, what would the nurse expect to find? 1- Clear cornea 2- Constricted pupil 3- Marked blurring of vision 4- Watery ocular discharge

3

Weber test

Test done by placing the stem of a vibrating tuning fork on the midline of the head and having the patient indicate in which ear the tone can be heard.

During a neurological physical examination, a patient tells the nurse that she is having difficulty raising her right eyelid. The nurse knows that this may be an indication of problems with which cranial nerve? 1- III 2- IV 3- VI 4- VII

1

A client has a history of hearing loss and is returning for an annual hearing examination. During client education, the nurse explains that hearing involves which areas of the ear? 1- all sections 2- outer section 3- middle section 4- inner section

1

A client is having a routine eye examination. The procedure being performed is done by using an instrument to indent or flatten the surface of the eye. This is known as ________ and it is routinely done to test for ________. 1- tonometry; intraocular pressure 2- retinoscopy; detached retina 3- tonometry; macular degeneration 4- retinoscopy; cataracts

1

A client suffered trauma to the sclera and is being treated for a subsequent infection. During client education, the nurse indicates where the sclera is attached. Which structure would not be included? 1- eyelids 2- cornea 3- iris 4- pupil

1

A client with multiple sclerosis is being seen by a neuroophthalmologist for a routine eye exam. The nurse explains to the client that during the examination, the client will be asked to maintain a fixed gaze on a stationary point while an object is moved from a point on the side, where it can't be seen, toward the center. The client will indicate when the object becomes visible The nurse further explains that the test being performed is called a: 1- perimetry test 2- color vision test 3- slit-lamp examination 4- retinal angiography

1

A nurse is conducting a health history with a client. During the history, the client tells the nurse, "Things that are far away often look blurred." The nurse inteprets this finding as: 1- myopia 2- hyperopia 3- presbyopia 4- cataract

1

A nurse is performing an eye examination. Which question would not be included in the examination? 1- "Are you able to raise both eyebrows?" 2- Have you experienced blurred, double, or distorted vision?" 3- "Do any family members have any eye conditions?" 4- "What medications are you taking?"

1

A nurse notices that a client's left upper eyelid is drooping. The nurse has observed: 1- ptosis 2- ptolemy 3- proptosis 4- nystagmus

1

A nurse who provides care in an ophthalmologist's office has received training on the technique for assessing patients' intraocular pressure (IOP). This nurse will possess the skills necessary to perform what type of diagnostic testing? 1- Tonometry 2- Direct ophthalmoscopy 3- Perimetry testing 4- Slit-lamp examination

1

A patient is to have an angiography done using fluorescein as a contrast agent to determine if the patient has macular edema. What laboratory work should the nurse monitor prior to the angiography? 1- BUN and creatinine 2- AST and ALT 3- Hemoglobin and hematocrit 4- Platelet count

1

A young baseball player was fielding a ground ball when it bounced and struck the player in the left eye, leaving a large ecchymosis and edema. In client education, after applying an ice pack, the nurse explains the functions of the various structures of the eye. What glands, contained in the eyelids, produce tears? 1- lacrimal 2- sebaceous 3- sweat 4- olfactory

1

An 87-year-old client is receiving a hearing test because she has perceived a change in her hearing. During your client education session, you indicate the lowest level of sound that individuals may normally hear. What is that level? 1- 20 dB 2- 10 dB 3- 5 dB 4- 25 dB

1

An 88-year-old client has a history of hearing loss and is returning for his annual hearing examination. During your client education session, you explain to the client that hearing involves which areas of the ear? 1- All sections of the ear are involved in perceiving sound. 2- The outer section of the ear is involved in perceiving sound. 3- The middle section of the ear is involved in perceiving sound. 4- The inner section of the ear is involved in perceiving sound.

1

An older adult patient has noticed a significant amount of vision loss in the last few years. What does the nurse recognize as the most common cause of visual loss in older adults? 1- Macular degeneration 2- Ocular trauma 3- Retinal vascular disease 4- Uveitis

1

The nurse is assessing an older client's vision. The nurse integrates knowledge of which of the following during the assessment? 1- The power of the lens to accommodate will be decreased. 2- Increased fat will be around the orbit. 3- The skin around the eyes will be more elastic. 4- The depth of the eyeball will be increased, leading to myopia.

1

The nurse is evaluating the client while taking the color vision test. Which response would the nurse anticipate when caring for a client with normal color vision? 1- The nurse would anticipate the client identifying numbers and shapes. 2- The nurse would anticipate a cross-eyed appearance. 3- The nurse would anticipate responding to the color names in the pictures. 4- The nurse would anticipate no differentiation in between colors.

1

The nursing instructor is discussing the difference between sensorineural and conductive hearing loss with his class. The discussion turns to evaluation for determining what kind of hearing loss a patient has. What Weber test result would indicate the presence of a sensorineural loss? 1- The sound is heard better in the ear in which he has better hearing. 2- The sound is heard equally in both ears. 3- The sound is heard better in the ear in which he has poorer hearing. 4- The sound is heard longer in the ear in which he has better hearing.

1

The upper eyelid normally covers the uppermost portion of the iris and is innervated by which cranial nerve? 1- III 2- I 3- IV 4- II

1

Which condition refers to hearing loss associated with degenerative changes? 1- Presbycusis 2- Myopia 3- Strabismus 4- Presbyopia

1

Which instructions regarding swimming should the nurse give to a client who is recovering from otitis externa? Select all that apply. 1- Wear soft plastic earplugs. 2- Wear a scarf. 3- Avoid cold water. 4- Insert a loose cotton earplug in the external ear.

1

Which nursing intervention should be included during the assessment of a client with an eye disorder? 1- Check the extraocular muscles by instructing the client to keep his or her head still when following an object. 2- Examine the retina with a direct ophthalmoscope. 3- Use a tonometer to indent or flatten the surface of the eye. 4- Instruct the client to stare at the central fixation spot on an Amsler grid and report if he or she sees any distortion of the squares.

1

Which of the following occurs when there is deviation from perfect ocular alignment? 1- Strabismus 2- Ptosis 3- Chemosis 4- Nystagmus

1

Which of the following tests uses a tuning fork between two positions to assess hearing? 1- Rinne 2- Whisper 3- Watch tick 4- Weber

1

Which one of the following patients is most likely to be experiencing a health problem that may be a result of vestibular dysfunction? 1- A 78-year-old woman who requires open reduction and internal fixation of her left hip following a fall 2- An 80-year-old man whose recent declines in cognition have prompted his move to a long-term care facility 3- A woman whose progressive weakness and loss of coordination are attributable to multiple sclerosis 4- A man who has been hospitalized with signs and symptoms of malnutrition and fluid volume deficit

1

You are the clinic nurse in an ophthalmic clinic. When assessing clients, which client has an abnormal intraocular pressure (IOP)? 1- A client with an IOP of 8 mm Hg 2- A client with an IOP of 15 mm Hg 3- A client with an IOP of 19 mm Hg 4- A client with an IOP of 21 mm Hg

1

During an assessment using the positions test, what does an asymmetrical movement indicate? Select all that apply. 1- Weakness in the extraocular muscles 2- Dysfunction of the cranial nerve 3- Cataract 4- Glaucoma

1,2

The nurse is reviewing the audiology consultation on a woman who has been experiencing progressive hearing loss. To accurately interpret these diagnostic findings, the nurse should be aware of what important characteristics of sound? Select all that apply. 1- Frequency 2- Pitch 3- Intensity 4- Character 5- Familiarity

1,2,3

A female patient with a profound visual deficit is unable to read the largest E on the Snellen chart. How should the nurse proceed with assessment of the patient's visual acuity? 1- Document the fact that the patient does not have functional vision. 2- Hold up a random number of fingers in front of the patient's eyes and ask her to count them. 3- Give the patient a hand-held version of the Snellen chart and have her hold it at the furthest distance at which she can read it. 4- Ask the patient to identify the contents of a picture in a book or magazine.

2

A nures is performing an otoscopic examination on a client. Which finding would the nurse document as abnormal? 1- Umbo in the center of the tympanic membrane 2- External auditory canal erythema 3- Tympanic membrane pearly gray 4- Manubrium superior to the umbo

2

A nurse conducted a history and physical for a newly admitted patient who states, "My arms are too short. I have to hold my book at a distance to read." The nurse knows that the patient is most likely experiencing: 1- Opacity in the lens. 2- Loss of accommodative power in the lens. 3- Shrinkage of the vitreous body. 4- Decreased eye muscle tone.

2

A patient has come to the office for her first eye examination and is diagnosed as having a visual acuity of 20/40. The patient asks the nurse what these numbers mean. What is a correct response by the nurse? 1- "A person whose vision is 20/40 can see an object from 40 feet away that a person with 20/20 vision can see from 20 feet away." 2- "A person whose vision is 20/40 can see an object from 20 feet away that a person with 20/20 vision can see from 40 feet away." 3- "A person whose vision is 20/40 can see an object from 40 inches away that a person with 20/20 vision can see from 20 inches away." 4- "A person whose vision is 20/40 can see an object from 20 inches away that a person with 20/20 vision can see from 40 inches away."

2

A patient is scheduled to have an electronystagmography as part of a diagnostic workup for Ménière's disease. What question is it most important for the nurse to ask the patient in preparation for this test? 1- "Have you ever experienced claustrophobia or feelings of anxiety while in enclosed spaces?" 2- "Do you currently take sedatives, tranquilizers, or antihistamines on a regular basis?" 3- "Do you have a history of falls or problems with loss of balance?" 4- "Do you have a history of either high or low blood pressure?"

2

An aging client is brought to the eye clinic by the son. The son states he has seen his parent holding reading materials at an increasing distance to focus properly. What age-related changes does this indicate? 1- Cataract 2- Presbyopia 3- Myopia 4- Macular degeneration

2

As part of an admission assessment, the nurse is including questions that pertain to the patient's vision. Before conducting a physical assessment, the nurse is seeking to identify factors that have the potential to influence the patient's vision. Which of the following assessment questions most directly addresses these factors? 1- "Are you a smoker?" 2- "What medications do you take?" 3- "Do you exercise regularly?" 4- "What is your occupation?"

2

Loud, persistent noise has what effect on the body? 1- Dilation of peripheral blood vessels 2- Increased blood pressure 3- Decreased heart rate 4- Decreased gastrointestinal activity

2

The client is having a Weber test. During a Weber test, where should the tuning fork be placed? 1- On the mastoid process behind the ear 2- In the midline of the client's skull or in the center of the forehead 3- Near the external meatus of each ear 4- Under the bridge of the nose

2

The nures is assessing a client using an Amsler Grid. The nurse is assessing for which of the following? 1- Visual acuity 2- Macular problems 3- Intraocular pressure 4- Visual field

2

The nurse is assessing a client's hearing using the Rinne test. When providing instruction to elicit client feedback, which instruction is essential? 1- Raise your hand when you hear the vibration. 2- Raise your hand when you no longer hear sound. 3- Raise your hand when the vibration exceeds the sound. 4- Raise your hand when the sound exceeds the vibration.

2

The nurse is explaining metastatic rhabdomyosarcoma to a group of parents with children diagnosed with the disease. The most common site of metastasis in clients diagnosed with rhabdomyosarcoma is the 1- brain. 2- lung. 3- bone. 4- lymph nodes.

2

The nurse is reviewing the results of a client's audiometric testing. The nurse determines that the client has a mild hearing loss based on the result signifying which loss of decibels? 1- 20 2- 30 3- 45 4- 80

2

To avoid the side effects of corticosteroids, which medication classification is used as an alternative in treating inflammatory conditions of the eyes? 1- Miotics 2- Nonsteroidal anti-inflammatory drugs (NSAIDs) 3- Mydriatics 4- Cycloplegics

2

Which diagnostic test distinguishes between conductive and sensorineural hearing loss? 1- Whisper test 2- Rinne test 3- Audiometry 4- Weber test

2

Which is the most common cause of visual loss in people older than 65 years of age? 1- Glaucoma 2- Macular degeneration 3- Cataracts 4- Retinal detachment

2

Which surgical procedure involves flattening the anterior curvature of the cornea by removing a stromal lamella layer? 1- Photorefractive keratectomy (PRK) 2- Laser-assisted stromal in situ keratomileusis (LASIK) 3- Keratoconus 4- Keratoplasty

2

A 56-year-old patient has come to the clinic for his routine eye examination and is told he needs bifocals. The patient asks the nurse what in his eye has changed so that he needs bifocals. What should the nurse respond? 1- "You know, you are getting older now, and we change as we get older." 2- "The parts of our eyes age, just like the rest of us." 3- "There is a gradual thickening of the lens of the eye, and it can limit accommodation of the eye." 4- "The eye gets shorter, back to front, as we age, and it changes how we see things."

3

A child goes to the school nurse and complains of not being able to hear her teacher. What test could the school nurse perform to make a general estimate of hearing loss? 1- Chiming clock test 2- Rinne test 3- Whisper test 4- Weber test

3

A client comes to the eye clinic for a routine check-up. The client tells the nurse he thinks he is color blind. What screening test does the nurse know will be performed on this client to assess for color blindness? 1- Rosenbaum 2- Jaeger 3- Ishihara 4- Snellen

3

A client is diagnosed with otitis externa. Which instruction is most appropriate for the nurse to give? 1- Keep the ear covered with a scarf. 2- Avoid using cold water when shampooing hair. 3- Avoid swimming for 7 to 10 days. 4- Keep a dry cotton ball in the ear canal.

3

A nurse is preparing to perform the whisper test to assess a client's gross auditory acuity. Which of the following would be most appropriate for the nurse to do? 1- Stand at a position diagonal to the client. 2- Have the client use a finger to occlude the ear to be tested. 3- Stand about 1 to 2 feet away from the ear to be tested. 4- Speak a phrase in a low normal tone of voice.

3

A nurse practitioner checks pupillary response with a penlight. The nurse is aware that the normal pupil size in room lighting is: 1- 1 to 2 mm. 2- 2 to 3 mm. 3- 3 to 5 mm. 4- 4 to 7 mm.

3

A nurse who coordinates care in a long-term care facility is aware that almost 100% of the residents wear glasses and that many of them require surgical corrective procedures. Which of the following phenomena is considered to be an age-related change to vision? 1- Beginning at around age 40, rods gradually replace cones. 2- The optic nerve (CN II) becomes progressively demyelinated with age. 3- The lens of the eye becomes more opaque with age. 4- Intraocular pressure gradually increases, peaking around age 75.

3

A patient comes to the clinic with a suspected eye infection. The nurse recognizes that the patient most likely has conjunctivitis, as evidenced by what symptom? 1- Blurred vision 2- Elevated IOP 3- A mucopurulent ocular discharge 4- Severe pain

3

A patient is scheduled to have an auditory brain stem response in 2 days. What does the nurse instruct the patient to do in preparation for the test? 1- Shave several areas on the scalp where the electrodes will be placed. 2- Do not eat or drink 8 hours prior to testing. 3- Wash and rinse hair before test but do not apply any other hair products. 4- Omit daily medications prior to testing.

3

A patient with multiple sclerosis is admitted to the unit. When the nurse assesses the patient, he notes that the patient is demonstrating involuntary rhythmic eye movements. What term will the nurse use when documenting these involuntary oscillations of the eye? 1- Vertigo 2- Tinnitus 3- Nystagmus 4- Dizziness

3

A pediatric nurse is caring for a child who has been brought to the clinic with otitis externa. What assessment finding is characteristic of otitis externa? 1- Tophi on the pinna and ear lobe 2- Dark yellow cerumen in the external auditory canal 3- Pain on manipulation of the auricle 4- Air bubbles visible in the middle ear

3

During a routine eye examination, a patient complains that she is unable to read road signs at a distance when driving her car. What should the patient be assessed for? 1- Astigmatism 2- Anisometropia 3- Myopia 4- Presbyopia

3

Nursing students are reviewing the structure and function of the ears in preparation for class the next day. The students demonstrate understanding of the information when they describe which of the following as a middle ear structure? 1- Auricle 2- Membranous labyrinth 3- Ossicles 4- Organ of Corti

3

The nurse is caring for a client ordered for multiple eye screening. Following which procedure will the nurse instruct the client on a yellow coloring to the skin and urine as being normal? 1- Ultrasonography 2- Retinal Imaging 3- Retinal Angiography 4- Retinoscopy

3

The nurse is conducting a physical assessment of a male patient who has been admitted to the hospital unit. The nursing documentation on the unit specifies an assessment of the patient's direct and consensual pupillary response. How should the nurse assess the patient's consensual pupillary response? 1- Ask the patient to follow the movement of pen from several feet away to near the tip of the patient's nose 2- Ask the patient to look straight ahead while bringing a penlight in from the periphery of the patient's vision 3- Shine a penlight in one of the patient's eyes while observing the response of the opposite eye 4- Shine a penlight in the patient's eye while asking him to identify a common object with the other eye

3

When undergoing testing of visual acuity with a Snellen chart, the client can read the line labeled 20/50 but misses three letters on the line. The nurse documents this finding as which of the following? 1- 20/20 + 30 2- 20/20/50 3- 20/50-3 4- 20/50

3

A client comes to the walk-in clinic complaining of an earache. The cause is found to be impacted cerumen. The client asks the nurse what he can do at home to soften hardened cerumen. What should the nurse recommend to a client to soften hardened cerumen? 1- Avoid harsh sunlight. 2- Increase intake of red meat. 3- Increase intake of beta-carotene. 4- Take nonprescription preparations.

4

A client's vision is assessed at 20/200. The client asks what that means. Which is the mostappropriate response by the nurse? 1- "You see an object from 200 feet away that a person with normal vision sees from 20 feet away." 2- "You see an object from 20 feet away just like a person with normal vision." 3- "You see an object from 200 feet away just like a person with normal vision." 4- "You see an object from 20 feet away that a person with normal vision sees from 200 feet away."

4

A nurse is asked to assess a patient's need for a hearing aid. The nurse knows that a general guideline to determine need would be a hearing loss of: 1- 10 dB in the range of 200 to 1,000 Hz. 2- 20 dB in the range of 300 to 1,000 Hz. 3- 30 dB in the range of 400 to 1,500 Hz. 4- 40 dB in the range of 500 to 2,000 Hz.

4

A patient is having an eye examination. The ophthalmologist is looking inside the patient's eye with a hand-held instrument. What instrument is being used to perform this procedure? 1- Slit-lamp examination 2- An indirect ophthalmoscope 3- An Ishihara plate 4- A direct ophthalmoscope

4

The nurse at the eye clinic is caring for a patient with suspected glaucoma. What complaint would be significant for a diagnosis of glaucoma? 1- A significant loss of central vision 2- Diminished acuity 3- Pain associated with a purulent discharge 4- The presence of halos around lights

4

The nurse is giving a visual field examination to a 55-year-old male client. The client asks what this test is for. What would be the nurse's best answer? 1- "This test measures visual acuity." 2- "This test measures how well your eyes move." 3- "This test is to see how well your eyes are aging." 4- "This test measures peripheral vision and detects gaps in the visual field."

4

Which statement is consistent with acute otitis media? 1- The infection usually lasts more than 6 weeks. 2- It is a relatively uncommon childhood infection. 3- It is usually caused by a fungal infection. 4- Conductive hearing loss may occur.

4