MED SURG EXAM 4

Cranial nerve 3, also called the oculomotor nerve

has the biggest job of the nerves that control eye movement. It controls 4 of the 6 eye muscles in each eye: Medial rectus muscle (moves the eye inward toward the nose) Inferior rectus muscle (moves the eye down)

The olfactory nerve, or cranial nerve 1

is the first of the 12 cranial nerves. It is instrumental in the sense of smell.

Signs and symptoms of Otitis externa In an individual with otitis externa, which of these signs would the nurse expect to find on assessment?

ANS: Enlarged superficial cervical nodes

What is the significance of an oral sebaceous cyst? A 32-year-old woman is at the clinic for "little white bumps in my mouth." During the assessment, the nurse notes that she has a 0.5 cm white, nontender papule under her tongue and one on the mucosa of her right cheek. What would the nurse tell the patient? a. "These spots indicate an infection such as strep throat." b. "These bumps could be indicative of a serious lesion, so I will refer you to a specialist." c. "This condition is called leukoplakia and can be caused by chronic irritation such as with smoking." d. "These bumps are Fordyce granules, which are sebaceous cysts and are not a serious condition."

ANS:D) "These bumps are Fordyce granules, which are sebaceous cysts and are not a serious condition." Rationale: Fordyce granules are small, isolated white or yellow papules on the mucosa of the cheek, tongue, and lips. These little sebaceous cysts are painless and are not significant. Chalky, white raised patches would indicate leukoplakia. In strep throat, the examiner would see tonsils that are bright red, swollen, and may have exudates or white spots.

signs and symptoms of serous otitis media When performing an otoscopic examination of a 5-year-old child with a history of chronic ear infections, the nurse sees that his right tympanic membrane is amber-yellow in color and that air bubbles are visible behind the tympanic membrane. The child reports occasional hearing loss and a popping sound with swallowing. The preliminary analysis based on this information is that the child:

ANS:Most likely has serous otitis media Rationale: The lymphatic drainage of the external ear flows to the parotid, mastoid, and superficial cervical nodes. The signs are severe swelling of the canal, inflammation, and tenderness. Rhinorrhea, periorbital edema, and pain over the maxillary sinuses do not occur with otitis externa

signs and symptoms of a perforated eardrum. The nurse is taking the history of a patient who may have a perforated eardrum. What would be an important question in this situation?

ANS: "Is there any relationship between ear pain and the discharge you mentioned?" Rationale: Typically with perforation, ear pain occurs first, stopping with a popping sensation, and then drainage occurs

Pathophysiology of repeat ear infections of a two-year-old child. The mother of a 2-year-old is concerned because her son has had three ear infections in the past year. What would be an appropriate response by the nurse?

ANS: "Your son's eustachian tube is shorter and wider than yours because of his age, which allows for infections to develop more easily." Rationale: The infant's eustachian tube is relatively shorter and wider, and its position is more horizontal than the adult's, so it is easier for pathogens from the nasopharynx to migrate through to the middle ear. The other responses are not appropriate

Compare and contrast the sclera of a black vs caucasian patient. Which of these assessment findings would the nurse expect to see when examining the eyes of a black patient?

ANS: A dark retinal background Rationale: There is an ethnically based variability in the color of the iris and in retinal pigmentation, with darker irises having darker retinas behind them.

signs and symptoms of corneal abrasion A patient comes into the emergency department after an accident at work. A machine blew dust into his eyes and he was not wearing safety glasses. The nurse examines his corneas by shining a light from the side across the cornea. What findings would suggest that he has suffered a corneal abrasion

ANS: A shattered look to the light rays reflecting off the cornea Rationale: A corneal abrasion causes irregular ridges in reflected light, which produce a shattered look to light rays. There should be no opacities in the cornea. The other responses are not correct

discharge instructions for a detached retinal repair. A client had a retinal detachment and has undergone surgical correction. What discharge instruction is most important? a. "Avoid reading, writing, or close work such as sewing." b. "Dim the lights in your house for at least a week." c. "Keep the follow-up appointment with the ophthalmologist." d. "Remove your eye patch every hour for eyedrops."

ANS: A) "Avoid reading, writing, or close work such as sewing." Rationale: After surgery for retinal detachment, the client is advised to avoid reading, writing, and close work because they cause rapid eye movements. Dim lights are not indicated. Keeping a postoperative appointment is important for any surgical client. The eye patch is not removed for eyedrops.

A client does not understand why vision loss due to glaucoma is irreversible. What explanation by the nurse is best? a. "Because eye pressure was too high, the tissue died." b. "Glaucoma always leads to permanent blindness." c. "The traumatic damage to your eye was too great." d. "The infection occurs so quickly it can't be treated."

ANS: A) "Because eye pressure was too high, the tissue died. Rationale: Glaucoma is caused when the intraocular pressure becomes too high and stays high long enough to cause tissue ischemia and death. At that point, vision loss is permanent. Glaucoma does not have to cause blindness. Trauma can cause glaucoma but is not the most common cause. Glaucoma is not an infection.

Patient with foreign body and eye what is the priority for this patient. A client has a foreign body in the eye. What action by the nurse takes priority? a. Administering ordered antibiotics b. Assessing the client's visual acuity c. Obtaining consent for enucleation d. Removing the object immediately

ANS: A) Administering ordered antibiotics Rationale: To prevent infection, antibiotics are provided. Visual acuity in the affected eye cannot be assessed. The client may or may not need enucleation. The object is only removed by the ophthalmologist.

Purpose of the procedure corneal staining. A client presents to the emergency department reporting a foreign body in the eye. For what diagnostic testing should the nurse prepare the client? a. Corneal staining b. Fluorescein angiography c. Ophthalmoscopy d. Tonometry

ANS: A) Corneal staining Rationale: Corneal staining is used when the possibility of eye trauma exists, including a foreign body. Fluorescein angiography is used to assess problems of retinal circulation. Ophthalmoscopy looks at both internal and external eye structures. Tonometry tests the intraocular pressure.

Patient treated with proxymetacaine (ocu-caine) What is discharge instruction. A client had proxymetacaine (Ocu-Caine) instilled in one eye in the emergency department. What discharge instruction is most important? a. Do not touch or rub the eye until it is no longer numb. b. Monitor the eye for any bleeding for the next day. c. Rinse the eye with warm saline solution at home. d. Use all the eyedrops as prescribed until they are gone.

ANS: A) Do not touch or rub the eye until it is no longer numb. Rationale: This drug is an ophthalmic anesthetic. The client can injure the numb eye by touching or rubbing it. Bleeding is not associated with this drug. The client should not be told to rinse the eye. This medication was given in the emergency department and is not prescribed for home use.

Leukeodema in which population of people I would normally have it. The nurse is performing an oral assessment on a 40-year-old Black patient and notices the presence of a 1 cm, nontender, grayish-white lesion on the left buccal mucosa. Which one of these statements is true? This lesion is: a. Leukoedema and is common in dark-pigmented persons. b. The result of hyperpigmentation and is normal. c. Torus palatinus and would normally be found only in smokers. d. Indicative of cancer and should be immediately tested.

ANS: A) Leukoedema and is common in dark-pigmented persons. Rationale: Leukoedema, a grayish-white benign lesion occurring on the buccal mucosa, is most often observed in Blacks.

An adolescent patient who is on the school swim team asks a nurse about ways to prevent swimmer's ear. The nurse will tell the patient to: a. allow the ears to drain well after every swim and shower. b. clean the ears with a cotton-tipped applicator after swimming. c. keep the ear canals free of cerumen. d. use antifungal ear drops before and after swimming.

ANS: A) allow the ears to drain well after every swim and shower. Rationale: Acute otitis externa (OE) can be minimized by keeping the natural defenses of the external auditory canal (EAC) healthy. Swimmers should be taught to dry the EAC after showering and swimming. Cleaning the ears with cotton-tipped swabs can remove the cerumen and abrade the epithelium. Removing cerumen removes the natural barrier to infection. Antifungal ear drops are used to treat acute OE but not as a preventive measure.

Presenting signs of the ear of a basal skull fracture. The nurse is assessing a 16-year-old patient who has suffered head injuries from a recent motor vehicle accident. Which of these statements indicates the most important reason for assessing for any drainage from the ear canal?

ANS: Blood or clear watery drainage can indicate a basal skull fracture

How is the intraocular pressure determined? The nurse is reviewing causes of increased intraocular pressure. Which of these factors determines intraocular pressure?

ANS: Amount of aqueous produced and resistance to its outflow at the angle of the anterior chamber Rationale: Intraocular pressure is determined by a balance between the amount of aqueous produced and resistance to its outflow at the angle of the anterior chamber. The other responses are incorrect.

Presenting signs and symptoms of the ear when exposed to extreme cold weather. An assessment of a 23-year-old patient reveals the following: an auricle that is tender and reddish-blue in color with small vesicles. The nurse would need to know additional information that includes which of these?

ANS: Any prolonged exposure to extreme cold Rationale: Frostbite causes reddish-blue discoloration and swelling of the auricle after exposure to extreme cold. Vesicles or bullae may develop, and the person feels pain and tenderness

During an assessment the nurse notices that an elderly patient has tears rolling down his face from his left eye. Closer examination shows that the lower lid is loose and rolling outward. The patient complains of his eye feeling "dry and itchy." Which action by the nurse is correct?

ANS: Assess for other signs of ectropion. Rationale: The condition described is known as ectropion, and it occurs in aging due to atrophy of elastic and fibrous tissues. The lower lid does not approximate to the eyeball, and, as a result, the puncta cannot siphon tears effectively, and excessive tearing results. Ptosis is drooping of the upper eyelid. These are not signs of a foreign body in the eye or basal cell carcinoma.

proper use of otoscope to assess a nasal cavity. The nurse is using an otoscope to assess the nasal cavity. Which of these techniques is correct? a. Inserting the speculum at least 3 cm into the vestibule b. Avoiding touching the nasal septum with the speculum c. Gently displacing the nose to the side that is being examined d. Keeping the speculum tip medial to avoid touching the floor of the nares

ANS: B) Avoiding touching the nasal septum with the speculum Rationale: The correct technique for using an otoscope is to insert the apparatus into the nasal vestibule, avoiding pressure on the sensitive nasal septum. The tip of the nose should be lifted up before inserting the speculum.

What is oral candidiasis and which patient is most likely to develop it. 40-year-old patient who has just finished chemotherapy for breast cancer tells the nurse that she is concerned about her mouth. During the assessment the nurse finds areas of buccal mucosa that are raw and red with some bleeding, as well as other areas that have a white, cheesy coating. The nurse recognizes that this abnormality is: a. Aphthous ulcers. b. Candidiasis. c. Leukoplakia. d. Koplik spots.

ANS: B) Candidiasis. Rationale: Candidiasis is a white, cheesy, curdlike patch on the buccal mucosa and tongue. It scrapes off, leaving a raw, red surface that easily bleeds. It also occurs after the use of antibiotics or corticosteroids and in persons who are immunosuppressed.

Examining the tonsils of a 30-year-old what are the normal findings. In assessing the tonsils of a 30 year old, the nurse notices that they are involuted, granular in appearance, and appear to have deep crypts. What is correct response to these findings? a. Refer the patient to a throat specialist. b. No response is needed; this appearance is normal for the tonsils. c. Continue with the assessment, looking for any other abnormal findings. d. Obtain a throat culture on the patient for possible streptococcal (strep) infection.

ANS: B) No response is needed; this appearance is normal for the tonsils. Rationale: The tonsils are the same color as the surrounding mucous membrane, although they look more granular and their surface shows deep crypts. Tonsillar tissue enlarges during childhood until puberty and then involutes.

The ideology of frequent nosebleeds in a pregnant woman. A woman who is in the second trimester of pregnancy mentions that she has had "more nosebleeds than ever" since she became pregnant. The nurse recognizes that this is due to: A) a problem with the patient's coagulation system. B) increased vascularity in the upper respiratory tract as a result of the pregnancy. C) increased susceptibility to colds and nasal irritation. D) inappropriate use of nasal sprays.

ANS: B) increased vascularity in the upper respiratory tract as a result of the pregnancy. Rationale: increased vascularity in the upper respiratory tract as a result of the pregnancy.

During an otoscopic examination, the nurse notices an area of black and white dots on the tympanic membrane and ear canal wall. ?

ANS: Blood in the middle ear Rationale: A colony of black or white dots fungal infection (otomycosis).

Condition retinitis Pigmentosa and what are the signs and symptoms. A client has been taught about retinitis pigmentosa (RP). What statement by the client indicates a need for further teaching? a. "Beta carotene, lutein, and zeaxanthin are good supplements." b. "I might qualify for a retinal transplant one day soon." c. "Since I'm going blind, sunglasses are not needed anymore." d. "Vitamin A has been shown to slow progression of RP."

ANS: C) "Since I'm going blind, sunglasses are not needed anymore." Rationale: Sunglasses are needed to prevent the development of cataracts in addition to the RP. The other statements are accurate.

What is the normal amount of teeth for an 18-month-old toddler? A mother is concerned because her 18-month-old toddler has 12 teeth. She is wondering if this is normal for a child of this age. The nurse's best response would be: a. "How many teeth did you have at this age?" b. "All 20 deciduous teeth are expected to erupt by age 4 years." c. "This is a normal number of teeth for an 18 month old." d. "Normally, by age 2 years, 16 deciduous teeth are expected."

ANS: C) "This is a normal number of teeth for an 18-month-old." Rationale: The guidelines for the number of teeth for children younger than 2 years old are as follows: the child's age in months minus the number 6 should be equal to the expected number of deciduous teeth. Normally, all 20 teeth are in by 2 years old. In this instance, the child is 18 months old, minus 6, which equals 12 deciduous teeth expected.

A client's intraocular pressure (IOP) is 28 mm Hg. What action by the nurse is best? a. Educate the client on corneal transplantation. b. Facilitate scheduling the eye surgery. c. Plan to teach about drugs for glaucoma. d. Refer the client to local Braille classes.

ANS: C) Plan to teach about drugs for glaucoma Rationale: This increased IOP indicates glaucoma. The nurse's main responsibility is teaching the client about drug therapy. Corneal transplantation is not used in glaucoma. Eye surgery is not indicated at this time. Braille classes are also not indicated at this time.

Black American population. Bluish lips and dark line along the gingival margin is this a normal finding or abnormal finding?. During an oral assessment of a 30-year-old Black patient, the nurse notices bluish lips and a dark line along the gingival margin. What action would the nurse perform in response to this finding? a. Check the patient's hemoglobin for anemia. b. Assess for other signs of insufficient oxygen supply. c. Proceed with the assessment, knowing that this appearance is a normal finding. d. Ask if he has been exposed to an excessive amount of carbon monoxide.

ANS: C) Proceed with the assessment, knowing that this appearance is a normal finding. Rationale: Some Blacks may have bluish lips and a dark line on the gingival margin; this appearance is a normal finding.

What is considered a normal pupillary light reflex? A patient has a normal pupillary light reflex. The nurse recognizes that this reflex indicates that:

ANS: Constriction of both pupils occurs in response to bright light. Rationale: The pupillary light reflex is the normal constriction of the pupils when bright light shines on the retina.

The nurse is assessing a patient's eyes for the accommodation response and would expect to see which normal finding?

ANS: Convergence of the axes of the eyes Rationale: The accommodation reaction includes pupillary constriction and convergence of the axes of the eyes. The other responses are not correct.

while doing an ear exam what are the signs and symptoms of frequent ear infections in the inner ear? The nurse is performing a middle ear assessment on a 15-year-old patient who has had a history of chronic ear infections. When examining the right tympanic membrane, the nurse sees the presence of dense white patches. The tympanic membrane is otherwise unremarkable. It is pearly, with the light reflex at 5 o'clock and landmarks visible. The nurse should:

ANS: Know that these are scars caused from frequent ear infections Rationale: Dense white patches on the tympanic membrane are sequelae of repeated ear infections. They do not necessarily affect hearing

Signs and symptoms of Carcinoma on the outside of the ear. The nurse is performing an assessment on a 65-year-old man. He reports crusty module behind the pinna. It intermittently bleeds and has not healed over the past 6 months. On physical assessment, the nurse finds an ulcerated crusted nodule with an indurated base. The preliminary analysis in this situation is that this:

ANS: Could be a potential carcinoma, and the patient should be referred for a biopsy Rationale: An ulcerated crusted nodule with an indurated base that fails to heal is characteristic of a carcinoma. These lesions fail to heal and bleed intermittently. Individuals with such symptoms should be referred for a biopsy. The other responses are not correct.

Very young child what are the possible outcomes from prolonged bottle sucking/bottle use. While obtaining a health history from the mother of a 1-year-old child, the nurse notices that the baby has had a bottle in his mouth the entire time. The mother states, "It makes a great pacifier." The best response by the nurse would be: a. "You're right. Bottles make very good pacifiers." b. "Using a bottle as a pacifier is better for the teeth than thumb-sucking." c "It's okay to use a bottle as long as it contains milk and not juice." d. "Prolonged use of a bottle can increase the risk for tooth decay and ear infections."

ANS: D) "Prolonged use of a bottle can increase the risk for tooth decay and ear infections." Rationale: Prolonged bottle use during the day or when going to sleep places the infant at risk for tooth decay and middle ear infections.

Pathophysiology of glaucoma and what are the signs and symptoms. A client with glaucoma is being assessed for new symptoms. Which symptom indicates a high priority need for reassessment of intraocular pressure? A. Burning in the eye B. Inability to differentiate colors C. Increased sensitivity to light D. Gradual vision changes

ANS: D) Gradual vision changes

A patient prescribed timolol (Timoptic eyedrops) what are the effects. A client is taking timolol (Timoptic) eyedrops. The nurse assesses the client's pulse at 48 beats/min. What action by the nurse is the priority? a. Ask the client about excessive salivation. b. Assess the client for shortness of breath. c. Give the drops using punctal occlusion. d. Hold the eyedrops and notify the provider.

ANS: D) Hold the eyedrops and notify the provider. Rationale: The nurse should hold the eyedrops and notify the provider because beta blockers can slow the heart rate. Excessive salivation can occur with cholinergic agonists. Shortness of breath is not related. If the drops are given, the nurse uses punctal occlusion to avoid systemic absorption.

Describe the sinuses of a newborn infant. The nurse is reviewing the development of the newborn infant. Regarding the sinuses, which statement is true in relation to a newborn infant? a. Sphenoid sinuses are full size at birth. b. Maxillary sinuses reach full size after puberty. c. Frontal sinuses are fairly well developed at birth. d. Maxillary and ethmoid sinuses are the only sinuses present at birth.

ANS: D) Maxillary and ethmoid sinuses are the only sinuses present at birth. Rationale: Only the maxillary and ethmoid sinuses are present at birth. The sphenoid sinuses are minute at birth and develop after puberty. The frontal sinuses are absent at birth, are fairly well developed at age 7 to 8 years, and reach full size after puberty.

Significance of ulceration of tongue with rolled edges. The nurse is performing an assessment. Which of these findings would cause the greatest concern? a. Painful vesicle inside the cheek for 2 days b. Presence of moist, nontender Stensen's ducts c. Stippled gingival margins that snugly adhere to the teeth d. Ulceration on the side of the tongue with rolled edges

ANS: D) Ulceration on the side of the tongue with rolled edges Rationale: Ulceration on the side or base of the tongue or under the tongue raises the suspicion of cancer and must be investigated. The risk of early metastasis is present because of rich lymphatic drainage. The vesicle may be an aphthous ulcer, which is painful but not dangerous. The other responses are normal findings.

What effects does the sympathetic nervous system have on the eyelids and the pupils? When examining a patient's eyes, the nurse recalls that stimulation of the sympathetic branch of the autonomic nervous system:

ANS: Elevates the eyelid and dilates the pupil. Rationale: Stimulation of the sympathetic branch of the autonomic nervous system dilates the pupil and elevates the eyelid. Parasympathetic nervous system stimulation causes the pupil to constrict. The muscle fibers of the iris contract the pupil in bright light to accommodate for near vision. The ciliary body controls the thickness of the lens.

What determines that a patient has bad vision. A patient's vision is recorded as 20/80 in each eye. The nurse interprets this finding to mean that the patient:

ANS: Has poor vision. Rationale: Normal visual acuity is 20/20 in each eye. The larger the denominator, the poorer the vision.

The normal pattern of hearing loss in the elderly patient. The nurse is performing an ear examination of an 80-year-old patient. Which of these findings would be considered normal?

ANS: High-tone frequency loss Rationale: A high-tone frequency hearing loss is apparent for those affected with presbycusis, the hearing loss that occurs with aging. The pinna loses elasticity, causing earlobes to be pendulous. The eardrum may be whiter in color and more opaque and duller than in the young adult

The portion of the ear responsible for the sensation of spinning patients feels like they are spinning. During an interview, the patient states he has the sensation that "everything around him is spinning." The nurse recognizes that the portion of the ear responsible for this sensation is the:

ANS: Labyrinth Rationale: If the labyrinth ever becomes inflamed, it feeds the wrong information to the brain, creating a staggering gait and a strong, spinning, whirling sensation called vertigo

Physiological changes in the eye of the elderly population. The nurse is reviewing for a class in age-related changes in the eye. Which of these physiological changes is responsible for presbyopia?

ANS: Loss of lens elasticity Rationale: The lens loses elasticity and decreases its ability to change shape to accommodate for near vision. This condition is called presbyopia.

Inner ear nerve degeneration what is it A 70-year-old patient tells the nurse that he has noticed that he is having trouble hearing, especially in large groups. He says he "can't always tell where the sound is coming from" and the words often sound "mixed up." What might the nurse suspect as the cause for this change?

ANS: Nerve degeneration in the inner ear Rationale: Presbycusis is a type of hearing loss that occurs in 60% of those older than 65 years of age, even in people living in a quiet environment. It is a gradual sensorineural loss caused by nerve degeneration in the inner ear. Words sound garbled, and the ability to localize sound is impaired also. This communication dysfunction is accentuated when background noise is present

Difference between objective vertigo, subjective vertigo and dizziness. During an examination, the nurse notices that the patient stumbles a little while walking, and, when she sits down, she holds on to the side of the chair. The patient states, "It feels like the room is spinning!." The nurse notices that the patient is experiencing:

ANS: Objective vertigo Rationale: With objective vertigo, the patient feels like the room spins; with subjective vertigo, the person feels like he or she is spinning. Tinnitus is a sound that comes from within a person; it can be a ringing, crackling, or buzzing sound. It accompanies some hearing or ear disorders. Dizziness is not the same as true vertigo; the person who is dizzy may feel unsteady and lightheaded

31 year old has a progressive loss of hearing what is the possible cost. A 31-year-old patient tells the nurse that he has noticed a progressive loss in his hearing. He says that it does seem to help when people speak louder or if he turns up the volume of a television or radio. The most likely cause of his hearing loss is:

ANS: Otosclerosis Rationale: Otosclerosis is a common cause of conductive hearing loss in young adults between the ages of 20 and 40 years. Presbycusis is a type of hearing loss that occurs with aging. Trauma and frequent ear infections are not a likely cause of his hearing loss

Risk factors for ear infections in children. The nurse is conducting a child safety class for new mothers. Which factor places young children at risk for ear infections?

ANS: Passive cigarette smoke Rationale: Exposure to passive and gestational smoke is a risk factor for ear infections in infants and children

The proper procedure for doing otoscopic procedure of a two-year-old. The nurse is preparing to do an otoscopic examination on a 2-year-old child. Which of the following reflects correct procedure?

ANS: Pull the pinna down. Rationale: For an otoscopic examination, pull the pinna down on an infant and a child under 3 years of age. The other responses are not part of the correct procedure.

What is visual accommodation? The nurse is testing a patient's visual accommodation, which refers to which action?

ANS: Pupillary constriction when looking at a near object Rationale: The muscle fibers of the iris contract the pupil in bright light and accommodate for near vision, which also results in pupil constriction. The other responses are not correct.

Which of the following is a risk factor for ear infections in young children?

ANS: Secondhand cigarette smoke

Doing acuity test on the Snellen chart how do you adjust if the patient cant read the largest letters A patient is unable to read even the largest letters on the Snellen chart. The nurse should take which action next?

ANS: Shorten the distance between the patient and the chart until it is seen and record that distance. Rationale: If the person is unable to see even the largest letters, then the nurse should shorten the distance to the chart until it is seen and should record that distance (e.g., "10/200"). If visual acuity is even lower, then the nurse should assess whether the person can count fingers when they are spread in front of the eyes or can distinguish light perception from a penlight. If vision is poorer than 20/30, then a referral to an ophthalmologist or optometrist is necessary, but first the nurse must assess the visual acuity.

What are the visual pathways and the visual fields? The nurse is conducting a visual examination. Which of these statements regarding visual pathways and visual fields is true?

ANS: The image formed on the retina is upside down and reversed from its actual appearance in the outside world. Rationale: The image formed on the retina is upside down and reversed from its actual appearance in the outside world. The light rays are refracted through the transparent media of the eye before striking the retina, and the nerve impulses are conducted through the optic nerve tract to the visual cortex of the occipital lobe of the brain. The left side of the brain interprets vision for the right eye.

Otoscopic exam on newborn what are the normal findings. The nurse is preparing to perform an otoscopic examination of a newborn infant. Which statement is true regarding this examination?

ANS: The normal membrane may appear thick and opaque Rationale: During the first few days, the tympanic membrane often looks thickened and opaque. It may look "injected" and have a mild redness from increased vascularity. The other statements are not correct

How to interpret a visual acuity reading? 20/20 vs 20/40 A patient's vision is recorded as 20/30 when the Snellen eye chart is used. The nurse interprets these results to indicate that:

ANS: The patient can read at 20 feet what a person with normal vision can read at 30 feet. Rationale: The top number indicates the distance the person is standing from the chart; the denominator gives the distance at which a normal eye can see.

During an assessment of the sclera of an African-American patient, the nurse would consider which of these an expected finding?

ANS: The presence of small brown macules on the sclera Rationale: In dark-skinned people, one normally may see small brown macules in the sclera.

How to test the hearing of a 7 to 9-month-old baby. The nurse assesses the hearing of a 7-month-old by clapping hands. What is the expected response? The infant:

ANS: Turns his or her head to localize the sound Rationale: With a loud sudden noise, the nurse should notice the infant turning his or her head to localize sound and responding to his or her own name. A startle reflex and acoustic blink reflex is expected in newborns; at age 3 to 4 months, the infant stops movements and appears to listen

A child that is on a swimming team. What are preventative measures from developing otitis externa which is also called swimmer's ear? A 17-year-old student is a swimmer on her high school's swim team. She has had three bouts of otitis externa this season and wants to know what to do to prevent it. The nurse instructs her to:

ANS: Use rubbing alcohol or 2% acid eardrops after every swim

Which tools are necessary to perform a visual acuity? The nurse is preparing to assess the visual acuity of a 16-year-old patient. How should the nurse proceed?

ANS: Use the Snellen chart positioned 20 feet away from the patient. Rationale: The Snellen alphabet chart is the most commonly used and most accurate measure of visual acuity. The confrontation test is a gross measure of peripheral vision. The Jaeger card or newspaper tests are used to test near vision.

Know cranial nerves 1, 3, 8 and 11. The nurse is reviewing the function of the cranial nerves (CNs). Which CN is responsible for conducting nerve impulses to the brain from the organ of Corti?

ANS: VIII Rationale: The nerve impulses are conducted by the auditory portion of CN VIII to the brain

Signs and symptoms of fungal ear infection. During an otoscopic examination, the nurse notices an area of black and white dots on the tympanic membrane and the ear canal wall. What does this finding suggest?

ANS: Yeast or fungal infection

At what age do we check color vision in children? A 2-week-old infant can fixate on an object but cannot follow a light or bright toy. The nurse would:

ANS: consider this a normal finding. Rationale: By 2 to 4 weeks an infant can fixate on an object. By the age of 1 month, the infant should fixate and follow a bright light or toy.

Normal finding in papillary response to light. When performing the corneal light reflex assessment, the nurse notes that the light is reflected at 2 o'clock in each eye. The nurse should

ANS: consider this a normal finding. Rationale: Reflection of the light on the corneas should be in exactly the same spot on each eye, or symmetric. If asymmetry is noted, then the nurse should administer the cover test

The nurse is assessing color vision of a male child. Which statement is correct? The nurse should:

ANS: test for color vision once between the ages of 4 and 8. Rationale: Test only boys for color vision once between the ages of 4 and 8 years. It is not tested in females because it is rare in females. Testing is done with the Ishihara test, which is a series of polychromatic cards.

The accessory nerve is the eleventh paired cranial nerve.

It has a purely somatic motor function, innervating the sternocleidomastoid and trapezius muscles.