Patho Ch 38 Disorders of Special Sensory Function
Which of the following signs and symptoms is most indicative of Ménière disease? A. Rotary vertigo and tinnitus B. Nausea and vomiting C. Progressive hearing loss and frequent falls D. Otalgia and recurrent otitis media
A Ménière disease is characterized by fluctuating episodes of tinnitus, feelings of ear fullness, and violent rotary vertigo (room spinning) that often renders the person unable to sit or walk. Nausea and vomiting, hearing loss, and falls may accompany the disease, but these signs and symptoms are less definitive than frequent episodes of rotary vertigo accompanied by tinnitus.
Which of the following clients are at risk for developing and acute episode of angle-closure glaucoma? Select all that apply. A.A 60-year-old female emotionally devastated after divorcing her husband of 35 years B. A soldier ordered to stay in a pitch-black cave to observe enemy militants for an extended period of time C.A person with low dietary intake of lutein, omega-3 fatty acids, and zinc D. A person with a high grade of myopia E. A surgical client who has received many doses of IV atropine to keep heart rate above 50
A, B, E Manifestations of acute angle-closure glaucoma are related to sudden, intermittent increases in intraocular pressure. These occur after prolonged periods in the dark, emotional upset, and other conditions that cause extensive and prolonged dilation of the pupil. Administration of pharmacologic agents, such as atropine, that cause pupillary dilation (mydriasis) also can precipitate an acute episode. Age-related macular degeneration (AMD) is the most common cause of reduced vision in the elderly. In addition to older age, identifiable risk factors include cigarette smoking, obesity, and low dietary intake of lutein, omega 3 fatty acids, zinc, and vitamins A, C, and E. Persons with high grades of myopia or nearsightedness may have abnormalities in the peripheral retina that predispose to sudden detachment.
A new mother brings her infant to the clinic reporting that the child is not sleeping or eating much. Upon assessment, the health care provider notes that the infant's ear canal is reddened with a bulging tympanic membrane. Which other data collected would lead to the diagnosis of acute otitis media (AOM)? Select all that apply. A. "Yes, he has been pulling at his ear." B. "We like to throw him up in the air hoping any water in his ear will drain." C. "He's been very irritable and fussy the past couple of days." D. "When I dropped a pan on the floor, he jumped." E. "He jabbers all the time usually."
A, C AOM is characterized by an acute onset of otalgia (ear pain), fever, and hearing loss. Younger children often have nonspecific signs and symptoms that manifest as ear tugging, irritability, nighttime awakening, and poor feeding. Key diagnostic criteria include ear pain that interferes with activity or sleep, tympanic membrane erythema (redness), and middle ear effusion. A child with otitis media with effusion (OME) may develop delayed speech and language skills.
Which of the following people are at high risk for developing nonulcerative inflammation of the cornea? Select all that apply. A. A welder with inadequate eye protection B. A contact lens wearer who is noncompliant with cleaning and sterilizing the lens C. A female who uses a tanning bed four to five times/week D. A person who touched the fever blister and then rubbed the eye E. A ski patrol who works 12 hours/day in bright, sunny mountain tops
A, C, E In nonulcerative keratitis, all the layers of the epithelium may be affected, but the epithelium remains intact. There are a number of causes of epithelial keratitis, including epidemic keratoconjunctivitis caused by adenoviruses 8 and 19 and ultraviolet (UV) light exposure keratitis. Most cases of UV keratitis occur in welders with inadequate eye protection, but may also occur with tanning booth and other UV lamp exposure, and from sun reflecting off snow. Most cases of herpes keratitis are caused by HSV type 1 (labial [lip] herpes) and is ulcerative in nature. Acanthamoeba keratitis is a rare but sight-threatening complication that typically occurs in people who wear soft contact lens, particularly overnight or without proper disinfection.
Which of the following vision deficits is a clinician justified in attributing to the normal aging process? A. Conjunctivitis B. Presbyopia C. Strabismus D. Angle-closure glaucoma
B The term presbyopia refers to a decrease in accommodation that occurs because of aging. Conjunctivitis, strabismus, and angle-closure glaucoma are considered abnormal and pathologic in clients of all ages.
A client has been diagnosed with open-angle glaucoma during routine eye exam. The client has been prescribed a topical b-adrenergic antagonist. Client teaching about how this drug works should include which of the following statements? β-adrenergic antagonists: A. Cause an early decrease in production of aqueous humor by constricting the vessels supplying the ciliary body. B. Lower intraocular pressure by decreasing aqueous humor production C. Reduce the secretion of aqueous humor D. Exert their effects by increasing the effects of acetylcholine, thereby increase aqueous outflow through contraction of the ciliary muscle and pupillary constriction
B Topical β-adrenergic antagonists, which are thought to lower intraocular pressure by decreasing aqueous humor production, are usually the drugs of first choice. The α-adrenergic agonists cause an early decrease in production of aqueous humor by constricting the vessels supplying the ciliary body. Carbonic anhydrase inhibitors reduce the secretion of aqueous humor. Cholinergic drugs exert their effects by increasing the effects of acetylcholine (a postganglionic neurotransmitter in the parasympathetic nervous system) and increase aqueous outflow through contraction of the ciliary muscle and pupillary constriction.
A client presents to the clinic complaining, "I have something in my eye." When questioned, the client admits to a scratching and burning sensation and light sensitivity. The health care provider suspects the client has developed: A. Conjunctivitis B. Retinal detachment C. Acute glaucoma D. Corneal edema
A Conjunctivitis causes bilateral tearing, itching, burning, foreign body sensation, and morning eyelash crusting and eye redness. The primary symptom of retinal detachment is painless changes in vision. Commonly, flashing lights or sparks, followed by small floaters or spots in the field of vision, are early symptoms. Attacks of glaucoma (increased intraocular pressure) are manifested by ocular pain, excruciating headache, blurred or iridescent vision, and corneal edema with hazy cornea, dilated (mydriasis), and fixed pupil; with repeated or prolonged attacks, the eye becomes reddened. With corneal edema, the cornea appears dull, uneven, and hazy; visual acuity decreases; and iridescent vision (i.e., rainbows around lights) occurs.
A client presents to the emergency department complaining of loss of part of his vision. An MRI with contrast reveals multiple aneurysms of the circle of Willis. The client is diagnosed with "bitemporal heteronymous anopia." For this client, what effect will this have on his vision? A. With both eyes open, the client has full binocular visual fields B. Bilateral loss of peripheral vision on both sides with a narrow binocular field C. Total, irreversible blindness D. Loss of a quarter of the visual field in both eyes
A The loss of the temporal fields (nasal retina) of both eyes is called bitemporal heteronymous anopia. With both eyes open, the person with bilateral defects still has the full binocular visual field. The loss of the same half-fields in the two eyes is called a homonymous loss, and the abnormality is called homonymous hemianopia. Blindness in one eye is called anopia. If half of the visual field for one eye is lost, the defect is called hemianopia; if a quarter of the field is lost, it is called quadrantanopia. Loss of the temporal or peripheral visual fields on both sides results in a narrow binocular field, commonly called tunnel vision.
Parents with a profoundly deaf child ask, "How can you test such a young infant for hearing loss?" The health care provider will likely explain which of the following testing procedures? Select all that apply. A. Tuning fork B. Audioscope C. EEG with auditory brain stem-evoked responses (ABRs) D. Playing music and slowly increasing the sound until response is elicited E. PET scanning
A, B, C Tuning forks are used to differentiate conductive and sensorineural hearing loss. Audioscopes can be used to assess a person's ability to hear pure tones at 1000 to 2000 Hz (usual speech frequencies). The ABR uses electroencephalographic (EEG) electrodes and high-gain amplifiers to produce a record of brain wave activity elicited during repeated acoustic stimulations of either or both ears. It involves subjecting the ear to loud clicks and using a computer to analyze nerve impulses as they are processed in the midbrain. Imaging studies such as computed tomography (CT) scans and magnetic resonance imaging (MRI) can be done to determine the site of a lesion (if tumor is suspected) and the extent of damage.
As part of the community health department, a nurse is educating a group of diabetic clients about prevention of blindness. Which of the following topics should be covered during this class? Select all that apply. A. Importance of yearly eye exams B. Need to have liver enzymes checked annually C. Tight control of blood glucose levels D. Keep BP below 130.85 (Am. Heart Assoc. Guidelines) E. Never eat dessert when you have eaten pasta for the meal
A, C, D Current guidelines recommend that persons with diabetes have yearly eye examinations. Preventing diabetic retinopathy from developing or progressing is considered the best approach to preserving vision. Growing evidence suggests that careful control of blood glucose levels in persons with diabetes mellitus may retard the onset and progression of retinopathy. There also is a need for intensive management of hypertension and hyperlipidemia, both of which have been shown to increase the risk of diabetic retinopathy in persons with diabetes.
A client presents to the ENT clinic with some vague signs/symptoms. Which complaints would lead the health care provider to suspect the client has otosclerosis? Select all that apply. A. Inability to hear whispering. B. Inability to hear when talking on the telephone. C. When chewing food, sounds are much intensified. D. In a noisy environment has a hard time hearing unless the health care provider speaks directly into the client's ear canal. E. The person's own voice sounds unusually loud.
A, C, E The symptoms of otosclerosis involve an insidious hearing loss. Initially, the affected person is unable to hear a whisper or someone speaking at a distance. In the earliest stages, the person's own voice sounds unusually loud, and the sound of chewing becomes intensified. Because of bone conduction, most of these persons can hear fairly well on the telephone, which provides an amplified signal. Many are able to hear better in a noisy environment. The pressure of otosclerotic bone on inner ear structures or the vestibulocochlear nerve (cranial nerve VIII) may contribute to the development of tinnitus, sensorineural hearing loss, and vertigo.
A client seeks medical care when he wrecks his car because of poor eyesight. At the time of admission, his blood glucose level was 390 mg/dL. The client is diagnosed with diabetes (type 2). The ophthalmologist must perform an urgent intravitreal injection. The nurse explains this to the client by stating the doctor will: A. Just put a couple of drops in each of your eyes B. Put a needle with syringe into your eyeball and inject some medication to decrease active bleeding. C. Remove some of the vitreous from your eye by withdrawing it with a needle/syringe and then strip some of the membranes off your inner eye. D. Use a laser to try to seal off any bleeding vessels in your eyeball.
B People with type 2 diabetes may have retinopathy as a presenting symptom at the time of diagnosis. Intravitreal injections of anti-VEGF agents are also being used to reduce active neovascularization and vitreous hemorrhage. Other treatment strategies for diabetic retinopathy include laser photocoagulation applied directly to leaking microaneurysms and grid photocoagulation with a checkerboard pattern of laser burns applied to diffuse areas of leakage and thickening. Because laser photocoagulation destroys the proliferating vessels and the ischemic retina, it reduces the stimulus for further neovascularization. Vitrectomy may be used for removing vitreous hemorrhage and severing vitreoretinal membranes that develop.
While on a cruise to the Caribbean, a person develops "motion sickness" with associated malaise, and nausea/vomiting. The nurse notes the client's BP is 88/52; pulse is 110; and skin moist with perspiration. The client diagnosis related to the clinical manifestations would most likely be: A. Light-headedness B. Vertigo C. Syncope D. Dizzy
B Vertigo can result from peripheral or central vestibular disorders (proprioception) unrelated to hearing loss. Vertigo is a vestibular disorder in which a unique illusion of motion occurs. Persons with vertigo frequently describe it as a sensation of spinning or tumbling, a "to-and-fro" motion, or falling forward or backward. Light-headedness, faintness, and unsteadiness are different in that the person perceives weakness yet still has a sense of balance. Syncope (loss of consciousness) is not directly associated with the sensation of vertigo. An inability to maintain normal gait may be described as dizziness despite the absence of objective vertigo.
A 60-year-old client's long history of poorly controlled hypertension has culminated in a diagnosis of retinal detachment. What type of retinal detachment is this client most likely to have experienced? A. Rhegmatogenous detachment B. Exudative retinal detachment C. Posterior vitreous detachment D. Traction retinal detachment
B Exudative (or serous) retinal detachment results from the accumulation of serous or hemorrhagic fluid in the subretinal space due to severe hypertension, inflammation, or neoplastic effusions. Rhegmatogenous detachment is a full-thickness break ("rhegma") in the sensory retina, with the passage of liquefied vitreous through the break into the subretinal space. Persons with high grades of myopia or nearsightedness may have abnormalities in the peripheral retina that predispose to sudden detachment. In moderate to severe myopia, the anteroposterior length of the eye is increased, and the retina tends to be thinner and more prone to formation of a hole or tear. As a result, there is greater vitreoretinal traction, and posterior vitreous detachment may occur at a younger age than in persons without myopia. Traction retinal detachment occurs with mechanical forces on the retina, usually mediated by fibrotic tissue, resulting from previous hemorrhage (e.g., from diabetic retinopathy), injury, infection, or inflammation. Intraocular surgery such as cataract extraction may produce traction on the peripheral retina that causes eventual detachment months or even years after surgery.
A female client with rheumatoid arthritis has taken high doses of aspirin for several years to control inflammatory pain. Which of the following statements leads the health care provider to suspect the client has developed ototoxicity? A. "I can't go to the movies anymore. It's so noisy, I miss half the words." B. "I've been getting dizzy and light-headed. I seem to have a constant ringing in my ear." C. "I almost got hit by a garbage truck. I didn't hear its backup beeper." D. "When my grandchildren whisper, I can't hear a word they are saying."
B Ototoxicity results in sensorineural hearing loss. Vestibular symptoms of ototoxicity include light-headedness, giddiness, and dizziness; if toxicity is severe, cochlear symptoms consisting of tinnitus or hearing loss occur. The symptoms of drug-induced hearing loss may be transient, as often is the case with salicylates and diuretics, or they may be permanent. Hearing loss in the elderly is further characterized by reduced hearing sensitivity and speech understanding in noisy environments, slowed central processing of acoustic information, and impaired localization of sound sources. High-frequency warning sounds, such as beepers, turn signals, and escaping steam, are not heard and localized, with potentially dangerous results. Clinical measures for hearing loss such as whispered voice tests and finger friction tests are reportedly imprecise and are not reliable methods for screening.
During accommodation, pupillary dilation partially compensates for the reduced size of the retinal image by: A. Thickening the lens B. Contracting the ciliary muscle C. Increasing light entering the pupil D. Narrowing the palpebral opening
C Accommodation is the process whereby a clear image is maintained as gaze is shifted from far to near objects. During accommodation, pupillary dilation partially compensates for the reduced size of the retinal image by increasing the light entering the pupil. Accommodation requires convergence of the eyes, pupillary constriction, and thickening of the lens through contraction of the ciliary muscle, which is controlled mainly by the parasympathetic fibers of the oculomotor cranial nerve (CN III). A third component of accommodation involves reflex narrowing of the palpebral opening during near vision and widening during far vision.
Which pregnant female is at risk of having an infant born with congenital cataracts? A. A first-time mother over the age of 35 B. A pregnant mother with baby number 2 on the way who tested positive for human papillomavirus (HPV) C. A diabetic mother who regulates her blood glucose levels with insulin D. A mother who is 34 weeks' pregnant diagnosed with preeclampsia
C Acquired congenital and infantile cataracts and other developmental defects of the ocular apparatus depend on the total dose of the agent and the embryonic stage at the time of exposure. During the last trimester of fetal life, genetically or environmentally influenced malformation of the superficial lens fibers can occur. Congenital lens opacities may occur in children of diabetic mothers. Mothers' age, HPV status, or preeclampsia does not place them at risk for giving birth to an infant with cataracts.
A 78-year-old female client has been scheduled for outpatient cataract surgery. While taking a presurgery history, which statement by the client correlates to the surgical procedure? A. "One of my eyes has redness and purulent drainage." B. "I had intense eye pain coupled with photosensitivity." C. "I have blurred vision in both my eyes and my visual is distorted." D. "I feel like I have a buildup of pressure in my eyeball."
C Age-related cataracts, which are the most common type, are characterized by increasingly blurred vision and visual distortion. Symptoms of conjunctivitis include a foreign body sensation, a scratching or burning sensation, itching, and photophobia or light sensitivity. Severe pain suggests corneal rather than conjunctival disease. A discharge, or exudate, may be present. It is usually watery, when the conjunctivitis is caused by allergy, a foreign body, or viral infection, and mucopurulent (mucus mixed with pus) in the presence of bacterial or fungal infection. Trauma that causes abrasions of the cornea can be extremely painful. Glaucoma is a chronic, pressure-induced degenerative neuropathy that produces changes in the optic nerve and visual field loss.
In comparison to children with acute otitis media (AOM), those with otitis media with effusion (OME) have: A. Systemic infection B. Earache and fever C. Excess middle ear fluid D. Sensorineural hearing loss
C Otitis media with effusion (OME) is a condition in which the tympanic membrane is intact and there is an accumulation of fluid in the middle ear without fever or other signs or symptoms of infection. Acute otitis media (AOM) is characterized by otalgia (earache), fever, temporary conductive hearing loss, and excess middle ear fluid in combination with signs and symptoms of an acute or systemic infection.
An elderly woman has been diagnosed with macular degeneration following a visit to an ophthalmologist. Which of the woman's following statements best demonstrates an accurate understanding of her new diagnosis? A."I suppose this goes to show that I should have controlled my blood pressure better." B. "I think this is something that I might have caught from my husband." C."My friend had this problem and a transplant did wonders for her vision." D. "I suppose that this may be one of the things that happen when you get older."
D Although some risk factors have been identified for macular degeneration, most diagnoses are attributed to increased age. The pathogenesis does not involve infection or hypertension, and a corneal transplant is not a recognized treatment modality.
One of the causes of conductive hearing loss is: A. Sudden loud noise B. Ototoxic medication C. Auditory nerve damage D. Excess middle ear fluid
D Conductive hearing loss occurs when auditory stimuli are not adequately transmitted through the auditory canal, tympanic membrane, middle ear, or ossicle chain to the inner ear; it is usually the result of middle ear fluid or infections. Other causes include ear canal cerumen, or foreign bodies, tympanic membrane thickening or damage, or bony structure (ossicles and oval window) damage of the middle ear caused by otosclerosis or Paget disease. Sensorineural deafness occurs when sound waves are conducted to the inner ear but abnormalities of the cochlear apparatus or auditory nerve decrease or distort the transfer of information to the brain. Causes of sensorineural deafness include genetic, infectious, traumatic loud noises, and ototoxic factors.
Diabetic and hypertensive retinopathy are both characterized by the appearance of: A. Macular edema B. Cloudy corneas C. Microinfarctions D. Intraretinal hemorrhages
D Diabetic (background) retinopathy involves thickening of the retinal capillary walls, ruptured capillaries, microaneurysms, intraretinal hemorrhages, cotton-wool exudates, and microinfarcts. Decreased vision in persons with background retinopathy is commonly due to macular edema secondary to leakage of plasma from the small macular blood vessels. Chronic systemic hypertension results in intraretinal arteriole thickening, reduced capillary perfusion pressure, microaneurysms, intraretinal hemorrhages, cotton-wool exudates, and edema. Malignant hypertension causes localized optic disk edema (papilledema) produced by escaped fluid. Cloudy corneas are characteristic of anterior chamber disorders rather than retinopathy.
A client develops fever, headache, and burning/itching in the periorbital area. After a few days, a vesicular rash appears around the eyelid margins. The health care provider will likely prescribe: A. Topical antimicrobial for infection caused by overuse of contact lens B. Oral antibiotics to treat chlamydial infection C. Topical mast cell stabilizer to treat allergies D. Antiviral medication for herpes zoster ophthalmicus
D Herpes zoster ophthalmicus usually presents with malaise, fever, headache, and burning and itching of the periorbital area. These symptoms commonly precede the ocular eruption by a day or two. The rash, which is initially vesicular, becomes pustular and then develops crusts. Treatment includes the use of oral and intravenous antiviral drugs. Initiation of treatment within the first 72 hours after the appearance of the rash reduces the incidence of ocular complications but not the postherpetic neuralgia. Chlamydial conjunctivitis is commonly spread by contact with genital secretions. It is treated with antimicrobial medications. Causes of ulcerative keratitis include infectious agents, exposure to trauma, and use of extended-wear contact lenses. The first manifestations of recurrent herpes keratitis are irritation, photophobia, and tearing. A history of fever blisters or other herpetic infection is often noted. Allergic conjunctivitis encompasses a spectrum of conjunctival conditions usually characterized by itching. Allergic conjunctivitis also has been successfully treated with topical mast cell stabilizers, histamine type 1 (H1) receptor antagonists, and topical nonsteroidal anti-inflammatory drugs.
During a routine 2-month checkup at the pediatric clinic, a mother expresses concern that her son looks "cross-eyed." She asks if she need to put patches over his good eye. Assessment reveals full eye movement, and the child uses each eye independently. The health care provider explains that the best treatment for the infant's eye problem is: A. A prescription for drops to put in the eyes twice/day. B. "Pretend like you are going to poke him in the eye so that he will blink more and tighten up some muscles." C. To buy some prescription eye glasses so that lazy eye will get stronger. D. To prepare for some surgery to correct this problem early on to correct the eye muscle disorder.
D The disorder may be nonaccommodative, accommodative, or a combination of the two. Infantile esotropia is the most common cause of nonaccommodative strabismus. It occurs in the first 6 months of life, with large-angle deviations, in otherwise developmentally and neurologically normal infants. Eye movements are full, and the child often uses each eye independently to alter fixation (cross-fixation). Infantile esotropia is usually treated surgically by weakening the medial rectus muscle on each eye while the infant is under general anesthesia. Recurrences are common with infantile esotropia, and multiple surgeries are often required.
Frustrated by her worsening tinnitus, a 55-year-old female client has sought care. Which of the following teaching points should the clinician provide to the client? A."I know this can be very difficult to live with, but it normally fades over time." B."I will prescribe some medication that will probably help quite well." C. "This might be a sign of a more serious neurologic problem that we will assess for." D. "Initially, there are some changes in your diet that you should implement."
D Tinnitus is not necessarily self-limiting, although it is not normally an indicator of neurologic disease. Pharmacologic treatments are limited, but dietary changes have met with success in many clients. (coffee, salt, saturated fats, sugars, alcohol)
