Chapter 20: Visual and Auditory Systems

While interviewing a patient, the nurse finds that the patient keeps the head skewed while talking. The patient could be experiencing what condition? A. Diplopia B. Color blindness C. Corneal abrasions D. Inflammation of the eyes

A. Diplopia Rationale When a person suffers from diplopia, he keeps his head skewed in an attempt to see a single image. Color blindness is tested by asking the patient to identify specific colors. A patient who has corneal abrasion and inflammation of the eyes will try to keep his eyes closed to avoid light. p. 357

The nurse is performing an assessment of cranial nerve VII. What determination will the nurse make when assessing this nerve? A. If the pupil constricts equally to light B. If there is control of light entering the eye C. If the patient can close and open the eyelid D. If there is bending of light entering into the eye

C. If the patient can close and open the eyelid Rationale Cranial nerve VII is a facial nerve that controls the actions of facial muscles and helps in blinking or in closing and opening of eyelids. Cranial nerve III is the oculomotor nerve that helps in the constriction of the pupils. Light entering the eye is controlled by dilation of the iris, which is associated with the function of the cranial nerve V. The lens present in the eye will help bend the light entering into the eye. p. 352

The nurse is assessing a patient's distance and near visual acuity. What test should the nurse perform? A. Ishihara B. Tonometry C. Snellen chart D. Confrontation visual field

C. Snellen chart Rationale The Snellen eye chart is used to test distance and near visual acuity. Ishihara is a test for color vision. Tonometry tests the intraocular pressure. The confrontation visual field test determines if a patient has a full field of vision without scotomas. p. 356

A patient tells a nurse, "I'm becoming more and more sensitive to loud noises." Which auditory system change does the nurse suspect? A. Brain B. Inner ear C. Middle ear D. External ear

A. Brain Rationale The brain is the main component of the auditory system, filtering unwanted and unnecessary sounds. A patient with increased sensitivity to sound will have changes in the brain. The inner ear is involved in reception of sound, balance, and body orientation. A patient with impaired middle ear function will have conductive loss of hearing. Damage to the external ear will result in collapse of the ear canal and, potentially, hearing loss. p. 363

The nurse is educating a patient with Ménière's disease about care management after discharge. Which statement by the patient indicates effective learning about care management? A. "I should eat a low-sodium diet." B. "I should exercise in the evening." C. "I should choose solid foods over liquids." D. "I should limit alcohol intake to 2 ounces a day."

A. "I should eat a low-sodium diet." Rationale Ménière's disease is a middle ear infection associated with an increase of fluid in the ear. A low-sodium diet reduces the risk of water retention, which lowers the risk of Ménière's disease. Performing exercise in the evening will be tedious for patients with Ménière's disease. The patient will have difficulty with solid foods because chewing may cause ear pain. The patient with Ménière's disease should completely avoid alcohol, which causes dizziness and vertigo. p. 363

The nurse assesses a bulging, red eardrum on otoscopic examination with a middle ear filled with pus and blood. What does the nurse infer from this finding? A. Acute otitis media B. Serous otitis media C. Seborrheic dermatitis D. Eustachian tube blockage

A. Acute otitis media Rationale A bulging red eardrum and middle ear filled with pus and blood indicate that the patient has acute otitis media. Serous otitis media, caused by transudation of blood and serum, manifests as yellow-amber bubbles above the fluid level. Seborrheic dermatitis is marked by scaling or lesions on the skin. Eustachian tube blockage is indicated by retraction of the eardrum and the cone of light is bent. p. 365

A nurse is assessing a patient with hearing loss that gives a history of taking various medications in the past few years. Which drugs taken by the patient may be ototoxic? Select all that apply. A. Aspirin B. Antibiotics C. Domperidone D. Antimalarial drugs E. Nutritional supplements

A. Aspirin B. Antibiotics D. Antimalarial drugs Rationale Many drugs are ototoxic. They can damage the hearing of an individual. They can cause hearing loss, tinnitus, and other problems. These drugs include aspirin, chemotherapy drugs, antibiotics, antimalarial drugs, nonsteroidal antiinflammatory drugs (NSAIDs), and diuretics. Domperidone is an antiemetic drug and is not ototoxic. Similarly, nutritional supplements are food supplements to ensure adequate nutrition. Nutritional supplements are not ototoxic. p. 362

The nurse is assessing a patient hearing by testing bone conduction. Which test will the nurse perform? Select all that apply. A. Rinne test B. Weber test C. Audiometry D. Tympanometry E. Electrocochleography

A. Rinne test B. Weber test Rationale Tuning fork tests such as the Rinne and Weber tests help detect hearing loss by differentiating between conductive and sensorineural loss. Audiometry is used to assess hearing acuity and to determine the degree and type of hearing loss. Tympanometry aids diagnosis of middle ear effusions through the application of positive and negative pressure on the probe placed in the ear. Electrocochleography is used to assess electrical activity in the cochlea and auditory nerve. Test-Taking Tip: Be alert for details about what you are being asked to do. In this question type, you are asked to select all options that apply to a given situation or patient. All options likely relate to the situation, but only some of the options may relate directly to the situation. p. 365

The nurse is performing an otoscopic examination on a patient. When observing the tympanic membrane, what does the nurse anticipate documenting if considered normal? A. Shiny, pearl gray in color and translucent B. Crater appearance with the inner ear visible C. Retracted in the center with a covering of cerumen D. Reddened with part of the malleus visible through the membrane

A. Shiny, pearl gray in color and translucent Rationale Tympanic membrane (ear drum) should appear white, pink, or pearly gray in color, shiny, and translucent. The surface should appear intact and smooth. The tympanic membrane has a crater appearance if a rupture from infection has occurred. The inner ear is not visible with an otoscope. The tympanic membrane appears retracted when otitis media with effusion occurs. Cerumen (ear wax) is produced in the ear canal and should not obstruct viewing the tympanic membrane. A reddened tympanic membrane occurs with otitis media (ear infection). The handle of the malleus is visible through the normally transparent tympanic membrane. p. 364

When examining the patient's ear with an otoscope, there is discharge in the canal and the patient reports pain with the examination. For what should the nurse next assess the patient? A. Swimmer's ear B. Sebaceous cyst C. Metabolic disorder D. Serous otitis media

A. Swimmer's ear Rationale Swimmer's ear, an infection of the external ear, probably is the cause of the discharge and pain. Asking the patient about swimming, ear protection, and exposure to types of water can identify contact with contaminated water. A sebaceous cyst and metabolic disorders would not cause drainage or discomfort in the external ear canal. After clearing the discharge, the tympanic membrane can be assessed for otitis media. p. 365

A patient tells the nurse, "I always need my fan on while I'm sleeping." Which ear abnormality may be indicated? A. Tinnitus B. Exostosis C. Otitis media D. Ménière's disease

A. Tinnitus Rationale Patients with chronic tinnitus often use a fan, radio or television, or some other source of background noise to drown out the tinnitus and help achieve peaceful sleep. Exostosis is a bony growth that causes narrowing of the canal. Otitis media is a chronic ear infection that manifests as fluid in a bulging red or blue eardrum. Ménière's disease is an abnormality of the ear associated with an increase of fluid in the ear. Test-Taking Tip: Avoid taking a wild guess at an answer. However, should you feel insecure about a question, eliminate the alternatives that you believe are definitely incorrect, then reread the information you've been given to make sure that you understand the intent of the question. This approach increases your chances of randomly selecting the correct answer or getting a clearer understanding of what is being asked. p. 363

A patient seeks assistance from the primary health care provider because of episodes of vertigo. Which diagnostic test will determine whether the vertigo is related to a problem of the inner ear? A. Carotid ultrasound B. Caloric stimulus test C. Pure-tone audiometry D. Tympanometry (impedance audiometry)

B. Caloric stimulus test Rationale Vertigo is the sensation that one is whirling in space and often is associated with nausea and vomiting. In the caloric stimulus test, cold or warm water is inserted in the ear canal to stimulate the semicircular canals in the labyrinth of the inner ear. The response to the stimulation causes nystagmus (eye ball jerking movement), nausea and vomiting, and vertigo, and is used to determine disease of the vestibular system. The carotid ultrasound determines the patency of the carotid arteries and adequate circulation to the brain. Audiometry is a screening test for hearing acuity and determines the severity and type of hearing loss. Tympanometry is used to diagnose middle ear effusion (fluid in the middle ear), which causes noncompliance and conductive hearing loss. p. 365

Which abnormality does the nurse suspect if, while performing an otoscopic examination, a nurse has trouble visualizing the tympanum because of the presence of a bony growth? A. Tophi B. Exostosis C. Swelling of pinna D. Impacted cerumen

B. Exostosis Rationale Interference with visualization of the tympanum by a bony growth indicates that the patient has exostosis. The presence of hard nodules in the helix or antihelix indicates tophi. Swelling of the pinna is associated with infection of the glands of skin, which in turn is associated with trauma. A patient with impacted cerumen will have impaired hearing because the wax is not properly excreted from the ear. p. 365

A patient comes to a clinic with hairline fluid level in the tympanum. There are yellowish bubbles above the fluid level. The nurse recognizes that what condition is most likely present? A. Sebaceous cyst B. Serous otitis media C. Impacted cerumen D. Conductive hearing loss

B. Serous otitis media Rationale Serous otitis media is characterized by inflammation of the middle ear and is accompanied by discharge. Inspection of the tympanum reveals presence of fluid, level with the hairline. A sebaceous cyst is seen as a black dot on the skin. Impacted cerumen is accumulated wax in the ear. This accumulation of wax often blocks the canal and makes it difficult to see the tympanum. Conductive hearing loss manifests as an inability to hear and is not associated with symptoms like fluid in the tympanum. p. 365

The nurse is assessing an adult patient's external ear canal and tympanum. How should the nurse proceed? A. Ask the patient to tip his or her head toward the nurse B. Identify a pearl gray tympanic membrane as a sign of infection C. Gently pull the auricle up and backward to straighten the canal D. Identify a normal light reflex by the appearance of irregular edges

C. Gently pull the auricle up and backward to straighten the canal Rationale When assessing an adult, grasp and gently pull the auricle up and backward to straighten the canal. With children under age three, pull the auricle back and down. When examining a patient's external ear canal and tympanum, ask the patient to tilt the head toward the opposite shoulder. A healthy, normal tympanic membrane will appear pearl gray, white, or pink and have a cone-shaped light reflex. p. 364

A patient is diagnosed with a collapsed ear canal. What type of complication does the nurse associate with this diagnosis? A. Calcification of ossicles B. Increased hair growth C. Loss of cartilage elasticity D. Reduced blood supply to the cochlea

C. Loss of cartilage elasticity Rationale Loss of cartilage elasticity results in collapse of the ear canal, which in turn causes the canal to lose the ability to transmit sound waves. Calcification of ossicles results in tinnitus (ringing in the ears) because ossicles transmit sound waves. Increased hair growth results in visible hair in the ear. Reduced blood supply to the cochlea results in impaired speech reception because the cochlea is the center for reception. p. 364

While completing a health history, the nurse learns that a patient has symptoms of tinnitis. Which follow-up question should the nurse ask? A. "Do you wash your hands before touching your face?" B. "Do you use cotton-tipped applicators to clean the ear canal?" C. "Have you been constipated or straining with bowel movements lately?" D. "Do you routinely take aspirin or have you increased your aspirin intake lately?"

D. "Do you routinely take aspirin or have you increased your aspirin intake lately?" Rationale Tinnitis, a sensation of ringing or buzzing in the ears, may result from high aspirin intake. Hand washing prevents infection. Cotton-tipped applicators should not be inserted inside the ear canal because this could impact cerumen or traumatize the ear canal. Straining is not a causative factor of tinnitus. p. 361

A patient is found to have acoustic neuromas. Which diagnostic test will the nurse prepare the patient for to aid in assessment? A. Posturography B. Electrocochleography C. Pure-tone audiometry D. Auditory brainstem response

D. Auditory brainstem response Rationale An acoustic neuroma is a tumor that develops in the nerve of the inner ear. Auditory brainstem response is the diagnostic test used to assess the inner pathway of the ear or detect tumors in the inner ear. Posturography is a balance test, useful in assessing vestibular function. Electrocochlography allows electrical activity in the cochlea to be recorded and analyzed. Pure-tone audiometry is useful in assessing sensorineural hearing loss. p. 365

A patient suspected of having glaucoma reports blurred vision, headache, and pain. For which diagnostic study will the nurse prepare the patient? A. Perimetry B. Keratometry C. Stereoscopic vision D. Ultrasonography B-Scan

A. Perimetry Rationale Perimetry (visual field test) is used to diagnose glaucoma. Keratometry measures corneal curvature. It is an assessment, not a diagnostic tool. Stereoscopic vision allows a patient to see objects in three dimensions. Ultrasonography B-scan is used to diagnose pathologic ocular conditions such as foreign bodies, tumors, and retinal detachments. p. 359

A patient with suspected hearing loss is advised to undergo a pure-tone audiometry. How should the nurse explain the procedure to the patient? Select all that apply. A. This test is carried out in a soundproof room. B. This test helps in diagnosing diseases of the labyrinth. C. The patient will hear varying sounds through earphones. D. Electrodes are placed in the ears and the activity is recorded. E. This test helps in diagnosing conductive and sensorineural hearing loss.

A. This test is carried out in a soundproof room. C. The patient will hear varying sounds through earphones. E. This test helps in diagnosing conductive and sensorineural hearing loss. Rationale Pure-tone audiometry is a test carried out to diagnose conductive and sensorineural hearing loss and to determine the patient's hearing range. The patient is placed in a soundproof room and is made to hear varying sounds through earphones. Whenever the patient hears a sound, the patient needs to give a nonverbal response, which is recorded. This test is not used for diagnosing diseases of the labyrinth. Electrodes are used in electronystagmography, not in this test. p. 365

During an assessment of near visual acuity of a patient, the nurse finds that there is no Jaeger eye chart available. Which is the most appropriate nursing action? A. Skip the test, as it is not important. B. Use Snellen's chart for assessment. C. Ask the patient to come back the next day. D. Use a newspaper or the label on a container.

D. Use a newspaper or the label on a container.

The nurse is educating a patient about the importance of wearing sunglasses when exposed to ultraviolet light. Which abnormality is associated with the chronic exposure of the eye lens to ultraviolet light? A. Cataract B. Presbyopia C. Blepharodermachalasis D. Yellow discoloration of the sclera

A. Cataract Rationale Chronic exposure of the eye lens to ultraviolet light reduces the function of the retina and results in cataract. Presbyopia is the loss of near vision, which may increase with age. Blepharodermachalasis is the presence of excessive skin in the upper lid, which is associated with a prolapse of fat into the eyelid tissue. Yellow discoloration of the sclera is associated with lipid deposition on the sclera. p. 354

A patient comes to the clinic reporting a ringing sensation in the ears. Which questions should a nurse ask to find out more about the patient's problem? Select all that apply. A. "Can you describe the type of ringing?" B. "When do you usually have this sensation?" C. "Have you ever collapsed due to dizziness?" D. "Do you get ear pain if you strain while defecating?" E. "What measures have you taken to resolve this complaint?"

A. "Can you describe the type of ringing?" B. "When do you usually have this sensation?" E. "What measures have you taken to resolve this complaint?" Rationale A ringing sensation in the ears is known as tinnitus. While assessing a patient for tinnitus, the nurse should try to get sufficient information about the complaint. Tinnitus may present as a buzzing, roaring, or ringing noise. Knowing the time or circumstances in which ringing occurs helps to know the cause or any concomitant modality. Asking the patient about the measures that have been taken for the complaints gives an insight to the severity of the problem and knowledge of any medications taken by the patient. Straining to defecate is not related to tinnitus. Dizziness is not seen in tinnitus because tinnitus doesn't affect the brain or blood supply to the brain. p. 362

A nurse is obtaining a health history from a patient with decreased visual acuity. Which question related to sexuality is relevant for this patient? A. "Do you use birth control pills?" B. "Do you have regular periods?" C. "How many children do you have?" D. "Do you and your partner use condoms during intercourse?"

A. "Do you use birth control pills?" Rationale Birth control pills have some side effects. Some pills may cause blurred vision, double vision, or floaters in the visual field. Such cases should be immediately reported to the health care practitioner. Eye complaints are not dependent on the number of children or the menstrual period. Similarly, condom use does not affect vision. p. 354

To determine if a patient has ocular problems, what questions should the nurse ask during the patient assessment? Select all that apply. A. "Does your eye problem hamper your daily activities?" B. "How much do you appreciate the fact that you can see?" C. "Do you wear contact lenses? How do you care for them?" D. "How do your eye problems make you feel about yourself?" E. "Have you participated in any activity that may be harmful to your eyes?"

A. "Does your eye problem hamper your daily activities?" E. "Have you participated in any activity that may be harmful to your eyes?" Rationale The nurse has to assess the patient's activity in order to assess the severity of the disorder. Assessing occupational hazards may help to understand the possible cause of the eye disorder. Asking the patient if daily activities are disturbed due to eye issues helps in assessing severity. The nurse should ask if the patient has participated in any harmful activity that may have caused eye damage. Asking how the patient cares for contact lenses helps in understanding how the patient cares for the eyes. Asking how the eye problem makes the patient feel about self helps to explore the patient's psychologic sphere. Asking how much the patient appreciates being able to see only reveals the patient's attitude. p. 354

An older adult patient reports hearing loss. During the assessment, a student nurse is teaching the patient about normal changes of aging of the auditory system. Which statement requires correction from the nursing instructor? A. "There is a reduced production of cerumen." B. "There is a decreased ability to filter sound to hear." C. "The tympanic membranes atrophy, or reduce in size." D. "There is an increased growth of hair in the auditory canal."

A. "There is a reduced production of cerumen." Rationale The production of cerumen increases, not decreases, with age and dries out, which causes difficulty hearing. A patient's ability to filter sound is reduced as he or she ages. In addition, the tympanic membrane atrophies with aging, and there is an increase in hair growth in the auditory canal when a patient ages. p. 361

A nurse assessing vestibular function places electrodes near the patient's eye to record specific eye movement. What does the nurse instruct the patient to do before performing the test? A. "You should eat a light meal." B. "You should consume ice cream." C. "You should gargle for 15 minutes." D. "You should drink eight glasses of water."

A. "You should eat a light meal." Rationale By recording eye movement through electrodes, electronystagmography aids diagnosis of diseases of the vestibular system. The nurse instructs the patient to eat a light meal before the test to reduce the risk of nausea caused by electrode movement near the eye. The nurse will not instruct the patient to consume ice cream, because electronystagmography will not cause inflammation or irritation of the trachea. Gargling helps clear the throat and mouth but does not affect the eyes. Electronystagmography does not require excess hydration. Test-Taking Tip: Identify which diagnostic examination of the ear involves the use of electrodes to record eye movements and the side effects associated with that test. This will help you find the instruction that the nurse would give to reduce the likelihood of side effects. p. 365

The nurse is preparing a patient for ultrasonography of the eye. What should the nurse inform the patient while explaining the test procedure? A. "You will not experience pain during the test." B. "You may have nausea and yellow-orange urine after the test." C. "You may have difficulty focusing on near objects for three to four hours after the test." D. "You should fixate on the center dot and record abnormalities of the grid lines during the test."

A. "You will not experience pain during the test." Rationale Ultrasonography involves corneal anesthetization and is not painful. During refractometry, the patient's eyes are dilated to visualize the retina and optic nerve. Therefore the patient may have difficulty focusing on near objects for three to four hours after refractometry. Fluorescein angiography involves administering a dye into the patient's body via the intravenous route. Therefore the patient may have nausea and yellow-orange discoloration of the urine after fluorescein angiography. The Amsler grid test assesses the patient's vision by asking the patient to report the abnormalities he or she finds in the grids. During the Amsler grid test, the patient should fixate on the center dot and record the abnormalities of the grid lines. Test-Taking Tip: Identify option components as correct or incorrect. This may help you identify a wrong answer. p. 359

The patient has described a loss of central vision. What test should the nurse teach the patient about to identify changes in macular function? A. Amsler grid test B. B-scan ultrasonography C. Fluorescein angiography D. Intraocular pressure testing with Tono-pen

A. Amsler grid test Rationale The Amsler grid test is self-administered and regular testing is necessary to identify any changes in macular function. B-scan ultrasonography is used to diagnose ocular pathologic conditions (e.g., intraocular foreign bodies or tumors, vitreous opacities, retinal detachments). Fluorescein angiography is used to diagnose problems related to the flow of blood through pigment epithelial and retinal vessels. Intraocular pressure testing with a Tono-pen is done to test for glaucoma. p. 359

A nurse is assessing the pupillary function of a patient. Which steps should be performed when assessing accommodation? Select all that apply. A. Ask the patient to look at the nurse's finger. B. Ask the patient to focus on a distant object. C. The nurse places a finger at a distance of 20 feet from the patient's nose. D. The nurse places a finger at a distance of 3 inches from the patient's nose. E. The nurse places a finger at a distance of 6 meters from the patient's nose.

A. Ask the patient to look at the nurse's finger. B. Ask the patient to focus on a distant object. D. The nurse places a finger at a distance of 3 inches from the patient's nose. Rationale In order to check the accommodation capacity of the patient's eyes, the nurse has to first ask the patient to focus on a distant object. The patient is then instructed to focus on the nurse's finger, which is placed 3 inches from the patient's nose. The normal response is convergence and constriction of the eyes. A Snellen chart is used for testing visual acuity. The distance of 20 feet, or 6 meters, is maintained while reading a Snellen chart. p. 358

During visual examination of a patient, the nurse notices that the patient has a red, watery eye and inflammation of the conjunctiva. What does the nurse anticipate the cause to be? A. Bacterial or viral infection B. Increased intraocular pressure C. Intraocular or periorbital tumors D. Inflammation of the anterior uvula tract

A. Bacterial or viral infection Rationale A red, watery eye and inflammation of the conjunctiva are the manifestations of conjunctivitis. It is caused by a bacterial or viral infection. Glaucoma is associated with increased ocular pressure. An increase in intraocular pressure does not cause the eye to become red and watery; rather, it begins with peripheral loss of vision and later results in complete blindness. Intraocular or periorbital tumors cause protrusion of the globe of the eye, called exophthalmos. Inflammation of the anterior uvula tract causes photophobia, or intolerance to light. Test-Taking Tip: Be alert for details. Details provided in the stem of the item, such as behavioral changes or clinical changes (or both) within a certain time period, can provide a clue to the most appropriate response or, in some cases, responses. p. 357

A patient expresses concern about the effect of vision loss on reading. This is an example of which component of a visual health history? A. Cognitive-perceptual B. Coping-stress tolerance C. Self-perception-self-concept D. Health perception-health management

A. Cognitive-perceptual Rationale A visual deficit that affects a patient's ability to read is an example of a cognitive-perceptual problem. The coping-stress tolerance component explores how a patient is tolerating and coping with changes in vision. A self-perception-self-concept response is related to how a patient feels about himself or herself. Health perception-health management allows the healthcare professional to assess the patient's awareness of his or her visual health and self-care. p. 354

A patient is diagnosed with sensorineural hearing loss. What potential causes of this disorder should the nurse discuss with the patient? Select all that apply. A. Damage to the inner ear B. An increase in cerumen output C. Damage to the tympanic membrane D. Impairment of the auditory pathway E. Damage to the vestibulocochlear nerve

A. Damage to the inner ear E. Damage to the vestibulocochlear nerve Rationale Damage to the inner ear or damage to the vestibulocochlear nerve that lines the inner ear results in sensorineural hearing loss. An increase in cerumen will result in central loss of hearing because the auditory canal is blocked. The tympanic membrane is found in the external ear; impairment of the tympanic membrane is associated with impaired transmission of sound waves. Impairment of the auditory pathway will result in central loss of hearing. p. 360

A college student has gone to the nurse reporting eye pain after studying for finals. What assessment should the nurse make first in determining the possible cause of this eye pain? A. Do you wear contacts? B. Do you have any allergies? C. Do you have double vision? D. Describe the change in your vision.

A. Do you wear contacts? Rationale College students frequently wear contact lenses and will be up late or all night studying for finals. If the student wears contacts, the wearing of them while studying, care of them, and length of wear time should be assessed before looking for a corneal abrasion from extended wear with fluorescein dye. There are no manifestations of allergies, diplopia, or visual changes mentioned. p. 355

While assessing the vision of a patient, a nurse asks the patient to cover one eye and count the number of fingers that the nurse brings into the patient's field of vision. What is the nurse assessing? A. Full field of vision B. Pupillary response C. Intraocular pressure D. Distance and near visual acuity

A. Full field of vision Rationale A nurse is performing a confrontation visual field test when the nurse asks the patient to cover one eye and count the number of fingers present in the patient's field of vision. This test helps determine the patient's full field of vision. The nurse performs a pupil function test by shining light into the patient's pupil and examining the pupillary response. Intraocular pressure testing with a Tono-pen will help measure intraocular pressure. The nurse performs a visual acuity test using a Snellen chart to determine distance and near visual acuity. p. 355

An older adult patient reports not being able to hear very well. What should the nurse do first to determine the cause of the hearing loss? A. Look for cerumen in the ear. B. Assess for increased hair growth in the ear. C. Tell the patient it is probably related to aging. D. Ask the patient if he has fallen because of dizziness.

A. Look for cerumen in the ear. Rationale Gerontologic differences in the assessment of the auditory system include increased production of drier cerumen, which can become impacted in the ear canal and contribute to hearing loss. Conductive hearing loss with impacted cerumen may lead to speaking softly because the patient's voice conducted through bone seems loud to the patient. Although increased hair growth occurs, it will not impact the hearing. Presbycusis may be occurring, but it should not be assumed. There is no reason to ask the patient if he has fallen because of dizziness; vertigo is not a normal change of aging of the ear. p. 361

The nurse is caring for an older adult patient. Which gerontologic findings of the visual system does the nurse anticipate may be present? Select all that apply. A. Loss of hair pigment B. Darkened iris pigment C. Increased tear secretion D. Increased rigidity of the lens E. Atrophy of the corneal nerves F. Increased orbital fat and muscle tone

A. Loss of hair pigment D. Increased rigidity of the lens E. Atrophy of the corneal nerves Rationale There is increased lens rigidity, resulting in presbyopia and loss of hair pigment. This loss is responsible for the graying of the eyebrows and eyelashes. Atrophy of the corneal nerves results in a decrease in the corneal sensitivity and reflex. The change in iris color that occurs in an aging patient is due to loss of pigment, which appears as a lightening of the iris. The older adult also experiences decreased secretion of tears, resulting in dryness of the eyes. Decreases in orbital fat and muscle tone result in entropion, ectropion, and mild ptosis. p. 353

A patient reports pain in the left eye, and the healthcare provider is using a fluorescein stain to assess the eye. What is a priority for the nurse in the care of this patient? A. Monitor for extravasation B. Monitor for retinal detachment C. Monitor the patient for nausea and vomiting D. Report yellow-orange discoloration of the urine

A. Monitor for extravasation Rationale Fluorescein is toxic to tissue, so it is important to monitor the patient for extravasation at the intravenous site. Retinal detachment is not a complication of fluorescein. Transient nausea and vomiting may occur, and the patient may experience urine discoloration. However, these are not as high-priority concerns as avoiding contact between the fluorescein and surrounding tissue. p. 359

Which refractive error describes the vision of a patient for whom nearby objects are clear but objects at a distance are blurred? A. Myopia B. Hyperopia C. Presbyopia D. Astigmatism

A. Myopia Rationale The individual with myopia (nearsightedness) can see nearby objects clearly, but objects at a distance appear blurred. The individual with hyperopia (farsightedness) can see distant objects clearly, but close objects appear blurred. Presbyopia is a loss of accommodation, causing an inability to focus on near objects. Astigmatism is an uneven curvature of the cornea, which results in visual distortion. p. 351

A patient is due for rotary chair testing to assess vestibular function. What action by the nurse is most appropriate? A. Observe the patient for vomiting. B. Instruct the patient to fast before the test. C. Explain to the patient that the test is time consuming. D. Keep the patient alone in the room to avoid distraction.

A. Observe the patient for vomiting. Rationale Rotary chair testing is done to evaluate the peripheral vestibular system. Testing is usually done in the dark; therefore, in order to ensure safety, the nurse should not leave the patient alone. The patient should be advised to eat a light meal before the test to avoid nausea. The nurse should monitor the patient for vomiting. The length of the test is not relevant. Test-Taking Tip: Pace yourself when taking practice quizzes. Because most nursing exams have specified time limits, you should pace yourself during the practice testing period accordingly. It is helpful to estimate the time that can be spent on each item and still complete the examination in the allotted time. You can obtain this figure by dividing the testing time by the number of items on the test. For example, a 1-hour (60-minute) testing period with 50 items averages 1.2 minutes per question. The NCLEX exam is not a timed test. Both the number of questions and the time to complete the test varies according to each candidate's performance. However, if the test taker uses the maximum of 5 hours to answer the maximum of 265 questions, each question equals 1.3 minutes. p. 365

The nurse completing a focused visual exam includes which assessments? Select all that apply. A. PERRLA ( pupils equal, round, reactive to light and accommodation) B. Keratometry C. Peripheral vision D. Extraocular movement E. Distance and near visual acuity

A. PERRLA ( pupils equal, round, reactive to light and accommodation) C. Peripheral vision D. Extraocular movement E. Distance and near visual acuity Rationale The nurse completing a focused visual assessment includes examination using PERRLA, which focuses on whether the pupils are equal, round, reactive to light, and able to focus on objects that are close up and far away (accommodation). The nurse will also perform assessments of peripheral vision, extraocular movement, and distance and near visual acuity. Keratometry measures corneal curvature and is not part of a focused visual assessment. p. 356

The nurse is assisting with determination of the functioning of the vestibular system. What tests will the nurse prepare the patient for to test this function? Select all that apply. A. Posturography B. Caloric test stimulus C. Electrocochleography D. Electronystagmography E. Auditory evoked potential

A. Posturography B. Caloric test stimulus D. Electronystagmography Rationale Posturography is a balance test that can isolate one vestibular system from another. The caloric test stimulus helps identify vestibular diseases by stimulating the endolymph of the semicircular canals. Electronystagmography is used to diagnose diseases of the vestibular system by recording specific movement of eyes when the ear is irrigated. In electrocochleography, electrical activity in the cochlea and auditory nerves is recorded. Auditory evoked potential is used to isolate auditory activity from the activity of the brain and is not associated with vestibular function. p. 365

The nurse reviews a patient's health assessment and notes the abbreviation: PERRLA under vision. Which assessment finding is included in this abbreviation? Select all that apply. A. Pupils are round B. Retina responds to light C. Lacrimal apparatus is functioning D. Intraocular pressure is even and within normal E. Pupils constrict when the patient focuses on a nearer object

A. Pupils are round E. Pupils constrict when the patient focuses on a nearer object Rationale The abbreviation for a normal pupillary response is PERRLA (pupils are equal [in size], round, react to light, and accommodation). Accommodation occurs when the pupil constricts when focusing on a nearer object. The retina is examined with use of an ophthalmoscope. The lacrimal apparatus contains the structures involved with tear formation and distribution to maintain eye moisture. Intraocular (within the eye) pressure is measured with various instruments and normally is 10 to 21 mm Hg. Test-Taking Tip: Be alert for details about what you are being asked to do. In this auestion type, you are asked to select all options that apply to a given situation or client. All options likely relate to the situation, but only some of the options may relate directly to the situation. p. 358

When interviewing a patient with hearing loss about past and present medications, which medications should the nurse ask the patient about directly? Select all that apply. A. Salicylates B. Herbal drugs C. Aminoglycosides D. Antimalarial agents E. Vitamin supplements

A. Salicylates C. Aminoglycosides D. Antimalarial agents Rationale The nurse should ask the patient specifically about salicylates, aminoglycosides, and antimalarial agents, because they may cause ototoxicity and lead to hearing loss. With some medications, the hearing loss may be reversible when treatment is stopped. Herbal drugs and vitamin supplements are not associated with hearing loss. p. 362

A patient reports seeing "spider web- like" formations in the visual field during the past few days. The nurse recognizes that which conditions might lead to these formations? Select all that apply. A. Tears in the retina B. Vitreous liquefaction C. Shortening of the ciliary muscles D. Hemorrhage in the vitreous humor E. Overaction of the extraocular muscle

A. Tears in the retina B. Vitreous liquefaction D. Hemorrhage in the vitreous humor Rationale Vitreous liquefaction is the most common cause of floaters and "spider web-like" images in the visual field. This can also be caused by trauma to the eye. Tears or holes in the retina and hemorrhage in the vitreous humor can also cause "spider web-like formations" in the visual field. Shortening of ciliary muscles affects the near vision of the person. Overaction of the extraocular muscle causes abnormal movement of the eyes. This is known as strabismus. p. 358

The nurse assesses the eyes of an older adult African American patient and observes the sclera in each eye has a slight yellowish cast with small blood vessels visible along the edges in the conjunctiva. What does the nurse conclude from these assessment findings? A. The assessment findings are within the normal range. B. The patient should have serum coagulation tests done. C. The patient likely has a history of uncontrolled hypertension. D. The patient needs serum liver function tests to determine hepatic function.

A. The assessment findings are within the normal range. Rationale A slight yellowish cast of the sclerae, a normal assessment finding, is caused by lipid deposits that occur with aging. A yellowish cast is normal in patients with dark skin. Small blood vessels are often visible in the conjunctiva near the periphery. Impaired coagulation or bleeding from trauma in the eye is visible as areas of dark red in the sclera. Effects of hypertension may be visible when observing blood vessels in the retina with an ophthalmoscope. A patient with jaundice displays yellowing of the entire scleral area, indicating the need for liver function tests. p. 351

A patient reports difficulty swallowing and chewing, and the nurse finds purulent drainage from the ear. How does the nurse interpret these findings? A. The patient has otalgia. B. The patient has tinnitus. C. The patient has presbycusis. D. The patient has impaired speech reception.

A. The patient has otalgia. Rationale The patient with otalgia will have difficulty swallowing and chewing and purulent drainage from the ear. Tinnitus is ringing of the ears that worsens with age because of the calcification of ossicles and may result in loss of hearing. Presbycusis is hearing loss associated with cumulative exposure to noise with increasing age. The patient with reduced blood supply to the cochlea will have impaired speech reception. Test-Taking Tip: Give attention to key words in the question stem. The patient has reduced nutrition because of the difficulty in chewing. Focus on what may cause this difficulty. p. 363

A nurse is assessing a patient's hearing ability. Which findings would indicate compromised hearing? Select all that apply. A. The patient is lip reading. B. The patient speaks very loudly. C. The patient feels dizzy when standing up. D. The patient asks to have certain words repeated. E. The patient fails to respond to questions when not looking directly at the nurse.

A. The patient is lip reading. D. The patient asks to have certain words repeated. E. The patient fails to respond to questions when not looking directly at the nurse. Rationale If the patient is lip reading or asks to have certain words repeated, the patient may have hearing loss. A patient with compromised hearing may look at the examiner intently but may miss a comment when not looking directly at the examiner. If the patient feels dizzy on standing up, it may indicate impaired equilibrium. While some people with hearing loss may speak loudly, this alone is not an indication of hearing loss. pp. 363

A nurse is obtaining a health history from a patient. The nurse suspects that the patient could have hearing loss. What findings may have led the nurse to this suspicion? Select all that apply. A. The patient tries to lip read the nurse's words. B. The patient blinks often and answers questions rapidly. C. The patient requests that questions be repeated frequently. D. The patient misses out on words when not looking at the nurse. E. The patient doesn't look at the nurse and answers questions while looking down.

A. The patient tries to lip read the nurse's words. C. The patient requests that questions be repeated frequently. D. The patient misses out on words when not looking at the nurse. Rationale The patient's body language and actions often provide signs of underlying hearing trouble. The patient tries to lip read the nurse's words in order to guess the question. The patient is often unable to hear the question and asks the nurse to repeat it. The patient looks intently at the nurse when trying to lip read. The patient tends to miss out on words when not looking at the nurse. These are some signs which suggest hearing loss. Blinking too often is not a sign of hearing loss. Similarly, if the patient avoids eye contact with the nurse, it is not suggestive of hearing loss. It may suggest that the patient has low confidence or interest or is disoriented. p. 361

The nurse is assessing the auditory system of a newly admitted older adult patient. Which of these are age-related changes may be anticipated in the auditory system? Select all that apply. A. Tinnitus B. Collapsed ear canal C. Increase in cerumen moisture D. Increased sensitivity to loud sounds E. Diminished sensitivity to low-pitched sounds

A. Tinnitus B. Collapsed ear canal D. Increased sensitivity to loud sounds Rationale Age-related changes in the auditory system include tinnitus, collapsed ear canal, increased sensitivity to loud sounds, diminished sensitivity to high-pitched sounds, and drier cerumen. Test-Taking Tip: Stay away from other nervous students before the test. Stop reviewing at least 30 minutes before the test. Take a walk, go to the library and read a magazine, listen to music, or do something else that is relaxing. Go to the test room a few minutes before class time so that you are not rushed in settling down in your seat. Tune out what others are saying. Crowd tension is contagious, so stay away from it. p. 361

The nurse observes a patient ambulating with a stumbling gait. What conditions should the nurse be aware may cause this patient's condition? A. Vertigo B. Tinnitus C. Nystagmus D. Presbycusis

A. Vertigo Rationale Vertigo is stimulated by movement; this condition can cause an unsteady gait. Presbycusis is hearing loss due to aging. Nystagmus is an abnormal eye movement or twitching of the eye. Tinnitus is ringing in the ears. pp. 361, 363

A patient is diagnosed with astigmatism and asks what this will mean for their vision. What is the best response by the nurse? A. "Astigmatism is a clouding of the lens causing problems with glare." B. "Astigmatism causes distorted vision because of corneal unevenness." C. "Astigmatism limits visual acuity because of damage to the optic nerve." D. "Astigmatism is elevated pressure within the eye caused by excess fluid."

B. "Astigmatism causes distorted vision because of corneal unevenness." Rationale Astigmatism, a refractive error causing distorted vision, occurs when the surface of the cornea is not smooth. Damage to the optic nerve results in loss of part or all of the visual field. Cataracts, the clouding of the lens, often occur with age and leads to problems seeing, including glare. Glaucoma is a disease causing damage to the optic nerve from elevated intraoptic pressure. p. 358

The nurse has a suspicion that a patient is experiencing nystagmus. Which statement made by a patient supports the nurse's suspicion? A. "I suddenly got dizzy and fell down." B. "My vision blurs when I move my head." C. "I need white noise to get a good night's sleep." D. "I need assistance to bend down or to lift things."

B. "My vision blurs when I move my head." Rationale Abnormal eye movement indicates nystagmus. Blurring of vision with eye or head movement also indicates nystagmus. The patient with vertigo will have balance problems, which may result in dizziness and falls. Patients with tinnitus and ringing ears require white noise for distraction and peaceful sleep. Patients with Ménière's disease need assistance with activities such as bending and lifting objects. Test-Taking Tip: Multiple-choice questions can be challenging because students think that they will recognize the right answer when they see it or that the right answer will somehow stand out from the other choices. This is a dangerous misconception. The more carefully the question is constructed, the more each of the choices will seem like the correct response. p. 361

A patient is advised to undergo a caloric test stimulus. How should a nurse explain the test to the patient? Select all that apply. A. "You will be in a standing position for the test." B. "You will be sitting or lying down for the test." C. "The test involves pouring cold or warm solution into your ears." D. "The test is performed to determine conductive or sensorineural hearing loss." E. "The test may result in nausea and vertigo after stimulation of semicircular canals."

B. "You will be sitting or lying down for the test." C. "The test involves pouring cold or warm solution into your ears." E. "The test may result in nausea and vertigo after stimulation of semicircular canals." Rationale This test is carried out to diagnose diseases of the labyrinth and vestibular systems. The patient is positioned in a sitting or supine position. In the process, a warm or cold solution is poured in the ear of the patient to stimulate the semicircular canals. If there is abnormality of the labyrinth, it may be manifested as nystagmus or nausea. Any abnormal response by the patient is recorded. This test is not performed with the patient standing. A tuning fork test is done to differentiate between conductive and sensorineural loss. p. 365

A patient comes to the clinic for an ophthalmic checkup. A nurse performs an assessment of visual acuity using a Snellen chart. The patient should be positioned how many feet away from the Snellen chart? A. 6 feet away B. 20 feet away C. 24 feet away D. 30 feet away

B. 20 feet away Rationale The distance to be maintained between the patient and the Snellen chart is 20 feet, or 6 meters. This chart is used to check the visual acuity of an individual. Any distance closer or further than this will not provide an accurate assessment of visual acuity. p. 356

A patient reports to the nurse that there is a sandy, gritty sensation in the eye along with irritation and discomfort. What medication should the nurse determine might be causing these symptoms? A. Corticosteroids B. Antihistamines C. Aminoglycosides D. β-adrenergic blockers

B. Antihistamines Rationale A sandy, gritty sensation in the eye that is accompanied by irritation and discomfort indicates corneal dryness. Decongestants and antihistamines cause ocular dryness. Long-term use of corticosteroids may result in glaucoma or cataracts. Medications that are used over-the-counter usually have ocular effects. Aminoglycosides are ototoxic and, therefore, can cause hearing loss, tinnitus, or vertigo. β-adrenergic blockers are used for treating glaucoma. p. 354

The nurse is assessing a patient's hearing problems. What actions should the nurse take in order to perform the assessment? Select all that apply. A. Ask if the patient wears earrings. B. Ask if the patient is feeling any ear pain. C. Assess if the patient can hear a clock ticking. D. Determine if the patient can hear loud noises. E. Check the external auditory meatus for any discharge.

B. Ask if the patient is feeling any ear pain. C. Assess if the patient can hear a clock ticking. E. Check the external auditory meatus for any discharge. Rationale While assessing any patient with hearing problems, it is important to collect subjective data as well as objective data. Subjective data are what the patient says regarding complaints. These consist of modalities of pain or discharge. Objective information is the information that the nurse can see or perceive. The nurse can assess the patient's ability to hear by testing for the ability to hear a clock ticking in the room. Checking the external auditory meatus helps the nurse observe if any discharge is present. The patient's auditory ability is assessed based on the ability to hear low sounds. There is no test for checking hearing ability based on loud noises. Wearing ear jewelry may cause inflammation but does not affect hearing capacity. p. 362

The nurse is performing an assessment of the auditory system for a patient diagnosed with sensorineural hearing loss. Which findings should the nurse expect to assess? Select all that apply. A. Ringing in the ears B. Complete hearing loss C. Inability to understand speech D. Distortion or faintness of sound E. Difficulty in understanding meaning of words being heard.

B. Complete hearing loss C. Inability to understand speech D. Distortion or faintness of sound Rationale Sensorineural hearing loss is caused by damage to or an abnormality of the inner ear or the nerve pathways. This condition is characterized by distortion or faintness of sound or inability to understand speech, and it can cause complete hearing loss. Patients with central hearing loss experience difficulty in understanding the meaning of spoken speech. Patients with tinnitus hear a ringing in the ears. p. 360

Which assessment finding supports the nurse's conclusion that a patient has altered function of the external ear? A. Damage to the cochlea B. Damage to the auditory canal C. Damage to the eustachian tube D. Damage to the auditory ossicles

B. Damage to the auditory canal Rationale The auditory canal is located in the external ear, so damage to the auditory canal results in altered function of the external ear. The cochlea and eustachian tube are located in the middle ear. Damage to the cochlea will result in altered function of the middle ear, not the external ear. The auditory ossicles are the bones in the middle ear; damage to the auditory ossicles results in altered function of the middle ear, not the external ear. p. 364

After an ophthalmic examination, a primary health care provider finds that the ciliary muscles of a patient have become smaller and stiffer than normal muscles. The nurse recalls that the patient will experience what change as a result of this condition? A. Clouding in the lens B. Decrease in near vision C. Decreased diameter of pupils D. Difficulty in perception of colors

B. Decrease in near vision Rationale Ciliary muscles are the muscles responsible for near vision. If these muscles become smaller or stiffer, the person has difficulty in adjusting near vision. A cataract is a very common age-related disorder. This is formed due to biochemical changes in the lens proteins, which results in clouding of the lens. Changes in perception of colors are not related to the dilator muscle. The diameter of the pupil is regulated by the muscle called the iris. Stiffening or rigidity of the iris causes decreased diameter of pupils. Color perception is carried by cones in the retina. A decrease in the number of cones causes difficulty in perception of colors. p. 351

A patient has ptosis resulting from myasthenia gravis. Which assessment finding would the nurse expect to see in this patient? A. Redness and swelling of the conjunctiva B. Drooping of the upper lid margin in one or both eyes C. Redness, swelling, and crusting along the lid margin D. Small, superficial white nodules along the lid margin

B. Drooping of the upper lid margin in one or both eyes Rationale Ptosis is the term used to describe drooping of the upper lid margin, which may be either unilateral or bilateral. Ptosis can be a result of mechanical causes, such as an eyelid tumor or excess skin, or from myogenic causes, such as myasthenia gravis. Ptosis is not related to redness and swelling of the conjunctiva or lid margin or small, superficial white nodules along the lid margin. p. 357

The nurse is assessing a patient with a middle ear infection. Which structure located in the middle ear may cause a middle ear infection when it is blocked? A. Auricle or pinna B. Eustachian tubes C. Sebaceous glands D. Tympanic membrane

B. Eustachian tubes Rationale Blockage of the Eustachian tubes can occur with a middle ear infection. The tympanic membrane (ear drum), the auricle (pinna), and the sebaceous glands are all located in the external ear. These structures will not cause a middle ear infection. p. 360

A patient is to undergo an Amsler Grid test. What instructions about the test should the nurse provide to the patient? Select all that apply. A. Keep the test card at a distance of 10 feet. B. Hold the test card at a comfortable distance. C. Report any abnormality like lines appearing wavy. D. Focus on the center dot that is present on the card. E. Focus on all four corners of the card in a clockwise pattern.

B. Hold the test card at a comfortable distance. C. Report any abnormality like lines appearing wavy. D. Focus on the center dot that is present on the card. Rationale An Amsler Grid test can be carried out by the patient. This test is done to identify any changes in macular function. The correct procedure for an Amsler Grid test is as follows: The patient holds the card at a comfortable reading distance, and focuses on a dot present in the center of the chart. The test card is held at the same distance a person holds a book for reading. The person has to focus on the center dot and not on the corners. If there is pathology involved, the patient may feel that the lines around the dot are wavy, distorted, or even missing. If the patient finds any abnormality in the surrounding line, he should make a note of it and take advice from a primary health care practitioner. The distance of 10 feet is not required for this test. The patient does not focus on the four corners of the card. p. 359

A patient has a hemorrhage in the fundus area of the eye. Where does the nurse determine that blood is accumulating? A. In the aqueous humor B. In the retinal background C. Between the cornea and the lens D. In the space between the iris and the lens

B. In the retinal background Rationale The fundus is the retinal background. Normally, no hemorrhages or exudates are present in the fundus. The fundus area is not the aqueous humor, between the cornea and the lens, or between the iris and the lens. STUDY TIP: A helpful method for decreasing test stress is to practice self-affirmation. After you have adequately studied and really know the material, start looking in the mirror each time you pass one and say to yourself—preferably out loud—"I know this material, and I will do well on the test." After several times of watching and hearing yourself reaffirm your knowledge, you will gain inner confidence and be able to perform much better during the test period. This technique really works for students who are adventurous enough to use it. It may feel silly at first, but if it works, who cares? It will work for performing skills in clinical as well, as long as you have practiced the skill sufficiently. p. 358

A patient has diplopia and is prescribed with alternating patching of one eye at a time. The nurse should include teaching about what concern for this patient? A. Conjuctivitis B. Increased risk for falls C. Dryness in the patched eye D. Increased risk for cataract formation

B. Increased risk for falls Rationale The patient with diplopia (double vision) alternately patches the eye to allow normal vision. The patient will be at increased risk for falls because patching causes impaired stereoscopic (three-dimensional) vision. The patient could fall because of impaired ability to judge distance. Conjunctivitis is redness from infection or inflammation of the conjunctiva, the mucous membrane that covers eyelids and forms a pocket under each eyelid. Dryness is not a usual problem with a patched eye because patching limits exposure to air and the environment. Cataracts occur with the aging process. Test-Taking Tip: Never leave a question unanswered. Even if answering is no more than an educated guess on your part, go ahead and mark an answer. You might be right, but if you leave it blank, you will certainly be wrong and lose precious points. p. 355

Which auditory system change does the nurse suspect in a patient who has alterations in balance and body orientation? A. Brain B. Inner ear C. Middle ear D. External ear

B. Inner ear Rationale The vestibular balance system is located in the inner ear. Therefore changes in the inner ear will result in alterations in balance and body orientation. Changes in the brain will increase the difficulty of hearing in a noisy environment and heighten sensitivity to sound. A patient with changes in the middle ear will have conductive hearing loss. A patient with changes in the external ear may have impacted cerumen or a collapsed ear canal. p. 364

The nurse is performing an assessment of the patient's ear and places a probe in the external ear canal, applying positive and negative pressure. What does the nurse determine this will infer? A. Range of hearing B. Middle ear effusion C. Disease of vestibular system D. Etiology of peripheral vestibular system

B. Middle ear effusion Rationale Placing a probe in the external ear canal and applying both positive and negative pressure is the procedure for tympanometry. This test is used to assess compliance of the middle ear and is useful in diagnosis of middle ear effusions. The caloric test stimulus is used to assess range of hearing. Electronystagmography, involving the recording of specific eye movements, aids identification of diseases of the vestibular system. Rotary chair testing, performed with the use of a motor-controlled chair, aids evaluation of the peripheral vestibular system. Test-Taking Tip: Be aware that information from previously asked questions may help you respond to other examination questions. p. 365

The nurse performs an otoscopic examination of the patient's left ear, which indicates the presence of an exostosis. What does the nurse anticipate will occur after this finding? A. Surgery B. No intervention C. Electrocochleography D. Irrigation of the ear canal

B. No intervention Rationale An exostosis is a bony growth into the ear canal that normally does not require intervention or correction. Therefore, surgery, electrocochleography, or irrigation of the ear canal are unnecessary. p. 365

A nurse is observing different behaviors in patients who are scheduled for an ophthalmic examination. Which patient should the nurse expect to have double vision? A. Patient A: The patient is dressed in an unusual color combination. B. Patient B: The patient is holding his or her head in a skewed position. C. Patient C: The patient covers his or her eyes with the hand to block the light in the room D. Patient D: The patient is making eye contact with the nurse while speaking.

B. Patient B: The patient is holding his or her head in a skewed position. Rationale Patient B is holding his or her head in skewed or oblique position, which is indicative of the patient having diplopia. Patients who have diplopia have double vision and hold the head in a skewed position in an attempt to see a single image. Patient A has dressed himself or herself in an unusual color combination, which is indicative of color blindness. Patient C covers his or her eyes to block the light, which is indicative of photophobia. Patient D is making eye contact with the nurse, which is positive behavior. Test-Taking Tip: Certain eye abnormalities alter the behavior of patients. Recall the abnormal behavior that may be observed in patients with diplopia. p. 374

The nurse is performing an assessment to determine pupillary function. What will the nurse assess when using this test? A. Perimetry B. Reaction to light C. Amsler Grid Test D. Following six cardinal fields of gaze

B. Reaction to light Rationale Pupil function is determined by inspection and reaction to light. Perimetry is visual field testing. The Amsler Grid Test is a self-administered test used to monitor macular problems. The six cardinal fields of gaze are used to assess extraocular movement and cranial nerves III, IV, and VI. p. 358

The nurse observes that a child has an asymmetric position of the eye. What condition is suspected? A. Blepheritis B. Strabismus C. Hordeolum D. Conjunctivitis

B. Strabismus Rationale An asymmetric eye position indicates that the patient has strabismus. Blepharitis is associated with redness, swelling, and crusting along the lid margins. Hordeolum is an infection of the sebaceous gland of the eyelid where the patient may have a superficial nodule along the lid margin. Conjunctivitis is associated with redness or swelling of conjunctiva; it is a bacterial infection. p. 357

A nurse finds that a patient has small, yellowish spots on the conjunctiva. Upon further interaction, the nurse finds that the patient works at a hospital in the radiology department. What should the nurse interpret from these findings? A. The patient has pterygium. B. The patient has pinguecula. C. The patient has presbyopia. D. The patient has arcus senilis.

B. The patient has pinguecula. Rationale Small, yellowish spots on the medial aspect of the conjunctiva are associated with pinguecula, which occurs as a result of tissue damage related to chronic exposure to ultraviolet light. Because the patient works in the radiology department, the likelihood of exposure to ultraviolet light is high. Pterygium is an abnormality of the cornea that is associated with chronic exposure to sunlight, which manifests as thickened, triangular, pale tissue extending from the inner canthus to the nasal border. Presbyopia is a refractive error that is associated with the loss of near vision. This condition manifests as increased rigidity of the lens, not yellow spots on the conjunctiva. Arcus senilis is an abnormality of the cornea that occurs because of cholesterol deposition in the peripheral cornea and manifests as a milky white and grayish ring around the eye. Test-Taking Tip: Tissue damage in eye occurs due to chronic exposure to ultraviolet light. Use this information to answer this question. p. 351

A nurse is performing an eye examination on a patient. Which findings should the nurse consider abnormal? Select all that apply. A. The pupils are equal and round. B. The right pupil is slightly smaller than the left. C. The pupils dilate when light stimuli is performed. D. The pupils constrict when light stimuli is performed. E. The right pupil constricts faster than the left when light stimuli are performed.

B. The right pupil is slightly smaller than the left. C. The pupils dilate when light stimuli is performed. E. The right pupil constricts faster than the left when light stimuli are performed. Rationale Whenever light stimulus is given, the pupils constrict to regulate the amount of light falling on the retina. The iris regulates the size of the pupils. Under normal circumstances, both of the pupils are equal in diameter. The normal shape of pupils is round. Pupils do not dilate when light falls on them. The pupils dilate when the amount of light in the environment is less. Dilation of the pupils enables more light to enter the eye and helps the person to see better. pp. 354-355

A patient tells a nurse, "I take an aspirin every two days because I'm always getting headaches." Which ear abnormality does the nurse expect? A. Vertigo B. Tinnitus C. Presbycusis D. Impaired speech reception

B. Tinnitus Rationale Tinnitus, a continuous ringing in the ears, is associated with calcification of the ossicles. Heavy intake of aspirin, an analgesic medication, often results in tinnitus because of its toxic effect on cranial nerve VIII. Vertigo is a sense of moving or spinning that is associated with imbalances in the vestibular system. Presbycusis is the loss of hearing with age. A patient who has damage to the cochlea will exhibit impaired speech reception. Test-Taking Tip: Avoid spending excessive time on any one question. Most questions can be answered in one to two minutes. p. 362

The nurse darkens the room and shines a penlight on the cornea and asks the patient to follow finger movement 10 inches from the patient's nose. Which cranial nerve paralysis should be examined? Select all that apply. A. Facial nerve B. Troclear nerve C. Abducens nerve D. Trigeminal nerve E. Oculomotor nerve

B. Troclear nerve C. Abducens nerve E. Oculomotor nerve Rationale The examiner is assessing the extraocular muscle function by darkening the room and shining the penlight over the cornea. The troclear, abducens, and oculomotor nerves are present near the eyeball, and an abnormality of these cranial nerves results in paralysis of the extraocular muscles. The facial nerve helps in the opening and closing movements of the eyelids. The trigeminal nerve helps in the dilation of the iris. p. 358

A patient has undergone a fluorescein angiography. The nurse should observe for what side effects of the procedure? Select all that apply. A. Redness of the eyes B. Yellowish discoloration of the skin C. Yellowish discoloration of the urine D. Nausea and vomiting after the procedure E. Red-colored urine indicative of presence of blood

B. Yellowish discoloration of the skin C. Yellowish discoloration of the urine D. Nausea and vomiting after the procedure Rationale In fluorescein angiography, fluorescein is injected in the body. This dye is a noniodine and nonradioactive dye. This procedure has some common side effects. The dye can cause yellowish discoloration of skin and urine. This dye can also cause some nausea and vomiting. Presence of blood in urine is a serious sign and is not a common side effect of this procedure. Redness of the eyes can have many causative factors and is unlikely after this procedure. p. 359

A patient who underwent ear surgery has sustained trauma and problems related to facial movement and eyelid closure. Which cranial nerve damage does the nurse suspect? A. Cranial nerve III B. Cranial nerve IV C. Cranial nerve VII D. Cranial nerve VIII

C. Cranial nerve VII Rationale Problems with voluntary facial movement and eyelid closure resulting from trauma after ear surgery indicate that the patient has sustained damage to the facial cranial nerve, cranial nerve VII. Damage to cranial nerves III (oculomotor nerve) and IV (trochlear nerve) results in paralysis of extraocular muscles. Damage to cranial nerve VIII (vestibulocochlear nerve) results in impaired hearing reception. p. 361

The nurse is interviewing a patient diagnosed with glaucoma. What question is most relevant to the patient's condition? A. "Have you ever had surgery?" B. "When was the last test for visual acuity done?" C. "Do you have a history of cardiac or pulmonary disease?" D. "Has there been any recent change in your eyeglasses or contact lenses?"

C. "Do you have a history of cardiac or pulmonary disease?" Rationale When collecting a health history for a patient diagnosed with glaucoma, the nurse should ask about cardiac or pulmonary disease. Glaucoma is often treated with beta-adrenergic blockers, which may decrease heart rate, decrease blood pressure, and exacerbate asthma or chronic obstructive pulmonary disease (COPD). Information regarding a visual acuity test, previous surgeries, and a change in lens prescription is gathered as general data but is not specifically related to glaucoma. p. 355

A patient has an ophthalmic condition resulting in decreased tear production in the eyes. The nurse expects that the patient will report which symptom? A. "I see a double of every object." B. "I cannot see clearly in dim light or at night." C. "I have a sandy, gritty, and irritating sensation in my eyes." D. "I cannot read books, newspapers, or anything close to me."

C. "I have a sandy, gritty, and irritating sensation in my eyes." Rationale Tears act as a lubricant in the eyes. In the absence or deficiency of tears, the patient has a dry, gritty, sandy, and irritating sensation in the eyes. Double vision is caused by an abnormality in the extraocular muscles because they regulate the vision. Tear production does not affect vision. Vision and night vision are regulated by the retina. Night blindness is caused due to damage to structures known as rods, which are present in the retina. Stiffening of the ciliary muscles affects the acuity of a patient's near vision. p. 352

A nurse is assessing a patient with chronic tinnitus. Which question is appropriate to ask when exploring the patient's sleep habits? A. "In what position do you sleep?" B. "At what time do you go to bed?" C. "Is your sleep disturbed by ringing in your ears?" D. "Do you wake up frequently for urination at night?"

C. "Is your sleep disturbed by ringing in your ears?" Rationale While assessing a patient with tinnitus, it is necessary to ask if tinnitus causes sleeplessness. This gives a clue about the seriousness of the disorder. The position and time of sleep is irrelevant in tinnitus. Whether the patient wakes up frequently for urination at night is not related to tinnitus. p. 362

A patient is having refractometry as part of the visual assessment. Which of these instructions from the nurse is correct? Select all that apply. A. "Are you allergic to iodine or contrast media?" B. "You will feel slight burning during this procedure." C. "Please try to hold your head still during the examination." D. "You may find it difficult to focus on near objects for three to four hours." E. "You might notice that your urine will turn a darker yellow-orange color today."

C. "Please try to hold your head still during the examination." D. "You may find it difficult to focus on near objects for three to four hours." Rationale The patient may need help to hold the head still during the examination. Pupil dilation makes it difficult to focus on near objects, and dilation may last three to four hours. The refractometry procedure is painless. Concerns about iodine/contrast media allergy and the possibility of urine color changes occur with fluorescein angiography, not refractometry. Test-Taking Tip: Do not panic while taking an exam! Panic will only increase your anxiety. Stop for a moment, close your eyes, take a few deep breaths, and resume review of the question. p. 359

A nurse is conducting a tuning fork test on a patient. The nurse has 4 forks, each with a different frequency: 500 Hz; 506 Hz; 512 Hz; and 520 Hz. Which fork should the nurse use? A. 500 B. 506 C. 512 D. 520

C. 512 Rationale The tuning fork test helps to differentiate between conductive and sensorineural hearing loss. The frequency of the fork is specific in order to get the desired effect. The fork that is used in this test is 512 Hz. p. 364

A patient with acute-angle glaucoma has a new prescription for eye drops. The nurse will question the patient about which of these conditions? A. Symptoms of dry eyes B. Use of corrective lenses C. A history of heart or lung disease D. Sensitivity to sulfonamide antibiotics

C. A history of heart or lung disease Rationale It is particularly important to determine whether the patient has any history of cardiac or pulmonary disease because β-adrenergic blockers often are used to treat glaucoma. These medications can slow heart rate, decrease blood pressure, and exacerbate asthma or chronic obstructive pulmonary disease (COPD). Dry eyes, use of corrective lenses, and sensitivity to sulfonamide antibiotics are incorrect. STUDY TIP: Laughter is a great stress reliever. Watching a short program that makes you laugh, reading something funny, or sharing humor with friends helps decrease stress. p. 354

The nurse is testing a patient for hearing acuity using a whisper test. Which actions by the nurse are appropriate? Select all that apply. A. Test both ears together. B. Stand directly in front of the patient. C. After exhaling, speak in a low whisper. D. Ask the patient to repeat numbers or words. E. Whisper loudly if the patient does not respond correctly.

C. After exhaling, speak in a low whisper. D. Ask the patient to repeat numbers or words. E. Whisper loudly if the patient does not respond correctly. Rationale When testing for hearing acuity, the nurse should stand 12 to 24 inches to the side of the patient and, after exhaling, speak in a low whisper. Ask the patient to repeat numbers or words or answer questions. Use a louder whisper if the patient does not respond correctly. Test each ear separately. The ear not being tested is covered by the patient. p. 365

Which structural impairment of the ear does the nurse suspect in a patient who has a nasopharyngeal infection? A. Damage to cranial nerve VII B. Damage to cranial nerve VIII C. Blockage of eustachian tube D. Reduced blood supply to cochlea

C. Blockage of eustachian tube Rationale The eustachian tube continues from the nasal pharynx, where the presence of a nasopharyngeal infection may result in blockage. Damage to cranial nerve VII results in loss of voluntary facial movement. Damage to cranial nerve VIII is associated with excess calcium deposition, but not nasopharyngeal infection. A nasopharyngeal infection does not result in impairment such as reduced blood supply to the cochlea. Test-Taking Tip: Start by reading each of the answer options carefully. Usually at least one of them will be clearly wrong. Eliminate this one from consideration. Now you have reduced the number of response choices by one and improved the odds. Continue to analyze the options. If you can eliminate one more choice in a four-option question, you have reduced the odds to 50/50. Recall often occurs while you are eliminating incorrect choices. One of the options may serve as a trigger that causes you to remember what a few seconds ago had been completely forgotten. p. 364

The nurse suspects a disease of the vestibular system after an assessment of a patient's auditory system that involves instilling a warm solution into the ears to irrigate them. Which diagnostic test has the nurse performed? A. Posturography B. Rotary chair testing C. Caloric test stimulus D. Electronystagmography

C. Caloric test stimulus Rationale Caloric test stimulus helps determine the patient's vestibular function by stimulating the endolymph of semicircular canal. The nurse introduces a warm solution into the patient's ears to irrigate them and watches for nystagmus to stimulate the endolymph. Posturography is a balance test that is performed in a boxlike device. Rotary chair testing is used to evaluate the peripheral vestibular system. Electronystagmography, in which electrodes track the movements of the eye over a graph, is used to assess the vestibular system. Test-Taking Tip: Recall the different diagnostic procedures for ear assessment and how each test is performed. This will help you choose the correct option. p. 365

The nurse assesses a patient has a small, white, superficial nodule along the lid margin. What condition should the nurse consider that is caused by an infection of the sebaceous gland of the eyelid? A. Blepharitis B. Strabismus C. Hordeolum D. Conjunctivitis

C. Hordeolum Rationale An eye infection that is accompanied by a small, white, superficial nodule along the lid margin and an infection of the sebaceous gland of eyelid indicate that the patient has hordeolum. It is caused by a Staphylococcus infection. Blepharitis is a bacterial infection in the lid margins, which manifests as redness, swelling, and crusting along the lid margins. Strabismus is the deviation in the position of the eye in one or more directions; it is not associated with bacterial infection. Conjunctivitis is a bacterial infection of the eye, which manifests as redness and swelling of the conjunctiva. p. 351

The nurse assesses a patient with protruding eyeballs, and the sclera is above the iris when the eyes are open. The patient reports feeling jittery and losing weight. What condition does the nurse determine correlates with these clinical manifestations? A. Blepharitis B. Hordeolum C. Hyperthyroidism D. Macular disease

C. Hyperthyroidism Rationale A patient who has hyperthyroidism may have exophthalmos, which manifests with a protruding eyeball and sclera above the iris when the eyelids are open. Blepharitis is the condition that is associated with redness, swelling, and crusting along the lid margins. Hordeolum is an infection of the sebaceous gland of the eyelid; the patient may have a superficial nodule along the lid margin. The patient who has macular disease will have a loss of central vision. p. 357

While assessing a patient, the health care practitioner comments that the vestibular apparatus has been damaged. The nurse expects to find what clinical manifestation? A. Vision loss B. Hearing loss C. Loss of balance of the body D. Increased sensitivity to noise

C. Loss of balance of the body Rationale The vestibular apparatus is a structure present in the inner ear. This structure is responsible for maintaining balance and body orientation. Damage to this structure alters a person's ability to balance the body. Vision loss is caused due to damage to the eye structures. Vestibular apparatus weakening doesn't cause hearing loss. Increased sensitivity to noise is caused due to changes in the brain. p. 361

The nurse is performing an assessment of a patient's ear with an otoscope and finds that the light reflex is fuzzy. How does the nurse interpret this finding? A. Degeneration of the hair cells B. Blockage of the eustachian tube C. Retraction of the tympanic membrane D. Degeneration of the neurons of the auditory nerve

C. Retraction of the tympanic membrane Rationale Retraction of the tympanic membrane will cause the edges of the light reflex to appear fuzzy. Degeneration of hair cells will reduce sensitivity to sound. Blockage of the eustachian tube results in a retracted eardrum but does not make the light reflex appear fuzzy. Degeneration of auditory neurons will reduce sensitivity to high-pitched sound. p. 364

When assessing for corneal light reflex in a patient, what is an appropriate nursing action? A. Turn on the lights in the room. B. Ask the patient to look at the roof. C. Shine a penlight directly on the cornea. D. Ask the patient to follow finger movement without moving his or her head.

C. Shine a penlight directly on the cornea. Rationale Corneal light reflex is assessed to determine weakness or imbalance of the extraocular muscles (EOM). The procedure is carried out in a dark room. The patient is asked to look straight ahead while a penlight is shined directly on the cornea. The light reflection should be located in the center of both corneas as the patient faces the light source. The patient is asked to follow finger movement when assessing for intact cranial nerves. p. 358

A nurse is assessing a patient with dilator muscle atrophy of the eye. The nurse expects to find what clinical manifestation? A. Formation of cataracts B. Excessive dryness of the eyes C. Slow recovery of pupil size after light stimuli D. Changes in perception of colors, especially blue and violet

C. Slow recovery of pupil size after light stimuli Rationale Dilator muscle atrophy or weakness affects the ability of the pupils to contract and relax. As age progresses, this muscle becomes weak. Due to weakness or atrophy, the recovery of pupil size after stimulation by light is delayed. Cataracts are formed due to biochemical changes in the lens proteins, which result in clouding of the lens. Excessive dryness is caused due to reduced production of tears or due to malposition of the eyelids. Changes in perception of colors are not related to the dilator muscle. Color perception is carried by cones in the retina. A decrease in the number of cones causes this problem. p. 353

The nurse is evaluating a patient's visual acuity. What tool should the nurse use to correctly evaluate this? A. Slit-lamp B. Audiometer C. Snellen chart D. Retinal angiography

C. Snellen chart Rationale The Snellen chart, which is used to evaluate the patient's ability to read letters or symbols at a distance of 20 feet, is a tool for measuring a patient's visual acuity. A slit-lamp is a special microscope used to examine the eye. An audiometer is a device used to assess hearing acuity. Retinal angiography is a radiographic procedure used to determine retinal damage. p. 356

A patient is exhibiting deviation of eye position in one or more directions. Which abnormal visual system finding does the nurse document is occurring with this patient? A. Diplopia B. Cataract C. Strabismus D. Exophthalmos

C. Strabismus Rationale Strabismus results from overreaction or underreaction of one or more extraocular muscles. Abnormality of extraocular muscle action related to muscle or cranial nerve pathologic conditions results in diplopia (double vision). A cataract is an opacification of the lens due to aging, trauma, diabetes, or long-term systemic corticosteroid use. The patient with exophthalmos may have hyperthyroidism, or intraocular or periorbital tumors. This patient presents with protrusion of the globe beyond its normal position within the bony orbit. p. 357

Upon assessment of the eyes of a patient, the nurse observes a yellowish discoloration in the sclera. What should the nurse conclude from the finding? A. The patient has a thin sclera. B. The patient has a normal finding. C. The patient has a lipid deposition. D. The patient has a subconjunctival hemorrhage.

C. The patient has a lipid deposition. Rationale The excessive deposition of lipids in the sclera may result in a yellowish discoloration of the sclera. A patient who has a thin sclera will have a bluish tinge in the sclera. The presence of a white sclera indicates that the patient has a normal finding. A patient who has a subconjunctival hemorrhage will have the appearance of a blood spot on the sclera. p. 358

A patient who was in a car accident tells a nurse, "I hit the vehicle that was moving in front of me; I thought it was far away and misjudged the distance." What should the nurse interpret from the patient's statement? A. The patient has hyperopia. B. The patient has presbyopia. C. The patient has impaired stereopsis. D. The patient has an abnormal response to light.

C. The patient has impaired stereopsis. Rationale Stereoscopic vision allows a patient to visualize in three dimensions. A patient who has impaired stereopsis will be unable to judge the distance between vehicles or between steps, which may result in accidents. Hyperopia is farsightedness or a loss of near vision. In this condition, a patient will be able to judge distances. Presbyopia is a loss of near vision that comes with age, but it does not result in the loss of three-dimensional vision. A patient who has an abnormal response to light will have impaired pupil response, but not the inability to judge distances. p. 359

During an auditory assessment, the nurse finds that the patient is able to hear a low whisper at a distance of 30 cm. How does the nurse interpret this information in the patient's report? A. The patient has impaired reception. B. The patient has mastoid tenderness. C. The patient has normal auditory function. D. The patient has sensorineural hearing loss.

C. The patient has normal auditory function. Rationale Ability to hear a low whisper of 20 dB at a short distance of 30 cm indicates that the patient has normal auditory function. Impairment of the cochlea will result in impairment of reception. The nurse palpates the mastoid area to detect tenderness and nodules. The tuning fork test, not the whisper test, helps detect sensorineural hearing loss. p. 364

A 40-year-old patient tells a nurse, "I've noticed over the last three months that I have blurred vision of near objects." The ophthalmic consultation report shows that the patient has increased rigidity of the lens. What should the nurse interpret from the finding? A. The patient has myopia. B. The patient has hyperopia. C. The patient has presbyopia. D. The patient has astigmatism.

C. The patient has presbyopia. Rationale A 40-year-old patient having blurred vision of objects closer to the visual field and rigidity of the lens indicate that the patient presbyopia. Presbyopia is the loss of accommodation, which occurs because of the increased rigidity of the lens. It causes an inability to focus on objects that are near. Presbyopia occurs as a normal process of aging. Myopia is nearsightedness or the loss of vision of faraway objects. This condition does not develop with old age and is found in all age groups. Hyperopia, or farsightedness, is an inability to accommodate for near objects. Astigmatism occurs because of an unevenness of the cornea, which results in distorted vision, but not in the loss of objects that are nearby. p. 351

The nurse observes an inconsistent nonverbal response from the patient as part of an auditory assessment in a soundproof room where sound is provided through headphones. How does the nurse interpret this finding? A. The patient has otalgia. B. The patient has vertigo. C. The patient has tinnitus. D. The patient has nystagmus.

C. The patient has tinnitus. Rationale Tinnitus is an abnormal ringing of ears that results in an inconsistent response on pure-tone audiometry because the patient will not be able to hear the sound consistently. Otalgia is pain in the ears, which may cause discomfort and result in nutritional disturbance. Vertigo is a spinning sensation, stimulated by motion of the head that results in impaired balance. Nystagmus is abnormal movement of the eye, observed as twitching of the eyeball. p. 362

The nurse is performing an assessment of a patient's ear with an otoscope and observes a retracted eardrum. What does the nurse determine the cause of this to be? A. Ear drainage B. Seborrheic dermatitis C. Vacuum in middle ear D. Infection of external ear

C. Vacuum in middle ear Rationale A vacuum in the middle ear will cause the malleus to appear shorter and more horizontal. A patient with sebaceous cysts behind the ear will exhibit drainage from the ear, not a retracted eardrum. A patient with seborrheic dermatitis will have scales and lesions on the skin. Infection of the external ear may result in discharge from the ear canal. p. 364

Which organs of the auditory system are involved in balance? Select all that apply. A. Malleus B. Cochlea C. Vestibule D. Tympanum E. Semicircular canals

C. Vestibule E. Semicircular canals Rationale The vestibule, an organ in the inner ear, comprises the labyrinth and is an organ of balance. The semicircular canal, a structure present in the inner ear, comprises the membranous labyrinth and is an organ of balance. The malleus, the smallest bone in the human body, is found in the middle ear and aids transmission of sound waves. The cochlea, a coiled structure, is a receptor organ for hearing. The tympanum, in the external ear, collects and transmits sound waves. p. 363

A nurse is interviewing a patient with visual impairment. Which question related to elimination should the nurse ask to determine changes in intraocular pressure? A. "Do you pass stools regularly?" B. "How many stools do you have in a day?" C. "What are the characteristics of the stools?" D. "Do you have to strain while passing stools?"

D. "Do you have to strain while passing stools?" Rationale It is important for the nurse to ask the patient if the patient has to strain during stools. Straining during defecation increases the intraocular pressure. While assessing the elimination pattern in relation to eye complaints, knowing the characteristics of stools is not important. The regularity, characteristic, and frequency of stools are important parameters while assessing the gastrointestinal system. However, they are not related to visual impairment. p. 355

The nurse is assessing an older adult patient who just has been transferred to a long-term care facility. Which question will best allow the nurse to assess the woman for the presence of presbycusis? A. "Do you ever experience any ringing in your ears?" B. "Have you ever fallen down because you became dizzy?" C. "Do you ever have pain in your ears when you're chewing or swallowing?" D. "Have you noticed any change in your hearing in recent months and years?"

D. "Have you noticed any change in your hearing in recent months and years?" Rationale Presbycusis is an age-related change in auditory acuity. Ringing in the ears is termed tinnitus, whereas dizziness and falls are related to balance and the function of the vestibular system. Presbycusis is not associated with pain during chewing and swallowing. p. 361

A nurse is interviewing a patient with irritation of the eyes. To assess eye health, the nurse should ask what sleep hygiene-related question? A. "What time do you go to sleep at night?" B. "What position do you generally sleep in?" C. "What kind of dreams do you generally have?" D. "How many hours of sleep do you get in 24 hours?"

D. "How many hours of sleep do you get in 24 hours?" Rationale The health of the eyes depends on various lifestyle factors. One important parameter is sleep. An adequate duration of sleep is required for optimum eye health. Asking how many hours the patient sleeps gives information about the duration of sleep. Bedtime is not an important factor in determining eye health, but duration is important. Position of sleep doesn't affect eye health. Similarly, information about dreams may be used in psychologic and emotional assessment, but is not related to eye health. p. 355

What is the function of the structure labeled 1 in the image? A. Processes and interprets sound B. Acts as a receptor organ for hearing C. Keeps the ear canal free from debris D. Acts as an instrument for sound transmission

D. Acts as an instrument for sound transmission Rationale The structure labeled 1 in the image is the tympanic membrane, a part of the external ear that acts as an instrument of sound transmission between the external auditory canal and the tympanic membrane. The vestibulocochlear nerve and temporal lobe help in processing and interpret the sound transferred in the form of an electrochemical impulse. The cochlea present in the inner ear functions as a receptor organ for hearing. The cilia, sebaceous oils, and ceruminous wax help in keeping the ear canal free from debris. p. 360

A patient has a milky white and grayish ring encircling the periphery of the cornea, and the laboratory reports of the patient reveal a total serum cholesterol of 220 mg/dL. Which condition is present? A. Pterygium B. Glaucoma C. Blepharitis D. Arcus senilis

D. Arcus senilis Rationale A total serum cholesterol of less than 180 mg/dL is considered optimal. The patient's serum total cholesterol of 220 mg/dL is high. Arcus senilis is an abnormality of the eye associated with high cholesterol levels. Cholesterol is deposited in the eye margin; therefore, the patient will see a milky white and grayish ring encircling the periphery of the cornea. Pterygium is an abnormality of the cornea that is associated with chronic exposure to sunlight, which manifests as thickened, triangular, pale tissue extending from the inner canthus to the nasal border. A patient who has glaucoma will have increased intraocular pressure, not cholesterol levels. Blepharitis is a bacterial infection in lid margins, which manifests as redness, swelling, and crusting along the lid margins. Test-Taking Tip: Be alert for details. Details provided in the stem of the item, such as behavioral changes or clinical changes (or both) within a certain time period, can provide a clue to the most appropriate response or, in some cases, responses. p. 353

A patient reports visual distortion and is assessed to have an uneven cornea. What refractive error does the nurse determine is most likely present? A. Myopia B. Hyperopia C. Presbyopia D. Astigmatism

D. Astigmatism Rationale Visual distortion that is associated with an uneven cornea indicates that the patient has astigmatism. Myopia is a refractive error in which the patient is not be able to view objects that are far away. Hyperopia is an impairment in vision in which the patient is not be able to see clearly see close objects. Presbyopia is the inability to focus on objects that are near and the condition increases with age. Myopia, hyperopia, and prebyopia are associated with an elongation or shortening of the eyeball, but not an uneven cornea. Test-Taking Tip: Multiple-choice questions can be challenging because students think that they will recognize the right answer when they see it or that the right answer will somehow stand out from the other choices. This is a dangerous misconception. The more carefully the question is constructed, the more each of the choices will seem like the correct response. p. 351

Which diagnostic study is the nurse performing if, while performing an auditory assessment in a darkened room, the nurse places electrodes over the mastoid process, at the vertex, and on the forehead? A. Rotary chair testing B. Electrocochleography C. Electronystagmography D. Auditory evoked potential

D. Auditory evoked potential Rationale Auditory evoked potential is conducted in a darkened room and electrodes are placed over the mastoid process, vertex, and forehead to isolate auditory activity from other activities. Rotary chair testing is performed in a dark room to evaluate the peripheral vestibular system, but in this test the patient is seated in a chair driven by a motor under computer control. Electrocochleography records electrical activity in the cochlea and auditory nerves. Electronystagmography, in which specific eye movements are recorded, is used to diagnose diseases of the vestibular system. p. 365

An adult patient has been treated for an ear infection. The nurse plans to examine the ear using an otoscope. What intervention should the nurse employ to lessen anxiety and discomfort associated with the examination? A. Apply water-soluble lubricant liberally to the otoscope. B. Place the otoscope under warm water for several minutes. C. Pull downward on the auricle while inserting the otoscope. D. Gently palpate the tragus and move the auricle, noting sensitive areas.

D. Gently palpate the tragus and move the auricle, noting sensitive areas. Rationale By touching the tragus and moving the auricle (pinna), the nurse identifies sensitive areas and avoids pain while inserting the otoscope. A speculum slightly smaller than the ear canal is attached to the otoscope base and inserted without lubrication or warming. In adults, the auricle is pulled upward to straighten the ear canal and facilitate introduction of the otoscope. p. 364

Which tool is used in the physical assessment of the retina and optic nerve? A. Penlight B. Refractometry C. Ultrasonography D. Ophthalmoscope

D. Ophthalmoscope Rationale An ophthalmoscope is used to examine the retina and optic nerve. A penlight is used to examine pupillary function and reaction to light. Refractometry is a measure of refractive error. This is performed with the patient looking through apertures at a Snelling acuity chart. Ultrasonography determines the correct power of a lens implant before cataract surgery. p. 358

Upon visual examination of a patient's conjunctiva, a small blood spot is observed on the sclera. Which describes this assessment finding? A. Anisocoria B. Conjunctivitis C. Allergic reaction D. Subconjunctival hemorrhage

D. Subconjunctival hemorrhage Rationale Subconjunctival hemorrhage is characterized by the appearance of a blood spot on the conjunctiva. The blood spot may be small, or it can affect the entire sclera. Anisocoria describes constricted pupils that are unequal. Conjunctivitis manifests as redness and swelling of the conjunctiva that may be itchy. Allergic reactions are characterized by redness, excessive tearing, and itching of the lid margins. p. 357

The nurse is assessing a patient's ears. What normal findings should the nurse document? Select all that apply. A. The shape of the TM is convex. B. Fluid level at hairline in the TM C. Diffuse light reflex over the TM D. TM that is pearly gray, shiny, and translucent E. The handle of the malleus and its short process are visible through the TM.

D. TM that is pearly gray, shiny, and translucent E. The handle of the malleus and its short process are visible through the TM. Rationale The TM is normally pearl gray, white, or pink, shiny, and translucent. The handle (manubrium) of the malleus and its short process (umbo) should be visible through the membrane. The TM is a concave or dome shape normally. Hairline fluid level is indicative of serous otitis media. If the TM is bulging or retracted, the edges of the light reflex will be fuzzy (diffuse) and may spread over the TM. p. 361

The nurse documents a patient's Snellen chart reading as: Right eye: 20/30; Left eye: 20/40. What does the nurse determine is the correct interpretation of this reading? A. The patient likely has presbyopia. B. The patient does not have color blindness. C. The vision acuity is stronger in the left eye. D. The patient has a refractory error consistent with myopia.

D. The patient has a refractory error consistent with myopia. Rationale Documentation of Snellen test results includes documenting the eye tested, the distance the vision is tested (20 feet), and the line that the patient is able to read correctly. Patients should wear corrective devices while being tested. Myopia is nearsightedness, the ability to see near objects clearly while distant objects are blurred. The findings of 20/30 and 20/40 are consistent with myopia. Presbyopia is a loss of ability to accommodate and focus on near objects that occurs normally with aging. The Ishihara color test assesses the patient's ability to distinguish color patterns and screens for color blindness. The vision acuity is stronger in the right eye (20/30) than the left eye (20/40). p. 356

A patient tells a nurse, "I see two of everything." What should the nurse interpret from this finding? A. The patient has reduced tear formation. B. The patient has inflammation of the cornea. C. The patient has an abnormality in size of the pupils. D. The patient has an abnormality of the extraocular muscle.

D. The patient has an abnormality of the extraocular muscle. Rationale The patient's statement, "I see two of all everything," indicates that the patient has double vision. This indicates that the patient has diplopia, which is associated with an abnormality of the extraocular muscle. Reduced tear formation will result in dry eyes and a gritty sensation, but not double vision. The presence of inflammation in the cornea results in photophobia. An abnormality in pupil size is associated with central nervous system disorders and is referred to as anisocoria. Test-Taking Tip: You have at least a 25 percent chance of selecting the correct response in multiple-choice items. If you are uncertain about a question, eliminate the choices that you believe are wrong and then call on your knowledge, skills, and abilities to choose from the remaining responses. p. 358

A nurse is caring for a patient after eye surgery and finds that the patient has difficulty passing stools. What should the nurse interpret from this finding? A. The patient is at risk for anisocoria. B. The patient is at risk for photophobia. C. The patient may have increased rigidity of the lens. D. The patient may have increased intraocular pressure.

D. The patient may have increased intraocular pressure. Rationale After eye surgery, it is important for the patient to resist straining, such as when trying to defecate. Straining from constipation may lead to increased intraocular pressure in the ears and eyes. Anisocoria is the unequal size of the eye pupils, which is a physiologic condition or is associated with trauma. Persistent, abnormal intolerance of the eyes to light is called photophobia, which is associated with infection or inflammation in the uveal tract. Patients who have a loss of near vision that is associated with age will have increased lens rigidity. p. 355

The nurse is conducting an assessment for a patient with hearing loss. Which cranial nerve is associated with the processing of sound? A. III B. VI C. VII D. VIII

D. VIII Rationale Cranial nerve VIII is associated with hearing and balance. Cranial nerve III controls eye movement, pupillary constriction, and upper eye lid elevation. Cranial nerve VI controls the sense of smell. Cranial nerve VII controls the expression in the forehead, eyes, and mouth, taste, salivation, and tearing. p. 360