Nursing Assessment: Sensorineural Function

During a neurological physical examination, a patient tells the nurse that she is having difficulty raising her right eyelid. The nurse knows that this may be an indication of problems with which cranial nerve?

III

The client is having a Weber test. During a Weber test, where should the tuning fork be placed?

In the midline of the client's skull or in the center of the forehead

The nurse is assessing an older client's vision. The nurse integrates knowledge of which of the following during the assessment?

The power of the lens to accommodate will be decreased.

The nurse at the eye clinic is caring for a patient with suspected glaucoma. What complaint would be significant for a diagnosis of glaucoma?

The presence of halos around lights

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

myopia Changes in vision can be associated with problems such as myopia (nearsightedness—distant objects appear blurred), hyperopia (farsightedness), presbyopia (diminished ability to focus on near objects with age due to the decline in amplitude of accommodation), and cataracts (opacity of the lens).

A client has developed diabetic retinopathy and is seeing the physician regularly to prevent further loss of sight. From where do the nerve cells of the retina extend?

optic nerve

A nurse notices that a client's left upper eyelid is drooping. The nurse has observed:

ptosis

A client is having a routine eye examination. The procedure being performed is done by using an instrument to indent or flatten the surface of the eye. This is known as ________ and it is routinely done to test for ________.

tonometry; intraocular pressure

A patient has come to the office for her first eye examination and is diagnosed as having a visual acuity of 20/40. The patient asks the nurse what these numbers mean. What is a correct response by the nurse?

"A person whose vision is 20/40 can see an object from 20 feet away that a person with 20/20 vision can see from 40 feet away."

A 56-year-old patient has come to the clinic for his routine eye examination and is told he needs bifocals. The patient asks the nurse what in his eye has changed so that he needs bifocals. What should the nurse respond?

"There is a gradual thickening of the lens of the eye, and it can limit accommodation of the eye."

The nurse is giving a visual field examination to a 55-year-old male client. The client asks what this test is for. What would be the nurse's best answer?

"This test measures peripheral vision and detects gaps in the visual field."

The nurse is precepting a nursing student when a new client comes to the eye clinic. The client explains that she thinks she may have a corneal abrasion. The nurse should explain what to the student nurse?

"To detect corneal abrasions, a slit lamp is used."

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

"What medications do you take?" Smoking, lack of exercise, and certain occupations all have the potential to directly or indirectly influence vision. However, medications are a much more common contributor to various eye disorders.

A client's vision is assessed at 20/200. The client asks what that means. Which is the most appropriate response by the nurse?

"You see an object from 20 feet away that a person with normal vision sees from 200 feet away."

It is determined that a patient is legally blind and will be unable to drive any longer. Legal blindness refers to a best-corrected visual acuity (BCVA) that does not exceed what reading in the better eye?

20/200

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

20/50-3

A client has undergone tonometry to evaluate for possible glaucoma. Which result would the nurse record as abnormal?

25 mm Hg

A nurse is reviewing the histories of several clients who have come to the clinic for a follow-up evaluation. Previous results of tonometry have been recorded. Which intraocular pressure test result would the nurse identify as a cause for concern?

25 mm Hg

A nurse is conducting an eye examination on a client. The nurse provides the client with a paper on which there is a grid of identical squares with a central fixation point. The nurse is using which tool?

Amsler grid

A male patient has reported to the nurse that he is experiencing sharp, intense pain when he blinks, and he claims that he has not previously experienced this problem. The nurse reports this finding to the primary care provider in the knowledge that the patient may have which of the following health problems?

An abrasion of the cornea

A client newly diagnosed with otitis media reports that the pain and pressure in the ear has suddenly disappeared. What is the best action by the nurse?

Assess the tympanic membrane.

The nurse is caring for a client with increased fluid accumulation in the eye. When assessing the client, which structure within the eye is noted to drain fluid from the anterior chamber? Canthus Choroid Fovea centralis Canal of Schlemm

Canal of Schlemm The canal of Schlemm drains the anterior chamber of the eye. By draining the fluid, it decreases the fluid amount and pressure in the eye. The other options have no draining ability.

The nurse is caring for geriatric clients who state that they are prescribed reading glasses. Some individuals state needing assistance with seeing writing far away, and others need assistance with closer vision. The nurse is correct to understand that the aging visual changes relate to which of the following? Changes in central vision Changes in accommodation Changes in refraction Changes in the visual field

Changes in accommodation The changes that occur in vision during aging, which include difficulty reading and the need for reading glasses, include changes in accommodation. Accommodation occurs when the ciliary muscles contract or relax to focus an image on the retina.

Which statement is consistent with acute otitis media?

Conductive hearing loss may occur.

Which of the following is the main refracting surface of the eye?

Cornea

A nurse is performing an otoscopic examination on a client. Which finding would the nurse document as abnormal?

External auditory canal erythema

A 13-year-old client is visiting the ophthalmologist after severe eye injuries. The client suffered trauma to her sclera and is being treated for subsequent infection. During your client education, you indicate where the sclera is attached. Which of the following structures would you NOT include?

Eyelids

The nurse is reviewing the audiology consultation on a woman who has been experiencing progressive hearing loss. To accurately interpret these diagnostic findings, the nurse should be aware of what important characteristics of sound? Select all that apply.

Frequency Pitch Intensity

A nurse is helping a patient with her morning bath. The patient complains of having dry eyes. The nurse knows that the eyelids contain multiple glands that protect the eye. Which of the following eyelid glands should the nurse first assess? Sweat Lacrimal Sebaceous Meibomian

Lacrimal The lacrimal and accessory lacrimal glands, which are located in the upper and outer portion of the eye, secrete tears that flow into the lacrimal sac. Tears are vital to eye health. The other glands secrete components of the tear film, but the lacrimal glands secrete the tears.

Which surgical procedure involves flattening the anterior curvature of the cornea by removing a stromal lamella layer?

Laser-assisted stromal in situ keratomileusis (LASIK)

A nurse conducted a history and physical for a newly admitted patient who states, "My arms are too short. I have to hold my book at a distance to read." The nurse knows that the patient is most likely experiencing:

Loss of accommodative power in the lens.

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

Macular degeneration Macular degeneration is the most common cause of visual loss in people older than 65 years of age.

To avoid the side effects of corticosteroids, which medication classification is used as an alternative in treating inflammatory conditions of the eyes?

Nonsteroidal anti-inflammatory drugs (NSAIDs)

Upon admission to the subacute medical unit, each patient has a history and head-to-toe nursing assessment performed. When assessing a patient's hearing history, the nurse should consider which of the following facts? Numerous medications have ototoxic effects. Endocrine and metabolic disease processes often cause hearing loss. Hearing loss is most often related to genetic factors. With a healthy lifestyle, normal hearing levels can be maintained throughout the lifespan.

Numerous medications have ototoxic effects. Medications can alter auditory function, so each agent should be evaluated for potential effects on ear disorders. Some common ototoxic medications include antibiotics, diuretics, and nonsteroidal anti-inflammatory agents. A family history often contributes to hearing loss, but this is not the case in a majority of individuals with hearing loss. Hearing normally deteriorates with age. Metabolic and endocrine disorders do not normally result in hearing loss.

The nurse is assisting the eye surgeon in completing an examination of the eye. Which piece of equipment would the nurse provide to the physician to examine the optic disc under magnification?

Ophthalmoscope

What is located in the cochlea of the inner ear?

Organ of Corti

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

Presbyopia

A client is newly diagnosed with otitis externa. Which information should the nurse teach the client before the client leaves the clinic?

Proper instillation of prescribed ear drops

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

Raise your hand when you no longer hear sound. It is essential to provide clear directions on when the client is to notify the nurse of client response. The information gleaned from the response is what the nurse uses to interpret the test. The correct time to induce feedback is when the vibration is held.

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

Rinne In the Rinne test, the examiner shifts the stem of a vibrating tuning fork between two positions to test air conduction of sound and bone conduction of sound. The whisper test involves covering the untested ear and whispering from a distance of 1 or 2 feet from the unoccluded ear; it assesses the ability of the patient to repeat what was whispered. The watch tick test relies on the ability of the patient to perceive the high-pitched sound made by a watch held at the patient's auricle. The Weber test uses bone conduction to test lateralization of sound.

Which diagnostic test distinguishes between conductive and sensorineural hearing loss?

Rinne test

A client complains to the nurse about having difficulty seeing to read, but reports no difficulty with driving. What test would the nurse prepare for the physician to administer to this client?

Rosenbaum

The nurse is examining the area behind the patient's auricle and sees a flaky scaliness. What disorder does the nurse suspect the patient has? Acute external otitis Sebaceous cysts Seborrheic dermatitis Tophi

Seborrheic dermatitis A flaky scaliness on or behind the auricle usually indicates seborrheic dermatitis and can be present on the scalp and facial structures as well.

When the patient tells the nurse that his vision is 20/200, and asks what that means, the nurse informs the patient that a person with 20/200 vision:

Sees an object from 20 feet away that a person with normal vision sees from 200 feet away.

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

Shine a penlight in one of the patient's eyes while observing the response of the opposite eye The pupillary response to light is determined by shining a bright light obliquely into each pupil. Pupils are assessed for direct reaction, in which the pupil tested with light constricts; and consensual reaction, in which the pupil of the opposite eye also constricts. Asking the patient to follow movement or identify an object are not techniques used to assess consensual pupillary response.

A nurse conducts the Weber test on a client. Which finding would the nurse interpret as normal?

Sound is heard equally in both ears.

A nurse is describing how sound is conducted to a client experiencing a decrease in hearing ability. When describing bone conduction, which information would the nurse most likely include? Sound is transmitted directly to the inner ear. Sound is conducted through the eardrum and inner ear. Sound leaves the bone and goes directly to the eardrum. Sound travels through the outer and middle ear to the ossicles.

Sound is transmitted directly to the inner ear. Sounds transmitted by air conduction travel over the air-filled external and middle ear through the vibration of the tympanic membrane and ossicles. Sounds transmitted by bone conduction travel directly through bone to the inner ear, bypassing the tympanic membrane and ossicles.

Which of the following occurs when there is deviation from perfect ocular alignment?

Strabismus

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

Tonometry Tonometry measures IOP by determining the amount of force or pressure necessary to indent or flatten (applanate) a small anterior area of the globe of the eye. Ophthalmoscopy, perimetry testing, and slit-lamp testing do not directly assess IOP.

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

Tonometry Tonometry measures IOP by determining the amount of force or pressure necessary to indent or flatten (applanate) a small anterior area of the globe of the eye. Ophthalmoscopy, perimetry testing, and slit-lamp testing do not directly assess IOP.

During an assessment using the positions test, what does an asymmetrical movement indicate? Select all that apply.

Weakness in the extraocular muscles Dysfunction of the cranial nerve

A child goes to the school nurse and complains of not being able to hear her teacher. What test could the school nurse perform to make a general estimate of hearing loss?

Whisper test

A nurse is conducting a physical assessment of a client's eyes. The nurse has just completed an evaluation of the client's visual acuity. Which assessment would the nurse conduct next? external eye examination direct ophthalmoscopy Amsler grid testing tonometry

external eye examination After the visual acuity has been recorded, an external eye examination is performed. The remainder of evaluations, such as direct ophthalmoscopy, Amsler grid testing, and tonometry may follow.