AD1 HESI: Eyes, Ears, and Sensory

The nurse is preparing to administer eardrops to a client who has impacted cerumen. Before administering the drops, the nurse will assess the client for which contraindications? Select all that apply Allergy to medication Itching in the ear canal Evidence of a fungal infection Conductive hearing loss in the affected ear

Allergy to medication

Which client has a condition consistent with mixed conductive-sensorineural type of hearing loss? A. Inflammation in the tympanic membrane B. Retraction in the tympanic membrane and damaged cochlear hair C. Damage to the vestibulocochlear nerve D. Fused bony ossicles

B. Retraction in the tympanic membrane and damaged cochlear hair Rationale: Client B is diagnosed with a retraction in the tympanic membrane, causing obstruction to sound wave transmission. Damaged cochlear hair results in decreased sensory perception.

The nurse is teaching the parents of and 18 month old child the procedure for instilling eardrops. How would this procedure be done?

By pulling the pinna down and back to straighten the auditory canal before instillation of the drops.

A client presents with hearing loss in the right ear. When the nurse performs a Weber test with a tuning fork, the client hears the sound better with the right ear. Which condition would the nurse suspect from these results?

Conduction hearing loss Rationale: During a Weber test, conduction hearing loss often causes the tuning fork to be heard better and more clearly in the impaired ear

Which observation by the nurse indicates a client's decrease in hearing acuity? Select all that apply Frequent use of words such as 'what' Postural changes while listening to the speaker Bending toward the other person while talking Mismatch between the questions asked and the responses given Startled expression to any unexpected sound in the environment

Frequent use of words such as 'what' Postural changes while listening to the speaker Bending toward the other person while talking Mismatch between the questions asked and the responses given

Which is being assessed when a school nurse conducts audiometric screenings?

Hearing acuity Rationale: Audiometric screening permits assessment of hearing ability.

Which assessment finding would the nurse document in the client's health record as a positive Romberg test?

Inability to stand with feet together when eyes are closed

Which instructions would the nurse give a 60 year old client who is at an increased risk for corneal damage? Select all that apply Use saline drops Increase humidity at home Wear prescribed lens for best vision Have corrective lenses solely for reading

Use saline drops Increase humidity at home Wear prescribed lens for best vision Rationale: A client who has reduced tear production may have an increased risk for corneal damage and eye infection. Using saline eye drops and increasing the humidity may reduce dryness and decrease corneal damage. Flattening of the cornea causes blurred vision. The client should be instructed to have regular eye examinations and wear the prescribed lens to prevent corneal damage.

Which interpretation would the nurse make when a 6 month old infant is startled by a loud noise but does not turn in the direction of the sound?

as evidence of hearing loss Rationale: By 3-4 months of age, an infant should localize sound by looking in the direction of the sound; failure to do so is suggestive of hearing loss.

Which response from the nurse would demonstrate an understanding of hallucinating behavior by a client?

Asking, 'What are the voices telling you to do?'

Which age should an infant develop binocularity?

3-4 months Rationale: Children develop binocularity (the ability to fixate on one visual field with both eyes simultaneously) by 3-4 months.

A client who sustained a head injury from a fall off a ladder has clear fluid leaking from the left ear. Which action would the nurse take?

Test the ear drainage with a glucose reagent strip. Rationale: If a basilar skull fracture has occurred, the CSF may drain through the client's ears or nose. This clear fluid may be tested with a glucose strip.

A client receiving intravenous vancomycin reports ringing in both ears. Which initial action would the nurse take?

Stop the infusion. Rationale: Vancomycin can cause temporary or permanent hearing loss.

Which situation may occur if monocular strabismus is not corrected early?

Amblyopia will progress in the weaker eye Rationale: Amblyopia is reduced visual acuity that may occur when a eye weakened by strabismus is not forced to function.

Which instruction will the nurse give a client recovering at home after ear surgery?

Avoid excessive coughing and people who have head colds. Rationale: After ear surgery, clients will be instructed to avoid excessive coughing, which increases pressure in the ear.

While assessing the client, the nurse observes abnormal eye movement. The client reports dizziness when standing or walking. Which structure of the auditory system might be affected in this client?

B Rationale: Abnormal eye movement is seen in nystagmus. Dizziness when standing or walking may indicate vertigo in the client. These both manifest because of problems with balance, which is maintained by the vestibular system marked by B.

For which clinical manifestations would the nurse focus when assessing clients taking tobramycin? Select all that apply Throat sores Blurred vision Watery diarrhea Hearing impairment Decreased sense of smell

Blurred vision Hearing impairment Decreased sense of smell Rationale: The client may suffer blurred vision, hearing impairment, or decreased sense of smell as a side effect associated with tobramycin. Excessive use of tobramycin is associated with these side effects include nephrotoxicity, neurotoxicity, and hearing deficit. Neurotoxicity results in damage to the nerves affecting the function of sensory organs.

Which health conditions are associated with lead poisoning in a preschooler? Amblyopia Strabismus Brain damage Hepatic steatosis Growth retardation

Brain damage Growth retardation Rationale: Exposure to excessive levels of lead affects a child's growth or causes learning and behavioral problems and brain and kidney damage.

The nurse is administering 40 mg of furosemide intravenously. Which sensation reported by the client would the nurse consider when determining that it is being administered too quickly?

Buzzing ears Rationale: Rapid administration of furosemide can cause tinnitus, loss of hearing, and ear pain.

The nurse asks the client to shrug the shoulders and to turn the head against passive resistance. Which cranial nerve is involved in this action?

Crania nerve XI Rationale: Cranial nerve XI (the spinal accessory nerve) is the motor nerve that coordinates the movement of head and shoulders.

While assessing a pediatric client, an ophthalmologist notices that the child is unable to focus on an object with both eyes simultaneously. Which other findings in the client confirms the diagnosis as strabismus? Select all that apply Impaired near vision Crossed appearance of eyes Elevated intraocular pressure Impaired extraocular muscles Degeneration of central retina

Crossed appearance of eyes Impaired extraocular muscles Rationale: Strabismus is a congenital condition in which both eyes do not focus on an object simultaneously, resulting in a crossed appearance of the eyes. This condition is caused by impaired extraocular muscles.

Which action would the nurse take to assist parents with bonding immediately after birth? Assess for typical parenting techniques Demonstrate desired behaviors to the parents Delay applying the antibiotic to the newborns eyes Postpone foot printing the newborn until later that day

Delay applying the antibiotic to the newborns eyes Rationale: The parents need an opportunity for close eye-to-eye contact during the first hour after birth. Prophylactic eye medications may irritate the newborn's eyes, preventing them from opening.

Which client condition is likely to improve significantly with the use of hearing aids> Destruction of the auditory nerve Diminished sensitivity of the cochlea Perforation of the tympanic membrane Immobilization of the auditory ossicles

Diminished sensitivity of the cochlea Rationale: Because hearing aids use the person's own middle ear, they increase hearing acuity in cases of diminished sensitivity of the cochlea; the amplified signal from the hearing aid gives the cochlea greater stimulation and promotes hearing.

Which factors increase the risk for social isolation for an older adult? Select all that apply Wearing bilateral hearing aids Having insulin-dependent diabetes Experiencing progressive macular degeneration Requiring the weekly help of a home health aide Living alone since a spouse's death 3 years ago Asking a neighbor for help with grocery shopping

Experiencing progressive macular degeneration Living alone since a spouse's death 3 years ago Rationale: Social interaction can be impeded when an individual lives alone or is experiencing depression. A visual impairment can impede social interaction.

Which cranial nerves assist with both sensory and motor function? Select all that apply Optic Facial Trochlear Accessory Trigeminal

Facial Trigeminal Rationale: The facial nerve (cranial nerve VII) assists with sensory perceptions such as pain and temperature from the ear area, deep sensations from the face, and taste from the anterior two-thirds of the tongue. Motor functions of this nerve include movements of muscles of the face and scalp.

The nurse teaches a client with exophthalmos how to reduce discomfort and prevent corneal ulceration. Which statement by the client indicates that teaching was effective? I should eliminate excessive blinking I should not move my extraocular muscles I should elevate the head of my bed at night I should avoid using a sleeping mask at night

I should avoid using a sleeping mask at night Rationale: The mask may irritate or scratch the eyes if the mask moves during sleep.

Which response would the nurse make to a client with schizophrenia who says, 'I'm starting to hear voices'?

I understand that you're hearing voices talking to you and that the voices are very real for you. What are the voices saying to you?

On the third day after surgery for a fractured hip, a client appears restless and says, 'I can't stand this another minute. There's a wrinkle in my sheet, and the water in my pitcher is warm.' The client changes position frequently and does not make eye contact with the nurse. Which interpretation of the client's behavior would the nurse use to determine additional actions?

Increased levels of anxiety Rationale: When a client is anxious and has a decreased ability to cope, minor environmental irritants are magnified; eye contact is avoided to decrease additional stimuli.

After many episodes of otitis media a 3 year old is to undergo myringotomy and have tubes implanted surgically. Which should the nurse include in the discharge preparation for this family?

Insert earplugs during the child's bath. Rationale: Water in the ears after myringotomy may be a source of infection.

The nurse knows that additional discharge instructions are needed for parents whose infant has just undergone corrective surgery for cleft palate when the parent makes which statement? We need to schedule regular hearing tests, even at this young age. Lying on the abdomen is prohibited, so we'll keep him in an infant seat. We know that some difficulty breathing is expected, so we'll position him upright. We'll use the elbow restraints you provided to keep him from putting his hands in his mouth.

Lying on the abdomen is prohibited, so we'll keep him in an infant seat. Rationale: After a cleft palate repair, the child is allowed to lie on the abdomen, especially immediately after surgery; this will allow drainage of secretions from the mouth.

Which condition would the nurse suspect when assessing an 11 month old infant sitting on the parent's lap crying and tugging at the right ear?

Otitis media Rationale: Young children who cannot verbalize the presence of pain use nonverbal behaviors to indicate discomfort; crying and tugging at the painful ear are typical behaviors of an infant with otitis media.

Which education would the nurse provide the parents of a 4 year old child with recurrent otitis media about the typical treatment for associated hearing loss?

Myringotomy Rationale: Myringotomy is a surgical incision of the eardrum to permit drainage of infected middle ear fluid and thus improving hearing.

Which clinical indicators would the nurse expect when assessing a client with Meniere disease? Select all that apply Nausea Dizziness Decreased pulse rate Increased temperature Jerky lateral eye movements

Nausea Dizziness Jerky lateral eye movements Rationale: Nausea is related to vertigo, which is associated with this disorder. The sensation of spinning occurs with inflammation of the inner ear. Jerky lateral eye movement (nystagmus), particularly toward the involved ear, occurs with Meniere disease.

A client says, 'I hear a man speaking from the corner of the room. Do you hear him, too?' Which response is best?

No, I don't hear him, but that must be upsetting for you. Rationale: The nurse states reality and then acknowledges the client's feelings.

Which technique used by the nurse demonstrates medication safety and effectiveness when assisting an older client to instill prescribed eyedrops for glaucoma?

Pressing the inner canthus for 1 to 2 minutes after instillation

A client who sustained a head injury reports to the nurse that food always tastes unappealingly bland even though the food has been prepared to be flavorful. Which area of the brain would the nurse suspect to be affected in the client?

Parietal lobe Rationale: Functions of the parietal lobe of brain include interpretation of taste impulses and spatial perception and understanding of sensory inputs.

Which assessment in a female client suggests an abnormal endocrine finding? Facial hair Protruding eyes Pulse of 90 bpm BP of 120/80

Protruding eyes Rationale: Protruding eyes are a clinical manifestation of hyperthyroidism, wherein the fluid accumulates in the eye and retro-orbital tissue.

The nurse is inspecting the ears of a 1 month old infant during a routine physical assessment. Which are the appropriate steps for performing an ear inspection in this client? Select all that apply Pull the pinna up and back to the 10 o'clock position Pull the pinna down and back to the 6 to 9 o'clock position Perform auditory tests by placing electrodes on child's head Refrain from restraining the child Insert a 2 mm speculum only 0.60 to 1.25 cm into the canal

Pull the pinna down and back to the 6 to 9 o'clock position Perform auditory tests by placing electrodes on child's head Rationale: The ear canal curves upward in infants. The nurse needs to pull the pinna down and back to the 6-9 o'clock range to straighten the canal for introducing the speculum. The auditory brainstem response (ABR) is used in newborns whereby activity in auditory nerve and brainstem pathways is measured by placing electrodes on the child's head.

An auditory screening reveals that a child has mild hearing loss. Which statement would the nurse use to explain this degree of hearing loss? A severe hearing deficit may develop It will not interfere with progress in school An immediate follow-up visit is not necessary Speech therapy and hearing aids may be required

Speech therapy and hearing aids may be required Rationale: A mild degree of hearing loss causes the child to miss 25-40% of conversations; it may result in speech deficits and interfere with the child's educational progress if it is not corrected. Hearing aids usually help improve function.

A client with pulmonary tuberculosis develops tinnitus and vertigo. Which antitubercular medication would the nurse suspect is causing these symptoms?

Streptomycin Rationale: Streptomycin is ototoxic and can cause damage to the eighth cranial nerve, resulting in deafness.

The nurse observes a child fail to make eye contact with parents and has poor impulse control. Upon further investigation, the child is found to have a father with a current behavior of alcohol abuse and child neglect. Which would the nurse conclude?

The child has developed reactive attachment disorder (RAD) Rationale: RAD is a psychological and developmental disorder that occurs in children who are neglected by their primary caregivers. Children with RAD are not cuddly with parents and fail to make eye contact. They also exhibit poor impulse control and may be destructive to themselves and others.

A client with diabetes mellitus complains of difficulty seeing. Which factor would the nurse suspect as being the cause?

The growth of new retina blood vessels or 'neovascularization' Rationale: Proliferative diabetic retinopathy is growth of new retinal blood vessels, also known as 'neovascularization.' When retinal blood flow is poor and hypoxia develops, retinal cells secrete growth factors that stimulate the formation of new blood vessels in the eye. These new vessels are thin, fragile, and bleed easily, leading to eye hemorrhage and vision loss. Hemorrhage in the eyes precipitate retinal detachment, resulting in blindness.

The nurse performs a Rinne test during a physical assessment of a client. The client indicates that the sound is louder when the vibrating tuning fork is placed against the mastoid bone than when held closely to the ear. Which conclusion would the nurse make about these results?

This is evidence of a conductive hearing loss. Rationale: Conductive hearing loss involves impaired transmission of sound waves to the inner ear so that sound transmitted directly through bone is perceived louder and longer than through air conductions.

While a mother is inspecting her newborn, she expresses concern that her baby's eyes are crossed. Which response by the nurse is appropriate?

This is expected. Your baby is trying to focus.

Which measures would the nurse include when teaching a client with hyperthyroidism how to manage the discomfort associated with exophthalmia? Select all that apply Use tinted glasses Use warm, moist compress Elevate head of bed 45 degrees Tape eyelids shut at night Apply a petroleum-based jelly along the lower eyelid

Use tinted glasses Elevate head of bed 45 degrees Tape eyelids shut at night Rationale: Tinted glasses decrease light on the eyes and protect eyes that are photosensitive. Elevating the head of the bed 45 degrees will promote a decrease in periorbital fluid. Taping the eyelids shut at night if they do not close reduces the risk of corneal dryness, which can lead to infection or injury.

The nurse is providing care to a preschool age client of Asian descent whose family speaks fluent English. Which assessment strategies would the nurse implement with the child and family? Select all that apply Using open-ended questions Avoiding prolonged eye contact Phrasing questions in a neutral manner Asking all questions directly to the interpreter Asking several questions for time management purposes

Using open-ended questions Avoiding prolonged eye contact Phrasing questions in a neutral manner Rationale: Open-ended questions should be used as frequently as possible during a health history interview. This is especially important for a family of Asian descent who tend to answer 'yes' or anticipate the answer the nurse wants to hear. Direct or prolonged eye contact is often seen as a sign of disrespect when assessing a family of Asian descent.

Which statement will the nurse include in the instructions for a client learning to self-administer eyedrops?

Apply pressure to the nasolacrimal duct after instillation

Which client statement is consistent with the presence of chalazion? I feel severe pain in my eyes I am unable to tolerate bright light I feel something is in my eyes I am unable to stop scratching at my eyes

I am unable to tolerate bright light Rationale: A chalazion is the painless inflammation of a sebaceous gland in the eyelid; a client with chalazion reports light sensitivity and excessive tearing.

Which test is used to diagnose diseases of the vestibular system?

Caloric reflex test Rationale: The caloric reflex test is a test of the vestibulo-ocular reflex that involves irrigating cold or warm water into the external auditory canal. It is used to check for nystagmus, nausea and vomiting, falling or vertigo, conditions associated with diseases of the vestibular system.

Which factors in a client's health history increase the risk of hearing loss? Select all that apply Diabetes Noisy environment Ear infections Vitamin C deficiency Loud Music

Diabetes Noisy environment Ear infections Loud Music Rationale: Diabetes may decrease the blood supply to the ears and thereby decrease hearing acuity. Exposure to loud noises causes hearing loss. Past ear infections may lead to a decrease in hearing acuity. Exposure to loud music often may cause loss of hearing acuity.

Which information would the registered nurse provide a nursing student about licensure? Select all that apply The hearing for suspension or revocation of a license occurs in a formal courtroom setting The hearing for suspension or revocation of a license is conducted by a panel of professionals The state board of nursing may revoke a license in case of a violation without informing the nurse Nurses must be notified of any charges they face and given an opportunity to defend themselves The state board of nursing may revoke or suspend a license if a nurse's conduct violates provisions in the licensing statutes

The hearing for suspension or revocation of a license is conducted by a panel of professionals Nurses must be notified of any charges they face and given an opportunity to defend themselves The state board of nursing may revoke or suspend a license if a nurse's conduct violates provisions in the licensing statutes

An older adult who was in a motor vehicle collision exhibits a decreased level of consciousness and serosanguineous drainage from the left ear. Which action would the nurse take>

Place a sterile pad over the external ear Rationale: A lowered LOC indicates a potential head injury, and drainage from an ear may be CSF; a sterile pad gently affixed over the ear will absorb drainage and prevent infection and can help detect the halo sign.