eyes and ears

A nurse is interviewing a client as part of a routine examination of his ears and hearing. The nurse notes that this client has high blood pressure. Which of the following questions regarding his hearing should the nurse ask that is associated with his high blood pressure?

"Do you experience any ringing, roaring, or crackling in your ears?"

Which vision acuity reading indicates blindness? 20/200 20/100 20/40 20/20

20/200

A patient in the clinic where you work is considered legally blind. The nurse knows that this means the vision in his better eye, corrected by glasses, is what? 20/300 or less 20/100 or less 20/400 or less 20/200 or less

20/200 or less

Which of the following assessment findings suggests a problem with the client's cranial nerves? A client's lens appears cloudy and she claims that her visual acuity has recently declined. A client's extraocular movements are asymmetrical and she complains of diplopia. A client states that he has recently begun seeing lights flashing in his field of vision. Fundoscopic examination reveals intraocular bleeding.

A client's extraocular movements are asymmetrical and she complains of diplopia.

You are assessing visual fields on a patient newly admitted for eye surgery. The patient's left eye repeatedly does not see your fingers until they have crossed the line of gaze. You would document that the patient has what? A left temporal hemianopsia A bitemporal hemianopsia A homonymous hemianopsia A quadrantic defect

A left temporal hemianopsia

The nurse is inspecting the cornea and lens of an elderly client and notices a white arc around the limbus of the client's eye. The nurse recognizes this condition, common in older adults, as which of the following? Ectropion Arcus senilis Myopia Presbyopia

Arcus senilis

The nurse is inspecting the cornea and lens of an elderly client and notices a white arc around the limbus of the client's eye. The nurse recognizes this condition, common in older adults, as which of the following? Myopia Ectropion Arcus senilis Presbyopia

Arcus senilis

A client is being assessed following a motor vehicle accident. The client's right eye is swollen shut and very painful. Why does this require further assessment? High-velocity injuries are typically non-penetrating Blunt-force trauma often results in fracture of the orbit This could be a sign of strabismus The client could have optiatrophy

Blunt-force trauma often results in fracture of the orbit

A nurse examines a client's retina during the ophthalmic examination and notices light-colored spots on the retinal background. The nurse should ask the client about a history of what disease process? Retinal detachment Anemia Renal insufficiency Diabetes

Diabetes

A 29-year-old physical therapist presents for evaluation of an eyelid problem. On observation, the right eyeball appears to be protruding forward. Based on this description, what is the most likely diagnosis? Ectropion Exophthalmos Ptosis Epicanthus

Exophthalmos

What is a characteristic symptom of Graves hyperthyroidism? Episcleritis Pinguecula Pterygium Exophthalmos

Exophthalmos

A six-month old male infant is brought to the emergency department by his parents for inconsolable crying and pulling at his right ear. When assessing this infant the nurse is aware that the tympanic membrane should be what color in a healthy ear?

Gray

The eustachian tube is a passage between the middle ear and the nasopharynx. What is the function of the eustachian tube? Helps to regulate pressure in the middle ear Protects the middle ear Allows for drainage of fluid from the middle ear Maintains fluid in the middle ear

Helps to regulate pressure in the middle ear

Which of the following describes a condition characterized by abnormal spongy bone formation around the stapes? Otitis externa Chronic otitis media Middle ear infection Otosclerosis

Otosclerosis (inability amplify sound)

Which statement reflects accurate documentation by the nurse of a normal, left tympanic membrane?

Pearly gray, translucent, with cone of light at 7 o'clock position

When testing the near reaction, an expected finding includes which of the following? Pupillary dilation on near gaze; constriction on distant gaze Pupillary constriction on near gaze; dilation on distant gaze Pupillary constriction on near gaze; constriction on distant gaze Pupillary dilation on near gaze; dilation on distant gaze

Pupillary constriction on near gaze; dilation on distant gaze

Which characteristic feature of the tympanic membrane should a nurse anticipate finding in a client with acute otitis media? Pearly, translucent, with no bulging Yellowish, bulging, with fluid bubbles Gray, translucent, with no retraction Red, bulging, with an absent light reflex

Red, bulging, with an absent light reflex

What part of the eye receives and transmits visual stimuli to the brain for processing? Optic disc Retina Vitreous chamber Posterior chamber

Retina

A client is assigned a visual acuity of 20/100 in her left eye. Which of the following is true? She can accurately name 20% of the letters at 20 feet. She can see at 20 feet what a normal person could see at 100 feet. She obtains a 20% correct score at 100 feet. She can see at 100 feet what a normal person could see at 20 feet.

She can see at 20 feet what a normal person could see at 100 feet.

Which action by the nurse demonstrates correct assessment of the corneal reflex of a client during an eye examination? Ask the client to read the Snellen chart Touch the cornea with a wisp of cotton Test the cornea of the eye with an ophthalmoscope Shine a penlight on the eye in a darkened room

Touch the cornea with a wisp of cotton

A nurse is inspecting a client's eyes to assess for the possibility of detached retinas. The nurse is aware that which of the following is the function of the retina? Permits the entrance of light to the eye Controls the amount of light entering the eye Transforms light rays into nerve impulses that are conducted to the brain Refracts light rays onto the posterior surface of the eye

Transforms light rays into nerve impulses that are conducted to the brain

The nurse has tested an adult client's visual fields and determined that the temporal field is 90 degrees in both eyes. The nurse should examine the client for other signs of glaucoma. document the findings in the client's records. ask the client if there is a genetic history of blindness. refer the client for further evaluation.

document the findings in the client's records.

While assessing the ears of an adult client, the nurse observes bloody drainage in the client's ear. The nurse should

refer the client to a physician.

A 52-year-old patient fails the Romberg test. The nurse explains that this might indicate a dysfunction in what part of the ear?

vestibular portion of the inner ear

A 55-year-old male client has just been diagnosed with presbycusis. In the interview with the client, the nurse should most expect the client to complain of having trouble hearing which of the following in the initial stages of this condition? The sound of his car engine starting The bass speakers of his stereo system His son giving him directions to a restaurant

A story his wife is telling him

A light is pointed at a client's pupil, which then contracts. It is also noted that the other pupil contracts as well, though it is not exposed to bright light. Which of the following terms describes this latter phenomenon? Direct reaction Accommodation Near reaction Consensual reaction

Consensual reaction

Which finding should a nurse recognize as normal when assessing the ears of an elderly client? Bulging tympanic membrane Decrease in cerumen production High-tone frequency loss Shortened earlobes

High-tone frequency loss

A client frequently experiences dry, irritated eyes. These findings are consistent with a problem in what part of the eye? Aqueous chamber Sinus Lacrimal apparatus Vitreous chamber

Lacrimal apparatus

When examining the eye with an ophthalmoscope, where would the nurse look to visualize the optic disc? Medially toward the nose Laterally toward the ear Downward toward the chin Upward toward the forehead

Medially toward the nose

The functional reflex that allows the eyes to focus on near objects is termed refraction. accommodation. pupillary reflex. indirect reflex.

accommodation.

The nurse has tested the near visual acuity of a 45-year-old client. The nurse explains to the client that the client has impaired near vision and discusses a possible reason for the condition. The nurse determines that the client has understood the instructions when the client says that presbyopia is usually due to constant misalignment of the eyes. muscle weakness. congenital cataracts. decreased accommodation.

decreased accommodation.

When assessing the fundus of the eye, the nurse recognizes which normal characteristic represented in dark-skinned individuals? fundus is grayish brown with a purplish cast no light reflex is visible the lower field of the fundus has characteristic stripes slightly darker fovea is just discernible

fundus is grayish brown with a purplish cast

The nurse is using the ophthalmoscope to examine the patient's eyes. The nurse holds the scope

in the right hand for the right eye and in the left hand for the left eye

A nurse is testing a client's pupillary reaction to light, noting that the pupil constricts when shining light obliquely into it. The nurse understands that muscles in which of the following structures adjust to control the amount of light entering the eye through the aperture of the pupil? Optic disc Lens Retina Iris

iris

The optic nerves from each eyeball cross at the visual cortex. optic disc. optic chiasma. vitreous humor.

optic chiasma.