Health Assessment Final Review (Prep U)
The nurse is caring for a 63-year-old client who can neither read nor speak English. What would be the appropriate chart to use to assess this patient's vision? Allen Snellen E Ishihara PERRLA
Snellen E Explanation: The Snellen E chart can be used for people who cannot read or speak English.
Which of the following assessment findings suggests a problem with the client's cranial nerves? A client states that he has recently begun seeing lights flashing in his field of vision. A client's extraocular movements are asymmetrical and she complains of diplopia. Fundoscopic examination reveals intraocular bleeding. 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. Explanation: Deficits in cranial nerves III, IV, and VI can manifest as impaired extraocular movements or diplopia. Flashes of light are associated with retinal detachment, while intraocular bleeding and cataracts do not have a neurological etiology.
A client performs the test for distant visual acuity and scores 20/50. How should the nurse most accurately interpret this finding? Client did not wear his glasses for this test and therefore it is not accurate. When 50 feet from the chart, the client can see better than a person standing at 20 feet. Client can read the 20/50 line correctly and two other letters on the line above. At 20 feet from the chart, the client sees what a person with good vision can see at 50 feet.
At 20 feet from the chart, the client sees what a person with good vision can see at 50 feet. Explanation: The Snellen chart tests distant visual acuity by seeing how far the client can read the letters standing 20 feet from the chart. The top number is how far the client is from the chart and the bottom number refers to the last line the client can read. A reading of 20/50 means the client sees at 20 feet what a person with normal vision can see at 50 feet. The minus number is the number of letters missed on the last line the client can distinguish.
A nurse begins the eye examination on a client who presents to the health care clinic for a routine examination. What is the correct action by the nurse to perform the test for near visual acuity? Have the client hold the Jaeger card 14 inches from the face and read with one eye at a time Sit the client in front of the examiner, extend one arm, and slowly move one finger upward Tell the client to remove glasses, if present, and read the Snellen card using both eyes Place the client 20 feet from the Snellen chart and record the smallest line the client can read
Have the client hold the Jaeger card 14 inches from the face and read with one eye at a time Explanation: Near vision is tested with a Jaeger card, Snellen card, or comparable card), held 14 inches from the face. Have the client cover one eye with an opaque card before reading from top to bottom. Sitting the client in front of the examiner, extending one arm, and slowly move one finger upward until it is seen by both the client and the examiner is a test for gross peripheral vision. If the client wears glasses, they should be left on for the test. Placing the client 20 feet from the chart and record the smallest line the client can read is the test for distant acuity.
On a health history, a client reports no visual disturbances, last eye exam being 2 years ago, and not wearing glasses. The nurse notices that the client squints when signing the consent for treatment form and holds the paper close to the face. What should the nurse do next? Document the findings in the client's record Perform both the distant and near visual acuity tests Test the pupils for direct and consensual reaction to light Obtain a referral to the ophthalmologist for a complete eye exam
Perform both the distant and near visual acuity tests Explanation: The first thing the nurse should do is perform both the distant and near visual acuity exams to assess for loss of far and near vision. Testing the pupil is important to assess reaction to light. The findings must be documented in the client's record. If abnormalities are found upon assessment, the client should be referred for a complete eye examination.
A client complains of pain in the calves, thighs, and buttocks whenever he climbs more than a flight of stairs. This pain, however, is quickly relieved as soon as he sits down and rests. The nurse should suspect which of the following conditions in this client? Advanced chronic arterial occlusive disease Neuropathy secondary to diabetes Venous disease Peripheral arterial disease
Peripheral arterial disease Explanation: Intermittent claudication is characterized by weakness, cramping, aching, fatigue, or frank pain located in the calves, thighs, or buttocks but rarely in the feet with activity. These symptoms are quickly relieved by rest but reproducible with same degree of exercise and may indicate peripheral arterial disease (PAD). Leg pain that awakens a client from sleep is often associated with advanced chronic arterial occlusive disease. A lack of pain sensation may signal neuropathy in such disorders as diabetes. Heaviness and an aching sensation aggravated by standing or sitting for long periods of time and relieved by rest are associated with venous disease.
What pulse is located in the groove between the medial malleolus and the Achilles tendon? Posterior tibial Dorsalis pedis Popliteal Femoral
Posterior tibial Explanation: The posterior tibial pulse is located in the groove between the medial malleolus and the Achilles tendon. The femoral pulse is about halfway between the symphysis pubis and the anterior iliac spine, just below the inguinal ligament. The popliteal pulse is often difficult to locate. It may be felt immediately lateral to the medial tendon. A light touch is important to avoid obliterating the dorsalis pedis pulse. It is normally about halfway up the foot immediately lateral to the extensor tendon of the great toe.
A nurse notices a middle-aged client in the waiting room pick up a magazine to read while she waits to be seen. She opens the magazine and then extends her arms to move it further from her eyes. Which condition does the nurse most suspect in this client? Exotropia Esotropia Strabismus Presbyopia
Presbyopia Explanation: Presbyopia, which is impaired near vision, is indicated when the client moves a reading chart or other reading material away from the eyes to focus on the print. It is caused by decreased accommodation and is a common condition in clients over 45 years of age. With the cover test, the eyes of the client should remain fixed straight ahead. If the covered eye moves when uncovered to reestablish focus, it is abnormal. If the eye turns outward it is called exotropia. If the uncovered eye turns inward, it is called esotropia. Strabismus is constant malalignment of the eyes.
The nurse is caring for a 63-year-old client who can neither read nor speak English. What would be the appropriate chart to use to assess this patient's vision? Allen Snellen E Ishihara PERRLA
Snellen E Explanation: The Snellen E chart can be used for people who cannot read or speak English.
As part of a physical assessment, the nurse performs the confrontation test to assess the client's peripheral vision. Which test result should a nurse recognize as indicating normal peripheral vision for a client using the confrontation test? Client's consensual pupil constricts in response to indirect light. Eyes converge on an object as it is moved towards the nose. Direct light shown into the client's pupils results in constriction. The client and the examiner see the examiner's finger at the same time.
The client and the examiner see the examiner's finger at the same time. Explanation: The observation that the client and examiner see the examiner's finger at the same time indicates normal peripheral vision. The client not seeing the examiner's finger or a delay in seeing it indicates reduced peripheral vision. Client's consensual pupils constricting in response to indirect light as well as direct light shown into the client's pupils resulting in constriction are observed when testing the pupils for reaction to light. Eyes converging on an object as it is moved towards the nose is a normal result for accommodation.
What notation demonstrates the nurses understanding of effective documentation when the assessment findings identify thick, purulent drainage in both eyes of a client? Thick, purulent drainage is noted at inner corner of OD. Thick, purulent drainage is noted at inner corner of OS. Thick, purulent drainage is noted at inner corner of OU. Thick, purulent drainage is noted at inner corner of both eyes.
Thick, purulent drainage is noted at inner corner of both eyes. Explanation: The abbreviations OD (right eye), OS (left eye), and OU (both eyes) are no longer used due to the potential for order errors. Instead, it is recommended to use "right eye," "left eye," or "both eyes."
What notation demonstrates the nurses understanding of effective documentation when the assessment findings identify thick, purulent drainage in both eyes of a client? Thick, purulent drainage is noted at inner corner of OD. Thick, purulent drainage is noted at inner corner of OS. Thick, purulent drainage is noted at inner corner of OU. Thick, purulent drainage is noted at inner corner of both eyes.
Thick, purulent drainage is noted at inner corner of both eyes. Explanation: The abbreviations OD (right eye), OS (left eye), and OU (both eyes) are no longer used due to the potential for order errors. Instead, it is recommended to use "right eye," "left eye," or "both eyes."
While performing a routine check-up on an 81-year-old retired grain farmer in the vascular surgery clinic, the nurse notes that he has a history of chronic arterial insufficiency. Which of the following physical examination findings of the lower extremities would be expected with this disease? Normal pulsation Normal temperature Marked edema Thin, shiny, atrophic skin
Thin, shiny, atrophic skin Explanation: Thin, shiny, atrophic skin is more commonly seen in chronic arterial insufficiency; in chronic venous insufficiency the skin often has a brown pigmentation and may be thickened.
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? Refracts light rays onto the posterior surface of the eye Controls the amount of light entering the eye Transforms light rays into nerve impulses that are conducted to the brain Permits the entrance of light to the eye
Transforms light rays into nerve impulses that are conducted to the brain Explanation: Visual perception occurs as light rays strike the retina, where they are transformed into nerve impulses, conducted to the brain through the optic nerve, and interpreted. The lens functions to refract (bend) light rays onto the retina. Muscles in the iris adjust to control the pupils size, which controls the amount of light entering the eye. The cornea permits the entrance of light, which passes through the lens to the retina.
The functional reflex that allows the eyes to focus on near objects is termed pupillary reflex. accommodation. refraction. indirect reflex.
accommodation. Explanation: Accommodation is a functional reflex allowing the eyes to focus on near objects. This is accomplished through movement of the ciliary muscles, causing an increase in the curvature of the lens.
The meibomian glands secrete an oily substance to lubricate the eyes. sweat. hormones. clear liquid tears.
an oily substance to lubricate the eyes. Explanation: Meibomian glands secrete an oily substance that lubricates the eyelid.
Which question should the nurse ask when assessing a client for a possible detached retina? "Is your vision loss located in the center of your view of vision?" "Are you seeing flashing lights?" "Can you see objects on the outer edges of your field of vision?" "Is the vision in both of your eyes affected?"
"Are you seeing flashing lights?" Explanation: Flashing lights suggest detachment of vitreous from retina. Slow central loss of vision is associated with macular degeneration. Peripheral loss in advanced open-angle glaucoma. Bilateral loss is often related to a chemical exposure.
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 have any ear pain?" "Do you experience any ringing, roaring, or crackling in your ears?" "Do you have any ear drainage?" "Are you ever concerned that you may be losing your ability to hear well?"
"Do you experience any ringing, roaring, or crackling in your ears?" Explanation: Ringing in the ears (tinnitus) may be associated with excessive ear wax buildup, high blood pressure, or certain ototoxic medications. None of the other questions pertains to conditions related to high blood pressure. Ear pain is associated with ear infections, cerumen blockage, sinus infections, teeth and gum problems, and swimmer's ear. Drainage usually indicates infection. Hearing loss may be related to any number of causes but is not associated with high blood pressure.
The nurse is assessing cranial nerves III, IV, and VI. Which instructions should the nurse provide to the client in order to perform this assessment? "Follow my finger with only your eyes." "Rotate your head from side to side." "Shrug your shoulders as I push down on them." "Stand very still with your eyes closed."
"Follow my finger with only your eyes." Explanation: Testing cranial nerves III, IV, and VI also tests the movement of the eye muscles by asking the client to move the eyes in different directions. Turning the head assesses neck range of motion and mobility. Shrugging shoulder against resistance assesses a different cranial nerve. Asking the client to stand still with the eyes closed is known as the Romberg's test to test balance.
A 52-year-old patient with myopia calls the ophthalmology clinic very upset. Shetells the nurse, "I keep seeing semi-clear spots floating across my vision. What is wrong with me?" What would be the most appropriate response by the nurse? "It is not an uncommon finding in people older than 40 years for this to happen. They are called 'floaters'." "Please come into the clinic right away so we can see what is wrong." "Because it is almost 5 o'clock, please go to the emergency department right away. This sounds very serious." "I have an opening tomorrow at 2 in the afternoon. Can you come in then?"
"It is not an uncommon finding in people older than 40 years for this to happen. They are called 'floaters'." Explanation: Floaters (translucent specks that drift across the visual field) are common in people older than 40 years of age and nearsighted patients; no additional follow-up is needed.
A 6-year-old boy has come to the clinic with his mother because of recent eye redness and discharge. The nurse's assessment has suggested a diagnosis of conjunctivitis. What should the nurse tell the mother about her son's eye? "In children, this problem is usually caused by an increase in pressure within the eye." "I'll prescribe some analgesics because your son is likely to have quite severe pain while his eye heals." "Antibiotics will clear this up, but you need to make sure he gets them as ordered to avoid vision damage." "This might have been the result of an allergy, but most likely it was caused by a bacteria or virus."
"This might have been the result of an allergy, but most likely it was caused by a bacteria or virus." Explanation: Conjunctivitis usually has an infectious etiology. Severe pain and vision damage are not common consequences.
The results of a client's Rinne test are as follows: bone condcution > air conduction. How should the nurse explain these findings to the client? "You have a high frequency hearing loss." "You have a conductive hearing loss." "You have nerve damage in your ears." "You have a unilateral hearing loss." "You have nerve damage in your ears." "You have a unilateral hearing loss."
"You have a conductive hearing loss." Explanation: The Rinne test tests for conductive hearing loss. The client's results indicate that bone conduction is greater than air conduction which indicates conductive hearing loss. Air conduction should be twice as long as bone conduction. The whisper test evaluates loss of high frequency sounds. An audiogram can reveal a nerve related or unilateral hearing loss.
Which vision acuity reading indicates blindness? 20/20 20/200 20/40 20/100
20/200 Explanation: The reading of 20/200 on a vision acuity test indicates blindness. The reading of 20/20 is considered normal vision. This means that the client being tested can distinguish what a person with normal vision can distinguish from 20 feet away. The top or first number is always 20, indicating the distance from the client to the chart. The bottom or second number refers to the last full line the client could read. The higher the second number, the poorer the vision. 20/40 and 20/100 also denote poor vision.
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? 20/100 or less 20/200 or less 20/300 or less 20/400 or less
20/200 or less Explanation: In the United States, a person is usually considered legally blind when vision in the better eye, corrected by glasses, is 20/200 or less.
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? 20/100 or less 20/200 or less 20/300 or less 20/400 or less
20/200 or less Explanation: In the United States, a person is usually considered legally blind when vision in the better eye, corrected by glasses, is 20/200 or less.
When visual acuity is tested using the Snellen eye chart, which result suggests better distance vision? 20/20 20/25 30/20 20/15
30/20 Explanation: The denominator in the Snellen eye chart refers to the distance in feet that a person with normal vision could read a line of text, while the numerator indicates the client's distance from the chart. Thus, a client with 30/20 vision can read text at distance of 30 feet that someone with a healthy, normal eye can only read at a distance of 20 feet. Vision of 20/15 is superior to norms, but not to the same extent as 30/20 vision.
Blood from the lower trunk and legs drains upward into the inferior vena cava. The percentage of the body's blood volume that is contained in the veins is nearly 50%. 60%. 70%. 80%.
70% Explanation: Blood from the lower trunk and legs drains upward into the inferior vena cava. The veins contain nearly 70% of the body's blood volume.
The nurse notes a tophus of the ear of an older adult. Which assessment data is consistent with a tophus? A hard nodule composed of uric acid crystals A sac with a membranous lining filled with fluid Scarring of the tympanic membrane Redness and bulging of the eardrum
A hard nodule composed of uric acid crystals Explanation: A tophus is a hard nodule composed of uric acid crystals. A cyst on the ear would present as a fluid-filled sac. Redness and bulging of the eardrum is characteristic of otitis media with effusion. Scarring of the tympanic membrane occurs with repeated ear infections with perforation of the tympanic membrane
A 2-month-old infant is being examined at the pediatrician's office. The mother said she noticed the baby was not making tears in the left eye. What does this finding suggest? A blocked lacrimal apparatus Blepharitis Vision loss Amblyopia
A blocked lacrimal apparatus Explanation: Infants begin making tears at approximately 2 weeks old. Lack of tear production is a sign of a blocked lacrimal apparatus. Amblyopia is a lazy eye. Blepharitis is inflammation of the margin of the eyelid. Lack of tears is not indicative of vision loss.
Which of the following assessment findings suggests a problem with the client's cranial nerves? A client states that he has recently begun seeing lights flashing in his field of vision. A client's extraocular movements are asymmetrical and she complains of diplopia. Fundoscopic examination reveals intraocular bleeding. 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. Explanation: Deficits in cranial nerves III, IV, and VI can manifest as impaired extraocular movements or diplopia. Flashes of light are associated with retinal detachment, while intraocular bleeding and cataracts do not have a neurological etiology.
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 homonymous hemianopsia A bitemporal hemianopsia A quadrantic defect
A left temporal hemianopsia Explanation: When the patient's left eye repeatedly does not see your fingers until they have crossed the line of gaze, a left temporal hemianopsia is present.
Which of the following wounds is most likely attributable to neuropathy? A painful wound in the client's shin, which is surrounded by apparently healthy skin A moderately painful wound on the lateral aspect of the client's ankle A painless wound on the sole of the client's foot, which is surrounded by calloused skin A wound on a client's highly edematous ankle that is surrounded by pigmented skin
A painless wound on the sole of the client's foot, which is surrounded by calloused skin Explanation: Neuropathic ulcers tend to develop on pressure points, such as the sole of the foot, and are often free of pain. Painful wounds surrounded by healthy skin are associated with arterial insufficiency and moderately painful ankle wounds surrounded by pigmented skin are often associated with venous ulcers.
What do retinal abnormalities include? Age-related macular degeneration Mydriasis Argyll Robertson syndrome Horner's syndrome
Age-related macular degeneration Explanation: Age-related macular degeneration gradually causes loss of sharp central vision, needed for common daily tasks (eg, driving, reading). The macula degenerates (dry) or abnormal blood vessels behind the retina grow under the macula (wet). Mydriasis, Argyll Robertson syndrome, and Horner's syndrome all affect the pupils, not the retina.
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? Arcus senilis Presbyopia Ectropion Myopia
Arcus senilis Explanation: Arcus senilis, a normal condition in older clients, appears as a white arc around the limbus. The condition has no effect on vision. Presbyopia, which is impaired near vision, is caused by decreased accommodation and is a common condition in clients over 45 years of age. Ectropion is when the lower eyelids evert, causing exposure and drying of the conjunctiva. This is a normal finding in the older client. Myopia is impaired far vision.
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? Arcus senilis Presbyopia Ectropion Myopia
Arcus senilis Explanation: Arcus senilis, a normal condition in older clients, appears as a white arc around the limbus. The condition has no effect on vision. Presbyopia, which is impaired near vision, is caused by decreased accommodation and is a common condition in clients over 45 years of age. Ectropion is when the lower eyelids evert, causing exposure and drying of the conjunctiva. This is a normal finding in the older client. Myopia is impaired far vision.
A mother of a small child calls the clinica and asks to schedule an appointment for ear tube removal. The call is transferred to the nurse. What is the nurse's best action? Schedule first available office appointment. Schedule appointment at hospital for tubes to be removed surgically. Ask healthcare provider about prescribing antibiotics before removal. Ask the mother how long the tubes have been in place.
Ask the mother how long the tubes have been in place. Explanation: Ear tubes generally fall out spontaneously in 2-5 years after placement, and the membrane most often closes. The client does not need manual removal in the office or operating room unless the child is experiencing problems. Antibiotics are indicated for infection and are not necessary for removal.
Which technique by the nurse demonstrates proper use of the ophthalmoscope? Uses right eye to examine the client's left eye Moves the scope around so the entire optic disk may be seen Approaches the client directly in front of the pupil Asks the client to fix the gaze upon an object and look straight ahead
Asks the client to fix the gaze upon an object and look straight ahead Explanation: After turning on the ophthalmoscope, the nurse should ask the client to gaze straight ahead and slightly upward. Ask the client to remove glasses but keep contact lens in place. The nurse should use the right eye to examine the right eye & left eye to examine the client's left eye. This allows the nurse to get as close as possible to the client's eye. Begin about 10-15 inches from the client at a 15 degree angle. The nurse should keep the ophthalmoscope still & ask the client to look into the light to view the fovea and macula.
A nurse assesses the peripheral vascular system of a client who is in the supine position. What further assessment should the nurse perform if unable to palpate the left popliteal pulse? Palpate the right leg with the client in supine position. Elevate and palpate the left leg in supine position. Assist the client to the prone position and palpate again. Place the client in the lateral position and palpate.
Assist the client to the prone position and palpate again. Explanation: If the nurse is unable to palpate the popliteal artery with the client in supine position, the nurse should assist the client to prone position and palpate again. If the nurse is still unable to palpate, a Doppler should be used. The nurse may partially raise the client's leg and place the fingers deep in the bend of the knee when in prone position, not in supine position. The nurse need not assist the client to lateral position and palpate.
As a part of the ear examination for hearing loss, a nurse conducts a Weber test on a client. To accurately perform this test, the nurse should place the base of the tuning fork in which of the following locations? At the center of the client's forehead On the client's mastoid process In front of the external auditory canal Behind the external auditory canal
At the center of the client's forehead Explanation: During a Weber test for assessment of hearing loss, the nurse should place the tuning fork at the center of the client's forehead. Placing the base of the tuning fork at the client's mastoid process and placing the prongs of the tuning fork in front of the external auditory canal are part of the Rinne test. Placing the base of the tuning fork in front of or behind the external auditory canal is an inappropriate technique.
A client presents to the health care clinic with reports of swelling, pain, and coolness of the lower extremities. The nurse should recognize that which of these lifestyle practices are risk factors for peripheral vascular disease? Select all that apply. Cigarette smoking Regular exercise Stress-reduction techniques Low alcohol intake Previous use of hormones High-fat diet
Cigarette smoking Previous use of hormones High-fat diet Explanation: The risk factors for the development of peripheral vascular disease include smoking, lack of exercise, high stress, moderate to high alcohol intake, previous use of hormonal birth control (females), and a high-fat diet.
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 Consensual reaction Near reaction Accommodation
Consensual reaction Explanation: The constriction of the contralateral pupil is called the consensual reaction. The response of the ipsilateral eye is the direct response. The dilation of the pupil when focusing on a close object is the near reaction. Accommodation is the changing of the shape of the lens to sharply focus on an object.
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 Consensual reaction Near reaction Accommodation
Consensual reaction Explanation: The constriction of the contralateral pupil is called the consensual reaction. The response of the ipsilateral eye is the direct response. The dilation of the pupil when focusing on a close object is the near reaction. Accommodation is the changing of the shape of the lens to sharply focus on an object.
Which of the following assessment findings is most congruent with chronic arterial insufficiency? Brown pigmentation around a client's ankles and shins Ulceration on the medial surface of the client's ankle Thickened and scarred skin on the client's ankle Cool foot temperature and ulceration on the client's great toe
Cool foot temperature and ulceration on the client's great toe Explanation: Pigmentation, medial ankle ulceration, and thickened, scarred skin are associated with venous insufficiency, while low temperature and toe ulceration are more commonly found in cases of arterial insufficiency.
A nurse palpates a client's hands and fingers. Which of the following findings would be consistent with arterial insufficiency? Cool skin Capillary refill time of 2 seconds Bilateral radial pulses of 2+ Epitrochlear lymph nodes not palpable
Cool skin Explanation: A cool extremity may be a sign of arterial insufficiency. The other findings listed are all normal.
A client has been diagnosed with astigmatism. The nurse should be prepared to teach the client about which treatment for this condition? Surgery Daily use of eye drops Corrective lenses No night driving
Corrective lenses Explanation: Astigmatism is corrected with a cylindrical lens that has more focusing power in one access than the other. These corrective lenses can and should be worn while driving at night. Eye drops and surgery are not usual treatments for this condition.
The nurse is assessing a client's visual acuity and visual fields. The nurse evaluates that the assessment results are within expected parameters. How should the nurse document this assessment finding? Cranial nerve II intact Cranial nerves III, IV, and VI intact Cranial nerve XI intact Cranial nerve I intact
Cranial nerve II intact Explanation: Cranial nerve II, or the optic nerve, is tested by assessing visual acuity, visual fields, and through fundoscopic examination. The cardinal fields of gaze and pupil reaction are tested when assessing cranial nerves III, IV, and VI. Cranial nerve I is the olfactory nerve. Cranial nerve XI is the accessory nerve.
A patient asks a nurse if any foods promote eye health. What food would the nurse include as a response? Deep-water fish Low-fat meat Foods that contain lots of water Multigrain foods
Deep-water fish Explanation: Foods that promote eye health include deep-water fish, fruits, and vegetables (e.g., carrots, spinach).
What is a characteristic symptom of Graves hyperthyroidism? Pterygium Exophthalmos Pinguecula Episcleritis
Exophthalmos Explanation: In exophthalmos the eyeball protrudes forward. When bilateral, it suggests the infiltrative ophthalmopathy of Graves hyperthyroidism.
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? Ptosis Exophthalmos Ectropion Epicanthus
Exophthalmos Explanation: In exophthalmos, the eyeball protrudes forward. If it is bilateral, it suggests the presence of Graves' disease, although unilateral exophthalmos could still be caused by Graves' disease. Alternative causes include a tumour and inflammation in the orbit.
When performing the cover test, a nurse notices that the client's left eye turns outward. How should the nurse document this finding in the client's record? Exotropia Esotropia Strabismus Presbyopia
Exotropia Explanation: With the cover test, the eyes of the client should remain fixed straight ahead. If the covered eye moves when uncovered to reestablish focus, it is abnormal. If the eye turns outward it is called exotropia. If the uncovered eye turns inward, it is called esotropia. Strabismus is constant malalignment of the eyes. Presbyopia is impaired near vision.
When performing the cover test, a nurse notices that the client's left eye turns outward. How should the nurse document this finding in the client's record? Exotropia Esotropia Strabismus Presbyopia
Exotropia Explanation: With the cover test, the eyes of the client should remain fixed straight ahead. If the covered eye moves when uncovered to reestablish focus, it is abnormal. If the eye turns outward it is called exotropia. If the uncovered eye turns inward, it is called esotropia. Strabismus is constant malalignment of the eyes. Presbyopia is impaired near vision.
A client exhibits purulent drainage in the right external ear canal. The client complains of pain that increases when the ear is touched. Which client teaching instructions should the nurse provide? Take over the counter common cold remedies to resolve the problem. Finish the entire course of antibiotic therapy. Permanent deafness is common with this condition. Tympanostomy tubes will usually fall out on their own over time.
Finish the entire course of antibiotic therapy. Explanation: The client's symptoms are consistent with otitis externa, usually treated with antibiotics and pain medication. The inflammation can cause temporary deafness, but permanent deafness is not common. Tympanostomy tubes are placed for middle ear effusions, not otitis externa.
A client visits a community clinic reporting severe allergies causing a "crackling sensation" in the ear. The physician diagnoses serous otitis media. Which of the following is a characteristic of this condition? Fluid collects in the middle ear causing an obstruction of the auditory tube. An upper respiratory infection spreads through the auditory tube. This condition develops if acute purulent otitis media is not treated promptly. This condition is usually associated with a puncture eardrum.
Fluid collects in the middle ear causing an obstruction of the auditory tube. Explanation: Serous otitis media results from fluid that collects in the middle ear, causing an obstruction of the auditory tube. This condition may stem from infection, allergy, tumors, or sudden changes in altitude. Symptoms include crackling sensations and fullness in the ear, with some hearing loss. Acute purulent otitis media is generally caused by an upper respiratory infection spreading through the auditory tube. Pus forms and collects in the middle ear to create pressure on the eardrum. Chronic otitis media can develop if acute purulent otitis media is not treated promptly. Chronic purulent otitis media is usually associated with a punctured eardrum or may be a complication of acute otitis media, mastoiditis, or a severe upper respiratory infection.
A client shares that a first-degree relative has an eye problem, but they not sure what the diagnosis is. What major eye problem will the nurse suggest screening the client for? Retinoblastoma Strabismus Retinitis pigmentosa Glaucoma
Glaucoma Explanation: Glaucoma in a first-degree relative increases the client's risk for the same problem two to three times. Retinoblastoma can be inherited from either parent but does not have increased incidence if a first-degree relative has the disease. Retinitis pigmentosa is also a genetic disease, but a client's risk of the disease is not increased if a first-degree relative is affected. Strabismus is not genetic in nature.
A client reports the appearance of rings around lights. A nurse should perform further assessment to confirm the onset of what disorder? Diabetes Cataract Glaucoma Hypertension
Glaucoma Explanation: Seeing rings around lights or halos is associated with narrow angle glaucoma. Diabetes produces change in the retina that can cause blurred vision. Cataracts are caused by clouding of the lens of the eyes. Hypertension affects the blood vessels of the eyes which may not cause any eye symptoms until the damage is severe.
A nurse is preparing to perform a general assessment of an adult client who is new to the clinic. How would the nurse prepare to obtain objective data about the client's ears? (Select all that apply.) Have the client sit on the examination table Place the client in semi-Fowler's position on the examination table Make sure the client is comfortable in a quiet room Perform the whisper, Weber, and Rinne tests before inspection Place the client's ears at the nurse's eye level
Have the client sit on the examination table Explanation: To obtain objective data about the ears, it is best to make sure the client is comfortable and the room is quiet. It is ideal for the client's ears to be at the nurse's eye level to facilitate inspection that does not cause discomfort for the client. For adults and older children, nurses can perform the examination with the patient sitting on the examination table. The nurse would inspect before performing the whisper, Weber, and Rinne tests. The client would sit in the upright position, not semi-Fowler's position for the exam.
A client presents to the emergency department after being hit in the head with a baseball bat during a game. The nurse should assess for which condition? Hyphema Blepharitis Chalazion Iris nevus
Hyphema Explanation: Hyphema is blood in the anterior chamber of the eye, usually caused by blunt trauma. Blepharitis is inflammation of the margin of the eyelid. Chalazion is a cyst in the eyelid. Iris nevus is a rare condition affecting one eye. The latter 3 conditions are not commonly attributed to blunt force trauma to the head as hyphema is.
The nurse is planning care for a patient recovering from orthopedic surgery. Interventions should be included to address which contributing factor to deep vein thrombosis development? Immobility Obesity Smoking Hypertension
Immobility Explanation: Immobility can lead to blood stasis, which is a contributing factor to the development of a deep vein thrombosis. Obesity is a risk factor for the development of arterial and venous disease. Smoking is a risk factor for arterial and venous disease and for the development of an abdominal aortic aneurysm. Hypertension is a risk factor for arterial disease and abdominal aortic aneurysm.
A middle-aged client reports difficulty in reading. Which action by the nurse is appropriate to test near visual acuity using a Jaeger reading card? Place the chart 20 feet away from the client on the wall Instruct the client to hold the chart away from the body at arm's length Instruct the client hold the chart 14 inches from the eyes Place the chart on a table 17 inches away from the client
Instruct the client hold the chart 14 inches from the eyes Explanation: To test near visual acuity, the nurse should have the client hold the chart 14 inches from the eyes. The Snellen chart should be kept at eye level, 20 feet away on the wall when testing for distant vision. An arms length is an arbitrary length depending on the size of the client and is not an accurate method for testing. The chart should not be placed on a table 17 inches away from the client.
A middle-aged client reports difficulty in reading. Which action by the nurse is appropriate to test near visual acuity using a Jaeger reading card? Place the chart 20 feet away from the client on the wall Instruct the client to hold the chart away from the body at arm's length Instruct the client hold the chart 14 inches from the eyes Place the chart on a table 17 inches away from the client
Instruct the client hold the chart 14 inches from the eyes Explanation: To test near visual acuity, the nurse should have the client hold the chart 14 inches from the eyes. The Snellen chart should be kept at eye level, 20 feet away on the wall when testing for distant vision. An arms length is an arbitrary length depending on the size of the client and is not an accurate method for testing. The chart should not be placed on a table 17 inches away from the client.
A 57-year-old maintenance worker comes to the office for evaluation of pain in his legs. He is a two-pack per day smoker since the age of 16, but he is otherwise healthy. The nurse is concerned that the client may have peripheral vascular disease. Which of the following is part of common or concerning symptoms for the peripheral vascular system? Intermittent claudication Chest pressure with exertion Shortness of breath Knee pain
Intermittent claudication Explanation: Intermittent claudication is leg pain that occurs with walking and is relieved by rest. It is a key symptom of peripheral vascular disease. This symptom is present in only about one third of clients with significant arterial disease and, if found, calls for more aggressive management of cardiovascular risk factors. Screening with ankle-brachial index can help detect this problem.
A 60-year-old client is concerned about developing cataracts in her eyes. She asks the nurse whether there is anything she can do to reduce her risk. Consumption of which of the following foods should the nurse recommend to the client for this purpose? Select all that apply. Kale Red wine Eggs Turkey Oranges Skim milk
Kale Eggs Oranges Explanation: Lutein and zeaxanthin found in green leafy vegetables, eggs, and other foods reduce the risk of chronic eye diseases, including age-related macular degeneration and cataracts. Foods rich in these nutrients include kale, spinach, collards, turnip greens, corn, green peas, broccoli, romaine lettuce, green beans, eggs, and oranges. Consumption of red wine, turkey, and skim milk are not associated with a reduced risk for cataracts.
A client frequently experiences dry, irritated eyes. These findings are consistent with a problem in what part of the eye? Vitreous chamber Aqueous chamber Lacrimal apparatus Sinus
Lacrimal apparatus Explanation: The lacrimal apparatus (which consists of the lacrimal gland, punctum, lacrimal sac, and nasolacrimal duct) protects and lubricates the cornea and conjunctiva by producing and draining tears.
A client frequently experiences dry, irritated eyes. These findings are consistent with a problem in what part of the eye? Vitreous chamber Aqueous chamber Lacrimal apparatus Sinus
Lacrimal apparatus Explanation: The lacrimal apparatus (which consists of the lacrimal gland, punctum, lacrimal sac, and nasolacrimal duct) protects and lubricates the cornea and conjunctiva by producing and draining tears.
The client has a history of breast cancer with reconstructive surgery. The nurse should assess the client for what potential complication? Lymphedema Peripheral arterial disease Venous stasis Varicose veins
Lymphedema Explanation: Lymphedema can be a result of scarring injury, removal of lymph nodes, radiation or chronic infection. Peripheral arterial disease is caused by decreased arterial blood supply. Venous stasis is due to blood not moving which puts the client at risk for varicose veins.
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 Upward toward the forehead Downward toward the chin
Medially toward the nose Explanation: Follow the blood vessels as they get wider. Follow the vessels medially toward the nose and look for the round yellowish orange structure which is the optic disc.
What are the glands that are located on the tarsal plates and open on the lid margins? Levator glands Chalazion glands Pterygium glands Meibomian glands
Meibomian glands Explanation: Within the eyelids lie firm strips of connective tissue called tarsal plates. Each plate contains a parallel row of meibomian glands, which open on the lid margin.
When teaching a class of school-age children about hygiene, the nurse should include which information about the ears? Ears should be cleaned with cotton applicators once a day at bedtime. Never put anything smaller than your elbow in your ears. Only allow your parents clean out your ears with cotton applicators. Producing less earwax can lead to a hearing loss.
Never put anything smaller than your elbow in your ears. Explanation: The nurse should reinforce proper cleaning techniques such as cleaning the bowl of the helix and never introducing anything into the external auditory canal. An elbow will not fit into an ear canal; therefore stating not to put anything smaller than an elbow into the ears, eliminates putting anything into the external ear canal. It's also a fun way to educate school age children. Cotton tipped applicators can cause complications and should not be used to clean the ears. An increased amount of earwax, not decreased, can lead to conductive hearing loss.
If palpable, superficial inguinal nodes are expected to be: Fixed, tender, and at 2.5 cm in diameter Discrete, tender, and 2 cm in diameter Nontender, mobile, and 1 cm in diameter Fixed, nontender, and 1.5 cm in diameter
Nontender, mobile, and 1 cm in diameter Explanation: Healthy lymph nodes are nontender and mobile. Inguinal lymph nodes can be 1 to 2 cm in diameter.
When assessing the lymph system of an adult client, the nurse notes that the epitrochlear nodes are nonpalpable. What does this indicate? Atherosclerosis Normal finding Possible lymphoma No lymphedema
Normal finding Explanation: Normally, the epitrochlear nodes are not palpable. Normal palpable nodes are 2 cm or less. Nonpalpable epitrochlear nodes are not an indication of lymphoma or atherosclerosis. They are not related to lymphedema or its absence.
A patient comes to the clinic and reports pain when he touches his ear. With what is this finding most consistent? Acoustic neuroma Otitis externa Otitis media Meniere disease
Otitis externa Explantion: Pain with auricle movement or tragus palpation indicates otitis externa or furuncle.
Goals, although not specific for peripheral vascular disease, focus on areas of risk. What are these areas of modifiable risk? Select all that apply. Overweight Lack of exercise Family history Ethnicity Smoking
Overweight Lack of exercise Smoking Explanation:Goals are not specific for peripheral vascular disease but instead focus on areas of risks for such disease, such as smoking, overweight, and lack of regular exercise. Family history and ethnicity are not modifiable risk factors.
On a health history, a client reports no visual disturbances, last eye exam being 2 years ago, and not wearing glasses. The nurse notices that the client squints when signing the consent for treatment form and holds the paper close to the face. What should the nurse do next? Document the findings in the client's record Perform both the distant and near visual acuity tests Test the pupils for direct and consensual reaction to light Obtain a referral to the ophthalmologist for a complete eye exam
Perform both the distant and near visual acuity tests Explanation: The first thing the nurse should do is perform both the distant and near visual acuity exams to assess for loss of far and near vision. Testing the pupil is important to assess reaction to light. The findings must be documented in the client's record. If abnormalities are found upon assessment, the client should be referred for a complete eye examination.
A client reports pain in the legs that begins with walking but is relieved by rest. Which condition should the nurse assess the client for? Obstruction in the femoral artery Peripheral vascular problems Diabetes mellitus Calcium deficiency
Peripheral vascular problems Explanation: The nurse should assess the client for peripheral vascular problems in both the legs. Intermittent claudication is a condition that indicates vascular deficiencies in the peripheral vascular system. In case of an acute obstruction, the leg pain would persist even when the client stopped walking. Diabetes can cause pain as a result of diabetic neuropathy, which is unrelated to walking. Low calcium level may cause leg cramps but would not necessarily be related to walking.
Which precaution should a nurse take to ensure the safety of a client when performing the Romberg test? Instruct the client to hold on to a chair Offer assistance by holding the client's arm Place arms around the client without touching Tell the client to keep the eyes open & focused ahead
Place arms around the client without touching Explanation: During the Romberg test, the nurse should put his or her arms around the client without touching to prevent the client from falling. The eyes are closed to assess the client's ability to maintain equilibrium without looking or holding onto something. The client should not be instructed to hold on to a chair during the test as it may interfere with the assessment of equilibrium. The nurse should not hold the client's arm as it would give support to the client and affect the result.
In order to effectively examine a patient's eyes with an ophthalmoscope, the The nurse should follow which procedure related to this piece of equipment? Remove eyeglasses before looking into the ophthalmoscope. Place the ophthalmoscope in the right hand and look through the right eye. Place the ophthalmoscope in the left hand and look through the right eye. Close the eye that is not looking through the ophthalmoscope during the examination.
Place the ophthalmoscope in the right hand and look through the right eye. Explanation: When using the ophthalmoscope, the nurse should hold the scope in the right hand and use the right eye. The nurse should wear glasses or contacts when using an ophthalmoscope for an examination. The nurse should not place the scope in the left hand and look through the right eye. The nurse should keep both eyes open during the examination.
Which terms refers to the progressive hearing loss associated with aging? Presbycusis Exostoses Otalgia Sensorineural hearing loss
Presbycusis Explanation: Both middle and inner ear age-related changes result in hearing loss. Exostoses refers to small, hard, bony protrusions in the lower posterior bony portion of the ear canal. Otalgia refers to a sensation of fullness or pain in the ear. Sensorineural hearing loss is loss of hearing related to damage of the end organ for hearing and/or cranial nerve VIII.
The nurse observes a middle-aged colleague fully extending her arm to read the label on a vial of medication. Which of the following age-related changes is the nurse likely to have observed? Presbyopia Cataract formation Loss of convergence Macular degeneration
Presbyopia Explanation: Prebyopia denotes an age-related deficit in close vision. It is less likely that cataracts, macular degeneration, or loss of convergence underlie the colleague's visual changes.
When testing the near reaction, an expected finding includes which of the following? Pupillary dilation on near gaze; dilation on distant gaze 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 constriction on near gaze; dilation on distant gaze Explanation: During accommodation, pupils constrict with near gaze and dilate with far gaze.
When testing the near reaction, an expected finding includes which of the following? Pupillary dilation on near gaze; dilation on distant gaze 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 constriction on near gaze; dilation on distant gaze Explanation: During accommodation, pupils constrict with near gaze and dilate with far 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 Explanation: A client with acute otitis media would have a red, bulging eardrum, with absent light reflex. A pearly, translucent membrane, with no bulging is a normal finding in the tympanic membrane. A yellowish, bulging membrane, with bubbles is seen in serous otitis media. A gray, translucent membrane, with no retraction is a normal finding in the tympanic membrane.
On visual confrontation testing, a client with a recent stroke cannot see the examiner's fingers on the entire right side with either eye covered. Which of the terms would describe this finding? Bitemporal hemianopsia Right temporal hemianopsia Right homonymous hemianopsia Binasal hemianopsia
Right homonymous hemianopsia Explanation: Because the right visual field in both eyes is affected, this is a right homonymous hemianopsia. A bitemporal hemianopsia refers to loss of both lateral visual fields. A right temporal hemianopsia is unilateral, and binasal himanopsia is the loss of the nasal visual fields bilaterally.
A client presents at the clinic complaining of a loss of balance. What test should the nurse expect the physician to carry out on a client with a loss of balance? Audiometric test Romberg test Weber test Rinne test
Romberg test Explanation: The Romberg test is used to evaluate a person's ability to sustain balance. The Audiometric test measures the hearing acuity precisely, while the Rinne test and the Weber test identify the types of hearing loss
Which of the following is a symptom of the eye? Scotomas Tinnitus Dysphagia Rhinorrhea
Scotomas Explanation: Scotomas are specks in the vision or areas where the client cannot see; therefore, this is a common and concerning symptom of the eye. Tinnitus is a ringing in the ears, dysphagia is difficulty swallowing, and rhinorrhea is a "runny nose."
A client is assigned a visual acuity of 20/100 in her left eye. Which of the following is true? She obtains a 20% correct score at 100 feet. 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 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. Explanation: The denominator of an acuity score represents the line on the chart the client can read. In the example above, the client could read the larger letters corresponding with what a normal person could see at 100 feet.
A 12-year-old presents to the clinic with his father for evaluation of a painful lump in the left eye. It started this morning. The client denies any trauma or injury. There is no visual disturbance. Upon physical examination, there is a red raised area at the margin of the eyelid that is tender to palpation; no tearing occurs with palpation of the lesion. Based on this description, what is the most likely diagnosis? Dacryocystitis Chalazion Stye Xanthelasma
Stye Explanation: A hordeolum or stye is a painful, tender, erythematous infection in a gland at the margin of the eyelid.
As part of a physical assessment, the nurse performs the confrontation test to assess the client's peripheral vision. Which test result should a nurse recognize as indicating normal peripheral vision for a client using the confrontation test? Client's consensual pupil constricts in response to indirect light. Eyes converge on an object as it is moved towards the nose. Direct light shown into the client's pupils results in constriction. The client and the examiner see the examiner's finger at the same time.
The client and the examiner see the examiner's finger at the same time. Explanation: The observation that the client and examiner see the examiner's finger at the same time indicates normal peripheral vision. The client not seeing the examiner's finger or a delay in seeing it indicates reduced peripheral vision. Client's consensual pupils constricting in response to indirect light as well as direct light shown into the client's pupils resulting in constriction are observed when testing the pupils for reaction to light. Eyes converging on an object as it is moved towards the nose is a normal result for accommodation.
A nurse performs the Snellen test on a client and obtains these results: OD 20/40, OS 20/30. What conclusion can the nurse make in regards to the client's vision based on these results? Vision is worse in the left eye than the right eye. The larger the bottom number, the worse the visual acuity. Client is legally blind in the left eye. Glasses are needed by the client for near vision.
The larger the bottom number, the worse the visual acuity. Explanation: OD = right eye, OS = left eye. Therefore, the client has worse vision in the right eye because the larger the number on the bottom, the worse the visual acuity. A client is considered legally blind when the vision in the better eye with corrective lens is 20/200 or less. Snellen test is to test for distant vision (far) not near vision.
Which action by the nurse is consistent with Weber's test? The nurse activates the tuning fork and places it on the midline of the parietal bone in line with both ears. The nurse strikes the tuning fork and places it on the patient's mastoid process to measure bone conduction. The nurse uses a bulb insufflator attached to an otoscope to observe movement of the tympanic membrane. The nurse shields their mouth and whispers a simple sentence approximately 18 inches from the patient's ear.
The nurse activates the tuning fork and places it on the midline of the parietal bone in line with both ears. Explanation: Using Weber's test, the nurse activates the tuning fork and places it on the midline of the parietal bone in line with both ears to differentiate the cause of unilateral hearing loss. In Rinne's test, the nurse strikes the tuning fork and places it on the patient's mastoid process to measure bone conduction. When examining the inner ear, the nurse uses a bulb insufflator attached to an otoscope to observe movement of the tympanic membrane. In the Whisper test, the nurse shields their mouth and whispers a simple sentence approximately 18 inches from the patient's ear.
Which action by the nurse is consistent with the Rinne test? The nurse strikes the tuning fork and places it on the patient's mastoid process to measure bone conduction. The nurse activates the tuning fork and places it on the midline of the parietal bone in line with both ears. The nurse uses a bulb insufflator attached to an otoscope to observe movement of the tympanic membrane. The nurse shields their mouth and whispers a simple sentence approximately 18 inches from the patient's ear.
The nurse strikes the tuning fork and places it on the patient's mastoid process to measure bone conduction. Explanation: In the Rinne test, the nurse strikes the tuning fork and places it on the patient's mastoid process to measure bone conduction. Using Weber's test, the nurse activates the tuning fork and places it on the midline of the parietal bone in line with both ears to differentiate the cause of unilateral hearing loss. When examining the inner ear, the nurse uses a bulb insufflator attached to an otoscope to observe movement of the tympanic membrane. In the Whisper test, the nurse shields their mouth and whispers a simple sentence approximately 18 inches from the patient's ear.
A client has an abnormal consensual pupillary reaction to light. A nurse understands that what reaction occurs in the client's eyes? Pupils dilate in response to a light shone in the eyes. Eyes do not converge to focus on a shining light. There is no reaction in the opposite pupil to light. Light reflection appears at different spots on both eyes.
There is no reaction in the opposite pupil to light. Explanation: When a light is shone into the eyes, both the pupil that receives direct light and the consensual (opposite) pupil should constrict. An abnormal response to this test is if either or both pupils do not constrict in response to light. Pupils do not dilate in response to light shone into them. Convergence of the eyes is called accommodation and occurs when focus of vision is moved from a far object to a close object. Light reflection appearing at different spots on both eyes is an abnormal result of the corneal light reflex test, not of the consensual pupillary reaction to light test.
During a pharmacology class the students are told that some drugs need to be closely monitored. What aspect should the nurse closely monitor for in clients who have been administered salicylates, loop diuretics, quinidine, quinine, or aminoglycosides? Signs of hypotension Reduced urinary output Tinnitus and sensorineural hearing loss Impaired facial movement
Tinnitus and sensorineural hearing loss Explanation: It is important that nurses are knowledgeable about the ototoxic effects of certain medications such as salicylates, loop diuretics, quinidine, quinine, and aminoglycosides. Signs and symptoms of ototoxicity include tinnitus and sensorineural hearing loss. Hypotension, reduced urinary output, and impaired facial movement are not signs of ototoxicity.
When preparing to examine a patient's sclera and conjunctiva during an eye examination, the nurse should instruct the patient to move both eyes to look in which direction? Up Down To the right To the left
Up Explanation: The correct technique to use when examining a patient's sclera and conjunctiva during an eye examination is to instruct the patient to look up. Having the patient look down, to the right, or to the left will not provide visualization of the sclera or conjunctiva during the examination.
When preparing to examine a patient's sclera and conjunctiva during an eye examination, the nurse should instruct the patient to move both eyes to look in which direction? Up Down To the right To the left
Up Explanation: The correct technique to use when examining a patient's sclera and conjunctiva during an eye examination is to instruct the patient to look up. Having the patient look down, to the right, or to the left will not provide visualization of the sclera or conjunctiva during the examination.
How can a nurse accurately assess the distant visual acuity of a client who is non-English speaking? Move an object through the six cardinal positions of gaze Use a Snellen E chart to perform the examination Have the client read from a Jaeger reading card Perform the confrontation test
Use a Snellen E chart to perform the examination Explanation: If a client does not speak English, is unable to read, or has a verbal communication problem, the Snellen E chart can be used to test the client's distant visual acuity. With this test, the client is asked to indicate by pointing which way the E is open on the chart. The six cardinal positions of gaze test eye muscle function and cranial nerve function. The Jaeger chart tests near visual acuity. Confrontation test is used to test visual fields for peripheral vision.
A teenager is brought to the clinic for a sports physical examination. The client states plans to play goalie on the community soccer team. What is the most important teaching opportunity presented for this client? Use of safety equipment Prevention of knee injuries Prevention of head injuries Use of correct foot gear
Use of safety equipment Explanation: The nurse should assess with each client the use of safety equipment when playing sports. Proper eye protection can prevent many sports-related eye injuries. All options are points for client teaching for this client; however, the most important opportunity involves the use of safety equipment.
When planning care for a client with an inner ear infection, the nurse will need to include interventions for which of the following potential problems? Rhinorrhea Fever Headache Vertigo
Vertigo Explanation: The labyrinth within the inner ear senses the position and movements of the head and helps to maintain balance. If these structures are infected or inflamed, the patient could develop vertigo. Rhinorrhea, fever, and headache are not potential problems associated with an inner ear infection.
The nurse assessing for unilateral hearing loss by using a tuning fork. What test is the nurse performing? Watch tick test Rinne test Whisper test Weber's test
Weber's test Explanation: The Weber's test uses bone conduction to test lateralization of sound and is useful in detecting unilateral hearing loss. 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 2 or 3 feet from the unoccluded ear and determining the patient's ability 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 nurse should make it a priority to assess which client for papilledema? a 45-year-old suspected of experiencing a subarachnoid hemorrhage an 80-year-old diagnosed with chronic open-angle glaucoma a 12-year-old demonstrating a deviated left eye a 56-year-old reporting double vision
a 45-year-old suspected of experiencing a subarachnoid hemorrhage Explanation: Papilledema describes swelling of the optic disc and anterior bulging of the physiologic cup. Increased intracranial pressure is transmitted to the optic nerve, causing edema of the optic nerve. Papilledema often signals serious disorders of the brain, such as meningitis, subarachnoid hemorrhage, trauma, and mass lesions. An enlarged physiological cup suggests chronic open-angle glaucoma. If cranial nerve IV is paralyzed, the left eye will deviate from its normal position in that direction of gaze, and the eyes will no longer appear conjugate, or parallel. Diplopia in adults may arise from a lesion in the brainstem or cerebellum, or from weakness or paralysis of one or more extraocular muscles, as in horizontal diplopia from palsy of cranial nerve (CN) III or VI, or vertical diplopia from palsy of CN III or IV.
The functional reflex that allows the eyes to focus on near objects is termed pupillary reflex. accommodation. refraction. indirect reflex.
accommodation. Explanation: Accommodation is a functional reflex allowing the eyes to focus on near objects. This is accomplished through movement of the ciliary muscles, causing an increase in the curvature of the lens.
An adult client tells the nurse that she frequently experiences burning and itching of both eyes. The nurse should assess the client for a foreign body. recent trauma. blind spots. allergies.
allergies. Explanation: Burning or itching pain is usually associated with allergies or superficial irritation.
After palpating the radial pulse of an adult client, the nurse suspects arterial insufficiency. The nurse should next assess the client's femoral pulse. popliteal pulse. brachial pulse. tibial pulse.
brachial pulse Explanation: You can also palpate the brachial pulses if you suspect arterial insufficiency. Do this by placing the first three fingertips of each hand at the client's right and left medial antecubital creases. Alternatively, palpate the brachial pulse in the groove between the biceps and triceps.
The nurse notes that the pupil of a client's left eye constricts when a light is shined into the right eye. How should the nurse document this finding? direct light response present in left eye pupils equal and react to accommodation consensual light response present in left eye consensual light response present in right eye
consensual light response present in left eye Explanation: The consensual light response occurs when one eye is exposed to light and the pupil of the other eye constricts. Since the light was shined in the right eye, the left pupil constricted. The left eye was not exposed to direct light. There is not enough information to determine if the pupils are equal or reacting to accommodation.
An adult client tells the nurse that his eyes are painful because he left his contact lenses in too long the day before yesterday. The nurse should instruct the client that prolonged wearing of contact lenses can lead to retinal damage. cataracts. myopia. corneal damage.
corneal damage. Explanation: Improper cleaning or prolonged wearing of contact lenses can lead to infection and corneal damage.
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 refer the client for further evaluation. examine the client for other signs of glaucoma. ask the client if there is a genetic history of blindness. document the findings in the client's records.
document the findings in the client's records. Explanation: Validate the eye assessment data that you have collected. This is necessary to verify that the data are reliable and accurate. Document the assessment data following the health care facility or agency policy.
The nurse observes an inward turning of the lower lid in a 77-year-old patient. The nurse documents entropion ectropion ptosis exophthalmos
entropion
The nurse observes an inward turning of the lower lid in a 77-year-old patient. The nurse documents entropion ectropion ptosis exophthalmos
entropion
While assessing the eye of an adult client, the nurse observes an inward turning of the client's left eye. The nurse should document the client's esotropia. strabismus. phoria. exotropia.
esotropia. Explanation: Esotropia is an inward turn of the eye.
While assessing the eye of an adult client, the nurse observes an inward turning of the client's left eye. The nurse should document the client's esotropia. strabismus. phoria. exotropia.
esotropia. Explanation: Esotropia is an inward turn of the eye.
An adult client tells the nurse that her peripheral vision is not what it used to be and she has a blind spot in her left eye. The nurse should refer the client for evaluation of possible... glaucoma. increased intracranial pressure. bacterial infection. migraine headaches.
glaucoma. Explanation: A scotoma is a blind spot that is surrounded by either normal or slightly diminished peripheral vision. It may be from glaucoma.
The nurse is planning to assess a client's near vision. Which technique should be used? shine a light on the bridge of the nose have the client read newspaper print held 14 inches from the eyes ask the client to move the eyes in the direction of a moving finger have the client stand 20 feet from a wall chart and read the letters after covering one eye
have the client read newspaper print held 14 inches from the eyes Explanation: Near vision is tested by asking the client to read newspaper print held 14 inches from the eyes. Shining a light on the bridge of the nose tests the corneal light reflex. Moving the eyes in the direction of a moving finger tests for extraocular movements. Having the client read letters on a wall chart tests for central and distance vision.
An adult client visits the clinic and tells the nurse that he has been experiencing double vision for the past few days. The nurse refers the client to a physician for evaluation of possible glaucoma. increased intracranial pressure. hypertension. ophthalmic migraine.
increased intracranial pressure. Explanation: Double vision (diplopia) may indicate increased intracranial pressure due to injury or a tumor.
An adult client visits the clinic and tells the nurse that he has had excessive tearing in his left eye. The nurse should assess the client's eye for viral infection. double vision. allergic reactions. lacrimal obstruction.
lacrimal obstruction. Explanation: Excessive tearing (epiphora) is caused by exposure to irritants or obstruction of the lacrimal apparatus. Unilateral epiphora is often associated with foreign body or obstruction.
A patient complains of feeling like he is slowly losing his central vision. The nurse knows this symptom could represent macular degeneration open-angle glaucoma hemianopsia retinal detachment
macular degeneration
An older client asks why vision is not as sharp as it used to be when the eyes are focused forward. What should the nurse realize this client is describing? cataracts glaucoma detached retina macular degeneration
macular degeneration Explanation: Macular degeneration causes a loss of central vision. Risk factors for macular degeneration are age, smoking history, obesity, family history, and female gender. Cataracts are characterized by cloudiness of the eye lenses. Glaucoma is an increase in intraocular pressure that places pressure on eye structures and affecting vision. A detached retina is the sudden loss of vision in one eye. This health problem may be precipitated by the appearance of blind spots.
The nurse is preparing to examine an adult client's eyes, using a Snellen chart. The nurse should position the client 609.6 cm (20 ft) away from the chart. ask the client to remove his glasses. ask the client to read each line with both eyes open. instruct the client to begin reading from the bottom of the chart.
position the client 609.6 cm (20 ft) away from the chart. Explanation: Used to test distant visual acuity, the Snellen chart consists of lines of different letters stacked one above the other. The letters are large at the top and decrease in size from top to bottom. The chart is placed on a wall or door at eye level in a well-lighted area. The client stands 20 feet from the chart and covers one eye with an opaque card (which prevents the client from peeking through the fingers). Then the client reads each line of letters until he or she can no longer distinguish them.
Photoreceptors of the eye are located in the eye's ciliary body. lens. retina. pupil.
retina. Explanation: The innermost layer, the retina, extends only to the ciliary body anteriorly. It receives visual stimuli and sends it to the brain. The retina consists of numerous layers of nerve cells, including the cells commonly called rods and cones. These specialized nerve cells are often referred to as "photoreceptors" because they are responsive to light
An adult client tells the nurse that his father had cataracts. He asks the nurse about risk factors for cataracts. The nurse should instruct the client that a potential risk factor is lack of vitamin C in the diet. ultraviolet light exposure. obesity. use of antibiotics.
ultraviolet light exposure. Explanation: Exposure to ultraviolet radiation puts the client at risk for the development of cataracts (opacities of the lenses of the eyes). Consistent use of sunglasses during exposure minimizes the client's risk.
A client has a brownish discoloration of the skin of both lower legs. What should the nurse suspect is occurring with this client? atherosclerosis arterial insufficiency venous insufficiency deep vein thrombosis
venous insufficiency Explanation: Brownish discoloration just above the malleolus suggests chronic venous insufficiency. There are no specific skin changes associated with atherosclerosis. The lower extremities in the dependent position would be pale in color in arterial insufficiency. The extremity would be warm and edematous with a deep vein thrombosis.
During a physical examination, the nurse detects warm skin and brown pigmentation around an adult client's ankles. The nurse suspects that the client may be experiencing venous insufficiency. arterial occlusive disease. venous ulcers. ankle edema.
venous insufficiency. Explanation: Manifestations of venous insufficiency include cramping pain, thickened tough skin, and areas of hyperpigmentation around the medial and lateral malleolus.
