Vision/Auditory Exam

A nurse is caring for a client who is unconscious and has lost the corneal reflex. Which of the following action should the nurse take?

Place a patch over the eye.

A nurse is collecting data from a client who self-administers pilocarpine ophthalmic drops. Which of the following findings by the nurse indicates a systemic adverse effect of this medication?

diarrhea

A nurse is collecting data from a client who has a suspected cataract. The nurse should collect data from which of the following areas to confirm the diagnosis

the lens of the clients eye

A nurse is reinforcing teaching with a client with bacterial conjunctivitis of the right eye, and a prescription for an antibiotic ophthalmic ointment. Which of the following statements should the nurse make?

"Apply the ointment in a thin line into the conjunctival sac."

A nurse is caring for a 3 year old client who has persistent otitis media. To help identify contributing factors, the nurse should ask the parents which of the following questions?

"Does anyone smoke in the same house as your daughter?"

A nurse is reviewing postoperative instructions with a client following cataract surgery. Which of the following client statements indicates an understanding of the instructions?

"I should call my doctor if my vision gets worse."

A nurse is caring for a client who is scheduled for an otoacoustic emissions (OAE) test. The client asks what to expect during the test. Which of the following responses should the nurse make? "You will have small electrodes placed on your scalp during the test." "You will have a small probe placed in your ear canal during the test." "You will have dye injected through an IV during the test." "You will have photographs taken using a special camera during the test."

"You will have a small probe placed in your ear canal during the test." During an OAE test, a small probe is placed in the auditory canal. A series of sounds are played through the probe, which then measures the returned echo.

A nurse is caring for a middle adult client who asks about expected age-related changes. Which of the following sensory changes should the nurse include as an age-related change? A. Presbyopia B. Diplopia C. Myopia D. Astigmatism

A. Presbyopia Presbyopia is the decrease in the ability to focus clearly on objects that are up close. Presbyopia typically begins during middle adulthood due to a loss of flexibility of the lens of the eye. Incorrect: Diplopia is double vison and is not an expected age-related change. Myopia is also known as nearsightedness. Myopia is an inability to see far objects clearly and is not an expected age-related change. An astigmatism is an eye defect that causes blurry or distorted far and near vision. An astigmatism is not an expected age-related change.

A nurse is reviewing the medical history of a client who has conductive hearing loss. The nurse should identify which of the following factors as a potential cause of conductive hearing loss? (Select all that apply.) A. Trauma to the outer ear B. Damage to inner ear structures C. Inflammation D. Down syndrome E. Cerumen buildup F. Otitis media

A. Trauma to the outer ear C. Inflammation E. Cerumen buildup F. Otitis media

a nurse is preparing a young adult client who has a hearing impairment for surgery. Which of the following actions should the nurse take?

Allow the client to keep her hearing aid in.

A nurse is assisting with the plan of care for a client who is postoperative following repair of a detached retina. Which of the following interventions should the nurse include in the plan of care?

Apply an eye shield during naps and at bedtime.

A charge nurse is observing a newly licensed nurse irrigate a client's ear, which is impacted with cerumen. Which of the following actions requires the charge nurse to intervene? A. Visualizing the eardrum before irrigating B. Instilling 50 mL of fluid with each irrigation C. Using firm, continuous pressure while irrigating D. Warming the irrigation fluid to at least 37°C (98°F)

B. Instilling 50 mL of fluid with each irrigation

A nurse is caring for a client who has hearing loss. Which of the following actions should the nurse use to enhance communication with the client? (Select all that apply.) A. Provide the client with large print materials. B. Ensure the client wears their hearing aids. C. Use a sign language interpreter. D. Communicate using paper and pen. E. Face the client when speaking.

B. Ensure the client wears their hearing aids. C. Use a sign language interpreter. D. Communicate using paper and pen. E. Face the client when speaking.

A nurse is assessing a client for hearing loss. Which of the following findings should the nurse identify as an indication of a possible hearing loss? (Select all that apply.) A. Speaks in soft tones B. Reports ringing in the ears C. Asks for questions to be repeated D. Withdraws from social activities E. Reports feeling dizzy at times F. Describes sounds as being muffled

C. Asks for questions to be repeated D. Withdraws from social activities F. Describes sounds as being muffled

A nurse is preparing a 4 year old child for discharge following a bilateral myringotomy with tympanovstomy tube placement. The mother asks what to do if the tube falls out. The nurse should give the parent which of the following instruction?

Call the health care clinic to report that the tubes have fallen out.

A nurse is caring for a client whose surgeon informed him postoperatively that he has a metastasizing malignant neoplasm in the colon. Which of the following statements by the client should the nurse identify as an indication that the client understands this information? A. "I have cancer of the colon that has begun to spread." B. "I have growths in my bowel that the doctor can treat easily." C. "As long as my tumor doesn't get any bigger, I'll be okay." D. "There is not much point in having more treatments."

Correct Answer: A. "I have cancer of the colon that has begun to spread." A neoplasm is a continued growth of nonessential cells, and the term "malignant" means that these cells are cancerous. These cells are also metastasizing, or spreading, to adjacent tissues; therefore, the client's statement is accurate.

A nurse is caring for a client who has a hearing impairment. Which of the following actions should the nurse take when communicating with the client? A. Face the client when speaking B. Speak in a loud voice C. Use a normal rate when speaking D. Avoid hand motions

Correct Answer: A. Face the client when speaking Facing the client will allow the client to observe the nurse's facial expressions and to lip read during the communication process.

A nurse is assessing a client who reports vision loss. The client describes the loss as beginning with a "flash" of light followed by a "curtain" across the field of vision. The nurse should identify that these manifestations indicate which of the following eye disorders? A. Glaucoma B. Retinal detachment C. Macular degeneration D. Cataracts

Correct Answer: B. Retinal detachment A flash of light and a sudden loss of vision are manifestations of retinal detachment. Clients report the event of vision loss as sudden and painless.

A nurse is assessing a client who reports an acute visual disturbance that he describes as a "curtain" pulled over his visual field with occasional flashes of light. The nurse should notify the provider that this client might have which of the following disorders? A. Cataracts B. Angle-closure glaucoma C. Retinal detachment D. Macular degeneration

Correct Answer: C. Retinal detachment The retina is the thin layer of light-sensitive tissue on the back of the wall of the eye. Retinal detachment is a medical emergency in which the retina of the eye peels away from its underlying layer of support tissue. Without immediate treatment, the entire retina can detach, leading to permanent vision loss. Manifestations include a sudden onset of decreased peripheral or central vision, dark floaters, flashes of light, and a shadow or curtain over a part of the visual field.

A nurse is teaching a client who has a new diagnosis of primary open-angle glaucoma (POAG). Which of the following pieces of information should the nurse include in the teaching? (Select all that apply.) A. Lost vision can improve with eye drops. B. Administer eye drops as needed for vision loss. C. Glasses will be necessary to correct the accompanying presbyopia. D. Driving can be dangerous due to the loss of peripheral vision. E. Laser surgery can help reestablish the flow of aqueous humor.

Correct Answers: D. Driving can be dangerous due to the loss of peripheral vision. E. Laser surgery can help reestablish the flow of aqueous humor

A nurse is caring for a client who reports decreased peripheral vision. The nurse should identify this as a manifestation of which of the following visual impairments? A. Diabetic retinopathy B. Macular degeneration C. Cataract D. Glaucoma

D. Glaucoma Glaucoma results in an increase in intraocular pressure and can cause loss of vision. Incorrect: Macular degeneration blurs the sharp central vision which makes driving, reading, and seeing faces difficult. It is associated with aging, and is the main cause of blindness for clients over 65 years of age. Diabetic retinopathy is a mild vision problem, which may have no manifestations in early stages. When manifestations do occur, they include seeing spots, floaters and having blurred vision.

A nurse is preparing to perform a cranial nerve assessment on a client. Which of the following actions should the nurse take to assess cranial nerve VIII? A. Monitor for symmetry when the client shrugs their shoulders. B. Ask the client to identify a smell in each nostril. C. Have the client stick out their tongue. D. Whisper something in one ear while occluding the other ear.

D. Whisper something in one ear while occluding the other ear. Cranial nerve VIII is the vestibulocochlear, or auditory, nerve, which has functions for both hearing and balance. To assess hearing, the nurse occludes one year then whispers a word or short phrase behind the client's head. The nurse then assesses the opposite ear.

A nurse is collecting data for a client who has a possible cataract. Which of the following manifestations should the nurse expect the client to report?

Decreased color perception

A nurse is assisting with the food tray for a client who is partially blind following a left-sided stroke. Which of the following nursing interventions promotes client independence?

Describe to the client the location of the food on the tray.

A nurse is admitting a client who has a partial hearing impairment. Which of the following actions is the nurses priority?

Determine if the client uses a hearing aid

A nurse is caring for a client who has burns to his face, ears, and eyelids. Which of the following is the priority finding to report to the provider?

Difficulty swallowing

A nurse is preparing to administer timolol ophthalmic drops to a client who has glaucoma. Which of the following actions should the nurse plan to take?

Drop prescribed amount of medication into the conjunctival sac.

A nurse at an outpatient surgery center is reinforcing discharge teaching with a clients partner following surgical removal of a cataract. Which of the following information should the nurse include in the teaching?

The client should wear dark glasses while outdoors.

A nurse is caring for an older adult client who is alert and competent and comes to the facility with her adult son for elective cataract extraction. After the provider explains the procedure, who should the nurse have sign the consent form?

The client.

A nurse is reinforcing teaching with a client who has been newly diagnosed with chronic open angle glaucoma. Which of the following statements by the client indicates an understanding of the teaching?

"I should call the clinic before taking any over the counter medications."

A nurse is reinforcing with a client who has chronic open angle glaucoma. The client has been prescribed pilocarpine ophthalmic solution. Which of the following statements by the client demonstrates an understanding of the teaching?

"I should expect to have blurred vision for up to two hours after using this medication."

A nurse is reinforcing discharge teaching with a client who is postoperative following a cataract extraction. Which of the following statements by the client indicates an understanding of the teaching?

"I will bend at my knees if I need to pick something up off the floor."

A nurse is reinforcing discharge teaching with a client who is postoperative following a cataract extraction from the left eye with placement of an intraocular lens implant. Which of the following statements by the client indicates a need for further teaching?

"I will change my eye patch dressing every other day."

A nurse is caring for the client who has Menieres disease. When asked by the client if he is allowed to ambulate independently, which of the following responses should the nurse make?

"Please call for assistance when you wish to get out of bed."

A home health nurse is assisting with the plan of care for an older adult client who has cataract surgery recently. Which of the following information should the nurse include in the plan of care?

"Rest in semi-fowlers position."

A nurse is reviewing the process of how a refraction assessment is performed with a client. Which of the following statements should the nurse make? "This test is performed using the Snellen chart." "This test is performed using lenses of various prescription strengths." "This test is performed by injecting dye into a vein." "This test is performed by measuring the amount of pressure inside the eyes."

"This test is performed using lenses of various prescription strengths."

A nurse is reinforcing teaching about a tonometry examination with a client who has manifestations of glaucoma. Which of the following statements should the nurse include in the teaching?

"This test will measure the intraocular pressure of the eye.

A nurse is caring for a client who is postpartum. The client states, "I am concerned about my baby hearing because my mother was born deaf." Which of h=the following statements should the nurse make?

"We do routine hearing screenings on newborns. You'll know the results before you leave the hospital."

A nurse is reinforcing teaching with a client who has glaucoma. Which of the following statements should the nurse make?

"Without treatment, glaucoma can cause blindness."

A nurse is reinforcing preoperative teaching with a client who is scheduled for cataract surgery. Which of the following statements should the nurse make?

"You should expect your vision to improve within 2 weeks of surgery."

A nurse is providing teaching about safe ambulation to a client who has vision loss. Which of the following items should the nurse include in the teaching? (Select all that apply.) A. A walking cane B. Area rugs C. A walker D. Audio materials E. A magnifying glass

A. A walking cane C. A walker

A nurse is reviewing discharge instructions with a client who has macular degeneration. Which of the following information should the nurse include in the instructions? A. Availability of aids to enhance vision B. Antibiotic therapy C. Risks associated with the loss of peripheral vision D. Treatment options

A. Availability of aids to enhance vision Clients who have impaired or low vision from age-related macular degeneration can benefit from the use of large print material or a magnifying glass. Adequate lighting in the client's environment can also enhance vision.

A nurse is preparing to administer medications to a client. Which of the following classifications of medications should the nurse identify as being ototoxic? (Select all that apply.) A. Loop diuretics B. Benzodiazepines C. NSAIDS D. Antihistamines E. Aminoglycoside antibiotics

A. Loop diuretics C. NSAIDS E. Aminoglycoside antibiotics

A nurse is caring for a client who states, "My doctor said I should have an EMG. What is that?" Which of the following responses should the nurse make? A. "It is a test that determines if there is a loss of the ability to smell." B. "It is a test that measures the response of the eardrum to various sounds." C. "It is a test that determines if there is nerve damage affecting a muscle." D. "It is a test that is performed to diagnose damage to the retina of the eye."

C. "It is a test that determines if there is nerve damage affecting a muscle." An EMG, or electromyography, is performed to determine if there is damage to the nerves leading to the muscles. During an EMG, very small needles are inserted into a muscle. The needles are attached by a wire to an EMG machine that records the electrical activity in the muscle. Damage to a nerve will alter this electrical activity. Incorrect: B. An otoacoustic emissions (OAE) test measures the response, or echo, of the eardrum to various sounds played through a small probe placed in the auditory canal. D. Damage to the retina is diagnosed via a slit lamp exam and a fluorescein angiography test.

A nurse is providing discharge instructions for a client following outpatient cataract surgery with insertion of an intraocular lens. Which of the following should the nurse include?

Lying on the unaffected side can prevent complications.

A nurse is caring for a client who has a hearing loss in her left ear. Which of the following nursing actions should the nurse take?

Minimize background noise to decrease distractions.

A nurse is contributing to the plan of care for a client who has labyrinthitis. Which of the following interventions should the nurse include in the plane?

Monitor clients cardinal field of vision.

The nurse is preparing to administer ear drops to an adult client. Which of the following actions should the nurse plan to take?

Pull the pinna upward and backward.

A nurse collecting data from a client who has Menieres disease? Which of the following id an expected finding for this client?

Gradual hearing loss

A nurse is preparing to administer ophthalmic solution to a client. Which of the following actions should the nurse take?

Hold the ophthalmic solution 2cm(3/4in) above the lower conjunctival sac.

A nurse notes that the left eyelid of a client who is unconscious remains partially open. To protect the eye, which of the following action should the nurse take?

Instill ophthalmic ointment into the lower lid.

A nurse is assisting in the plan of care for a client who is one day postoperative for a repair of a detached retina. Which of the following actions should the nurse include in the plan?

Instruct the client to avoid reading for long periods of time.

A nurse is collecting data from a client who was involved in a motor vehicle crash. Which of the following techniques should the nurse use to test for corneal reflexes?

Lightly touch the eye with a wisp of cotton.

A nurse is collecting data from a client who has open angled glaucoma. Which of the following findings should the nurse expect?

Loss of peripheral vision.

A nurse is attempting to obtain information from a child who is hearing impaired. Which of the following actions should the nurse take?

Speak slowly while facing the child.

A nurse is preparing to administer eye drops for a client who has glaucoma. When instilling the medication, which of the following actions should the nurse take? Instruct the client to blink several times after instilling the medication. Ask the client to look straight ahead during instillation of the medication. Apply pressure to the puncta after instilling the medication. Place each drop of the medication directly on to the client's cornea.

The nurse should instill the medication into the conjunctival sac and apply pressure to the puncta for 1 to 2 min afterwards to prevent systemic absorption of the medication.The nurse should instruct the client to look upward toward the ceiling during instillation of the medication to allow for proper placement of the medication and to suppress the client's blink reflex.

A nurse is collecting data from an infant who has otitis media. The nurse should expect which of the following findings?

Tugging on the affected ear lobe.

A nurse is caring for a group of clients. For which of the following tasks should the nurse plan to wear protective eye equipment?

Withdrawing cord blood from a neonate. Suctioning secretions from a child's newly places tracheostomy tube.

A nurse in a provider office is caring for a client who has total vision loss and is the handler of a service dog. which of the following actions should the nurse take to show consideration for the client and the service animal?

a. Consult the client before approaching the dog.

A nurse is planning care for an older adult client who has Meniere's disease. Which of the following interventions should the nurse include in the plan? a. Encourage the client to change positions slowly b. Perform range-of motion to the client's every hr. c. Limit the client's fluid intake up 1,500 (1,000) mL/day

a. Encourage the client to change positions slowly

A nurse is caring for a client who has a new diagnosis of primary open angled glaucoma and a prescription for timolol ophthalmia drops. For which of the following adverse effects should the nurse monitor the client?

bradycardia

A nurse is assessing an older adult client at a health fair. Which of the following statements by the client is the nurse's priority? a. I've noticed that there is a gray ring around the colored part of my eye b. I can't seem to get reading materials far enough away to see the words c. I'm having more difficulty telling the difference between blues and greens d. In the last day, I have had a severe headache and pain around my right eye

d. In the last day, I have had a severe headache and pain around my right eye

A nurse in an emergency department is assessing a client who reports sudden, severe eye pain with blurry vision. The provider determines that the client has primary angle-closure glaucoma. Which of the following medications should the nurse expect to administer?

osmotic diuretics via IV bolus

A nurse is reinforcing teaching with a client about how to use her new hearing aids. Which of the following statements should the nurse identify as an indication that the client needs further instruction?

"I will clean the hearing aids with alcohol wipes."

A nurse is developing a teaching plan for a client who has Ménière's disease. Which of the following instructions should the nurse include?

"Move your head slowly to decrease vertigo."

A client who is deaf and communicates using sign language is being admitted by a nurse who does not know sign language. Which of the following actions should the nurse take? a. Request an interpreter during the initial assessment b. Familiarize themselves with commonly used signed language c. Obtain a board that uses colored pictures as communication d. Ask a family member to be present during the admission

a. Request an interpreter during the initial assessment