Chapter 21: Nursing Assessment: Visual and Auditory Systems

21. The nurse should report which assessment finding immediately to the health care provider? a. The tympanum is blue-tinged. b. There is a cone of light visible. c. Cerumen is present in the auditory canal. d. The skin in the ear canal is dry and scaly.

ANS: A A bluish-tinged tympanum can occur with acute otitis media, which requires immediate care to prevent perforation of the tympanum. Cerumen in the ear canal may need to be removed before proceeding with the examination but is not unusual or pathologic. The presence of a cone of light on the eardrum is normal. Dry and scaly skin in the ear canal may need further assessment but does not require urgent care.

1. The nurse is providing health promotion teaching to a group of older adults. Which information will the nurse include when teaching about routine glaucoma testing? a. A Tono-pen will be applied to the surface of the eye. b. The test involves reading a Snellen chart from 20 feet. c. Medications will be used to dilate the pupils for the test. d. The examination involves checking the pupil's reaction to light.

ANS: A Glaucoma is caused by an increase in intraocular pressure, which would be measured using the Tono-pen. The other techniques are used in testing for other eye disorders. DIF: Cognitive Level: Apply (application) REF: 369 | 375 TOP: Nursing Process: Implementation MSC: NCLEX: Health Promotion and Maintenance

25. The nurse working in the vision and hearing clinic receives telephone calls from several patients who want appointments in the clinic as soon as possible. Which patient should be seen first? a. 71-year-old who has noticed increasing loss of peripheral vision b. 74-year-old who has difficulty seeing well enough to drive at night c. 60-year-old who has difficulty hearing clearly in a noisy environment d. 64-year-old who has decreased hearing and ear "stuffiness" without pain

ANS: A Increasing loss of peripheral vision is characteristic of glaucoma and the patient should be scheduled for an examination as soon as possible. The other patients have symptoms commonly associated with aging: presbycusis, possible cerumen impaction, and impaired night vision.

13. The nurse is assessing a 65-year-old patient for presbyopia. Which instruction will the nurse give the patient before the test? a. "Hold this card and read the print out loud." b. "Cover one eye at a time while reading the wall chart." c. "You'll feel a short burst of air directed at your eyeball." d. "A light will be used to look for a change in your pupils."

ANS: A The Jaeger card is used to assess near vision problems and presbyopia in persons over 40 years of age. The card should be held 14 inches away from eyes while the patient reads words in various print sizes. Using a penlight to determine pupil change is testing pupil response. A short burst of air may be used to test intraocular pressure but is not used for testing presbyopia. Covering one eye at a time while reading a wall chart at 20 feet describes the Snellen test.

12. Which information will the nurse provide to the patient scheduled for refractometry? a. "You will need to wear sunglasses for a few hours after the exam." b. "The surface of your eye will be numb while the doctor does the exam." c. "You should not take any of your eye medicines before the examination." d. "The doctor will shine a bright light into your eye during the examination."

ANS: A The pupils are dilated using cycloplegic medications during refractometry. This effect will last several hours and cause photophobia. The other teaching would not be appropriate for a patient who was having refractometry.

5. Assessment of a patient's visual acuity reveals that the left eye can see at 20 feet what a person with normal vision can see at 50 feet and the right eye can see at 20 feet what a person with normal vision can see at 40 feet. The nurse records which finding? a. OS 20/50; OD 20/40 b. OU 20/40; OS 50/20 c. OD 20/40; OS 20/50 d. OU 40/20; OD 50/20

ANS: A When documenting visual acuity, the first number indicates the standard (for normal vision) of 20 feet and the second number indicates the line that the patient is able to read when standing 20 feet from the Snellen chart. OS is the abbreviation for left eye and OD is the abbreviation for right eye. The remaining three answers do not correctly describe the patient's visual acuity.

The nurse is testing the visual acuity of a patient in the outpatient clinic. The nurse's instructions for this test include asking the patient to a. stand 20 feet from the wall chart. b. follow the examiner's finger with the eyes only. c. look at an object far away and then near to the eyes. d. look straight ahead while a light is shone into the eyes.

ANS: A When the Snellen chart is used to check visual acuity, the patient should stand 20 feet away. Accommodation is tested by looking at an object at both near and far distances. Shining a pen light into the eyes tests for pupil response. Following the examiner's fingers with the eyes tests extraocular movements.

14. A patient arrives in the emergency department complaining of eye itching and pain after sleeping with contact lenses in place. To facilitate further examination of the eye, fluorescein angiography is ordered. The nurse will teach the patient to a. hold a card and fixate on the center dot. b. report any burning or pain at the IV site. c. remain still while the cornea is anesthetized. d. let the examiner know when images shown appear clear.

ANS: B Fluorescein angiography involves injecting IV dye. If extravasation occurs, fluorescein is toxic to the tissues. The patient should be instructed to report any signs of extravasation such as pain or burning. The nurse should closely monitor the IV site as well. The cornea is anesthetized during ultrasonography. Refractometry involves measuring visual acuity and asking the patient to choose lenses that are the sharpest; it is a painless test. The Amsler grid test involves using a hand held card with grid lines. The patient fixates on the center dot and records any abnormalities of the grid lines.

2. The nurse is performing an eye examination on a 76-year-old patient. The nurse should refer the patient for a more extensive assessment based on which finding? a. The patient's sclerae are light yellow. b. The patient reports persistent photophobia. c. The pupil recovers slowly after responding to a bright light. d. There is a whitish gray ring encircling the periphery of the iris.

ANS: B Photophobia is not a normally occurring change with aging, and would require further assessment. The other assessment data are common gerontologic differences and would not be unusual in a 76-year-old patient. DIF: Cognitive Level: Apply (application) REF: 371 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

17. When the patient turns his head quickly during the admission assessment, the nurse observes nystagmus. What is the indicated nursing action? a. Assess the patient with a Rinne test. b. Place a fall-risk bracelet on the patient. c. Ask the patient to watch the mouths of staff when they are speaking. d. Remind unlicensed assistive personnel to speak loudly to the patient.

ANS: B Problems with balance related to vestibular function may present as nystagmus or vertigo and indicate an increased risk for falls. The Rinne test is used to check hearing. Reading lips and louder speech are compensatory behaviors for decreased hearing.

22. Which equipment will the nurse obtain to perform a Rinne test? a. Otoscope b. Tuning fork c. Audiometer d. Ticking watch

ANS: B Rinne testing is done using a tuning fork. The other equipment is used for other types of ear examinations.

24. Which action can the nurse working in the emergency department delegate to experienced unlicensed assistive personnel (UAP)? a. Ask a patient with decreased visual acuity about medications taken at home. b. Perform Snellen testing of visual acuity for a patient with a history of cataracts. c. Obtain information from a patient about any history of childhood ear infections. d. Inspect a patient's external ear for redness, swelling, or presence of skin lesions.

ANS: B The Snellen test does not require nursing judgment and is appropriate to delegate to UAP who have been trained to perform it. History taking about infection or medications and assessment are actions that require critical thinking and should be done by the RN.

11. A patient who underwent eye surgery is required to wear an eye patch until the scheduled postoperative clinic visit. Which nursing diagnosis will the nurse include in the plan of care? a. Disturbed body image related to eye trauma and eye patch b. Risk for falls related to temporary decrease in stereoscopic vision c. Ineffective health maintenance related to inability to see surroundings d. Ineffective denial related to inability to admit the impact of the eye injury

ANS: B The loss of stereoscopic vision created by the eye patch impairs the patient's ability to see in three dimensions and to judge distances. It also increases the risk for falls. There is no evidence in the assessment data for ineffective health maintenance, disturbed body image, or ineffective denial.

15. A patient complains of dizziness when bending over and of nausea and dizziness associated with physical activities. The nurse will plan to teach the patient about a. tympanometry. b. rotary chair testing. c. pure-tone audiometry. d. bone-conduction testing.

ANS: B The patient's clinical manifestations of dizziness and nausea suggest a disorder of the labyrinth, which controls balance and contains three semicircular canals and the vestibule. Rotary chair testing is used to test vestibular function. The other tests are used to test for problems with hearing.

7. The nurse is observing a student who is preparing to perform an ear examination for a 30-year-old patient. The nurse will need to intervene if the student a. pulls the auricle of the ear up and posterior. b. chooses a speculum larger than the ear canal. c. stabilizes the hand holding the otoscope on the patient's head. d. stops inserting the otoscope after observing impacted cerumen.

ANS: B The speculum should be smaller than the ear canal so it can be inserted without damage to the external ear canal. The other actions are appropriate when performing an ear examination.

4. Which assessment finding alerts the nurse to provide patient teaching about cataract development? a. History of hyperthyroidism b. Unequal pupil size and shape c. Blurred vision and light sensitivity d. Loss of peripheral vision in both eyes

ANS: C Classic signs of cataracts include blurred vision and light sensitivity. Thyroid problems are a major cause of exophthalmos. Unequal pupil is indicative of anisocoria, not cataracts. Loss of peripheral vision is a sign of glaucoma.

9. A 65-year-old patient is being evaluated for glaucoma. Which information given by the patient has implications for the patient's treatment? a. "I use aspirin when I have a sinus headache." b. "I have had frequent episodes of conjunctivitis." c. "I take metoprolol (Lopressor) daily for angina." d. "I have not had an eye examination for 10 years."

ANS: C It is important to note whether the patient takes any β-adrenergic blockers because this classification of medications is also used to treat glaucoma, and there may be an increase in adverse effects. The use of aspirin does not increase intraocular pressure and is safe for patients with glaucoma. Although older patients should have yearly eye examinations, the treatment for this patient will not be affected by the 10-year gap in eye care. Conjunctivitis does not increase the risk for glaucoma.

18. The nurse recording health histories in the outpatient clinic would plan a focused hearing assessment for adult patients taking which medication? a. Atenolol (Tenormin) taken to prevent angina b. Acetaminophen (Tylenol) taken frequently for headaches c. Ibuprofen (Advil) taken for 20 years to treat osteoarthritis d. Albuterol (Proventil) taken since childhood to treat asthma

ANS: C Nonsteroidal antiinflammatory drugs (NSAIDs) are potentially ototoxic. Acetaminophen, atenolol, and albuterol are not associated with hearing loss.

23. Which action should the nurse take when providing patient teaching to a 76-year-old with mild presbycusis? a. Use patient education handouts rather than discussion. b. Use a higher-pitched tone of voice to provide instructions. c. Ask for permission to turn off the television before teaching d. Wait until family members have left before initiating teaching.

ANS: C Normal changes with aging make it more difficult for older patients to filter out unwanted sounds, so a quiet environment should be used for teaching. Loss of sensitivity for high-pitched tones is lost with presbycusis. Because the patient has mild presbycusis, the nurse should use both discussion and handouts. There is no need to wait until family members have left to provide patient teaching.

16. When the nurse is taking a health history of a new patient at the ear clinic, the patient states, "I have to sleep with the television on." Which follow-up question is most appropriate to obtain more information about possible hearing problems? a. "Do you grind your teeth at night?" b. "What time do you usually fall asleep?" c. "Have you noticed ringing in your ears?" d. "Are you ever dizzy when you are lying down?"

ANS: C Patients with tinnitus may use masking techniques, such as playing a radio, to block out the ringing in the ears. The responses "Do you grind your teeth at night?" and "Are you ever dizzy when you are lying down?" would be used to obtain information about other ear problems, such as vestibular disorders and referred temporomandibular joint (TMJ) pain. The response "What time do you usually fall asleep?" would not be helpful in assessing problems with the patient's ears.

19. The charge nurse must intervene immediately if observing a nurse who is caring for a patient with vestibular disease a. speaking slowly to the patient. b. facing the patient directly when speaking. c. encouraging the patient to ambulate independently. d. administering Rinne and Weber tests to the patient.

ANS: C Vestibular disease affects balance, so the nurse should monitor the patient during activities that require balance. The other actions might be used for patients with hearing disorders.

3. The nurse performing an eye examination will document normal findings for accommodation when a. shining a light into the patient's eye causes pupil constriction in the opposite eye. b. a blink reaction follows touching the patient's pupil with a piece of sterile cotton. c. covering one eye for 1 minute and noting pupil constriction as the cover is removed. d. the pupils constrict while fixating on an object being moved closer to the patient's eyes.

ANS: D Accommodation is defined as the ability of the lens to adjust to various distances. The pupils constrict while fixating on an object being moved far away to near the eyes. The other responses may also be elicited as part of the eye examination, but they do not indicate accommodation.

20. The nurse in the eye clinic is examining a 67-year-old patient who says "I see small spots that move around in front of my eyes." Which action will the nurse take first? a. Immediately have the ophthalmologist evaluate the patient. b. Explain that spots and "floaters" are a normal part of aging. c. Inform the patient that these spots may indicate retinal damage. d. Use an ophthalmoscope to examine the posterior eye chambers.

ANS: D Although "floaters" are usually caused by vitreous liquefaction and are common in aging patients, they can be caused by hemorrhage into the vitreous humor or by retinal tears, so the nurse's first action will be to examine the retina and posterior chamber. Although the ophthalmologist will examine the patient, the presence of spots or floaters in a 65-year-old is not an emergency. The spots may indicate retinal damage, but the nurse should assess the eye further before discussing this with the patient.

6. When assessing a patient's consensual pupil response, the nurse should a. have the patient cover one eye while facing the nurse. b. observe for a light reflection in the center of both corneas. c. instruct the patient to follow a moving object using only the eyes. d. shine a light into one pupil and observe the response of both pupils.

ANS: D The consensual pupil response is tested by shining a light into one pupil and observing for both pupils to constrict. Observe the corneal light reflex to evaluate for weakness or imbalance of the extraocular muscles. In a darkened room, ask the patient to look straight ahead while a penlight is shone directly on the cornea. The light reflection should be located in the center of both corneas as the patient faces the light source. To perform confrontation visual field testing, the patient faces the examiner and covers one eye, then counts the number of fingers that the examiner brings into the visual field. Instructing the patient to follow a moving object only with the eyes is testing for visual fields and extraocular movements.

8. When obtaining a health history from a 49-year-old patient, which patient statement is most important to communicate to the primary health care provider? a. "My eyes are dry now." b. "It is hard for me to see at night." c. "My vision is blurry when I read." d. "I can't see as far over to the side."

ANS: D The decrease in peripheral vision may indicate glaucoma, which is not a normal visual change associated with aging and requires rapid treatment. The other patient statements indicate visual problems (presbyopia, dryness, and lens opacity) that are considered a normal part of aging.