Chapter 41: Intro to the Sensory System **

The nurse is obtaining a visual history from a client who has noted an increase in glare and changes in color perception. Which assessment would the nurse anticipate to confirm a definitive diagnosis? A. Identification of opacities on the lens B. Identification of white circle around the cornea C. Identification of yellowish aging spot on the retina D. Identification of redness of the sclera

Identification of opacities on the lens

The nurse is performing a Weber test on a client. During this test, where should the nurse place the tuning fork? A. On the mastoid process behind the ear B. In the midline of the client's skull or in the center of the forehead C. Near the external meatus of each ear D. Under the bridge of the nose

In the midline of the client's skull or in the center of the forehead

A client is having problems with dizziness and complains of the "room spinning". The physician performs the caloric stimulation test. The nurse knows that a diminished response in one eye during the caloric stimulation test is indicative of what? A. Inner ear disorder B. Middle ear disorder C. Outer ear disorder D. Age-related macular degeneration

Inner ear disorder

A client comes to the occupational health nurse complaining of eye irritation. The client works in a dusty, outdoor environment. Why should the nurse advise periodic blinking to this client? A. To control the amount of sunlight that enters the eye B. To minimize the impact of the wind on the eye and to trap foreign debris C. To clear the dust and particles from the surface of the eyes D. To prevent the collection of tears over the surface of the eye

To clear the dust and particles from the surface of the eyes

A client presents to the emergency room with symptoms of blurred vision. Which type of question would be best to ask first? A. "Have you ever had these symptoms before?" B. "Did these symptoms come on abruptly?" C. "Do you have a family history of vision problems?" D. "Do you have any other diseases?"

"Have you ever had these symptoms before?"

The nurse is instructing a nursing student when a new client comes to the eye clinic. The client reports suspecting a corneal abrasion. The nurse should explain what to the student nurse? A. "To detect corneal abrasions, an ophthalmoscope is used." B. "To detect corneal abrasions, ultrasonography is used." C. "To detect corneal abrasions, a slit lamp is used." D. "To detect corneal abrasions, retinal angiography is used."

"To detect corneal abrasions, a slit lamp is used."

The nurse is establishing a visual test using the Snellen chart for a client experiencing visual changes. At which distance should the nurse instruct the client to stand? A. A 10-feet distance B. A 20-feet distance C. A 30-feet distance D. A 40-feet distance

A 20-feet distance

The nurse is conducting hearing tests at the local junior high school. Which of the following indicates normal hearing in a child? A. A client who first perceives sound at 20 dB B. A client who first perceives sound at 40 dB C. A client for whom the painful sound occurs at 80 dB D. A client for whom the painful sound occurs at 100 dB

A client who first perceives sound at 20 dB

A client has been referred to an opthalmologist for suspected macular degeneration. The nurse knows to prepare what test for the physician to give the client? A. Ishihara polychromatic plates B. Visual field C. Amsler grid D. Slit lamp

Amsler grid

The nurse is obtaining a history on a client stating the inability to read the newspaper and seeing detail when looking at an image. Which assessment test would add additional data for a diagnosis? A. Assess if the pupils are equal and reactive to light. B. Assess vision on the Snellen chart. C. Assess peripheral vision. D. Assess color vision.

Assess peripheral vision

Audiometry is testing that measures hearing acuity precisely. Who does the nurse know can perform audiometric testing? A. School nurse B. Hearing aide salesperson C. Audiologist D. Office nurse

Audiologist

The nurse is collecting the history of a client diagnosed with a cataract and is performing a focused assessment. Which finding should the nurse anticipate? A. A burning sensation and the sensation of an object in the eye B. Blurred or cloudy vision C. Inability to produce sufficient tears D. A swollen lacrimal caruncle

Blurred or cloudy vision

The nurse is caring for a client with increased fluid accumulation in the eye. When assessing the client, which structure within the eye is noted to drain fluid from the anterior chamber? A. Fovea centralis B. Canthus C. Canal of Schlemm D. Choroid

Canal of Schlemm

The nurse is caring for geriatric clients who state that they are prescribed reading glasses. Some individuals state needing assistance with seeing writing far away, and others need assistance with closer vision. What does the nurse understand to be related to visual changes caused by aging? A. Changes in refraction B. Changes in the visual field C. Changes in central vision D. Changes in accommodation

Changes in accommodation

The client is consulting with a physician regarding a potential diagnosis of Meniere disease. The nurse is assisting in positional testing and documentation. Which diagnostic test would the nurse anticipate to obtain a more precise evaluation of vestibular function? A. Audiometry B. Electronystagmography C. Caloric stimulation test D. Romberg test

Electronystagmography

The nurse is assessing a client's eyes as part of the inspection part of the assessment process. For which reason does the nurse identify a normal variation in the angle of the lateral and medial canthus? A. Ethnic differences B. Chromosomal differences C. Structural changes D. Cosmetic alterations

Ethnic differences

The nurse is caring for a client who just returned from a trip requiring an airline flight. The client reported ear pain upon descent. The nurse is correct in stating which site as being the pressure equalizer in the ear? A. Eustachian tube B. Auricle C. Tympanic membrane D. Labyrinth

Eustachian tube

The nursing student is taking an anatomy and physiology class. What anatomical structure equalizes air pressure in the middle ear? A. Eustachian tube B. The malleus C. The pinna D. The meatus

Eustachian tube

When caring for a client with a foreign object removed from the eye, the nurse is most correct to assess the eye protective functions of which structure(s)? SATA A. Eyelids and lashes B. Aqueous humor C. Superior and inferior oblique muscles D. Conjunctiva E. Sclera F. Tears

Eyelids and lashes Tears

The nurse is assisting with the administration of a caloric stimulation test. Which client response would the nurse document as an expected response? A. Dizziness B. Headache C. Nystagmus D. Double vision

Nystagmus

The nurse is assisting in providing coordination of services between the physician's office and the vision specialist's office for a client who is being referred for potential retinal surgery. Which eye care specialist will the nurse make the referral to? A. Optician B. Optometrist C. Ophthalmologist D. Ophthalmic technician

Opthalmologist

The nurse is assisting the eye surgeon in completing an examination of a client's eye. Which piece of equipment would the nurse provide to the surgeon to examine the optic disc under magnification? A. Retinoscope B. Ophthalmoscope C. Tonometer D. Amsler grid

Opthalmoscope

What is located in the cochlea of the inner ear? A. Semicircular canals B. Labyrinth C. Vestibulocochlear nerve D. Organ of Corti

Organ of Corti

The nurse is assessing a client's hearing using the Rinne test. When providing instruction to elicit client feedback, which instruction is essential? A. Raise your hand when you hear the vibration. B. Raise your hand when you no longer hear sound. C. Raise your hand when the vibration exceeds the sound. D. Raise your hand when the sound exceeds the vibration.

Raise your hand when you no longer hear sound

The nurse is caring for a client ordered for multiple eye screening. Following which procedure will the nurse instruct the client on a yellow coloring to the skin and urine as being normal? A. Ultrasonography B. Retinal Imaging C. Retinal Angiography D. Retinoscopy

Retinal Angiography

A nurse is assessing a pediatric client in a public health clinic. The parent states that the client has been sneezing and rubbing the eyes. The nurse observes the client's eyes and documents objective symptoms of watery and red eyes. When reporting the assessment findings to the health care provider, which description is appropriate? A. Signs and symptoms of conjunctivitis B. Signs and symptoms of ptosis C. Signs and symptoms of nystagmus D. Signs and symptoms of proptosis

Signs and symptoms of conjunctivitis

The nurse is assessing a client for objective symptoms of hearing difficulties. Which sign leads the nurse to take alternate measure to ensure client understanding of teaching? A. The client interrupts by asking the nurse to repeat instruction. B. The client is quiet and responds appropriately. C. The client leans forward and turns the head. D. The client quietly reads the instructional literature.

The client leans forward and turns the head

The nurse is completing a corneal light reflex test on a client, using a penlight. Which result would indicate a normal test result? A. The pupils have reaction to light. B. The eyes follow the light in all four directions. C. The client can see the light using peripheral vision. D. The light reflection is in the same spot on each eye.

The light reflection is in the same spot on each eye

A client states having difficulty noting details on faces or television. Which of the following structures of the eye allows for detailed vision? A. The pupil B. The iris C. The cornea D. The macula lutea

The macula lutea

The nurse is evaluating the client taking the color vision test. Which response would the nurse anticipate when caring for a client with normal color vision? A. The nurse would anticipate the client identifying numbers and shapes. B. The nurse would anticipate a cross-eyed appearance. C. The nurse would anticipate responding to the color names in the pictures. D. The nurse would anticipate no differentiation in between colors.

The nurse would anticipate the client identifying numbers and shapes.