Exam 2 Ears and eyes
Confrontation test
-Confront the peripheral , Testing peripheral vision - The Tester Covers the same eye for tester and testee. The tester moves their hand around in the peripheral. If tester sees it, then the testee should see it too. -Tester must have good vision to do this test to testee.
a Person with which type of eye disease will have a hard time with a Confrontation test?
-Glaucoma sufferers will most likely fail this test because they have a hard time with peripheral vision.
Pupillary Light Reflex
-Hand at nose to separate viewing area for vision. -Tester makes Light comes in from the side The DIRECT RESPONSE is the eye constricting to that light. THE CONSENSUAL RESPONSE is the other eye (who did not see the light) restricting as well.
Diagnostic Positions Test (Cardinal Fields of Gaze)
-Lead the eyes through the six cardinal positions of gaze will elicit any muscle weakness during movement. -Ask person to hold head steady and follow finger. -Progress clockwise in each direction. -A normal response is parallel tracking of the object with both eyes -Tests Cranial nerves III (Occulomotoer), IV (Trochlear), and VI (Abducens)
To test for Perrla, which 2 tests do we need?
-Pupillary light reflex & -Accommodation Test
snellen eye chart
20/20 numerator is distance at which you are standing denominator is the distance someone else with 20/20 vision stands to read the same thing you were able to read. The larger the denominator, the poorer the vision
Extraocular eye muscle function which cranial nerves are used?
3,4,6
A nurse shines a light toward the bridge of the patient's nose and notices that the light reflection in the right cornea is at the 9 o'clock position and in the left cornea at the 9 o'clock position. What is the interpretation of this finding? a. The extraocular muscles of both eyes are intact. b. The cornea of each eye is transparent. c. The sclera of each eye is clear. d. The consensual reaction of both eyes is intact
A
A patient complains of itching, swelling, and drainage from the eyes with a postnasal drip and sneezing. What type of nasal drainage does the nurse anticipate seeing during inspection of this patient's nares? a. Clear b. Malodorous c. Yellow d. Green P. 145
A
An adult patient comes to the clinic complaining of right ear pain. What technique does the nurse use to inspect this patient's auditory canal? a. Position the otoscope speculum 1.0 to 1.5 cm (about 0.5 inches) into the ear canal. b. Remove cerumen from each canal before inserting otoscope. c. Choose the smallest otoscope speculum that will fit the patient's ear comfortably. d. Pull the pinna slightly downward and backward before inserting the otoscope speculum.
A
What instruction does a nurse give a patient to facilitate palpation of the right lobe of the thyroid gland? a. "Swallow for me one time." b. "Flex your head down and to the left." c. "Rotate your head to the right for me." d. "Hold your breath for a few seconds."
A
When inspecting a patient's eyes, the nurse assesses the presence of cranial nerve III (oculomotor nerve) by observing the eyelids open and close bilaterally. What other technique does a nurse use to test the function of this cranial nerve? a. Pupillary constriction to light b. Visual acuity c. Peripheral vision d. Presence of the red reflex
A
When inspecting a patient's nasal mucous membrane, which finding does the nurse expect to see? a. Deep pink turbinates b. Red, edematous mucous membranes c. Septum that angles to the left d. Clear exudate
A
When using an ophthalmoscope to examine the internal eye, how does the nurse distinguish the retinal arteries from the retinal veins? a. The arteries are narrower than veins. b. The arteries are a darker red than veins. c. The arteries have no light reflex and the veins have a narrow band of light in the center. d. The arteries have prominent pulsations and veins have no pulsations.
A
Which cranial nerve is assessed by using the Snellen visual acuity chart? a. Optic cranial nerve (CN II) b. Oculomotor cranial nerve (CN III) c. Abducens cranial nerve (CN IV) d. Trochlear cranial nerve (CN VI)
A
Which finding indicates that this patient has a sensorineural hearing loss? a. The patient hears sound by air conduction longer than by bone conduction. b. The patient hears sound from a vibrating tuning fork in the affected ear only. c. The patient hears normal conversation at 40 dB and a whisper at 20 dB. d. The patient hears the rubbing of fingers together from a distance of 4 inches from each ear.
A
During the ear examination of an 80-year-old patient, which of the following would be a normal finding? 1. A high-tone frequency loss 2. Increased elasticity of the pinna 3. A thin, translucent membrane 4. A shiny, pink tympanic membrane
ANS: 1 A high-tone frequency hearing loss is apparent for those affected with presbycusis, the hearing loss that occurs with aging.
When performing an otoscopic examination of a 5-year-old child with a history of chronic ear infections, the nurse sees that his right tympanic membrane is amber- yellow in color and there are air bubbles behind the tympanic membrane. The child reports occasional hearing loss and a popping sound with swallowing. The preliminary analysis based on this information is that: 1. this is most likely a serous otitis media. 2. the child has an acute purulent otitis media. 3. there is evidence of a resolving cholesteatoma. 4. the child is experiencing the early stages of perforation.
ANS: 1 An amber-yellow color to the tympanic membrane suggests serum in the middle ear. Often an air/fluid level or bubbles behind the tympanic membrane are visible. The patient may have feelings of fullness, transient hearing loss, and a popping sound with swallowing.
While discussing the history of a 6-month-old infant, the mother tells the nurse that she took a great deal of aspirin while she was pregnant. What question would the nurse want to include in the history? 1. "Does your baby seem to startle with loud noise?" 2. "Has the baby had any surgeries on the ears?" 3. "Have you noticed any drainage from her ears?" 4. "How many ear infections has your baby had since birth?"
ANS: 1 Children at risk for hearing deficit include those exposed in utero to a variety of conditions, such as maternal rubella, or to maternal ototoxic drugs.
A 31-year-old patient tells the nurse that he has noticed a progressive loss in his hearing. He says that it does seem to help when people speak louder or if he turns up the volume. The most likely cause of his hearing loss is: 1.otosclerosis. 2.presbycusis. 3.trauma to the bones. 4.frequent ear infections.
ANS: 1 Otosclerosis is a common cause of conductive hearing loss in young adults between the ages of 20 and 40 years.
The nurse is preparing to do an otoscopic examination on a 2-year-old child. Which of the following reflects correct procedure? 1. Pull the pinna down. 2. Pull the pinna up and back. 3. Tilt the child's head slightly toward the examiner. 4. Have the child touch his chin to his chest.
ANS: 1 Pull the pinna down on an infant and a child under 3 years of age.
A colleague is assessing an 80-year-old patient who has ear pain and asks him to hold his nose and swallow. The nurse knows that which of the following is true concerning this technique? 1.This should not be used in an 80-year-old patient. 2.This technique is helpful in assessing for otitis media. 3.This is especially useful in assessing a patient with an upper respiratory infection. 4.This will cause the eardrum to bulge slightly and make landmarks more visible.
ANS: 1 The eardrum is flat, slightly pulled in at the center, and flutters when the person performs the Valsalva maneuver or holds the nose and swallows (insufflation). One may elicit these maneuvers to assess drum mobility. Avoid these with an aging person because they may disrupt equilibrium.
The portion of the ear that consists of movable cartilage and skin is called the: 1.auricle. 2.concha. 3.outer meatus. 4.mastoid process.
ANS: 1 The external ear is called the auricle or pinna and consists of movable cartilage and skin.
Which of the following statements is true concerning air conduction? 1. It is the most efficient pathway for hearing. 2. It is caused by the vibrations of bones in the skull. 3. The amplitude of sound determines the pitch that is heard. 4. A loss of air conduction is called a conductive hearing loss.
ANS: 1 The normal pathway of hearing is air conduction, and it is the most efficient.
The nurse assesses the hearing of a 7-month-old by clapping hands. What is the expected response? 1. The infant turns the head to localize sound. 2. No obvious response to noise 3. A startle and acoustic blink reflex 4. The infant stops movement and appears to listen.
ANS: 1 With a loud sudden noise, you should note these responses: 6 to 8 months—infant turns head to localize sound, responds to own name.
A patient states that she is unable to hear well with her left ear. The Weber test shows lateralization to the right ear. Rinne has AC>BC with ratio of 2:1 in both ears, left-AC 10 sec and BC 5 sec, right-AC 30 sec and BC 15 sec. What would be the interpretation of these results? 1. The patient may have sensorineural loss. 2. The test results are reflective of normal hearing. 3. Conduction of sound through bones is impaired. 4. These results make no sense, so further tests should be done.
ANS: 1 With sensorineural loss, sound lateralizes to "better" ear or unaffected ear. Normal ratio of AC>BC is intact but is reduced overall. That is, the person hears poorly both ways.
While performing the otoscopic exam of a 3-year-old boy who has been pulling on his left ear, the nurse finds that his left tympanic membrane is bright red and the light reflex is not visible. The most likely cause is: 1. fungal infection. 2. acute otitis media. 3. rupture of the drum. 4. blood behind the drum.
ANS: 2 Absent or distorted light reflex and a bright red color of the eardrum are indicative of acute otitis media.
The nurse suspects that a patient has otitis media. Early signs of otitis media include which of the following findings of the tympanic membrane? 1. Red and bulging 2. Hypomobility 3. Retraction with landmarks clearly visible 4. Flat, slightly pulled in at the center, and moves with insufflation
ANS: 2 An early sign of otitis media is hypomobility of the tympanic membrane.
The nurse is performing a middle ear assessment on a 15-year-old patient who has a history of chronic ear infections. When examining the right tympanic membrane, the nurse sees the presence of dense white patches. The tympanic membrane is otherwise unremarkable. It is pearly, with the light reflex at 5 o'clock and landmarks visible. The nurse should: 1. refer the patient for the possibility of a fungal infection. 2. know that these are scars caused from frequent ear infections. 3. consider that these findings may represent the presence of blood in the middle ear. 4. be concerned about the ability to hear because of this abnormality on the tympanic membrane.
ANS: 2 Dense white patches on the tympanic membrane are sequelae of repeated ear infections. They do not necessarily affect hearing.
The nurse is assessing a 16-year-old patient with head injuries from a recent motor vehicle accident. Which of the following statements indicates the most important reason for assessing for any drainage from the canal? 1.If the drum has ruptured, there will be purulent drainage. 2.Bloody or clear watery drainage can indicate a basal skull fracture. 3.The auditory canal many be occluded from increased cerumen. 4.There may be occlusion of the canal caused by foreign bodies from the accident.
ANS: 2 Frank blood or clear watery drainage (cerebrospinal leak) after trauma suggests a basal skull fracture and warrants immediate referral.
A patient in her first trimester of pregnancy is diagnosed with rubella. The nurse recognizes that the significance of this in relation to the infant's hearing is which of the following? 1.Rubella may affect the mother's hearing but not the infant's. 2.Rubella can damage the infant's organ of Corti, which will impair hearing. 3.Rubella is only dangerous to the infant in the second trimester of pregnancy. 4.Rubella can impair the development of CN VIII and thus affect hearing.
ANS: 2 If maternal rubella infection occurs during the first trimester, it can damage the organ of Corti and impair hearing.
When examining the ear with an otoscope, the nurse remembers that the tympanic membrane should appear: 1. light pink with a slight bulge. 2. pearly gray and slightly concave. 3. pulled in at the base of the cone of light. 4. whitish with a small fleck of light in the superior portion.
ANS: 2 It is a translucent membrane with a pearly gray color and a prominent cone of light in the anteroinferior quadrant, which is the reflection of the otoscope light. The drum is oval and slightly concave, pulled in at its center by one of the middle ear ossicles, the malleus.
A 31-year-old patient tells the nurse that he has noticed pain in his left ear when people speak loudly to him. The nurse knows that this finding: 1. is normal for people of that age. 2. is a characteristic of recruitment. 3. may indicate a middle ear infection. 4. indicates that the patient has a cerumen impaction.
ANS: 2 Recruitment is a marked loss occurring when sound is at low intensity; sound actually may become painful when repeated at a louder volume.
A 17-year-old student is a swimmer on her high school's swim team. She has had three bouts of otitis externa so far this season and wants to know what to do to prevent it. The nurse instructs her to: 1. use a cotton-tipped swab to dry the ear canals thoroughly after each swim. 2. use rubbing alcohol or 2% acetic acid eardrops after every swim. 3. irrigate the ears with warm water and a bulb syringe after each swim. 4. rinse the ears with a warmed solution of mineral oil and hydrogen peroxide.
ANS: 2 With otitis externa (swimmer's ear), swimming causes the external canal to become waterlogged and swell; skinfolds are set up for infection. Prevent by using rubbing alcohol or 2% acetic acid ear drops after every swim.
In performing a voice test to assess hearing, which of the following would the nurse do? 1. Shield the lips so that the sound is muffled. 2. Whisper two-syllable words and ask the patient to repeat them. 3. Ask the patient to place his finger in his ear to occlude outside noise. 4. Stand about 4 feet away to ensure that the patient can really hear at this distance.
ANS: 2 With your head 30 to 60 cm (1 to 2 ft) from the person's ear, exhale and whisper slowly some two-syllable words such as Tuesday, armchair, baseball, or fourteen. Normally, the person repeats each word correctly after you say it.
The nurse is testing the hearing of a 78-year-old man and keeps in mind the changes in hearing that occur with aging, such as: (Select all that apply.) 1.Hearing loss related to aging begins in the mid 40s. 2.The progression is slow. 3.The aging person has low-frequency tone loss. 4.The aging person may find it harder to hear consonants than vowels. 5.Sounds may be garbled and difficult to localize. 6.Hearing loss reflects nerve degeneration of the middle ear.
ANS: 2, 4, 5 Presbycusis is a type of hearing loss that occurs with aging; it is a gradual sorineural loss caused by nerve degeneration in the inner ear or auditory nerve. Its onset usually occurs in the fifth decade, and then it slowly progresses. The person first notices a high-frequency tone loss; it is harder to hear consonants (high-pitched components of speech) than vowels. This makes words sound garbled. The ability to localize sound is impaired also.
A patient has been shown to have a sensorineural hearing loss. During the assessment, it would be important for the nurse to: 1. speak loudly so he can hear the questions. 2. assess for middle ear infection as a possible cause. 3. ask the patient what medications he is currently taking. 4. look for the source of the obstruction in the external ear.
ANS: 3 A simple increase in amplitude may not enable the person to understand words. Sensorineural hearing loss may be caused by presbycusis, a gradual nerve degeneration that occurs with aging and by ototoxic drugs, which affect the hair cells in the cochlea.
A patient with a middle ear infection asks the nurse, "What does the middle ear do?" The nurse responds by telling the patient that the middle ear functions to: 1. maintain balance. 2. interpret sounds as they enter the ear. 3. conduct vibrations of sounds to the inner ear. 4. increase amplitude of sound for the inner ear to function.
ANS: 3 Among its other functions, the middle ear conducts sound vibrations from the outer ear to the central hearing apparatus in the inner ear.
The nurse is performing an assessment on a 65-year-old male. He reports a crusty nodule behind the pinna. It bleeds intermittently and has not healed over the past 6 months. On physical assessment, the nurse finds an ulcerated crusted nodule with an indurated base. The preliminary analysis in this situation is that this: 1.is most likely a benign sebaceous cyst. 2.is most likely a Darwin's tubercle and is not significant. 3.could be a potential carcinoma and should be referred. 4.is a tophus, which is common in the elderly and is a sign of gout.
ANS: 3 An ulcerated crusted nodule with an indurated base that fails to heal is characteristic of a carcinoma. These lesions fail to heal and bleed intermittently. Individuals with such symptoms should be referred for a biopsy.
During an assessment of a 20-year-old Asian patient, the nurse notices that he has dry, flaky cerumen in his canal. What is the significance of this finding? 1. This is probably the result of lesions from eczema in his ear. 2. This represents poor hygiene. 3. This is a normal finding and no further follow-up is necessary. 4. This could be indicative of change in cilia; the nurse should assess for conductive hearing loss.
ANS: 3 Asians and American Indians are more likely to have dry cerumen, whereas blacks and whites usually have wet cerumen.
Which of the following would be true regarding otoscopic examination of a newborn? 1. Immobility of the drum is a normal finding. 2. An injected membrane would indicate infection. 3. The normal membrane may appear thick and opaque. 4. The appearance of the membrane is identical to that of an adult.
ANS: 3 During the first few days, the tympanic membrane often looks thickened and opaque. It may look "injected" and have a mild redness from increased vascularity.
29. During a hearing assessment the nurse finds that sound lateralizes to the patient's left ear with the Weber test. What can the nurse conclude from this? 1. The patient has a conductive hearing loss in the right ear. 2. Lateralization is a normal finding with the Weber test. 3. The patient could have either a sensorineural or a conductive loss. 4. A mistake has occurred; the test must be repeated.
ANS: 3 It is necessary to perform the Weber and Rinne tests to determine the type of loss. With conductive loss, sound lateralizes to the "poorer" ear owing to background room noise. With sensorineural loss, sound lateralizes to the "better" ear or unaffected ear.
A 70-year-old patient tells the nurse that he has noticed that he is having trouble hearing, especially in large groups. He says he "can't always tell where the sound is coming from" and the words often sound "mixed up." What might the nurse suspect as the cause for this change? 1.Atrophy of the apocrine glands 2.Cilia becoming coarse and stiff 3.Nerve degeneration in the inner ear 4.Scarring of the tympanic membrane
ANS: 3 Presbycusis is a type of hearing loss that occurs with aging, even in people living in a quiet environment. It is a gradual sensorineural loss caused by nerve degeneration in the inner ear or auditory nerve. This makes words sound garbled. The ability to localize sound is impaired also. This communication dysfunction is accentuated when background noise is present.
The nurse is performing an otoscopic examination on an adult. Which of the following is true? 1. Tilt the person's head forward during the exam. 2. Once the speculum is in the ear, release the traction. 3. Pull the pinna up and back before inserting the speculum. 4. Use the smallest speculum to decrease the amount of discomfort.
ANS: 3 Pull the pinna up and back on an adult or older child. This helps straighten the S- shape of the canal.
The nurse is examining a patient's ears and notices cerumen in the external canal. Which of the following statements about cerumen is correct? 1.Sticky honey-colored cerumen is a sign of infection. 2.The presence of cerumen is indicative of poor hygiene. 3.The purpose of cerumen is to protect and lubricate the ear. 4.Cerumen is necessary for transmitting sound through the auditory canal.
ANS: 3 The ear is lined with glands that secrete cerumen, a yellow waxy material that lubricates and protects the ear.
Which of the following cranial nerves is responsible for conducting nerve impulses to the brain from the organ of Corti? 1. CN I 2. CN III 3. CN VIII 4. CN XI
ANS: 3 The nerve impulses are conducted by the auditory portion of CN VIII to the brain.
During an examination, the patient states he is hearing a buzzing sound and says that it is "driving me crazy!" The nurse recognizes that this symptom is: 1. vertigo. 2. pruritus. 3. tinnitus. 4. cholesteatoma.
ANS: 3 Tinnitus is a sound that comes from within a person; it can be a ringing, crackling, or buzzing sound. It accompanies some hearing or ear disorders.
During an otoscopic examination, the nurse notes an area of black and white dots on the tympanic membrane and ear canal wall. What does this finding suggest? 1. Malignancy 2. Viral infection 3. Blood in the middle ear 4. Yeast or fungal infection
ANS: 4 A colony of black or white dots on the drum or canal wall suggests a yeast or fungal infection (otomycosis).
An assessment of a 23-year-old patient reveals the following: an auricle that is tender and reddish-blue in color with small vesicles. Additional information the nurse would need to know includes which of the following? 1. Any change in the ability to hear 2. Any recent drainage from the ear 3. Recent history of trauma to the ear 4. Any prolonged exposure to extreme cold
ANS: 4 Frostbite causes reddish-blue discoloration and swelling of the auricle after exposure to extreme cold. Vesicles or bullae may develop, and the person feels pain and tenderness.
During an interview, the patient states he has the sensation that "everything around him is spinning." The nurse recognizes that the portion of the ear responsible for this sensation is: 1.the cochlea. 2.cranial nerve VIII. 3.the organ of Corti. 4.the bony labyrinth.
ANS: 4 If the labyrinth ever becomes inflamed, it feeds the wrong information to the brain, creating a staggering gait and a strong, spinning, whirling sensation called vertigo.
In performing an examination of a 3-year-old with a suspected ear infection, the nurse would: 1. omit the otoscopic exam if the child has a fever. 2. pull the ear up and back before inserting the speculum. 3. ask the mother to leave the room while examining the child. 4. perform the otoscopic examination at the end of the assessment.
ANS: 4 In addition to its place in the complete examination, eardrum assessment is manda- tory for any infant or child requiring care for illness or fever. For the infant or young child, the timing of the otoscopic examination is best toward the end of the complete examination.
Which of the following is a risk factor for ear infections in young children? 1. Family history 2. Air conditioning 3. Excessive cerumen 4. Secondhand cigarette smoke
ANS: 4 Passive or second hand smoke is a risk factor for ear infections.
The mother of a 2-year-old is concerned about the upcoming placement of tympanostomy tubes in her son's ears. The nurse would include which of the following in the teaching plan? 1. The tubes are placed in the inner ear. 2. The tubes are used in children with sensorineural loss. 3. The tubes are permanently inserted during a surgical procedure. 4. The purpose of the tubes is to decrease the pressure and allow for drainage.
ANS: 4 Polyethylene tubes are inserted surgically into the eardrum to relieve middle ear pressure and promote drainage of chronic or recurrent middle ear infections. Tubes extrude spontaneously in 6 months to 1 year.
Which of the following statements concerning the eustachian tube is true? 1. It is responsible for the production of cerumen. 2. It remains open except when swallowing or yawning. 3. It allows passage of air between the middle and outer ear. 4. It helps equalize air pressure on both sides of the tympanic membrane.
ANS: 4 The eustachian tube allows equalization of air pressure on each side of the tympanic membrane so that the membrane does not rupture (e.g., during altitude changes in an airplane). The tube is normally closed, but it opens with swallowing or yawning.
The mother of a 2-year-old is concerned because her son has had three ear infections in the past year. What would be an appropriate response by the nurse? 1."It is unusual for a small child to have frequent ear infections unless there is something else wrong." 2."We need to check the immune system of your son to see why he is having so many ear infections." 3."Ear infections are not uncommon in infants and toddlers because they tend to have more cerumen in the external ear." 4."Your son's eustachian tube is shorter and wider than yours because of his age, which allows for infections to develop more easily."
ANS: 4 The infant's eustachian tube is relatively shorter and wider, and its position is more horizontal than the adult's, so it is easier for pathogens from the nasopharynx to migrate through to the middle ear.
In an individual with otitis externa, which of the following signs would the nurse expect to find on assessment? 1. Rhinorrhea 2. Periorbital edema 3. Pain over the maxillary sinuses 4. Enlarged superficial cervical nodes
ANS: 4 The lymphatic drainage of the external ear flows to the parotid, mastoid, and superficial cervical nodes. The signs are severe swelling of the canal, inflammation, and tenderness.
The nurse is taking the history of a patient who may have a perforated eardrum. What would be an important question in this situation? 1. "Do you ever notice ringing or crackling in your ears?" 2. "When was the last time you had your hearing checked?" 3. "Have you ever been told you have any type of hearing loss?" 4. "Was there any relationship between the ear pain and the discharge you mentioned?"
ANS: 4 Typically with perforation, ear pain occurs first, stopping with a popping sensation, and then drainage occurs.
A nurse assessing the hearing of a patient with presbycusis expects which finding on a test for hearing? a. Bone conduction will be longer than air conduction on the Rinne test (BC > AC). b. Air conduction will be longer than bone conduction on the Rinne test (AC > BC). c. Sound lateralizes to the affected ear on the Weber test. d. Sound lateralizes to both ears equally on the Weber test.
B
A nurse shines a light toward the bridge of the patient's nose and notices that the light reflection in the right cornea is at the 2 o'clock position and in the left cornea at the 10 o'clock position. Based on these data, the nurse should take what action? a. Document these findings as normal. b. Perform the cover-uncover test. c. Perform the confrontation test. d. Document these findings as abnormal.
B
A patient complains of nasal drainage and sinus headache. The nurse suspects a nasal infection and anticipates observing which finding during examination? a. Foul-smelling drainage b. Purulent green-yellow drainage c. Bloody drainage d. Watery drainage P. 145
B
A teenager comes to the clinic complaining about the whiteheads and blackhead on his face interfering with his social life. During the examination the nurse palpates an enlarged submental lymph node. Where is this lymph node located? a. In front of the ear b. Under the mandible c. At the base of the skull d. Along the angle of the jaw
B
After seeing the red reflex and retinal vessels through the ophthalmoscope, how does the nurse locate the optic disc? a. By rotating the diopter to the block (positive) numbers until the optic disc comes into focus b. By following the retinal vessels inward toward the nose until optic disc is seen c. By using the green beam light while looking outward toward the ear until the disc is seen d. By locating the macula and then looking temporally (toward the ear) until the disc is seen
B
During an eye examination of an Asian patient, a nurse notices an involuntary rhythmical, horizontal movement of the patient's eyes. How does a nurse document this finding? a. An expected racial variation b. Nystagmus c. Exophthalmus d. Myopia
B
During the Rinne test, a nurse determines that the patient hears the tuning fork held on the mastoid process for 15 seconds and hears the tuning fork held in front of the ear for 30 seconds. The same results are found in both ears. Based on this finding, what is the most appropriate response of the nurse? a. Repeat the test again using a 2000 Hz tuning fork. b. Tell the patient that this represents an expected finding. c. Refer the patient for additional testing to detect hearing abnormality. d. Perform a Weber test to confirm the findings of the Rinne test.
B
During the history, a patient reports blurred vision, seeing double at times, and a glare from headlights from oncoming cars at night. Based on this information, what finding does the nurse expect to find on assessment of this patient's eyes? a. Anterior chamber depth is shallow. b. Red reflex is absent. c. Extraocular muscle movement is asymmetric. d. Retinal arteries are wider than retinal veins.
B
How does the nurse perform a Weber test to assess hearing function? a. Whispers three to four words into the patient's ear and asks him to repeat the words heard b. Places a vibrating tuning fork in the middle of the head and asks the patient if the sound is heard the same in both ears c. Places a set of headphones over both ears, plays several tones, and asks the patient to identify the sounds d. Places a vibrating tuning fork on the mastoid process and asks the patient to signal when he can no longer hear the sound
B
How does the nurse test the function of the patient's spinal accessory nerve (CN XI)? a. Ask the patient to stick out the tongue and move it side to side. b. Ask the patient to shrug the shoulders against the resistance of the nurse's hands. c. Ask the patient to open the mouth and observe the uvula rise when he says "ah." d. Ask the patient to move the chin to the chest and then up toward the ceiling.
B
The nurse palpates the patient's jaw movement, placing two fingers in front of each ear and asking the patient to slowly open and close the mouth. What additional request does the nurse ask the patient to do to assess the jaw? a. Clinch the jaws together as tightly as possible. b. Move the lower jaw from side to side. c. Open the mouth as wide as possible, like a yawn. d. Move the lower jaw forward and backward several times. P. 149
B
To assess jaw movement of an adult patient, the nurse uses which technique? a. Asking the patient to open the mouth and then passively moving the patient's open jaw from side to side b. Placing two fingers in front of each ear and asking the patient to slowly open and close the mouth c. Asking the patient to open the mouth and to resist the nurse's attempt to close the mouth d. Using the pads of all fingers to feel along the mandible for tenderness and nodules p. 149 FIG 10-15
B
Which finding on assessment of a patient's eyes should the nurse document as abnormal? a. An Asian American patient with an upward slant to the palpebral fissure b. A Caucasian American patient whose sclerae are visible between the upper and lower lids and the iris c. An African American patient who has off-white sclerae with tiny black dots of pigmentation near the limbus d. An American Indian patient whose pupillary diameters are 5 mm bilaterally
B
During an examination of the head and neck of a healthy adult, the nurse expects which findings? Select all that apply. a. Small red lesions with white flakes scattered on the scalp b. The head and facial bones are proportional for the size of the body c. Depressions palpated on the right and left sides over the parietal bones d. Head held flexed 15 degrees to the left e. Face and jaw are symmetric and proportional f. Temporomandibular joint moves smoothly
B, E, F
A nurse shines a light in the right pupil to test constriction and notices that the left pupil constricts as well. Based on these data, the nurse should take what action? a. Document this finding as an abnormal finding. b. Assess the patient for accommodation. c. Document this finding as a consensual reaction. d. Assess the patient's corneal light reflex.
C
A nurse uses which technique to assess a patient's peripheral vision? a. The nurse asks the patient to keep the head still and by moving the eyes only, follow the nurse's finger as it moves side to side, up and down, and obliquely. b. The nurse covers one of the patient's eyes with a card and observes the uncovered eye for movement, then removes the card and observes the just uncovered eye for movement. c. With the patient and nurse facing each other and a card covering their corresponding eyes, the nurse moves an object into the visual field and the patient reports when the object is seen. d. The nurse shines a light on both corneas at the same time and notes the location of the reflection in each eye.
C
During a Weber test, a patient with right ear hearing loss reports hearing sound longer in the right ear than the left ear. What results should the nurse expect to find from this patient during a Rinne test? a. Air conduction will be twice as long as bone conduction (2:1 ratio). b. Air conduction will be 1.5 times as long as bone conduction (1.5:1 ratio). c. Bone conduction will be longer than air conduction. d. Bone conduction will be equal to air conduction.
C
During an eye assessment, a nurse asks the patient to cover one eye with a card as the nurse covers his or her eye directly opposite the patient's covered eye. The nurse moves an object into the field of vision and asks the patient to tell when the object can be seen. This assessment technique collects what data about the patient's eyes? a. Symmetry of extraocular muscles b. Visual acuity in the uncovered eye c. Peripheral vision of the uncovered eye d. Consensual reaction of the uncovered eye
C
How does a nurse assess movements of the eyes? a. By assessing peripheral vision b. By noting the symmetry of the corneal light reflex c. By assessing the cardinal fields of gaze d. By performing the cover-uncover test
C
What instructions does the nurse give the patient before using the Snellen visual acuity chart? a. "Remove your eyeglasses before attempting to read the lowest line." b. "Stand 10 feet from the chart and read the first line aloud." c. "Hold a white card over one eye and read the smallest possible line." d. "Squint if necessary to improve the ability to read the largest letters." P. 149
C
While taking a history, the nurse observes that the patient's facial cranial nerves (CN VII) are intact based on which behaviors of the patient? a. The patient's eyes move to the left, right, up, down, and obliquely during conversation. b. The patient moistens the lips with the tongue. c. The sides of the mouth are symmetric when the patient smiles. d. The patient's eyelids blink periodically. P. 137
C (Since the facial cranial nerves control symmetry)
Two things should happen when you change your eyes from looking at a far away object to a near object
Convergence and Constriction constrict to accommodate and converge to accomodate
A nurse examines a patient's auditory canal and tympanic membrane with an otoscope and observes which finding as normal? a. Clear fluid lining the auditory canal b. A firm tympanic membrane without fluctuation with puffs of air c. A small hole within the cone of light d. A shiny, translucent tympanic membrane
D
A patient comes to the clinic for evaluation after a sinus infection. To evaluate the therapy, the nurse uses transillumination to assess the sinuses and notes which finding indicating recovery from a frontal sinus infection? a. The soft palate illuminates brightly when the light source is placed against the lateral nose. b. No illumination is noted when the light source is placed firmly against the lateral nose. c. A bright glow illuminates the hard palate when the light source is placed against each temporal bone. d. A reddish light is noted above the eyebrows when the light is placed against each supraorbital rim.
D
How does a nurse recognize normal accommodation? a. The patient has peripheral vision of 90 degrees left and right. b. The patient's eyes move up and down, side to side, and obliquely. c. The right pupil constricts when a light is shown in the left pupil. d. The patient's pupils dilate when looking toward a distant object.
D
How does the nurse perform a Rinne test of hearing function? a. Whispers several words to the patient and requests that the patient repeat the words heard b. Places a vibrating tuning fork in the middle of the head and asks the patient if the sound is heard the same in both ears or if it is louder in one ear than the other c. Places a set of headphones over both ears, plays several tones, and asks the patient to identify the sounds d. Places a vibrating tuning fork on the mastoid process until the patient no longer hears it, and then moves it in front of the ear until the patient no longer hears it
D
On inspection of the external eye structures of an African American patient, the nurse notices the sclerae are not white, but appear a darker shade with tiny black dots of pigmentation near the limbus. How does the nurse document this finding? a. As an indication of a type of anemia b. As a hordeolum or sty c. As jaundice d. As an expected racial variation
D
Which finding warrants a referral for additional evaluation? a. Earlobes hanging freely from the base of the pinna b. Ears having painless nodules less than 1 cm in diameter at the helix c. Ears measuring 8 cm in length d. Pinna is 20 degrees lower than the outer canthus of the eye
D
Which tests do we use to test Extraocular eye muscle function?
First do the Corneal Light Reflex if test is abnormal, go to next test which is Cover test. Diagnostic Positions Test (Cardinal Fields of Gaze)
Cover test
Have patient cover one eye. make sure that uncovered eye doesn't bounce around. Then check covered eye to see if it jumps around as well. The eye muscle should not jump on either eye.
Perrla means
Pupils equal, round, reacting to light, and accommodation
Corneal Light reflex
Take a penlight right to the middle of the eyes. You should see a reflection in the same spot on each eye. Record your findings as such. Example: Reflection is noted at the 2 oclock position bilaterally If this test comes up abnormally, then you would proceed to do the cover test.
Accommodation Test
The Testee looks over the Testers shoulder at a far away object (clock) Now the Testee looks at the Testers Nose. Eyes should dilate to look at the far away object (clock) and eyes should constrict when looking at the Testers Nose (near object), Thie eye should accommodate to the near object.
snellen eye chart
Visual acuity test
A common cause of a conductive hearing loss is: a) impacted cerumen b) acute rheumatic fever c) a CVA d) otitis externa
a
In examining a young adult woman, you observe her tympanic membrane to be yellow in color. You suspect she has: a) serum in the middle ear b) blood in the middle ear c) infection of the drumhead d) jaundice
a
Sensorineural hearing loss may be related to: a) a gradual nerve degeneration b) foreign bodies c) impacted cerumen d) perforated tympanic membrane
a
While viewing with the otoscope, the examiner instructs the person to hold the nose and swallow. During this maneuver, the eardrum should: a) flutter b) retract c) bulge d) remain immobile
a
She said almost every eye test will be on her test while she was lecturing
a little bit later she said she really wants us to know Pupillary Light reflex, Perrla, Diagnostic test, confrontation test, and corneal light reflex. Im just going to study this whole eye quizlet i made.
A patient with a head injury has clear, watery drainage from the ear; the examiner should: a) place a cotton ball loosely at the entrance to the ear canal b) assess for the presence of glucose in the drainage c) perform pneumatic otoscopy to assess for drum hypomotility. d) assess for the presence of a tympanostomy tube in the ear.
b
During the otoscopic examination of a child younger than 3 years, the examiner: a) pulls the pinna up and back b) pulls the pinna down c) holds the pinna gently but firmly in its normal position d) tilts the head slightly towards the examiner.
b
The sensation of vertigo is the result of: a) otitis media b) pathology in the semicircular canals c) pathology in the cochlea d) 4th cranial nerve damage
b
Upon examination of the tympanic membrane, visualization of which of the following findings indicates the infection of acute purulent otitis media? a) absent light reflex, bluish drum, oval dark areas b) absent light reflex, reddened drum, bulging drum c) oval dark areas on drum d) absent light reflex, air-fluid level, or bubbles behind drum e) retracted drum, very prominent landmarks
b
When the ear is being examined with an otoscope, the patient's head should be: a) tilted toward the examiner b) tilted away from the examiner c) as vertical as possible d) tilted down
b
In examining the ear of an adult, the canal is straightened by pulling the auricle: a) down and forward b) down and back c) up and back d) up and forward
c
Using the otoscope, the tympanic membrane is visualized. The color of a normal membrane is: a) deep pink b) creamy white c) pearly gray d) dependent upon the ethnicity of the individual.
c
When assessing hearing acuity in a 6 month-old child, the examiner should: a) use an audiometer b) observe for shyness and withdrawal c) watch for head turning when saying the child's name d) test the startle (Moro) reflex
c
Before examining the ear with the otoscope, the ________ should be palpated for tenderness. a) helix, eternal auditory meatus, and lobule b) mastoid process, tympanic membrane, and malleus c) pinna, pars flaccida, and antitragus d) pinna, tragus, and mastoid process
d
Darwin's tubercle is: a) an overgrowth of scar tissue b) a blocked sebaceous gland c) a sign of gout called tophi d) a congenital, painless nodule at the helix
d
Risk reduction for acute otitis media includes: a) use of pacifiers b) increasing group daycare c) avoiding breastfeeding d) eliminating smoking in the house and car
d
The hearing receptors are located in the: a) vestibule b) semicircular canals c) middle ear d) cochlea
d
Convergence
is the ability of the eye to simultaneously demonstrate inward movement of both eyes toward each other. This is helpful in effort to make focus on near objects clearer. This should happen when looking at a far away object and then a near object.
