Health Assessment Chapter 16 & 17

A nurse is interviewing a client as part of a routine examination of his ears and hearing. The nurse notes that this client has high blood pressure. Which of the following questions regarding his hearing should the nurse ask that is associated with his high blood pressure?

"Do you experience any ringing, roaring, or crackling in your ears?"

A patient calls the clinic and tells the nurse that the doctor told her that she has "otalgia." The patient cannot remember what the doctor explained this to be. How would the nurse most appropriately respond?

"Otalgia is pain in the ear."

The results of a client's Rinne test are as follows: bone condcution > air conduction. How should the nurse explain these findings to the client?

"You have a conductive hearing loss."

The nurse notes a tophus of the ear of an older adult. Which assessment data is consistent with a tophus?

A hard nodule composed of uric acid crystals

The nurse is performing visual acuity testing on an older adult who has fallen and fractured their femur. What finding would be considered normal for this client? (Select all that apply.)

Arcus senilis Cataract Decreased tear production

A mother of a small child calls the clinica and asks to schedule an appointment for ear tube removal. The call is transferred to the nurse. What is the nurse's best action?

Ask the mother how long the tubes have been in place.

Which technique by the nurse demonstrates proper use of the ophthalmoscope?

Asks the client to fix the gaze upon an object and look straight ahead

The thin mucous membrane that lines the inner eyelid and covers the sclera is known as what?

Conjunctiva

A light is pointed at a client's pupil, which then contracts. It is also noted that the other pupil contracts as well, though it is not exposed to bright light. Which of the following terms describes this latter phenomenon?

Consensual reaction

A nurse inspects the eyes of a young child and notices the inward turning of the eyes. What test should the nurse perform to assess whether this finding is normal or abnormal?

Corneal light reflex

The nursing student hopefuls are taking a pre-nursing anatomy and physiology class. What will they learn is the anatomical feature that equalizes air pressure in the middle ear?

Eustachian tube

When performing the cover test, a nurse notices that the client's left eye turns outward. How should the nurse document this finding in the client's record?

Exotropia

A client exhibits purulent drainage in the right external ear canal. The client complains of pain that increases when the ear is touched. Which client teaching instructions should the nurse provide?

Finish the entire course of antibiotic therapy.

When assessing risk factors for eye and vision problems, the nurse knows that genetics can play a role. What major eye problem are clients most likely at increased risk for if a first-degree relative has it?

Glaucoma

A client presents to the emergency department after being hit in the head with a baseball bat during a game. The nurse should assess for which condition?

Hyphema

A client has an abnormal consensual pupillary reaction to light. A nurse understands that what reaction occurs in the client's eyes?

Nonreaction of the opposite pupil to light

A patient comes to the clinic and reports pain when he touches his ear. With what is this finding most consistent?

Otitis externa

Which of the following describes a condition characterized by abnormal spongy bone formation around the stapes?

Otosclerosis

Which terms refers to the progressive hearing loss associated with aging?

Presbycusis

The nurse observes a middle-aged colleague fully extending her arm to read the label on a vial of medication. Which of the following age-related changes is the nurse likely to have observed?

Presbyopia

A 67-year-old lawyer comes to the clinic for an annual examination. He denies any history of eye trauma or recent visual changes. Inspection of his eyes reveals a triangular thickening of the bulbar conjunctiva across the outer surface of the cornea. He has a normal pupillary reaction to light and accommodation. Based on this description, what is the most likely diagnosis?

Pterygium

What action should the nurse implement when assessing the ear of an adult client using an otoscope?

Pull the auricle out, up, and back.

Which characteristic feature of the tympanic membrane should a nurse anticipate finding in a client with acute otitis media?

Red, bulging, with an absent light reflex

A client is assigned a visual acuity of 20/100 in her left eye. Which of the following is true?

She can see at 20 feet what a normal person could see at 100 feet.

A client is admitted to the health care facility after sustaining a crushing injury to the right eye. The nurse should anticipate abnormal results for which vision test?

Six cardinal positions of gaze

As part of a physical assessment, the nurse performs the confrontation test to assess the client's peripheral vision. Which test result should a nurse recognize as indicating normal peripheral vision for a client using the confrontation test?

The client and the examiner see the examiner's finger at the same time.

Which action by the nurse is consistent with the Rinne test?

The nurse strikes the tuning fork and places it on the patient's mastoid process to measure bone conduction.

When planning care for a client with an inner ear infection, the nurse will need to include interventions for which of the following potential problems?

Vertigo

The nurse should make it a priority to assess which client for papilledema?

a 45-year-old suspected of experiencing a subarachnoid hemorrhage

The meibomian glands secrete

an oily substance to lubricate the eyes.

While assessing the eye of an adult client, the nurse observes an inward turning of the client's left eye. The nurse should document the client's

esotropia.

An adult client visits the clinic and tells the nurse that he has had excessive tearing in his left eye. The nurse should assess the client's eye for

lacrimal obstruction.

The optic nerves from each eyeball cross at the

optic chiasma.

The nurse is preparing to examine an adult client's eyes, using a Snellen chart. The nurse should

position the client 609.6 cm (20 ft) away from the chart.

The nurse is planning to conduct the Weber test on an adult male client. To perform this test, the nurse should plan to

strike a tuning fork and place it on the center of the client's head or forehead.

An adult client tells the nurse that his father had cataracts. He asks the nurse about risk factors for cataracts. The nurse should instruct the client that a potential risk factor is

ultraviolet light exposure.

A client is diagnosed with a scotoma. What question is appropriate for the nurse to ask to obtain more data about this condition?

"Are the blind spots constant or intermittent?"

Which question asked by the nurse is assessing problems with tinnitus?

"Do you experience buzzing in your ears?"

A patient has Darwin tubercle. What is this?

A small painless nodule on the helix

A client presents to a primary care office with a complaint of double vision (diplopia). On questioning, the client claims to have not suffered any head injuries. Which of the following underlying conditions should the nurse most suspect in this client?

Brain tumor

A patient asks a nurse if any foods promote eye health. What food would the nurse include as a response?

Deep-water fish

A nurse examines a client's retina during the ophthalmic examination and notices light-colored spots on the retinal background. The nurse should ask the client about a history of what disease process?

Diabetes

When considering eye safety, what instructions should the nurse provide to a patient newly prescribed contact lenses? (Select all that apply.)

Do not share lenses. Keep the lenses clean. Wash hands before inserting or removing the lenses. Discard unused portions of contact solutions at the expiration date.

A nurse is educating a client about the function of the parts of the auditory system. Which is the function of the eustachian tube?

Equalizes the pressure in the middle ear with atmospheric pressure.

A client visits a community clinic reporting severe allergies causing a "crackling sensation" in the ear. The physician diagnoses serous otitis media. Which of the following is a characteristic of this condition?

Fluid collects in the middle ear causing an obstruction of the auditory tube.

Which finding should a nurse recognize as a normal when assessing the ears of an elderly client?

High tone frequency loss

Normal movement of the eye involves what cranial nerves? (Mark all that apply.)

II III IV VI

The client is having a Weber test. During a Weber test, where should the tuning fork be placed?

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

A client frequently experiences dry, irritated eyes. These findings are consistent with a problem in what part of the eye?

Lacrimal apparatus

A client admitted to the health care facility is diagnosed with vertigo. Which test is appropriate for the nurse to perform to assess for equilibrium in the client?

Romberg

Which of the following is a symptom of the eye?

Scotomas

The nurse is caring for a 63-year-old client who can neither read nor speak English. What would be the appropriate chart to use to assess this patient's vision?

Snellen E

A 12-year-old presents to the clinic with his father for evaluation of a painful lump in the left eye. It started this morning. The client denies any trauma or injury. There is no visual disturbance. Upon physical examination, there is a red raised area at the margin of the eyelid that is tender to palpation; no tearing occurs with palpation of the lesion. Based on this description, what is the most likely diagnosis?

Stye

Which area of the fundus is the central focal point for incoming images?

The fovea

A nurse performs the Snellen test on a client and obtains these results: OD 20/40, OS 20/30. What conclusion can the nurse make in regards to the client's vision based on these results?

The larger the bottom number, the worse the visual acuity

During a pharmacology class the students are told that some drugs need to be closely monitored. What aspect should the nurse closely monitor for in clients who have been administered salicylates, loop diuretics, quinidine, quinine, or aminoglycosides?

Tinnitus and sensorineural hearing loss

While performing an otoscopic examination of a client's ear, the nurse finds white patches on the tympanic membrane. How would the nurse note this finding in the chart?

Tympanic membrane visualized with areas of opacity noted

The functional reflex that allows the eyes to focus on near objects is termed

accommodation.

After examining the client's tympanic membranes, the nurse documents "Right tympanic membrane, red and bulging with no light reflex." The nurse recognizes that these are signs of

acute otitis media.

The nurse has performed the Rinne test on an older adult client. After the test, the client reports that her bone conduction sound was heard longer than the air conduction sound. The nurse determines that the client is most likely experiencing

conductive hearing loss.

The transmission of sound waves through the external ear and the middle ear is known as

conductive hearing.

A patient complains of feeling like he is slowly losing his central vision. The nurse knows this symptom could represent

macular degeneration

An older client asks why vision is not as sharp as it used to be when the eyes are focused forward. What should the nurse realize this client is describing?

macular degeneration

Photoreceptors of the eye are located in the eye's

retina.

The nurse notes that the ophthalmologist suspects death of the optic nerve. When looking into the eye, the nurse would expect to see what color if the disc is dead?

white