Lewis Chapter 20: Assessment of Visual and Auditory Systems

The nurse is assessing an older adult patient who has just been transferred to the long-term care facility. Which assessment question will best allow the nurse to assess for the presence of presbycusis? "Do you ever experience any ringing in your ears?" "Have you ever fallen down because you became dizzy?" "Do you ever have pain in your ears when you're chewing or swallowing?" "Have you noticed any change in your hearing in recent months and years?"

"Have you noticed any change in your hearing in recent months and years?" Presbycusis is an age-related change in auditory acuity

A patient complains of intermittent eye dryness. Which question should the nurse ask the patient to determine the etiology of this symptom? "Do you take ginkgo to treat asthma or tinnitus?" "What do you take if you have allergy symptoms?" "Are you taking propranolol for an anxiety disorder?" "How long have you been taking prednisone (Deltasone)?"

"What do you take if you have allergy symptoms?" Antihistamines or decongestants taken for allergies or colds can cause ocular dryness.

The patient reports a *loss of central vision*. What *test* should the *nurse teach the patient* about to identify changes in macular function? Amsler grid test B-scan ultrasonography Fluorescein angiography Intraocular pressure testing with Tono-Pen

Amsler grid test The *Amsler grid test* is *self-administered* and regular testing is necessary to identify any changes in macular function.

During the course of an interview to assess vision, a patient complains of dry eyes. What should the nurse implement next? Assess for contact lenses. Suggest saline eye drops. Ask about eyeglass usage. Check the medication list.

Check the medication list. The nurse should evaluate the patient's medication list to identify agents that can contribute to dry eyes so follow-up nursing care can be planned.

A patient has ptosis resulting from myasthenia gravis. Which assessment finding would the nurse expect to see in this patient? Redness and swelling of the conjunctiva Drooping of the upper lid margin in one or both eyes Redness, swelling, and crusting along the eyelid margins Small, superficial white nodules along the eyelid margin

Drooping of the upper lid margin in one or both eyes

A patient working in a noisy factory reports being off balance when standing or walking but not while lying down. What term will the nurse use to document this patient's symptoms? Vertigo Syncope Dizziness Nystagmus

Dizziness Dizziness is a sensation of being off balance that occurs when standing or walking; it does not occur when lying down.

A college student reports eye pain after studying for finals. What assessment should the nurse make first in determining the possible etiology of this eye pain? Do you wear contacts? Do you have any allergies? Do you have double vision? Describe the change in your vision.

Do you wear contacts? College students frequently wear contact lenses and stay up late or all night studying for finals. If the student wears contacts, the wearing of them while studying, care of them, and length of wear time will be assessed before looking for a corneal abrasion from extended wear with fluorescein dye.

A patient reporting frequent vertigo is scheduled for electronystagmography to test vestibular function. Which instructions should the nurse provide to the patient before the procedure? Eat a light meal before the procedure. Avoid carbonated beverages before the procedure. Take nothing by mouth for 3 hours before the procedure. No special dietary restrictions are needed until after the procedure.

Eat a light meal before the procedure. Instruct patient to eat a light meal before the test to avoid nausea

When assessing an adult patient's external ear canal and tympanum, what assessment techniques should the nurse use? Ask the patient to tip his or her head toward the nurse. Identify a pearl gray tympanic membrane as a sign of infection. Gently pull the auricle up and backward to straighten the canal. Identify a normal light reflex by the appearance of irregular edges.

Gently pull the auricle up and backward to straighten the canal. When examining a patient's external ear canal and tympanum, ask the patient to tilt the head toward the opposite shoulder. Grasp and gently pull the auricle up and backward to straighten the canal. A healthy, normal tympanic membrane will appear pearl gray, white, or pink and have a cone-shaped light reflex.

The nurse is assessing a patient's medical history. What aspects of the patient's medical history are most likely to have potential consequences for the patient's visual system? Hypothyroidism and polycythemia Hypertension and diabetes mellitus Atrial fibrillation and atherosclerosis Vascular dementia and chronic fatigue

Hypertension and diabetes mellitus Hypertension and diabetes frequently contribute to visual pathologies.

Otoscopic examination of the patient's left ear indicates the presence of an *exostosis*. What does the nurse prepare to teach the patient about regarding the *growth*? Surgery Electrocochleography Monitoring of the growth Irrigation of the ear canal

Monitoring of the growth

A patient newly diagnosed with *glaucoma* asks the nurse what has made the *pressure in the eyes* so high. Which is the nurse's most accurate response? Back pressure from cardiac congestion causes corneal edema. Cerebral venous dilation prevents normal interstitial fluid resorption. Increased production of aqueous humor or blocked drainage increases pressure. Congenital anomalies of the lacrimal gland or duct obstruct the passage of tears.

Increased production of aqueous humor or blocked drainage increases pressure. *Intraocular pressure* is *increased* in *glaucoma* as a result of *excess aqueous humor production* or *decreased outflow* Cardiac or cerebral circulation changes do not cause glaucoma

An older adult patient states they don't seem to hear well and have to ask people to repeat themselves. What should the nurse do first to determine the cause of the hearing loss? Look for cerumen in the ear. Assess for increased hair growth in the ear. Tell the patient it is probably related to aging. Ask the patient if he has fallen because of dizziness.

Look for cerumen in the ear. Gerontologic differences in the assessment of the auditory system include increased production of and drier cerumen, which can become impacted in the ear canal and contribute to hearing loss. Conductive hearing loss with impacted cerumen may lead to speaking softly as the patient's voice conducted through bone seems loud to the patient.

During a health history, a *43-yr*-old teacher complains of increasing *difficulty reading* printed materials for the past year. What change related to aging does the nurse suspect? Myopia Hyperopia Presbyopia Astigmatism

Presbyopia *Presbyopia* is a loss of accommodation causing an *inability to focus on near objects*. This occurs as a normal part of aging process starting around age 40 years. *Myopia* is nearsightedness (*near objects are clear and far objects are blurred*). *Astigmatism* results in *visual distortion* related to unevenness in the cornea. *Hyperopia* is farsightedness (*near objects are blurred and far objects are clear*ly seen).

When examining the patient's ear with an otoscope, the nurse observes discharge in the canal and the patient reports pain with the examination. What should the nurse next assess the patient for? Sebaceous cyst Swimmer's ear Metabolic disorder Serous otitis media

Swimmer's ear Swimmer's ear or an infection of the external ear is probably the cause of the discharge and pain. Asking the patient about swimming, ear protection, and exposure to types of water can identify contact with contaminated water. After clearing the discharge, the tympanic membrane can be assessed for otitis media.

The nurse is assessing a *65-yr*-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 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."

a. "Hold this card and read the print out loud." The *Jaeger card* is used to *assess near vision problems* and *presbyopia* in persons *older than 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.

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

a. "I take metoprolol (Lopressor) for angina." It is important to note whether the patient takes any *b-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.

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-yr-old who has noticed increasing loss of peripheral vision b. 74-yr-old who has difficulty seeing well enough to drive at night c. 60-yr-old who has difficulty hearing clearly in a noisy environment d. 64-yr-old who has decreased hearing and ear "stuffiness" without pain

a. 71-yr-old who has noticed increasing loss of peripheral vision Increasing loss of peripheral vision is characteristic of glaucoma, and the patient should be scheduled for an examination as soon as possible.

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.

a. A Tono-Pen will be applied to the surface of the eye 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.

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 c. OD 20/40; OS 20/50 b. OU 20/40; OS 50/20 d. OU 40/20; OD 50/20

a. OS 20/50; OD 20/40

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 away 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.

a. stand 20 feet away from the wall chart.

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

b. "You will need to wear sunglasses for a few hours after the examination." The *pupils* are *dilated* using *cycloplegic medications* during refractometry. This effect will last several hours and cause photophobia.

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.

b. Perform Snellen testing of visual acuity for a patient with a history of cataracts.

When the patient *turns his head quickly* during the admission assessment, the nurse observes *nystagmus* (rapid involuntary movement of the eyes). 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.

b. Place a fall-risk bracelet on the patient. Problems with *balance* related to *vestibular function* may present as *nystagmus or vertigo* and indicate an increased *risk for falls*.

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 coping related to inability to admit the impact of the eye injury

b. Risk for falls related to temporary decrease in stereoscopic vision 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*.

The nurse is performing an eye examination on a *76-yr-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.

b. The patient reports persistent photophobia. *Photophobia* is *not a normally occurring change* with aging and would require further assessment. The other assessment data are common gerontologic differences in assessment and would not be unusual in a 76-yr-old patien

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

b. Tuning fork Rinne testing is done using a tuning fork.

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

b. Tympanum is blue-tinged. A bluish-tinged tympanum can occur with acute otitis media, which requires immediate care to prevent perforation of the tympanum.

The nurse is observing a student who is preparing to perform an ear examination for a 30-yr-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.

b. chooses a speculum larger than the ear canal.

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.

b. report any burning or pain at the IV site. *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.

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. c. pure-tone audiometry. b. rotary chair testing. d. bone-conduction testing.

b. rotary chair testing 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.

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 appropriate to obtain more information about possible hearing problems? a. "Do you grind your teeth at night?" TestBankWorld.org 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?"

c. "Have you noticed ringing in your ears?" Patients with *tinnitus* may use *masking techniques*, such as playing a radio, to block out the ringing in the ears.

Which action should the nurse take when providing patient teaching to a 76-yr-old patient 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.

c. Ask for permission to turn off the television before teaching. 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.

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

c. Blurred vision and light sensitivity Classic signs of cataracts include blurred vision and light sensitivity. Thyroid problems are a major cause of exophthalmos. Unequal pupil is not indicative of cataracts. Loss of peripheral vision is a sign of glaucoma.

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

c. Ibuprofen taken for 20 years to treat osteoarthritis *Nonsteroidal antiinflammatory drugs* are *potentially ototoxic* (toxic affect on the ear).

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 pupils. c. shine a light into one eye and observe responses of both pupils. d. instruct the patient to follow a moving object using only the eyes.

c. shine a light into one eye and observe responses of both pupils.

When obtaining a health history from a 49-yr-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."

d. "I can't see as far over to the side." The *decrease in peripheral vision* may *indicate glaucoma*, which is not a normal visual change associated with aging and requires rapid treatment.

The nurse in the eye clinic is examining a *67-yr*-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. Warn the patient that these spots may indicate retinal damage. d. Use an ophthalmoscope to examine the posterior eye chambers.

d. Use an ophthalmoscope to examine the posterior eye chambers. 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-yr-old patient is not an emergency. The spots may indicate retinal damage, but the nurse should assess the eye further before discussing this with the patient.

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

d. encouraging the patient to ambulate independently. Vestibular disease affects balance, so the nurse should monitor the patient during activities that require balance.

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 toward the patient's eyes.

d. the pupils constrict while fixating on an object being moved toward the patient's eyes.