Ch 21, Visual and Auditory Assessment

Pt. has doubled vision

Pt. is holding his/her head in a skewed position.

ANSWER: A. "You should eat a light meal." By recording eye movement through electrodes, electronystagmography aids diagnosis of diseases of the vestibular system. The nurse instructs the patient to eat a light meal before the test to reduce the risk of nausea caused by electrode movement near the eye. The nurse will not instruct the patient to consume ice cream, because electronystagmography will not cause inflammation or irritation of the trachea. Gargling helps clear the throat and mouth but does not affect the eyes. Electronystagmography does not require excess hydration. Text Reference - p. 384

A nurse assessing vestibular function places electrodes near the patient's eye to record specific eye movement. What does the nurse instruct the patient to do before performing the test? A. "You should eat a light meal." B. "You should consume ice cream." C. "You should gargle for 15 minutes." D. "You should drink eight glasses of water."

ANSWER: C. "How many hours of sleep do you get in 24 hours?" The health of the eyes depends on various lifestyle factors. One important parameter is sleep. An adequate duration of sleep is required for optimum eye health. Asking how many hours the patient sleeps gives information about the duration of sleep. Bedtime is not an important factor in determining eye health, but duration is important. Position of sleep doesn't affect eye health. Similarly, information about dreams may be used in psychologic and emotional assessment, but is not related to eye health. Text Reference - p. 373

A nurse is interviewing a patient with irritation of the eyes. To assess eye health, the nurse should ask what sleep hygiene-related question? A. "What time do you go to sleep at night?" B. "What position do you generally sleep in?" C. "How many hours of sleep do you get in 24 hours?" D. "What kind of dreams do you generally have?"

ANSWER: C. The patient has presbyopia. A 40-year-old patient having blurred vision of objects closer to the visual field and rigidity of the lens indicate that the patient has presbyopia. Presbyopia is the loss of accommodation, which occurs because of the increased rigidity of the lens. It causes an inability to focus on objects that are near. Presbyopia occurs as a normal process of aging. Myopia is nearsightedness or the loss of vision of faraway objects. This condition does not develop with old age and is found in all age groups. Hyperopia, or farsightedness, is an inability to accommodate for near objects. Astigmatism occurs because of an unevenness of the cornea, which results in distorted vision, but not in the loss of objects that are nearby. Text Reference - p. 369

A 40-year-old patient tells a nurse, "I've noticed over the last three months that I have blurred vision of near objects." The ophthalmic consultation report shows that the patient has increased rigidity of the lens. What should the nurse interpret from the finding? A. The patient has myopia. B. The patient has hyperopia. C. The patient has presbyopia. D. The patient has astigmatism.

ANSWER: A. Do you wear contacts? College students frequently wear contact lenses and will be 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 should be assessed before looking for a corneal abrasion from extended wear with fluorescein dye. There are no manifestations of allergies, diplopia, or visual changes mentioned. Text Reference - p. 376

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

ANSWER: B. The patient has pinguecula. Small, yellowish spots on the medial aspect of the conjunctiva are associated with pinguecula, which occurs as a result of tissue damage related to chronic exposure to ultraviolet light. Because the patient works in the radiology department, the likelihood of exposure to ultraviolet light is high. Pterygium is an abnormality of the cornea that is associated with chronic exposure to sunlight, which manifests as thickened, triangular, pale tissue extending from the inner canthus to the nasal border. Presbyopia is a refractive error that is associated with the loss of near vision. This condition manifests as increased rigidity of the lens, not yellow spots on the conjunctiva. Arcus senilis is an abnormality of the cornea that occurs because of cholesterol deposition in the peripheral cornea and manifests as a milky white and grayish ring around the eye. Test-Taking Tip: Tissue damage in eye occurs due to chronic exposure to ultraviolet light. Use this information to answer this question. Text Reference - p. 371

A nurse finds that a patient has small, yellowish spots on the conjunctiva. Upon further interaction, the nurse finds that the patient works at a hospital in the radiology department. What should the nurse interpret from these findings? A. The patient has pterygium. B. The patient has pinguecula. C. The patient has presbyopia. D. The patient has arcus senilis.

ANSWER: C. Slow recovery of pupil size after light stimuli Dilator muscle atrophy or weakness affects the ability of the pupils to contract and relax. As age progresses, this muscle becomes weak. Due to weakness or atrophy, the recovery of pupil size after stimulation by light is delayed. Cataracts are formed due to biochemical changes in the lens proteins which result in clouding of the lens. Excessive dryness is caused due to reduced production of tears or due to malposition of the eyelids. Changes in perception of colors are not related to the dilator muscle. Color perception is carried by cones in the retina. A decrease in the number of cones causes this problem. Text Reference - p. 371

A nurse is assessing a patient with dilator muscle atrophy of the eye. The nurse expects to find what clinical manifestation? A. Formation of cataracts B. Excessive dryness of the eyes C. Slow recovery of pupil size after light stimuli D. Changes in perception of colors, especially blue and violet

ANSWER: A. Aspirin B. Antibiotics D. Antimalarial drugs Many drugs are ototoxic. They can damage the hearing of an individual. They can cause hearing loss, tinnitus, and other problems. These drugs include aspirin, chemotherapy drugs, antibiotics, antimalarial drugs, nonsteroidal antiinflammatory drugs (NSAIDs), and diuretics. Domperidone is an antiemetic drug and is not ototoxic. Similarly, nutritional supplements are food supplements to ensure adequate nutrition. Nutritional supplements are not ototoxic. Text Reference - p. 380

A nurse is assessing a patient with hearing loss. The patient has been taking various medications in the past few years. Which drugs may be ototoxic? Select all that apply. A. Aspirin B. Antibiotics C. Domperidone D. Antimalarial drugs E. Nutritional supplements

ANSWER: A. The patient is lip reading. D. The patient asks to have certain words repeated. E. The patient fails to respond to questions when not looking directly at the nurse. If the patient is lip reading or asks to have certain words repeated, the patient may have hearing loss. A patient with compromised hearing may look at the examiner intently but may miss a comment when not looking directly at the examiner. If the patient feels dizzy on standing up, it may indicate impaired equilibrium. While some people with hearing loss may speak loudly, this alone is not an indication of hearing loss. Text Reference - p. 381

A nurse is assessing a patient's hearing ability. Which clues would indicate compromised hearing? Select all that apply. A. The patient is lip reading. B. The patient feels dizzy when standing up. C. The patient speaks very loudly. D. The patient asks to have certain words repeated. E. The patient fails to respond to questions when not looking directly at the nurse.

ANSWER: A. Ask the patient to look at the nurse's finger. B. Ask the patient to focus on a distant object. D. The nurse places a finger at a distance of 3 inches from the patient's nose. In order to check the accommodation capacity of the patient's eyes, the nurse has to first ask the patient to focus on a distant object. The patient is then instructed to focus on the nurse's finger which is placed 3 inches from the patient's nose. The normal response is convergence and constriction of the eyes. A Snellen chart is used for testing visual acuity. The distance of 20 feet, or 6 meters, is maintained while reading a Snellen chart. Text Reference - p. 375

A nurse is assessing the pupillary function of a patient. Which steps should be performed when assessing accommodation? Select all that apply. A. Ask the patient to look at the nurse's finger. B. Ask the patient to focus on a distant object. C. The nurse places a finger at a distance of 20 feet from the patient's nose. D. The nurse places a finger at a distance of 3 inches from the patient's nose. E. The nurse places a finger at a distance of 6 meters from the patient's nose.

ANSWER: D. The patient may have increased intraocular pressure. After eye surgery, it is important for the patient to resist straining, such as when trying to defecate. Straining from constipation may lead to increased intraocular pressure in the ears and eyes. Anisocoria is the unequal size of the eye pupils, which is a physiologic condition or is associated with trauma. Persistent, abnormal intolerance of the eyes to light is called photophobia, which is associated with infection or inflammation in the uveal tract. Patients who have a loss of near vision that is associated with age will have increased lens rigidity. Text Reference - p. 373

A nurse is caring for a patient after eye surgery and finds that the patient has difficulty passing stools. What should the nurse interpret from this finding? A. The patient is at risk for anisocoria. B. The patient is at risk for photophobia. C. The patient may have increased rigidity of the lens. D. The patient may have increased intraocular pressure.

ANSWER: The tuning fork test helps to differentiate between conductive and sensorineural hearing loss. The frequency of the fork is specific in order to get the desired effect. The fork that is used in this test is 512 Hz. Text Reference - p. 382

A nurse is conducting a tuning fork test on a patient. The nurse has 4 forks, each with a different frequency: 500 Hz; 506 Hz; 512 Hz; and 520 Hz. Which fork should the nurse use? Record your answer using a whole number. Fill in the blank using a whole number. ___ Hz

ANSWER: C. "Do you have to strain while passing stools?" It is important for the nurse to ask the patient if the patient has to strain during stools. Straining during defecation increases the intraocular pressure. While assessing the elimination pattern in relation to eye complaints, knowing the characteristics of stools is not important. The regularity, characteristic, and frequency of stools are important parameters while assessing the gastrointestinal system. However, they are not related to visual impairment. Text Reference - p. 373

A nurse is interviewing a patient with visual impairment. Which question related to elimination should the nurse ask to determine changes in intraocular pressure? A. "Do you pass stools regularly?" B. "What are the characteristics of the stools?" C. "Do you have to strain while passing stools?" D. "How many stools do you have in a day?"

ANSWER: A. "Do you use birth control pills?" Birth control pills have some side effects. Some pills may cause blurred vision, double vision, or floaters in the visual field. Such cases should be immediately reported to the health care practitioner. Eye complaints are not dependent on the number of children or the menstrual period. Similarly, condom use does not affect vision. Text Reference - p. 373

A nurse is obtaining a health history from a patient with decreased visual acuity. Which question related to sexuality is relevant for this patient? A. "Do you use birth control pills?" B. "How many children do you have?" C. "Do you have regular periods?" D. "Do you and your partner use condoms during intercourse?"

ANSWER: B. The pupils dilate when light stimuli is performed. C. The right pupil is slightly smaller than the left. E. The right pupil constricts faster than the left when light stimuli are performed. Whenever light stimulus is given, the pupils constrict to regulate the amount of light falling on the retina. The size of the pupils is regulated by the iris. Under normal circumstances, both of the pupils are equal in diameter. The normal shape of pupils is round. Pupils do not dilate when light falls on them. The pupils dilate when the amount of light in the environment is less. Dilation of the pupils enables more light to enter the eye and helps the person to see better. Text Reference - p. 375

A nurse is performing an eye examination on a patient. Which findings should the nurse consider abnormal? Select all that apply. A. The pupils are equal and round. B. The pupils dilate when light stimuli is performed. C. The right pupil is slightly smaller than the left. D. The pupils constrict when light stimuli is performed. E. The right pupil constricts faster than the left when light stimuli are performed.

ANSWER: B. Serous otitis media Serous otitis media is characterized by inflammation of the middle ear and is accompanied by discharge. Inspection of the tympanum reveals presence of fluid, level with the hairline. A sebaceous cyst is seen as a black dot on the skin. Impacted cerumen is accumulated wax in the ear. This accumulation of wax often blocks the canal and makes it difficult to see the tympanum. Conductive hearing loss manifests as an inability to hear, and is not associated with symptoms like fluid in the tympanum. Text Reference - p. 383

A patient comes to a clinic with hairline fluid level in the tympanum. There are yellowish bubbles above the fluid level. The nurse recognizes that what condition is most likely present? A. Sebaceous cyst B. Serous otitis media C. Impacted cerumen D. Conductive hearing loss

ANSWER: B. 20 feet away The distance to be maintained between the patient and the Snellen chart is 20 feet, or 6 meters. This chart is used to check the visual acuity of an individual. Any distance closer or further than this will not provide an accurate assessment of visual acuity. Text Reference - p. 374

A patient comes to the clinic for an ophthalmic checkup. A nurse performs an assessment of visual acuity using a Snellen chart. The patient should be positioned how many feet away from the Snellen chart? A. 6 feet away B. 20 feet away C. 24 feet away D. 30 feet away

ANSWER: A. The patient has otalgia. The patient with otalgia will have difficulty swallowing and chewing and purulent drainage from the ear. Tinnitus is ringing of the ears that worsens with age because of the calcification of ossicles and may result in loss of hearing. Presbycusis is hearing loss associated with cumulative exposure to noise with increasing age. The patient with reduced blood supply to the cochlea will have impaired speech reception. Text Reference - p. 382

A patient complains of difficulty in swallowing and chewing, and the nurse finds purulent drainage from the ear. How does the nurse interpret these findings? A. The patient has otalgia. B. The patient has tinnitus. C. The patient has presbycusis. D. The patient has impaired speech reception.

ANSWER: B. In the retinal background The fundus is the retinal background. Normally, no hemorrhages or exudates are present in the fundus. The fundus area is not the aqueous humor, between the cornea and the lens, or between the iris and the lens. Text Reference - p. 369

A patient has a hemorrhage in the fundus area of the eye. The nurse knows that blood is accumulating A. In the aqueous humor B. In the retinal background C. Between the cornea and the lens D. In the space between the iris and the lens

ANSWER: D. Arcus senilis A total serum cholesterol of less than 180 mg/dL is considered optimal. The patient's serum total cholesterol of 220 mg/dL is high. Arcus senilis is an abnormality of the eye associated with high cholesterol levels. Cholesterol is deposited in the eye margin; therefore, the patient will see a milky white and grayish ring encircling the periphery of the cornea. Pterygium is an abnormality of the cornea that is associated with chronic exposure to sunlight, which manifests as thickened, triangular, pale tissue extending from the inner canthus to the nasal border. A patient who has glaucoma will have increased intraocular pressure, not cholesterol levels. Blepharitis is a bacterial infection in lid margins, which manifests as redness, swelling, and crusting along the lid margins. Text Reference - p. 371

A patient has a milky white and grayish ring encircling the periphery of the cornea, and the laboratory reports of the patient reveal a total serum cholesterol of 220 mg/dL. Which condition is present? A. Pterygium B. Glaucoma C. Blepharitis D. Arcus senilis

ANSWER: B. Increased risk for falls The patient with diplopia (double vision) alternately patches the eye to allow normal vision. The patient will be at increased risk for falls because patching causes impaired stereoscopic (three-dimensional) vision. The patient could fall because of impaired ability to judge distance. Conjunctivitis is redness from infection or inflammation of the conjunctiva, the mucous membrane that covers eyelids and forms a pocket under each eyelid. Dryness is not a usual problem with a patched eye because patching limits exposure to air and the environment. Cataracts occur with the aging process. Text Reference - p. 376

A patient has diplopia and the patient is prescribed with alternating patching of one eye at a time. The nurse should include teaching about what concern for this patient? A. Conjuctivitis B. Increased risk for falls C. Dryness in the patched eye D. Increased risk for cataract formation

ANSWER: B. Drooping of the upper lid margin in one or both eyes Ptosis is the term used to describe drooping of the upper lid margin, which may be either unilateral or bilateral. Ptosis can be a result of mechanical causes, such as an eyelid tumor or excess skin, or from myogenic causes, such as myasthenia gravis. Ptosis is not related to redness and swelling of the conjunctiva or lid margin or small, superficial white nodules along the lid margin. Text Reference - p. 376

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

ANSWER: A. Yellowish discoloration of the skin B. Yellowish discoloration of the urine D. Nausea and vomiting after the procedure In fluorescein angiography, fluorescein is injected in the body. This dye is a noniodine and nonradioactive dye. This procedure has some common side effects. The dye can cause yellowish discoloration of skin and urine. This dye can also cause some nausea and vomiting. Presence of blood in urine is a serious sign and is not a common side effect of this procedure. Redness of the eyes can have many causative factors and is unlikely after this procedure. Text Reference - p. 378

A patient has undergone a fluorescein angiography. The nurse should observe for what side effects of the procedure? Select all that apply. A. Yellowish discoloration of the skin B. Yellowish discoloration of the urine C. Red-colored urine indicative of presence of blood D. Nausea and vomiting after the procedure E. Redness of the eyes

ANSWER: B. "You will be sitting or lying down for the test." C. "The test involves pouring cold or warm solution into your ears." E. "The test may result in nausea and vertigo after stimulation of semicircular canals." This test is carried out to diagnose diseases of the labyrinth and vestibular systems. The patient is positioned in a sitting or supine position. In the process, a warm or cold solution is poured in the ear of the patient to stimulate the semicircular canals. If there is abnormality of the labyrinth, it may be manifested as nystagmus or nausea. Any abnormal response by the patient is recorded. This test is not performed with the patient standing. A tuning fork test is done to differentiate between conductive and sensorineural loss. Text Reference - p. 384

A patient is advised to undergo a caloric test stimulus. How should a nurse explain the test to the patient? Select all that apply. A. "You will be in a standing position for the test." B. "You will be sitting or lying down for the test." C. "The test involves pouring cold or warm solution into your ears." D. "The test is performed to determine conductive or sensorineural hearing loss." E. "The test may result in nausea and vertigo after stimulation of semicircular canals."

ANSWER: A. Observe the patient for vomiting. Rotary chair testing is done to evaluate the peripheral vestibular system. Testing is usually done in the dark; therefore, in order to ensure safety, the nurse should not leave the patient alone. The patient should be advised to eat a light meal before the test to avoid nausea. The nurse should monitor the patient for vomiting. Text Reference - p. 384

A patient is due for rotary chair testing to assess vestibular function. Which is the most appropriate nursing intervention? A. Observe the patient for vomiting. B. Instruct the patient to fast before the test. C. Explain to the patient that the test is time consuming. D. Keep the patient alone in the room to avoid distraction.

ANSWER: D. Auditory brainstem response An acoustic neuroma is a tumor that develops in the nerve of the inner ear. Auditory brainstem response is the diagnostic test used to assess the inner pathway of the ear or detect tumors in the inner ear. Posturography is a balance test, useful in assessing vestibular function. Electrocochlography allows electrical activity in the cochlea to be recorded and analyzed. Pure-tone audiometry is useful in assessing sensorineural hearing loss. Text Reference - p. 383

A patient is found to have acoustic neuromas. Which diagnostic test will aid assessment of the patient's condition? A. Posturography B. Electrocochleography C. Pure-tone audiometry D. Auditory brainstem response

ANSWER: C. "Please try to hold your head still during the examination." D. "You may find it difficult to focus on near objects for three to four hours." The patient may need help to hold the head still during the examination. Pupil dilation makes it difficult to focus on near objects, and dilation may last three to four hours. The refractometry procedure is painless. Concerns about iodine/contrast media allergy and the possibility of urine color changes occur with fluorescein angiography, not refractometry. Text Reference - p. 375

A patient is having refractometry as part of the visual assessment. Which of these instructions from the nurse is correct? Select all that apply. A. "Are you allergic to iodine or contrast media?" B. "You will feel slight burning during this procedure." C. "Please try to hold your head still during the examination." D. "You may find it difficult to focus on near objects for three to four hours." E. "You might notice that your urine will turn a darker yellow-orange color today."

ANSWER: C. "I have a sandy, gritty, and irritating sensation in my eyes." Tears act as a lubricant in the eyes. In the absence or deficiency of tears, the patient has a dry, gritty, sandy, and irritating sensation in the eyes. Double vision is caused by an abnormality in the extraocular muscles because they regulate the vision. Tear production does not affect vision. Vision and night vision are regulated by the retina. Night blindness is caused due to damage to structures known as rods, which are present in the retina. Stiffening of the ciliary muscles affects the acuity of a patient's near vision. Text Reference - p. 376

A patient is suffering from an ophthalmic condition which results in decreased tear production in the eyes. The nurse expects that the patient will report which symptom? A. "I see a double of every object." B. "I cannot see clearly in dim light or at night." C. "I have a sandy, gritty, and irritating sensation in my eyes." D. "I cannot read books, newspapers, or anything close to me."

ANSWER: A. Hold the test card at a comfortable distance. C. Focus on the center dot that is present on the card. E. Report any abnormality like lines appearing wavy. An Amsler Grid test can be carried out by the patient. This test is done to identify any changes in macular function. The correct procedure for an Amsler Grid test is as follows: The patient holds the card at a comfortable reading distance, and focuses on a dot present in the center of the chart. The test card is held at the same distance a person holds a book for reading. The person has to focus on the center dot and not on the corners. If there is pathology involved, the patient may feel that the lines around the dot are wavy, distorted, or even missing. If the patient finds any abnormality in the surrounding line, he should make a note of it and take advice from a primary healthcare practitioner. The distance of 10 feet is not required for this test. The patient does not focus on the four corners of the card. Text Reference - p. 378

A patient is to undergo an Amsler Grid test. What instructions about the test should the nurse provide to the patient? Select all that apply. A. Hold the test card at a comfortable distance. B. Keep the test card at a distance of 10 feet. C. Focus on the center dot that is present on the card. D. Focus on all four corners of the card in a clockwise pattern. E. Report any abnormality like lines appearing wavy.

ANSWER: A. Tears in the retina B. Vitreous liquefaction E. Hemorrhage in the vitreous humor Vitreous liquefaction is the most common cause of floaters and "spider web-like" images in the visual field. This can also be caused by trauma to the eye. Tears or holes in the retina and hemorrhage in the vitreous humor can also cause "spider web-like formations" in the visual field. Shortening of ciliary muscles affects the near vision of the person. Overaction of the extraocular muscle causes abnormal movement of the eyes. This is known as strabismus. Text Reference - p. 376

A patient reports seeing "spider web-like" formations in the visual field during the past few days. The nurse recognizes that which conditions might lead to these formations? Select all that apply. A. Tears in the retina B. Vitreous liquefaction C. Shortening of the ciliary muscles D. Overaction of the extraocular muscle E. Hemorrhage in the vitreous humor

ANSWER: D. The patient has an abnormality of the extraocular muscle. The patient's statement, "I see two of all everything," indicates that the patient has double vision. This indicates that the patient has diplopia, which is associated with an abnormality of the extraocular muscle. Reduced tear formation will result in dry eyes and a gritty sensation, but not double vision. The presence of inflammation in the cornea results in photophobia. An abnormality in pupil size is associated with central nervous system disorders and is referred to as anisocoria. Text Reference - p. 376

A patient tells a nurse, "I see two of everything." What should the nurse interpret from this finding? A. The patient has reduced tear formation. B. The patient has inflammation of the cornea. C. The patient has an abnormality in size of the pupils. D. The patient has an abnormality of the extraocular muscle.

ANSWER: A. Brain The brain is the main component of the auditory system, filtering unwanted and unnecessary sounds. A patient with increased sensitivity to sound will have changes in the brain. The inner ear is involved in reception of sound, balance, and body orientation. A patient with impaired middle ear function will have conductive loss of hearing. Damage to the external ear will result in collapse of the ear canal and, potentially, hearing loss. Text Reference - p. 380

A patient tells a nurse, "I'm becoming more and more sensitive to loud noises." Which auditory system change does the nurse suspect? A. Brain B. Inner Ear C. Middle Ear D. External Ear

ANSWER: C. Cranial nerve VII Problems with voluntary facial movement and eyelid closure resulting from trauma after ear surgery indicate that the patient has sustained damage to the facial cranial nerve, cranial nerve VII. Damage to cranial nerves III (oculomotor nerve) and IV (trigeminal nerve) results in paralysis of extraocular muscles. Damage to cranial nerve VIII (vestibulocochlear nerve) results in impaired hearing reception. Text Reference - p. 378

A patient who underwent ear surgery has sustained trauma and problems related to facial movement and eyelid closure. Which cranial nerve damage does the nurse suspect? A. Cranial nerve III B. Cranial nerve IV C. Cranial nerve VII D. Cranial nerve VIII

ANSWER: C. The patient has impaired stereopsis. Stereoscopic vision allows a patient to visualize in three dimensions. A patient who has impaired stereopsis will be unable to judge the distance between vehicles or between steps, which may result in accidents. Hyperopia is farsightedness or a loss of near vision. In this condition, a patient will be able to judge distances. Presbyopia is a loss of near vision that comes with age, but it does not result in the loss of three-dimensional vision. A patient who has an abnormal response to light will have impaired pupil response, but not the inability to judge distances. Text Reference - p. 377

A patient who was in a car accident tells a nurse, "I hit the vehicle that was moving in front of me; I thought it was far away and misjudged the distance." What should the nurse interpret from the patient's statement? A. The patient has hyperopia. B. The patient has presbyopia. C. The patient has impaired stereopsis. D. The patient has an abnormal response to light.

ANSWER: C. A history of heart or lung disease It is particularly important to determine whether the patient has any history of cardiac or pulmonary disease because β-adrenergic blockers often are used to treat glaucoma. These medications can slow heart rate, decrease blood pressure, and exacerbate asthma or chronic obstructive pulmonary disease (COPD). Dry eyes, use of corrective lenses, and sensitivity to sulfonamide antibiotics are incorrect. Text Reference - p. 372

A patient with acute-angle glaucoma has a new prescription for eyedrops. The nurse will question the patient about which of these conditions? A. Symptoms of dry eyes B. Use of corrective lenses C. A history of heart or lung disease D. Sensitivity to sulfonamide antibiotics

ANSWER: A. Assist the patient in holding his or her head still for the procedure. B. Explain to the patient that the dye may cause nausea and vomiting. C. Take measures to prevent extravasation of the dye when administered intravenously. E. Inform the patient that his or her urine and skin may have yellow-orange discoloration. Fluorescein is a nonradioactive, noniodine dye used for fluorescein angiography. The procedure is done to determine the flow of blood through pigment epithelial and retinal vessels. It is often completed in diabetic patients to accurately locate areas of diabetic retinopathy. During the procedure, the dye is administered intravenously into a peripheral vein. Serial photographs of the retina are taken through dilated pupils. The nurse may be required to help the patient hold his or her head still for the procedure and should inform the patient that the dye may cause nausea and vomiting. The nurse should take measures to prevent extravasation in order to prevent damage to the surrounding tissues. The patient should be informed that the dye may impart a yellow-orange color to the skin and urine. The patient should be informed that pupils need to be dilated with eyedrops before the procedure. After refractometry, the patient may not be able to focus on near objects due to dilation of the pupil. Text Reference - p. 378

A patient with diabetic retinopathy is prepared for fluorescein angiography. Which nursing interventions are appropriate? Select all that apply. A. Assist the patient in holding his or her head still for the procedure. B. Explain to the patient that the dye may cause nausea and vomiting. C. Take measures to prevent extravasation of the dye when administered intravenously. D. Inform the patient that focusing on near objects will not be difficult. E. Inform the patient that his or her urine and skin may have yellow-orange discoloration. F. Explain to the patient that eyedrops are used to constrict the pupil.

ANSWER: A. Assist the patient in holding his or her head still for the procedure. B. Explain to the patient that the dye may cause nausea and vomiting. C. Take measures to prevent extravasation of the dye when administered intravenously. E. Inform the patient that his or her urine and skin may have yellow-orange discoloration. Fluorescein is a nonradioactive, noniodine dye used for fluorescein angiography. The procedure is done to determine the flow of blood through pigment epithelial and retinal vessels. It is often completed in diabetic patients to accurately locate areas of diabetic retinopathy. During the procedure, the dye is administered intravenously into a peripheral vein. Serial photographs of the retina are taken through dilated pupils. The nurse may be required to help the patient hold his or her head still for the procedure and should inform the patient that the dye may cause nausea and vomiting. The nurse should take measures to prevent extravasation in order to prevent damage to the surrounding tissues. The patient should be informed that the dye may impart a yellow-orange color to the skin and urine. The patient should be informed that pupils need to be dilated with eyedrops before the procedure. After refractometry, the patient may not be able to focus on near objects due to dilation of the pupil. Text Reference - p. 378

A patient with diabetic retinopathy is prepared for fluorescein angiography. Which nursing interventions are appropriate? Select all that apply. A. Assist the patient in holding his or her head still for the procedure. B. Explain to the patient that the dye may cause nausea and vomiting. C. Take measures to prevent extravasation of the dye when administered intravenously. D. Inform the patient that focusing on near objects will not be difficult. E. Inform the patient that his or her urine and skin may have yellow-orange discoloration. F. Explain to the patient that eyedrops are used to constrict the pupil.

ANSWER: B. Decrease in near vision Ciliary muscles are the muscles responsible for near vision. If these muscles become smaller or stiffer, the person has difficulty in adjusting near vision. A cataract is a very common age-related disorder. This is formed due to biochemical changes in the lens proteins which results in clouding of the lens. Changes in perception of colors are not related to the dilator muscle. The diameter of the pupil is regulated by the muscle called the iris. Stiffening or rigidity of the iris causes decreased diameter of pupils. Color perception is carried by cones in the retina. A decrease in the number of cones causes difficulty in perception of colors. Text Reference - p. 371

After an ophthalmic examination, a primary health care provider finds that the ciliary muscles of a patient have become smaller and stiffer than normal muscles. The nurse recalls that the patient will experience what change as a result of this condition? A. Clouding in the lens B. Decrease in near vision C. Decreased diameter of pupils D. Difficulty in perception of colors

The Weber test without lateralization and the Rinne test with air conduction greater than bone conduction are normal physical assessment findings of the auditory conduction system. The tuning fork test is another name for these tests, but audiometric evaluation would be needed with inconsistent results. The whisper test is whispering words for the patient to repeat and is not shown in this video. Audiometry testing, not usually done by a nurse, is done to diagnose conductive and sensorineural hearing loss using earphones in a soundproof room to present the sounds to the patient. Text Reference - p. 382

The nurse is performing tests to differentiate between conductive and sensorineural hearing loss.

ANSWER: When assessing the external auditory canal and tympanum, the nurse first inspects the canal opening for patency. Next, the nurse palpates the tragus to check for discomfort. The nurse then moves the auricle while checking for discomfort and tips the patient's head for better visualization. The nurse then grasps the auricle and pulls back gently to insert the otoscope while bracing his or her own fingers on the patient's cheek. Text Reference - p. 382

What are the steps followed by the nurse in the correct order for assessing a patient's external auditory canal and tympanum.

ANSWER: D. The patient has a refractory error consistent with myopia. Documentation of Snellen test results includes documenting the eye tested, the distance the vision is tested (20 feet), and the line that the patient is able to read correctly. Patients should wear corrective devices while being tested. Myopia is nearsightedness, the ability to see near objects clearly while distant objects are blurred. The findings of 20/30 and 20/40 are consistent with myopia. Presbyopia is a loss of ability to accommodate and focus on near objects that occurs normally with aging. The Ishihara color test assesses the patient's ability to distinguish color patterns and screens for color blindness. The vision acuity is stronger in the right eye (20/30) than the left eye (20/40). Text Reference - p. 374

Documentation of a patient's reading of a Snellen chart is: Right eye: 20/30; Left eye: 20/40. Select the correct interpretation of the results. A. The patient likely has presbyopia. B. The patient does not have color blindness. C. The vision acuity is stronger in the left eye. D. The patient has a refractory error consistent with myopia.

ANSWER: B. Use a newspaper or the label on a container. If the nurse does not have access to a Jaeger eye chart, the nurse can ask the patient to read a newspaper or the label on a container. The findings should be documented as "reads newspaper headline at X inches." Snellen's chart is used for assessing distant vision. The test should not be skipped, because an assessment of near vision is important to the patient's overall health. The patient does not need to return on a different day, because a near visual acuity assessment can be completed with a newspaper test. Text Reference - p. 375

During an assessment of near visual acuity of a patient, the nurse finds that there is no Jaeger eye chart available. Which is the most appropriate nursing action? A. Use Snellen's chart for assessment. B. Use a newspaper or the label on a container. C. Ask the patient to come back the next day. D. Skip the test, as it is not important.

ANSWER: B. Troclear nerve C. Abducens nerve E. Oculomotor nerve The examiner is assessing the extraocular muscle function by darkening the room and shining the penlight over the cornea. The troclear, abducens, and oculomotor nerves are present near the eyeball and an abnormality of these cranial nerves results in paralysis of the extraocular muscles. The facial nerve helps in the opening and closing movements of the eyelids. The trigeminal nerve helps in the dilation of the iris. Text Reference - p. 375

During an eye examination, the room is darkened and a penlight is shined on the cornea. The patient is asked to follow finger movement, which is 10 inches from the patient's nose. Which cranial nerve paralysis should be examined? Select all that apply. A. Facial nerve B. Troclear nerve C. Abducens nerve D. Trigeminal nerve E. Oculomotor nerve

ANSWER: C. 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. Dry eyes aggravate wearing contact lenses but contact lenses do not normally cause dry eyes. The nurse should not suggest saline eye drops until the etiology of the dry eyes is determined. Eyeglasses do not cause dry eyes. Text Reference - p. 372

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

ANSWER: D. Presbyopia The nurse should expect the patient to have presbyopia characterized by an inability to focus on near objects. This condition is caused by a loss of accommodation and is common in older adults. Patients with myopia can see near objects clearly, but objects in the distance are blurred. In common terms, this is called nearsightedness. Hyperopia causes an inability to see distant objects clearly, but close objects are blurred. In lay terms, this is called farsightedness. Astigmatism is caused by unevenness in the cornea, which results in visual distortion. Text Reference - p. 369

During the eye assessment of a 60-year-old patient, which age-related eye problem may the nurse expect to find? A. Myopia B. Hyperopia C. Astigmatism D. Presbyopia

ANSWER: A. Deposition of lipid The sclera is usually white. Lipid deposition in the sclera gives it a yellow appearance. Decreased tear secretion results in dryness of the eye. A decrease in the number of cones in the eye leads to reduced color perception (especially of blue and violet). Exposure to ultraviolet radiations over a long period of time causes cataracts. Text Reference - p. 371

During visual assessment of a patient, the nurse notices that the patient's sclera has turned yellow. The client does not report a change in vision or any eye discomfort. What should the nurse assume is the reason for the discoloration? A. Deposition of lipid B. Decreased tear secretion C. Decrease in the number of cones D. Chronic exposure to ultraviolet light

ANSWER: A. Bacterial or viral infection A red, watery eye and inflammation of the conjunctiva are the manifestations of conjunctivitis. It is caused by a bacterial or viral infection. Glaucoma is associated with increased ocular pressure. An increase in intraocular pressure does not cause the eye to become red and watery; rather, it begins with peripheral loss of vision and later results in complete blindness. Intraocular or periorbital tumors cause protrusion of the globe of the eye, called exophthalmos. Inflammation of the anterior uvula tract causes photophobia, or intolerance to light. Text Reference - p. 376

During visual examination of a patient, the nurse notices that the patient has a red, watery eye and inflammation of the conjunctiva. What does the nurse anticipate the cause to be? A. Bacterial or viral infection B. Increased intraocular pressure C. Intraocular or periorbital tumors D. Inflammation of the anterior uvula tract

ANSWER: A. "You will not experience pain during the test." Ultrasonography involves corneal anesthetization and is not painful. During refractometry, the patient's eyes are dilated to visualize the retina and optic nerve. Therefore, the patient may have difficulty focusing on near objects for three to four hours after refractometry. Fluorescein angiography involves administering a dye into the patient's body via the intravenous route. Therefore, the patient may have nausea and yellow-orange discoloration of the urine after fluorescein angiography. The Amsler grid test assesses the patient's vision by asking the patient to report the abnormalities he or she finds in the grids. During the Amsler grid test, the patient should fixate on the center dot and record the abnormalities of the grid lines. Text Reference - p. 378

The nurse is preparing a patient for ultrasonography of the eye. Of what should the nurse inform the patient while explaining the test procedure? A. "You will not experience pain during the test." B. "You may have difficulty focusing on near objects for three to four hours after the test." C. "You may have nausea and yellow-orange urine after the test." D. "You should fixate on the center dot and record abnormalities of the grid lines during the test."

ANSWER: A. Observe the corneal light reflex in a darkened room. D. Observe eye movement through the six cardinal positions of gaze. Eye movement depends on muscle function and cranial nerves III, IV, and VI. Testing the corneal light reflex evaluates the strength and balance of the extraocular muscles. Asking the patient to follow an object through the six cardinal positions of gaze demonstrates the ability for equal and coordinated eye movement. Testing pupillary response determines the eyes' response to light and ability to accommodate. An examination with the ophthalmoscope allows the evaluator to see the condition of blood vessels in the retina and condition of the optic disc (optic nerve). The Amsler Grid is used to determine the presence of macular degeneration. Text Reference - p. 370

How does the nurse assess the functioning of the extraocular muscles? Select all that apply. A. Observe the corneal light reflex in a darkened room. B. Test pupillary response and accommodation bilaterally. C. Use an ophthalmoscope to visualize the optic disc in both eyes. D. Observe eye movement through the six cardinal positions of gaze. E. Ask the patient to describe lines while focusing on the center dot of the Amsler Grid.

ANSWER: B. No intervention An exostosis is a bony growth into the ear canal that normally does not require intervention or correction. Text Reference - p. 381

Otoscopic examination of the patient's left ear indicates the presence of an exostosis. The nurse recognizes that this finding likely will be followed up by what? A. Surgery B. No intervention C. Electrocochleography D. Irrigation of the ear canal

ANSWER: C. Snellen eye chart A Snellen chart is used to test visual acuity. The Ishihara test is used to check for color blindness. An ophthalmoscope is used to examine the inner structures of the eye. Checking the six cardinal positions of gaze is done to assess extraocular muscles. Text Reference - p. 374

The nurse is testing a patient's visual acuity. Which assessment tool or procedure is appropriate for this process? A. Ishihara cards B. Ophthalmoscope C. Snellen eye chart D. Checking the six cardinal positions of gaze

ANSWER: B. Hypertension and diabetes mellitus Hypertension and diabetes frequently contribute to visual pathologies. Hypothyroidism, polycythemia, atrial fibrillation, atherosclerosis, vascular dementia, and chronic fatigue are less likely to have a direct, deleterious effect on a patient's vision. Text Reference - p. 373

What aspects of the patient's medical history are most likely to have potential consequences for the patient's visual system? A. Hypothyroidism and polycythemia B. Hypertension and diabetes mellitus C. Atrial fibrillation and atherosclerosis D. Vascular dementia and chronic fatigue

ANSWER: A. Astigmatism causes distorted vision because of corneal unevenness. Astigmatism, a refractive error causing distorted vision, occurs when the surface of the cornea is not smooth. Damage to the optic nerve results in loss of part or all of the visual field. Cataracts, the clouding of the lens, often occur with age and leads to problems seeing, including glare. Glaucoma is a disease causing damage to the optic nerve from elevated intraoptic pressure. Text Reference - p. 369

The health center nurse learns from a student that his or her vision problem was diagnosed as astigmatism. Select the correct response to explain the problem. A. Astigmatism causes distorted vision because of corneal unevenness. B. Astigmatism limits visual acuity because of damage to the optic nerve. C. Astigmatism is a clouding of the lens causing problems with glare. D. Astigmatism is elevated pressure within the eye caused by excess fluid.

ANSWER: B. The assessment findings are within the normal range. A slight yellowish cast of the sclerae, a normal assessment finding, is caused by lipid deposits that occur with aging. A yellowish cast is normal in patients with dark skin. Small blood vessels are often visible in the conjunctiva near the periphery. Impaired coagulation or bleeding from trauma in the eye is visible as areas of dark red in the sclera. Effects of hypertension may be visible when observing blood vessels in the retina with an ophthalmoscope. A patient with jaundice displays yellowing of the entire scleral area, indicating the need for liver function tests. Text Reference - p. 377

The nurse assesses the eyes of an African American patient 70 years of age. The nurse observes the patient's sclera in each eye has a slight yellowish cast. Small blood vessels are visible along the edges in the conjunctiva. What does the nurse conclude from these assessment findings? A. The patient should have serum coagulation tests done. B. The assessment findings are within the normal range. C. The patient likely has a history of uncontrolled hypertension. D. The patient needs serum liver function tests to determine hepatic function.

ANSWER: D. TM that is pearly gray, shiny, and translucent. E. The handle of the malleus and its short process are visible through the TM. The TM is normally pearl gray, white, or pink, shiny, and translucent. The handle (manubrium) of the malleus and its short process (umbo) should be visible through the membrane. The TM is a concave or dome shape normally. Hairline fluid level is indicative of serous otitis media. If the TM is bulging or retracted, the edges of the light reflex will be fuzzy (diffuse) and may spread over the TM. Text Reference - p. 378

The nurse is assessing a patient's ears. Normal findings associated with the tympanic membrane (TM) include which of these? Select all that apply. A. The shape of the TM is convex. B. Fluid level at hairline in the TM. C. Diffuse light reflex over the TM. D. TM that is pearly gray, shiny, and translucent. E. The handle of the malleus and its short process are visible through the TM.

ANSWER: D. "Have you noticed any change in your hearing in recent months and years?" Presbycusis is an age-related change in auditory acuity. Ringing in the ears is termed tinnitus, whereas dizziness and falls are related to balance and the function of the vestibular system. Presbycusis is not associated with pain during chewing and swallowing. Text Reference - p. 377

The nurse is assessing an 86-year-old female who just has been transferred to a long-term care facility. Which assessment question best will allow the nurse to assess the woman for the presence of presbycusis? A "Do you ever experience any ringing in your ears?" B. "Have you ever fallen down because you became dizzy?" C. "Do you ever have pain in your ears when you're chewing or swallowing?" D. "Have you noticed any change in your hearing in recent months and years?"

ANSWER: A. Tinnitus B. Collapsed ear canal D. Increased sensitivity to loud sounds Age-related changes in the auditory system are presented in Table 21-7 and include: tinnitus, collapsed ear canal, increased sensitivity to loud sounds, diminished sensitivity to high-pitched sounds, and drier cerumen. Text Reference - p. 379

The nurse is assessing the auditory system of a newly admitted 79-year-old patient. Which of these are age-related changes in the auditory system? Select all that apply. A. Tinnitus B. Collapsed ear canal C. Increase in cerumen moisture D. Increased sensitivity to loud sounds E. Diminished sensitivity to low-pitched sounds

ANSWER: C. The patient has tinnitus. Tinnitus is an abnormal ringing of ears that results in an inconsistent response on pure-tone audiometry because the patient will not be able to hear the sound consistently. Otalgia is pain in the ears, which may cause discomfort and result in nutritional disturbance. Vertigo is a spinning sensation, stimulated by motion of the head that results in impaired balance. Nystagmus is abnormal movement of the eye, observed as twitching of the eyeball. Text Reference - p. 383

The nurse observes an inconsistent nonverbal response from the patient as part of an auditory assessment in a soundproof room where sound is provided through headphones. How does the nurse interpret this finding? A. The patient has otalgia. B. The patient has vertigo. C. The patient has tinnitus. D. The patient has nystagmus.

ANSWER: B. Glaucoma Excess aqueous humor production or decreased outflow can elevate intraocular pressure above the normal 10 to 21 mm Hg, a condition called glaucoma. Cataracts are opacities of the lenses. Retinal detachment occurs as a result of retinal degenerative conditions. Macular degeneration is an age-related condition that occurs as a result of vascular changes and results in loss of central vision. Text Reference - p. 372

The nurse reads in a patient's medical record that the patient has a history of increased intraocular pressure. The nurse is aware that this is a result of which disease? A. Cataracts B. Glaucoma C. Retinal detachment D. Macular degeneration

ANSWER: A. Pupils are round E. Pupils constrict when the patient focuses on a nearer object The abbreviation for a normal pupillary response is PERRLA (pupils are equal [in size], round, react to light, and accommodation). Accommodation occurs when the pupil constricts when focusing on a nearer object. The retina is examined with use of an ophthalmoscope. The lacrimal apparatus contains the structures involved with tear formation and distribution to maintain eye moisture. Intraocular (within the eye) pressure is measured with various instruments and normally is 10 to 21 mm Hg. Text Reference - p. 375

The nurse reviews a patient's health assessment and notes the abbreviation: PERRLA under vision. Which assessment finding is included in this abbreviation? Select all that apply. A. Pupils are round B. Retina responds to light C. Lacrimal apparatus is functioning D. Intraocular pressure is even and within normal E. Pupils constrict when the patient focuses on a nearer object

ANSWER: A. Amsler grid test The Amsler grid test is self-administered and regular testing is necessary to identify any changes in macular function. B-scan ultrasonography is used to diagnose ocular pathologic conditions (e.g., intraocular foreign bodies or tumors, vitreous opacities, retinal detachments). Fluorescein angiography is used to diagnose problems related to the flow of blood through pigment epithelial and retinal vessels. Intraocular pressure testing with a Tono-pen is done to test for glaucoma. Text Reference - p. 377

The patient has described a loss of central vision. What test should the nurse teach the patient about to identify changes in macular function? A. Amsler grid test B. B-scan ultrasonography C. Fluorescein angiography D. Intraocular pressure testing with Tono-pen

ANSWER: A. "Does your eye problem hamper your daily activities?" D. "Have you participated in any activity that may be harmful to your eyes?" The nurse has to assess the patient's activity in order to assess the severity of the disorder. Assessing occupational hazards may help to understand the possible cause of the eye disorder. Asking the patient if daily activities are disturbed due to eye issues helps in assessing severity. The nurse should ask if the patient has participated in any harmful activity that may have caused eye damage. Asking how the patient cares for contact lenses helps in understanding how the patient cares for the eyes. Asking how the eye problem makes the patient feel about self helps to explore the patient's psychologic sphere. Asking how much the patient appreciates being able to see only reveals the patient's attitude. Text Reference - p. 374

To determine if a patient has ocular problems, what questions should the nurse ask during the patient assessment? Select all that apply. A. "Does your eye problem hamper your daily activities?" B. "Do you wear contact lenses? How do you care for them?" C. "How do your eye problems make you feel about yourself?" D. "Have you participated in any activity that may be harmful to your eyes?" E. "How much do you appreciate the fact that you can see?"

ANSWER: C. The patient has a lipid deposition. The excessive deposition of lipids in the sclera may result in a yellowish discoloration of the sclera. A patient who has a thin sclera will have a bluish tinge in the sclera. The presence of a white sclera indicates that the patient has a normal finding. A patient who has a subconjunctival hemorrhage will have the appearance of a blood spot on the sclera. Text Reference - p. 375

Upon examining the eyes of a patient, a nurse observes a yellowish discoloration in the sclera. What should the nurse conclude from the finding? A. The patient has a thin sclera. B. The patient has a normal finding. C. The patient has a lipid deposition. D. The patient has a subconjunctival hemorrhage.

ANSWER: C. Closing and opening of the eyelid Cranial nerve VII is a facial nerve that controls the actions of facial muscles and helps in blinking or in closing and opening of eyelids. Cranial nerve III is the oculomotor nerve that helps in the constriction of the pupils. Light entering the eye is controlled by dilation of the iris, which is associated with the function of the cranial nerve V. The lens present in the eye will help bend the light entering into the eye. Text Reference - p. 370

What is the function of the cranial nerve VII? A. Pupil constriction B. Control of light entering the eye C. Closing and opening of the eyelid D. Bending of light entering into the eye

ANSWER: A. 20 dB A soft whisper is of low intensity, about 20 dB. The intensity of normal speech ranges from 40 to 60 dB. Speech at 70 dB speech is of greater-than-normal intensity. Text Reference - p. 384

What is the intensity of a soft whisper? A. 20 dB B. 40 dB C. 50 dB D. 70 dB

ANSWER: C. Pure-tone audiometry Pure-tone audiometry is the test most commonly used in assessing hearing range and thereby determining the presence of hearing loss. Tympanometry is used to diagnose middle ear effusions. Electrocochleography is recording the electrical activity of the cochlea and auditory nerve. Auditory evoked potential is used to isolate auditory brain activity from other brain activities. Text Reference - p. 383

What is the test most commonly performed to assess the auditory system? A. Tympanometry B. Electrocochleography C. Pure-tone audiometry D. Auditory evoked potential

ANSWER: C. Corneal curvature A keratometry helps assess a corneal curvature. The retina and optic nerve head are assessed through an ophthalmoscopic examination. The pupil functioning test is helpful to assess pupillary response. Text Reference - p. 375

What should a nurse assess through a keratometry? A. Retina B. Optic nerve head C. Corneal curvature D. Pupillary response

ANSWER: C. Snellen chart The Snellen chart, which is used to evaluate the patient's ability to read letters or symbols at a distance of 20 feet, is a tool for measuring a patient's visual acuity. A slit-lamp is a special microscope used to examine the eye. An audiometer is a device used to assess hearing acuity. Retinal angiography is a radiographic procedure used to determine retinal damage. Text Reference - p. 374

What should the nurse use to evaluate a patient's visual acuity? A. Slit-lamp B. Audiometer C. Snellen chart D. Retinal angiography

ANSWER: C. Gently pull the auricle up and backward to straighten the canal When assessing an adult, grasp and gently pull the auricle up and backward to straighten the canal. With children under age three, pull the auricle back and down. When examining a patient's external ear canal and tympanum, ask the patient to tilt the head toward the opposite shoulder. A healthy, normal tympanic membrane will appear pearl gray, white, or pink and have a cone-shaped light reflex. Text Reference - p. 382

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

ANSWER: C. Shine a penlight directly on the cornea. Corneal light reflex is assessed to determine weakness or imbalance of the extraocular muscles (EOM). The procedure is carried out in a dark room. The patient is asked to look straight ahead while a penlight is shined directly on the cornea. The light reflection should be located in the center of both corneas as the patient faces the light source. The patient is asked to follow finger movement when assessing for intact cranial nerves. Text Reference - p. 375

When assessing for corneal light reflex in a patient, what is an appropriate nursing action? A. Turn on the lights in the room. B. Ask the patient to look at the roof. C. Shine a penlight directly on the cornea. D. Ask the patient to follow finger movement without moving his or her head.

ANSWER: C. Do you have a history of cardiac or pulmonary disease? When collecting a health history for a patient diagnosed with glaucoma, the nurse should ask about cardiac or pulmonary disease. Glaucoma is often treated with beta-adrenergic blockers, which may decrease heart rate, decrease blood pressure, and exacerbate asthma or chronic obstructive pulmonary disease (COPD). Information regarding a visual acuity test, previous surgeries, and a change in lens prescription is gathered as general data but is not specifically related to glaucoma. Text Reference - p. 372

When interviewing a patient diagnosed with glaucoma about health history, which question is most relevant to the patient's condition? A. When was the last test for visual acuity done? B. Have you ever had surgery? C. Do you have a history of cardiac or pulmonary disease? D. Has there been any recent change in your eyeglasses or contact lenses?

ANSWER: C. After exhaling, speak in a low whisper. D.Ask the patient to repeat numbers or words. E.Whisper loudly if the patient does not respond correctly. When testing for hearing acuity, the nurse should stand 12 to 24 inches to the side of the patient and, after exhaling, speak in a low whisper. Ask the patient to repeat numbers or words or answer questions. Use a louder whisper if the patient does not respond correctly. Test each ear separately. The ear not being tested is covered by the patient. Text Reference - p. 382

When testing a patient for hearing acuity using a whisper test, which actions are appropriate? Select all that apply. A. Test both ears together. B. Stand directly in front of the patient. C. After exhaling, speak in a low whisper. D. Ask the patient to repeat numbers or words. E. Whisper loudly if the patient does not respond correctly.

ANSWER: A. Glaucoma A patient who has an excess production of aqueous humor will have increased intraocular pressure, which results in glaucoma. Pterygium is an abnormality of the conjunctiva that is associated with chronic exposure of the eye lens to ultraviolet rays. Presbyopia is a refractive error in which the patient has a loss of near vision; it is associated with aging. Arcus senilis is associated with excess cholesterol deposition in the eye. Text Reference - p. 369

Which abnormality is associated with an excess production of aqueous humor? A. Glaucoma B. Pterygium C. Presbyopia D. Arcus senilis

ANSWER: A. Cataract Chronic exposure of the eye lens to ultraviolet light reduces the function of the retina and results in cataract. Presbyopia is the loss of near vision, which may increase with age. Blepharodermachalasis is the presence of excessive skin in the upper lid, which is associated with a prolapse of fat into the eyelid tissue. Yellow discoloration of the sclera is associated with lipid deposition on the sclera. Text Reference - p. 371

Which abnormality is associated with the chronic exposure of the eye lens to ultraviolet light? A. Cataract B. Presbyopia C. Blepharodermachalasis D. Yellow discoloration of the sclera

ANSWER: B. Damage to the auditory canal The auditory canal is located in the external ear, so damage to the auditory canal results in altered function of the external ear. The cochlea and eustachian tube are located in the middle ear. Damage to the cochlea will result in altered function of the middle ear, not the external ear. The auditory ossicles are the bones in the middle ear; damage to the auditory ossicles results in altered function of the middle ear, not the external ear. Text Reference - p. 377

Which assessment finding supports the nurse's conclusion that a patient has altered function of the external ear? A. Damage to the cochlea B. Damage to the auditory canal C. Damage to the eustachian tube D.Damage to the auditory ossicles

ANSWER: B. Inner Ear The vestibular balance system is located in the inner ear. Therefore, changes in the inner ear will result in alterations in balance and body orientation. Changes in the brain will increase the difficulty of hearing in a noisy environment and heighten sensitivity to sound. A patient with changes in the middle ear will have conductive hearing loss. A patient with changes in the external ear may have impacted cerumen or a collapsed ear canal. Text Reference - p. 380

Which auditory system change does the nurse suspect in a patient who has alterations in balance and body orientation? A. Brain B. Inner Ear C. Middle Ear D. External Ear

ANSWER: A. Acute otitis media A bulging red eardrum and middle ear filled with pus and blood indicate that the patient has acute otitis media. Serous otitis media, caused by transudation of blood and serum, manifests as yellow-amber bubbles above the fluid level. Seborrheic dermatitis is marked by scaling or lesions on the skin. Eustachian tube blockage is indicated by retraction of the eardrum and the cone of light is bent. Text Reference - p. 383

Which condition does the nurse expect will be diagnosed in a patient who has a bulging, red eardrum and on otoscopic examination, is found to have a middle ear filled with pus and blood? A. Acute otitis media B. Serous otitis media C. Seborrheic dermatitis D. Eustachian tube blockage

ANSWER: C. Hyperthyroidism A patient who has hyperthyroidism may have exophthalmos, which manifests with a protruding eyeball and sclera above the iris when the eyelids are open. Blepharitis is the condition that is associated with redness, swelling, and crusting along the lid margins. Hordeolum is an infection of the sebaceous gland of the eyelid; the patient may have a superficial nodule along the lid margin. The patient who has macular disease will have a loss of central vision. Text Reference - p. 376

Which condition is associated with the findings of a protruding eyeball and the sclera being above the iris when the eyes are open? A. Blepharitis B. Hordeolum C. Hyperthyroidism D. Macular disease

ANSWER: C. Hordeolum An eye infection that is accompanied by a small, white, superficial nodule along the lid margin and an infection of the sebaceous gland of eyelid indicate that the patient has hordeolum. It is caused by a Staphylococcus infection. Blepharitis is a bacterial infection in the lid margins, which manifests as redness, swelling, and crusting along the lid margins. Strabismus is the deviation in the position of the eye in one or more directions; it is not associated with bacterial infection. Conjunctivitis is a bacterial infection of the eye, which manifests as redness and swelling of the conjunctiva. Text Reference - p. 376

Which condition is diagnosed in the patient who has a small, white, superficial nodule along the lid margin caused by an infection of the sebaceous gland of the eyelid? A. Blepharitis B. Strabismus C. Hordeolum D. Conjunctivitis

ANSWER: B. Strabismus An asymmetrical eye position indicates that the patient has strabismus. Blepharitis is associated with redness, swelling, and crusting along the lid margins. Hordeolum is an infection of the sebaceous gland of the eyelid where the patient may have a superficial nodule along the lid margin. Conjunctivitis is associated with redness or swelling of conjunctiva; it is a bacterial infection. Text Reference - p. 376

Which condition refers to an asymmetrical position of the eye? A. Blepheritis B. Strabismus C. Hordeolum D. Conjunctivitis

ANSWER: B. Provides the color of the eye The iris is the small, round opening in the center of the pupil; it provides the color of the eye. The glands in the conjunctiva of the eye secrete mucus and tears. The lacrimal gland provides oxygen to the cornea. The sclera is the tough outer shell of the eye that helps protect intraocular structures. Text Reference - p. 370

Which describes a function of the iris? A. Secretes mucus and tears B. Provides the color of the eye C. Provides oxygen to the cornea D. Protects intraocular structures

ANSWER: D. Auditory evoked potential Auditory evoked potential is conducted in a darkened room and electrodes are placed over the mastoid process, vertex, and forehead to isolate auditory activity from other activities. Rotary chair testing is performed in a dark room to evaluate the peripheral vestibular system, but in this test the patient is seated in a chair driven by a motor under computer control. Electrocochleography records electrical activity in the cochlea and auditory nerves. Electronystagmography, in which specific eye movements are recorded, is used to diagnose diseases of the vestibular system. Text Reference - p. 383

Which diagnostic study is the nurse performing if, while performing an auditory assessment in a darkened room, the nurse places electrodes over the mastoid process, at the vertex, and on the forehead? A. Rotary chair testing B. Electrocochleography C. Electronystagmography D. Auditory evoked potential

ANSWER: B. Antihistamines A sandy, gritty sensation in the eye that is accompanied by irritation and discomfort indicates corneal dryness. Decongestants and antihistamines cause ocular dryness. Long-term use of corticosteroids may result in glaucoma or cataracts. Medications that are used over-the-counter usually have ocular effects. Aminoglycosides are ototoxic and, therefore, can cause hearing loss, tinnitus, or vertigo. β-adrenergic blockers are used for treating glaucoma. Text Reference - p. 372

Which medication may cause a sandy, gritty sensation in the eye along with irritation and discomfort? A. Corticosteroids B. Antihistamines C. Aminoglycosides D. β-adrenergic blockers

ANSWER: D. Administering stool softeners The nurse provides stool softeners to reduce constipation after a stapedectomy in order to prevent increases in intracranial pressure. Ambulation does not increase intracranial pressure. The nurse should not administer diuretics, which would cause the patient to retain fluids and increase intracranial pressure. The patient who has undergone stapedectomy requires a sodium-restricted diet to reduce fluid retention, but does not need to restrict potassium. Text Reference - p. 381

Which nursing intervention helps prevent complications associated with increased intracranial pressure in a patient who has undergone stapedectomy? A. Restricting ambulation B. Administering diuretics C. Restricting potassium intake D. Administering stool softeners

ANSWER: C. Vestibule E. Semicircular canals The vestibule, an organ in the inner ear, comprises the labyrinth and is an organ of balance. The semicircular canal, a structure present in the inner ear, comprises the membranous labyrinth and is an organ of balance. The malleus, the smallest bone in the human body, is found in the middle ear and aids transmission of sound waves. The cochlea, a coiled structure, is a receptor organ for hearing. The tympanum, in the external ear, collects and transmits sound waves. Text Reference - p. 378

Which organs of the auditory system are involved in balance? Select all that apply. A. Malleus B. Cochlea C. Vestibule D. Tympanum E. Semicircular canals

ANSWER: D. Astigmatism Visual distortion that is associated with an uneven cornea indicates that the patient has astigmatism. Myopia is a refractive error in which the patient is not be able to view objects that are far away. Hyperopia is an impairment in vision in which the patient is not be able to see clearly see close objects. Presbyopia is the inability to focus on objects that are near and the condition increases with age. Myopia, hyperopia, and prebyopia are associated with an elongation or shortening of the eyeball, but not an uneven cornea. Text Reference - p. 369

Which refractive error is present in a patient who has visual distortion and an uneven cornea? A. Myopia B. Hyperopia C. Presbyopia D. Astigmatism

ANSWER: C. Presbyopia Presbyopia is a refractive error manifested by the loss of accommodation that results in inability to focus on near objects. Myopia is a refractive error of the eye in which near objects can be seen clearly, whereas faraway objects appear blurred. Hyperopia is characterized by blurred vision of near objects, whereas distant objects appear clear. Astigmatism is a refractive error of the eye; it manifests as visual distortion caused by unevenness in the cornea. Text Reference - p. 369

Which refractive error of the eye results in loss of accommodation? A. Myopia B. Hyperopia C. Presbyopia D. Astigmatism

ANSWER: C. Cornea The cornea is the first transparent layer of the eye through which light passes. The lens is behind the cornea. The retina is at the back of the eye, behind the cornea, lens, and aqueous humor, where light will reach after passing through the cornea. Text Reference - p. 369

Which structure of the eye is the first through which light passes? A. Lens B. Retina C. Cornea D. Aqueous humor

ANSWER: A. Iris D. Choroid E. Ciliary body The middle layer of the eyeball is the uveal tract, which is composed of the iris, choroid, and ciliary body. The hard outer layer of the eyeball is composed of the sclera. The innermost layer of the eyeball is the retina. Text Reference - p. 369

Which structures are present in the middle layer of the eyeball? Select all that apply. A. Iris B. Sclera C. Retina D. Choroid E. Ciliary body

ANSWER: A. Rinne test B. Weber test Tuning fork tests such as the Rinne and Weber tests help detect hearing loss by differentiating between conductive and sensorineural loss. Audiometry is used to assess hearing acuity and to determine the degree and type of hearing loss. Tympanometry aids diagnosis of middle ear effusions through the application of positive and negative pressure on the probe placed in the ear. Electrocochleography is used to assess electrical activity in the cochlea and auditory nerve. Text Reference - p. 382

Which tests involve the assessment of hearing by means of bone conduction? Select all that apply. A. Rinne test B. Weber test C. Audiometry D. Tympanometry E. Electrocochleography

ANSWER: A. Posturography B. Caloric test stimulus D. Electronystagmography Posturography is a balance test that can isolate one vestibular system from another. The caloric test stimulus helps identify vestibular diseases by stimulating the endolymph of the semicircular canals. Electronystagmography is used to diagnose diseases of the vestibular system by recording specific movement of eyes when the ear is irrigated. In electrocochleography, electrical activity in the cochlea and auditory nerves is recorded. Auditory evoked potential is used to isolate auditory activity from the activity of the brain and is not associated with vestibular function. Text Reference - p. 384

Which tests will help determine the functioning of the vestibular system? Select all that apply. A. Posturography B. Caloric test stimulus C. Electrocochleography D. Electronystagmography E. Auditory evoked potential

ANSWER: C. Loss of balance of the body The vestibular apparatus is a structure present in the inner ear. This structure is responsible for maintaining balance and body orientation. Damage to this structure alters a person's ability to balance the body. Vision loss is caused due to damage to the eye structures. Vestibular apparatus weakening doesn't cause hearing loss. Increased sensitivity to noise is caused due to changes in the brain. Text Reference - p. 379

While assessing a patient, the health care practitioner comments that the vestibular apparatus has been damaged. The nurse expects to find what clinical manifestation? A. Vision loss B. Hearing loss C. Loss of balance of the body D. Increased sensitivity to noise

ANSWER: A. Full field of vision A nurse is performing a confrontation visual field test when the nurse asks the patient to cover one eye and count the number of fingers present in the patient's field of vision. This test helps determine the patient's full field of vision. The nurse performs a pupil function test by shining light into the patient's pupil and examining the pupillary response. Intraocular pressure testing with a Tono-pen will help measure intraocular pressure. The nurse performs a visual acuity test using a Snellen chart to determine distance and near visual acuity. Text Reference - p. 375

While assessing the vision of a patient, a nurse asks the patient to cover one eye and count the number of fingers that the nurse brings into the patient's field of vision. What is the nurse assessing? A. Full field of vision B. Pupillary response C. Intraocular pressure D. Distance and near visual acuity