Chapter 41: Introduction to the Sensory System
The nurse is discussing the results of a client's diagnostic testing with the nurse practitioner. What Weber test result would indicate the presence of a sensorineural loss?
The sound is heard better in the ear in which hearing is better.
Which manifestation is most problematic for the client diagnosed with Ménière disease?
Vertigo
Loud, persistent noise has what effect on the body?
Increased blood pressure
A nurse is performing an eye examination. Which question would not be included in the examination?
"Are you able to raise both eyebrows?"
A client is ready to be discharged home after a cataract extraction with intraocular lens implant and the nurse is reviewing signs and symptoms that need to be reported to the ophthalmologist immediately. Which of the client's statements best demonstrates an adequate understanding?
"I need to call the doctor if I see flashing lights."
A client's vision is assessed at 20/200. The client asks what that means. Which is the mostappropriate response by the nurse?
"You see an object from 20 feet away that a person with normal vision sees from 200 feet away."
It is determined that a patient is legally blind and will be unable to drive any longer. Legal blindness refers to a best-corrected visual acuity (BCVA) that does not exceed what reading in the better eye?
20/200
A patient is suspected of having glaucoma. What reading of IOP would demonstrate an increase resulting from optic nerve damage?
21 mm Hg or higher
A client has undergone tonometry to evaluate for possible glaucoma. Which result would the nurse record as abnormal?
25 mm Hg
The ophthalmologist tells a patient that he has increased intraocular pressure (IOP). The nurse understands that increased pressure resulting from optic nerve damage is indicated by a reading of:
>21 mm Hg.
An older adult client has been diagnosed with macular degeneration and the nurse is assessing for changes in visual acuity since last visit. When assessing the client for recent changes in visual acuity, the client states that the lines on an Amsler grid as being distorted. What is the nurse's most appropriate response?
Arrange for the client to visit an ophthalmologist .
The nurse is providing discharge education to an adult client who will begin a regimen of ocular medications for the treatment of glaucoma. How can the nurse best determine if the client is able to self-administer these medications safely and effectively?
Ask the client to demonstrate the instillation of her medications.
A client newly diagnosed with otitis media reports that the pain and pressure in the ear has suddenly disappeared. What is the best action by the nurse?
Assess the tympanic membrane.
The nurse has taken shift report on a group of clients and has been told that one client has an ocular condition that has primarily affected the rods in his eyes. Considering this information, what should the nurse do while caring for the client?
Ensure adequate lighting in the client's room.
A nurse is educating a client about the function of the parts of the auditory system. Which is the function of the eustachian tube?e.
Equalizes the pressure in the middle ear with atmospheric pressure
Which portion of the middle ear equalizes pressure?
Eustachian tube
The nurse asks a client to follow the movement of a pencil up, down, right, left, and both ways diagonally. The nurse is assessing which of the following?
Extraocular muscle function
A group of high school students is attending a concert, which will be at a volume of 80 to 90 dB. What is a health consequence of this sound level?
Hearing loss may occur with a decibel level in this range.
A nurse is helping a patient with her morning bath. The patient complains of having dry eyes. The nurse knows that the eyelids contain multiple glands that protect the eye. Which of the following eyelid glands should the nurse first assess?
Lacrimal
Which surgical procedure involves flattening the anterior curvature of the cornea by removing a stromal lamella layer?
Laser-assisted stromal in situ keratomileusis (LASIK)
A nurse conducted a history and physical for a newly admitted patient who states, "My arms are too short. I have to hold my book at a distance to read." The nurse knows that the patient is most likely experiencing:
Loss of accommodative power in the lens.
An older adult patient has noticed a significant amount of vision loss in the last few years. What does the nurse recognize as the most common cause of visual loss in older adults?
Macular degeneration
The nurse is performing an assessment of the visual fields for a patient with glaucoma. When assessing the visual fields in acute glaucoma, what would the nurse expect to find?
Marked blurring of vision
To avoid the side effects of corticosteroids, which medication classification is used as an alternative in treating inflammatory conditions of the eyes?
Nonsteroidal anti-inflammatory drugs (NSAIDs)
The nurse is assessing a client with multiple sclerosis who is demonstrating involuntary, rhythmic eye movements. What term will the nurse use when documenting these eye movements?
Nystagmus
Nursing students are reviewing the anatomy and physiology of the ears as part of a group presentation for their fellow classmates about the ear's function. The students demonstrate understanding when they identify which structures as separating the middle ear from the inner ear?
Oval window and round window
Which term refers to swelling of the optic disc due to increased intracranial pressure?
Papilledema
The nurse is performing an assessment of a patient's ears. When looking at the tympanic membrane, the nurse observes a healthy membrane. What should the appearance be?
Pearly gray and translucent
Nursing students are reviewing eye structures. The students demonstrate understanding of the material when they identify which of the following as the site of aqueous humor production?
Posterior chamber
A nurse is required to care for older adult clients in an extended health care facility. The nurse understands which is a potential effect of aging on vision?
Presbyopia
A nurse conducting a session on eye care needs to educate clients about the aqueous humor and vitreous humor. Which is the function of the aqueous humor?
Provides nutrients and oxygen to the cornea
Which of the following structures are responsible for night vision?
Rods
When the patient tells the nurse that his vision is 20/200, and asks what that means, the nurse informs the patient that a person with 20/200 vision:
Sees an object from 20 feet away that a person with normal vision sees from 200 feet away.
A client has been diagnosed with hearing loss related to damage of the cochlea. What term is used to describe this condition?
Sensorineural hearing loss
A nurse is preparing to perform the whisper test to assess a client's gross auditory acuity. Which of the following would be most appropriate for the nurse to do?
Stand about 1 to 2 feet away from the ear to be tested.
Which of the following is indicated when asymmetrical movement is noted during a positions test?
Weakness in the extraocular muscles
A client is in the ED after being struck in the left eye with a baseball, leaving a large ecchymosis and edema. In client education, the nurse explains to the client the functions of the various structures of the eye. What are functions of the eyelids? Select all that apply.
impact ocular light spread tears
What is the role of the nurse toward a client who is undergoing an eye examination and tests? Select all that apply.
assuring that the client receives eye care to preserve his or her eye function and prevent further visual loss assessing and obtaining an accurate baseline of the function and structure of the eyes
Changes in pressure at high altitudes can cause discomfort in the ears. Which structure within the middle ear is instrumental in equalizing pressure?
eustachian tubes
A client suffered trauma to the sclera and is being treated for a subsequent infection. During client education, the nurse indicates where the sclera is attached. Which structure would not be included?
eyelids
A client with multiple sclerosis is being seen by a neuroophthalmologist for a routine eye exam. The nurse explains to the client that during the examination, the client will be asked to maintain a fixed gaze on a stationary point while an object is moved from a point on the side, where it can't be seen, toward the center. The client will indicate when the object becomes visible The nurse further explains that the test being performed is called a:
perimetry test
A nurse notices that a client's left upper eyelid is drooping. The nurse has observed:
ptosis
During an assessment using the positions test (cardinal positions of gaze), what does an asymmetrical movement indicate? Select all that apply.
weakness in the extraocular muscles dysfunction of the cranial nerve
