NUR 350 Chap 20
A nurse is interviewing a patient with visual impairment. Which question related to elimination should the nurse ask to determine changes in intraocular pressure? "Do you pass stools regularly?" "How many stools do you have in a day?" "What are the characteristics of the stools?" "Do you have to strain while passing stools?"
"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. p. 355
While completing a health history, the nurse learns that a patient has symptoms of tinnitis. Which follow-up question should the nurse ask? "Do you wash your hands before touching your face?" "Do you use cotton-tipped applicators to clean the ear canal?" "Have you been constipated or straining with bowel movements lately?" "Do you routinely take aspirin or have you increased your aspirin intake lately?"
"Do you routinely take aspirin or have you increased your aspirin intake lately?" Tinnitis, a sensation of ringing or buzzing in the ears, may result from high aspirin intake. Hand washing prevents infection. Cotton-tipped applicators should not be inserted inside the ear canal because this could impact cerumen or traumatize the ear canal. Straining is not a causative factor of tinnitus. p. 361
To determine if a patient has ocular problems, what questions should the nurse ask during the patient assessment? "Does your eye problem hamper your daily activities?" "How much do you appreciate the fact that you can see?" "Do you wear contact lenses? How do you care for them?" "How do your eye problems make you feel about yourself?" "Have you participated in any activity that may be harmful to your eyes?"
"Does your eye problem hamper your daily activities?" "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. p. 354
A patient is having refractometry as part of the visual assessment. Which of these instructions from the nurse is correct? "Are you allergic to iodine or contrast media?" "You will feel slight burning during this procedure." "Please try to hold your head still during the examination." "You may find it difficult to focus on near objects for three to four hours." "You might notice that your urine will turn a darker yellow-orange color today."
"Please try to hold your head still during the examination." "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. p. 359
A patient with acute-angle glaucoma has a new prescription for eye drops. The nurse will question the patient about which of these conditions? Symptoms of dry eyes Use of corrective lenses A history of heart or lung disease Sensitivity to sulfonamide antibiotics
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. p. 354
A patient reports to the nurse that there is a sandy, gritty sensation in the eye along with irritation and discomfort. What medication should the nurse determine might be causing these symptoms? Corticosteroids Antihistamines Aminoglycosides β-adrenergic blockers
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. p. 354
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? Pterygium Glaucoma Blepharitis Arcus senilis
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. p. 353
The nurse is assessing a patient's hearing problems. What actions should the nurse take in order to perform the assessment? Ask if the patient wears earrings. Ask if the patient is feeling any ear pain. Assess if the patient can hear a clock ticking. Determine if the patient can hear loud noises. Check the external auditory meatus for any discharge.
Ask if the patient is feeling any ear pain. Assess if the patient can hear a clock ticking. Check the external auditory meatus for any discharge. While assessing any patient with hearing problems, it is important to collect subjective data as well as objective data. Subjective data are what the patient says regarding complaints. These consist of modalities of pain or discharge. Objective information is the information that the nurse can see or perceive. The nurse can assess the patient's ability to hear by testing for the ability to hear a clock ticking in the room. Checking the external auditory meatus helps the nurse observe if any discharge is present. The patient's auditory ability is assessed based on the ability to hear low sounds. There is no test for checking hearing ability based on loud noises. Wearing ear jewelry may cause inflammation but does not affect hearing capacity. p. 362
A nurse is assessing the pupillary function of a patient. Which steps should be performed when assessing accommodation? Ask the patient to look at the nurse's finger. Ask the patient to focus on a distant object. The nurse places a finger at a distance of 20 feet from the patient's nose. The nurse places a finger at a distance of 3 inches from the patient's nose. The nurse places a finger at a distance of 6 meters from the patient's nose.
Ask the patient to look at the nurse's finger. Ask the patient to focus on a distant object. 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. p. 358
A patient reports visual distortion and is assessed to have an uneven cornea. What refractive error does the nurse determine is most likely present? Myopia Hyperopia Presbyopia Astigmatism
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. p. 351
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? Bacterial or viral infection Increased intraocular pressure Intraocular or periorbital tumors Inflammation of the anterior uvula tract
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. p. 357
Which structural impairment of the ear does the nurse suspect in a patient who has a nasopharyngeal infection? Multiple choice question Damage to cranial nerve VII Damage to cranial nerve VIII Blockage of eustachian tube Reduced blood supply to cochlea
Blockage of eustachian tube The eustachian tube continues from the nasal pharynx, where the presence of a nasopharyngeal infection may result in blockage. Damage to cranial nerve VII results in loss of voluntary facial movement. Damage to cranial nerve VIII is associated with excess calcium deposition, but not nasopharyngeal infection. A nasopharyngeal infection does not result in impairment such as reduced blood supply to the cochlea. p. 364
Which structural impairment of the ear does the nurse suspect in a patient who has a nasopharyngeal infection? Damage to cranial nerve VII Damage to cranial nerve VIII Blockage of eustachian tube Reduced blood supply to cochlea
Blockage of eustachian tube The eustachian tube continues from the nasal pharynx, where the presence of a nasopharyngeal infection may result in blockage. Damage to cranial nerve VII results in loss of voluntary facial movement. Damage to cranial nerve VIII is associated with excess calcium deposition, but not nasopharyngeal infection. A nasopharyngeal infection does not result in impairment such as reduced blood supply to the cochlea. p. 364
The nurse is performing an assessment of the auditory system for a patient diagnosed with sensorineural hearing loss. Which findings should the nurse expect to assess? Ringing in the ears Complete hearing loss Inability to understand speech Distortion or faintness of sound Difficulty in understanding meaning of words being heard.
Complete hearing loss Inability to understand speech Distortion or faintness of sound Sensorineural hearing loss is caused by damage to or an abnormality of the inner ear or the nerve pathways. This condition is characterized by distortion or faintness of sound or inability to understand speech, and it can cause complete hearing loss. Patients with central hearing loss experience difficulty in understanding the meaning of spoken speech. Patients with tinnitus hear a ringing in the ears. p. 360
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? Cranial nerve III Cranial nerve IV Cranial nerve VII Cranial nerve VIII
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. p. 361
Which assessment finding supports the nurse's conclusion that a patient has altered function of the external ear? Damage to the cochlea Damage to the auditory canal Damage to the eustachian tube Damage to the auditory ossicles
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. p. 364
A college student has gone to the nurse reporting eye pain after studying for finals. What assessment should the nurse make first in determining the possible cause 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 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. p. 355
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 lid margin Small, superficial white nodules along the lid margin
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. p. 357
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? Full field of vision Pupillary response Intraocular pressure Distance and near visual acuity
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. p. 355
An adult patient has been treated for an ear infection. The nurse plans to examine the ear using an otoscope. What intervention should the nurse employ to lessen anxiety and discomfort associated with the examination? Apply water-soluble lubricant liberally to the otoscope. Place the otoscope under warm water for several minutes. Pull downward on the auricle while inserting the otoscope. Gently palpate the tragus and move the auricle, noting sensitive areas.
Gently palpate the tragus and move the auricle, noting sensitive areas. By touching the tragus and moving the auricle (pinna), the nurse identifies sensitive areas and avoids pain while inserting the otoscope. A speculum slightly smaller than the ear canal is attached to the otoscope base and inserted without lubrication or warming. In adults, the auricle is pulled upward to straighten the ear canal and facilitate introduction of the otoscope. p. 364
The nurse is assessing an adult patient's external ear canal and tympanum. How should the nurse proceed? 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 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. p. 364
A patient is to undergo an Amsler Grid test. What instructions about the test should the nurse provide to the patient? Keep the test card at a distance of 10 feet. Hold the test card at a comfortable distance. Report any abnormality like lines appearing wavy. Focus on the center dot that is present on the card. Focus on all four corners of the card in a clockwise pattern.
Hold the test card at a comfortable distance. Report any abnormality like lines appearing wavy. Focus on the center dot that is present on the card. 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 health care practitioner. The distance of 10 feet is not required for this test. The patient does not focus on the four corners of the card. p. 359
The nurse assesses a patient with protruding eyeballs, and the sclera is above the iris when the eyes are open. The patient reports feeling jittery and losing weight. What condition does the nurse determine correlates with these clinical manifestations? Multiple choice question Blepharitis Hordeolum Hyperthyroidism Macular disease
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. p. 357
The nurse is performing an assessment of cranial nerve VII. What determination will the nurse make when assessing this nerve? If the pupil constricts equally to light If there is control of light entering the eye If the patient can close and open the eyelid If there is bending of light entering into the eye
If the patient can close and open 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. p. 352
A patient has diplopia and is prescribed with alternating patching of one eye at a time. The nurse should include teaching about what concern for this patient? Conjuctivitis Increased risk for falls Dryness in the patched eye Increased risk for cataract formation
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. p. 355
While assessing a patient, the health care practitioner comments that the vestibular apparatus has been damaged. The nurse expects to find what clinical manifestation? Vision loss Hearing loss Loss of balance of the body Increased sensitivity to noise
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. p. 361
A patient is diagnosed with a collapsed ear canal. What type of complication does the nurse associate with this diagnosis? Calcification of ossicles Increased hair growth Loss of cartilage elasticity Reduced blood supply to the cochlea
Loss of cartilage elasticity Loss of cartilage elasticity results in collapse of the ear canal, which in turn causes the canal to lose the ability to transmit sound waves. Calcification of ossicles results in tinnitus (ringing in the ears) because ossicles transmit sound waves. Increased hair growth results in visible hair in the ear. Reduced blood supply to the cochlea results in impaired speech reception because the cochlea is the center for reception. p. 364
The nurse is caring for an older adult patient. Which gerontologic findings of the visual system does the nurse anticipate may be present? Loss of hair pigment Darkened iris pigment Increased tear secretion Increased rigidity of the lens Atrophy of the corneal nerves Increased orbital fat and muscle tone
Loss of hair pigment Increased rigidity of the lens Atrophy of the corneal nerves There is increased lens rigidity, resulting in presbyopia and loss of hair pigment. This loss is responsible for the graying of the eyebrows and eyelashes. Atrophy of the corneal nerves results in a decrease in the corneal sensitivity and reflex. The change in iris color that occurs in an aging patient is due to loss of pigment, which appears as a lightening of the iris. The older adult also experiences decreased secretion of tears, resulting in dryness of the eyes. Decreases in orbital fat and muscle tone result in entropion, ectropion, and mild ptosis. p. 353
The nurse is performing an assessment of the patient's ear and places a probe in the external ear canal, applying positive and negative pressure. What does the nurse determine this will infer? Range of hearing Middle ear effusion Disease of vestibular system Etiology of peripheral vestibular system
Middle ear effusion Placing a probe in the external ear canal and applying both positive and negative pressure is the procedure for tympanometry. This test is used to assess compliance of the middle ear and is useful in diagnosis of middle ear effusions. The caloric test stimulus is used to assess range of hearing. Electronystagmography, involving the recording of specific eye movements, aids identification of diseases of the vestibular system. Rotary chair testing, performed with the use of a motor-controlled chair, aids evaluation of the peripheral vestibular system. p. 365
Which refractive error describes the vision of a patient for whom nearby objects are clear but objects at a distance are blurred? Myopia Hyperopia Presbyopia Astigmatism
Myopia The individual with myopia (nearsightedness) can see nearby objects clearly, but objects at a distance appear blurred. The individual with hyperopia (farsightedness) can see distant objects clearly, but close objects appear blurred. Presbyopia is a loss of accommodation, causing an inability to focus on near objects. Astigmatism is an uneven curvature of the cornea, which results in visual distortion. p. 351
When interviewing a patient with hearing loss about past and present medications, which medications should the nurse ask the patient about directly? Salicylates Herbal drugs Aminoglycosides Antimalarial agents Vitamin supplements
Salicylates Aminoglycosides Antimalarial agents The nurse should ask the patient specifically about salicylates, aminoglycosides, and antimalarial agents, because they may cause ototoxicity and lead to hearing loss. With some medications, the hearing loss may be reversible when treatment is stopped. Herbal drugs and vitamin supplements are not associated with hearing loss. p. 362
When examining the patient's ear with an otoscope, there is discharge in the canal and the patient reports pain with the examination. For what should the nurse next assess the patient? Swimmer's ear Sebaceous cyst Metabolic disorder Serous otitis media
Swimmer's ear Swimmer's ear, an infection of the external ear, probably is 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. A sebaceous cyst and metabolic disorders would not cause drainage or discomfort in the external ear canal. After clearing the discharge, the tympanic membrane can be assessed for otitis media. p. 365
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? Tears in the retina Vitreous liquefaction Shortening of the ciliary muscles Hemorrhage in the vitreous humor Overaction of the extraocular muscle
Tears in the retina Vitreous liquefaction 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. p. 358
A patient tells a nurse, "I see two of everything." What should the nurse interpret from this finding? The patient has reduced tear formation. The patient has inflammation of the cornea. The patient has an abnormality in size of the pupils. The patient has an abnormality of the extraocular muscle.
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. p. 358
A nurse is observing different behaviors in patients who are scheduled for an ophthalmic examination. Which patient should the nurse expect to have double vision? The patient is dressed in an unusual color combination The patient is holding his or her head in a skewed position The patient covers his or her eyes with the hand to block the light in the room The patient is making eye contact with the nurse while speaking
The patient is holding his or her head in a skewed position atient B is holding his or her head in skewed or oblique position, which is indicative of the patient having diplopia. Patients who have diplopia have double vision and hold the head in a skewed position in an attempt to see a single image. Patient A has dressed himself or herself in an unusual color combination, which is indicative of color blindness. Patient C covers his or her eyes to block the light, which is indicative of photophobia. Patient D is making eye contact with the nurse, which is positive behavior. p. 374
A nurse is assessing a patient's hearing ability. Which findings would indicate compromised hearing? The patient is lip reading. The patient speaks very loudly. The patient feels dizzy when standing up. The patient asks to have certain words repeated. The patient fails to respond to questions when not looking directly at the nurse.
The patient is lip reading. The patient asks to have certain words repeated. 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. pp. 363
A patient tells a nurse, "I take an aspirin every two days because I'm always getting headaches." Which ear abnormality does the nurse expect? Vertigo Tinnitus Presbycusis Impaired speech reception
Tinnitus Tinnitus, a continuous ringing in the ears, is associated with calcification of the ossicles. Heavy intake of aspirin, an analgesic medication, often results in tinnitus because of its toxic effect on cranial nerve VIII. Vertigo is a sense of moving or spinning that is associated with imbalances in the vestibular system. Presbycusis is the loss of hearing with age. A patient who has damage to the cochlea will exhibit impaired speech reception. p. 362
The nurse darkens the room and shines a penlight on the cornea and asks the patient to follow finger movement 10 inches from the patient's nose. Which cranial nerve paralysis should be examined? Facial nerve Troclear nerve Abducens nerve Trigeminal nerve Oculomotor nerve
Troclear nerve Abducens nerve 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. p. 358
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? Skip the test, as it is not important. Use Snellen's chart for assessment. Ask the patient to come back the next day. Use a newspaper or the label on a container.
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. p. 358
The nurse is conducting an assessment for a patient with hearing loss. Which cranial nerve is associated with the processing of sound? III VI VII VIII
VIII Cranial nerve VIII is associated with hearing and balance. Cranial nerve III controls eye movement, pupillary constriction, and upper eye lid elevation. Cranial nerve VI controls the sense of smell. Cranial nerve VII controls the expression in the forehead, eyes, and mouth, taste, salivation, and tearing. p. 360
The nurse observes a patient ambulating with a stumbling gait. What conditions should the nurse be aware may cause this patient's condition? Vertigo Tinnitus Nystagmus Presbycusis
Vertigo Vertigo is stimulated by movement; this condition can cause an unsteady gait. Presbycusis is hearing loss due to aging. Nystagmus is an abnormal eye movement or twitching of the eye. Tinnitus is ringing in the ears. pp. 361, 363
A patient has undergone a fluorescein angiography. The nurse should observe for what side effects of the procedure? Redness of the eyes Yellowish discoloration of the skin Yellowish discoloration of the urine Nausea and vomiting after the procedure Red-colored urine indicative of presence of blood
Yellowish discoloration of the skin Yellowish discoloration of the urine 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. p. 359