Chapter 41, Introduction to the Sensory System

A nurse is assessing a pediatric client in a public health clinic. The parent states that the client has been sneezing and rubbing the eyes. The nurse looks at the client's eyes and documents objective symptoms of watery and red eyes. When reporting to the physician the assessment findings, which word is appropriate? A) Conjunctivitis B) Ptosis C) Nystagmus D) Proptosis

Ans: A Feedback: Conjunctivitis often stems from an allergy causing inflammation of the conjunctiva, which is a thin, transparent mucous membrane. Conjunctivitis can cause symptoms of itchiness, redness, and watery eyes.

A client is having problems with dizziness and complains of the "room spinning." The physician performs the caloric stimulation test. The nurse knows that a diminished response in one eye during the caloric stimulation testis indicative of what? A) Inner ear disorder B) Middle ear disorder C) Outer ear disorder D) Age-related macular degeneration

Ans: A Feedback: During the caloric stimulation test, a diminished response in one eye is significant for an inner ear disorder such as Ménière's disease.

The nurse is obtaining a visual history from a client who has noted an increased in glare and changes in color perception. Which assessment would the nurse anticipate to confirm a definitive diagnosis? A) Identification of opacities on the lens B) Identification of white circle around the cornea C) Identification of yellowish aging spot on the retina D) Identification of redness of the sclera

Ans: A Feedback: The client states an increased glare and changes in color perception, which indicates a cataract. Identification of opacities on the lens confirms that diagnosis.

The nursing student hopefuls are taking a pre-nursing anatomy and physiology class. What anatomical structure equalizes air pressure in the middle ear? A) Eustachian tube B) The malleus C) The pinna D) The meatus

Ans: A Feedback: The eustachian tube extends from the floor of the middle ear to the pharynx and is lined with mucous membrane. It equalizes air pressure in the middle ear.

The nurse is caring for a client who just returned from a trip requiring an airline flight. The client commented on how his ears hurt upon descent. The nurse is correct in stating which site as being the pressure equalizer in the ear? A) Eustachian tube B) Auricle C) Tympanic membrane D) Labyrinth

Ans: A Feedback: The eustachian tube extends from the floor of the middle ear to the pharynx. It equalizes air pressure in the middle ear.

The nurse is assessing client's eyes as part of the inspection part of the assessment process. For which reason does the nurse identify a normal variation in the angle of the lateral and medial canthus? A) Ethnic differences B) Chromosomal differences C) Structural changes D) Cosmetic alterations

Ans: A Feedback: The line between the lateral and medial canthus is usually horizontal. Variations are noted abnormally in children with Down syndrome and normally in individuals of Asian descent.

You are doing hearing tests at the local junior high school. Which of the following indicates normal hearing in a child? A) A client who first perceives sound at 20 dB B) A client who first perceives sound at 40 dB C) A client for whom the painful sound occurs at 80 dB D) A client for whom the painful sound occurs at 100 dB

Ans: A Feedback: The lowest level of sound that normal persons may first perceive is 20 dB. The painful sounds occur at 120 dB. The hearing acuity is determined by measuring the intensity at which a person first perceives sound.

The nurse is evaluating the client while taking the color vision test. Which response would the nurse anticipate when caring for a client with normal color vision? A) The nurse would anticipate the client identifying numbers and shapes. B) The nurse would anticipate a cross-eyed appearance. C) The nurse would anticipate responding to the color names in the pictures. D) The nurse would anticipate no differentiation in between colors.

Ans: A Feedback: The nurse is correct to anticipate the client being able to identify numbers and shapes dictated by different color codes. The other options do not test for color vision or indicate an inability to differentiate colors.

A client presents to the emergency room with symptoms of blurred vision. Which type of question would be best to ask first? A) "Have you ever had these symptoms before?" B) "Did these symptoms come on abruptly?" C) "Do you have a family history of vision problems?" D) "Do you have any other diseases?"

Ans: A Feedback: When a client presents with unusual symptoms, a first question assesses if he or she has ever had these symptoms before.

The nurse is working in a long-term care facility. Which clues does the nurse note which suggests that the client is not hearing what the nurse said? Select all that apply. A) The client does not want to be social. B) The client responds inappropriately. C) The client asks for surrounding sounds be increased. D) The client nods the head and smiles. E) The client withdraws from activity.

Ans: A, B, D, E Feedback: A nurse notices clues that the client is having difficulty hearing.

When caring for a client with a foreign object removed from the eye, the nurse is most correct to assess the eye protective functions of which structures? Select all that apply. A) Eyelids and lashes B) Aqueous humor C) Superior and inferior oblique muscles D) Conjunctiva E) Sclera F) Tears

Ans: A, F Feedback: The nurse is correct to assess the eyelids and lashes and also tears as the protective structures. The eyelids protect against foreign bodies and adjust the amount of light that enters the eye. The eyelashes trap foreign debris.

The nurse is assessing a client's hearing using the Rinne test. When providing instruction to elicit client feedback, which instruction is essential? A) Raise your hand when you hear the vibration. B) Raise your hand when you no longer hear sound. C) Raise your hand when the vibration exceeds the sound. D) Raise your hand when the sound exceeds the vibration.

Ans: B Feedback: It is essential to provide clear directions on when the client is to notify the nurse of client response. The information gleaned from the response is what the nurse uses to interpret the test.

The client is having a Weber test. During a Weber test, where should the tuning fork be placed? A) On the mastoid process behind the ear B) In the midline of the client's skull or in the center of the forehead C) Near the external meatus of each ear D) Under the bridge of the nose

Ans: B Feedback: The Weber test is performed by striking the tuning fork and placing its stem in the midline of the client's skull or in the center of the forehead.

The client is consulting with a physician regarding a potential diagnosis of Ménière's disease. The nurse is assisting in positional testing and documentation. Which diagnostic test would the nurse anticipate to obtain a more precise evaluation of vestibular function? A) Audiometry B) Electronystagmography C) Caloric stimulation test D) Romberg test

Ans: B Feedback: The electronystagmography is a more precise method for evaluation vestibular function. It is performed in conjunction with caloric stimulation.

The nurse is establishing a visual test using the Snellen chart for a client experiencing visual changes. At which distance should the nurse instruct the client to stand? A) A 10-feet distance B) A 20-feet distance C) A 30-feet distance D) A 40-feet distance

Ans: B Feedback: The nurse is correct in instructing the client to stand at a 20-feet distance from the Snellen chart. Often, the nurse places tape on the floor to denote the correct distance for the client

The nurse is assisting the eye surgeon in completing an examination of the eye. Which piece of equipment would the nurse provide to the physician to examine the fundus and interior of the eye? A) Retinoscope B) Ophthalmoscope C) Tonometer D) Amsler grid

Ans: B Feedback: The nurse is correct to provide an ophthalmoscope to the surgeon for examination of the fundus or interior of the eye. A retinoscope is used to determine errors in refraction. A tonometer measures intraocular pressure. An Amsler grid tests for problems with the macula.

A client, diagnosed with a cataract, comes into the clinic. What assessment should the nurse observe in this client? A) A burning sensation and the sensation of an object in the eye B) Blurred or cloudy visual image C) Inability to produce sufficient tears D) A swollen lacrimal caruncle

Ans: B Feedback: When a cataract forms, the light is blocked from reaching the macula, and the visual image becomes blurred or cloudy.

The nurse is assisting with the administration of a caloric stimulation test. Which client response would the nurse document as an expected response? A) Dizziness B) Headache C) Nystagmus D) Double vision

Ans: C Feedback: A caloric stimulation test assesses vestibular reflexes of the inner ear that control balance. Warm or cool water or air is instilled into the external meatus of the ear separately. Nystagmus, a quivering movement of the eyes, is the expected response. Slight dizziness may be experienced but is not the expected response.

The nurse is instructing a nursing student when a new client comes to the eye clinic. The client explains that he thinks he has a corneal abrasion. The nurse should explain what to the student nurse? A) "To detect corneal abrasions, an ophthalmoscope is used." B) "To detect corneal abrasions, ultrasonography is used." C) "To detect corneal abrasions, a slit lamp is used." D) "To detect corneal abrasions, retinal angiography is used."

Ans: C Feedback: A slit lamp is a binocular microscope that magnifies the surface of the eye. A beam of light, narrowed to a slit, is directed at the cornea, facilitating an examination of structures and fluid in the anterior segment of the eye.

Audiometry is testing that measures hearing acuity precisely. Who does the nurse know can perform audiometric testing? A) School nurse B) Hearing aide salesperson C) Audiologist D) Office nurse

Ans: C Feedback: Audiometry is done by an audiologist. Audiometric testing measures hearing acuity precisely.

A client has been referred to an ophthalmologist for suspected macular degeneration. The nurse knows to prepare what test for the physician to give the client? A) Ishihara polychromatic plates B) Visual field C) Amsler grid D) Slit lamp

Ans: C Feedback: Clients with macular problems are tested with an Amsler grid. It is made up of a geometric grid of identical squares with a central fixation point.

The nurse is caring for a client with increased fluid accumulation in the eye. When assessing the client, which structure within the eye is noted to drain fluid from the anterior chamber? A) Fovea centralis B) Canthus C) Canal of Schlemm D) Choroid

Ans: C Feedback: The canal of Schlemm drains the anterior chamber of the eye. By draining the fluid, it decreases the fluid amount and pressure in the eye. The other options have no draining ability.

The nurse is obtaining a history on a client stating the inability to read the newspaper and even seeing detail when looking at an image. Which assessment test would add additional data for a diagnosis? A) Assess if the pupils are equal and reactive to light. B) Assess vision on the Snellen chart. C) Assess peripheral vision. D) Assess color vision.

Ans: C Feedback: The client states symptoms of the inability to discriminate letters, words, and details of an image, indicating the degeneration of the macula.

The nurse is assessing a client for objective symptoms of hearing difficulties. Which symptom leads the nurse to take alternate measures to ensure client understanding of teaching? A) The client interrupts by asking the nurse to repeat instruction. B) The client is quiet and responds appropriately. C) The client leans forward and turns the head. D) The client quietly reads the instructional literature.

Ans: C Feedback: The nurse assesses objective symptoms of leaning forward and turning the head as symptoms of having difficulty hearing.

The nurse is caring for a client ordered multiple eye screening. Following which procedure will the nurse instruct the client on a yellow coloring to the skin and urine as being normal? A) Ultrasonography B) Retinal Imaging C) Retinal Angiography D) Retinoscopy

Ans: C Feedback: The nurse is most correct to instruct the client that his skin and urine may turn yellow following a retinal angiography.

The nurse is assisting in providing coordination of services between the physician's office and vision specialist's office for a client who is being referred for potential retinal surgery. Which eye care specialist will the nurse make the referral to? A) Optician B) Optometrist C) Ophthalmologist D) Ophthalmic technician

Ans: C Feedback: The ophthalmologist is a physician who performs surgery on clients with eye disorders. The optician makes eyeglasses or contact lenses.

A client comes to the occupational health nurse complaining of eye irritation. The client works in a dusty, outdoor environment. Why should the nurse advise periodic blinking to this client? A) To control the amount of sunlight that enters the eye B) To minimize the impact of the wind on the eye and to trap foreign debris C) To clear the dust and particles from the surface of the eyes D) To prevent the collection of tears over the surface of the eye

Ans: C Feedback:Periodic blinking clears the dust and particles from the surface of the eyes. The eyelids also spread tears over the surface of the eye, which helps bathe and lubricate the surface.

The nurse is completing a corneal light reflex test using a penlight. Which result would indicate a normal test result? A) The pupils have reaction to light. B) The eyes follow the light in all four directions. C) The client can see the light using peripheral vision. D) The light reflection is in the same spot on each eye.

Ans: D Feedback: A normal corneal light reflex test is when the light reflex is even, reflecting the light at the same spot on both eyes. If the light reflex is uneven, it indicates deviated alignment of the eyes, possibly due to muscle weakness or paralysis.

The nurse is working in the emergency department when a physician asks for help as the client is performing a Romberg test. In which position would the nurse stand to be most helpful? A) The nurse would stand directly in front of the client. B) The nurse would stand between the client and physician. C) The nurse would stand across the room but in direct alignment from the client. D) The nurse would stand laterally to the client, opposite side to where the physician is standing.

Ans: D Feedback: The Romberg test is used to evaluate a person's ability to sustain balance. The client stands with the feet together and arms extended.

The nurse is caring for geriatric clients stating that they are prescribed reading glasses. Some individuals state needing assistance with seeing writing far away, and others need assistance with closer vision. The nurse is correct to understand that the aging visual changes relate to which of the following? A) Changes in refraction B) Changes in the visual field C) Changes in central vision D) Changes in accommodation

Ans: D Feedback: The changes that occur in vision during aging, which include difficulty reading and the need for reading glasses, include changes in accommodation.

What is located in the cochlea of the inner ear? A) Semicircular canals B) Labyrinth C) Vestibulocochlear nerve D) Organ of Corti

Ans: D Feedback: The fluid motion created by the vibrating stapes excites the nerve endings in the sensitive sound receptors of the organ of Corti located in the cochlea.

A client states having difficulty noting details on faces or television. Which of the following structures of the eye allows for detailed vision? A) The pupil B) The iris C) The cornea D) The macula lutea

Ans: D Feedback: The macula lutea is composed entirely of cones and allows for detailed vision. It lies in the center of the retina. This client could potentially have macular degeneration.

Which of the following nursing diagnosis is most appropriate when caring for a client with deteriorating vision? A) Risk for Injury B) Hopelessness C) Impaired Adjustment D) Altered Sensory Perceptions

Ans: D Feedback: When caring for a client with deteriorating vision, the most appropriate nursing diagnosis focuses on the alteration in sensory perceptions.