Lewis- Chapter 21: Nursing Assessment: Visual and Auditory Systems

hyperopia

farsightedness, or an inability of the eye to focus on nearby objects

presbycusis

hearing loss associated with aging

myopia

nearsightedness, or an inability of the eye to focus on objects far away

refraction

the ability of the eye to bend light rays so that they fall on the retina

conjunctiva

transparent mucous membrane that covers the inner surfaces of the eyelids (the palpebral conjunctiva) and also extends over the sclera (bulbar conjunctiva)

A 64-year-old female patient reporting frequent vertigo is scheduled for electronystagmography to test vestibular function. Which instructions should the nurse provide to the patient before the procedure? A. Eat a light meal before the procedure. B. Avoid carbonated beverages before the procedure. C. Take nothing by mouth for 3 hours before the procedure. D. No special dietary restrictions are needed until after the procedure.

A Instruct patient to eat a light meal before the test to avoid nausea. Results of vestibular tests can be altered by use of caffeine, other stimulants, sedatives, and antivertigo drugs.

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

A 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.

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.

A 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 will 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.

A 76-year-old male patient's wife is complaining that he is not being able to hear very well. He speaks with a quiet voice. With knowledge about geriatric changes in the auditory system, what should the nurse do first to determine the cause of the hearing loss? A Look for cerumen in the ear. B Assess for increased hair growth in the ear. C Tell the patient it is probably related to aging. D Ask the patient if he has fallen because of dizziness.

A Gerontologic differences in the assessment of the auditory system include increased production of and drier cerumen, which can become impacted in the ear canal and contribute to hearing loss. Conductive hearing loss with impacted cerumen may lead to speaking softly as the patient's voice conducted through bone seems loud to the patient. Although increased hair growth occurs, it will not impact the hearing. Presbycusis may be occurring, but it should not be assumed. There is no reason to ask the patient if he has fallen because of dizziness, and vertigo is not a normal change of aging of the ear.

The nurse is performing tests to differentiate between conductive and sensorineural hearing loss. What test(s) are being performed and what results show no change in hearing? A Weber test with no lateralization and Rinne test with air conduction greater than bone conduction B The tuning fork test to determine if audiometric evaluation is needed because of consistent results C The whisper test with the patient understanding the words said without being able to read the speaker's lips D Audiometry testing to determine the need for a hearing aid when the pure-tone threshold shows a 45 decibel loss

A 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.

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.

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

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

B An exostosis is a bony growth into the ear canal that normally does not require intervention or correction.

A 28-year-old female patient complains of intermittent eye dryness. Which question should the nurse ask the patient to determine the etiology of this symptom? A. "Do you take ginkgo to treat asthma or tinnitus"? B. "What do you take if you have allergy symptoms"? C. "Are you taking propranolol for an anxiety disorder"? D. "How long have you been taking prednisone (Deltasone)"?

B Anithistamines or decongestants taken for allergies or colds can cause ocular dryness. Ginkgo biloba is an herbal product and has been used to treat asthma and tinnitus. Side effects of ginkgo may include headache, nausea, gastrointestinal upset, diarrhea, dizziness, allergic skin reactions, and increased bleeding. β-adrenergic blockers can potentiate drugs used to treat glaucoma. Long-term use of prednisone (corticosteroids) may contribute to the development of glaucoma or cataracts.

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

B Hypertension and diabetes frequently contribute to visual pathologies. The other cited health problems are less likely to have a direct, deleterious effect on a patient's vision.

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 margins D. Small, superficial white nodules along the lid margin

B 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.

When examining the patient's ear with an otoscope, there is discharge in the canal and the patient noted pain with the examination. What should the nurse next assess the patient for? A Sebaceous cyst B Swimmer's ear C Metabolic disorder D Serous otitis media

B Swimmer's ear or an infection of the external ear is probably the cause of the discharge and pain. Asking the patient about swimming, ear protection, and exposure to types of water can identify contact with contaminated water. After clearing the discharge, the tympanic membrane can be assessed for otitis media. A sebaceous cyst and metabolic disorders would not cause drainage or discomfort in the external ear canal.

The nurse is assessing an 86-year-old female who has just been transferred to the long-term care facility. Which assessment question will best 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?"

D 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.

A 44-year-old woman who works in a noisy factory reports being off balance when standing or walking but not while lying down. What term will the nurse use to document this patient's symptoms? A. Vertigo B. Syncope C. Dizziness D. Nystagmus

C Dizziness is a sensation of being off balance that occurs when standing or walking; it does not occur when lying down. Nystagmus is an abnormal eye movement that may be observed as a twitching of the eyeball or described by the patient as a blurring of vision with head or eye movement. Vertigo is a sense that the person or objects around the person are moving or spinning and is usually stimulated by movement of the head. Syncope is a brief lapse in consciousness accompanied by a loss in postural tone (fainting).

A 64-year-old man newly diagnosed with glaucoma asks the nurse what has made the pressure in his eyes so high. Which is the nurse's most accurate response? A. Back pressure from cardiac congestion causes corneal edema. B. Cerebral venous dilation prevents normal interstitial fluid resorption. C. Increased production of aqueous humor or blocked drainage increases pressure. D. Congenital anomalies of the lacrimal gland or duct obstruct the passage of tears.

C Intraocular pressure is increased in glaucoma as a result of excess aqueous humor production or decreased outflow. Cardiac or cerebral circulation changes do not cause glaucoma. Lacrimal anomalies do not affect aqueous humor production.

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

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

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

C 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.

During the assessment of the patient's eyes, how should the nurse document what is seen in this video? A Extraocular movements are weakened. B Intraocular pressure is within normal limits. C Pupils are equal, round, and reactive to light. D Pupils dilating with the light shining on them

C The pupils in this video are equal in size, round in shape, and react to light. Extraocular movement was not tested, nor was intraocular pressure. The pupils did not dilate with the light shining on them.

presbyopia

a hyperopic shift to farsightedness resulting from a loss of elasticity of the lens of the eye; condition commonly develops with advancing age, with the first symptoms appearing at about age 40

retina

a layered nervous tissue membrane of the eye, continuous with the optic nerve, that receives images of external objects and transmits visual impulses through the optic nerve to the brain

vertigo

a sensation that a person or objects around the person are moving or spinning and is usually stimulated by movement of the head

tinnitus

a subjective noise sensation, often described as ringing, heard in one or both ears

nystagmus

an abnormal involuntary repetitive movement of the eyes

sclera

an opaque structure composed of collagen fibers meshed together that encircles the globe of the eye; commonly referred to as the "white" of the eye

astigmatism

an unevenness in the corneal or lenticular curvature, causing horizontal and vertical rays to be focused at two different points on the retina, which results in visual distortion

lens

biconvex, avascular, transparent structure located behind the iris