Sensory System- Medical Surgical Nursing

The nurse places eye drops for a patient with an injured eye and covers the eye with a patch as prescribed. Discharge instructions are given to the patient. Which patient statements indicate that further instruction is needed? SELECT ALL THAT APPLY 1. i should exercise my patched eye four times a day 2. i can watch tv without moving my eye too much 3. i should apply pressure to the tear duct of the eye every 5 minutes 4. i should try to open my eyelid under the patch hourly while awake 5. i can listen to music or an audiotaped book but should not read or watch TV 6. when i change the patch, it should be taped securely enough to help the eyelid stay closed

. i should exercise my patched eye four times a day 2. i can watch tv without moving my eye too much 3. i should apply pressure to the tear duct of the eye every 5 minutes 4. i should try to open my eyelid under the patch hourly while awake

Prior to measuring a patients hearing the nurse obtains a tuning fork. Which hearing tests is the nurse preparing to conduct? SELECT ALL THAT APPLY 1. Rinne test 2. Weber test 3. Caloric test 4. Tympanometry 5. Electronystagmogram

1. Rinne test 2. Weber test

The nurse is assisting with a patient who is having a test to measure intraocular pressure. Which equipment should the nurse expect to be used? 1. a tonometer 2. ultrasonography 3. an ophthalmoscope 4. a slit-lamp microscope

1. a tonometer

A patient is scheduled for a indocyanine green angiography. For what should the nurse assess before this patient has the test? 1. allergy to dye 2. last solid food 3. medications taken 4. transportation home

1. allergy to dye

A patient scheduled for cataract surgery asks if the surgery is safe. What should the nurse do? 1. ask the surgeon to talk to the patient 2. encourage visitors to distract the patient 3. give the patient a sedative for relaxation 4. reassure the patient that everything will be all right

1. ask the surgeon to talk to the patient

The nurse has reinforced teaching with a patient about diagnostic tests that evaluate eye muscle balance. Which tests identified by the patient indicate teaching has been effective? SELECT ALL THAT APPLY 1. cover test 2. corneal light reflex 3. tonometer readings 4. electroretiography 5. computed tomography 6. fluoreescein angiography

1. cover test 2. corneal light reflex

A patient is diagnosed with a cornea abrasion. When reviewing this injury with the patient which layer of the eye should the nurse explain as being damaged? 1. fibrous tunic 2. nervous tunic 3. vascular tunic 4. muscular tunic

1. fibrous tunic

The nurse is caring for a patient with sensorineural hearing loss. Which prescribed medications should the nurse question before providing to this patient? SELECT ALL THAT APPLY 1. gentamicin 2. furosemide 3. indomethacin 4. acetaminophen 5. warfin sodium

1. gentamicin 2. furosemide 3. indomethacin

The nurse is teaching a patient with glaucoma how to instill eyedrops. Which action should the nurse instruct the patient to take? 1. look up while pulling lid outward 2. squeeze the eyelids shut for 2 minutes after instillation 3. look straight ahead while pulling down the lower eyelid 4. if the eye waters, wipe from the outer canthus to the inner canthus

1. look up while pulling lid outward

A patient with otitis media is experiencing sever ear pain. Which nonpharmacologic measures should the nurse use to help this patient? SELECT ALL THAT APPLY 1. offer a massage 2. apply heat to the area 3. offer liquid of soft diet 4. apply an ice pack to the area 5. dim the light and reduce environmental noise

1. offer a massage 2. apply heat to the area 3. offer liquid of soft diet

The nurse is collecting data from a patient who has a bulging eardrum. For which health problem should the nurse anticipate providing care to this patient? 1. otitis media 2. external ear infection 3. hematoma in the middle ear 4. normal tympanic membrane

1. otitis media

The nurse suspects a patient has a hearing deficit. What behavior did the patient demonstrate that indicates a hearing loss? 1. patient cups the ear during interview 2. patient answers questions appropriately 3. patient complains of people talking loudly 4. patient leans away from the nurse during interview

1. patient cups the ear during interview

The nurse determines that a patient is experiencing common age-related changes in vision and hearing. What did the nurse assess in the patient? SELECT ALL THAT APPLY 1. presbycusis 2. yellowing of the lens 3. distorted depth perception 4. decreased lacrimal secreations 5.increased pupil size and response to light 5. loss of ability to hear low-frequency sounds

1. presbycusis 2. yellowing of the lens 3. distorted depth perception 4. decreased lacrimal secreations

A patient is diagnosed with night blindness. For which supplement should the nurse prepare to review with this patient? 1. vitamin A 2. vitamin B 3. vitamin C 4. vitamin D

1. vitamin A

The nurse is teaching a patient about conjunctivitis. Which statement indicates that the patient understands the most important means to prevent the spread of this infection? 1. wash hands 2. patch the eyes 3. irrigate the eyes 4. keep the eyes moist

1. wash hands

A patient being sent home from a clinic after evaluation for a perforated eardrum is advised not to shower. Which statement indicates that the patient understands why showering should not be performed? 1. water should not enter the ear 2. motion of the ear would cause pain 3. showering would disturb equilibrium 4. the patient should move as little as possible

1. water should not enter the ear

The nurse is collecting data and has just completed the Weber test on a patient with normal findings. How should the nurse correctly document the findings? 1. BC greater that A3 2. Left and right ear heard equally 3. Left ear heard better than right ear 4. Air conduction greater than bone conduction(BC)

2. Left and right ear heard equally

The nurse palpates a downward small protrusion the helix of a patients ear known as Darwins tubercle. How should the nurse document this finding? 1. A tumor 2. Within normal limits 3. A lump filled with fluid 4. An abnormal palpable calcification

2. Within normal limits

The nurse notes that a patient has astigmatism. What should the nurse expect when collecting data from this patient? 1. blind spots 2. blurred vision 3. distorted near vision 4. distorted distance vision

2. blurred vision

The nurse is assisting with health screening in a clinic. Which should the nurse consider a normal finding if noted lining the ear canal? 1. mucus 2. cerumen 3. perilymph 4. endolymph

2. cerumen

The nurse is reinforcing teaching provided to a patient with open-angle glaucoma. What is most important for the nurse to include in the patient teaching? 1. regardless of treatment, peripheral vision will be eventually lost 2. compliance with drug therapy is essential to prevent loss of vision 3. damage to the eye caused by glaucoma is reversible in early stages 4. eye pain is experienced until the optic nerve atrophies, causing blindness

2. compliance with drug therapy is essential to prevent loss of vision

A patient with acute angle glaucoma and a fractured femur that is scheduled for surgery is prescribed the preoperative medication morphine 10 mg IM, and atropine 0.4mg IM. Which action should the nurse take? 1. hold the morphine 2. contact the physician 3. give medication as ordered 4. collect data on patients pain

2. contact the physician

A patient with Mnires disease is crying and wants to know why this disease is occurring. Which outcome should the nurse recommend for this patient? 1. prevent injury 2. decrease anxiety 3. prevent ear infection 4. maintain fluid volume

2. decrease anxiety

During a health history the nurse suspects that a patient is at risk for vision problem. Which information within the family history did the nurse use to make this decision? SELECT ALL THAT APPLY 1. asthma 2. diabetes 3. cataracts 4. blindness 5. glaucoma

2. diabetes 3. cataracts 4. blindness 5. glaucoma

The nurse is reviewing the process of hearing with a patient experiencing a hearing deficit. What should the nurse explain as being the receptors in the organ of Corti? 1. hair cells for balance 2. hair cells for hearing 3. ganglion cells for balance 4. ganglion cells for vibrations

2. hair cells for hearing

The nurse is reinforcing teaching provided to a patient recovering from a staphedectomy. Which patient statement indicates teaching has been effective? 1. i will avoid airplane travel for 6 months 2. i will cough or sneeze with my mouth open 3. i will gently blow my nose with both sides open 4. i will keep the ear moist by packing it with cotton balls

2. i will cough or sneeze with my mouth open

The nurse is reinforcing teaching provided to a patient with Mnires disease. Which discharge order should the nurse question? 1. return if symptoms worsen 2. increase daily sodium intake to 4g 3. ask for assistance when ambulating 4. during an attack, lie down and keep head still

2. increase daily sodium intake to 4g

The nurse is collecting data from a patient with cataracts. Which symptom should the nurse expect because of this health problem? 1. visual fatigue 2. loss of visual acuity 3. loss of central vision 4. floating filaments in vision

2. loss of visual acuity

The nurse is caring for a patient recovering from a stapedectomy. What is the priority nursing action to maintain safety? 1. check for drainage 2. put the side rails up 3. test hearing capability 4. have patient cough and deep breath

2. put the side rails up

The nurse determines that a patients hearing aid is functioning properly. What did the nurse observe to come to this conclusion? 1. it whistles constantly 2. the patient converses easily 3. it is properly placed in the ear 4. the patient ignores verbal stimuli

2. the patient converses easily

A family member of an 85-year-old patient explains that the patient sits about 2 feet away from the TV and is not interested in going out anymore. Which additional information should the nurse use to support visual impairmen? 1. the patient watched TV 2. the patient does not go out anymore 3. the patient visits with a relative occasionally 4. the patient has not moved to a new home in 45 years

2. the patient does not go out anymore

The nurse is collecting data from a patient with an inner ear disorder. Which finding should be the most concerning to the nurse? 1. otalgia 2. vertigo 3. nausea 4. headache

2. vertigo

The nurse is testing a patients peripheral visual ability. What technique should the nurse use? 1. cover test 2. visual fields 3. corneal light reflex test 4. six cardinal fields of gaze

2. visual fields

A patient is being tested for visual acuity. What distance from the eyes should the patient hold the visual acuity chart during this testing? 1. 3 feet 2. 1 foot 3. 14 inches 4. 20 inches

3. 14 inches

The nurse performs a Snellen chart examination on a patient. What snellen chart documentation indicates normal vision for the patient? 1. Left eye 80/20 2. Left eye 20/200 3. Both eyes 20/20 4. Right eye 200/20

3. Both eyes 20/20

After collecting data the nurse suspects a patient has hearing loss. Which finding supports this conclusion? 1. Converses easily with the nurse 2. Answers questions appropriately 3. Speaks in an unusually loud voice 4. Relaxes facial features during conversation

3. Speaks in an unusually loud voice

The nurse is contributing to the plan of care for a patient recovering from a myringoplasty. Which intervention should be included in this patients plan of care? 1.restricting fluids 2. coughing each hour 3. avoiding excessive movement 4. encouraging visitors to speak loudly

3. avoiding excessive movement

The nurse is contributing to the teaching of a high school health class regarding cerumen removal from the ear. Which instruction should the nurse recommend? 1. cerumen is removed regularly and throroughly 2. wax is removed only when there is evidence of infection 3. cerumen protects the auditory canal; just use a washcloth to clean external ear 4. cerumen must be softened with Debrox before removal, and then an ear irrigation should be done.

3. cerumen protects the auditory canal; just use a washcloth to clean external ear

A patient with acute ear pain and drainage comes into the community clinic. Which diagnostic tests should the nurse prepare to collect prior to beginning treatment for this patient? SELECT ALL THAT APPLY 1. biopsy 2. audiometric testing 3. complete blood count 4. rinne and weber tests 5. culture of ear discharge

3. complete blood count 4. rinne and weber tests 5. culture of ear discharge

The nurse is teaching a patient with a hearing disorder. Which hearing loss should the nurse explain are helped with a hearing aid? 1. central 2. congenital 3. conductive 4. sensorineural

3. conductive

An older patient is experiencing a change in color vision. Which structure of the eye does the nurse realize is affected in this patient? 1. iris 2. rods 3. cones 4. retina

3. cones

The nurse is assisting with the auditory assessment phase of the physical examination for a high school swimming team. The nurse identifies a student who has pain and itching of the ear. For which disorder should the nurse anticipate treatment is needed? 1. otitis media 2. furunculosis 3. external otitis 4. chronic mastoiditis

3. external otitis

The nurse is caring for a patient with chronic otitis media. For which complication should the nurse observe in the patient? 1. tonsillitis 2. sore throat 3. hearing loss 4. cerebral edema

3. hearing loss

The nurse is collecting data form a patient who has Mnires disease. Which finding should the nurse expect? 1. nystagmus, nausea, and edema 2. syncope, headache, and diplopia 3. hearing loss, vertigo, and tinnitus 4. blurred vision, vomiting, and artgralgia

3. hearing loss, vertigo, and tinnitu

The nurse is caring for a patient who has an acute attack of Mniers disease. What action should the nurse take first? 1. administer prescribed diuretics 2. administer ab anti-anxiety medication 3. help the patient into bed with side rails up 4. ensure that the patient is on fluid restriction

3. help the patient into bed with side rails up

A patient with diabetic retinopathy is being discharged home. Which patient statement indicates understanding of the discharge plan to maintain vision? 1. i should avoid being in the sun 2. i should reduce my insulin dosage 3. i should keep my diabetes under control 4. i will need to schedule routine eye examination every 3 years

3. i should keep my diabetes under control

A patient diagnosed with myopia asks the nurse to explain the condition. How should the nurse respond? 1. it is blindness 2. it is farsightedness 3. it is nearsightedness 4. it is cataract development

3. it is nearsightedness

The nurse is caring for a patient after a left stapendectomy. In which position should the nurse place the patient? 1. flat 2. prone 3. left ear upward 4. right ear upward

3. left ear upward

The nurse is preparing a patient who will be having a digital retinal scan. Which patient statement indicates further teaching is necessary? 1. this test is used to help detect eye disease early 2. the scanner will take a picture in about 2 weeks 3. my eyes will need to be dilated before the procedure 4. a digital image of most of my retina will be produced for the doctor to view

3. my eyes will need to be dilated before the procedure

The nurse is planning to perform an ear irrigation to remove a patients cerumen. Which patient condition would contraindicate this procedure? 1. previous hearing loss 2. chronic, severe earache 3. previous perforated eardrum 4. previous external ear infection

3. previous perforated eardrum

The nurse is caring for a patient who ask the nurse, What part of the eye gives the eye its color? What is the correct response by the nurse? 1. iris 2. lens 3. pupil 4.retina

3. pupil

During a home visit the nurse identifies signs of visual impairment in a 74-year-old patient. Which action should the nurse recommend? 1. avoid travel 2. make adjustments in lifestyle 3. schedule an eye examination 4. accept visual impairment as part of aging

3. schedule an eye examination

The nurse is testing a patients visual muscle balance and movement. What technique should the nurse use to gather this data? 1. visual fields 2. direct pupillary reflex 3. six cardinal fields of gaze 4. consensual pupillary reflect

3. six cardinal fields of gaze

The nurse is collecting data visually on a patient. Which lighting environment should the nurse use to examine the patients pupils? 1. natural lighting 2. brightly lit room 3. slightly darkened room 4. completely darkened room

3. slightly darkened room

The nurse is caring for a patient who has presbycusis. What approach should the nurse use to enhance communication with this patient? 1. speaking in a soft voice 2. speaking in a very loud voice 3. speaking in a low-pitched voice 4. speaking in a high-pitched voice

3. speaking in a low-pitched voice

The caregiver of a patient with macular degeneration becomes increasingly frustrated because of food spills on the patients clothing. Which explanation should help the caregiver understand what the patient is experiencing? 1. the patients vision is blurred 2. there is total blindness in one eye occurring 3. the central vision is gone and only perpheral vision remains 4. there are black dots in the field of vision that causes confusion

3. the central vision is gone and only perpheral vision remains

The nurse is reviewing the structure of the eye with a patient scheduled for cataract surgery. Which structure should the nure explain is the gelatin-like substance that gives shape to the eye and fills the space behind the lens? 1. conjunctiva 2. lacrimal fluid 3. vitreous humor 4. aqueous humor

3. vitreous humor

A patients Snellen chart findings are 20/60. How should the nurse explain this finding to the patient? 1. your vision is better than normal 2. you must be at 60 feet to see what normal vision sees at 20 feet 3. you must be at 20 feet to see that normal vision sees at 60 feet 4. you are considered legally blind, even though with prescription glasses you'll be able to see

3. you must be at 20 feet to see that normal vision sees at 60 feet

The nurse is conducting an initial screening to determine a patients gross hearing acuity as part of a complete physical. Which test should the nurse include in the assessment? 1. Romberg 2. Calorie test 3.Whisper test 4. Otoscopic examination

3.Whisper test

During data collection a patient states that at times the ears hurt when there are loud noises. The nurse realizes that the patient is describing noises at which decibel level? 1. 50 2. 75 3. 110 4. 130

4. 130

A patient is diagnosed as being legally blind. What Snellen chart rating should the nurse expect when collecting data with this patient? 1. 20/20 2. 20/40 3. 20/100 4. 20/200

4. 20/200

The nurse is caring for a patient who asks what arcus senilis is. How should the nurse explain this findings? 1. An eye infection 2. A mental condition 3. A drooping of the eyelid 4. A lipid deposit in the cornea

4. A lipid deposit in the cornea

A patient is diagnosed with sensotinerual deafness. The nurse realizes that which cranial nerve is malfunctioning in this patient? 1. CN II 2. CN IV 3. CN VI 4. CN VIII

4. CN VIII

The nurse is reinforcing teaching provided to a patient with Mnires disease. Which patient statement indicates understanding of how to manage vertigo? 1. listen to soft music 2. increase fluid intake 3. increase sodium intake 4. avoid sudden movement

4. avoid sudden movement

A patient diagnosed with cataracts asks how they develop. How should the nurse respond to this patient ? 1. cataracts usually result from chronic systemic diseases 2. cataracts usually result from the prolonged use of toxic substances 3. cataracts are believed to result from eye injuries sustained early in life 4. cataracts may form as a result of exposure to ultraviolet light over time

4. cataracts may form as a result of exposure to ultraviolet light over time

While checking a patients pupils the nurse notes that the left pupil constricts when a light is shined into the right eye. What does this information suggest to the nurse? 1. tropia present 2. estropia absent 3. accommodation absent 4. consensual response present

4. consensual response present

The nurse is reinforcing teaching provided to a patient being treated for myopia. Which patient statement indicates a correct understanding of the teaching? 1. cataract surgery must occur 2. corrective convex lenses are needed 3. mydriatic opthalmic drops are used 4. corrective concave lenses are needed

4. corrective concave lenses are needed

A patient ask how the ears are able to equalize pressure when flying in an airplane. Which anatomical ear structure should the nurse review with the patient? 1.stapes 2. auricle 3. cochlea 4. eustachian tubes

4. eustachian tubes

The nurse is having difficulty communicating with a hearing-impaired patient. Which action should the nurse take to improve communication? 1. speak softly 2. speak rapidly 3. avoid verbal communication 4. face the patient when speaking

4. face the patient when speaking

The nurse is reinforcing teaching provided to a patient with primary open-angle glaucoma (POAG) about symptoms to report. Which patient statement indicates a correct understanding of the teaching? 1. hypotension and bradycardia 2. fever and reddened conjunctiva 3. loss of central vision and dizziness 4. headache and seeing halos around lights

4. headache and seeing halos around lights

A patient with glaucoma is prescribed pilocarpine 1% eye drops every 6 hours. What outcome should the nurse expect from this medication? 1. reduction of inflammation of the iris and choroids 2. prevention of dryness of the cornea and conjunctiva 3. dilation of the pupil by paralyzing the ciliary muscle 4. promotion of drainage of aqueous humor from the anterior chamber of the eye

4. promotion of drainage of aqueous humor from the anterior chamber of the eye

The nurse performs a visual assessment on a patient and documents . the findings using the acronym PERRLA. What does PERRLA indicare? 1. palperbral angle rigid, right and left angles 2. patients eyes round, regular, lively, active 3. pupils equilateral, regular, round, little accommodation 4. pupils equal, round, and reactive to light and accommodation

4. pupils equal, round, and reactive to light and accommodation

The nurse is assisting with a patients physical examination. For which test should the nurse plan for patient safety? 1. rinnes test 2. webers test 3. whisper test 4. rombergs test

4. rombergs test

The nurse has reinforced teaching with a patient after diagnostic testing reveals tinnitus. Which patient statement indicates that teaching has been effective? 1. there is a toxic substance in my ear 2. that is why i have so much discharge all of the time 3. my ear pain should get better if i follow the doctors orders 4. the ringing sound i hear in my ear may be a symptom of another problem

4. the ringing sound i hear in my ear may be a symptom of another problem

The nurse administers eyedrops to a patient and instructs the patient to apply pressure to the inner corner of the eye for 1 minute after application of the drops. Which statement indicates to the nurse that the patient correctly understands the main purpose of applying pressure? 1. to protect the facial skin from the eyedrops 2. to increase the onset of action of the eyedrops 3. to maintain greater concentration of the eyedrops 4. to reduce absorption of eyedrops through tear duct

4. to reduce absorption of eyedrops through tear duct

The nurse is collecting data from a patient with a detached retina. Which findings should the nurse expect in this patient? SELECT ALL THAT APPLY 1. severe pain 2. blurred vision 3. flashing lights 4. loss of perpheral vision 5. loss of acuity in the affected eye

5. loss of acuity in the affected eye