Exam 45: Assessing the Eye and Ear

The nurse is reviewing the physiology of the ear with a patient with a hearing disorder. What should the nurse explain about the function of the inner ear?

During an assessment the nurse suspects that a victim of a motor vehicle crash is a narcotic substance user. Which assessment findings would confirm the nurse's suspicion?

The nurse is preparing to assess a patient's corneal reflex. Place an X on the site where the nurse may lightly touch the eye with a wisp of cotton.

The nurse is assessing a patient for a possible conductive hearing loss. What should the nurse perform first?

The patient assessment reveals absence of the fovea centralis. The next examination that may be anticipated by the nurse would be:

A patient has sustained an injury to the inner layer of the left retina. The nurse realizes that this patient will have difficulty with:

A patient has a tonometer test result of 28 mmHg. Which explanation by the nurse about this pressure reading is most accurate?

The nurse is conducting an assessment of a patient's hearing. Which test is the nurse conducting, as demonstrated in the picture?

A patient who is using atropine eyedrops is found to have a poor consensual light response. The nurse recognizes that this finding is considered:

The nurse is preparing to perform an otoscopic exam of the ear. The patient is restless but has agreed to the exam. List in order of priority the steps the nurse would perform. Standard Text: Click and drag the options below to move them up or down. Choice A) Explain the procedure to the patient. B) Grasp the superior portion of the auricle and pull up, out, and back to straighten the auditory canal. C) Hold the handle of the otoscope in the dominant hand, otoscope handle upward. D) Wash the hands. E) Turn on the otoscope light. F) Rest the hand holding the otoscope against the patient's head. G) none of the above

A patient with a sore throat is complaining of "trouble with hearing." The nurse realizes that this patient might be experiencing:

Before assessing an older adult patient, the nurse reviews the age-related changes in the ear. (See accompanying box.) After the assessment, the nurse recognizes which priority concern related to the finding of vestibular degeneration? Age-Related Change: The Inner Ear Loss of hair cells, \downarrow blood supply, less flexible basilar membrane, degeneration of spiral ganglion cells, and \downarrow production of endolymph result in progressive hearing loss with age (presbycusis) and hearing aids may be required. High-frequency sounds are lost; middle- and low-frequency sounds may also be lost or decreased, which may distort speech. Vestibular structures degenerate; organ of Corti and cochlea atrophy resulting in loss of equilibrium.

A patient is found to need corrective lenses. Which diagnostic test was most likely used to determine this finding?

The nurse is assessing a 75-year-old patient. Which patient report would require immediate action by the nurse?

The nurse is performing the Weber test when assessing a patient's hearing. For which abnormalities does this technique assess?

The nurse determines that an older patient has age-related changes in the vestibular structures of the ear. What should the nurse identify as risks for this patient?

An older patient says, "I seem to be talking so much louder these days and I don't know why!" The nurse realizes that this patient might be experiencing:

A 20-year-old patient is experiencing difficulty with near vision. The nurse realizes that this finding is:

The nurse suspects that a patient has bone-conductive hearing loss. Which assessment technique should the nurse use to differentiate between bone conduction loss and air conduction loss?

The nurse is assessing a patient with retinitis pigmentosa. Which findings should the nurse identify as consistent with this health problem?