Deck 51: Sensory System Function, Assessment, and Therapeutic Measures: Vision and Hearing

Question 1

The nurse is explaining how the retina works to a patient who is experiencing visual changes. Which factor shared by the nurse is correct?

A)The retina reacts to chemical stimulation from rods and cones.
B)The rods and cones are stimulated by chemical stimulation of the retina.
C)The fovea centralis is located directly behind the center of the lens and contains cones.
D)The rods of the retina are most sensitive to light and are most responsible for color vision.

Answer 1

The fovea centralis is located directly behind the center of the lens and contains cones.

Question 2

The nurse is working at a summer camp for preadolescent children. One of the children comes to the nurse rubbing an eye and stating pain from getting sand in the eye. After the child is effectively treated, which teaching is the nurse prompted to provide to all the attendees?

A)It is dangerous to throw sand at each other.
B)Wear sunglasses if it is windy at the beach.
C)Do not rub your eye if it has something in it.
D)Remove the sand with any available fluid.

Answer 2

Do not rub your eye if it has something in it.

Question 3

The nurse is conducting an initial screening to determine a patient's gross hearing acuity as part of a complete physical. Which test does the nurse include in the assessment?

A)Romberg
B)Calorie test
C)Whisper voice
D)Otoscopic examination

Answer 3

Whisper voice

Question 4

The nurse is attending while the HCP performs an otoscopic examination of a patient's ears. The nurse is aware that the examination is performed primarily for which purpose?

A)To examine the eardrum
B)To look for foreign objects
C)To remove excessive earwax
D)To obtain a sample of drainage

Question 5

A patient's Snellen chart findings are 20/60. Which explanation does the nurse provide to the patient regarding this finding?

A)"Your vision is better than normal."
B)"You must be at 60 feet to see what normal vision sees at 20 feet."
C)"You must be at 20 feet to see what normal vision sees at 60 feet."
D)"You are considered legally blind, even though with prescription glasses you'll be able to see."

Question 6

The nurse is preparing a patient with diabetes mellitus for a fluorescein angiography. For which reason does the nurse understand the performance of this test?

A)To find leakage or damage to the blood vessels of the retina
B)To identify the dry form of macular degeneration
C)To find the amount of vision damage related to glaucoma
D)To find abnormalities of the eye structure from hypoglycemia

Question 7

A patient has an injury resulting in a major damage to the pinna of the right ear. The patient expresses fear about hearing loss in the damaged ear. Which statement by the nurse will alleviate the patient's fear?

A)"The left ear will become over sensitive to sound."
B)"The impulses for hearing come from the middle and inner ear."
C)"The outside of your ear will need to be surgically restructured."
D)"This much damage to the outer ear also indicates severe damage internally."

Question 8

The nurse is giving instructions to a patient who is scheduled for an electronystagmogram due to a diagnosis of vertigo and ringing in the ears. Which finding regarding the patient's medical history will cause the nurse to notify the prescribing health care provider (HCP) for cancellation of the test?

A)The patient has a history of alcohol abuse.
B)The patient has a pacemaker.
C)The patient takes tranquilizers.
D)The patient lives alone.

Question 9

The National Eye Institute has performed research regarding the impact of nutrition on eye diseases. Which factor does the nurse recognize as an incorrect conclusion from this research?

A)A diet high in green, leafy vegetables lowers the risk of age-related macular degeneration (AMD).
B)With intensive glycemic control, patients with diabetes mellitus do not experience retinopathy.
C)Supplements containing vitamins and minerals will reduce the risk of developing advanced AMD.
D)There is no benefit of supplemented omega-3 fatty acids on AMD; eating fish lowers the rate.

Question 10

The nurse is conducting hearing acuity evaluation on a patient using the Rinne test. The test involves the use of a tuning fork. Which test result will be validated with the documentation "AC greater than BC"?

A)The patient hears the tuning fork twice as long when it is placed on the mastoid bone.
B)The patient is unable to hear the tuning fork when it is lifted away from the mastoid bone.
C)The patient continues to hear the tuning fork for twice as long when it is lifted from the mastoid bone.
D)The patient stops hearing the tuning fork when it is moved from in front of the ear and placed on the mastoid bone.

Question 11

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?

A)A tonometer
B)Ultrasonography
C)An ophthalmoscope
D)A slit-lamp microscope

Question 12

The nurse is preparing to administer eye medication as prescribed by the HCP after eye surgery for cataract removal. The HCP prescribes one drop with punctal occlusion. Which action will the nurse perform when administering this medication?

A)Have the nonmedicated eyelid held closed during medication administration.
B)Place the index finger on the corner of the eye and apply pressure against the nose bone.
C)Instruct the patient to squeeze the eye tightly shut once the drop is administered.
D)Tilt the head back, apply the drop, ask the patient to blink twice, and blot any leakage.

Question 13

During a physical examination of a patient, pupillary reflexes are checked. A light is shone into the right eye while it is observed. Pupillary reaction and pupil size are noted. Then a light is shone into the left eye as the right eye is still observed. Which response occurs during the second step of the test?

A)Direct response
B)Indirect response
C)Consensual response
D)Accommodation response

Question 14

A patient is scheduled to have cataract surgery. Which structure of the patient's eye does the nurse explain will be involved in the procedure?

A)The iris
B)The fibrous tunic
C)The ciliary body
D)The lens

Question 15

The nurse performs a visual assessment on a patient and documents the findings using the acronym PERRLA. Which assessment finding does PERRLA indicate?

A)Palpebral angle rigid, right and left angles
B)Patient's eyes round, regular, lively, active
C)Pupils equilateral, regular, round, little accommodation
D)Pupils equal, round, and reactive to light and accommodation

Question 16

The nurse in an HCP's office is providing assistance with a patient who has purulent drainage from the ear. Which action by the HCP does the nurse expect?

A)Flushing of the drainage from the ear canal
B)Packing the ear lightly to absorb the drainage
C)Excising the eardrum to promote drainage
D)Obtaining a swab of the drainage for culture

Question 17

The nurse is collecting information about a patient's auditory system during a physical examination. Which process will the nurse perform first?

A)Observation
B)Inspection
C)Palpation
D)Auscultation

Question 18

The nurse is assisting with the preparation of a patient for a cochlear implant due to profound deafness. Which teaching will the nurse reinforce for this patient?

A)Preparation instructions for surgery
B)Care of the external equipment
C)The impact of hearing for the first time
D)Physical limitations after the procedure

Question 19

While checking a patient's pupils, the nurse notes that the left pupil constricts when a light is shone into the right eye. Which information does this finding suggest to the nurse?

A)Tropia present
B)Esotropia absent
C)Accommodation absent
D)Consensual response present

Question 20

The nurse is collecting information about the eyes from an older adult patient. Which finding is unexpected during the examination?

A)The lenses of the eyes are slightly opaque in appearance.
B)The patient states that the glare of the pen light is too bright.
C)The best color discrimination is between blue, green, and purple.
D)The patient has needed reading glasses since the age of 45 years.

Question 21

Prior to measuring a patient's hearing, the nurse obtains a tuning fork. Which hearing tests is the nurse preparing to conduct? (Select all that apply.)

A)Rinne test
B)Weber test
C)Caloric test
D)Tympanometry
E)Electronystagmogram

Question 22

The nurse places eyedrops 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 further instruction is needed? (Select all that apply.)

A)"I should exercise my patched eye four times daily."
B)"I can watch television without moving my eye too much."
C)"I should apply pressure to the tear duct of the eye every 5 minutes."
D)"I should try to open my eyelid under the patch hourly while awake."
E)"I can listen to music or an audiotaped book, but should not read or watch television."

Question 23

During a health history, the nurse suspects that a patient is at risk for a vision problem. Which information within the family history does the nurse use to make this decision? (Select all that apply.)

A)Asthma
B)Diabetes
C)Cataracts
D)Blindness
E)Glaucoma

Question 24

The nurse determines that a patient is experiencing common age-related changes in vision and hearing. Which findings does the nurse identify in the patient? (Select all that apply.)

A)Presbycusis
B)Yellowing of the lens
C)Distorted depth perception
D)Decreased lacrimal secretions
E)Increased pupil size and response to light

Question 25

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.)

A)Cover test
B)Corneal light reflex
C)Tonometer readings
D)Electroretinography
E)Computed tomography 6.Fluorescein angiography