Deck 21: Nursing Assessment: Visual and Auditory Systems

Question 1

A patient arrives in the emergency department complaining of eye itching and pain caused by sleeping with contact lenses in place. To facilitate further examination of the eye, the nurse will anticipate the need for

A) a refractometer.
B) fluorescein dye.
C) a tonometer.
D) Lidocaine ointment.

Answer 1

fluorescein dye.

Question 2

When taking a health history from a new patient in the outpatient clinic, which information may indicate the need to perform a focused hearing assessment?

A) The patient has a 20-year history of rheumatoid arthritis.
B) The patient uses acetaminophen (Tylenol) frequently.
C) The patient takes atenolol (Tenormin) to prevent angina.
D) The patient had a scalp laceration about a year ago.

Answer 2

The patient has a 20-year history of rheumatoid arthritis.

Question 3

During the nursing history, a patient complains of dizziness when bending over and of nausea and dizziness associated with physical activities. The nurse will plan to teach the patient about

A) rotary chair testing.
B) pure-tone audiometry.
C) tympanometry.
D) bone-conduction testing.

Answer 3

rotary chair testing.

Question 4

The nurse is assessing a 48-year-old patient for presbyopia. Which equipment will the nurse need to obtain prior to the examination?

A) Snellen chart
B) Jaeger chart
C) Penlight
D) Tono-pen

Question 5

A nurse at the eye clinic advises all patients to wear sunglasses that protect the eyes from ultraviolet light because ultraviolet sunlight exposure is associated with the development of

A) glaucoma.
B) exophthalmos.
C) anisocoria.
D) cataracts.

Question 6

The nurse is obtaining a health history for a 64-year-old patient with glaucoma who is a new patient at the eye clinic. Which information given by the patient will have the most implications for the patient's treatment?

A) "I use aspirin when I have a sinus headache."
B) "I have not had an eye examination for at least 10 years."
C) "I take metoprolol (Lopressor) daily for angina."
D) "I have had frequent episodes of conjunctivitis."

Question 7

When obtaining a health history from a 52-year-old patient, which patient statement will be of most concern to the nurse?

A) "My vision seems blurry now when I read."
B) "I have noticed that my eyes are drier now."
C) "It is hard for me to see when I drive at night."
D) "The middle part of my vision is decreased."

Question 8

Assessment of a patient's visual acuity reveals that the left eye can see at 20 feet what a person with normal vision can see at 40 feet and the right eye can see at 20 feet what a person with normal vision can see at 50 feet. The nurse records these findings as visual acuity

A) OS 20/40; OD 20/50.
B) OU 20/40; OS 50/20.
C) OD 20/40; OS 20/50.
D) OU 40/20; OD 50/20.

Question 9

A patient being admitted to the hospital has an eye patch in place and tells the nurse "I had a recent eye injury, so I need to wear this patch for a few weeks." Which nursing diagnosis will the nurse include in the plan of care?

A) Ineffective denial related to inability to admit the impact of the eye injury
B) Risk for falls related to current decrease in stereoscopic vision
C) Disturbed body image related to eye trauma and need to wear eye patch
D) Impaired physical mobility related to inability to see surroundings

Question 10

When the nurse is taking a health history of a new patient at the ear clinic, the patient states, "I always sleep with the radio on." Which response by the nurse is most appropriate?

A) "Are you ever dizzy when you are lying down?"
B) "Do you grind your teeth at night?"
C) "Have you noticed any ringing in your ears?"
D) "What time do you usually fall asleep?"

Question 11

The nurse notes all these assessment data when examining a patient's auditory canal and tympanic membrane. Which one is of most concern?

A) Cerumen is present in the auditory canal.
B) The tympanum is bluish-tinged.
C) There is a cone of light visible.
D) The skin in the ear canal is dry and scaly.

Question 12

The nurse working in the outpatient clinic receives a new order to check the visual acuity for a patient. The nurse will need to obtain a (an)

A) Snellen chart.
B) ophthalmoscope.
C) penlight.
D) Amsler grid.

Question 13

An 87-year-old patient has marked bilateral presbycusis. In performing a Rinne test on the patient, the nurse would anticipate that the patient

A) lateralizes the sound when a tuning fork is placed on the forehead.
B) hears best when the tuning fork is placed next to the ear canal.
C) hears the tuning fork better when it is placed on the mastoid bone.
D) hears the sound equally well in both ears when the fork is placed midline on the skull.

Question 14

Which assessment information obtained by the nurse when performing an eye examination for a 68-year-old patient indicates that more extensive examination of the eyes is needed?

A) The patient has persistent photophobia.
B) The sclerae are light yellow.
C) The pupil recovers slowly after being stimulated by a penlight.
D) There is a whitish gray ring encircling the periphery of the iris.

Question 15

When assessing a sedated patient, the nurse notes that the patient blinks only five or six times a minute. The nurse should plan to

A) notify the health care provider immediately.
B) use artificial tears every hour.
C) apply patches to the eyes.
D) check the pupil response to light.

Question 16

A patient in the eye clinic is scheduled for refractometry. Which information will be included in patient teaching?

A) "You should not take any of your eye medicines before the examination."
B) "The surface of your eye will be numb while the doctor does the exam."
C) "The doctor will shine a bright light into your eye during the examination."
D) "You will need to wear sunglasses for a few hours after the exam."

Question 17

A patient schedules annual testing for glaucoma with the ophthalmologist. Which information will be included when teaching the patient about routine glaucoma testing?

A) The test involves reading a Snellen chart at a distance of 20 feet.
B) Application of a Tono-pen to the cornea of the eye will be needed.
C) The examination includes checking the pupil's reaction to a bright light.
D) Cycloplegic medications are used to allow visualization of the retina.

Question 18

Which action will the nurse take in order to assess the patient's visual field?

A) Check extraocular movements
B) Assess the six cardinal positions of gaze
C) Look for consensual pupillary response
D) Perform the confrontation test

Question 19

When performing an eye examination, the nurse will assess for accommodation by

A) touching the patient's pupil with a small piece of sterile cotton and watching for a blink reaction.
B) observing the pupils when the patient focuses on a close object and then on a distant object.
C) shining a light into the patient's eye and watching the pupil response in the opposite eye.
D) covering one eye for 1 minute and noting the pupil reaction when the cover is removed.

Question 20

The nurse in the eye clinic is examining a 44-year-old patient who says "I see small spots that move around in front of my eyes." Which action will the nurse take first?

A) Have the ophthalmologist evaluate the patient immediately for possible eye damage.
B) Explain that "floaters" are a normal part of aging and do not require follow-up.
C) Use an ophthalmoscope to examine the posterior chamber and retina of the patient's eyes.
D) Inform the patient that these spots are common and can be surgically removed if they are bothersome.

Question 21

When assessing the activity-exercise pattern of a patient with chronic vertigo syndrome, the nurse notes that the patient states, "I love to run for exercise, and I usually run five or six times a week, but now I feel dizzy when I run." Which action should be included in the plan of care?

A) Teaching the patient about the need to avoid activities that cause dizziness
B) Having the patient try running more in the early part of the day
C) Encouraging the patient to try riding a bicycle instead of running
D) Developing an exercise program that gradually increases time spent running

Question 22

The nurse is observing a student who is preparing to perform an ear examination of a 24-year-old patient. The nurse will need to intervene if the student

A) pulls the auricle of the ear down and backward.
B) chooses a speculum smaller than the ear canal.
C) stabilizes the hand holding the otoscope on the patient's head.
D) stops inserting the otoscope after observing impacted cerumen.