Question 1

The nurse is providing health promotion teaching to a group of older adults.Which information will the nurse include when teaching about routine glaucoma testing?

Accepted Answer

A)   A Tono-pen will be applied to the surface of the eye.
B)   The test involves reading a Snellen chart from 20 feet.
C)   Medications will be used to dilate the pupils for the test.
D)   The examination involves checking the pupil's reaction to light. A

Question 2

The nurse performing an eye examination will document normal findings for accommodation when

Accepted Answer

A)   shining a light into the patient's eye causes pupil constriction in the opposite eye.
B)   a blink reaction follows touching the patient's pupil with a piece of sterile cotton.
C)   covering one eye for 1 minute and noting pupil constriction as the cover is removed.
D)   the pupils constrict while fixating on an object being moved closer to the patient's eyes. D

Question 3

The charge nurse must intervene immediately if observing a nurse who is caring for a patient with vestibular disease

Accepted Answer

A)   speaking slowly to the patient.
B)   facing the patient directly when speaking.
C)   encouraging the patient to ambulate independently.
D)   administering Rinne and Weber tests to the patient. C

Question 4

The nurse working in the vision and hearing clinic receives telephone calls from several patients who want appointments in the clinic as soon as possible.Which patient should be seen first?

Accepted Answer

A)   71-year-old who has noticed increasing loss of peripheral vision
B)   74-year-old who has difficulty seeing well enough to drive at night
C)   60-year-old who has difficulty hearing clearly in a noisy environment
D)   64-year-old who has decreased hearing and ear "stuffiness" without pain

Question 5

The nurse is assessing a 65-year-old patient for presbyopia.Which instruction will the nurse give the patient before the test?

Accepted Answer

A)   "Hold this card and read the print out loud."
B)   "Cover one eye at a time while reading the wall chart."
C)   "You'll feel a short burst of air directed at your eyeball."
D)   "A light will be used to look for a change in your pupils."

Question 6

Which action should the nurse take when providing patient teaching to a 76-year-old with mild presbycusis?

Accepted Answer

A)   Use patient education handouts rather than discussion.
B)   Use a higher-pitched tone of voice to provide instructions.
C)   Ask for permission to turn off the television before teaching
D)   Wait until family members have left before initiating teaching.

Question 7

The nurse is observing a student who is preparing to perform an ear examination for a 30-year-old patient.The nurse will need to intervene if the student

Accepted Answer

A)   pulls the auricle of the ear up and posterior.
B)   chooses a speculum larger 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.

Question 8

When assessing a patient's consensual pupil response,the nurse should

Accepted Answer

A)   have the patient cover one eye while facing the nurse.
B)   observe for a light reflection in the center of both corneas.
C)   instruct the patient to follow a moving object using only the eyes.
D)   shine a light into one pupil and observe the response of both pupils.

Question 9

Which equipment will the nurse obtain to perform a Rinne test?

Accepted Answer

A)   Otoscope
B)   Tuning fork
C)   Audiometer
D)   Ticking watch

Question 10

When the patient turns his head quickly during the admission assessment,the nurse observes nystagmus.What is the indicated nursing action?

Accepted Answer

A)   Assess the patient with a Rinne test.
B)   Place a fall-risk bracelet on the patient.
C)   Ask the patient to watch the mouths of staff when they are speaking.
D)   Remind unlicensed assistive personnel to speak loudly to the patient.

Question 11

A patient who underwent eye surgery is required to wear an eye patch until the scheduled postoperative clinic visit.Which nursing diagnosis will the nurse include in the plan of care?

Accepted Answer

A)   Disturbed body image related to eye trauma and eye patch
B)   Risk for falls related to temporary decrease in stereoscopic vision
C)   Ineffective health maintenance related to inability to see surroundings
D)   Ineffective denial related to inability to admit the impact of the eye injury

Question 12

The nurse should report which assessment finding immediately to the health care provider?

Accepted Answer

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

Question 13

Which assessment finding alerts the nurse to provide patient teaching about cataract development?

Accepted Answer

A)   History of hyperthyroidism
B)   Unequal pupil size and shape
C)   Blurred vision and light sensitivity
D)   Loss of peripheral vision in both eyes

Question 14

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 50 feet and the right eye can see at 20 feet what a person with normal vision can see at 40 feet.The nurse records which finding?

Accepted Answer

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

Question 15

A patient arrives in the emergency department complaining of eye itching and pain after sleeping with contact lenses in place.To facilitate further examination of the eye,fluorescein angiography is ordered.The nurse will teach the patient to

Accepted Answer

A)   hold a card and fixate on the center dot.
B)   report any burning or pain at the IV site.
C)   remain still while the cornea is anesthetized.
D)   let the examiner know when images shown appear clear.

Question 16

When the nurse is taking a health history of a new patient at the ear clinic,the patient states,"I have to sleep with the television on." Which follow-up question is most appropriate to obtain more information about possible hearing problems?

Accepted Answer

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

Question 17

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

Accepted Answer

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

Question 18

When obtaining a health history from a 49-year-old patient,which patient statement is most important to communicate to the primary health care provider?

Accepted Answer

A)   "My eyes are dry now."
B)   "It is hard for me to see at night."
C)   "My vision is blurry when I read."
D)   "I can't see as far over to the side."

Question 19

Which test is the nurse performing in the video clip?

Accepted Answer

A)   Rinne test
B)   Weber test
C)   Audiometry
D)   Tympanometry

Question 20

Which information will the nurse provide to the patient scheduled for refractometry?

Accepted Answer

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

Exam 21: Nursing Assessment: Visual and Auditory Systems