Deck 21: Nursing Assessment: Visual and Auditory Systems

Question 1

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

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.

Answer 1

encouraging the patient to ambulate independently.

Question 2

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

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."

Answer 2

"You will need to wear sunglasses for a few hours after the exam."

Question 3

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

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.

Answer 3

shine a light into one pupil and observe the response of both pupils.

Question 4

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

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 5

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

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.

Question 6

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

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 7

The nurse recording health histories in the outpatient clinic would plan a focused hearing assessment for adult patients taking which medication?

A) Atenolol (Tenormin) taken to prevent angina
B) Acetaminophen (Tylenol) taken frequently for headaches
C) Ibuprofen (Advil) taken for 20 years to treat osteoarthritis
D) Albuterol (Proventil) taken since childhood to treat asthma

Question 8

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

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 9

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

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 10

A 65-year-old patient is being evaluated for glaucoma.Which information given by the patient has implications for the patient's treatment?

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

Question 11

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?

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 12

The nurse is performing an eye examination on a 76-year-old patient.The nurse should refer the patient for a more extensive assessment based on which finding?

A) The patient's sclerae are light yellow.
B) The patient reports persistent photophobia.
C) The pupil recovers slowly after responding to a bright light.
D) There is a whitish gray ring encircling the periphery of the iris.

Question 13

The nurse is testing the visual acuity of a patient in the outpatient clinic.The nurse's instructions for this test include asking the patient to

A) stand 20 feet from the wall chart.
B) follow the examiner's finger with the eyes only.
C) look at an object far away and then near to the eyes.
D) look straight ahead while a light is shone into the eyes.

Question 14

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

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 15

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?

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 16

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

Question 17

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?

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 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?

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

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?

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.

Question 20

The nurse in the eye clinic is examining a 67-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) Immediately have the ophthalmologist evaluate the patient.
B) Explain that spots and "floaters" are a normal part of aging.
C) Inform the patient that these spots may indicate retinal damage.
D) Use an ophthalmoscope to examine the posterior eye chambers.

Question 21

Which test is the nurse performing in the video clip?

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

Question 22

Which action can the nurse working in the emergency department delegate to experienced unlicensed assistive personnel (UAP)?

A) Ask a patient with decreased visual acuity about medications taken at home.
B) Perform Snellen testing of visual acuity for a patient with a history of cataracts.
C) Obtain information from a patient about any history of childhood ear infections.
D) Inspect a patient's external ear for redness, swelling, or presence of skin lesions.

Question 23

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

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 24

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

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

Question 25

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?

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 26

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

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.