Deck 64: Assessment of the Eyes and Ears

Question 1

Before insertion of the otoscope speculum in the ear of an adult, the nurse would pull the pinna

A) down and back.
B) down and forward, and out.
C) up and back, and out.
D) up and forward.

Answer 1

up and back, and out.

Question 2

A nurse is working with a client who has moderate hearing loss. Communication adaptations the nurse uses include (Select all that apply)

A) enunciating words clearly.
B) facing the client directly.
C) slowing the speech down.
D) speaking very loudly.

Answer 2

enunciating words clearly.
facing the client directly.
slowing the speech down.

Question 3

The nurse conducting an otoscopic examination visualizes an eardrum that is shiny and pearl gray in color. The nurse would know that this assessment is consistent with

A) a history of otitis media.
B) a normal tympanic membrane.
C) blood in the middle ear.
D) infection in the ear canal.

Answer 3

a normal tympanic membrane.

Question 4

The nurse assessing a client with declining visual acuity would use gentle questioning and tact because (Select all that apply)

A) a client might not give accurate answers if he/she thinks driving will be restricted.
B) lack of a family history might mean a client has no risk of vision disorders.
C) social stigma accompanying blindness may cause the client anxiety.
D) vision disorders affect dependence and independence.
E) vocational barriers may force the client to seek different employment.

Question 5

A client has severe hearing loss that occurred within the last year. It is important for the nurse to also assess the client for

A) accompanying visual losses.
B) frustration and loneliness.
C) hypertension and heart disease.
D) impaired physical mobility.

Question 6

The nurse conducting a physical examination is assessing a client's pupillary reactions. To do this correctly, the nurse would

A) ask the client to open the eyes and stare into the penlight.
B) ask the client to stare straight ahead and then turn on the penlight.
C) bring the penlight up from the client's chin to shine directly over the pupil.
D) bring the penlight in from the side to shine directly over the pupil.

Question 7

A client is complaining of dryness, burning, and grittiness in both eyes. The nurse would conduct further assessments to confirm a suspicion of

A) acute angle glaucoma.
B) allergies.
C) hypertensive eye disease.
D) mild corneal abrasion.

Question 8

To evaluate a client's balance using Romberg's test, the nurse would

A) seat the client and request the client touch the nurse's outstretched finger with eyes closed.
B) seat the client upright with eyes closed, and then ask the client to touch the nose.
C) stand the client with feet a foot apart, eyes closed, and arms outstretched.
D) stand the client with feet together, eyes closed, and arms to the side.

Question 9

Using a Snellen chart, the nurse would credit a client with reading the line of print if the client has correctly read more than

A) 50% of the characters.
B) 60% of the characters.
C) 80% of the characters.
D) 90% of the characters.

Question 10

If a client shows intolerance to light during pupil examination, the nurse would record that the client exhibits

A) photophobia.
B) reduced accommodation.
C) strabismus.
D) unequal pupil response.

Question 11

An important primary prevention activity the nurse could teach a community group for vision is (Select all that apply)

A) having an annual ophthalmologic examination.
B) keeping blood pressure under control.
C) taking medication for glaucoma as prescribed.
D) wearing safety goggles and sunglasses.

Question 12

The nurse would explain to a client that the voice, rather than a ticking watch, is used to test auditory acuity because watches

A) can be muffled by the examiner's hand.
B) have different sound frequencies.
C) make a familiar and predictable sound.
D) produce a higher pitch.

Question 13

The nurse would interpret a myopic client's (20/30) vision as the client's ability to

A) read at 30 feet what a person with normal vision can read at 20 feet.
B) read at 20 feet what a person with normal vision can read at 30 feet.
C) read correctly 30 figures or characters at 20 feet.
D) read 20% of the figures or characters at 30 feet.

Question 14

A client is being treated for arthritis with large doses of aspirin, and the nurse assesses the client for ototoxicity. The most indicative clinical manifestation of damage to the eighth cranial nerve is

A) ear pain.
B) hearing loss.
C) nystagmus.
D) tinnitus.

Question 15

After completion of an eye examination using direct ophthalmoscopy, the assessment that the nurse would document as "normal" is

A) irregular margins to optic disc.
B) oval optic disc.
C) physiologic cup 75% of optic disc diameter.
D) retinal veins darker than arteries.

Question 16

The nurse would ask a client with the diagnosis of myopia about a family history of

A) central vision loss.
B) color blindness.
C) farsightedness.
D) nearsightedness.

Question 17

The nurse examining the conjunctivae of a healthy young adult would document a normal finding when recording that the color of the conjunctivae is

A) dark red.
B) pale.
C) pink.
D) yellow tinged.

Question 18

The nurse performing an assessment of a client with a neuromuscular disorder finds that the left upper eyelid sags and covers a portion of the pupil. The nurse would note this finding on the client record as

A) amblyopia.
B) lid eversion.
C) presbyopia.
D) ptosis.

Question 19

The occupational health nurse evaluating noise levels in the workplace would be concerned when readings show the noise level to be more than

A) 10-15 decibels.
B) 20-30 decibels.
C) 45-50 decibels.
D) 85-90 decibels.

Question 20

When a nurse testing visual acuity is using a Snellen chart, the distance that the client would be positioned from the chart is

A) 5 feet.
B) 10 feet.
C) 15 feet.
D) 20 feet.