Question 1

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

Accepted Answer

Vestibular disease affects balance,so the nurse should monitor the patient during activities that require balance.The other actions might be used for patients with hearing disorders.

Question 2

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

Accepted Answer

The pupils are dilated using cycloplegic medications during refractometry.This effect will last several hours and cause photophobia.The other teaching would not be appropriate for a patient who was having refractometry.

Question 3

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

Accepted Answer

The consensual pupil response is tested by shining a light into one pupil and observing for both pupils to constrict.Observe the corneal light reflex to evaluate for weakness or imbalance of the extraocular muscles.In a darkened room,ask the patient to look straight ahead while a penlight is shone directly on the cornea.The light reflection should be located in the center of both corneas as the patient faces the light source.To perform confrontation visual field testing,the patient faces the examiner and covers one eye,then counts the number of fingers that the examiner brings into the visual field.Instructing the patient to follow a moving object only with the eyes is testing for visual fields and extraocular movements.

Question 4

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

Accepted Answer

Classic signs of cataracts include blurred vision and light sensitivity.Thyroid problems are a major cause of exophthalmos.Unequal pupil is indicative of anisocoria,not cataracts.Loss of peripheral vision is a sign of glaucoma.

Question 5

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

Accepted Answer

Accommodation is defined as the ability of the lens to adjust to various distances.The pupils constrict while fixating on an object being moved far away to near the eyes.The other responses may also be elicited as part of the eye examination,but they do not indicate accommodation.

Question 6

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

Accepted Answer

The Jaeger card is used to assess near vision problems and presbyopia in persons over 40 years of age.The card should be held 14 inches away from eyes while the patient reads words in various print sizes.Using a penlight to determine pupil change is testing pupil response.A short burst of air may be used to test intraocular pressure but is not used for testing presbyopia.Covering one eye at a time while reading a wall chart at 20 feet describes the Snellen test.

Question 7

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

Accepted Answer

Nonsteroidal antiinflammatory drugs (NSAIDs)are potentially ototoxic.Acetaminophen,atenolol,and albuterol are not associated with hearing loss.

Question 8

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

Accepted Answer

Problems with balance related to vestibular function may present as nystagmus or vertigo and indicate an increased risk for falls.The Rinne test is used to check hearing.Reading lips and louder speech are compensatory behaviors for decreased hearing.

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

Accepted Answer

Fluorescein angiography involves injecting IV dye.If extravasation occurs,fluorescein is toxic to the tissues.The patient should be instructed to report any signs of extravasation such as pain or burning.The nurse should closely monitor the IV site as well.The cornea is anesthetized during ultrasonography.Refractometry involves measuring visual acuity and asking the patient to choose lenses that are the sharpest; it is a painless test.The Amsler grid test involves using a hand held card with grid lines.The patient fixates on the center dot and records any abnormalities of the grid lines.

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?

Accepted Answer

It is important to note whether the patient takes any b-adrenergic blockers because this classification of medications is also used to treat glaucoma,and there may be an increase in adverse effects.The use of aspirin does not increase intraocular pressure and is safe for patients with glaucoma.Although older patients should have yearly eye examinations,the treatment for this patient will not be affected by the 10-year gap in eye care.Conjunctivitis does not increase the risk for glaucoma.

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?

Accepted Answer

Patients with tinnitus may use masking techniques,such as playing a radio,to block out the ringing in the ears.The responses "Do you grind your teeth at night?" and "Are you ever dizzy when you are lying down?" would be used to obtain information about other ear problems,such as vestibular disorders and referred temporomandibular joint (TMJ)pain.The response "What time do you usually fall asleep?" would not be helpful in assessing problems with the patient's ears.

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?

Accepted Answer

Photophobia is not a normally occurring change with aging,and would require further assessment.The other assessment data are common gerontologic differences and would not be unusual in a 76-year-old patient.

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

Accepted Answer

When the Snellen chart is used to check visual acuity,the patient should stand 20 feet away.Accommodation is tested by looking at an object at both near and far distances.Shining a pen light into the eyes tests for pupil response.Following the examiner's fingers with the eyes tests extraocular movements.

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

Accepted Answer

The speculum should be smaller than the ear canal so it can be inserted without damage to the external ear canal.The other actions are appropriate when performing an ear examination.

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?

Accepted Answer

When documenting visual acuity,the first number indicates the standard (for normal vision)of 20 feet and the second number indicates the line that the patient is able to read when standing 20 feet from the Snellen chart.OS is the abbreviation for left eye and OD is the abbreviation for right eye.The remaining three answers do not correctly describe the patient's visual acuity.

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

Accepted Answer

The patient's clinical manifestations of dizziness and nausea suggest a disorder of the labyrinth,which controls balance and contains three semicircular canals and the vestibule.Rotary chair testing is used to test vestibular function.The other tests are used to test for problems with hearing.

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?

Accepted Answer

The loss of stereoscopic vision created by the eye patch impairs the patient's ability to see in three dimensions and to judge distances.It also increases the risk for falls.There is no evidence in the assessment data for ineffective health maintenance,disturbed body image,or ineffective denial.

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

The decrease in peripheral vision may indicate glaucoma,which is not a normal visual change associated with aging and requires rapid treatment.The other patient statements indicate visual problems (presbyopia,dryness,and lens opacity)that are considered a normal part of aging.

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?

Accepted Answer

Glaucoma is caused by an increase in intraocular pressure,which would be measured using the Tono-pen.The other techniques are used in testing for other eye disorders.

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?

Accepted Answer

Although "floaters" are usually caused by vitreous liquefaction and are common in aging patients,they can be caused by hemorrhage into the vitreous humor or by retinal tears,so the nurse's first action will be to examine the retina and posterior chamber.Although the ophthalmologist will examine the patient,the presence of spots or floaters in a 65-year-old is not an emergency.The spots may indicate retinal damage,but the nurse should assess the eye further before discussing this with the patient.

Quiz 21: Nursing Assessment: Visual and Auditory Systems