Chapter 21: Nursing Assessment: Visual and Auditory Systems My Nursing Test Banks

Lewis: Medical-Surgical Nursing, 8th Edition

Chapter 21: Nursing Assessment: Visual and Auditory Systems

Test Bank

MULTIPLE CHOICE

1. Which information will the nurse include when teaching a 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 surface of the eye will be needed.

c.

The examination includes checking the pupils reaction to a bright light.

d.

Medications to dilate the pupil will be used before testing for glaucoma.

ANS: B

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.

DIF: Cognitive Level: Application REF: 392

TOP: Nursing Process: Implementation MSC: NCLEX: Health Promotion and Maintenance

2. Which assessment information obtained by the nurse when performing an eye examination for a 78-year-old patient indicates that more extensive examination of the eyes is needed?

a.

The patients sclerae are light yellow in color.

b.

The patient complains of persistent photophobia.

c.

The pupil recovers slowly after being stimulated by a penlight.

d.

There is a whitish gray ring encircling the periphery of the iris.

ANS: B

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 78-year-old patient.

DIF: Cognitive Level: Application REF: 387

TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

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

a.

covering one eye for 1 minute and noting the pupil reaction when the cover is removed.

b.

shining a light into the patients eye and watching the pupil response in the opposite eye.

c.

observing the pupils when the patient focuses on a close object and then on a distant object.

d.

touching the patients pupil with a small piece of sterile cotton and watching for a blink reaction.

ANS: C

Accommodation is defined as the ability of the lens to adjust to various distances. The other nursing actions also may be part of the eye examination, but they do not test for accommodation.

DIF: Cognitive Level: Application REF: 385 | 386

TOP: Nursing Process: Assessment MSC: NCLEX: Health Promotion and Maintenance

4. The 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.

cataracts.

b.

glaucoma.

c.

anisocoria.

d.

exophthalmos.

ANS: A

Ultraviolet light exposure is associated with the accelerated development of cataracts. Glaucoma is caused by increased intraocular pressure, exophthalmos is associated with hyperthyroidism, and anisocoria can occur normally in a small percentage of the population or may be caused by injury or central nervous system disorders.

DIF: Cognitive Level: Comprehension REF: 387

TOP: Nursing Process: Implementation MSC: NCLEX: Health Promotion and Maintenance

5. Assessment of a patients 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 which of the following 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

ANS: A

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 patients visual acuity.

DIF: Cognitive Level: Comprehension REF: 390 | 392

TOP: Nursing Process: Assessment MSC: NCLEX: Health Promotion and Maintenance

6. Which nursing action is included when assessing a patients visual field?

a.

Position the patient 20 feet from the Snellen chart.

b.

Have the patient cover one eye while facing the nurse.

c.

Instruct the patient to follow a moving object using only the eyes.

d.

Shine a light into one pupil and observe the response for both pupils.

ANS: B

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. The other actions are needed to test for visual acuity, extraocular movements, and consensual pupil response.

DIF: Cognitive Level: Application REF: 390

TOP: Nursing Process: Assessment MSC: NCLEX: Health Promotion and Maintenance

7. 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.

chooses a speculum smaller than the ear canal.

b.

pulls the auricle of the ear down and backward.

c.

stabilizes the hand holding the otoscope on the patients head.

d.

stops inserting the otoscope after observing impacted cerumen.

ANS: B

The auricle should be pulled up and back when assessing an adult. The other actions are appropriate when performing an ear examination.

DIF: Cognitive Level: Application REF: 398

TOP: Nursing Process: Assessment MSC: NCLEX: Health Promotion and Maintenance

8. When obtaining a health history from a 52-year-old patient, which patient statement is most important to communicate to the health care provider?

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 peripheral part of my vision is decreased.

ANS: D

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.

DIF: Cognitive Level: Application REF: 387 | 391

TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

9. 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 patients 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.

ANS: C

It is important to note whether the patient takes any -adrenergic blockers because this category of medications also is 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.

DIF: Cognitive Level: Application REF: 396

TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

10. In order to assess the visual acuity for a patient in the outpatient clinic, the nurse will need to obtain a (an)

a.

penlight.

b.

Amsler grid.

c.

Snellen chart.

d.

ophthalmoscope.

ANS: C

The Snellen chart is used to check visual acuity. An ophthalmoscope, penlight, and Amsler grid also may be used during an eye examination, but they are not helpful in assessing visual acuity.

DIF: Cognitive Level: Comprehension REF: 392

TOP: Nursing Process: Assessment MSC: NCLEX: Health Promotion and Maintenance

11. 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.

Risk for falls related to current decrease in stereoscopic vision

b.

Ineffective health maintenance related to inability to see surroundings

c.

Disturbed body image related to eye trauma and need to wear eye patch

d.

Ineffective denial related to inability to admit the impact of the eye injury

ANS: A

The loss of stereoscopic vision created by the eye patch impairs the patients 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 denial, disturbed body image, or ineffective health maintenance.

DIF: Cognitive Level: Application REF: 393 TOP: Nursing Process: Diagnosis

MSC: NCLEX: Safe and Effective Care Environment

12. A patient in the eye clinic is scheduled for refractometry. Which information will the nurse include in patient teaching?

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.

ANS: A

The pupil is dilated by 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.

DIF: Cognitive Level: Application REF: 394

TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

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

a.

Penlight

b.

Tono-pen

c.

Jaeger chart

d.

Snellen chart

ANS: C

Presbyopia is the normal loss of near vision that occurs with age and is assessed using a Jaeger chart. The Snellen chart, penlight, and the Tono-pen are used when assessing for other visual disorders.

DIF: Cognitive Level: Application REF: 390 | 392

TOP: Nursing Process: Assessment MSC: NCLEX: Health Promotion and Maintenance

14. 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 tonometer.

b.

eye patching.

c.

a refractometer.

d.

fluorescein dye.

ANS: D

Eye itching and pain suggest a possible corneal abrasion or ulcer, which can be visualized using fluorescein dye. The other items listed would not be helpful in determining the cause of this patients symptoms.

DIF: Cognitive Level: Application REF: 391 TOP: Nursing Process: Planning

MSC: NCLEX: Physiological Integrity

15. 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.

tympanometry.

b.

rotary chair testing.

c.

pure-tone audiometry.

d.

bone-conduction testing.

ANS: B

The patients 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.

DIF: Cognitive Level: Application REF: 400 TOP: Nursing Process: Planning

MSC: NCLEX: Physiological Integrity

16. 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 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 any ringing in your ears?

d.

Are you ever dizzy when you are lying down?

ANS: C

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 Have you noticed any ringing in your ears? 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 patients ears.

DIF: Cognitive Level: Application REF: 389

TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

17. Which finding by the nurse during the admission assessment for a patient may indicate that the patient is at risk for falls while hospitalized?

a.

Lateralization with Weber test

b.

Positive result for Rinne testing

c.

Inability to hear a low-pitched whisper

d.

Nystagmus when head is turned rapidly

ANS: D

Nystagmus suggests that the patient may have problems with balance related to disease of the vestibular system. The other tests are used to check hearing; abnormal results for these do not indicate potential problems with balance.

DIF: Cognitive Level: Application REF: 396

TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

18. 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 uses albuterol (Proventil) for acute asthma.

b.

The patient takes atenolol (Tenormin) to prevent angina.

c.

The patient uses acetaminophen (Tylenol) frequently for headaches.

d.

The patient has taken ibuprofen (Advil) for 20 years to treat arthritis.

ANS: D

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

DIF: Cognitive Level: Application REF: 396

TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

19. Which action will the nurse include in the plan of care for a patient who has vestibular disease?

a.

Check Rinne and Weber tests.

b.

Face the patient when speaking.

c.

Enunciate clearly when speaking.

d.

Monitor the patients ability to ambulate safely.

ANS: D

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

DIF: Cognitive Level: Application REF: 396 | 398 TOP: Nursing Process: Planning

MSC: NCLEX: Physiological Integrity

20. The nurse in the eye clinic is examining a 65-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 damage to the retina.

d.

Use an ophthalmoscope to examine the posterior chamber of the eyes.

ANS: D

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 nurses 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.

DIF: Cognitive Level: Application REF: 387 | 391

OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation

MSC: NCLEX: Physiological Integrity

21. Which observation by the nurse when examining a patients auditory canal and tympanic membrane is a priority to report to the health care provider?

a.

There is a cone of light visible.

b.

The tympanum is bluish-tinged.

c.

Cerumen is present in the auditory canal.

d.

The skin in the ear canal is dry and scaly.

ANS: B

A bluish-tinged tympanum can occur with acute otitis media, which requires immediate care to prevent perforation of the tympanum. Cerumen in the ear canal may need to be removed before proceeding with the examination but is not unusual or pathologic. The presence of a cone of light on the eardrum is normal. Dry and scaly skin in the ear canal may need further assessment but does not require urgent care.

DIF: Cognitive Level: Application REF: 399

OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment

MSC: NCLEX: Physiological Integrity

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