Chapter 26: The Sensory System: Eye and Ear My Nursing Test Banks

Chapter 26: The Sensory System: Eye and Ear

MULTIPLE CHOICE

1. The nurse uses a visual aid to show how the ______ refracts light rays to be directed to the lens.

a.

pupil

b.

cornea

c.

retina

d.

ciliary body

ANS: B

The cornea bends or refracts the light rays onto the retina. The pupil acts to regulate the entrance of light into the eye. The ciliary body helps to change the shape of the eye for far and near vision. The retina is the inner coat of the eyeball and is found in the posterior portion of it. The retina contains several layers. The layer with rods and cones acts as the receptor for light images.

DIF: Cognitive Level: Knowledge REF: 569 OBJ: 1 (clinical)

TOP: Cornea: Function KEY: Nursing Process Step: Implementation

MSC: NCLEX: Health Promotion and Maintenance

2. The nurse explains that, when the physician takes a tonometer reading, the reading reflects the amount of pressure applied by the:

a.

sclera.

b.

aqueous humor.

c.

vitreous humor.

d.

cornea.

ANS: B

The tonometer reads the pressure exerted by the aqueous humor in the anterior chamber. The sclera is the part of the eyeball that is opaque white and covers the posterior portion of the eyeball. The vitreous humor is the substance found in the posterior chamber of the eye between the lens and the retina. The cornea is a transparent structure in the eye that allows light to hit the lens. It is involved in the bending of light rays.

DIF: Cognitive Level: Comprehension REF: 575 OBJ: 1 (theory)

TOP: Optic Pressure KEY: Nursing Process Step: Implementation

MSC: NCLEX: Health Promotion and Maintenance

3. The nurse explains to the patient that the assessment of a choked disc while examining the fundus of the eye indicates:

a.

the disc has an infarct.

b.

there is increased intracranial pressure (ICP).

c.

there is significant hypertension.

d.

the lens has become opaque.

ANS: B

Visualization of the optic disc provides information about the pressure within the eye and within the skull. When intracranial pressure gets higher, the optic disc appears swollen or choked.

DIF: Cognitive Level: Application REF: 569 OBJ: 2 (theory)

TOP: Fundus Assessment: Choked Disc KEY: Nursing Process Step: Assessment

MSC: NCLEX: Health Promotion and Maintenance

4. An office assistant tells the nurse his job requires him to work at his computer 7 to 8 hours each day. What preventive information should the nurse provide to the patient?

a.

Wear protective goggles.

b.

Wear corrective eyeglasses.

c.

Rest his eyes every 2 hours.

d.

Irrigate his eyes every day.

ANS: C

Resting the muscles of the eye every several hours helps prevent eye fatigue. Protective goggles will not help to prevent eye strain. There is no indication the patient has visual disturbances or eye irritation.

DIF: Cognitive Level: Comprehension REF: 571 OBJ: 1 (clinical)

TOP: Eye Rest KEY: Nursing Process Step: Implementation

MSC: NCLEX: Health Promotion and Maintenance

5. The nurse is reviewing the health history of a 26-year-old patient. Which finding is consistent with recommendations concerning preventive eye examinations?

a.

The patient has had annual eye examinations since age 18.

b.

The patient has not had an eye examination since age 18.

c.

The patient had a baseline eye examination at age 25.

d.

The patient had an eye examination 3 years ago.

ANS: C

Adults should have an eye examination once between ages 20 and 29, twice between ages 30 and 39, and a baseline screening at age 40. After age 65, eyes should be examined by an eye specialist every 2 years.

DIF: Cognitive Level: Application REF: 571 OBJ: 1 (theory)

TOP: Periodic Eye Examination: Frequency

KEY: Nursing Process Step: Evaluation

MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

6. The nurse cautions her teenage daughter that eye cosmetics should be discarded every:

a.

2 months.

b.

3 months.

c.

6 months.

d.

year.

ANS: C

Eye cosmetics should be discarded every 6 months to prevent infection.

DIF: Cognitive Level: Comprehension REF: 572 OBJ: 1 (theory)

TOP: Eye Cosmetics: Source of Infection

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Health Promotion and Maintenance

7. The nurse is caring for a blind patient. When the nurse enters the patients room, which action is most appropriate?

a.

Touch the patient before speaking to allow her to locate the nurses position.

b.

Speak to the patient by name when entering the room to avoid startling her.

c.

Speak to the patient only when at bedside to increase orientation.

d.

Walk about in the room, carrying on conversation.

ANS: B

Speaking to the person by name allows the patient to know someone has entered the room and will avoid startling the patient.

DIF: Cognitive Level: Comprehension REF: 578 OBJ: 5 (theory)

TOP: Visually Impaired: Orientation KEY: Nursing Process Step: Evaluation

MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

8. In orienting a visually impaired patient to a meal plate, the most appropriate actions of the nurse would include:

a.

identifying the location of the plate.

b.

holding the patients hand and directing it to the plate.

c.

putting eating utensil in the patients hand.

d.

identifying food according to an imaginary clock face.

ANS: D

Identifying food location by position on an imaginary clock face is helpful to the visually impaired patient.

DIF: Cognitive Level: Comprehension REF: 579 OBJ: 5 (theory)

TOP: Visually Impaired: Self-Feeding KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

9. The visually impaired person has entered the outpatient clinic with a guide dog. What action by the nurse is most appropriate?

a.

The nurse should quietly greet the dog and pat it.

b.

The nurse should direct the patient and the dog to an area where the dog will not be distracted.

c.

The nurse should take the harness from the patient and direct the dog and patient to a seat.

d.

The nurse should not interact with the patient and dog until the dog has led the patient to a seat.

ANS: D

The dog should not be distracted while it is working. The dog will seat the patient if possible; if not, the nurse can ask how best the patient can be directed.

DIF: Cognitive Level: Application REF: 579 OBJ: 5 (theory)

TOP: Guide Dog Etiquette KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

10. A 40-year-old patient has questioned the nurse about being tested for glaucoma. To encourage eye health, the nurse should encourage the patient to have a glaucoma test every:

a.

year.

b.

1 to 2 years.

c.

2 to 3 years.

d.

3 to 5 years.

ANS: C

Glaucoma testing should be done every 2 to 3 years for people over age 40.

DIF: Cognitive Level: Comprehension REF: 579 OBJ: 1 (theory)

TOP: Glaucoma Testing: Frequency KEY: Nursing Process Step: Implementation

MSC: NCLEX: Health Promotion and Maintenance

11. When assessing for macular degeneration, the nurse will use which assessment tool?

a.

Snellen eye chart

b.

Corneal reflex test

c.

Visual field test

d.

Amsler grid test

ANS: D

The Amsler grid test assesses the extent of macular degeneration by noting the patients perception of missing or wavy lines on the grid. The Snellen eye chart is used to assess visual acuity. Visual field assessments may be used to assess peripheral vision.

DIF: Cognitive Level: Comprehension REF: 575 OBJ: 2 (clinical)

TOP: Amsler Grid Test: Function KEY: Nursing Process Step: Implementation

MSC: NCLEX: Health Promotion and Maintenance

12. The nurse is caring for a patient who is experiencing diabetes-related visual changes. The nurse correctly explains to the patient that vision-related complications of diabetes are caused by:

a.

prolonged periods of hyperglycemia.

b.

frequent injections of regular insulin.

c.

lens opacity.

d.

corneal dryness.

ANS: A

Prolonged periods of hyperglycemia cause damage to the retina from bleeding. Insulin does not result in visual changes in the patient with diabetes. Lens opacity and corneal dryness will not promote vision-related complications in the patient with diabetes mellitus.

DIF: Cognitive Level: Application REF: 573 OBJ: 5 (theory)

TOP: Diabetes: Retinal Damage KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential

13. The nurse is assessing an 84-year-old patient. Which finding is consistent with aging?

a.

Thick cerumen

b.

Increased perception of low-frequency sounds

c.

Pain in outer ear canal

d.

Increased hair on the pinna

ANS: A

Thickened, hard cerumen collections in the outer ear can disrupt sound conduction and impair hearing. Age-related changes may include reduced perception of low-frequency sounds. Pain in the outer ear is not a normal change related to aging, nor is increased hair on the pinna.

DIF: Cognitive Level: Comprehension REF: 580 OBJ: 2 (clinical)

TOP: Ear: Age-Related Changes KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

14. The patient is experiencing frequent attacks of vertigo. When planning care, the nurse may encourage which potential remedy?

a.

Increasing sodium in the diet

b.

Quitting smoking

c.

Increasing fluid intake

d.

Drinking a glass of red wine before supper

ANS: B

Cessation of smoking will decrease incidence of vertigo in the person with middle ear disorders.

DIF: Cognitive Level: Comprehension REF: 589 OBJ: 5 (theory)

TOP: Remedies to Reduce Vertigo KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential

15. The nurse is observing a patient read a pamphlet. The nurse notes that the patient has her head tilted to the side. Which inference can the nurse make about these behaviors?

a.

The patient has poor vision.

b.

The patient is experiencing nystagmus.

c.

The patient is experiencing photophobia.

d.

The patient is experiencing diplopia.

ANS: D

Tilting the head may indicate a visual disturbance such as double vision or that one eye is stronger than the other. Squinting may be associated with poor vision. Nystagmus refers to involuntary eye movements. Shading the eyes may be noted with photophobia.

DIF: Cognitive Level: Application REF: 574 OBJ: 2 (theory)

TOP: Focused Assessment KEY: Nursing Process Step: Diagnosis

MSC: NCLEX: Physiological Integrity: Physiological Adaptation

16. The nurse is teaching a group of schoolchildren about the relationship between diet and vision. The nurse encourages the ingestion of foods high in vitamin A. Which food is considered a good source of this vitamin?

a.

Kale

b.

Cauliflower

c.

Strawberries

d.

Apples

ANS: A

Vitamin A protects against night blindness, slow adaptation to darkness, and glare blindness. The carotenoids are the precursors for vitamin A and are found in green leafy and yellow vegetables.

DIF: Cognitive Level: Comprehension REF: 571 OBJ: 1 (theory)

TOP: Nutrition Considerations KEY: Nursing Process Step: Implementation

MSC: NCLEX: Health Promotion and Maintenance: Health Promotion/Disease Prevention

17. The nurse is caring for a patient who has come to the clinic with reports of an eye disorder. The assessment reveals a small, hard lesion on the eyelid. The nurse is aware that which condition is consistent with these findings?

a.

Blepharitis

b.

Chalazion

c.

Hordeolum

d.

Conjunctivitis

ANS: B

Chalazion is an internal stye caused by infection of the meibomian gland.

DIF: Cognitive Level: Application REF: 571 OBJ: 2 (theory)

TOP: Clinical Signs and Symptoms of Selected Eye Diseases, Medical Treatment, and Nursing Interventions KEY: Nursing Process Step: Diagnosis

MSC: NCLEX: Physiological Integrity: Physiological Adaptation

MULTIPLE RESPONSE

18. The student nurse is ambulating with a blind patient. Which actions indicate the need for further instruction by the nursing instructor? (Select all that apply.)

a.

The student nurse holds the patients dominant arm.

b.

The student nurse allows the patient to put both hands on his shoulders.

c.

The student nurse allows the patient to hold the nurses arm.

d.

The student nurse holds the patients hand.

e.

The student nurse walks just behind the patient.

ANS: A, B, D, E

Allowing the patient who is visually impaired to hold the nurses arm and follow is the most effective and safe technique.

DIF: Cognitive Level: Analysis REF: 578 OBJ: 5 (theory)

TOP: Ambulation of the Blind: Technique

KEY: Nursing Process Step: Evaluation

MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential

19. The nurse assesses the age-related changes that occur in the eye. Which findings would be consistent with aging? (Select all that apply.)

a.

Subcutaneous fat increases.

b.

Cornea flattens and increases astigmatism.

c.

There is loss of water from lens.

d.

Presbyopia occurs.

e.

Ectropion occurs.

ANS: B, C, D, E

Subcutaneous fat decreases with aging. All other options occur with aging.

DIF: Cognitive Level: Comprehension REF: 570 OBJ: 3 (theory)

TOP: Eye: Age-Related Changes KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity: Physiological Adaptation

20. The nurse recalls that the Healthy People 2020 objectives for vision include directives for: (Select all that apply.)

a.

vision screening for children 10 years of age and younger.

b.

reduction of uncorrected refractive errors.

c.

reduction of diabetic retinopathy.

d.

reduction of visual impairment related to cataracts.

e.

increased use of protective eyewear.

ANS: B, C, D, E

Vision screening for children should begin at age 5. All other options listed are objectives as cited by Healthy People 2020.

DIF: Cognitive Level: Comprehension REF: 571 OBJ: 1 (clinical)

TOP: Healthy People 2020: Objectives for Vision

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Health Promotion and Maintenance

21. When providing education to the patient, the nurse discusses symptoms of visual problems that require professional attention. The teaching includes conditions or problems in which the eyes: (Select all that apply.)

a.

tire easily.

b.

burn.

c.

itch.

d.

redden with use.

e.

protrude.

ANS: A, B, C, D

Protruding eyes are not usually a visual problem, but a sign of a systemic problem such as hyperthyroidism.

DIF: Cognitive Level: Comprehension REF: 571 OBJ: 3 (clinical)

TOP: Visual Disorders: Signs and Symptoms

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Health Promotion and Maintenance

22. When assessing the visual field, which actions should be performed by the examiner? (Select all that apply.)

a.

Cover his own right eye.

b.

Cover the patients left eye.

c.

Move a finger from the examiners nose to an area outside of the visual field.

d.

Ask the patient to report when the examiners finger is seen.

e.

Direct the patient to look directly into the examiners eyes.

ANS: A, B, D, E

The examiners finger is moved from an area outside the field of vision into it. The examiner and the patient should observe the finger at the same time.

DIF: Cognitive Level: Comprehension REF: 574 OBJ: 2 (clinical)

TOP: Visual Field Evaluation: Technique

KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance

23. The nurse points out that the person with disorders of the inner ear can be injured by falls because of: (Select all that apply.)

a.

dizziness.

b.

vertigo.

c.

tinnitus.

d.

loss of balance.

e.

ataxia.

ANS: A, B, D, E

Tinnitus does not cause falls.

DIF: Cognitive Level: Comprehension REF: 581 OBJ: 5 (theory)

TOP: Inner Ear Disorders: Symptoms KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential

24. Drugs that would alert a nurse to the possibility of ototoxicity include: (Select all that apply.)

a.

vancomycin.

b.

furosemide.

c.

aspirin.

d.

ibuprofen.

e.

amoxicillin.

ANS: A, B, C, D

Amoxicillin is not ototoxic.

DIF: Cognitive Level: Comprehension REF: 583 OBJ: 5 (theory)

TOP: Ototoxic Drugs KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity: Pharmacological and Parenteral Therapies

COMPLETION

25. The nurse clarifies to the patient with an eye disorder that the fluid in the anterior chamber is called __________ humor, whereas the fluid in the posterior chamber is called __________ humor.

ANS:

aqueous, vitreous

The fluid in the anterior chamber is aqueous humor and the fluid in the posterior chamber is vitreous humor.

DIF: Cognitive Level: Knowledge REF: 588 OBJ: 2 (clinical)

TOP: Eye Chamber Fluids KEY: Nursing Process Step: Implementation

MSC: NCLEX: Health Promotion and Maintenance

26. The receptors of light and color in the eyeball are the __________ and the __________.

ANS:

rods, cones

cones, rods

The rods and cones are the receptors of light and color.

DIF: Cognitive Level: Knowledge REF: 568 OBJ: 2 (clinical)

TOP: Rods and Cones: Function KEY: Nursing Process Step: Planning

MSC: NCLEX: Health Promotion and Maintenance

27. The nurse interviewing a patient with macular degeneration will inquire about the patients habits, especially __________, which is a significant contributor to the disorder.

ANS:

smoking

Smoking is a significant contributor to macular degeneration.

DIF: Cognitive Level: Comprehension REF: 571 OBJ: 2 (clinical)

TOP: Macular Degeneration: Smoking KEY: Nursing Process Step: Assessment

MSC: NCLEX: Health Promotion and Maintenance

MATCHING

Place the steps of instillation of eyedrops in appropriate order.

a.

Expose the conjunctival sac.

b.

Ask the patient to close the eyelids and move the eyes back and forth.

c.

Ask the patient to look up.

d.

Ask the patient to tilt the head toward the eye receiving the drops.

e.

Drop medication in the conjunctival sac.

28. Step 1

29. Step 2

30. Step 3

31. Step 4

32. Step 5

28. ANS: C DIF: Cognitive Level: Comprehension REF: 28-32

OBJ: 4 (theory) TOP: Eyedrop Instillation

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

29. ANS: D DIF: Cognitive Level: Comprehension REF: 28-32

OBJ: 4 (theory) TOP: Eyedrop Instillation

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

30. ANS: A DIF: Cognitive Level: Comprehension REF: 28-32

OBJ: 4 (theory) TOP: Eyedrop Instillation

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

31. ANS: E DIF: Cognitive Level: Comprehension REF: 28-32

OBJ: 4 (theory) TOP: Eyedrop Instillation

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

32. ANS: B DIF: Cognitive Level: Comprehension REF: 28-32

OBJ: 4 (theory) TOP: Eyedrop Instillation

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

Leave a Reply