Chapter 38Assessment of Sensory Function My Nursing Test Banks

Chapter 38Assessment of Sensory Function

MULTIPLE CHOICE

1.A client is diagnosed with an inability to recognize visual information. The nurse realizes that which of the following cranial nerves is involved in the transmitting of visual stimuli to the brain for interpretation?

1.

CN II

2.

CN III

3.

CN IV

4.

CN VI

ANS: 1

The optic nerve is the second cranial nerve and is responsible for the transmitting of visual stimuli. Cranial Nerves III, IV, and VI control extraocular eye movements.

PTS: 1 DIF: Analyze REF: Anatomy and Physiology of the Eye

2.A client is diagnosed with a vision disorder. The nurse realizes that the client will experience an alteration in sensory information because the eyes transmit what percentage of all sensory information to the brain?

1.

30%

2.

50%

3.

70%

4.

90%

ANS: 3

Approximately 70% of all sensory information reaches the brain through the eyes.The other percentages are incorrect.

PTS: 1 DIF: Analyze REF: Anatomy and Physiology of the Eye

3.The nurse is performing an assessment on a client. To test the optic nerves function, what should the nurse do?

1.

Check for extraocular movement.

2.

Check the pupils for reaction to light.

3.

Check to see if the patient can blink.

4.

Use a Snellen chart.

ANS: 4

A Snellen chart is used to assess visual acuity of the optic nerve. Extraocular movements assess cranial nerves III, IV, and VI. Pupil reaction to light and eye blinking are not functions of the optic nerve.

PTS: 1 DIF: Apply REF: Assessment of the Eye

4.The nurse realizes that a client, diagnosed with chronic dry eyes, may have a disorder of the lacrimal gland because it:

1.

covers the eye for protection.

2.

produces tears to lubricate the eye.

3.

helps the eye keep its shape.

4.

provides blood to the eye.

ANS: 2

The lacrimal gland moistens the eye by producing and distributing tears to lubricate the eye. The lacrimal gland does not cover the eye for protection, help the eye keep its shape, or provide blood to the eye.

PTS:1DIF:AnalyzeREF:External Eye

5.When assessing the corneal reflex, the nurse realizes this reflex is a function of which cranial nerve (CN)?

1.

CN II

2.

CN III

3.

CN IV

4.

CN V

ANS: 4

The stimulation of the trigeminal nerve (CN V) causes the corneal reflex, a protective blink. Cranial nerves II, III, or IV do not control the corneal reflex.

PTS: 1 DIF: Analyze REF: Internal Eye

6.A client is having difficulty perceiving different colors. The nurse realizes the client may have a disorder that affects the photosensitive receptor cells of the retina, which makes the perception of color possible, or a disorder that affects the:

1.

rods.

2.

cones.

3.

optic discs.

4.

irises.

ANS: 2

Other neurosensory elements located in the retina are cones, which mediate color vision. Rods mediate black-and-white vision. The optic disc and iris are not responsible for color vision.

PTS: 1 DIF: Analyze REF: Internal Eye

7.A client was assessed as having normal intraocular pressure. The nurse would document this clients pressure as being:

1.

5 mmHg 3 mmHg.

2.

15 mmHg 3 mmHg.

3.

30 mmHg 3 mmHg.

4.

50 mmHg 3 mmHg.

ANS: 2

Normal intraocular pressure is about 15 mmHg 3 mmHg. An intraocular pressure of 5 mmHg would be too low. A pressure of 30 to 50 mmHg would be considered critical.

PTS: 1 DIF: Apply REF: Internal Eye

8.A client tells the nurse that she has to swallow to improve her hearing. The nurse realizes that this action:

1.

causes the tympanic membrane to vibrate.

2.

makes the hammer vibrate.

3.

stabilizes equilibrium.

4.

equalizes pressure.

ANS: 4

The middle ear is connected to the nasopharynx by the eustachian tubes, which serve as a channel to equalize pressure. The equalization of pressure is aided by yawning or swallowing. Swallowing does not cause the tympanic membrane to vibrate. This action does not cause the hammer to vibrate. This action also does not stabilize equilibrium.

PTS: 1 DIF: Analyze REF: Middle Ear

9.The nurse who assesses a hematoma behind a clients left ear over the mastoid bone would document this finding as being:

1.

normal.

2.

Battles sign.

3.

caused by sun exposure.

4.

perichondritis.

ANS: 2

A hematoma behind the ear over the mastoid bone would be documented as Battles sign and is an indication of head trauma to the temporal bone. This is not a normal finding. Battles sign is caused by head trauma to the temporal bone and not by sun exposure. Perichondritis is inflamed connective tissue of the ear cartilage.

PTS:1DIF:Apply

REF: Table 38-4 External Ear Assessment Findings in the Inspection of the Ear

10.During the assessment of a clients external ear canal, the nurse identifies a painful pustule. The nurse realizes this assessment finding could be caused by:

1.

furunculosis.

2.

exostoses.

3.

hemotympanum.

4.

acute otitis media.

ANS: 1

Infection of the hair follicle in the ear, or furunculosis, is caused by a painful boil-like pustule in the external ear canal. Exostoses are hard, bony lesions deep in the external ear canal. Hemotympanum is blood in the middle ear. Acute otitis media causes inflammation of the middle ear that is diagnosed by assessing the tympanic membrane.

PTS: 1 DIF: Analyze REF: Table 38-5 Otoscopic Assessment of the Ear

MULTIPLE RESPONSE

1.Which of the following tests can be done by the nurse to assess a clients hearing? (Select all that apply.)

1.

Voice-whisper test

2.

Allens test

3.

Weber test

4.

Cochlear test

5.

Rinne test

6.

Stapes test

ANS: 1, 3, 5

Tests that can be conducted by the nurse to assess for hearing include the voice-whisper test, the Weber test, and the Rinne test. The Allens test is used to assess blood flow to the hand. The cochlear test and stapes test do not exist.

PTS: 1 DIF: Apply REF: Ear: Examination and Findings

2.The nurse, assisting with the examination of a clients eyes, is preparing the ophthalmoscope. Which of the following apertures might be needed for this examination? (Select all that apply.)

1.

Small round light

2.

Large round light

3.

Grid

4.

Slit light

5.

Green light

6.

Black light

ANS: 1, 2, 3, 4, 5

Apertures of the ophthalmoscope include small round light, large round light, grid, slit light, and green light. A black light is not an aperture of the ophthalmoscope.

PTS: 1 DIF: Apply REF: Table 38-1 Apertures of the Ophthalmoscope

3.Which of the following would the nurse include when assessing a clients ears? (Select all that apply.)

1.

Onset of dizziness

2.

Changes in hearing

3.

Presence of otorrhea

4.

Duration of otalgia

5.

Swallowing difficulties

6.

Degree of neck pain

ANS: 1, 2, 3, 4

When assessing a clients ears, the nurse should include onset of dizziness, changes in hearing, presence of otorrhea, and duration of otalgia. Swallowing difficulties and degree of neck pain are not a part of this assessment.

PTS: 1 DIF: Apply REF: Patient Playbook: Assessing Ear Problems

4.The nurse assesses a client as having many risk factors for otitis media. Which of the following would increase the clients risk for developing this disorder? (Select all that apply.)

1.

Frequent upper respiratory tract infections

2.

Attends daycare

3.

Male gender

4.

Female gender

5.

Age 15

6.

Rides a bicycle

ANS: 1, 2, 3

Risk factors for the development of otitis media include age less than 2 years; history of frequent upper respiratory infections; lives in cold weather; male gender; is Caucasian, Native American, or an Alaskan native; has a strong positive family history for the disorder; used a pacifier past the age of 6 months; lives in a smoky environment; attends daycare; was bottle fed; has been diagnosed with Down syndrome; or has craniofacial disorders. Female gender, age 15, and riding a bicycle are not risk factors for the development of otitis media.

PTS: 1 DIF: Analyze REF: Red Flag: Risk Factors for Otitis Media

5.A client tells the nurse that he has noticed a decrease in hearing. Which of the following would be risk factors for the client to have a change in hearing? (Select all that apply.)

1.

Smoking

2.

Neck trauma

3.

Cardiovascular disease

4.

Aging

5.

Diabetes

6.

Chronic infection

ANS: 1, 3, 4, 6

Risk factors for hearing loss include noise exposure, smoking, ototoxic drugs, congenital or hereditary factors, cardiovascular disease, aging, tumors, trauma, chronic infections, systemic disease, tympanic membrane perforation, Mnires disease, and barotrauma. Neck trauma and diabetes are not risk factors for a hearing loss.

PTS: 1 DIF: Analyze REF: Red Flag: Hearing Loss Risk Factors

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