Chapter 62 My Nursing Test Banks

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Chapter 62

Question 1

Type: MCSA

The nurse notes that the cerumen (earwax) in a patients ear may indicate an infection. The nurse makes that assessment because of which characteristic of the cerumen?

1. It is nearly absent.

2. It is hardened, dry, and foul-smelling.

3. It is brown, wet, and sticky.

4. It is dry, white, and flaky.

Correct Answer: 2

Rationale 1: Cerumen lubricates the ear and is always present.

Rationale 2: Hardened, dry, or foul-smelling cerumen may indicate an infection.

Rationale 3: Cerumen should be moist and may vary in color from brown to white.

Rationale 4: In a majority of Asians and Native Americans, cerumen is dry, white, and flaky.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 62-1

Question 2

Type: MCSA

Which patient statement would the nurse evaluate as indicating that the patient has otalgia?

1. I fainted when I saw blood on my hand.

2. My ears ring all of the time.

3. I feel dizzy most of the time.

4. When I got up this morning, my ear was hurting.

Correct Answer: 4

Rationale 1: Fainting is recorded as syncope. It is not necessarily related to otalgia.

Rationale 2: Ringing in the ears is tinnitus. This symptom is not specifically related to otalgia.

Rationale 3: Dizziness may be a symptom of vertigo and is not specifically related to otalgia.

Rationale 4: Otalgia is ear pain.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 62-1

Question 3

Type: MCSA

Which subjective symptom of the sensory system may also be an objective symptom?

1. Presyncope

2. Vertigo

3. Otalgia

4. Tinnitus

Correct Answer: 4

Rationale 1: Presyncope is a feeling of fainting. The observer may see signs that a patient is weak or dizzy but cannot directly observe the feeling of fainting.

Rationale 2: Vertigo is the illusion of rotational movement, tilting, or swaying, with feelings of imbalance during standing and walking. The patient has to report the sensation.

Rationale 3: Otalgia is ear pain that only the patient feels and must report.

Rationale 4: Tinnitus is primarily a localized, internal auditory perception usually not heard by others. However, objective tinnitus can be heard by others and is caused by vascular problems of the carotid arteries or jugular veins.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 62-2

Question 4

Type: MCSA

A 45-year-old patient is admitted complaining of dizziness, hearing loss, and a full feeling in one ear. Based on the patients age and symptoms, the nurse would ask which additional assessment question?

1. Do you have reduced feeling in your cheek on that side?

2. Have you noticed any impairment in your sense of smell?

3. Do you have a headache?

4. Do you have ringing in your ears?

Correct Answer: 4

Rationale 1: The disorder suggested by these symptoms and the patients age does not cause paresthesia.

Rationale 2: The disorder suggested by these symptoms and the patients age does not impair the ability to smell.

Rationale 3: The disorder suggested by these symptoms and the patients age does not cause headache.

Rationale 4: Mnires disease is a dysfunction of the labyrinth of the ear, with symptoms of vertigo, hearing loss, unilateral aural fullness, and tinnitus. It is most common between the ages of 30 and 60.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 62-5

Question 5

Type: MCMA

The nurse is planning a community education session on ways to prevent deafness. The nurse should discuss which modifiable factors that increase the risk for permanent hearing loss?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Occupational exposure to loud noises

2. Prolonged exposure to loud music

3. Taking aspirin for pain relief

4. Cleaning the ears with a cotton-tipped applicator

5. Family history of hearing loss

Correct Answer: 1,2,4

Rationale 1: Occupational noise exposure is implicated in one-third of hearing loss.

Rationale 2: Exposure to loud music over time can cause hearing loss.

Rationale 3: Aspirin can cause temporary tinnitus or hearing loss.

Rationale 4: Use of cotton-tipped applicators can cause damage to the ear canal or tympanic membrane.

Rationale 5: While a family history of hearing loss does increase the risk, this is a nonmodifable risk factor.

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 62-3

Question 6

Type: MCMA

A nurse is preparing to conduct the Weber test. Which nursing actions are indicated?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Have the patient close the eyes.

2. Place an ear protection device on the patient.

3. Place a tuning fork in the middle of the top of the patients head.

4. Ask the patient to indicate when a sound ends.

5. Assess for lateralization of sound.

Correct Answer: 3,5

Rationale 1: The Weber test is valid with eyes open or closed.

Rationale 2: Ear protection devices are not used in the Weber test.

Rationale 3: The Weber test uses a tuning fork placed midline on the patients head.

Rationale 4: The Weber test does not include the length of time a sound is heard.

Rationale 5: The nurse asks the patient if the sound is louder on one side or the other. The patients response indicates lateralization of sound.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 62-2

Question 7

Type: MCSA

The nurse is conducting the whisper test. Which nursing action is indicated?

1. Whisper directly into the patients ears, one at a time.

2. Stand across the room from the patient.

3. Whisper words from 1 to 2 feet behind the patient.

4. Ask the patient to whisper a series of words.

Correct Answer: 3

Rationale 1: The nurse will not whisper directly into the patients ear.

Rationale 2: The nurse will not stand across the room.

Rationale 3: The nurse should whisper words from 1 to 2 feet behind the patient.

Rationale 4: The nurse whispers the words in this test.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 62-2

Question 8

Type: MCSA

The nurse is assisting with caloric testing on a patient who is persistently unconscious. Which response would the nurse expect if severe brainstem injury exists?

1. No response

2. Right beating nystagmus to cold water introduced in the right ear

3. Left beating nystagmus to introduction of warm water in the left ear

4. Nystagmus in both eyes with introduction of warm or cold water in either ear

Correct Answer: 1

Rationale 1: If the patient has a severe brainstem injury, there will be no response to caloric testing.

Rationale 2: The patient with severe brainstem injury will not have this response.

Rationale 3: The patient with severe brainstem injury will not have this response.

Rationale 4: The patient with severe brainstem injury will not have this response.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 62-5

Question 9

Type: MCMA

A patient has been prescribed sildenafil (Viagra) and says, I know that this mediation can cause eye problems, but the television commercials dont say what kind of problems. How should the nurse respond?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Dont pay attention to television commericals.

2. Be watchful for hazing of your vision.

3. Your eyes may become more sensitive to light.

4. Sildenafil may cause deposits on your retina.

5. You may notice changes in your ability to see colors.

Correct Answer: 2,3

Rationale 1: There is no indication that advertisements for medications are not accurate.

Rationale 2: Sildenafil may cause vision haze.

Rationale 3: Light sensitivity is one of the changes associated with sildenafil.

Rationale 4: Sildenafil is not implicated in retinal deposits.

Rationale 5: Color vision problems are not associated with sildenafil.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 62-3

Question 10

Type: MCSA

Review of patients medical record reveals the notation, CF at 6 feet on R. How should the nurse interpret this information?

1. The patient can discriminate light perception only and only at less than 6 feet.

2. The patients vision is normal.

3. The patient can see hand motion.

4. The patient can count the nurses fingers at the distance of 6 feet.

Correct Answer: 4

Rationale 1: If this was the case, the documentation would read LP at the furthest distance applicable.

Rationale 2: This notation does not indicate normal vision.

Rationale 3: Hand motion is documented as HM.

Rationale 4: CF indicates finger count. The distance and which eye is being tested are also documented.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 62-1

Question 11

Type: FIB

During the assessment of a patients fields of gaze, the nurse notices the left eye lags slightly behind the right when moving from the primary position to right upward position. All other movements are symmetrical and smooth. To allow for trending, the nurse would record ______ for this result.

Standard Text:

Correct Answer: 1

Rationale : Results of this test are recorded as normal, -1 (minimal), -2 (moderate), -3 (severe), or -4 (total). The results from this patients exam vary from normal only in the slight lag at the beginning of the test. This would be evaluated as minimal.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 62-4

Question 12

Type: MCMA

The nurse is testing a patient for visual tropia. Which actions are steps in this test?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Have the patient remove corrective lenses.

2. Sit in front of the patient.

3. Have the patient stare at an object about 20 feet behind the nurse.

4. Cover one of the patients eyes.

5. Record eye movement toward the nose as exotropia.

Correct Answer: 2,3,4,5

Rationale 1: The patient should wear corrective lenses if they are normally worn.

Rationale 2: The nurse sits in front of the patient.

Rationale 3: The patient should fixate on an object about 20 feet behind the nurse and then, to test near response, fixate of an object about 16 inches away.

Rationale 4: The test includes covering and uncovering each eye individually.

Rationale 5: If the eye moves toward the nose, it was fixated outward so the eye is exotropic.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 62-4

Question 13

Type: MCMA

The nurse is doing confrontational field testing. Which techniques are correct?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Stand behind and slightly to the right or left of the patient.

2. Assume that the nurses visual field is normal.

3. Assess the patients right eye with the nurses left eye.

4. Test eight major quadrants of gaze.

5. Use the nurses fingers as the test object.

Correct Answer: 2,3,5

Rationale 1: The nurse should be in front of the patient.

Rationale 2: This is a test of the patients visual fields and uses the nurses visual field as the control or normal.

Rationale 3: The assessment should be on the same side; because the nurse and patient are facing one another, the patients right eye is on the same side as the nurses left eye.

Rationale 4: The nurse tests four major quadrants.

Rationale 5: In most cases, it is sufficient to use the nurses fingers as the test object. In some cases, a bright object may be used.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 62-4

Question 14

Type: MCSA

The school nurse is educating middle school students about the connection between noise and hearing loss. Which information should the nurse provide?

1. Hearing loss requires multiple exposures to high noise levels.

2. Rock concerts are considered to produce moderate levels of noise.

3. One exposure to intense impulse noise will probably not damage hearing.

4. Noise-induced hearing loss is also referred to as toxic loss.

Correct Answer: 4

Rationale 1: Multiple exposures to high noise levels can result in hearing loss, but it is not the only way noise can impact hearing.

Rationale 2: Rock concerts can produce a high level (90 to 170 dB) of noise.

Rationale 3: One-time exposure to an intense impulse noise such as from an explosion can result in hearing loss.

Rationale 4: Referring to noise-induced hearing loss as toxic loss may help to emphasize the seriousness of this situation.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 62-3

Question 15

Type: MCSA

Using a pneumatoscope, the nurse discovers that a patients tympanic membrane (TM) does not move. The nurse would conduct further assessment for which condition?

1. Rupture of the TM

2. Fluid behind the TM

3. Presence of an umbo

4. Nystagmus

Correct Answer: 1

Rationale 1: If the TM does not move when air is introduced into the ear canal, it is possible that the TM is ruptured.

Rationale 2: Presence of fluid behind the TM would not result in immobility of the TM.

Rationale 3: The umbo is a normal portion of the ear structure. It would not cause the TM to be fixed and immovable.

Rationale 4: Nystagmus is movement of the eye and would not be associated with fixed and immovable TM.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 62-1

Question 16

Type: MCMA

A patient who is employed as a waitress in a new restaurant says, The restaurant plays loud rock music all the time. Do you think my hearing is in danger? What information should the nurse provide?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. If you have to shout to ask customers for their orders, the noise level is probably toxic.

2. If your ears ring or buzz when you leave work, you are at risk for hearing loss.

3. Be alert for ear pain during or after work.

4. As long as your work shifts are shorter than 8 hours, you should not be in danger of hearing loss.

5. Most hearing loss is caused by a single very loud noise accompanied by pressure changes on the eardrum.

Correct Answer: 1,2,3

Rationale 1: The patient should be able to hear and be heard without shouting from a distance of 3 feet. If the patient has to shout to be heard when taking orders, the noise level is probably over 85 decibels, which is in the dangerous range.

Rationale 2: Ringing or buzzing of the ears is a warning sign of hazardous noise exposure.

Rationale 3: Pain in the ears after leaving a noisy area is a warning sign of hazardous noise exposure.

Rationale 4: Frequent exposure to high levels of noise can cause hearing loss.

Rationale 5: This statement represents the physics of an explosion, which can cause hearing loss but is not the most common etiology.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 62-3

Question 17

Type: MCSA

Which patient report would the nurse evaluate as indicating that changes in accommodation are occurring?

1. I have noticed that it is more difficult for me to read signs when I am driving.

2. I have pain behind my eyes.

3. I have difficulty reading the newspaper.

4. I get dizzy when watching television.

Correct Answer: 3

Rationale 1: Problems with reading objects at a distance are not characteristic of difficulties with accommodation.

Rationale 2: Problems with accommodation may cause the eyes to tire but should not cause pain.

Rationale 3: Problems with accommodation are likely to manifest as difficulty reading print at close range.

Rationale 4: Dizziness is not associated with changes of accommodation.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 62-4

Question 18

Type: MCSA

The nurse has visualized a patients optic disc using an ophthalmoscope. Which finding would the nurse evaluate as normal?

1. The optic disc is circular in shape.

2. The margins of the disc blur into the surrounding tissues.

3. The disc has a distinct bluish color.

4. There is a depression on the side of the disc.

Correct Answer: 1

Rationale 1: The normal shape of the optic disc is oval or circular.

Rationale 2: The margins of the disc are normally distinct.

Rationale 3: The normal color of the optic disc is pinkish-orange.

Rationale 4: The depression or cup should be in the center of the disc.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 62-1

Question 19

Type: MCMA

Assessment of an 86-year-old patient reveals drooping of the right lower lid and eyelashes that curve outward. How would the nurse document these findings?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Ptosis

2. Entropion

3. Enophthalmos

4. Ectropion

5. Hypopyon

Correct Answer: 1,4

Rationale 1: Ptosis is drooping of the eyelid.

Rationale 2: Entropion is the curving inward of the eyelashes.

Rationale 3: Enophthalmos is a sunken appearance of the eyeball.

Rationale 4: Ectropion is the curving outward of the eyelashes.

Rationale 5: Hypopyon is the presence of pus in the anterior chamber of the eye.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 62-1

Question 20

Type: MCMA

Neonatal hearing screening indicates that a baby may have hearing loss. The nurse would review the mothers prenatal history for which conditions?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. A sinus infection during the first trimester

2. Confirmed influenza

3. Oral contraceptive use until 2 months prior to becoming pregnant

4. Exposure to rubella while pregnant

5. Two ear infections in the mother during pregnancy

Correct Answer: 2,4

Rationale 1: There is no indication that a single sinus infection during pregnancy is implicated in hearing loss in the infant.

Rationale 2: Intrauterine exposure to maternal influenza can result in congenital hearing loss.

Rationale 3: Using oral contraceptives and discontinuing them prior to pregnancy are not implicated in hearing loss in the infant.

Rationale 4: Intrauterine exposure to maternal rubella may result in hearing loss in the infant.

Rationale 5: There is no indication that ear infections in the mother result in hearing loss in the infant.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 62-5

 

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