Deck 4: Assessing the Eye and the Ear

Question 1

The nurse is screening children before they enter preschool. Which is the expected visual acuity for preschool-age patients?

A) 20/20
B) 20/40
C) 20/60
D) 20/100

Answer 1

20/40

Question 2

The nurse is collecting a health history for a patient who presents with diplopia. Which question is most appropriate for the nurse to include in this patient's health history?

A) "Are you experiencing discomfort?"
B) "Does the double vision get worse when you are tired?"
C) "Did you experience a sudden loss of vision?"
D) "Do you wear contact lenses?"

Answer 2

"Does the double vision get worse when you are tired?"

Question 3

The nurse is assessing a patient visual accommodation. Which cranial nerve does the nurse plan to assess?

A) Cranial nerve I
B) Cranial nerve II
C) Cranial nerve III
D) Cranial nerve IV

Answer 3

Cranial nerve III

Question 4

An older adult professor complains of dryness of the eyes after reading or doing computer work. When educating this patient about the dryness, which cause will the nurse include in the teaching session?

A) Fatty deposits around the eyelids
B) The lens becoming more opaque
C) A decrease in tear production
D) Decreased ability to constrict the pupil

Question 5

Before otoscopic exam, the nurse should palpate which areas for tenderness?

A) Helix, tragus, and stapes
B) Tragus, lobule, and concha
C) Tragus, mastoid process, and helix
D) Tragus, lobule, and mastoid process

Question 6

The Weber test is used to screen for hearing deficits. When performing the Weber test, where should the nurse place the tuning fork?

A) On the mastoid process
B) In front of the ear
C) On the forehead
D) On the tragus

Question 7

The nurse is conducting an ear assessment for an Asian American patient. Which is an anticipated finding for this patient based on ethnicity?

A) Increased incidence of otitis media
B) Brown, wet, and sticky cerumen
C) Decreased risk for hearing loss
D) Dry, white, and flaky cerumen

Question 8

The nurse is conducting an eye assessment and plans to assess cranial nerve function. Which cranial nerves (CNs) control eye movements?

A) CN III
B) CN IV
C) CN VI
D) All of the above

Question 9

The nurse is assessing the patient's sclera and notes a bluish tinge. Which diagnosis does the nurse anticipate based on this assessment finding?

A) Episcleritis
B) Jaundice
C) Vitamin A deficiency
D) Osteogenesis imperfecta

Question 10

A mother is concerned because her newborn is not able to follow a moving toy with her eyes. When educating the mother about fixating and following an object, at which age should the nurse tell the mother to expect this to occur?

A) 2 weeks
B) 4 weeks
C) 2 months
D) 3 months

Question 11

The nurse is conducting an eye assessment for an infant. The nurse notes the absence of the red reflex. What does this finding suggest to the nurse?

A) The infant is color blind.
B) The infant may have retinopathy of prematurity.
C) The infant has a mature macula.
D) The infant may have congenital cataracts.

Question 12

The nurse is preparing to perform the Rinne test of hearing function. Which action by the nurse is appropriate?

A) Whispers several words to the patient and asks him or her to repeat what was heard
B) Places a vibrating tuning fork in the middle of the head
C) Places a set of earphones over both ears, plays several tones, and asks the patient to identify the sounds heard
D) Uses a tuning fork to compare the length of time the patient hears sound conducted by the mastoid bone versus air conduction

Question 13

The nurse is conducting a health history for an older adult patient who states, "I seem to have more trouble driving at night the older that I get." When teaching the patient why this occurs, which will the nurse include in the teaching session?

A) Decreased contraction of ciliary body
B) Degeneration of cones
C) Degeneration of rods
D) Arcus senilis

Question 14

The nurse is assessing a patient's ears. Which is a primary function of the ears that the nurse will include in the assessment process?

A) Visual assessment
B) Taste assessment
C) Smell assessment
D) Equilibrium assessment

Question 15

The nurse is preparing to perform an ear assessment. Which speculum for the otoscope should the nurse select?

A) The largest and longest
B) The largest and shortest
C) The smallest and longest
D) The smallest and shortest

Question 16

The nurse assesses the patient's tympanic membrane. Which is considered a normal assessment finding?

A) Light pink
B) Deep red
C) Pearly gray
D) Yellow-white

Question 17

During the otoscopic exam, how should the nurse hold the adult patient's ear?

A) Pull the helix up and back
B) Pull the lobule down and forward
C) Pull the lobule down and back
D) Pull the helix up and forward

Question 18

The nurse is assessing a patient who is experiencing eye pain. Which assessment question is appropriate when collecting the health history for this patient?

A) "Does light bother your eye?"
B) "Have you noticed any changes in your vision?"
C) "Have you noticed any tearing of the eye?"
D) "Do you wear contact lenses?"

Question 19

During the Weber test, the nurse determines that the patient hears the sound of a tuning fork equally in each ear. Which action by the nurse is appropriate based on this assessment finding?

A) Repeat the test again using a 200-Hz tuning fork.
B) Tell the patient that this represents a normal finding.
C) Refer the patient for additional testing to determine the exact hearing abnormality.
D) Ask the patient to keep the eyes closed so that the test can be repeated.

Question 20

The nurse assesses a patient and notes difficulty seeing objects that are near. Which medical term will the nurse use when documenting this assessment finding in the medical record?

A) Astigmatism
B) Hyperopia
C) Myopia
D) Nystagmus

Question 21

The nurse is assessing the patient's gross hearing. Which action is appropriate?

A) Asking the patient to stand 2 to 4 feet away while whispering
B) Asking the patient to stand 5 feet away while yelling
C) Asking the patient to stand 1 to 2 feet away while whispering
D) Asking the patient to stand 10 feet away while yelling

Question 22

The nurse is preparing to assess a patient's extraocular function. Which test or exam will the nurse use for this specific eye assessment?

A) Superior field test
B) Pupillary reaction test
C) Denver Age Screening exam
D) Six cardinal positions of gaze test

Question 23

The nurse is assessing the mobility of the tympanic membrane for a pediatric patient. Which action by the nurse is appropriate?

A) Illuminating the ear canal
B) Using the pneumatic attachment
C) Irrigating the ear canal
D) Whispering in the ear

Question 24

The nurse administers a Romberg test to assess the patient's balance. Which action by the nurse is appropriate?

A) Asking the patient to keep the eyes open
B) Asking the patient to keep the eyes closed
C) Asking the patient to open the eyes and then close the eyes
D) None of the above

Question 25

During an otoscope assessment, the nurse notes the patient is experiencing cerumen build-up. Based on this data, which type of hearing loss does the nurse anticipate?

A) Sensorineural
B) Perceptive
C) Conductive
D) Central

Question 26

The nurse notes that the patient's tympanic membrane (TM) is golden brown. There is thick, elastic drainage noted as well. Which conclusion by the nurse is accurate?

A) The patient has scar tissue from a previous ruptured TM.
B) The patient has bleeding as a result of trauma.
C) The patient is experiencing a complication of chronic otitis media.
D) The patient is experiencing adhesive otitis media.

Question 27

The nurse assesses the adult patient's pupils and documents normal size of 3 to ________________mm.

Question 28

The nurse is assessing the eyes of an infant. The infant's mother asks when permanent eye color is established. The nurse states that permanent eye color is established by ________________months of age.

Question 29

Normal visual acuity for a 3-year-old is approximately ________________or better.

Question 30

During the first 1 to ________________months, infants' eye movements are often disconjugate, making screening for strabismus difficult.

Question 31

The nurse is assessing the pupils of a newborn. After ________________weeks, if no pupillary light reflex is present, blindness is indicated.

Question 32

The nurse is assessing the patient for high-pitch deficits. Which action by the nurse is appropriate?

A) Placing a ticking watch 5 inches from the ear
B) Placing a turning fork 5 inches from the ear
C) Asking the patient to repeat back what is whispered
D) Asking the patient which volume is used to watch TV

Question 33

Which cranial nerves (CNs) are responsible for the functioning of the six extraocular muscles?

A) CNs I, II, and III
B) CNs III, IV, and VI
C) CNs III, IV, and V
D) CNs III, V, and VI

Question 34

The nurse conducts a routine eye exam on an adult patient. Data indicate that the patient's far vision is 20/25. When telling the patient about the result of the exam, which statement from the nurse is appropriate?

A) "You can read from 20 ft what the person with normal vision can read from 25 ft."
B) "You can read the entire chart from 20 ft."
C) "You can read from 25 ft what the person with normal vision can read from 20 ft."
D) "Your left eye can read the chart from 20 ft and your right eye can read the chart from 25 ft."

Question 35

The nurse is assessing a pediatric patient and knows that it is important to screen for color blindness between 4 and ________________years of age.

Question 36

The nurse is preparing to administer the corneal light reflex test. Which does the test assess in the patient?

A) Peripheral vision
B) Visual acuity
C) Parallel alignment and ocular muscles
D) Trigeminal nerve

Question 37

The nurse is preparing to irrigate the patient's ear canal. Which action is the priority?

A) Warming the solution to room temperature
B) Sending the solution for sterilization
C) Monitoring vital signs
D) Assessing that the tympanic membrane is intact