Deck 45: Assessing the Eye and Ear

Question 1

A patient receiving an eye exam has to stand 20 feet from the chart to read a line that a person with normal vision could read 100 feet from the chart. The nurse would document this as ______ vision.

Answer 1

20/100

Question 2

A patient recovering from a stroke is reporting vision changes. The nurse realizes that these changes are occurring because:

A) the stroke occurred in the optic region of the patient's brain.
B) the brain interprets information received through the eyes.
C) the patient is experiencing another stroke.
D) the patient is unable to talk because of the stroke.

Answer 2

the brain interprets information received through the eyes.

Question 3

A patient is scheduled for diagnostic tests to determine the cause of a hearing and balance disorder. For which diagnostic tests should the nurse prepare this patient?

A) tonometry
B) computed tomography (CT) scan
C) electronystagmography (ENG)
D) auditory evoked potentials (AEP)
E) auditory brainstem response (ABR)

Answer 3

electronystagmography (ENG)
auditory evoked potentials (AEP)
auditory brainstem response (ABR)

Question 4

When performing the cover test, the nurse notes that a patient's left eye deviates inward when focusing on an object. What should this finding suggest to the nurse?

A) presbyopia
B) hyperopia
C) weakness
D) myopia

Question 5

The patient assessment reveals absence of the fovea centralis. The next examination that may be anticipated by the nurse would be:

A) inspection of the red reflex.
B) inspection of the retina.
C) inspection of the macula.
D) inspection of the optic disc.

Question 6

While exiting a burning building, a patient's eyebrows and lashes were burned. The nurse recognizes that this patient might experience:

A) wound infections.
B) fluid and electrolyte imbalance.
C) foreign bodies in the eyes.
D) itchiness as the hair grows back.

Question 7

A patient has sustained an injury to the inner layer of the left retina. The nurse realizes that this patient will have difficulty with:

A) tear production.
B) blinking.
C) reading.
D) peripheral vision and color perception.

Question 8

When assessing the external features of the eye, the nurse should be able to identify each accessory eye structure. Which part of the eye should the nurse focus on when assessing the sclera? Place an X on the area that indicates the sclera.

Question 9

The nurse is preparing to perform an otoscopic exam of the ear. The patient is restless but has agreed to the exam. List in order of priority the steps the nurse would perform. Standard Text: Click and drag the options below to move them up or down.
Choice

A) Explain the procedure to the patient.
B) Grasp the superior portion of the auricle and pull up, out, and back to straighten the auditory canal.
C) Hold the handle of the otoscope in the dominant hand, otoscope handle upward.
D) Wash the hands.
E) Turn on the otoscope light.
F) Rest the hand holding the otoscope against the patient's head.
G) none of the above

Question 10

An older patient says, "I seem to be talking so much louder these days and I don't know why!" The nurse realizes that this patient might be experiencing:

A) loss of hair cells in the middle ear.
B) cochlear atrophy.
C) impacted cerumen.
D) stiffening of the middle ear structures.

Question 11

A patient is found to need corrective lenses. Which diagnostic test was most likely used to determine this finding?

A) computed tomography (CT) scan
B) tonometry
C) refractometry
D) response to atropine eye drops

Question 12

A 20-year-old patient is experiencing difficulty with near vision. The nurse realizes that this finding is:

A) consistent with the aging process.
B) normal in a 20-year-old patient.
C) evidence of presbyopia.
D) evidence of hyperopia.

Question 13

During the assessment of a patient's outer eyes, the nurse suspects that the patient has a hair follicle infection. What did the nurse most likely assess in this patient?

A) xanthelasma
B) ptosis
C) exophthalmos
D) sty

Question 14

A patient is found to have small, raised lesions on the rim of the ear. The nurse realizes that this finding is consistent with which health problem?

A) hypertension
B) gout
C) heart disease
D) kidney failure

Question 15

A patient with a sore throat is complaining of "trouble with hearing." The nurse realizes that this patient might be experiencing:

A) a sinus infection.
B) a middle ear infection.
C) infected tonsils.
D) an inner ear infection.

Question 16

The nurse positions a patient for an eye examination. After repeated attempts, the patient is able to read all the letters on the Snellen chart without difficulty at a distance of 15 feet. From this finding the nurse determines that the patient:

A) has normal 20/20 vision.
B) has normal reading vision.
C) has visual impairments.
D) has a normal pupillary reflex.

Question 17

During a Weber test, a patient is found to have increased hearing in the right ear. The nurse realizes that this finding is consistent with:

A) normal aging.
B) conductive hearing loss in the right ear.
C) possible buildup of cerumen or otitis media in the left ear.
D) perforated left eardrum.

Question 18

A patient with an injury to the right eye has received an eye patch. The nurse understands that this patient might experience difficulty with:

A) depth perception.
B) reading.
C) light perception.
D) color perception.

Question 19

The nurse is assessing a patient's visual fields by covering the right eye with an opaque covering. The nurse should then perform which action?

A) cover own right eye
B) cover own left eye
C) keep both eyes uncovered
D) turn the lights on in the room before conducting this examination

Question 20

A patient who is using atropine eyedrops is found to have a poor consensual light response. The nurse recognizes that this finding is considered:

A) abnormal and should be reported to the physician.
B) normal because of the eyedrops.
C) evidence of retinal degeneration.
D) evidence of optic nerve damage.

Question 21

A patient is experiencing dizziness and disequilibrium with head movements. For which problem should the nurse plan care?

A) imbalanced fluids
B) difficulty adjusting to life changes
C) problems with coping
D) potential to fall

Question 22

Before assessing an older adult patient, the nurse reviews the age-related changes in the ear. (See accompanying box.) After the assessment, the nurse recognizes which priority concern related to the finding of vestibular degeneration? $\begin{array}{|llcc|}\hline\text { Age-Related Change: The Inner Ear }\\\hline \text { Loss of hair cells, }\downarrow \text { blood supply, less flexible basilar membrane, degeneration of spiral }\\\text { ganglion cells, and } \downarrow \text { production of endolymph result in progressive hearing loss with age }\\\text { (presbycusis) and hearing aids may be required. }\\\hline \text { High-frequency sounds are lost; middle- and low-frequency sounds may also be lost or }\\\text { decreased, which may distort speech. }\\\hline\text { Vestibular structures degenerate; organ of Corti and cochlea atrophy resulting in loss of }\\\text { equilibrium. }\\\hline\end{array}$

A) skin breakdown
B) fall prevention
C) nausea
D) low night vision

Question 23

A patient with complaints of dizziness states, "When I'm walking through our house, I sometimes have to hold on to furniture to keep from falling." The physician has determined that the patient has an ear disorder. Place an "X" over the area of the ear that is most likely responsible for the patient's symptom.

Question 24

The nurse is performing an assessment of an 82-year-old patient's eyes. Which patient statements should the nurse expect based on the patient's age?

A) "I've been having some drainage from the inside corner of my eye."
B) "My eyes feel so dry most of the time."
C) "I have almost fallen several times at home going down our basement stairs."
D) "I have this white circle around the color of my eyes."
E) "I have a hard time driving at night."

Question 25

The nurse suspects that a patient has bone-conductive hearing loss. Which assessment technique should the nurse use to differentiate between bone conduction loss and air conduction loss?

A) Rinne test
B) Weber test
C) assessment of balance and body position
D) palpation of mastoid process

Question 26

The nurse is conducting an assessment of a patient's hearing. Which test is the nurse conducting, as demonstrated in the picture?

A) Rinne test
B) tympanogram
C) auditory precision test
D) Weber test

Question 27

The nurse determines that an older patient has age-related changes in the vestibular structures of the ear. What should the nurse identify as risks for this patient?

A) infection
B) falls
C) medication errors
D) food intolerance
E) problems communicating

Question 28

The nurse is assessing a 75-year-old patient. Which patient report would require immediate action by the nurse?

A) occasional presence of floaters
B) greater need for additional light and reading glasses
C) development of a white circle around the iris
D) frequent falls from tripping over items on the floor

Question 29

The nurse is performing the Weber test when assessing a patient's hearing. For which abnormalities does this technique assess?

A) conductive hearing loss
B) sensorineural hearing loss
C) otitis media
D) degree of hearing loss
E) tumor of the middle ear

Question 30

The nurse is preparing to assess an older patient's ears. Which techniques should the nurse consider when conducting this assessment?

A) whisper test
B) Rinne test
C) Weber test
D) electronystagmography (ENG)
E) audiometer

Question 31

A patient has a tonometry measurement of 29 mmHg. What additional assessment findings should the nurse identify that indicate this patient has glaucoma?

A) narrowing visual fields
B) loss of definition of the optic disc
C) areas of hemorrhage, exudate, and white patches
D) narrowing of the vein where an arteriole crosses over
E) displaced blood vessels from the center of the optic disc

Question 32

During a health history interview the nurse becomes concerned that a patient is at risk for a genetic hearing disorder. On what information did the nurse base this clinical decision?

A) The patient's mother, age 76, uses hearing aids.
B) The patient's father had tubes in the ears as a child.
C) The patient's brother lost his hearing because of a thyroid disorder.
D) The patient's sister was treated for ear drainage after swimming.
E) The patient's nephew had surgery to remove a tumor on the acoustic nerve.

Question 33

The nurse is assessing a patient for a possible conductive hearing loss. What should the nurse perform first?

A) external ear exam
B) Weber test
C) Rinne test
D) tympanogram

Question 34

A patient has a tonometer test result of 28 mmHg. Which explanation by the nurse about this pressure reading is most accurate?

A) The pressure in the eye has been measured and is too low. Medication will be required to increase the pressure and prevent blindness from retinal damage.
B) The pressure in the inner ear has been measured to evaluate the semicircular canals' function related to nerve damage and is within the normal range.
C) The pressure in the middle ear that builds up with mastoiditis has been measured. The condition needs to be treated with surgical insertion of tubes to drain the fluid behind the tympanic membrane.
D) The pressure in the eye has been measured and is above normal. This condition could lead to possible retinal changes if not treated.

Question 35

The nurse is assessing a patient for neurological changes after a head trauma. Which eye assessment should the nurse perform?

A) ptosis
B) extraocular movements
C) accommodation
D) color of iris
E) nystagmus

Question 36

During an assessment the nurse suspects that a victim of a motor vehicle crash is a narcotic substance user. Which assessment findings would confirm the nurse's suspicion?

A) small pupils
B) dilated pupils
C) unequal pupil size
D) poor pupillary response to light
E) one dilated and unresponsive pupil

Question 37

The nurse is assessing a patient with retinitis pigmentosa. Which findings should the nurse identify as consistent with this health problem?

A) loss of visual acuity
B) loss of peripheral vision
C) progressive night blindness
D) one dilated, unresponsive pupil
E) reduced perception of blue-green tones

Question 38

The nurse is assessing the ears of a patient who is African American. Which assessment finding should the nurse identify as abnormal?

A) During the Rinne test, the patient hears the sound by air conduction for an equal amount of time as by bone conduction.
B) The patient is able to hear whispers from 18 inches away.
C) The patient's cerumen is dark gray.
D) The patient's tympanic membrane is pearly gray.

Question 39

The nurse is reviewing the physiology of the ear with a patient with a hearing disorder. What should the nurse explain about the function of the inner ear?

A) It coordinates visual pathways.
B) It integrates efferent neuron messages.
C) It provides information about head position.
D) It maintains middle ear structure and function.
E) It conducts sound.

Question 40

The nurse is preparing to assess a patient's corneal reflex. Place an X on the site where the nurse may lightly touch the eye with a wisp of cotton.