Deck 51: Sensory System Function, Assessment, and Therapeutic Measures: Vision and Hearing

Question 1

The nurse is collecting data visually on a patient. Which of the following lighting environments will the nurse use to examine the patient's pupils?

A)Brightly lit room
B)Slightly darkened room
C)Natural lighting
D)Completely darkened room

Answer 1

Slightly darkened room

Question 2

The nurse is testing a patient's visual muscle balance and movement. What technique could the nurse use to gather data on this?

A)Visual fields
B)Six cardinal fields of gaze
C)Consensual pupillary reflex
D)Direct pupillary reflex

Answer 2

Six cardinal fields of gaze

Question 3

The nurse is interviewing a patient. What behavior observed during the interview could indicate hearing loss?

A)Patient cups the ear during interview.
B)Patient leans away from the nurse during interview.
C)Patient answers questions appropriately.
D)Patient complains of people talking loudly.

Answer 3

Patient cups the ear during interview.

Question 4

The nurse is assisting with a patient who is having a test to measure intraocular pressure. Which of the following should the nurse expect to be used?

A)Ultrasonography
B)An ophthalmoscope
C)A slit-lamp microscope
D)A tonometer

Question 5

The nurse is caring for a patient who asks the nurse, "What part of the eye gives the eye its color?" What is the correct response by the nurse?

A)Lens
B)Iris
C)Pupil
D)Retina

Question 6

The nurse is collecting data for a patient who has hearing loss. Which data collection finding for the patient indicates this?

A)Converses easily with the nurse
B)Answers questions appropriately
C)Relaxes facial features during conversation
D)Speaks in an unusually loud voice

Question 7

What anatomical ear structure functions to equalize pressure in the middle ear so that the eardrum can vibrate freely?

A)Auricle
B)Cochlea
C)Eustachian tube
D)Stapes

Question 8

The nurse is caring for a patient who asks what arcus senilis is. What is the nurse's best explanation of arcus senilis?

A)"An eye infection."
B)"A drooping of the eyelid."
C)"A mental condition."
D)"A lipid deposit in the cornea."

Question 9

The nurse is collecting data and has just completed the Weber test on a patient with normal findings. How would the nurse correctly document the findings?

A)Air conduction greater than bone conduction (BC).
B)BC greater than A3.
C)Left ear heard better than right ear.
D)Left and right ear heard equally.

Question 10

Which of the following is the gelatin-like substance that gives shape to the eye and fills the space behind the lens?

A)Vitreous humor
B)Aqueous humor
C)Lacrimal fluid
D)Conjunctiva

Question 11

The nurse is testing a patient's peripheral visual ability. What technique would the nurse use?

A)Visual fields
B)Six cardinal fields of gaze
C)Cover test
D)Corneal light reflex test

Question 12

The nurse is assisting with health screenings in a clinic. Which of the following would be considered a normal finding if noted lining the ear canal?

A)Mucus
B)Cerumen
C)Perilymph
D)Endolymph

Question 13

The nurse has reinforced teaching with a patient after diagnostic testing reveals tinnitus. Which of the following patient statements indicates that teaching has been effective?

A)"There is a toxic substance in my ear."
B)"That is why I have so much discharge all of the time."
C)"My ear pain should get better if I follow the doctor's orders."
D)"The ringing sound I hear in my ear may be a symptom of another problem."

Question 14

The nurse is teaching a patient whose Snellen chart findings are 20/60. Which of the following statements would the nurse include in the patient teaching?

A)"You are considered legally blind, even though with prescription glasses you'll be able to see."
B)"Your vision is better than normal."
C)"You must be at 20 feet to see what normal vision sees at 60 feet."
D)"You must be at 60 feet to see what normal vision sees at 20 feet."

Question 15

The nurse performs a visual assessment on a patient and is documenting the findings as the acronym PERRLA. What does PERRLA indicate?

A)Palpebral angle rigid, right and left angles
B)Patient's eyes round, regular, lively, active
C)Pupils equilateral, regular, round, little accommodation
D)Pupils equal, round, and reactive to light and accommodation

Question 16

The nurse palpates a downward small protrusion of the helix known as Darwin's tubercle. The nurse should document this as which of these?

A)An abnormal palpable calcification
B)Within normal limits
C)A lump filled with fluid
D)A tumor

Question 17

The nurse is providing initial screening to determine gross hearing acuity as part of a complete physical. Which of the following tests would the nurse include in the assessment?

A)Romberg
B)Whisper voice
C)Otoscopic examination
D)Calorie test

Question 18

The nurse is contributing to the teaching for a high school health class regarding cerumen removal from the ear. Which of these instructions should the nurse recommend?

A)"Cerumen protects the auditory canal; just use a washcloth to clean the external ear."
B)"Cerumen must be softened with Debrox before removal, and then an ear irrigation should be done."
C)"Wax is removed only when there is evidence of infection."
D)"Cerumen is removed regularly and thoroughly."

Question 19

The nurse performs a Snellen chart examination on a patient. What Snellen chart finding would indicate normal vision for the patient?

A)Both eyes 20/20
B)Left eye 20/200
C)Left eye 80/20
D)Right eye 200/20

Question 20

The nurse administers eyedrops to a patient and instructs the patient to apply pressure to the inner corner of the eye for 1 minute after application of the drops. Which of these, if stated by a patient, indicates to the nurse correct understanding of the main purpose of why this pressure is applied?

A)"To protect the facial skin from the eyedrops."
B)"To reduce absorption of eyedrops through tear duct."
C)"To increase the onset of action of the eyedrops."
D)"To maintain greater concentration of the eyedrops."

Question 21

The nurse is teaching a patient with a hearing disorder. Which of the following hearing losses would the nurse include are helped with a hearing aid?

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

Question 22

The nurse evaluates that a patient's hearing aid is functioning properly when which of these occurs?

A)It whistles constantly.
B)The patient ignores verbal stimuli.
C)It is properly placed in the ear.
D)The patient converses easily.

Question 23

The nurse places eye drops for a patient with an injured eye and covers the eye with a patch as prescribed. Discharge instructions are given to the patient. Which of the following patient statements indicate that further instruction is needed? (Select all that apply.?

A)"I can watch television without moving my eye too much."
B)"I can listen to music or an audiotaped book but should not read or watch TV."
C)"I should try to open my eyelid under the patch hourly while awake."
D)"I should exercise my patched eye four times daily."
E)"I should apply pressure to the tear duct of the eye every 5 minutes."
F)"When I change the patch, it should be taped securely enough to help the eyelid stay closed."

Question 24

The nurse is caring for a patient who has presbycusis. What intervention would most enhance the nurse's communication with the patient?

A)Speaking in a low-pitched voice
B)Speaking in a high-pitched voice
C)Speaking in a very loud voice
D)Speaking in a soft voice

Question 25

Which of the following is the cranial nerve for hearing?

A)CN II
B)CN IV
C)CN VI
D)CN VIII

Question 26

What are the receptors in the organ of Corti?

A)Hair cells for hearing
B)Ganglion cells for vibrations
C)Hair cells for balance
D)Ganglion cells for balance

Question 27

The nurse is caring for a patient who is blind. What technique should the nurse use when ambulating the patient?

A)Follow the patient with the patient's hand on the nurse's elbow.
B)Precede the patient with the patient's hand on the nurse's elbow.
C)Walk in front of the patient, telling the patient of any obstacles.
D)Walk behind the patient with the nurse's hand on the patient's shoulder.

Question 28

When being tested for visual acuity, the patient should hold a handheld visual acuity chart approximately ________________inches from the eyes.

Question 29

The nurse has reinforced teaching with a patient about diagnostic tests that evaluate eye muscle balance. Which of the following tests identified by the patient would indicate a correct understanding of the teaching? (Select all that apply.?

A)Electroretinography
B)Corneal light reflex
C)Fluorescein angiography
D)Cover test
E)Tonometer readings
F)Computed tomography
Completion
Complete each statement.

Question 30

The nurse is preparing a patient who will be having a digital retinal scan. Which of the following statements by the patient indicates further teaching is necessary?

A)"My eyes will need to be dilated before the procedure."
B)"The scanner will take a picture in about 2 seconds."
C)"A digital image of most of my retina will be produced for the doctor to view."
D)"This test is used to help detect eye disease early."
Multiple Response
Identify one or more choices that best complete the statement or answer the question.

Question 31

Which of the following are common age-related changes in vision and hearing? (Select all that apply.?

A)Increased pupil size and response to light
B)Decreased lacrimal secretions
C)Loss of ability to hear low-frequency sounds
D)Distorted depth perception
E)Yellowing of the lens
F)Presbycusis

Question 32

The nurse is assisting with a patient's physical examination. For which of the following tests would the nurse anticipate the need to plan for patient safety?

A)Weber's test
B)Whisper test
C)Rinne's test
D)Romberg's test

Question 33

What structure changes the shape of the lens of the eye?

A)Ciliary muscle
B)Iris
C)Retina
D)Optic nerve