Deck 62: Nursing Assessment of the Patient With Sensory Disorders

Question 1

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

A) Whisper directly into the patient's ears, one at a time.
B) Stand across the room from the patient.
C) Whisper words from 1 to 2 feet behind the patient.
D) Ask the patient to whisper a series of words.

Answer 1

Whisper words from 1 to 2 feet behind the patient.

Question 2

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. Select all that apply.

A) Have the patient remove corrective lenses.
B) Sit in front of the patient.
C) Have the patient stare at an object about 20 feet behind the nurse.
D) Cover one of the patient's eyes.
E) Record eye movement toward the nose as exotropia.

Answer 2

Sit in front of the patient.
Have the patient stare at an object about 20 feet behind the nurse.
Cover one of the patient's eyes.
Record eye movement toward the nose as exotropia.

Question 3

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

A) Rupture of the TM
B) Fluid behind the TM
C) Presence of an umbo
D) Nystagmus

Answer 3

Rupture of the TM

Question 4

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

A) It is nearly absent.
B) It is hardened, dry, and foul-smelling.
C) It is brown, wet, and sticky.
D) It is dry, white, and flaky.

Question 5

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

A) "Do you have reduced feeling in your cheek on that side?"
B) "Have you noticed any impairment in your sense of smell?"
C) "Do you have a headache?"
D) "Do you have ringing in your ears?"

Question 6

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. Select all that apply.

A) Have the patient close the eyes.
B) Place an ear protection device on the patient.
C) Place a tuning fork in the middle of the top of the patient's head.
D) Ask the patient to indicate when a sound ends.
E) Assess for lateralization of sound.

Question 7

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. Select all that apply.

A) "If you have to shout to ask customers for their orders, the noise level is probably toxic."
B) "If your ears ring or buzz when you leave work, you are at risk for hearing loss."
C) "Be alert for ear pain during or after work."
D) "As long as your work shifts are shorter than 8 hours, you should not be in danger of hearing loss."
E) "Most hearing loss is caused by a single very loud noise accompanied by pressure changes on the eardrum."

Question 8

Neonatal hearing screening indicates that a baby may have hearing loss. The nurse would review the mother's prenatal history for which conditions?.Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply.

A) A sinus infection during the first trimester
B) Confirmed influenza
C) Oral contraceptive use until 2 months prior to becoming pregnant
D) Exposure to rubella while pregnant
E) Two ear infections in the mother during pregnancy

Question 9

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

A) The patient can discriminate light perception only and only at less than 6 feet.
B) The patient's vision is normal.
C) The patient can see hand motion.
D) The patient can count the nurse's fingers at the distance of 6 feet.

Question 10

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. Select all that apply.

A) Occupational exposure to loud noises
B) Prolonged exposure to loud music
C) Taking aspirin for pain relief
D) Cleaning the ears with a cotton-tipped applicator
E) Family history of hearing loss

Question 11

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. Select all that apply.

A) Ptosis
B) Entropion
C) Enophthalmos
D) Ectropion
E) Hypopyon

Question 12

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

A) Presyncope
B) Vertigo
C) Otalgia
D) Tinnitus

Question 13

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

A) Hearing loss requires multiple exposures to high noise levels.
B) Rock concerts are considered to produce moderate levels of noise.
C) One exposure to intense "impulse" noise will probably not damage hearing.
D) Noise-induced hearing loss is also referred to as toxic loss.

Question 14

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. Select all that apply.

A) Stand behind and slightly to the right or left of the patient.
B) Assume that the nurse's visual field is normal.
C) Assess the patient's right eye with the nurse's left eye.
D) Test eight major quadrants of gaze.
E) Use the nurse's fingers as the test object.

Question 15

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

A) "I have noticed that it is more difficult for me to read signs when I am driving."
B) "I have pain behind my eyes."
C) "I have difficulty reading the newspaper."
D) "I get dizzy when watching television."

Question 16

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?

A) No response
B) Right beating nystagmus to cold water introduced in the right ear
C) Left beating nystagmus to introduction of warm water in the left ear
D) Nystagmus in both eyes with introduction of warm or cold water in either ear

Question 17

During the assessment of a patient's 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.

Question 18

A patient has been prescribed sildenafil (Viagra) and says, "I know that this mediation can cause eye problems, but the television commercials don't 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. Select all that apply.

A) "Don't pay attention to television commericals."
B) "Be watchful for hazing of your vision."
C) "Your eyes may become more sensitive to light."
D) "Sildenafil may cause deposits on your retina."
E) "You may notice changes in your ability to see colors."

Question 19

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

A) "I fainted when I saw blood on my hand."
B) "My ears ring all of the time."
C) "I feel dizzy most of the time."
D) "When I got up this morning, my ear was hurting."

Question 20

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

A) The optic disc is circular in shape.
B) The margins of the disc blur into the surrounding tissues.
C) The disc has a distinct bluish color.
D) There is a depression on the side of the disc.