Question 1

During assessment of a patient's eyes,the nurse notes that the pupil of the right eye is irregular and appears to protrude into the iris.The nurse should question the patient about a history of which of the following?

A) Pinguecula
B) Eye trauma
C) Corticosteroid use
D) Glaucoma surgery

Glaucoma surgery

Accepted Answer

An irregular pupil that appears to protrude into the iris is a sign of anterior chamber angle closure, which can occur after glaucoma surgery. Therefore, the nurse should question the patient about a history of glaucoma surgery.

Question 2

When examining a patient's eyes,the nurse suspects a weakness or imbalance of the extraocular nerves on finding which of the following data?&#10;A) A limited field of vision&#10;B) A sluggish papillary reflex&#10;C) An irregular corneal light reflex&#10;D) Conjugate movement of the eyes through the cardinal fields of gaze

Accepted Answer

An irregular corneal light reflex can indicate a weakness or imbalance of the extraocular muscles, which are controlled by the cranial nerves. This finding suggests that the eyes may not be aligning properly, which is a sign of extraocular nerve dysfunction.

Question 3

During assessment of a 68-year-old patient's eyes,the nurse determines that the patient needs more extensive examination of the eyes when which of the following data are found?&#10;A) Persistent photophobia&#10;B) Light-yellow colouring of the sclera&#10;C) Slow recovery of the pupil after light stimulation&#10;D) A whitish-grey ring encircling the periphery of the iris

Accepted Answer

Persistent photophobia can indicate underlying eye conditions or diseases that require further examination by an eye specialist.

Question 4

A 42-year-old man complains of seeing small spots moving in front of his eyes.What should the nurse do?&#10;A) Refer the patient to an ophthalmologist for further evaluation.&#10;B) Explain that these &#34;floaters&#34; are usually normal and caused by liquefaction of the vitreous.&#10;C) Examine the retina of the patient's eye with an ophthalmoscope to visualize the spots.&#10;D) Inform the patient that these spots usually occur with aging and can be surgically removed if they are bothersome.

Accepted Answer

The answer of A 42-year-old man complains of seeing small...

Question 5

When assessing a patient,the nurse is alerted to the possibility of tinnitus when the patient reports which of the following information?&#10;A) Using a pillow over her upright ear&#10;B) Playing the radio for background music&#10;C) Putting her feet against the end of the bed frame&#10;D) Elevating her head and shoulders on three pillows

Accepted Answer

Tinnitus is a ringing, buzzing, or other noise in the ears or head that is not caused by an external sound source. Playing the radio for background music may indicate that the patient is trying to mask or cover up the tinnitus they are experiencing. Using a pillow over an upright ear, putting feet against the end of the bed frame, and elevating head and shoulders on pillows are not indicators of tinnitus.

Question 6

In the visual pathway,fibres from the nasal portion of each retina cross over to the opposite side of which structure?&#10;A) Optic nerve&#10;B) Lateral geniculate body&#10;C) Optic chiasma&#10;D) Fovea centralis

Accepted Answer

Fibers from the nasal portion of each retina cross over at the optic chiasm to the opposite side of the brain, specifically to the contralateral lateral geniculate body. This allows for the processing of visual information from both sides of the visual field by both hemispheres of the brain.

Question 7

Women are at greater risk for which one of the following diseases?&#10;A) Cataracts&#10;B) Eye trauma&#10;C) Colour blindness&#10;D) Macular degeneration

Accepted Answer

Macular degeneration is a disease that affects the central vision and is more common in women than men. It is a leading cause of blindness in people over 50 years old. Cataracts and eye trauma have no gender preference, and colour blindness is more common in men than women.

Question 8

A 56-year-old patient schedules annual testing for glaucoma with the ophthalmologist.What is involved in the procedure that is used to test for glaucoma?&#10;A) Reading a Snellen chart at 6 metres (20 feet)&#10;B) Application of a Tono-Pen to the cornea of the eye&#10;C) Shining a light into the pupil to determine its reaction&#10;D) Ophthalmoscopic examination of the posterior chamber

Accepted Answer

The most common method for testing for glaucoma is to measure the pressure in the eye using an instrument called a tonometer. The Tono-Pen is a handheld device that is used to gently touch the cornea of the eye to measure the pressure inside the eye.

Question 9

For which reason would a patient be having the diagnostic test keratometry?&#10;A) To determine field of vision&#10;B) To determine papillary response&#10;C) To measure the corneal curvature&#10;D) To provide a magnified view of the optic nerve head

Accepted Answer

Keratometry is a diagnostic test that measures the curvature of the cornea. It is commonly used prior to contact lens fitting or cataract surgery to determine the appropriate lens power and curvature.

Question 10

While observing a patient undergoing a caloric test,the nurse recognizes that which of the following is a normal finding?&#10;A) Vertigo&#10;B) Ear pain&#10;C) Hearing loss&#10;D) Little or no nystagmus

Accepted Answer

Vertigo is a normal finding during a caloric test as it indicates that the vestibular system is responding appropriately to the stimulation.

Question 11

When documenting the physical assessment findings of the pupils,the nurse writes PERRLA.How does the nurse interpret the initial &#34;R&#34; in this chart entry?&#10;A) Redness&#10;B) Round&#10;C) Reactive to light&#10;D) Retinal vessels normal

Accepted Answer

The answer of When documenting the physical assessment findings of...

Question 12

At the eye clinic,the nurse advises all patients to protect the eyes from ultraviolet (UV)light with the use of good sunglasses because UV light exposure is associated with the development of which of the following conditions?

A) Glaucoma
B) Exophthalmos
C) Floaters and anisocoria
D) Cataracts

Accepted Answer

The answer of At the eye clinic,the nurse advises all...

Question 13

In performing the confrontation test,for what is the nurse assessing?&#10;A) Visual acuity&#10;B) Visual field perimetry&#10;C) Extraocular muscle function&#10;D) Consensual pupillary response

Accepted Answer

The answer of In performing the confrontation test,for what is...

Question 14

The nurse examines a patient's auditory canal and tympanic membrane with an otoscope.Which of the following is an abnormal finding?&#10;A) The presence of cerumen&#10;B) A bluish-tinged tympanum&#10;C) The presence of a cone of light&#10;D) A translucent,shiny tympanum

Accepted Answer

The answer of The nurse examines a patient's auditory canal...

Question 15

How should the nurse assess a patient's pupillary response to accommodation?&#10;A) Shine a light into the patient's eye,and watch the pupil response in the opposite eye.&#10;B) Cover one eye for 1 minute,and note the pupil reaction when the cover is removed.&#10;C) Touch the cornea with a small piece of sterile cotton,and observe for a change in pupil size.&#10;D) Ask the patient to focus on an object at 60 to 90 cm and then to focus on the object at 7 to 8 cm.

Accepted Answer

The answer of How should the nurse assess a patient's...

Question 16

An 87-year-old patient has marked bilateral presbycusis.In performing a Rinne's test on the patient,what would the nurse anticipate?&#10;A) The patient can &#34;feel&#34; the noise longer than she can hear the noise.&#10;B) The patient hears the tuning fork best when it is placed next to the ear canal.&#10;C) The patient hears the tuning fork better when it is placed on the mastoid bone.&#10;D) The sound is equally diminished in both ears when the fork is placed in the middle of the forehead.

Accepted Answer

The answer of An 87-year-old patient has marked bilateral presbycusis.In...

Question 17

Which of the following is a possible cause of diplopia?&#10;A) Superficial corneal erosion&#10;B) Anterior uveitis&#10;C) Abnormalities of extraocular muscle action&#10;D) Liquefaction of the vitreous humor

Accepted Answer

The answer of Which of the following is a possible...

Question 18

A 44-year-old patient tells the nurse that she recently bought some reading glasses at the drugstore because they help her see at close range much better.When she asks the nurse what is happening to her eyes,the nurse explains that this often occurs in middle age and is a result of which of the following aging processes?

A) Thinning of the retina
B) Loss of lens elasticity
C) Degeneration of the cornea
D) Unevenness of the cornea

Accepted Answer

The answer of A 44-year-old patient tells the nurse that...

Question 19

At a clinic visit,a patient's wife tells the nurse that her husband is losing his hearing.The patient protests,saying that his wife mumbles.During the visit,the nurse identifies a hearing loss in the patient based on which of the following findings?

A) He speaks softly but slurs constantly during conversation.
B) He cannot repeat a word whispered at 25 cm from one ear.
C) He asks for frequent repetition and has a flat facial expression.
D) He leans forward to hear the nurse and complains of buzzing in the ears.

Accepted Answer

The answer of At a clinic visit,a patient's wife tells...

Question 20

During a nursing history,the patient comments that he cannot bend over and lift an object without becoming dizzy and that he frequently has to stop physical activities because of dizziness and nausea.Dysfunction of which of the following is most likely causing the patient's symptoms?

A) Cochlea
B) Middle ear
C) Organ of Corti
D) Semicircular canals

Accepted Answer

The answer of During a nursing history,the patient comments that...

Deck 23: Nursing Assessment: Visual and Auditory Systems