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

Question 1

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

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

Answer 1

Visual fields

Question 2

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 statement indicates to the nurse that the patient correctly understandings the main purpose of applying pressure?

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

Answer 2

"To reduce absorption of eyedrops through tear duct."

Question 3

The nurse performs a visual assessment on a patient and documents the findings using 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

Answer 3

Pupils equal, round, and reactive to light and accommodation

Question 4

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

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

Question 5

The nurse has reinforced teaching with a patient after diagnostic testing reveals tinnitus.Which patient statement 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 6

The nurse is caring for a patient who asks what arcus senilis is.How should the nurse explain this finding?

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

Question 7

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

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

Question 8

The nurse is reviewing the structure of the eye with a patient scheduled for cataract surgery.Which structure should the nurse explain is the gelatin-like substance that gives shape to the eye and fills the space behind the lens?

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

Question 9

The nurse performs a Snellen chart examination on a patient.What Snellen chart documentation indicates normal vision for the patient?

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

Question 10

The nurse is assisting with health screenings in a clinic.Which should the nurse consider a normal finding if noted lining the ear canal?

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

Question 11

After collecting data the nurse suspects a patient has hearing loss.Which finding supports this conclusion?

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

Question 12

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

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

Question 13

A patient asks how the ears are able to equalize pressure when flying in an airplane.Which anatomical ear structure should the nurse review with the patient?

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

Question 14

A patient's Snellen chart findings are 20/60.How should the nurse explain this finding to the patient?

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

Question 15

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) Iris
B) Lens
C) Pupil
D) Retina

Question 16

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

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

Question 17

The nurse is conducting an initial screening to determine a patient's gross hearing acuity as part of a complete physical.Which test should the nurse include in the assessment?

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

Question 18

The nurse is collecting data visually on a patient.Which lighting environment should the nurse use to examine the patient's pupils?

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

Question 19

The nurse palpates a downward small protrusion the helix of a patient's ear known as Darwin's tubercle.How should the nurse document this finding?

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

Question 20

The nurse suspects a patient has a hearing deficit.What behavior did the patient demonstrate that indicates a hearing loss?

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

Question 21

The nurse determines that a patient is experiencing common age-related changes in vision and hearing.What did the nurse assess in the patient? (Select all that apply.)

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

Question 22

The nurse is assisting with a patient's physical examination.For which test should the nurse plan for patient safety?

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

Question 23

The nurse is preparing a patient who will be having a digital retinal scan.Which patient statement indicates further teaching is necessary?

A) "This test is used to help detect eye disease early."
B) "The scanner will take a picture in about 2 seconds."
C) "My eyes will need to be dilated before the procedure."
D) "A digital image of most of my retina will be produced for the doctor to view."

Question 24

The nurse determines that a patient's hearing aid is functioning properly.What did the nurse observe to come to this conclusion?

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

Question 25

The nurse is teaching a patient with a hearing disorder.Which hearing loss should the nurse explain are helped with a hearing aid?

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

Question 26

A patient is being tested for visual acuity.What distance from the eyes should the patient hold the visual acuity chart during this testing?

A) 3 feet
B) 1 foot
C) 14 inches
D) 20 inches

Question 27

A patient is diagnosed with a corneal abrasion.When reviewing this injury with the patient which layer of the eye should the nurse explain as being damaged?

A) Fibrous tunic
B) Nervous tunic
C) Vascular tunic
D) Muscular tunic

Question 28

The nurse has reinforced teaching with a patient about diagnostic tests that evaluate eye muscle balance.Which tests identified by the patient indicate teaching has been effective? (Select all that apply.)

A) Cover test
B) Corneal light reflex
C) Tonometer readings
D) Electroretinography
E) Computed tomography
F) Fluorescein angiography

Question 29

An older patient is experiencing a change in color vision.Which structure of the eye does the nurse realize is affected in tis patient?

A) Iris
B) Rods
C) Cones
D) Retina

Question 30

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 patient statements indicate that further instruction is needed? (Select all that apply.)

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

Question 31

A patient is diagnosed with night blindness.For which supplement should the nurse prepare to review with this patient?

A) Vitamin A
B) Vitamin B
C) Vitamin C
D) Vitamin D

Question 32

During a health history the nurse suspects that a patient is at risk for a vision problem.Which information within the family history did the nurse use to make this decision? (Select all that apply.)

A) Asthma
B) Diabetes
C) Cataracts
D) Blindness
E) Glaucoma

Question 33

A patient is diagnosed as being legally blind.What Snellen chart rating should the nurse expect when collecting data with this patient?

A) 20/20
B) 20/40
C) 20/100
D) 20/200

Question 34

Prior to measuring a patient's hearing the nurse obtains a tuning fork.Which hearing tests is the nurse preparing to conduct? (Select all that apply.)

A) Rinne test
B) Weber test
C) Caloric test
D) Tympanometry
E) Electronystagmogram

Question 35

A patient is diagnosed with sensorineural deafness.The nurse realizes that which cranial nerve is malfunctioning in this patient?

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

Question 36

During data collection a patient states that at times the ears hurt when there are loud noises.The nurse realizes that the patient is describing noises at which decibel level?

A) 50
B) 75
C) 110
D) 130

Question 37

A patient is scheduled for an indocyanine green angiography.For what should the nurse assess before this patient has the test?

A) Allergy to dye
B) Last solid food
C) Medications taken
D) Transportation home

Question 38

While checking a patient's pupils the nurse notes that the left pupil constricts when a light is shined into the right eye.What does this information suggest to the nurse?

A) Tropia present
B) Esotropia absent
C) Accommodation absent
D) Consensual response present

Question 39

The nurse is reviewing the process of hearing with a patient experiencing a hearing deficit.What should the nurse explain as being the receptors in the organ of Corti?

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

Question 40

The nurse is caring for a patient who has presbycusis.What approach should the nurse use to enhance communication with this patient?

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

Question 41

The nurse is explaining the process of hearing to a group of high school students.Place the steps in order (1-6)as they occur during the process of hearing.All options must be used.

A) ____ Sound waves strike the eardrum causing it to vibrate.
B) ____ Vibrations pass through the cochlea.
C) ____ The stapes transmits vibrations to the inner ear at the oval window.
D) ____ Vibrations are transmitted through the auditory bones.
E) ____ Vibrations pass through hair cells in the organ of Corti.
F) ____ Impulses are carried by the eighth cranial nerve to the brain.

Question 42

The nurse is preparing to provide eye medication to a patient.In which order should the nurse perform this procedure? Place the steps in the order (1-6)in which they should be performed.All options must be used.

A) ____ Instruct the patient to tilt head backward and look up toward the ceiling.
B) ____ Check the medications for dosage, strength, side effects, contraindications, and expiration date.
C) ____ Approach the patient's eye from the side, and instill the prescribed amount of medication into the lower lid pocket.
D) ____ Gently pull the lower lid down and out to form a pocket.
E) ____ Gently apply pressure with a tissue to the punctum for at least 1 minute to prevent the medication from being absorbed systemically.
F) ____ Wipe any excess medication from eyelids or cheek.