Deck 38: Assessment of Sensory Function

Question 1

The nurse who assesses a hematoma behind a client's left ear over the mastoid bone would document this finding as being:

A) normal.
B) Battle's sign.
C) caused by sun exposure.
D) perichondritis.

Answer 1

Battle's sign.

Question 2

A client is diagnosed with a vision disorder. The nurse realizes that the client will experience an alteration in sensory information because the eyes transmit what percentage of all sensory information to the brain?

A) 30%
B) 50%
C) 70%
D) 90%

Answer 2

70%

Question 3

The nurse assesses a client as having many risk factors for otitis media. Which of the following would increase the client's risk for developing this disorder? (Select all that apply.)

A) Frequent upper respiratory tract infections
B) Attends daycare
C) Male gender
D) Female gender
E) Age 15
F) Rides a bicycle

Answer 3

Frequent upper respiratory tract infections
Attends daycare
Male gender

Question 4

The nurse is performing an assessment on a client. To test the optic nerve's function, what should the nurse do?

A) Check for extraocular movement.
B) Check the pupils for reaction to light.
C) Check to see if the patient can blink.
D) Use a Snellen chart.

Question 5

During the assessment of a client's external ear canal, the nurse identifies a painful pustule. The nurse realizes this assessment finding could be caused by:

A) furunculosis.
B) exostoses.
C) hemotympanum.
D) acute otitis media.

Question 6

A client tells the nurse that she has to swallow to improve her hearing. The nurse realizes that this action:

A) causes the tympanic membrane to vibrate.
B) makes the hammer vibrate.
C) stabilizes equilibrium.
D) equalizes pressure.

Question 7

A client tells the nurse that he has noticed a decrease in hearing. Which of the following would be risk factors for the client to have a change in hearing? (Select all that apply.)

A) Smoking
B) Neck trauma
C) Cardiovascular disease
D) Aging
E) Diabetes
F) Chronic infection

Question 8

When assessing the corneal reflex, the nurse realizes this reflex is a function of which cranial nerve (CN)?

A) CN II
B) CN III
C) CN IV
D) CN V

Question 9

A client was assessed as having normal intraocular pressure. The nurse would document this client's pressure as being:

A) 5 mmHg ± 3 mmHg.
B) 15 mmHg ± 3 mmHg.
C) 30 mmHg ± 3 mmHg.
D) 50 mmHg ± 3 mmHg.

Question 10

The nurse realizes that a client, diagnosed with chronic dry eyes, may have a disorder of the lacrimal gland because it:

A) covers the eye for protection.
B) produces tears to lubricate the eye.
C) helps the eye keep its shape.
D) provides blood to the eye.

Question 11

Which of the following would the nurse include when assessing a client's ears? (Select all that apply.)

A) Onset of dizziness
B) Changes in hearing
C) Presence of otorrhea
D) Duration of otalgia
E) Swallowing difficulties
F) Degree of neck pain

Question 12

A client is having difficulty perceiving different colors. The nurse realizes the client may have a disorder that affects the photosensitive receptor cells of the retina, which makes the perception of color possible, or a disorder that affects the:

A) rods.
B) cones.
C) optic discs.
D) irises.

Question 13

The nurse, assisting with the examination of a client's eyes, is preparing the ophthalmoscope. Which of the following apertures might be needed for this examination? (Select all that apply.)

A) Small round light
B) Large round light
C) Grid
D) Slit light
E) Green light
F) Black light

Question 14

Which of the following tests can be done by the nurse to assess a client's hearing? (Select all that apply.)

A) Voice-whisper test
B) Allen's test
C) Weber test
D) Cochlear test
E) Rinne test
F) Stapes test

Question 15

A client is diagnosed with an inability to recognize visual information. The nurse realizes that which of the following cranial nerves is involved in the transmitting of visual stimuli to the brain for interpretation?

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