Chapter 64 : Assessment of the Eyes and Ears Nursing School Test Banks

Black & Hawks: Medical-Surgical Nursing, 8th Edition

Test Bank

Chapter 64 : Assessment of the Eyes and Ears

MULTIPLE CHOICE

1. The nurse performing an assessment of a client with a neuromuscular disorder finds that the left upper eyelid sags and covers a portion of the pupil. The nurse would note this finding on the client record as

a.

amblyopia.

b.

lid eversion.

c.

presbyopia.

d.

ptosis.

ANS: D

Visual changes or loss of vision may be caused by abnormalities in the eye or anywhere along the visual pathway. Considerations include a refractive (focusing) error and interference from lid drooping (ptosis).

DIF: Comprehension/Understanding REF: p. 1678 OBJ: Assessment

MSC: Physiological Integrity Reduction of Risk Potential-System Specific Assessments

2. A client is being treated for arthritis with large doses of aspirin, and the nurse assesses the client for ototoxicity. The most indicative clinical manifestation of damage to the eighth cranial nerve is

a.

ear pain.

b.

hearing loss.

c.

nystagmus.

d.

tinnitus.

ANS: D

Certain medications can damage the vestibulocochlear nerve (eighth cranial nerve), with resultant hearing loss. Aspirin is a common cause of tinnitus.

DIF: Application/Applying REF: p. 1693 OBJ: Assessment

MSC: Physiological Integrity Pharmacological and Parenteral Therapies-Adverse Effects/Contraindications

3. The nurse conducting an otoscopic examination visualizes an eardrum that is shiny and pearl gray in color. The nurse would know that this assessment is consistent with

a.

a history of otitis media.

b.

a normal tympanic membrane.

c.

blood in the middle ear.

d.

infection in the ear canal.

ANS: B

The normal eardrum is slightly conical, shiny, smooth, and pearl gray in color.

DIF: Comprehension/Understanding REF: p. 1695 OBJ: Assessment

MSC: Physiological Integrity Reduction of Risk Potential-System Specific Assessments

4. Before insertion of the otoscope speculum in the ear of an adult, the nurse would pull the pinna

a.

down and back.

b.

down and forward, and out.

c.

up and back, and out.

d.

up and forward.

ANS: C

With the nondominant hand, the pinna is pulled up, back, and out (in the adult), thus straightening the ear canal.

DIF: Application/Applying REF: p. 1695 OBJ: Assessment

MSC: Physiological Integrity

5. The nurse would ask a client with the diagnosis of myopia about a family history of

a.

central vision loss.

b.

color blindness.

c.

farsightedness.

d.

nearsightedness.

ANS: D

Because many ocular disorders tend to be familial, the nurse should ask specifically about strabismus, glaucoma, myopia (nearsightedness), and hyperopia (farsightedness).

DIF: Application/Applying REF: pp. 1681-1683

OBJ: Assessment

MSC: Physiological Integrity Reduction of Risk Potential-System Specific Assessments

6. The nurse examining the conjunctivae of a healthy young adult would document a normal finding when recording that the color of the conjunctivae is

a.

dark red.

b.

pale.

c.

pink.

d.

yellow tinged.

ANS: C

Healthy conjunctivae are pink to light red; paleness or a bright-red color is abnormal.

DIF: Application/Applying REF: p. 1683 OBJ: Assessment

MSC: Physiological Integrity Reduction of Risk Potential-System Specific Assessments

7. The nurse conducting a physical examination is assessing a clients pupillary reactions. To do this correctly, the nurse would

a.

ask the client to open the eyes and stare into the penlight.

b.

ask the client to stare straight ahead and then turn on the penlight.

c.

bring the penlight up from the clients chin to shine directly over the pupil.

d.

bring the penlight in from the side to shine directly over the pupil.

ANS: D

The client is instructed to look straight ahead. To test direct response to light, the penlight is brought in from the side to shine directly over the center of pupil. Light should cause the iris to constrict, causing the pupil to become smaller.

DIF: Application REF: pp. 1684-1685 OBJ: Assessment

MSC: Physiological Integrity Reduction of Risk Potential-System Specific Assessments

8. If a client shows intolerance to light during pupil examination, the nurse would record that the client exhibits

a.

photophobia.

b.

reduced accommodation.

c.

strabismus.

d.

unequal pupil response.

ANS: A

Abnormal results include photophobia (light intolerance), irregular or unequal pupils, and pupils that do not react to light or accommodation. Strabismus is deviation in the alignment of one eye in relation to the other; it often presents as crossed eyes.

DIF: Comprehension/Understanding REF: p. 1678 OBJ: Assessment

MSC: Physiological Integrity Reduction of Risk Potential-System Specific Assessments

9. When a nurse testing visual acuity is using a Snellen chart, the distance that the client would be positioned from the chart is

a.

5 feet.

b.

10 feet.

c.

15 feet.

d.

20 feet.

ANS: D

Visual acuity is traditionally measured with the Snellen chart at a distance of 20 feet. At this distance, rays of light from an object are practically parallel, and little effort of accommodation is required.

DIF: Comprehension REF: p. 1686 OBJ: Assessment

MSC: Physiological Integrity Reduction of Risk Potential-System Specific Assessments

10. Using a Snellen chart, the nurse would credit a client with reading the line of print if the client has correctly read more than

a.

50% of the characters.

b.

60% of the characters.

c.

80% of the characters.

d.

90% of the characters.

ANS: A

The nurse credits the client for the smallest line of print that is read with more than 50% accuracy.

DIF: Application/Applying REF: p. 1686 OBJ: Assessment

MSC: Physiological Integrity Reduction of Risk Potential-System Specific Assessments

11. After completion of an eye examination using direct ophthalmoscopy, the assessment that the nurse would document as normal is

a.

irregular margins to optic disc.

b.

oval optic disc.

c.

physiologic cup 75% of optic disc diameter.

d.

retinal veins darker than arteries.

ANS: D

The optic disc appears round, with well-defined margins (except in the nasal margin) and a creamy pink color. The physiologic cup (depressed center of the disc) should be no larger than one half the diameter of the optic disc. The retinal veins are darker than the retinal arteries.

DIF: Application/Applying REF: p. 1685 OBJ: Assessment

MSC: Physiological Integrity Reduction of Risk Potential-System Specific Assessments

12. The occupational health nurse evaluating noise levels in the workplace would be concerned when readings show the noise level to be more than

a.

10-15 decibels.

b.

20-30 decibels.

c.

45-50 decibels.

d.

85-90 decibels.

ANS: D

Ordinary speech level measures about 60 decibels; heavy traffic is about 70 decibels. Noise greater than 80 decibels is uncomfortable to the human ear, and exposure to noise at greater than 85-90 decibels for a length of time causes damage.

DIF: Comprehension/Understanding REF: pp. 1693-1694

OBJ: Assessment

MSC: Health Promotion and Maintenance Prevention and/or Early Detection of Health Problems-Disease Prevention

13. To evaluate a clients balance using Rombergs test, the nurse would

a.

seat the client and request the client touch the nurses outstretched finger with eyes closed.

b.

seat the client upright with eyes closed, and then ask the client to touch the nose.

c.

stand the client with feet a foot apart, eyes closed, and arms outstretched.

d.

stand the client with feet together, eyes closed, and arms to the side.

ANS: D

The inner ear is assessed for balance by performing Rombergs test. The client is asked to stand with feet together, eyes closed, and arms at the sides while the nurse observes the clients ability to hold that posture without sway.

DIF: Application/Applying REF: pp. 1695-1696

OBJ: Assessment

MSC: Physiological Integrity Reduction of Risk Potential-System Specific Assessments

14. The nurse would interpret a myopic clients vision as the clients ability to

a.

read at 30 feet what a person with normal vision can read at 20 feet.

b.

read at 20 feet what a person with normal vision can read at 30 feet.

c.

read correctly 30 figures or characters at 20 feet.

d.

read 20% of the figures or characters at 30 feet.

ANS: B

The vision evaluation is based on vision at 20 feet, with being perfect. Vision of means that the client can read at 20 feet what a person with normal vision can read at 30 feet.

DIF: Application/Applying REF: p. 1686 OBJ: Assessment

MSC: Physiological Integrity Reduction of Risk Potential-System Specific Assessments

15. The nurse would explain to a client that the voice, rather than a ticking watch, is used to test auditory acuity because watches

a.

can be muffled by the examiners hand.

b.

have different sound frequencies.

c.

make a familiar and predictable sound.

d.

produce a higher pitch.

ANS: D

The ticks of a watch have a higher pitch, which is less relevant to functional hearing than is the voice.

DIF: Comprehension/Understanding REF: p. 1695 OBJ: Intervention

MSC: Physiological Integrity Reduction of Risk Potential-System Specific Assessments

16. A client has severe hearing loss that occurred within the last year. It is important for the nurse to also assess the client for

a.

accompanying visual losses.

b.

frustration and loneliness.

c.

hypertension and heart disease.

d.

impaired physical mobility.

ANS: B

Clients with hearing loss can become frustrated, embarrassed, and lonely, which may all lead to isolation and depression. It is important to assess for these psychosocial consequences of hearing loss. Visual losses do not often accompany hearing loss, hypertension and heart disease are not related to hearing loss, and hearing loss does not cause impaired physical mobility, unless the client curtails activities voluntarily.

DIF: Analysis/Analyzing REF: p. 1690 OBJ: Assessment

MSC: Psychosocial Integrity Coping and Adaptation-Grief and Loss

17. A client is complaining of dryness, burning, and grittiness in both eyes. The nurse would conduct further assessments to confirm a suspicion of

a.

acute angle glaucoma.

b.

allergies.

c.

hypertensive eye disease.

d.

mild corneal abrasion.

ANS: D

Mild corneal abrasions or dry eyes can cause the listed manifestations. Allergies usually cause itching. Acute angle glaucoma is severely painful (see Chapter 65). Hypertension usually causes visual problems.

DIF: Analysis/Analyzing REF: p. 1678 OBJ: Intervention

MSC: Physiological Integrity Physiological Adaptation-Pathophysiology

MULTIPLE RESPONSE

1. An important primary prevention activity the nurse could teach a community group for vision is (Select all that apply)

a.

having an annual ophthalmologic examination.

b.

keeping blood pressure under control.

c.

taking medication for glaucoma as prescribed.

d.

wearing safety goggles and sunglasses.

ANS: B, D

Primary prevention attempts to prevent disease processes before they start. Maintaining normal blood pressure can prevent hypertension-related eye problems. Wearing safety goggles and sunglasses can prevent eye injury. An annual eye exam is secondary prevention and taking glaucoma medications would be tertiary prevention.

DIF: Comprehension/Understanding REF: p. 1680 OBJ: Intervention

MSC: Health Promotion and Maintenance Prevention and/or Early Detection of Health Problems-Disease Prevention

2. The nurse assessing a client with declining visual acuity would use gentle questioning and tact because (Select all that apply)

a.

a client might not give accurate answers if he/she thinks driving will be restricted.

b.

lack of a family history might mean a client has no risk of vision disorders.

c.

social stigma accompanying blindness may cause the client anxiety.

d.

vision disorders affect dependence and independence.

e.

vocational barriers may force the client to seek different employment.

ANS: A, C, D, E

There are many reasons why clients who have visual disorders might be anxious or fearful, including fear of losing driving privileges, social stigma, loss of independence, and vocational barriers. The nurse interviewing and assessing a client with visual problems needs to use tact and therapeutic communication in order to obtain accurate information.

DIF: Application/Applying REF: p. 1681 OBJ: Assessment

MSC: Psychosocial Integrity Coping and Adaptation-Unexpected Body Image Changes

3. A nurse is working with a client who has moderate hearing loss. Communication adaptations the nurse uses include (Select all that apply)

a.

enunciating words clearly.

b.

facing the client directly.

c.

slowing the speech down.

d.

speaking very loudly.

ANS: A, B, C

Options a, b, and c will help the hearing-impaired client hear and understand you. Speaking very loudly, or shouting, is unnecessary.

DIF: Application/Applying REF: p. 1690 OBJ: Intervention

MSC: Psychosocial Integrity Coping and Adaptation-Therapeutic Communication

Elsevier items and derived items 2009 by Saunders, an imprint of Elsevier Inc.

Some material was previously published.

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