Chapter 45 Verified Test Bank Assessing The Eye And Ear - Medical Surgical Nursing 7e | Test Bank by LeMone, Burke, Bauldoff by LeMone, Burke, Gerene Bauldoff. DOCX document preview.
LeMone & Burke's Medical-Surgical Nursing, 7e (Bauldoff/Gubrud/Carno)
Chapter 45 Assessing the Eye and Ear
1) A patient recovering from a stroke is reporting vision changes. For which reason should the nurse consider these changes are occurring?
1. The stroke occurred in the optic region of the patient's brain.
2. The brain interprets information received through the eyes.
3. The patient is experiencing another stroke.
4. The patient is unable to talk because of the stroke.
Page Ref: 1673
Cognitive Level: Analyzing
Client Need & Sub: Physiological Integrity: Physiological Adaptation
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 45.1 Describe the anatomy, physiology, and functions of the eye, and identify abnormal findings that may indicate visual impairment.
MNL Learning Outcome: 3. Interpret abnormal findings of the eye and ear collected during assessment.
2) While exiting a burning building, a patient's eyebrows and lashes were burned. What should the nurse suspect this patient might experience?
1. Wound infections
2. Fluid and electrolyte imbalance
3. Foreign bodies in the eyes
4. Itchiness as the hair grows back
Page Ref: 1673
Cognitive Level: Analyzing
Client Need & Sub: Physiological Integrity: Physiological Adaptation
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 45.1 Describe the anatomy, physiology, and functions of the eye, and identify abnormal findings that may indicate visual impairment.
MNL Learning Outcome: 3. Interpret abnormal findings of the eye and ear collected during assessment.
3) A patient has sustained an injury to the inner layer of the left retina. Which change should the patient expect to experience?
1. Tear production
2. Blinking
3. Reading
4. Peripheral vision and color perception
Page Ref: 1674-1675
Cognitive Level: Analyzing
Client Need & Sub: Physiological Integrity: Physiological Adaptation
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 45.1 Describe the anatomy, physiology, and functions of the eye, and identify abnormal findings that may indicate visual impairment.
MNL Learning Outcome: 3. Interpret abnormal findings of the eye and ear collected during assessment.
4) A patient with an injury to the right eye has received an eye patch. Which difficulty might the patient experience because of the patch?
1. Depth perception
2. Reading
3. Light perception
4. Color perception
Page Ref: 1676
Cognitive Level: Analyzing
Client Need & Sub: Physiological Integrity: Physiological Adaptation
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 45.1 Describe the anatomy, physiology, and functions of the eye, and identify abnormal findings that may indicate visual impairment.
MNL Learning Outcome: 3. Interpret abnormal findings of the eye and ear collected during assessment.
5) During an eye examination, a patient is able to read all the letters on the Snellen chart without difficulty at a distance of 15 feet. How should the nurse interpret this finding?
1. Normal 20/20 vision
2. Normal reading vision
3. Visual impairments
4. Normal pupillary reflex
Page Ref: 1678
Cognitive Level: Analyzing
Client Need & Sub: Health Promotion and Maintenance: Health Screening
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 45.2 Outline the components of the assessment of the eye and vision, including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment.
MNL Learning Outcome: 3. Interpret abnormal findings of the eye and ear collected during assessment.
6) A patient is found to need corrective lenses. Which diagnostic test was most likely used to determine this finding?
1. Computed tomography (CT) scan
2. Tonometry
3. Refractometry
4. Response to atropine eye drops
Page Ref: 1682
Cognitive Level: Applying
Client Need & Sub: Health Promotion and Maintenance: Health Screening
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 45.3 Describe the anatomy, physiology, and functions of the ear, and identify abnormal findings that may indicate hearing impairment.
MNL Learning Outcome: 4. Recognize the purpose of and related nursing interventions for patients undergoing diagnostic tests for assessment of the eye and ear.
7) The nurse is assessing a patient's visual fields by covering the right eye with an opaque covering. Which action should the nurse perform next?
1. Cover own right eye.
2. Cover own left eye.
3. Keep both eyes uncovered.
4. Turn the lights on in the room before conducting this examination.
Page Ref: 1678
Cognitive Level: Applying
Client Need & Sub: Health Promotion and Maintenance: Techniques of Physical Assessment
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 45.2 Outline the components of the assessment of the eye and vision, including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment.
MNL Learning Outcome: 1. Utilize appropriate techniques to perform a health history and physical assessment of the eye and ear.
8) A 20-year-old patient is experiencing difficulty with near vision. How should the nurse interpret this finding?
1. Consistent with the aging process
2. Normal in a 20-year-old patient
3. Evidence of presbyopia
4. Evidence of hyperopia
Page Ref: 1678
Cognitive Level: Analyzing
Client Need & Sub: Health Promotion and Maintenance: Health Screening
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 45.2 Outline the components of the assessment of the eye and vision, including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment.
MNL Learning Outcome: 3. Interpret abnormal findings of the eye and ear collected during assessment.
9) When performing the cover test, the nurse notes that a patient's left eye deviates inward when focusing on an object. What should this finding indicate to the nurse?
1. Presbyopia
2. Hyperopia
3. Weakness
4. Myopia
Page Ref: 1678
Cognitive Level: Analyzing
Client Need & Sub: Health Promotion and Maintenance: Health Screening
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 45.2 Outline the components of the assessment of the eye and vision, including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment.
MNL Learning Outcome: 3. Interpret abnormal findings of the eye and ear collected during assessment.
10) A patient who is using atropine eyedrops is found to have a poor consensual light response. What should the nurse conclude from this finding?
1. An abnormal finding that should be reported to the healthcare provider
2. Normal because of the eyedrops
3. Evidence of retinal degeneration
4. Evidence of optic nerve damage
Page Ref: 1679
Cognitive Level: Analyzing
Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 45.2 Outline the components of the assessment of the eye and vision, including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment.
MNL Learning Outcome: 3. Interpret abnormal findings of the eye and ear collected during assessment.
11) During the assessment of a patient's outer eyes, the nurse suspects that the patient has a hair follicle infection. What did the nurse most likely assess in this patient?
1. Xanthelasma
2. Ptosis
3. Exophthalmos
4. Sty
Page Ref: 1679
Cognitive Level: Analyzing
Client Need & Sub: Physiological Integrity: Physiological Adaptation
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 45.2 Outline the components of the assessment of the eye and vision, including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment.
MNL Learning Outcome: 3. Interpret abnormal findings of the eye and ear collected during assessment.
12) A patient is assessed as having an absence of the fovea centralis. Which should be inspected next?
1. Red reflex
2. Retina
3. Macula
4. Optic disc
Page Ref: 1680
Cognitive Level: Applying
Client Need & Sub: Physiological Integrity: Reduction of Risk Potential
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 45.2 Outline the components of the assessment of the eye and vision, including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment.
MNL Learning Outcome: 2. Recognize normal findings of the eye and ear collected during assessment and health promotion activities to support the health of this body system.
13) A patient with a sore throat is complaining of "trouble with hearing." What might the patient be experiencing?
1. Sinus infection
2. Middle ear infection
3. Infected tonsils
4. Inner ear infection
Page Ref: 1683
Cognitive Level: Analyzing
Client Need & Sub: Physiological Integrity: Physiological Adaptation
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 45.3 Describe the anatomy, physiology, and functions of the ear, and identify abnormal findings that may indicate hearing impairment.
MNL Learning Outcome: 3. Interpret abnormal findings of the eye and ear collected during assessment.
14) During a Weber test, a patient is found to have increased hearing in the right ear. What should the nurse suspect is occurring with this patient?
1. Normal aging
2. Conductive hearing loss in the right ear
3. Possible buildup of cerumen or otitis media in the left ear
4. Perforated left eardrum
Page Ref: 1686
Cognitive Level: Analyzing
Client Need & Sub: Physiological Integrity: Physiological Adaptation
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 45.4 Outline the components of the assessment of the ear and hearing, including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment.
MNL Learning Outcome: 3. Interpret abnormal findings of the eye and ear collected during assessment.
15) A patient is found to have small, raised lesions on the rim of the ear. Which health problem should the nurse suspect is occurring with the patient?
1. Hypertension
2. Gout
3. Heart disease
4. Kidney failure
Page Ref: 1687
Cognitive Level: Analyzing
Client Need & Sub: Physiological Integrity: Physiological Adaptation
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 45.4 Outline the components of the assessment of the ear and hearing, including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment.
MNL Learning Outcome: 3. Interpret abnormal findings of the eye and ear collected during assessment.
16) An older patient says, "I seem to be talking so much louder these days and I don't know why!" What should the nurse realize this patient might be experiencing?
1. Loss of hair cells in the middle ear
2. Cochlear atrophy
3. Impacted cerumen
4. Stiffening of the middle ear structures
Page Ref: 1689
Cognitive Level: Analyzing
Client Need & Sub: Health Promotion and Maintenance: Aging Process
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 45.5 Differentiate considerations for assessing vision and hearing of older adults, veterans, and adults with sequelae of childhood/congenital conditions.
MNL Learning Outcome: 2. Recognize normal findings of the eye and ear collected during assessment and health promotion activities to support the health of this body system.
17) A patient is scheduled for diagnostic tests to determine the cause of a hearing and balance disorder. For which diagnostic test should the nurse prepare this patient? Select all that apply.
1. Tonometry
2. Computed tomography (CT) scan
3. Electronystagmography (ENG)
4. Auditory evoked potentials (AEP)
5. Auditory brainstem response (ABR)
Page Ref: 1688
Cognitive Level: Applying
Client Need & Sub: Physiological Integrity: Reduction of Risk Potential
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Planning/Teaching/Learning
Learning Outcome: 45.4 Outline the components of the assessment of the ear and hearing, including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment.
MNL Learning Outcome: 4. Recognize the purpose of and related nursing interventions for patients undergoing diagnostic tests for assessment of the eye and ear.
18) The nurse is preparing to perform an otoscopic examination of the ear. List in order of priority the steps the nurse would perform.
Choice 1. Explain the procedure to the patient.
Choice 2. Grasp the superior portion of the auricle and pull up, out, and back to straighten the auditory canal.
Choice 3. Hold the handle of the otoscope in the dominant hand, otoscope handle upward.
Choice 4. Wash the hands.
Choice 5. Turn on the otoscope light.
Choice 6. Rest the hand holding the otoscope against the patient's head.
Page Ref: 1685-1686
Cognitive Level: Applying
Client Need & Sub: Health Promotion and Maintenance: Techniques of Physical Assessment
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 45.4 Outline the components of the assessment of the ear and hearing, including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment.
MNL Learning Outcome: 1. Utilize appropriate techniques to perform a health history and physical assessment of the eye and ear.
19) A patient is experiencing dizziness and disequilibrium with head movements. For which problem should the nurse plan care?
1. Imbalanced fluids
2. Difficulty adjusting to life changes
3. Problems with coping
4. Potential to fall
Page Ref: 1689
Cognitive Level: Applying
Client Need & Sub: Physiological Integrity: Reduction of Risk Potential
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning
Learning Outcome: 45.5 Differentiate considerations for assessing vision and hearing of older adults, veterans, and adults with sequelae of childhood/congenital conditions.
MNL Learning Outcome: 3. Interpret abnormal findings of the eye and ear collected during assessment.
20) The nurse suspects that a patient has bone-conductive hearing loss. Which assessment technique should the nurse use to differentiate between bone conduction loss and air conduction loss?
1. Rinne test
2. Weber test
3. Assessment of balance and body position
4. Palpation of mastoid process
Page Ref: 1686
Cognitive Level: Applying
Client Need & Sub: Physiological Integrity: Reduction of Risk Potential
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 45.4 Outline the components of the assessment of the ear and hearing, including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment.
MNL Learning Outcome: 1. Utilize appropriate techniques to perform a health history and physical assessment of the eye and ear.
21) A patient has a tonometer test result of 28 mmHg. Which explanation by the nurse about this pressure reading is most accurate?
1. The pressure in the eye has been measured and is too low. Medication will be required to increase the pressure and prevent blindness from retinal damage.
2. The pressure in the inner ear has been measured to evaluate the semicircular canals' function related to nerve damage and is within the normal range.
3. The pressure in the middle ear that builds up with mastoiditis has been measured. The condition needs to be treated with surgical insertion of tubes to drain the fluid behind the tympanic membrane.
4. The pressure in the eye has been measured and is above normal. This condition could lead to possible retinal changes if not treated.
Page Ref: 1682
Cognitive Level: Analyzing
Client Need & Sub: Physiological Integrity: Reduction of Risk Potential
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.4. Communicate effectively with all members of the healthcare team, including the patient and the patient's support network | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Communication and Documentation
Learning Outcome: 45.2 Outline the components of the assessment of the eye and vision, including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment.
MNL Learning Outcome: 3. Interpret abnormal findings of the eye and ear collected during assessment.
22) The nurse is assessing a 75-year-old patient. Which patient report would require immediate action by the nurse?
1. Occasional presence of floaters
2. Greater need for additional light and reading glasses
3. Development of a white circle around the iris
4. Frequent falls from tripping over items on the floor
Page Ref: 1689
Cognitive Level: Analyzing
Client Need & Sub: Health Promotion and Maintenance: Aging Process
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 45.5 Differentiate considerations for assessing vision and hearing of older adults, veterans, and adults with sequelae of childhood/congenital conditions.
MNL Learning Outcome: 2. Recognize normal findings of the eye and ear collected during assessment and health promotion activities to support the health of this body system.
23) The nurse is assessing a patient for neurological changes after a head trauma. Which eye assessment should the nurse perform? Select all that apply.
1. Ptosis
2. Extraocular movements
3. Accommodation
4. Color of iris
5. Nystagmus
Page Ref: 1678-1679
Cognitive Level: Applying
Client Need & Sub: Physiological Integrity: Physiological Adaptation
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 45.2 Outline the components of the assessment of the eye and vision, including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment.
MNL Learning Outcome: 1. Utilize appropriate techniques to perform a health history and physical assessment of the eye and ear.
24) The nurse is assessing a patient for a possible conductive hearing loss. What should the nurse perform first?
1. External ear examination
2. Weber test
3. Rinne test
4. Tympanogram
Page Ref: 1687
Cognitive Level: Applying
Client Need & Sub: Physiological Integrity: Physiological Adaptation
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 45.4 Outline the components of the assessment of the ear and hearing, including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment.
MNL Learning Outcome: 1. Utilize appropriate techniques to perform a health history and physical assessment of the eye and ear.
25) The nurse is performing an assessment of an 82-year-old patient's eyes. Which patient statement should the nurse expect based on the patient's age? Select all that apply.
1. "I've been having some drainage from the inside corner of my eye."
2. "My eyes feel so dry most of the time."
3. "I have almost fallen several times at home going down our basement stairs."
4. "I have this white circle around the color of my eyes."
5. "I have a hard time driving at night."
Page Ref: 1688-1689
Cognitive Level: Analyzing
Client Need & Sub: Health Promotion and Maintenance: Aging Process
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 45.5 Differentiate considerations for assessing vision and hearing of older adults, veterans, and adults with sequelae of childhood/congenital conditions.
MNL Learning Outcome: 2. Recognize normal findings of the eye and ear collected during assessment and health promotion activities to support the health of this body system.
26) The nurse is assessing the ears of a patient who is African American. Which assessment finding should the nurse identify as abnormal?
1. During the Rinne test, the patient hears the sound by air conduction for an equal amount of time as by bone conduction.
2. The patient is able to hear whispers from 18 inches away.
3. The patient's cerumen is dark gray.
4. The patient's tympanic membrane is pearly gray.
Page Ref: 1686
Cognitive Level: Analyzing
Client Need & Sub: Physiological Integrity: Physiological Adaptation
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 45.4 Outline the components of the assessment of the ear and hearing, including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment.
MNL Learning Outcome: 3. Interpret abnormal findings of the eye and ear collected during assessment.
27) The nurse is reviewing the physiology of the ear with a patient with a hearing disorder. What should the nurse explain about the function of the inner ear? Select all that apply.
1. It coordinates visual pathways.
2. It integrates efferent neuron messages.
3. It provides information about head position.
4. It maintains middle ear structure and function.
5. It conducts sound.
Page Ref: 1683
Cognitive Level: Applying
Client Need & Sub: Physiological Integrity: Physiological Adaptation
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning
Learning Outcome: 45.3 Describe the anatomy, physiology, and functions of the ear, and identify abnormal findings that may indicate hearing impairment.
MNL Learning Outcome: 2. Recognize normal findings of the eye and ear collected during assessment and health promotion activities to support the health of this body system.
28) The nurse is preparing to assess an older patient's ears. Which technique should the nurse consider when conducting this assessment? Select all that apply.
1. Whisper test
2. Rinne test
3. Weber test
4. Electronystagmography (ENG)
5. Audiometer
Page Ref: 1686-1687
Cognitive Level: Applying
Client Need & Sub: Health Promotion and Maintenance: Techniques of Physical Assessment
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 45.4 Outline the components of the assessment of the ear and hearing, including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment.
MNL Learning Outcome: 1. Utilize appropriate techniques to perform a health history and physical assessment of the eye and ear.
29) The nurse determines that an older patient has age-related changes in the vestibular structures of the ear. What should the nurse identify as a risk for this patient? Select all that apply.
1. Infection
2. Falls
3. Medication errors
4. Food intolerance
5. Problems communicating
Page Ref: 1689
Cognitive Level: Applying
Client Need & Sub: Health Promotion and Maintenance: Aging Process
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning
Learning Outcome: 45.5 Differentiate considerations for assessing vision and hearing of older adults, veterans, and adults with sequelae of childhood/congenital conditions.
MNL Learning Outcome: 2. Recognize normal findings of the eye and ear collected during assessment and health promotion activities to support the health of this body system.
30) A patient has a tonometry measurement of 29 mmHg. What additional assessment finding should the nurse identify that indicates this patient has glaucoma? Select all that apply.
1. Narrowing visual fields
2. Loss of definition of the optic disc
3. Areas of hemorrhage, exudate, and white patches
4. Narrowing of the vein where an arteriole crosses over
5. Displaced blood vessels from the center of the optic disc
Page Ref: 1678, 1680
Cognitive Level: Analyzing
Client Need & Sub: Physiological Integrity: Physiological Adaptation
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 45.2 Outline the components of the assessment of the eye and vision, including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment.
MNL Learning Outcome: 3. Interpret abnormal findings of the eye and ear collected during assessment.
31) The nurse is assessing a patient with retinitis pigmentosa. Which finding should the nurse identify as consistent with this health problem? Select all that apply.
1. Loss of visual acuity
2. Loss of peripheral vision
3. Progressive night blindness
4. One dilated, unresponsive pupil
5. Reduced perception of blue-green tones
Page Ref: 1677
Cognitive Level: Analyzing
Client Need & Sub: Physiological Integrity: Physiological Adaptation
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 45.2 Outline the components of the assessment of the eye and vision, including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment.
MNL Learning Outcome: 3. Interpret abnormal findings of the eye and ear collected during assessment.
32) During a health history interview, the nurse becomes concerned that a patient is at risk for a genetic hearing disorder. On what information did the nurse base this clinical decision? Select all that apply.
1. The patient's mother, age 76, uses hearing aids.
2. The patient's father had tubes in the ears as a child.
3. The patient's brother lost his hearing because of a thyroid disorder.
4. The patient's sister was treated for ear drainage after swimming.
5. The patient's nephew had surgery to remove a tumor on the acoustic nerve.
Page Ref: 1685
Cognitive Level: Analyzing
Client Need & Sub: Physiological Integrity: Reduction of Risk Potential
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 45.4 Outline the components of the assessment of the ear and hearing, including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment.
MNL Learning Outcome: 3. Interpret abnormal findings of the eye and ear collected during assessment.
33) During an assessment the nurse suspects that a victim of a motor vehicle crash is a narcotic substance user. Which assessment finding would confirm the nurse's suspicion? Select all that apply.
1. Small pupils
2. Dilated pupils
3. Unequal pupil size
4. Poor pupillary response to light
5. One dilated and unresponsive pupil
Page Ref: 1679
Cognitive Level: Analyzing
Client Need & Sub: Physiological Integrity: Physiological Adaptation
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 45.2 Outline the components of the assessment of the eye and vision, including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment.
MNL Learning Outcome: 3. Interpret abnormal findings of the eye and ear collected during assessment.
34) The nurse is preparing a teaching tool on eye health for a community fair. Which information should the nurse include about the frequency of eye examinations? Select all that apply.
1. Every year after the age of 60
2. Every 5 years until the age of 40
3. Every 3 years until the age of 50
4. Every 2 years until the age of 60
5. Every 6 months until the age of 10
Page Ref: 1689
Cognitive Level: Applying
Client Need & Sub: Health Promotion and Maintenance: Health Screening
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: VII.5. Use evidence-based practices to guide health teaching, health counseling, screening, outreach, disease and outbreak investigation, referral and follow-up throughout the lifespan | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Planning/Teaching/Learning
Learning Outcome: 45.6 Summarize topics that nurses teach to promote healthy vision and hearing across the lifespan.
MNL Learning Outcome: 2. Recognize normal findings of the eye and ear collected during assessment and health promotion activities to support the health of this body system.
35) After a routine physical examination, a patient is referred to a hearing specialist. Which assessment finding was used to support this referral? Select all that apply.
1. Reduced hearing
2. Ringing in the ears
3. Buildup of cerumen
4. Pink inner canal walls
5. Pearly gray tympanic membrane
Page Ref: 1689
Cognitive Level: Analyzing
Client Need & Sub: Health Promotion and Maintenance: Health Screening
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: VII.5. Use evidence-based practices to guide health teaching, health counseling, screening, outreach, disease and outbreak investigation, referral and follow-up throughout the lifespan | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 45.6 Summarize topics that nurses teach to promote healthy vision and hearing across the lifespan.
MNL Learning Outcome: 3. Interpret abnormal findings of the eye and ear collected during assessment.
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