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

Multiple Choice
Identify the choice that best completes the statement or answers the question.

____ 1. 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)
____ 2. 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
____ 3. 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.”
____ 4. 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
____ 5. 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
____ 6. 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
____ 7. 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.”
____ 8. 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
____ 9. 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
____ 10. 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
____ 11. 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
____ 12. 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
____ 13. 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
____ 14. 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
____ 15. 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
____ 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
____ 17. 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.”
____ 18. 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.”
____ 19. 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.
____ 20. 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.”
____ 21. 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
____ 22. 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
____ 23. 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.
____ 24. 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
____ 25. 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
____ 26. 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
____ 27. 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
____ 28. 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
____ 29. 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.”
____ 30. 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
____ 31. 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
____ 32. 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
____ 33. 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
____ 34. 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
____ 35. 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
Multiple Response
Identify one or more choices that best complete the statement or answer the question.

____ 36. 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
____ 37. 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.”
____ 38. 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
____ 39. 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
____ 40. 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
Other

41. 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.

42. 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.

Chapter 51. Sensory System Function, Assessment, and Therapeutic Measures: Vision and Hearing
Answer Section

MULTIPLE CHOICE

1. ANS: B
Normally a patient hears sound the same in both ears for a normal finding. A. C. D. These statements would be appropriate if hearing was greater in one ear over the other.

PTS: 1 DIF: Moderate
KEY: Client Need: Health Promotion and Maintenance | Cognitive Level: Application

2. ANS: C
For both eyes 20/20 is normal vision. A. B. D. These statements indicate a difference in vision between the eyes.

PTS: 1 DIF: Moderate
KEY: Client Need: Health Promotion and Maintenance | Cognitive Level: Analysis

3. ANS: D
Tinnitus is ringing, buzzing, or roaring in the ears. A. Tinnitus does not mean that the patient has a toxic substance in the ear. B. Discharge is otorrhea. C. Ear pain is otalgia.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Physiological Adaptation | Cognitive Level: Analysis

4. ANS: B
A downward protrusion of the helix, called Darwin’s tubercle, is a normal finding. A. C. D. Darwin’s tubercle is not a tumor, a lump filled with fluid, or an abnormal calcification.

PTS: 1 DIF: Moderate
KEY: Client Need: Health Promotion and Maintenance | Cognitive Level: Application

5. ANS: C
Auditory function can be grossly evaluated using three different assessment tests: whisper voice test, Rinne’s test, and Weber’s test. A. B. D. These tests do not determine gross hearing.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Reduction of Risk Potential | Cognitive Level: Application

6. ANS: C
Speaking in an unusually quiet or loud voice can indicate hearing loss. A. B. D. These findings indicate normal hearing.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Physiological Adaptation | Cognitive Level: Analysis

7. ANS: D
In individuals older than 40 years of age, there may be bilateral opaque whitening of the outer rim of the cornea known as arcus senilis. It is caused from lipid deposits and is considered normal. A. B. C. Arcus senilis is not an eye infection, mental condition, or drooping of the eyelid.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Physiological Adaptation | Cognitive Level: Application

8. ANS: A
Estimation of intraocular pressure is measured by using one of several types of tonometer. B. C. D. Ultrasound machine, ophthalmoscope, nor a slit-lamp microscope is used to measure intraocular pressure.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Reduction of Risk Potential | Cognitive Level: Application

9. ANS: D
The eustachian tube extends from the middle ear to the nasopharynx and permits air to enter or leave the middle ear cavity. A. C. The stapes and cochlea are structures within the middle ear. B. The auricle conducts sound into the ear.

PTS: 1 DIF: Moderate
KEY: Client Need: Health Promotion and Maintenance | Cognitive Level: Application

10. ANS: B
The external eyes are inspected for color and symmetry of the irises. B. C. D. These eye structures do not affect the color of the eyes.

PTS: 1 DIF: Moderate
KEY: Client Need: Health Promotion and Maintenance | Cognitive Level: Application

11. ANS: C
The posterior cavity of the eye is between the lens and retina and contains vitreous humor. This semisolid substance helps keep the retina in place. A. B. D. These eye structures do not give shape to the eye.

PTS: 1 DIF: Moderate
KEY: Client Need: Health Promotion and Maintenance | Cognitive Level: Application

12. ANS: B
The ear canal is lined with skin that contains ceruminous glands. Cerumen, or earwax, is the secretion that keeps the eardrum pliable and traps dust. A. C. D. These fluids are not normal findings within the ear canal.

PTS: 1 DIF: Moderate
KEY: Client Need: Health Promotion and Maintenance | Cognitive Level: Analysis

13. ANS: B
Peripheral vision is tested by visual fields by confrontation. A. C. D. The other tests are not used to assess peripheral vision.

PTS: 1 DIF: Moderate
KEY: Client Need: Health Promotion and Maintenance | Cognitive Level: Application

14. ANS: D
PERRLA is an acronym used to describe pupils equal, round, and reactive to light and accommodation. A. B. C. These are incorrect descriptions for the acronym PERRLA.

PTS: 1 DIF: Moderate
KEY: Client Need: Health Promotion and Maintenance | Cognitive Level: Analysis|

15. ANS: C
To test pupillary response to light, both consensual and direct examinations should be completed. A slightly darkened room works best. A. B. This would be too much light to test pupillary response. D. This would not be an adequate amount of light to test pupillary response.

PTS: 1 DIF: Moderate
KEY: Client Need: Health Promotion and Maintenance | Cognitive Level: Application

16. ANS: C
When using the six cardinal fields of gaze, the examiner moves his or her finger in the six cardinal fields of gaze, coming back to the point of origin between each field of gaze. This measures visual muscle balance and movement. A. B. D. These tests do not measure visual muscle balance and movement.

PTS: 1 DIF: Moderate
KEY: Client Need: Health Promotion and Maintenance | Cognitive Level: Application

17. ANS: C
Normal vision is 20/20, which means the patient can read at 20 feet what the normal eye can read at 20 feet. Visual impairment occurs at 20/70 and legal blindness at 20/200 or more with correction. For 20/60, the patient has less acute vision and must be at 20 feet to see what normal vision sees at 60 feet. A. B. D. These are inaccurate explanations for the finding of 20/60.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Reduction of Risk Potential | Cognitive Level: Application

18. ANS: D
Whenever eye medications, especially eyedrops, are administered, the punctum (tear duct) of the eye should have pressure applied to it for at least 1 minute. This reduces systemic absorption of the medication via the punctum. A. B. C. Pressure applied to the inner corner of the eye is not done to protect facial skin, increase the onset of action of the medication, or to maintain greater concentration of the medication.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Pharmacological and Parenteral Therapies | Cognitive Level: Analysis

19. ANS: A
Cupping the ear is a behavior associated with a hearing loss. B. C. D. Answering questions appropriately, complaining of loud talking, or leaning away from the nurse during an interview are not behaviors associated with a hearing loss.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Physiological Adaptation | Cognitive Level: Analysis

20. ANS: C
The external ear should be cleaned. A. The ear is generally self-cleaning. B. Wax is normally removed during showering. D. Wax serves as a protective mechanism to lubricate and trap foreign material.

PTS: 1 DIF: Moderate
KEY: Client Need: Health Promotion and Maintenance | Cognitive Level: Application

21. ANS: C
Hearing aids are instruments that amplify sounds for conductive hearing loss. A. B. D. The use of a hearing aid can increase hearing for those who do not have nerve damage deafness.

PTS: 1 DIF: Moderate
KEY: Client Need: Health Promotion and Maintenance | Cognitive Level: Application

22. ANS: A
Eye disorders related to inadequate vitamin intake include corneal damage and night blindness from lack of vitamin A. B. Optic neuritis can develop as a result of vitamin B deficiency. C. D. There are no specific eye disorders associated with vitamin C or D deficiencies.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Pharmacological and Parenteral Therapies | Cognitive Level: Application

23. ANS: B
The goal of the hearing aid is to facilitate conversation, so if this is occurring, then the hearing aid is functioning. A. D. These observations would indicate that the hearing aid is not functioning properly. C. Being placed in the ear correctly does not indicate that the device is working correctly.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Basic Care and Comfort | Cognitive Level: Analysis

24. ANS: C
Presbycusis is an age-related change in which progressive hearing loss is caused by loss of hair cells and decreased blood supply in the ear, resulting in a decreased ability to hear high-frequency sounds. Talking in a lower pitch helps with communication. A. B. D. Speaking in a soft voice, very loud voice, or high-pitched voice will not enhance communication with this patient.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Basic Care and Comfort| Cognitive Level: Application|

25. ANS: C
The cones are specialized to respond to a portion of the visible light spectrum; there are red-absorbing, blue-absorbing, and green-absorbing cones. Differing combinations of three cone types allow interpretation of color. A. The iris is the area that provides eye color. B. Rods generate an action potential in dim light but only allow shades of gray vision. D. The retina lines the posterior two-thirds of the eyeball and contains the photoreceptors responsible for vision.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Physiological Adaptation | Cognitive Level: Analysis

26. ANS: B
The medial canal is the cochlear duct, which contains the receptors for hearing in the organ of Corti. The receptors are called hair cells, which contain endings of the cochlear branch of the eighth cranial nerve. A. The hair cells in the organ of Corti do not contribute to balance. C. D. The cells within the organ of Corti are not ganglionic.

PTS: 1 DIF: Moderate
KEY: Client Need: Health Promotion and Maintenance | Cognitive Level: Application

27. ANS: D
When the hair cells in the ear bend, they generate impulses that are carried by the eighth cranial nerve to the brain for interpretation. A. CN II is responsible for olfactory functioning. B. C. CNs IV and VI participate in eye motor functioning.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Physiological Adaptation | Cognitive Level: Analysis

28. ANS: D
Romberg’s test, or falling test, is a simple test to assess vestibular function. If the patient has difficulty maintaining balance or loses balance, it can indicate an inner ear problem. If a fall appears likely, be prepared to support the patient to prevent injury. A. B. C. Patient safety is not an issue with these tests.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Reduction of Risk Potential | Cognitive Level: Application

29. ANS: C
The eyes do not need to be dilated for this procedure. A. B. D. Digital imaging is a newer way of viewing the retina without requiring the use of dilating eyedrops. The instrument takes a digital picture of the retina in 2 seconds. The majority of the retina is viewable and assists in early detection of eye disease.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Reduction of Risk Potential | Cognitive Level: Analysis

30. ANS: D
Legal blindness occurs at a Snellen chart rating of 20/200 with correction. A. B. C. These Snellen chart ratings do not indicate legal blindness.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Reduction of Risk Potential | Cognitive Level: Application

31. ANS: C
When being tested for visual acuity, the patient should hold a handheld visual acuity chart approximately 14 inches from the eyes. A. B. D. These distances are inappropriate when testing a patient for visual acuity.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Reduction of Risk Potential | Cognitive Level: Application

32. ANS: D
Noises reach a pain threshold at 130 dB. A. B. C. Noises at these decibel levels should not cause ear pain.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Basic Care and Comfort | Cognitive Level: Analysis

33. ANS: A
The wall of the eyeball has three layers. The outer fibrous tunic contains the sclera and cornea. C. The middle vascular tunic contains the choroid, ciliary body that suspends the lens, and iris. B. The inner nervous tunic contains the retina. D. Muscular tunic is not a layer of the eyeball.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Reduction of Risk Potential | Cognitive Level: Application

34. ANS: D
A consensual response occurs when the pupil of one eye constricts when the other eye has a light shined into it. A. Tropia is a deviation of the eye away from the visual axis. B. Esotropia is deviation of the eye towards the nose. C. Accommodation is the ability of the pupil to respond to near and far distances.

PTS: 1 DIF: Moderate
KEY: Client Need: Health Promotion and Maintenance | Cognitive Level: Analysis

35. ANS: A
Angiography with dye is a test using special cameras to find leaking or damaged blood vessels in the retinal or deeper choroidal circulation. Indocyanine green (ICG) is a green dye that shows up with invisible infrared light to highlight the choroidal circulation. The patient is assessed for dye allergies because indocyanine green dye contains iodine. B. C. D. The nurse does not need to assess for intake of solid food, medications, or transportation plans.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Reduction of Risk Potential | Cognitive Level: Application

MULTIPLE RESPONSE

36. ANS: A, B, C, D
Age-related changes in vision and hearing include presbycusis, yellowing of the lens, distorted depth perception, and decreased lacrimal secretions. E. Pupil size and response to light decreases. F. There is a loss in the ability to hear high-frequency sounds.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Physiological Adaptation | Cognitive Level: Analysis

37. ANS: A, B, C, D
The patient should not exercise the patched eye, watch television, apply pressure to the tear duct, or open the eye under the patch. E. F. Listening to an audio book and taping the patch securely indicate teaching has been effective.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Reduction of Risk Potential | Cognitive Level: Analysis

38. ANS: A, B
The cover test is used in conjunction with an abnormal corneal light reflex test to evaluate muscle balance. C. D. E. F. These tests do not evaluate eye muscle balance.

PTS: 1 DIF: Moderate
KEY: Client Need: Health Promotion and Maintenance | Cognitive Level: Analysis

39. ANS: B, C, D, E
Family history that may affect vision includes glaucoma, diabetes, blindness, and cataracts. A. Asthma does not affect vision.

PTS: 1 DIF: Moderate
KEY: Client Need: Health Promotion and Maintenance | Cognitive Level: Application

40. ANS: A, B
The Rinne test is performed with a tuning fork and is useful for differentiating between conductive and sensorineural hearing loss. The Weber test is also performed using a tuning fork. C. The caloric test is used to test the function of the eighth cranial nerve and to assess vestibular reflexes of the inner ear that control balance. D. Tympanometry is a test used to measure compliance of the tympanic membrane and differentiate problems in the middle ear. E. The electronystagmogram is used to diagnose the causes of unilateral hearing loss of unknown origin, vertigo, or ringing in the ears.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Reduction of Risk Potential | Cognitive Level: Application

OTHER

41. ANS:
A. ANS: 2
B. ANS: 1
C. ANS: 4
D. ANS: 3
E. ANS: 5
F. ANS: 6
The order in which the nurse should provide the eye medication is as follows: B) check the medications for dosage, strength, side effects, contraindications, and expiration date; A) instruct the patient to tilt head backward and look up toward the ceiling; D) gently pull the lower lid down and out to form a pocket; C) approach the patient’s eye from the side, and instill the prescribed amount of medication into the lower lid pocket; E) gently apply pressure with a tissue to the punctum for at least 1 minute to prevent the medication from being absorbed systemically; and F) wipe any excess medication from eyelids or cheek

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Pharmacological and Parenteral Therapies |Cognitive Level: Application|

42. ANS:
A. ANS: 1
B. ANS: 4
C. ANS: 3
D. ANS: 2
E. ANS: 5
F. ANS: 6
The order in which the nurse should explain the process of hearing is as follows: A. sound waves strike the eardrum causing it to vibrate; D) vibrations are transmitted through the auditory bones; C) the stapes transmits vibrations to the inner ear at the oval window; B) vibrations pass through the cochlea; E) vibrations pass through hair cells in the organ of Corti; and F) impulses are carried by the eighth cranial nerve to the brain.

PTS: 1 DIF: Moderate
KEY: Client Need: Health Promotion and Maintenance | Cognitive Level: Application