During the initial interview, the nurse inspects the external anatomy of the eye. The eye is a sensory
organ of vision, and it is well protected by a bony orbital cavity and surrounded with a cushion of fat.
The RN not
...
During the initial interview, the nurse inspects the external anatomy of the eye. The eye is a sensory
organ of vision, and it is well protected by a bony orbital cavity and surrounded with a cushion of fat.
The RN notes tat the cornea looks cloudy and an arcus senilis is seen around the cornea.
Q. Which action should the nurse take first? - ✔✔A. Assess whether the cornea looks thickened and
raised and document the finding.
(Rationale) As the lipid accumulates, the cornea may look thickened and raised. The assessment finding
should be documented in the electronic medical record
During the assessment of Frank's hearing, the nurse performs a series of tests, including Frank's ability
to hear whispered and conversational tones.
Q. How will the nurse assess for the presence of tinnitus? - ✔✔A. Ask the client if he ever hears ringing
in his ears.
(Rationale) Tinnitus is the presence of ringing in the ears, which is often associated with hearing loss.
Frank seems nervous and asks for a glass of water. After taking a drink, he attempts to set the glass
down, but places the glass on the edge of the counter, causing it to crash to the floor.
Q. To follow up this situation, which assessment will provide the most useful data? - ✔✔A. Visual field
and depth perception.
(Rationale) Under- or over-reaching for objects is an indication of a visual deficit. Assessment of visual
field and depth perception will provide the most useful data related to this situation.
Frank's visual acuity is measured using a Snellen chart. The reading
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