CHAPTER 21: NURSING ASSESSMENT:
VISUAL AND AUDITORY SYSTEMS
LATEST UPDATE 2022
1. The nurse is providing health promotion teaching to a group of older adults. Which
information will the nurse include when teaching
...
CHAPTER 21: NURSING ASSESSMENT:
VISUAL AND AUDITORY SYSTEMS
LATEST UPDATE 2022
1. The nurse is providing health promotion teaching to a group of older adults. Which
information will the nurse include when teaching about routine glaucoma testing?
a.
A Tono-pen will be applied to the surface of the eye.
b.
The test involves reading a Snellen chart from 20 feet.
c.
Medications will be used to dilate the pupils for the test.
d.
The examination involves checking the pupil's reaction to light. - ANS: A
Glaucoma is caused by an increase in intraocular pressure, which would be
measured using the Tono-pen. The other techniques are used in testing for other
eye disorders.
DIF: Cognitive Level: Apply (application) REF: 369 | 375
TOP: Nursing Process: Implementation MSC: NCLEX: Health Promotion and
Maintenance
2. The nurse is performing an eye examination on a 76-year-old patient. The nurse
should refer the patient for a more extensive assessment based on which finding?
a.
The patient's sclerae are light yellow.
b.
The patient reports persistent photophobia.
c.
The pupil recovers slowly after responding to a bright light.
d.
There is a whitish gray ring encircling the periphery of the iris. - ANS: B
Photophobia is not a normally occurring change with aging, and would require further
assessment. The other assessment data are common gerontologic differences and
would not be unusual in a 76-year-old patient.
DIF: Cognitive Level: Apply (application) REF: 371
TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity
3. The nurse performing an eye examination will document normal findings for
accommodation when
a.
shining a light into the patient's eye causes pupil constriction in the opposite eye.
b.
a blink reaction follows touching the patient's pupil with a piece of sterile cotton.
c.
covering one eye for 1 minute and noting pupil constriction as the cover is removed.
d.
the pupils constrict while fixating on an object being moved closer to the patient's
eyes. - ANS: D
Accommodation is defined as the ability of the lens to adjust to various distances.
The pupils constrict while fixating on an object being moved far away to near the
eyes. The other responses may also be elicited as part of the eye examination, but
they do not indicate accommodation.
4. Which assessment finding alerts the nurse to provide patient teaching about
cataract development?
a.
History of hyperthyroidism
b.
Unequal pupil size and shape
c.
Blurred vision and light sensitivity
d.
Loss of peripheral vision in both eyes - ANS: C
Classic signs of cataracts include blurred vision and light sensitivity. Thyroid
problems are a major cause of exophthalmos. Unequal pupil is indicative of
anisocoria, not cataracts. Loss of peripheral vision is a sign of glaucoma.
5. Assessment of a patient's visual acuity reveals that the left eye can see at 20 feet
what a person with normal vision can see at 50 feet and the right eye can see at 20
feet what a person with normal vision can see at 40 feet. The nurse records which
finding?
a.
OS 20/50; OD 20/40
b.
OU 20/40; OS 50/20
c.
OD 20/40; OS 20/50
d.
OU 40/20; OD 50/20 - ANS: A
When documenting visual acuity, the first number indicates the standard (for normal
vision) of 20 feet and the second number indicates the line that the patient is able to
read when standing 20 feet from the Snellen chart. OS is the abbreviation for left eye
and OD is the abbreviation for right eye. The remaining three answers do not
correctly describe the patient's visual acuity.
6. When assessing a patient's consensual pupil response, the nurse should
a.
have the patient cover one eye while facing the nurse.
b.
observe for a light reflection in the center of both corneas.
c.
instruct the patient to follow a moving object using only the eyes.
d.
shine a light into one pupil and observe the response of both pupils. - ANS: D
The consensual pupil response is tested by shining a light into one pupil and
observing for both pupils to constrict. Observe the corneal light reflex to evaluate for
weakness or imbalance of the extraocular muscles. In a darkened room, ask the
patient to look straight ahead while a penlight is shone directly on the cornea. The
light reflection should be located in the center of both corneas as the patient faces
the light source. To perform confrontation visual field testing, the patient faces the
examiner and covers one eye, then counts the number of fingers that the examiner
brings into the visual field. Instructing the patient to follow a moving object only with
the eyes is testing for visual fields and extraocular movements.
7. The nurse is observing a student who is preparing to perform an ear examination
for a 30-year-old patient. The nurse will need to intervene if the student
a.
pulls the auricle of the ear up and posterior.
b.
chooses a speculum larger than the ear canal.
c.
stabilizes the hand holding the otoscope on the patient's head.
d.
stops inserting the otoscope after observing impacted cerumen. - ANS: B
The speculum should be smaller than the ear canal so it can be inserted without
damage to the external ear canal. The other actions are appropriate when
performing an ear examination.
8. When obtaining a health history from a 49-year-old patient, which patient
statement is most important to communicate to the primary health care provider?
a.
"My eyes are dry now."
b.
"It is hard for me to see at night."
c.
"My vision is blurry when I read."
d.
"I can't see as far over to the side." - ANS: D
The decrease in peripheral vision may indicate glaucoma, which is not a normal
visual change associated with aging and requires rapid treatment. The other patient
statements indicate visual problems (presbyopia, dryness, and lens opacity) that are
considered a normal part of aging.
9. A 65-year-old patient is being evaluated for glaucoma. Which information given by
the patient has implications for the patient's treatment?
a.
"I use aspirin when I have a sinus headache."
b.
"I have had frequent episodes of conjunctivitis."
c.
"I take metoprolol (Lopressor) daily for angina."
d.
"I have not had an eye examination for 10 years." - ANS: C
It is important to note whether the patient takes any β-adrenergic blockers because
this classification of medications is also used to treat glaucoma, and there may be an
increase in adverse effects. The use of aspirin does not increase intraocular
pressure and is safe for patients with glaucoma. Although older patients should have
yearly eye examinations, the treatment for this patient will not be affected by the 10-
year gap in eye care. Conjunctivitis does not increase the risk for glaucoma.
The nurse is testing the visual acuity of a patient in the outpatient clinic. The nurse's
instructions for this test include asking the patient to
a.
stand 20 feet from the wall chart.
b.
follow the examiner's finger with the eyes only.
c.
look at an object far away and then near to the eyes.
d.
look straight ahead while a light is shone into the eyes. - ANS: A
When the Snellen chart is used to check visual acuity, the patient should stand 20
feet away. Accommodation is tested by looking at an object at both near and far
distances. Shining a pen light into the eyes tests for pupil response. Following the
examiner's fingers with the eyes tests extraocular movements.
11. A patient who underwent eye surgery is required to wear an eye patch until the
scheduled postoperative clinic visit. Which nursing diagnosis will the nurse include in
the plan of care?
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