3. What is the function of the sclera?
a. Secrete aqueous humor b. Focus light rays on the retina c. Protective outer layer of the eyeball
d. Photoreceptor cells stimulated in dim environments 4. What accurately describes the conjunctiva?
a. Junction of the upper and lower eyelids b. Point where the optic nerve exits the eyeball c. Transparent mucous membrane lining the eyelids
d. Drains tears from the surface of the eye into the lacrimal canals 5. Which tissue nourishes the ciliary body, iris, and part of the retina?
a. Pupil b. Cones c. Choroid
d. Canal of Schlemm
6. Identify the cranial nerves that are responsible for the following eye functions.
Eye Function Cranial Nerve
Eyelid movement, open and close Pupil constriction
Pupil dilation Visual acuity
7. Identify the causes of the following assessment findings of the eye that are associated with aging.
Assessment Finding Cause Floaters
Ectropion Pinguecula Arcus senilis Yellowish sclera Dry, irritated eyes Decreased pupil size Changes in color perception
8. Priority Decision: When obtaining a health history from a patient with cataracts, it is most important for the nurse to ask about the patient's use of which drug?
a. Corticosteroids
b. Oral hypoglycemic agents c. β-Adrenergic blocking agents d. Antihistamines and decongestants
9. Identify a specific finding identified by the nurse during assessment of each of the patient's functional health patterns that indicates either a risk factor for visual problems or the response of the patient to an eye problem.
Functional Health Pattern Risk Factor or Response to Visual Problem Health perception–health management
Nutritional-metabolic Elimination Activity-exercise Sleep-rest Cognitive-perceptual Self-perception–self-concept Role-relationship Sexuality-reproductive Coping–stress tolerance Value-belief
10. Describe what is meant by the finding that the patient has a visual acuity of OD: 20/40; OS: 20/50.
11. The nurse documents PERRLA following assessment of a patient's eyes. What is one finding that supports this statement?
a. A slightly oval shape of the pupils
b. The presence of nystagmus on far lateral gaze
c. Dilation of the pupil when a light is shined in the opposite eye
d. Constriction of the pupils when an object is brought closer to the eyes
12. Identify the assessment techniques used to obtain the following assessment data.
Assessment Data Assessment Technique Peripheral vision field
Extraocular muscle functions Near visual acuity Visual acuity Intraocular pressure
13. In which individuals should the nurse expect to find a yellow cast to the sclera?
a. Infants b. Older persons
c. Persons with brown irises d. Patients with eye infections
14. To determine the presence of corneal abrasions or defects in a patient with an eye injury, what would the nurse provide?
a. A tonometer b. Fluorescein dye c. Pocket penlight d. An ophthalmoscope
15. What are possible abnormal assessment findings when assessing the eyelid (select all that apply)?
a. Ptosis b. Strabismus c. Blepharitis d. Anisocoria e. Swollen pinna
16. When the patient has a diagnosis of hyperthyroidism, which abnormal assessment of the eye could be found?
a. Light intolerance b. Unequal pupil size c. Protrusion of eyeball d. Deviation of eye position
17. When examining the patient's eye with an ophthalmoscope, the nurse would consider which finding to be of most concern?
a. No blood vessels in the macula
b. Depression at the center of the optic disc c. A break in the retina at the site of the macula d. Pieces of liquefied vitreous in the vitreous chamber
18. To prepare a patient for a fluorescein angiography, what should the nurse explain about the test?
a. Measures curvature of the cornea
b. Involves IV dye injection to evaluate blood flow through retinal blood vessels
c. Includes application of eyedrops containing a dye that will localize arterial abnormalities in the retina
d. Anesthetizes the eye so that probes can be inserted into the anterior chamber to measure intraocular pressure
19. What is the organ of balance and equilibrium?
a. Cochlea b. Organ of Corti c. Ossicular chain d. Semicircular canals
20. How does the eustachian tube assist the auditory system?
a. Transmits sound stimuli to the brain b. Sets bones of the middle ear in motion
c. Allows for equalization of pressure in the middle ear d. Transmits stimuli from the semicircular canals to the brain
21. Which changes of aging can impair hearing in the older adult (select all that apply)?
a. Atrophy of eardrum (middle ear) b. Increased hair growth (external ear)
c. Increased production and dryness of cerumen (external ear) d. Increased vestibular apparatus in semicircular canals (inner ear) e. Decreased cochlear efficiency from increased blood supply (inner ear) f. Neuron degeneration in auditory nerve and central pathways (inner ear) 22. The nurse suspects a patient has presbycusis when she says she has
a. ringing in the ears.
b. a sensation of fullness in the ears.
c. difficulty understanding the meaning of words.
d. a decrease in the ability to hear high-pitched sounds.
23. Describe the significance of the following questions asked of the patient while obtaining subjective data during assessment of the auditory system
Question Significance
Do you have a history of childhood ear infections or ruptured eardrums?
Do you use any over-the-counter or prescription medications on a regular basis?
Have you ever been treated for a head injury?
Is there a history of hearing loss in your parents?
Have you been exposed to excessive noise levels in your work or recreational activities?
Has the amount of social activities you are involved in changed?
24. What accurately describes an assessment of the ear?
a. Major landmarks of the tympanic membrane include the umbo, handle of malleus, and cone of light.
b. The presence of a retracted eardrum on otoscopic examination is indicative of positive pressure in the middle ear.
c. In chronic otitis media, the nurse would expect to find a lack of landmarks and a bulging eardrum on otoscopic examination.
d. To straighten the ear canal in an adult before insertion of the otoscope, the nurse grasps the auricle and pulls downward and backward.
25. What indicates sensorineural hearing loss (select all that apply)?
a. Positive Rinne test b. Negative Rinne test
c. Weber lateralization to impaired ear d. Weber lateralization to good ear e. External or middle ear pathology f. Inner ear or nerve pathway pathology
26. Priority Decision: Results of an audiometry indicate that a patient has a 10-dB hearing loss at 8000 Hz. What is the most appropriate action by the nurse?
a. Encourage the patient to start learning to lip-read.
b. Speak at a normal speed and volume with the patient.
c. Avoid words in conversation that have many high-pitched consonants.
d. Discuss the advantages and disadvantages of various hearing aids with the patient.
27. When does caloric testing indicate disease of the vestibular system of the ear?
a. Hearing is improved with irrigation of the external ear canal.
b. No nystagmus is elicited with application of water in the external ear.
c. The patient experiences intolerable pain with irrigation of the external ear.
d. With cool water irrigation, nystagmus is produced opposite the side of instillation.
28. Identify a specific finding identified by the nurse during assessment of each of the patient's functional health patterns that indicates either a risk factor for hearing problems or the response of the patient to an ear problem.
Functional Health Pattern Risk Factor or Response to Hearing Problem Health perception–health management
Nutritional-metabolic Elimination Activity-exercise Sleep-rest Cognitive-perceptual Self-perception–self-concept Role-relationship Sexuality-reproductive Coping–stress tolerance Value-belief