C H A P T E R
Copyright © 2014 by Mosby, an imprint of Elsevier Inc. All rights reserved. 75
Nursing Assessment: Visual and
76 Chapter 21 Nursing Assessment: Visual and Auditory Systems
2. What is in the posterior cavity of the eye?
a. Zonules c. Aqueous humor
b. Cornea d. Vitreous humor
3. What is the function of the sclera?
a. Secrete aqueous humor b. Focus light rays on the retina
c. Protective white 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 c. Choroid
b. Cones d. Canal of Schlemm
6. Identify the cranial nerves that are responsible for the following eye functions.
Eye Function Cranial Nerve
Eyelid movement 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 percept
8. Priority Decision: When obtaining a health history from a patient with cataracts, what is most important for the nurse to ask about the use of?
a. Corticosteroids c. Antihistamines and decongestants
b. Oral hypoglycemic agents d. β-Adrenergic blocking agents
Chapter 21 Nursing Assessment: Visual and Auditory Systems 77 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 c. Persons with brown irises
b. Dark-skinned persons 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 c. Pocket penlight
b. Fluorescein dye d. An ophthalmoscope
78 Chapter 21 Nursing Assessment: Visual and Auditory Systems
15. What are possible abnormal assessment findings when assessing the eyelid (select all that apply)?
a. Ptosis d. Anisocoria
b. Strabismus e. Swelling of the pinna
c. Blepharitis
16. When the patient has a diagnosis of hyperthyroidism, which abnormal assessment of the eye could be found?
a. Light intolerance c. Protrusion of eyeball
b. Unequal pupil size d. Deviation of eye position
17. When examining the patient’s eye with an ophthalmoscope, which finding would be of most concern to the nurse?
a. Depression at the center of the optic disc c. A break in the retina at the site of the macula b. Blurring of the nasal margin of the optic disc 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 epithelial and retinal blood vessels c. 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 c. Ossicular chain
b. Organ of Corti 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 of 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. c. difficulty understanding the meaning of words.
b. a sensation of fullness in the ears. 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?
Chapter 21 Nursing Assessment: Visual and Auditory Systems 79 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 d. Weber lateralization to good ear
b. Negative Rinne test e. External or middle ear pathology
c. Weber lateralization to impaired ear 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. Irrigation of the external ear with water produces nystagmus 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 for 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
C H A P T E R
1. Myopia is present in 25% of Americans. Which characteristics are associated with myopia (select all that apply)?
a. Excessive light refraction d. Corrected with concave lens b. Abnormally short eyeball e. Image focused in front of retina c. Unequal corneal curvature
2. The patient is diagnosed with presbyopia. When he asks the nurse what that is, what is the best explanation the nurse can give to the patient?
a. Abnormally long eyeballs c. Correctable with cylinder lens
b. Absence of crystalline lens d. Loss of accommodation associated with age 3. To determine if an unconscious patient has contact lenses in place, what should be done by the nurse?
a. Use a penlight to shine a light obliquely over the eyeball.
b. Apply drops of fluorescein dye to the eye to stain the lenses yellow.
c. Touch the cornea lightly with a dry cotton ball to see if the patient reacts.
d. Tense the lateral canthus to cause a lens to be ejected if it is present in the eye.
4. What surgical choices are available for correction of a refractive error (select all that apply)?
a. LASIK d. Photorefractive keratectomy (PRK)
b. Contact lenses e. Surgical implantation of intraocular lens
c. Corrective lenses
5. A patient tells the nurse on admission to the health care facility that he recently has been classified as legally blind.
What does the nurse understand about the patient’s vision?
a. Has lost usable vision but has some light perception
b. Will need time for grieving and adjusting to living with total blindness c. Will be dependent on others to ensure a safe environment for functioning
d. May be able to perform many tasks and activities with vision enhancement techniques
6. Identify five nursing measures that should be implemented to increase a visually impaired patient’s safety and comfort.
a. d.
b. e.
c.
7. A patient is admitted to the emergency department with a wood splinter imbedded in the right eye. Which intervention by the nurse is most appropriate?
a. Irrigate the eye with a large amount of sterile saline.
b. Carefully remove the splinter with a pair of sterile forceps.
c. Cover the eye with a dry sterile patch and a protective shield.
d. Apply light pressure on the closed eye to prevent bleeding or loss of aqueous humor.
8. What best describes pinkeye?
a. Blindness c. Epidemic keratoconjunctivitis
b. Acute bacterial conjunctivitis d. Chronic inflammation of sebaceous glands 9. What describes inflammation of the cornea?
a. Keratitis c. Hordeolum
b. Blepharitis d. Conjunctivitis