Nokea
A client has been referred to an ophthalmologist for suspected macular degeneration. The nurse knows to prepare what test for the physician to give the client?
- A. Ishihara polychromatic plates
- B. Visual field
- C. Amsler grid
- D. Slit lamp
Correct Answer: C
Rationale: Clients with macular problems are tested with an Amsler grid. It is made up of a geometric grid of identical squares with a central fixation point. The examiner instructs the client to stare at the central fixation spot on the grid and report if they see any distortion of the squares. Clients with macular problems may say some of the squares are faded or wavy. An Ishihara polychromatic plate, visual field, or slit lamp test will not diagnose macular degeneration.
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Audiometry is testing that measures hearing acuity precisely. Who does the nurse know can perform audiometric testing?
- A. School nurse
- B. Hearing aide salesperson
- C. Audiologist
- D. Office nurse
Correct Answer: C
Rationale: Audiometry is done by an audiologist. Audiometric testing measures hearing acuity precisely. The other options can screen hearing, but they cannot do audiometric testing.
A client is having problems with dizziness and complains of the 'room spinning.' The physician performs the caloric stimulation test. The nurse knows that a diminished response in one eye during the caloric stimulation test is indicative of what?
- A. Inner ear disorder
- B. Middle ear disorder
- C. Outer ear disorder
- D. Age-related macular degeneration
Correct Answer: A
Rationale: During the caloric stimulation test, a diminished response in one eye is significant for an inner ear disorder such as M?©ni?¨re disease. It does not signify a middle ear disorder, an outer ear disorder, or age-related macular degeneration.
The nurse is assisting with the administration of a caloric stimulation test. Which client response would the nurse document as an expected response?
- A. Dizziness
- B. Headache
- C. Nystagmus
- D. Double vision
Correct Answer: C
Rationale: A caloric stimulation test assesses vestibular reflexes of the inner ear that control balance. Warm or cool water or air is instilled into the external meatus of the ear separately. Nystagmus, a quivering movement of the eyes, is the expected response. Slight dizziness may be experienced but is not the expected response. Headache and double vision are not expected responses.
The nursing student is taking an anatomy and physiology class. What anatomical structure equalizes air pressure in the middle ear?
- A. Eustachian tube
- B. The malleus
- C. The pinna
- D. The meatus
Correct Answer: A
Rationale: The eustachian tube extends from the floor of the middle ear to the pharynx and is lined with mucous membrane. It equalizes air pressure in the middle ear. The other options do not equalize pressure in the middle ear.
The client is consulting with a physician regarding a potential diagnosis of M?©ni?¨re disease. The nurse is assisting in positional testing and documentation. Which diagnostic test would the nurse anticipate to obtain a more precise evaluation of vestibular function?
- A. Audiometry
- B. Electronystagmography
- C. Caloric stimulation test
- D. Romberg test
Correct Answer: B
Rationale: The electronystagmography is a more precise method for evaluation vestibular function. It is performed in conjunction with caloric stimulation. When the fluid is instilled in the ear, a machine records the duration and velocity of eye movements with electrodes attached around the eye. Audiometry measures hearing acuity. The Romberg test measures balance.