Nokea
A client states having difficulty noting details on faces or television. Which of the following structures of the eye allows for detailed vision?
- A. The pupil
- B. The iris
- C. The cornea
- D. The macula lutea
Correct Answer: D
Rationale: The macula lutea is composed entirely of cones and allows for detailed vision. It lies in the center of the retina. This client could potentially have macular degeneration. The iris is the highly vascular, pigmented portion of the eye surrounding the pupil that adjusts in response to light. The cornea covers the anterior portion of the eyeball.
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The nurse is caring for a client with increased fluid accumulation in the eye. When assessing the client, which structure within the eye is noted to drain fluid from the anterior chamber?
- A. Fovea centralis
- B. Canthus
- C. Canal of Schlemm
- D. Choroid
Correct Answer: C
Rationale: The canal of Schlemm drains the anterior chamber of the eye. By draining the fluid, it decreases the fluid amount and pressure in the eye. The other options have no draining ability.
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.
A nurse is assessing a pediatric client in a public health clinic. The parent states that the client has been sneezing and rubbing the eyes. The nurses observes the client's eyes and documents objective symptoms of watery and red eyes. When reporting the assessment findings to the health care provider, which description is appropriate?
- A. Signs and symptoms of conjunctivitis
- B. Signs and symptoms of ptosis
- C. Signs and symptoms of nystagmus
- D. Signs and symptoms of proptosis
Correct Answer: A
Rationale: Conjunctivitis often stems from an allergy causing inflammation of the conjunctiva, which is a thin, transparent mucous membrane. Conjunctivitis can cause symptoms of itchiness, redness, and watery eyes. Ptosis is drooping of the upper eyelid. Proptosis is an extended and upper eyelid that delays in closing or remains partially open. Nystagmus is an uncontrolled oscillating movement of the eyeball.
The nurse is conducting hearing tests at the local junior high school. Which of the following indicates normal hearing in a child?
- A. A client who first perceives sound at 20 dB
- B. A client who first perceives sound at 40 dB
- C. A client for whom the painful sound occurs at 80 dB
- D. A client for whom the painful sound occurs at 100 dB
Correct Answer: A
Rationale: The lowest level of sound that normal persons may first perceive is 20 dB. The painful sounds occur at 120 dB. The hearing acuity is determined by measuring the intensity at which a person first perceives sound.