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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.
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The nurse is establishing a visual test using the Snellen chart for a client experiencing visual changes. At which distance should the nurse instruct the client to stand?
- A. A 10-feet distance
- B. A 20-feet distance
- C. A 30-feet distance
- D. A 40-feet distance
Correct Answer: B
Rationale: The nurse is correct in instructing the client to stand at a 20-feet distance from the Snellen chart. Often, the nurse places tape on the floor to denote the correct distance for the client to stand.
The nurse is instructing a nursing student when a new client comes to the eye clinic. The client reports suspecting a corneal abrasion. The nurse should explain what to the student nurse?
- A. To detect corneal abrasions, an ophthalmoscope is used.
- B. To detect corneal abrasions, ultrasonography is used.
- C. To detect corneal abrasions, a slit lamp is used.
- D. To detect corneal abrasions, retinal angiography is used.
Correct Answer: C
Rationale: A slit lamp is a binocular microscope that magnifies the surface of the eye. A beam of light, narrowed to a slit, is directed at the cornea, facilitating an examination of structures and fluid in the anterior segment of the eye. This examination is used to identify disorders such as corneal abrasions, iritis, conjunctivitis, and cataracts. The other options are not used to detect corneal abrasions.
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 assessing a client's hearing using the Rinne test. When providing instruction to elicit client feedback, which instruction is essential?
- A. Raise your hand when you hear the vibration.
- B. Raise your hand when you no longer hear sound.
- C. Raise your hand when the vibration exceeds the sound.
- D. Raise your hand when the sound exceeds the vibration.
Correct Answer: B
Rationale: It is essential to provide clear directions on when the client is to notify the nurse of client response. The information gleaned from the response is what the nurse uses to interpret the test. The correct time to induce feedback is when the vibration is heard.
The nurse is obtaining a history on a client stating the inability to read the newspaper and seeing detail when looking at an image. Which assessment test would add additional data for a diagnosis?
- A. Assess if the pupils are equal and reactive to light.
- B. Assess vision on the Snellen chart.
- C. Assess peripheral vision.
- D. Assess color vision.
Correct Answer: C
Rationale: The client states symptoms of the inability to discriminate letters, words, and details of an image, indicating the degeneration of the macula. If the macula is damaged, the client will only have the ability to see movement and gross objects in the peripheral fields. Assessing the peripheral vision will add essential information. The other visual tests are not as important at this time.