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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.
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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.
The nurse is collecting the history of a client diagnosed with a cataract and is performing a focused assessment. Which finding should the nurse anticipate?
- A. A burning sensation and the sensation of an object in the eye
- B. Blurred or cloudy vision
- C. Inability to produce sufficient tears
- D. A swollen lacrimal caruncle
Correct Answer: B
Rationale: When a cataract forms, the light is blocked from reaching the macula and the visual image becomes blurred or cloudy. The client does not experience any burning or the sensation of an object in the eye, an inability to produce sufficient tears, or a swollen lacrimal caruncle.
A client comes to the occupational health nurse complaining of eye irritation. The client works in a dusty, outdoor environment. Why should the nurse advise periodic blinking to this client?
- A. To control the amount of sunlight that enters the eye
- B. To minimize the impact of the wind on the eye and to trap foreign debris
- C. To clear the dust and particles from the surface of the eyes
- D. To prevent the collection of tears over the surface of the eye
Correct Answer: C
Rationale: Periodic blinking clears the dust and particles from the surface of the eyes. The eyelids also spread tears over the surface of the eye, which helps bathe and lubricate the surface. The eyelids protect against foreign bodies and adjust the amount of light that enters the eye, whereas the eyelashes trap foreign debris.
The nurse is assisting the eye surgeon in completing an examination of a client's eye. Which piece of equipment would the nurse provide to the surgeon to examine the optic disc under magnification?
- A. Retinoscope
- B. Ophthalmoscope
- C. #NAME?
- D. Amsler grid
Correct Answer: B
Rationale: The nurse is correct to provide an ophthalmoscope to the surgeon for examination of the optic disc. A retinoscope is used to determine errors in refraction. A tonometer measures intraocular pressure. An Amsler grid tests for problems with the macula.
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.