Nokea
The nurse in the eye clinic is examining an older-adult patient who says 'I see small spots that move around in front of my eyes.' Which of the following actions should the nurse take first?
- A. Immediately have the ophthalmologist evaluate the patient.
- B. Explain that spots and 'floaters' are a normal part of aging.
- C. Inform the patient that these spots may indicate damage to the retina.
- D. Use an ophthalmoscope to examine the posterior chamber of the eyes.
Correct Answer: D
Rationale: Although 'floaters' are usually caused by vitreous liquefaction and are common in aging patients, they can be caused by hemorrhage into the vitreous humour or by retinal tears, so the nurse's first action will be to examine the retina and posterior chamber. Although the ophthalmologist will examine the patient, the presence of spots or floaters in a 65-year-old is not an emergency. The spots may indicate retinal damage, but the nurse should assess the eye further before discussing this with the patient.
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The nurse is assessing a patient's auditory canal and tympanic membrane. Which of the following findings is a priority to report to the health care provider?
- A. There is a cone of light visible.
- B. The tympanum is bluish-tinged.
- C. Cerumen is present in the auditory canal.
- D. The skin in the ear canal is dry and scaly.
Correct Answer: B
Rationale: A bluish-tinged tympanum can occur with acute otitis media, which requires immediate care to prevent perforation of the tympanum. Cerumen in the ear canal may need to be removed before proceeding with the examination but is not unusual or pathological. The presence of a cone of light on the eardrum is normal. Dry and scaly skin in the ear canal may need further assessment but does not require urgent care.
The nurse is observing a student who is preparing to perform an ear examination of an adult patient. Which of the following actions by the student should cause the nurse to intervene in the assessment?
- A. Chooses a speculum smaller than the ear canal
- B. Pulls the auricle of the ear down and backward
- C. Stabilizes the hand holding the otoscope on the patient's head
- D. Stops inserting the otoscope after observing impacted cerumen
Correct Answer: B
Rationale: The auricle should be pulled up and back when assessing an adult. The other actions are appropriate when performing an ear examination.
Which of the following actions should the nurse include in the plan of care for a patient who has vestibular disease?
- A. Check Rinne's and Weber's tests.
- B. Face the patient when speaking.
- C. Enunciate clearly when speaking.
- D. Monitor the patient's ability to ambulate safely.
Correct Answer: D
Rationale: Vestibular disease affects balance so the nurse should monitor the patient during activities that require balance. The other actions might be used for patients with hearing disorders.
The nurse is performing an eye examination on a patient and is assessing for accommodation. Which of the following actions should the nurse implement?
- A. Cover one eye for 1 minute and note the pupil reaction when the cover is removed.
- B. Shine a light into the patient's eye and assess the pupil response in the opposite eye.
- C. Observe the pupils when the patient focuses on a distant object and then on a close object.
- D. Touch the patient's pupil with a small piece of sterile cotton and watch for a blink reaction.
Correct Answer: C
Rationale: Accommodation is defined as the ability of the lens to adjust to various distances. The other nursing actions also may be part of the eye examination, but they do not test for accommodation.
The nurse is obtaining a health history from an older-adult patient, who is new to the eye clinic and who has glaucoma. Which of the following information given by the patient will have the most implications for the patient's treatment?
- A. I use Aspirin when I have a sinus headache.'
- B. I have had frequent episodes of conjunctivitis.'
- C. I take metoprolol daily for angina.'
- D. I have not had an eye examination for 10 years.'
Correct Answer: C
Rationale: It is important to note whether the patient takes any β-adrenergic blockers because this category of medications also is used to treat glaucoma, and there may be an increase in adverse effects. The use of Aspirin does not increase intraocular pressure and is safe for patients with glaucoma. Although older patients should have yearly eye examinations, the treatment for this patient will not be affected by the 10-year gap in eye care. Conjunctivitis does not increase the risk for glaucoma.