Nokea
The nurse is admitting a patient to the hospital preoperatively. Which of the following findings may indicate that the patient is at risk for falls while hospitalized?
- A. Lateralization with Weber's test
- B. Positive result for Rinne's testing
- C. Inability to hear a low-pitched whisper
- D. Nystagmus when head is turned rapidly
Correct Answer: D
Rationale: Nystagmus suggests that the patient may have problems with balance related to disease of the vestibular system. The other tests are used to check hearing, abnormal results for these do not indicate potential problems with balance.
You may also like to solve these questions
The nurse is conducting an auditory assessment with a patient. Which of the following findings should the nurse document as normal?
- A. Ability to hear low whisper at 30 cm
- B. Rinne's test results: bone conduction is better than air conduction
- C. Weber's test results - no lateralization
- D. Curved cone light reflex
- E. Symmetrical location of ears
Correct Answer: A,C,E
Rationale: Normal findings in the physical assessment of the auditory system include ears symmetrical in location and shape, auricles and tragus nontender, without lesions; clear canal and tympanic membrane intact, landmarks and light reflex intact; ability to hear low whispers at 30 cm and no lateralization Weber's test result. Rinne's test result for a normal finding is that air conduction is better than bone conduction.
Which assessment information obtained by the nurse when performing an eye examination for an older-adult patient indicates that more extensive examination of the eyes is needed?
- A. The patient's sclerae are light yellow in colour.
- B. The patient complains of persistent photophobia.
- C. The pupil recovers slowly after being stimulated by a penlight.
- D. There is a whitish gray ring encircling the periphery of the iris.
Correct Answer: B
Rationale: Photophobia is not a normally occurring change with aging and would require further assessment. The other assessment data are common age-related differences and would not be unusual in an older-adult patient.
The nurse is caring for a patient in the emergency department with symptoms of eye itching and pain caused by sleeping with contact lenses in place. Which of the following equipment should the nurse anticipate preparing to facilitate further examination of the patient's eye?
- A. Tonometer
- B. Eye patch
- C. Refractometer
- D. Fluorescein dye
Correct Answer: D
Rationale: Eye itching and pain suggest a possible corneal abrasion or ulcer, which can be visualized using fluorescein dye. The other items listed would not be helpful in determining the cause of this patient's symptoms.
The nurse is teaching a patient about routine glaucoma testing. Which of the following information should the nurse include in the teaching plan?
- A. The test involves reading a Snellen chart at a distance of 6 m.
- B. Application of a Tono-pen to the surface of the eye will be needed.
- C. The examination includes checking the pupil's reaction to a bright light.
- D. Medications to dilate the pupil will be used before testing for glaucoma.
Correct Answer: B
Rationale: Glaucoma is caused by an increase in intraocular pressure, which would be measured using the Tono-pen. The other techniques are used in testing for other eye disorders.
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.