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The nurse is assessing a client for objective symptoms of hearing difficulties. Which sign leads the nurse to take alternate measures to ensure client understanding of teaching?
- A. The client interrupts by asking the nurse to repeat instruction.
- B. The client is quiet and responds appropriately.
- C. The client leans forward and turns the head.
- D. The client quietly reads the instructional literature.
Correct Answer: C
Rationale: The nurse assesses objective signs of leaning forward and turning the head as indicative of difficulty hearing. The nurse would use alternate formats of teaching to reinforce key points. Asking to repeat information is a subjective indication of hearing difficulty. Responding appropriately and reading instructional literature does not indicate a hearing difficulty.
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The nurse is assessing a client's eyes as part of the inspection part of the assessment process. For which reason does the nurse identify a normal variation in the angle of the lateral and medial canthus?
- A. Ethnic differences
- B. Chromosomal differences
- C. Structural changes
- D. Cosmetic alterations
Correct Answer: A
Rationale: The line between the lateral and medial canthus is usually horizontal. Variations are noted abnormally in children with Down syndrome and normally in individuals of Asian descent. Structural changes and cosmetic variations are not considered normal changes noted on assessment.
The nurse is caring for geriatric clients who state that they are prescribed reading glasses. Some individuals state needing assistance with seeing writing far away, and others need assistance with closer vision. What does the nurse understand to be related to visual changes caused by aging?
- A. Changes in refraction
- B. Changes in the visual field
- C. Changes in central vision
- D. Changes in accommodation
Correct Answer: D
Rationale: The changes that occur in vision during aging, which include difficulty reading and the need for reading glasses, include changes in accommodation. Accommodation occurs when the ciliary muscles contract or relax to focus an image on the retina.
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.
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 in providing coordination of services between the physician's office and vision specialist's office for a client who is being referred for potential retinal surgery. Which eye care specialist will the nurse make the referral to?
- A. Optician
- B. Optometrist
- C. Ophthalmologist
- D. Ophthalmic technician
Correct Answer: C
Rationale: The ophthalmologist is a physician who performs surgery on clients with eye disorders. The optician makes eyeglasses or contact lenses. The optometrist tests vision and prescribes corrective lenses. The ophthalmic technician assists in selective eye tests and procedures.