Nokea
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.
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What is located in the cochlea of the inner ear?
- A. Semicircular canals
- B. Labyrinth
- C. Vestibulocochlear nerve
- D. Organ of Corti
Correct Answer: D
Rationale: The fluid motion created by the vibrating stapes excites the nerve endings in the sensitive sound receptors of the organ of Corti located in the cochlea. The labyrinth is the name for the inner ear, and the semicircular canals and vestibulocochlear nerves are other components of the inner ear.
The nurse is evaluating the client taking the color vision test. Which response would the nurse anticipate when caring for a client with normal color vision?
- A. The nurse would anticipate the client identifying numbers and shapes.
- B. The nurse would anticipate a cross-eyed appearance.
- C. The nurse would anticipate responding to the color names in the pictures.
- D. The nurse would anticipate no differentiation in between colors.
Correct Answer: A
Rationale: The nurse is correct to anticipate the client being able to identify numbers and shapes dictated by different color codes. The other options do not test for color vision or indicate an inability to differentiate colors.
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.
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.
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.