Nokea
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.
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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.
The nurse is preparing to assess the visual acuity for a patient in the outpatient clinic. Which of the following supplies should the nurse obtain to prepare for this assessment?
- A. Penlight
- B. Amsler grid
- C. Snellen chart
- D. Ophthalmoscope
Correct Answer: C
Rationale: The Snellen chart is used to check visual acuity. An ophthalmoscope, penlight, and Amsler grid also may be used during an eye examination, but they are not helpful in assessing visual acuity.
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 taking a health history of a new patient at the ear clinic and the patient states, 'I always sleep with the radio on.' Which of the following questions is most appropriate to obtain more information about possible hearing problems?
- A. Do you grind your teeth at night?'
- B. What time do you usually fall asleep?'
- C. Have you noticed any ringing in your ears?'
- D. Are you ever dizzy when you are lying down?'
Correct Answer: C
Rationale: Patients with tinnitus may use masking techniques, such as playing a radio, to block out the ringing in the ears. The responses 'Do you grind your teeth at night?' and 'Are you dizzy when lying down?' would be used to obtain information about other ear problems, such as vestibular disorders and referred temporomandibular joint (TMJ) pain. The response 'What time do you usually fall asleep?' would not be helpful in assessing problems with the patient's ears.
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.