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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.
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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.
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 caring for a client ordered for multiple eye screening. Following which procedure will the nurse instruct the client on a yellow coloring to the skin and urine as being normal?
- A. Ultrasonography
- B. Retinal Imaging
- C. Retinal Angiography
- D. Retinoscopy
Correct Answer: C
Rationale: The nurse is correct to instruct the client that skin and urine may turn yellow following a retinal angiography. Sodium fluorescein is a water-soluble dye that is injected into a vein. The dye then travels to the retinal arteries and capillaries, where pictures are obtained of the vascular supply. The other options do not include a dye injection.
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.
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.