Nokea
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.
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The nurse is obtaining a history on a client stating the inability to read the newspaper and seeing detail when looking at an image. Which assessment test would add additional data for a diagnosis?
- A. Assess if the pupils are equal and reactive to light.
- B. Assess vision on the Snellen chart.
- C. Assess peripheral vision.
- D. Assess color vision.
Correct Answer: C
Rationale: The client states symptoms of the inability to discriminate letters, words, and details of an image, indicating the degeneration of the macula. If the macula is damaged, the client will only have the ability to see movement and gross objects in the peripheral fields. Assessing the peripheral vision will add essential information. The other visual tests are not as important at this time.
A nurse is assessing a pediatric client in a public health clinic. The parent states that the client has been sneezing and rubbing the eyes. The nurses observes the client's eyes and documents objective symptoms of watery and red eyes. When reporting the assessment findings to the health care provider, which description is appropriate?
- A. Signs and symptoms of conjunctivitis
- B. Signs and symptoms of ptosis
- C. Signs and symptoms of nystagmus
- D. Signs and symptoms of proptosis
Correct Answer: A
Rationale: Conjunctivitis often stems from an allergy causing inflammation of the conjunctiva, which is a thin, transparent mucous membrane. Conjunctivitis can cause symptoms of itchiness, redness, and watery eyes. Ptosis is drooping of the upper eyelid. Proptosis is an extended and upper eyelid that delays in closing or remains partially open. Nystagmus is an uncontrolled oscillating movement of the eyeball.
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.
When caring for a client with a foreign object removed from the eye, the nurse is most correct to assess the eye protective functions of which structure(s)? Select all that apply.
- A. Eyelids and lashes
- B. Aqueous humor
- C. Superior and inferior oblique muscles
- D. Conjunctiva
- E. Sclera
- F. Tears
Correct Answer: A,F
Rationale: The nurse is correct to assess the eyelids and lashes and also tears as the protective structures. The eyelids protect against foreign bodies and adjust the amount of light that enters the eye. The eyelashes trap foreign debris. Periodic blinking clears dust and particles from the surface of the eyes. The aqueous humor and sclera are intraocular structures. Oblique muscles move the eye left and right. The conjunctiva is a sensitive transparent mucous membrane that alerts the individual to a foreign object in the eye.
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.