Nokea
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.
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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 is conducting an auditory assessment with a patient. Which of the following findings should the nurse document as normal?
- A. Ability to hear low whisper at 30 cm
- B. Rinne's test results: bone conduction is better than air conduction
- C. Weber's test results - no lateralization
- D. Curved cone light reflex
- E. Symmetrical location of ears
Correct Answer: A,C,E
Rationale: Normal findings in the physical assessment of the auditory system include ears symmetrical in location and shape, auricles and tragus nontender, without lesions; clear canal and tympanic membrane intact, landmarks and light reflex intact; ability to hear low whispers at 30 cm and no lateralization Weber's test result. Rinne's test result for a normal finding is that air conduction is better than bone conduction.
The nurse is preparing a patient in the eye clinic for refractometry. Which of the following information should the nurse include in patient teaching?
- A. You will need to wear sunglasses for a few hours after the exam.'
- B. The surface of your eye will be numb while the doctor does the exam.'
- C. You should not take any of your eye medicines before the examination.'
- D. The doctor will shine a bright light into your eye during the examination.'
Correct Answer: A
Rationale: The pupil is dilated by using cycloplegic medications during refractometry. This effect will last several hours and cause photophobia. The other teaching would not be appropriate for a patient who was having refractometry.
The nurse is performing an eye examination on a patient and is assessing for accommodation. Which of the following actions should the nurse implement?
- A. Cover one eye for 1 minute and note the pupil reaction when the cover is removed.
- B. Shine a light into the patient's eye and assess the pupil response in the opposite eye.
- C. Observe the pupils when the patient focuses on a distant object and then on a close object.
- D. Touch the patient's pupil with a small piece of sterile cotton and watch for a blink reaction.
Correct Answer: C
Rationale: Accommodation is defined as the ability of the lens to adjust to various distances. The other nursing actions also may be part of the eye examination, but they do not test for accommodation.
The nurse is delivering a health-promotion session at the eye clinic and advises all patients to wear sunglasses that protect the eyes from ultraviolet light. Which of the following conditions is associated with ultraviolet sunlight exposure?
- A. Cataract
- B. Glaucoma
- C. Anisocoria
- D. Exophthalmos
Correct Answer: A
Rationale: Ultraviolet light exposure is associated with the accelerated development of cataracts. Glaucoma is caused by increased intraocular pressure, anisocoria refers to unequal pupil sizes, and exophthalmos is associated with conditions like hyperthyroidism, not ultraviolet exposure.