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The nurse is completing a corneal light reflex test on a client, using a penlight. Which result would indicate a normal test result?
- A. The pupils have reaction to light.
- B. The eyes follow the light in all four directions.
- C. The client can see the light using peripheral vision.
- D. The light reflection is in the same spot on each eye.
Correct Answer: D
Rationale: A normal corneal light reflex test is when the light reflex is even, reflecting the light at the same spot on both eyes. If the light reflex is uneven, it indicates deviated alignment of the eyes, possibly due to muscle weakness or paralysis.
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The nursing student is taking an anatomy and physiology class. What anatomical structure equalizes air pressure in the middle ear?
- A. Eustachian tube
- B. The malleus
- C. The pinna
- D. The meatus
Correct Answer: A
Rationale: The eustachian tube extends from the floor of the middle ear to the pharynx and is lined with mucous membrane. It equalizes air pressure in the middle ear. The other options do not equalize pressure in the middle ear.
The nurse is caring for a client who just returned from a trip requiring an airline flight. The client reported ear pain upon descent. The nurse is correct in stating which site as being the pressure equalizer in the ear?
- A. Eustachian tube
- B. Auricle
- C. Tympanic membrane
- D. Labyrinth
Correct Answer: A
Rationale: The eustachian tube extends from the floor of the middle ear to the pharynx. It equalizes air pressure in the middle ear. The auricle is the fleshy portion of the outer ear which funnels sound waves to the inner ear. The tympanic membrane is the eardrum. The labyrinth is the inner ear which contains fluid.
A client presents to the emergency room with symptoms of blurred vision. Which type of question would be best to ask first?
- A. Have you ever had these symptoms before?
- B. Did these symptoms come on abruptly?
- C. Do you have a family history of vision problems?
- D. Do you have any other diseases?
Correct Answer: A
Rationale: When a client presents with unusual symptoms, a first question assesses if the client has ever had these symptoms before. This prepares a starting place for the assessment. If the client did have these symptoms before, questions regarding the specific nature and similarities of that experience guide the assessment.
The nurse is performing a Weber test on a client. During this test, where should the nurse place the tuning fork?
- A. On the mastoid process behind the ear
- B. In the midline of the client's skull or in the center of the forehead
- C. Near the external meatus of each ear
- D. Under the bridge of the nose
Correct Answer: B
Rationale: The Weber test is performed by striking the tuning fork and placing its stem in the midline of the client's skull or in the center of the forehead. In the Rinne test, the tuning fork is struck and placed on the mastoid process behind the ear. The tuning fork is not placed near the external meatus of each ear or under the bridge of the nose.
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.