Nokea
The nurse is conducting hearing tests at the local junior high school. Which of the following indicates normal hearing in a child?
- A. A client who first perceives sound at 20 dB
- B. A client who first perceives sound at 40 dB
- C. A client for whom the painful sound occurs at 80 dB
- D. A client for whom the painful sound occurs at 100 dB
Correct Answer: A
Rationale: The lowest level of sound that normal persons may first perceive is 20 dB. The painful sounds occur at 120 dB. The hearing acuity is determined by measuring the intensity at which a person first perceives sound.
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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.
The nurse is instructing a nursing student when a new client comes to the eye clinic. The client reports suspecting a corneal abrasion. The nurse should explain what to the student nurse?
- A. To detect corneal abrasions, an ophthalmoscope is used.
- B. To detect corneal abrasions, ultrasonography is used.
- C. To detect corneal abrasions, a slit lamp is used.
- D. To detect corneal abrasions, retinal angiography is used.
Correct Answer: C
Rationale: A slit lamp is a binocular microscope that magnifies the surface of the eye. A beam of light, narrowed to a slit, is directed at the cornea, facilitating an examination of structures and fluid in the anterior segment of the eye. This examination is used to identify disorders such as corneal abrasions, iritis, conjunctivitis, and cataracts. The other options are not used to detect corneal abrasions.
The nurse is assessing a client's hearing using the Rinne test. When providing instruction to elicit client feedback, which instruction is essential?
- A. Raise your hand when you hear the vibration.
- B. Raise your hand when you no longer hear sound.
- C. Raise your hand when the vibration exceeds the sound.
- D. Raise your hand when the sound exceeds the vibration.
Correct Answer: B
Rationale: It is essential to provide clear directions on when the client is to notify the nurse of client response. The information gleaned from the response is what the nurse uses to interpret the test. The correct time to induce feedback is when the vibration is heard.
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 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.