Nokea
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.
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The nurse is admitting a patient to the hospital who has an eye patch in place and tells the nurse 'I had a recent eye injury, so I need to wear this patch for a few weeks.' Which of the following nursing diagnoses will the nurse include in the plan of care?
- A. Risk for falls as evidenced by impaired vision (decrease in stereoscopic vision)
- B. Ineffective health maintenance related to impaired decision-making (inability to see surroundings)
- C. Disturbed body image related to alteration in self-perception
- D. Ineffective denial related to threat of unpleasant reality
Correct Answer: A
Rationale: The loss of stereoscopic vision created by the eye patch impairs the patient's ability to see in three dimensions and to judge distances. It also increases the risk for falls. There is no evidence in the assessment data for ineffective denial, disturbed body image, or ineffective health maintenance.
The nurse is assessing a patient's auditory canal and tympanic membrane. Which of the following findings is a priority to report to the health care provider?
- A. There is a cone of light visible.
- B. The tympanum is bluish-tinged.
- C. Cerumen is present in the auditory canal.
- D. The skin in the ear canal is dry and scaly.
Correct Answer: B
Rationale: A bluish-tinged tympanum can occur with acute otitis media, which requires immediate care to prevent perforation of the tympanum. Cerumen in the ear canal may need to be removed before proceeding with the examination but is not unusual or pathological. The presence of a cone of light on the eardrum is normal. Dry and scaly skin in the ear canal may need further assessment but does not require urgent care.
Which assessment information obtained by the nurse when performing an eye examination for an older-adult patient indicates that more extensive examination of the eyes is needed?
- A. The patient's sclerae are light yellow in colour.
- B. The patient complains of persistent photophobia.
- C. The pupil recovers slowly after being stimulated by a penlight.
- D. There is a whitish gray ring encircling the periphery of the iris.
Correct Answer: B
Rationale: Photophobia is not a normally occurring change with aging and would require further assessment. The other assessment data are common age-related differences and would not be unusual in an older-adult patient.
The nurse is admitting a patient to the hospital preoperatively. Which of the following findings may indicate that the patient is at risk for falls while hospitalized?
- A. Lateralization with Weber's test
- B. Positive result for Rinne's testing
- C. Inability to hear a low-pitched whisper
- D. Nystagmus when head is turned rapidly
Correct Answer: D
Rationale: Nystagmus suggests that the patient may have problems with balance related to disease of the vestibular system. The other tests are used to check hearing, abnormal results for these do not indicate potential problems with balance.
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.