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The nurse is establishing a visual test using the Snellen chart for a client experiencing visual changes. At which distance should the nurse instruct the client to stand?
- A. A 10-feet distance
- B. A 20-feet distance
- C. A 30-feet distance
- D. A 40-feet distance
Correct Answer: B
Rationale: The nurse is correct in instructing the client to stand at a 20-feet distance from the Snellen chart. Often, the nurse places tape on the floor to denote the correct distance for the client to stand.
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The nurse is evaluating the client taking the color vision test. Which response would the nurse anticipate when caring for a client with normal color vision?
- A. The nurse would anticipate the client identifying numbers and shapes.
- B. The nurse would anticipate a cross-eyed appearance.
- C. The nurse would anticipate responding to the color names in the pictures.
- D. The nurse would anticipate no differentiation in between colors.
Correct Answer: A
Rationale: The nurse is correct to anticipate the client being able to identify numbers and shapes dictated by different color codes. The other options do not test for color vision or indicate an inability to differentiate colors.
A client comes to the occupational health nurse complaining of eye irritation. The client works in a dusty, outdoor environment. Why should the nurse advise periodic blinking to this client?
- A. To control the amount of sunlight that enters the eye
- B. To minimize the impact of the wind on the eye and to trap foreign debris
- C. To clear the dust and particles from the surface of the eyes
- D. To prevent the collection of tears over the surface of the eye
Correct Answer: C
Rationale: Periodic blinking clears the dust and particles from the surface of the eyes. The eyelids also spread tears over the surface of the eye, which helps bathe and lubricate the surface. The eyelids protect against foreign bodies and adjust the amount of light that enters the eye, whereas the eyelashes trap foreign debris.
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.
What is located in the cochlea of the inner ear?
- A. Semicircular canals
- B. Labyrinth
- C. Vestibulocochlear nerve
- D. Organ of Corti
Correct Answer: D
Rationale: The fluid motion created by the vibrating stapes excites the nerve endings in the sensitive sound receptors of the organ of Corti located in the cochlea. The labyrinth is the name for the inner ear, and the semicircular canals and vestibulocochlear nerves are other components of the inner ear.
A client has been referred to an ophthalmologist for suspected macular degeneration. The nurse knows to prepare what test for the physician to give the client?
- A. Ishihara polychromatic plates
- B. Visual field
- C. Amsler grid
- D. Slit lamp
Correct Answer: C
Rationale: Clients with macular problems are tested with an Amsler grid. It is made up of a geometric grid of identical squares with a central fixation point. The examiner instructs the client to stare at the central fixation spot on the grid and report if they see any distortion of the squares. Clients with macular problems may say some of the squares are faded or wavy. An Ishihara polychromatic plate, visual field, or slit lamp test will not diagnose macular degeneration.