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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.
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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 nurse is assessing a client for objective symptoms of hearing difficulties. Which sign leads the nurse to take alternate measures to ensure client understanding of teaching?
- A. The client interrupts by asking the nurse to repeat instruction.
- B. The client is quiet and responds appropriately.
- C. The client leans forward and turns the head.
- D. The client quietly reads the instructional literature.
Correct Answer: C
Rationale: The nurse assesses objective signs of leaning forward and turning the head as indicative of difficulty hearing. The nurse would use alternate formats of teaching to reinforce key points. Asking to repeat information is a subjective indication of hearing difficulty. Responding appropriately and reading instructional literature does not indicate a hearing difficulty.
The nurse is caring for a client ordered for multiple eye screening. Following which procedure will the nurse instruct the client on a yellow coloring to the skin and urine as being normal?
- A. Ultrasonography
- B. Retinal Imaging
- C. Retinal Angiography
- D. Retinoscopy
Correct Answer: C
Rationale: The nurse is correct to instruct the client that skin and urine may turn yellow following a retinal angiography. Sodium fluorescein is a water-soluble dye that is injected into a vein. The dye then travels to the retinal arteries and capillaries, where pictures are obtained of the vascular supply. The other options do not include a dye injection.
A client is having problems with dizziness and complains of the 'room spinning.' The physician performs the caloric stimulation test. The nurse knows that a diminished response in one eye during the caloric stimulation test is indicative of what?
- A. Inner ear disorder
- B. Middle ear disorder
- C. Outer ear disorder
- D. Age-related macular degeneration
Correct Answer: A
Rationale: During the caloric stimulation test, a diminished response in one eye is significant for an inner ear disorder such as M?©ni?¨re disease. It does not signify a middle ear disorder, an outer ear disorder, or age-related macular degeneration.
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.