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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.
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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 states having difficulty noting details on faces or television. Which of the following structures of the eye allows for detailed vision?
- A. The pupil
- B. The iris
- C. The cornea
- D. The macula lutea
Correct Answer: D
Rationale: The macula lutea is composed entirely of cones and allows for detailed vision. It lies in the center of the retina. This client could potentially have macular degeneration. The iris is the highly vascular, pigmented portion of the eye surrounding the pupil that adjusts in response to light. The cornea covers the anterior portion of the eyeball.
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 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.
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.