Nokea
The nurse is observing a student who is preparing to perform an ear examination of an adult patient. Which of the following actions by the student should cause the nurse to intervene in the assessment?
- A. Chooses a speculum smaller than the ear canal
- B. Pulls the auricle of the ear down and backward
- C. Stabilizes the hand holding the otoscope on the patient's head
- D. Stops inserting the otoscope after observing impacted cerumen
Correct Answer: B
Rationale: The auricle should be pulled up and back when assessing an adult. The other actions are appropriate when performing an ear examination.
You may also like to solve these questions
The nurse is obtaining a nursing history from a patient when the patient indicates symptoms of dizziness when bending over and nausea and dizziness associated with physical activities. Which of the following topics should the nurse include in this patient's teaching plan?
- A. Tympanometry
- B. Rotary chair testing
- C. Pure-tone audiometry
- D. Bone-conduction testing
Correct Answer: B
Rationale: The patient's clinical manifestations of dizziness and nausea suggest a disorder of the labyrinth, which controls balance and contains three semicircular canals and the vestibule. Rotary chair testing is used to test vestibular function. The other tests are used to test for problems with hearing.
The nurse is preparing a patient in the eye clinic for refractometry. Which of the following information should the nurse include in patient teaching?
- A. You will need to wear sunglasses for a few hours after the exam.'
- B. The surface of your eye will be numb while the doctor does the exam.'
- C. You should not take any of your eye medicines before the examination.'
- D. The doctor will shine a bright light into your eye during the examination.'
Correct Answer: A
Rationale: The pupil is dilated by using cycloplegic medications during refractometry. This effect will last several hours and cause photophobia. The other teaching would not be appropriate for a patient who was having refractometry.
The nurse in the eye clinic is examining an older-adult patient who says 'I see small spots that move around in front of my eyes.' Which of the following actions should the nurse take first?
- A. Immediately have the ophthalmologist evaluate the patient.
- B. Explain that spots and 'floaters' are a normal part of aging.
- C. Inform the patient that these spots may indicate damage to the retina.
- D. Use an ophthalmoscope to examine the posterior chamber of the eyes.
Correct Answer: D
Rationale: Although 'floaters' are usually caused by vitreous liquefaction and are common in aging patients, they can be caused by hemorrhage into the vitreous humour or by retinal tears, so the nurse's first action will be to examine the retina and posterior chamber. Although the ophthalmologist will examine the patient, the presence of spots or floaters in a 65-year-old is not an emergency. The spots may indicate retinal damage, but the nurse should assess the eye further before discussing this with the patient.
The nurse is assessing an older-adult patient for the presence of presbyopia. Which of the following equipment will the nurse need to obtain before the examination?
- A. Penlight
- B. Tono-pen
- C. Jaeger chart
- D. Snellen chart
Correct Answer: C
Rationale: Presbyopia is the normal loss of near vision that occurs with age and is assessed using a Jaeger chart. This assessment should begin after 40 years of age. The Snellen chart, penlight, and the Tono-pen are used when assessing for other visual disorders.
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.