Nokea
The nurse is obtaining a health history from a middle-aged adult patient. Which of the following patient statements is most important to communicate to the health care provider?
- A. My vision seems blurry now when I read.'
- B. I have noticed that my eyes are drier now.'
- C. It is hard for me to see when I drive at night.'
- D. The peripheral part of my vision is decreased.'
Correct Answer: D
Rationale: The decrease in peripheral vision may indicate glaucoma, which is not a normal visual change associated with aging and requires rapid treatment. The other patient statements indicate visual conditions (presbyopia, dryness, and lens opacity) that are considered a normal part of aging.
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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.
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 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.
Which of the following actions should the nurse include in the plan of care for a patient who has vestibular disease?
- A. Check Rinne's and Weber's tests.
- B. Face the patient when speaking.
- C. Enunciate clearly when speaking.
- D. Monitor the patient's ability to ambulate safely.
Correct Answer: D
Rationale: Vestibular disease affects balance so the nurse should monitor the patient during activities that require balance. The other actions might be used for patients with hearing disorders.
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.