Nokea
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.
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The nurse is teaching a patient about routine glaucoma testing. Which of the following information should the nurse include in the teaching plan?
- A. The test involves reading a Snellen chart at a distance of 6 m.
- B. Application of a Tono-pen to the surface of the eye will be needed.
- C. The examination includes checking the pupil's reaction to a bright light.
- D. Medications to dilate the pupil will be used before testing for glaucoma.
Correct Answer: B
Rationale: Glaucoma is caused by an increase in intraocular pressure, which would be measured using the Tono-pen. The other techniques are used in testing for other eye disorders.
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 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 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.
The nurse is admitting a patient to the hospital who has an eye patch in place and tells the nurse 'I had a recent eye injury, so I need to wear this patch for a few weeks.' Which of the following nursing diagnoses will the nurse include in the plan of care?
- A. Risk for falls as evidenced by impaired vision (decrease in stereoscopic vision)
- B. Ineffective health maintenance related to impaired decision-making (inability to see surroundings)
- C. Disturbed body image related to alteration in self-perception
- D. Ineffective denial related to threat of unpleasant reality
Correct Answer: A
Rationale: The loss of stereoscopic vision created by the eye patch impairs the patient's ability to see in three dimensions and to judge distances. It also increases the risk for falls. There is no evidence in the assessment data for ineffective denial, disturbed body image, or ineffective health maintenance.