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The nurse is performing a Weber test on a client. During this test, where should the nurse place the tuning fork?
- A. On the mastoid process behind the ear
- B. In the midline of the client's skull or in the center of the forehead
- C. Near the external meatus of each ear
- D. Under the bridge of the nose
Correct Answer: B
Rationale: The Weber test is performed by striking the tuning fork and placing its stem in the midline of the client's skull or in the center of the forehead. In the Rinne test, the tuning fork is struck and placed on the mastoid process behind the ear. The tuning fork is not placed near the external meatus of each ear or under the bridge of the nose.
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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.
Audiometry is testing that measures hearing acuity precisely. Who does the nurse know can perform audiometric testing?
- A. School nurse
- B. Hearing aide salesperson
- C. Audiologist
- D. Office nurse
Correct Answer: C
Rationale: Audiometry is done by an audiologist. Audiometric testing measures hearing acuity precisely. The other options can screen hearing, but they cannot do audiometric testing.
When caring for a client with a foreign object removed from the eye, the nurse is most correct to assess the eye protective functions of which structure(s)? Select all that apply.
- A. Eyelids and lashes
- B. Aqueous humor
- C. Superior and inferior oblique muscles
- D. Conjunctiva
- E. Sclera
- F. Tears
Correct Answer: A,F
Rationale: The nurse is correct to assess the eyelids and lashes and also tears as the protective structures. The eyelids protect against foreign bodies and adjust the amount of light that enters the eye. The eyelashes trap foreign debris. Periodic blinking clears dust and particles from the surface of the eyes. The aqueous humor and sclera are intraocular structures. Oblique muscles move the eye left and right. The conjunctiva is a sensitive transparent mucous membrane that alerts the individual to a foreign object in the eye.
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.
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.