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The nurse is performing an eye examination on a patient and is assessing for accommodation. Which of the following actions should the nurse implement?
- A. Cover one eye for 1 minute and note the pupil reaction when the cover is removed.
- B. Shine a light into the patient's eye and assess the pupil response in the opposite eye.
- C. Observe the pupils when the patient focuses on a distant object and then on a close object.
- D. Touch the patient's pupil with a small piece of sterile cotton and watch for a blink reaction.
Correct Answer: C
Rationale: Accommodation is defined as the ability of the lens to adjust to various distances. The other nursing actions also may be part of the eye examination, but they do not test for accommodation.
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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 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 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.
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.
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.