Nokea
The nurse is preparing to assess the visual acuity for a patient in the outpatient clinic. Which of the following supplies should the nurse obtain to prepare for this assessment?
- A. Penlight
- B. Amsler grid
- C. Snellen chart
- D. Ophthalmoscope
Correct Answer: C
Rationale: The Snellen chart is used to check visual acuity. An ophthalmoscope, penlight, and Amsler grid also may be used during an eye examination, but they are not helpful in assessing visual acuity.
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The nurse is caring for a patient in the emergency department with symptoms of eye itching and pain caused by sleeping with contact lenses in place. Which of the following equipment should the nurse anticipate preparing to facilitate further examination of the patient's eye?
- A. Tonometer
- B. Eye patch
- C. Refractometer
- D. Fluorescein dye
Correct Answer: D
Rationale: Eye itching and pain suggest a possible corneal abrasion or ulcer, which can be visualized using fluorescein dye. The other items listed would not be helpful in determining the cause of this patient's symptoms.
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 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.
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 a health history with a new patient in the outpatient clinic. Which of the following medications in the health history may indicate the need to perform a focused hearing assessment?
- A. Salbutamol for acute asthma
- B. Atenolol to prevent angina
- C. Acetaminophen frequently for headaches
- D. Ibuprofen for 20 years to treat arthritis
Correct Answer: D
Rationale: Nonsteroidal anti-inflammatory drugs (NSAIDs) are potentially ototoxic. Acetaminophen, atenolol, and salbutamol are not associated with hearing loss. Other drugs that are potentially ototoxic include aminoglycosides, other antibiotics, salicylates, antimalarial agents, chemotherapeutic drugs, and diuretics.