Nokea
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.
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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.
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.
The nurse is caring for a child who has a perforated eardrum. Which of the following are possible causes?
- A. Persistent otitis media
- B. Mastoiditis
- C. Eustachian tube blockage
- D. Serous otitis media
- E. Acute otitis media
Correct Answer: A,B,E
Rationale: Perforation of the eardrum, central or marginal, can be caused by persistent otitis media, mastoiditis, and acute otitis media. Eustachian tube blockage could be the cause of a retracted eardrum. Serous otitis media presents as hairline fluid level, yellow-amber bubbles above the fluid line.
The nurse is assessing a patient's auditory canal and tympanic membrane. Which of the following findings is a priority to report to the health care provider?
- A. There is a cone of light visible.
- B. The tympanum is bluish-tinged.
- C. Cerumen is present in the auditory canal.
- D. The skin in the ear canal is dry and scaly.
Correct Answer: B
Rationale: A bluish-tinged tympanum can occur with acute otitis media, which requires immediate care to prevent perforation of the tympanum. Cerumen in the ear canal may need to be removed before proceeding with the examination but is not unusual or pathological. The presence of a cone of light on the eardrum is normal. Dry and scaly skin in the ear canal may need further assessment but does not require urgent care.
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.