Nokea
What is located in the cochlea of the inner ear?
- A. Semicircular canals
- B. Labyrinth
- C. Vestibulocochlear nerve
- D. Organ of Corti
Correct Answer: D
Rationale: The fluid motion created by the vibrating stapes excites the nerve endings in the sensitive sound receptors of the organ of Corti located in the cochlea. The labyrinth is the name for the inner ear, and the semicircular canals and vestibulocochlear nerves are other components of the inner ear.
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The nurse is obtaining a history on a client stating the inability to read the newspaper and seeing detail when looking at an image. Which assessment test would add additional data for a diagnosis?
- A. Assess if the pupils are equal and reactive to light.
- B. Assess vision on the Snellen chart.
- C. Assess peripheral vision.
- D. Assess color vision.
Correct Answer: C
Rationale: The client states symptoms of the inability to discriminate letters, words, and details of an image, indicating the degeneration of the macula. If the macula is damaged, the client will only have the ability to see movement and gross objects in the peripheral fields. Assessing the peripheral vision will add essential information. The other visual tests are not as important at this time.
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.
The nurse is conducting hearing tests at the local junior high school. Which of the following indicates normal hearing in a child?
- A. A client who first perceives sound at 20 dB
- B. A client who first perceives sound at 40 dB
- C. A client for whom the painful sound occurs at 80 dB
- D. A client for whom the painful sound occurs at 100 dB
Correct Answer: A
Rationale: The lowest level of sound that normal persons may first perceive is 20 dB. The painful sounds occur at 120 dB. The hearing acuity is determined by measuring the intensity at which a person first perceives sound.
The nurse is collecting the history of a client diagnosed with a cataract and is performing a focused assessment. Which finding should the nurse anticipate?
- A. A burning sensation and the sensation of an object in the eye
- B. Blurred or cloudy vision
- C. Inability to produce sufficient tears
- D. A swollen lacrimal caruncle
Correct Answer: B
Rationale: When a cataract forms, the light is blocked from reaching the macula and the visual image becomes blurred or cloudy. The client does not experience any burning or the sensation of an object in the eye, an inability to produce sufficient tears, or a swollen lacrimal caruncle.