Nokea
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.
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A client is having problems with dizziness and complains of the 'room spinning.' The physician performs the caloric stimulation test. The nurse knows that a diminished response in one eye during the caloric stimulation test is indicative of what?
- A. Inner ear disorder
- B. Middle ear disorder
- C. Outer ear disorder
- D. Age-related macular degeneration
Correct Answer: A
Rationale: During the caloric stimulation test, a diminished response in one eye is significant for an inner ear disorder such as M?©ni?¨re disease. It does not signify a middle ear disorder, an outer ear disorder, or age-related macular degeneration.
The nurse is assisting with the administration of a caloric stimulation test. Which client response would the nurse document as an expected response?
- A. Dizziness
- B. Headache
- C. Nystagmus
- D. Double vision
Correct Answer: C
Rationale: A caloric stimulation test assesses vestibular reflexes of the inner ear that control balance. Warm or cool water or air is instilled into the external meatus of the ear separately. Nystagmus, a quivering movement of the eyes, is the expected response. Slight dizziness may be experienced but is not the expected response. Headache and double vision are not expected responses.
A client comes to the occupational health nurse complaining of eye irritation. The client works in a dusty, outdoor environment. Why should the nurse advise periodic blinking to this client?
- A. To control the amount of sunlight that enters the eye
- B. To minimize the impact of the wind on the eye and to trap foreign debris
- C. To clear the dust and particles from the surface of the eyes
- D. To prevent the collection of tears over the surface of the eye
Correct Answer: C
Rationale: Periodic blinking clears the dust and particles from the surface of the eyes. The eyelids also spread tears over the surface of the eye, which helps bathe and lubricate the surface. The eyelids protect against foreign bodies and adjust the amount of light that enters the eye, whereas the eyelashes trap foreign debris.
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 caring for a client who just returned from a trip requiring an airline flight. The client reported ear pain upon descent. The nurse is correct in stating which site as being the pressure equalizer in the ear?
- A. Eustachian tube
- B. Auricle
- C. Tympanic membrane
- D. Labyrinth
Correct Answer: A
Rationale: The eustachian tube extends from the floor of the middle ear to the pharynx. It equalizes air pressure in the middle ear. The auricle is the fleshy portion of the outer ear which funnels sound waves to the inner ear. The tympanic membrane is the eardrum. The labyrinth is the inner ear which contains fluid.