Nokea
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.
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The nurse is assessing an older-adult patient for the presence of presbyopia. Which of the following equipment will the nurse need to obtain before the examination?
- A. Penlight
- B. Tono-pen
- C. Jaeger chart
- D. Snellen chart
Correct Answer: C
Rationale: Presbyopia is the normal loss of near vision that occurs with age and is assessed using a Jaeger chart. This assessment should begin after 40 years of age. The Snellen chart, penlight, and the Tono-pen are used when assessing for other visual 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 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 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.
Which of the following actions should the nurse include in the plan of care for a patient who has vestibular disease?
- A. Check Rinne's and Weber's tests.
- B. Face the patient when speaking.
- C. Enunciate clearly when speaking.
- D. Monitor the patient's ability to ambulate safely.
Correct Answer: D
Rationale: Vestibular disease affects balance so the nurse should monitor the patient during activities that require balance. The other actions might be used for patients with hearing disorders.