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Lewis: Medical-Surgical Nursing, 8th Edition

Chapter 21: Nursing Assessment: Visual and Auditory Systems


Test Bank
MULTIPLE CHOICE
1. Which information will the nurse include when teaching a patient about routine glaucoma

testing?
a. The test involves reading a Snellen chart at a distance of 20 feet.
b. Application of a Tono-pen to the surface of the eye will be needed.
c. The examination includes checking the pupils reaction to a bright light.
d. Medications to dilate the pupil will be used before testing for glaucoma.
ANS: B

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.
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation

REF: 392
MSC: NCLEX: Health Promotion and Maintenance

2. Which assessment information obtained by the nurse when performing an eye

examination for a 78-year-old patient indicates that more extensive examination of the
eyes is needed?
a. The patients sclerae are light yellow in color.
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.
ANS: B

Photophobia is not a normally occurring change with aging and would require further
assessment. The other assessment data are common gerontologic differences and would
not be unusual in a 78-year-old patient.
DIF: Cognitive Level: Application
TOP: Nursing Process: Assessment

REF: 387
MSC: NCLEX: Physiological Integrity

3. When performing an eye examination, the nurse will assess for accommodation by
a. covering one eye for 1 minute and noting the pupil reaction when the cover is

removed.

b. shining a light into the patients eye and watching the pupil response in the

opposite eye.

c. observing the pupils when the patient focuses on a close object and then on a

distant object.

d. touching the patients pupil with a small piece of sterile cotton and watching for a

blink reaction.

Test Bank

21-2

ANS: C

Accommodation is defined as the ability of the lens to adjust to various distances. The
other nursing actions also may be part of the eye examination, but they do not test for
accommodation.
DIF: Cognitive Level: Application
TOP: Nursing Process: Assessment

REF: 385 | 386


MSC: NCLEX: Health Promotion and Maintenance

4. The nurse at the eye clinic advises all patients to wear sunglasses that protect the eyes

from ultraviolet light because ultraviolet sunlight exposure is associated with the
development of
a. cataracts.
b. glaucoma.
c. anisocoria.
d. exophthalmos.
ANS: A

Ultraviolet light exposure is associated with the accelerated development of cataracts.


Glaucoma is caused by increased intraocular pressure, exophthalmos is associated with
hyperthyroidism, and anisocoria can occur normally in a small percentage of the
population or may be caused by injury or central nervous system disorders.
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Implementation

REF: 387
MSC: NCLEX: Health Promotion and Maintenance

5. Assessment of a patients visual acuity reveals that the left eye can see at 20 feet what a

person with normal vision can see at 40 feet and the right eye can see at 20 feet what a
person with normal vision can see at 50 feet. The nurse records which of the following
findings as visual acuity?
a. OS 20/40; OD 20/50
b. OU 20/40; OS 50/20
c. OD 20/40; OS 20/50
d. OU 40/20; OD 50/20
ANS: A

When documenting visual acuity, the first number indicates the standard (for normal
vision) of 20 feet and the second number indicates the line that the patient is able to read
when standing 20 feet from the Snellen chart. OS is the abbreviation for left eye and OD
is the abbreviation for right eye. The remaining three answers do not correctly describe
the patients visual acuity.
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment

REF: 390 | 392


MSC: NCLEX: Health Promotion and Maintenance

6. Which nursing action is included when assessing a patients visual field?


a. Position the patient 20 feet from the Snellen chart.
b. Have the patient cover one eye while facing the nurse.
c. Instruct the patient to follow a moving object using only the eyes.
d. Shine a light into one pupil and observe the response for both pupils.

Test Bank

21-3

ANS: B

To perform confrontation visual field testing, the patient faces the examiner and covers
one eye, then counts the number of fingers that the examiner brings into the visual field.
The other actions are needed to test for visual acuity, extraocular movements, and
consensual pupil response.
DIF: Cognitive Level: Application
TOP: Nursing Process: Assessment

REF: 390
MSC: NCLEX: Health Promotion and Maintenance

7. The nurse is observing a student who is preparing to perform an ear examination of a 24-

year-old patient. The nurse will need to intervene if the student


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 patients head.
d. stops inserting the otoscope after observing impacted cerumen.
ANS: B

The auricle should be pulled up and back when assessing an adult. The other actions are
appropriate when performing an ear examination.
DIF: Cognitive Level: Application
TOP: Nursing Process: Assessment

REF: 398
MSC: NCLEX: Health Promotion and Maintenance

8. When obtaining a health history from a 52-year-old patient, which patient statement 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.
ANS: D

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 problems (presbyopia, dryness, and lens opacity) that are considered a
normal part of aging.
DIF: Cognitive Level: Application
TOP: Nursing Process: Assessment

REF: 387 | 391


MSC: NCLEX: Physiological Integrity

9. The nurse is obtaining a health history for a 64-year-old patient with glaucoma who is a

new patient at the eye clinic. Which information given by the patient will have the most
implications for the patients treatment?
a. I use aspirin when I have a sinus headache.
b. I have had frequent episodes of conjunctivitis.
c. I take metoprolol (Lopressor) daily for angina.
d. I have not had an eye examination for 10 years.
ANS: C

Test Bank

21-4

It is important to note whether the patient takes any -adrenergic blockers because this
category of medications also is used to treat glaucoma, and there may be an increase in
adverse effects. The use of aspirin does not increase intraocular pressure and is safe for
patients with glaucoma. Although older patients should have yearly eye examinations, the
treatment for this patient will not be affected by the 10-year gap in eye care.
Conjunctivitis does not increase the risk for glaucoma.
DIF: Cognitive Level: Application
TOP: Nursing Process: Assessment

REF: 396
MSC: NCLEX: Physiological Integrity

10. In order to assess the visual acuity for a patient in the outpatient clinic, the nurse will

need to obtain a (an)


a. penlight.
b. Amsler grid.
c. Snellen chart.
d. ophthalmoscope.
ANS: C

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.
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment

REF: 392
MSC: NCLEX: Health Promotion and Maintenance

11. A patient being admitted to the hospital has an eye patch in place and tells the nurse I

had a recent eye injury, so I need to wear this patch for a few weeks. Which nursing
diagnosis will the nurse include in the plan of care?
a. Risk for falls related to current decrease in stereoscopic vision
b. Ineffective health maintenance related to inability to see surroundings
c. Disturbed body image related to eye trauma and need to wear eye patch
d. Ineffective denial related to inability to admit the impact of the eye injury
ANS: A

The loss of stereoscopic vision created by the eye patch impairs the patients ability to
see in three dimensions and to judge distances. It also increases the risk for falls. There is
no evidence in the assessment data for ineffective denial, disturbed body image, or
ineffective health maintenance.
DIF: Cognitive Level: Application
REF: 393
Diagnosis
MSC: NCLEX: Safe and Effective Care Environment

TOP: Nursing Process:

12. A patient in the eye clinic is scheduled for refractometry. Which information will the

nurse include in patient teaching?


a. You will need to wear sunglasses for a few hours after the exam.
b. The surface of your eye will be numb while the doctor does the exam.
c. You should not take any of your eye medicines before the examination.
d. The doctor will shine a bright light into your eye during the examination.

Test Bank

21-5

ANS: A

The pupil is dilated by using cycloplegic medications during refractometry. This effect
will last several hours and cause photophobia. The other teaching would not be
appropriate for a patient who was having refractometry.
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation

REF: 394
MSC: NCLEX: Physiological Integrity

13. The nurse is assessing a 48-year-old patient for presbyopia. Which equipment will the

nurse need to obtain before the examination?


a. Penlight
b. Tono-pen
c. Jaeger chart
d. Snellen chart
ANS: C

Presbyopia is the normal loss of near vision that occurs with age and is assessed using a
Jaeger chart. The Snellen chart, penlight, and the Tono-pen are used when assessing for
other visual disorders.
DIF: Cognitive Level: Application
TOP: Nursing Process: Assessment

REF: 390 | 392


MSC: NCLEX: Health Promotion and Maintenance

14. A patient arrives in the emergency department complaining of eye itching and pain

caused by sleeping with contact lenses in place. To facilitate further examination of the
eye, the nurse will anticipate the need for
a. a tonometer.
b. eye patching.
c. a refractometer.
d. fluorescein dye.
ANS: D

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 patients symptoms.
DIF: Cognitive Level: Application
Planning
MSC: NCLEX: Physiological Integrity

REF: 391

TOP: Nursing Process:

15. During the nursing history, a patient complains of dizziness when bending over and of

nausea and dizziness associated with physical activities. The nurse will plan to teach the
patient about
a. tympanometry.
b. rotary chair testing.
c. pure-tone audiometry.
d. bone-conduction testing.
ANS: B

Test Bank

21-6

The patients clinical manifestations of dizziness and nausea suggest a disorder of the
labyrinth, which controls balance and contains three semicircular canals and the
vestibule. Rotary chair testing is used to test vestibular function. The other tests are used
to test for problems with hearing.
DIF: Cognitive Level: Application
Planning
MSC: NCLEX: Physiological Integrity

REF: 400

TOP: Nursing Process:

16. When the nurse is taking a health history of a new patient at the ear clinic, the patient

states, I always sleep with the radio on. Which follow-up question is most appropriate
to obtain more information about possible hearing problems?
a. Do you grind your teeth at night?
b. What time do you usually fall asleep?
c. Have you noticed any ringing in your ears?
d. Are you ever dizzy when you are lying down?
ANS: C

Patients with tinnitus may use masking techniques, such as playing a radio, to block out
the ringing in the ears. The responses Do you grind your teeth at night? and Have you
noticed any ringing in your ears? would be used to obtain information about other ear
problems, such as vestibular disorders and referred temporomandibular joint (TMJ) pain.
The response What time do you usually fall asleep? would not be helpful in assessing
problems with the patients ears.
DIF: Cognitive Level: Application
TOP: Nursing Process: Assessment

REF: 389
MSC: NCLEX: Physiological Integrity

17. Which finding by the nurse during the admission assessment for a patient may indicate

that the patient is at risk for falls while hospitalized?


a. Lateralization with Weber test
b. Positive result for Rinne testing
c. Inability to hear a low-pitched whisper
d. Nystagmus when head is turned rapidly
ANS: D

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.
DIF: Cognitive Level: Application
TOP: Nursing Process: Assessment

REF: 396
MSC: NCLEX: Physiological Integrity

18. When taking a health history from a new patient in the outpatient clinic, which

information may indicate the need to perform a focused hearing assessment?


a. The patient uses albuterol (Proventil) for acute asthma.
b. The patient takes atenolol (Tenormin) to prevent angina.
c. The patient uses acetaminophen (Tylenol) frequently for headaches.
d. The patient has taken ibuprofen (Advil) for 20 years to treat arthritis.

Test Bank

21-7

ANS: D

Nonsteroidal anti-inflammatory drugs (NSAIDs) are potentially ototoxic.


Acetaminophen, atenolol, and albuterol are not associated with hearing loss.
DIF: Cognitive Level: Application
TOP: Nursing Process: Assessment

REF: 396
MSC: NCLEX: Physiological Integrity

19. Which action will the nurse include in the plan of care for a patient who has vestibular

disease?
a. Check Rinne and Weber tests.
b. Face the patient when speaking.
c. Enunciate clearly when speaking.
d. Monitor the patients ability to ambulate safely.
ANS: D

Vestibular disease affects balance so the nurse should monitor the patient during
activities that require balance. The other action might be used for patients with hearing
disorders.
DIF: Cognitive Level: Application
Planning
MSC: NCLEX: Physiological Integrity

REF: 396 | 398

TOP: Nursing Process:

20. The nurse in the eye clinic is examining a 65-year-old patient who says I see small spots

that move around in front of my eyes. Which action will 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.
ANS: D

Although floaters are usually caused by vitreous liquefaction and are common in aging
patients, they can be caused by hemorrhage into the vitreous humor or by retinal tears, so
the nurses 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-yearold is not an emergency. The spots may indicate retinal damage, but the nurse should
assess the eye further before discussing this with the patient.
DIF: Cognitive Level: Application
OBJ: Special Questions: Prioritization
MSC: NCLEX: Physiological Integrity

REF: 387 | 391


TOP: Nursing Process: Implementation

21. Which observation by the nurse when examining a patients auditory canal and tympanic

membrane 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.

Test Bank

21-8

ANS: B

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 pathologic. 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.
DIF: Cognitive Level: Application
OBJ: Special Questions: Prioritization
MSC: NCLEX: Physiological Integrity

REF: 399
TOP: Nursing Process: Assessment