Test Bank For NURSING HEALTH ASSESSMENT 3rd Edition By Dillon

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Test Bank For NURSING HEALTH ASSESSMENT 3rd Edition By Dillon

Chapter 04: Assessing the Eye and the Ear

Multiple Choice

Identify the choice that best completes the statement or answers the question.

____ 1. The nurse is assessing a patient’s ears. Which is a primary function of the ears that the nurse will include in the assessment process?

1)

Visual assessment

2)

Taste assessment

3)

Smell assessment

4)

Equilibrium assessment

____ 2. The nurse is assessing a patient who is experiencing eye pain. Which assessment question is appropriate when collecting the health history for this patient?

1)

“Does light bother your eye?”

2)

“Have you noticed any changes in your vision?”

3)

“Have you noticed any tearing of the eye?”

4)

“Do you wear contact lenses?”

____ 3. The nurse is collecting a health history for a patient who presents with diplopia. Which question is most appropriate for the nurse to include in this patient’s health history?

1)

“Are you experiencing discomfort?”

2)

“Does the double vision get worse when you are tired?”

3)

“Did you experience a sudden loss of vision?”

4)

“Do you wear contact lenses?”

____ 4. The nurse is assessing a patient visual accommodation. Which cranial nerve does the nurse plan to assess?

1)

Cranial nerve I

2)

Cranial nerve II

3)

Cranial nerve III

4)

Cranial nerve IV

____ 5. The nurse is conducting an eye assessment for an infant. The nurse notes the absence of the red reflex. What does this finding suggest to the nurse?

1)

The infant is color blind.

2)

The infant may have retinopathy of prematurity.

3)

The infant has a mature macula.

4)

The infant may have congenital cataracts.

____ 6. The nurse is assessing the patient’s sclera and notes a bluish tinge. Which diagnosis does the nurse anticipate based on this assessment finding?

1)

Episcleritis

2)

Jaundice

3)

Vitamin A deficiency

4)

Osteogenesis imperfecta

____ 7. The nurse assesses a patient and notes difficulty seeing objects that are near. Which medical term will the nurse use when documenting this assessment finding in the medical record?

1)

Astigmatism

2)

Hyperopia

3)

Myopia

4)

Nystagmus

____ 8. The nurse is conducting an eye assessment and plans to assess cranial nerve function. Which cranial nerves (CNs) control eye movements?

1)

CN III

2)

CN IV

3)

CN VI

4)

All of the above

____ 9. A mother is concerned because her newborn is not able to follow a moving toy with her eyes. When educating the mother about fixating and following an object, at which age should the nurse tell the mother to expect this to occur?

1)

2 weeks

2)

4 weeks

3)

2 months

4)

3 months

____ 10. The nurse is screening children before they enter preschool. Which is the expected visual acuity for preschool-age patients?

1)

20/20

2)

20/40

3)

20/60

4)

20/100

____ 11. An older adult professor complains of dryness of the eyes after reading or doing computer work. When educating this patient about the dryness, which cause will the nurse include in the teaching session?

1)

Fatty deposits around the eyelids

2)

The lens becoming more opaque

3)

A decrease in tear production

4)

Decreased ability to constrict the pupil

____ 12. The nurse is conducting a health history for an older adult patient who states, “I seem to have more trouble driving at night the older that I get.” When teaching the patient why this occurs, which will the nurse include in the teaching session?

1)

Decreased contraction of ciliary body

2)

Degeneration of cones

3)

Degeneration of rods

4)

Arcus senilis

____ 13. The Weber test is used to screen for hearing deficits. When performing the Weber test, where should the nurse place the tuning fork?

1)

On the mastoid process

2)

In front of the ear

3)

On the forehead

4)

On the tragus

____ 14. The nurse is conducting an ear assessment for an Asian American patient. Which is an anticipated finding for this patient based on ethnicity?

1)

Increased incidence of otitis media

2)

Brown, wet, and sticky cerumen

3)

Decreased risk for hearing loss

4)

Dry, white, and flaky cerumen

____ 15. The nurse is preparing to perform the Rinne test of hearing function. Which action by the nurse is appropriate?

1)

Whispers several words to the patient and asks him or her to repeat what was heard

2)

Places a vibrating tuning fork in the middle of the head

3)

Places a set of earphones over both ears, plays several tones, and asks the patient to identify the sounds heard

4)

Uses a tuning fork to compare the length of time the patient hears sound conducted by the mastoid bone versus air conduction

____ 16. During the Weber test, the nurse determines that the patient hears the sound of a tuning fork equally in each ear. Which action by the nurse is appropriate based on this assessment finding?

1)

Repeat the test again using a 200-Hz tuning fork.

2)

Tell the patient that this represents a normal finding.

3)

Refer the patient for additional testing to determine the exact hearing abnormality.

4)

Ask the patient to keep the eyes closed so that the test can be repeated.

____ 17. Before otoscopic exam, the nurse should palpate which areas for tenderness?

1)

Helix, tragus, and stapes

2)

Tragus, lobule, and concha

3)

Tragus, mastoid process, and helix

4)

Tragus, lobule, and mastoid process

____ 18. The nurse is preparing to perform an ear assessment. Which speculum for the otoscope should the nurse select?

1)

The largest and longest

2)

The largest and shortest

3)

The smallest and longest

4)

The smallest and shortest

____ 19. During the otoscopic exam, how should the nurse hold the adult patient’s ear?

1)

Pull the helix up and back

2)

Pull the lobule down and forward

3)

Pull the lobule down and back

4)

Pull the helix up and forward

____ 20. The nurse assesses the patient’s tympanic membrane. Which is considered a normal assessment finding?

1)

Light pink

2)

Deep red

3)

Pearly gray

4)

Yellow-white

____ 21. During an otoscope assessment, the nurse notes the patient is experiencing cerumen build-up. Based on this data, which type of hearing loss does the nurse anticipate?

1)

Sensorineural

2)

Perceptive

3)

Conductive

4)

Central

____ 22. The nurse conducts a routine eye exam on an adult patient. Data indicate that the patient’s far vision is 20/25. When telling the patient about the result of the exam, which statement from the nurse is appropriate?

1)

“You can read from 20 ft what the person with normal vision can read from 25 ft.”

2)

“You can read the entire chart from 20 ft.”

3)

“You can read from 25 ft what the person with normal vision can read from 20 ft.”

4)

“Your left eye can read the chart from 20 ft and your right eye can read the chart from 25 ft.”

____ 23. The nurse is preparing to assess a patient’s extraocular function. Which test or exam will the nurse use for this specific eye assessment?

1)

Superior field test

2)

Pupillary reaction test

3)

Denver Age Screening exam

4)

Six cardinal positions of gaze test

____ 24. Which cranial nerves (CNs) are responsible for the functioning of the six extraocular muscles?

1)

CNs I, II, and III

2)

CNs III, IV, and VI

3)

CNs III, IV, and V

4)

CNs III, V, and VI

____ 25. The nurse is preparing to administer the corneal light reflex test. Which does the test assess in the patient?

1)

Peripheral vision

2)

Visual acuity

3)

Parallel alignment and ocular muscles

4)

Trigeminal nerve

____ 26. The nurse administers a Romberg test to assess the patient’s balance. Which action by the nurse is appropriate?

1)

Asking the patient to keep the eyes open

2)

Asking the patient to keep the eyes closed

3)

Asking the patient to open the eyes and then close the eyes

4)

None of the above

____ 27. The nurse is assessing the patient’s gross hearing. Which action is appropriate?

1)

Asking the patient to stand 2 to 4 feet away while whispering

2)

Asking the patient to stand 5 feet away while yelling

3)

Asking the patient to stand 1 to 2 feet away while whispering

4)

Asking the patient to stand 10 feet away while yelling

____ 28. The nurse is assessing the patient for high-pitch deficits. Which action by the nurse is appropriate?

1)

Placing a ticking watch 5 inches from the ear

2)

Placing a turning fork 5 inches from the ear

3)

Asking the patient to repeat back what is whispered