A nurse is assessing a patient's hearing ability. Which findings would indicate compromised hearing?
The patient is lip reading
The patient asks to have certain words repeated
The patient fails to respond to questions when not looking directly at the nurse
The nurse is performing an assessment of a patient's ear with an otoscope and finds that the light reflex is fuzzy. How does the nurse interpret this finding?
Retraction of the tympanic membrane
A patient is due for rotary chair testing to assess vestibular function. What action by the nurse is most appropriate?
Observe the patient for vomiting
Rotary chair testing
Done to evaluate the peripheral vestibular system. Testing is usually done in the dark; therefore, in order to ensure safety, the nurse should not leave the patient alone. The patient should be advised to eat a light meal before the test to avoid nausea.
The nurse is testing a patient for hearing acuity using a whisper test. Which actions by the nurse are appropriate?
After exhaling, speak in a low whisper
Ask the patient to repeat numbers or words
Whisper loudly if the patient does not respond correctly
Testing hearing acuity
The nurse should stand 12 to 24 inches to the side of the patient and, after exhaling, speak in a low whisper. Ask the patient to repeat numbers or words or answer questions. Use a louder whisper if the patient does not respond correctly. Test each ear se
A patient seeks assistance from the primary health care provider because of episodes of vertigo. Which diagnostic test will determine whether the vertigo is related to a problem of the inner ear?
Caloric stimulus test
Caloric stimulus Test
Cold or warm water is inserted in the ear canal to stimulate the semicircular canals in the labyrinth of the inner ear. The response to the stimulation causes nystagmus (eye ball jerking movement), nausea and vomiting, and vertigo, and is used to determin
Vertigo
Is the sensation that one is whirling in space and often is associated with nausea and vomiting.
Audiometry
Is a screening test for hearing acuity and determines the severity and type of hearing loss.
Tympanometry
Is used to diagnose middle ear effusion (fluid in the middle ear), which causes noncompliance and conductive hearing loss.
When interviewing a patient with hearing loss about past and present medications, which medications should the nurse ask the patient about directly?
Salicylates
Aminoglycosides
Antimalarial agents
The nurse should ask the patient specifically about salicylates, aminoglycosides, and antimalarial agents, because they may cause ototoxicity and lead to hearing loss.
The nurse is interviewing a patient diagnosed with glaucoma. What question is most relevant to the patient's condition?
Do you have a history of cardiac or pulmonary disease?
Why is it important to ask patients with glaucoma about history of cardiac or pulmonary disease?
Glaucoma is often treated with beta-adrenergic blockers, which may decrease heart rate, decrease blood pressure, and exacerbate asthma or chronic obstructive pulmonary disease (COPD).
The nurse is assessing a patient's ears. What normal findings should the nurse document?
TM is pearly gray, shiny and translucent
The handle of the malleus and its short process are visible through the TM
The TM is concave or dome shaped normally
A nurse is assessing the pupillary function of a patient. Which steps should be performed when assessing accommodation?
Ask the patient to look at the nurse's finger
Ask the patient to focus on a distant object
The nurse places a finger at a distance of 3 inches from the patient's nose
Auditory evoked potential
Is conducted in a darkened room and electrodes are placed over the mastoid process, vertex, and forehead to isolate auditory activity from other activities.
Electrocochleography
records electrical activity in the cochlea and auditory nerves
Electronystagmography
in which specific eye movements are recorded, is used to diagnose diseases of the vestibular system.
Ototoxic drugs
aspirin
chemotherapy drugs
antibiotics
antimalarial drugs
NSAIDs
diuretics
A patient tells a nurse, "I'm becoming more and more sensitive to loud noises." Which auditory system change does the nurse suspect?
Brain
The brain is the main component of the auditory system, filtering unwanted and unnecessary sounds. A patient with increased sensitivity to sound will have changes in the brain.
Inner ear
is involved in reception of sound, balance, and body orientation
Impaired Middle ear
conductive hearing loss
Damaged external ear
will result in collapse of the ear canal and potentially hearing loss
A patient is advised to undergo a caloric test stimulus. How should a nurse explain the test to the patient?
You will be sitting or lying down for the test
The test involves pouring cold or warm solution into your ears
The test may result in nausea and vertigo after stimulation of semicircular canals
An adult patient has been treated for an ear infection. The nurse plans to examine the ear using an otoscope. What intervention should the nurse employ to lessen anxiety and discomfort associated with the examination?
Gently palpate the tragus and move the auricle, noting sensitive areas
A patient is found to have acoustic neuromas. Which diagnostic test will the nurse prepare the patient for to aid in assessment?
Auditory brainstem response. This test is used to assess the inner pathway of the ear or detect tumors in the inner ear.
Acoustic neuroma
A tumor that develops in the nerve of the inner ear
Posturography
is a balance test, useful in assessing vestibular function
Pure tone audiometry
useful in diagnosing conductive and sensorineural hearing loss
Carried out in a soundproof room
The patient will hear varying sounds through earphones
Lipid deposition on the sclera
may result in yellowish discoloration of the sclera
Thin sclera
will have a bluish tinge
Subconjunctival hemorrhage
Will have the appearance of a blood spot on the sclera
indication of having diplopia
Patient hold head in a skewed or oblique position
Diplopia
double vision
A patient has undergone a fluorescein angiography. The nurse should observe for what side effects of the procedure?
Yellowish discoloration of the skin and urine
Nausea and vomiting after the procedure
Damage to the inner ear or damage to the vestibulocochlear nerve that lines the inner ear results in
sensorineural hearing loss
An increase in cerumen will result in
central hearing loss because the auditory canal is blocked
impairment of the tympanic membrane is associated with
impaired transmission of sound waves
Which abnormality is associated with the chronic exposure of the eye lens to ultraviolet light?
cataract
A patient expresses concern about the effect of vision loss on reading. This is an example of which component of a visual health history?
cognitive-perceptual
Strabismus
an asymmetric eye position
Blepharitis
associated with redness, swelling, and crusting along the lid margins
Hordeolum
an infection of the sebaceous gland of the eyelid where the patient may have a superficial nodule along the lid margin
Conjuncitivitis
is associated with redness or swelling of conjunctiva; it is a bacterial infection.
A patient is to undergo an Amsler Grid test. What instructions about the test should the nurse provide to the patient?
-Hold the test card at a comfortable distance
-Report any abnormality like lines appearing wavy
-Focus on the center dot that is present on the card
While assessing a patient, the health care practitioner comments that the vestibular apparatus has been damaged. The nurse expects to find what clinical manifestation?
Loss of balance of the body.
The vestibular apparatus is a structure present in the inner ear. This structure is responsible for maintaining balance and body orientation.
A patient has a milky white and grayish ring encircling the periphery of the cornea, and the laboratory reports of the patient reveal a total serum cholesterol of 220 mg/dL. Which condition is present?
Arcus senilis
Arcus senilis is an abnormality of the eye associated with high cholesterol levels.
Snellen chart distance
20 feet or 6 meters
The nurse is conducting an assessment for a patient with hearing loss. Which cranial nerve is associated with the processing of sound?
Cranial nerve VIII
Perimetry
visual field test used to diagnose glaucoma