Chapter 21: Nursing Assessment: Visual and Auditory Systems

Chapter 21: Nursing Assessment: Visual and Auditory Systems

Complete Chapter Questions With Answers

Sample Questions Are Posted Below

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 pupil’s 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 REF: 392
TOP: Nursing Process: Implementation 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 patient’s 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 REF: 387
TOP: Nursing Process: Assessment 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 patient’s 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 patient’s 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 REF: 385 | 386
TOP: Nursing Process: Assessment 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 REF: 387
TOP: Nursing Process: Implementation MSC: NCLEX: Health Promotion and Maintenance