Chapter 04: Assessing the Eye and the Ear

Chapter 04: Assessing the Eye and the Ear

 

Complete Chapter Questions With Answers

 

Sample Questions Are Posted Below

 

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.

 

Answer Section

 

MULTIPLE CHOICE

 

1. ANS:  4

Chapter number and title: 4, Assessing the Eye and the Ear

Chapter learning objective: N/A

Chapter page reference: 134

Integrated Processes: Nursing Process: Assessment

Client Need: Health Promotion and Maintenance

Cognitive level: Knowledge [Remembering]

Concept: Sensory Perception

Difficulty: Easy

	Feedback
1	A visual assessment is not appropriate when assessing ear function.
2	A taste assessment is not appropriate when assessing ear function.
3	A smell assessment is not appropriate when assessing ear function.
4	When conducting an assessment of ear function, the nurse will assess the patient’s equilibrium.

 

 

PTS:   1                    CON:  Sensory Perception

 

2. ANS:  1

Chapter number and title: 4, Assessing the Eye and the Ear

Chapter learning objective: N/A

Chapter page reference: 110

Integrated Processes: Nursing Process: Assessment

Client Need: Physiological Integrity: Basic Care and Comfort

Cognitive level: Application [Applying]

Concept: Sensory Perception

Difficulty: Moderate

	Feedback
1	An appropriate question to ask a patient who is experiencing eye pain is to determine whether light bothers the eye.
2	The nurse would ask the patient whether there are changes in vision with vision loss.
3	The nurse would ask the patient about tearing of the eye if the patient presents with a foreign object in the eye.
4	The nurse would ask the patient whether contact lenses are used if the patient presents with dry eyes.

 

 

PTS:   1                    CON:  Sensory Perception

 

3. ANS:  2

Chapter number and title: 4, Assessing the Eye and the Ear

Chapter learning objective: N/A

Chapter page reference: 110

Integrated Processes: Nursing Process: Assessment

Client Need: Physiological Integrity: Physiological Adaptation

Cognitive level: Application [Applying]

Concept: Sensory Perception

Difficulty: Moderate

	Feedback
1	Diplopia does not cause pain or discomfort.
2	Diplopia is the medical term for double vision. The nurse would ask the patient whether the double vision gets worse when the patient is tired.
3	Diplopia is not a sudden loss of vision but double vision.
4	The nurse would ask the patient about wearing contact lenses if the patient presented with dry eye, not diplopia.

 

 

PTS:   1                    CON:  Sensory Perception

 

4. ANS:  3

Chapter number and title: 4, Assessing the Eye and the Ear

Chapter learning objective: N/A

Chapter page reference: 126

Integrated Processes: Nursing Process: Assessment

Client Need: Health Promotion and Maintenance

Cognitive level: Application [Applying]

Concept: Sensory Perception

Difficulty: Moderate

	Feedback
1	The nurse does not assess cranial nerve I when assessing the patient’s accommodation.
2	The nurse does not assess cranial nerve II when assessing the patient’s accommodation.
3	The nurse would assess the function of cranial nerve III when assessing the patient’s accommodation.
4	The nurse does not assess cranial nerve IV when assessing the patient’s accommodation.

 

 

PTS:   1                    CON:  Sensory Perception

 

5. ANS:  4

Chapter number and title: 4, Assessing the Eye and the Ear

Chapter learning objective: N/A

Chapter page reference: 108

Integrated Processes: Nursing Process: Evaluation

Client Need: Physiological Integrity: Physiological Adaptation

Cognitive level: Evaluation [Evaluating]

Concept: Sensory Perception

Difficulty: Moderate

	Feedback
1	This finding would not indicate that the infant is color blind, has retinopathy of prematurity, or has a mature macula.
2	This finding would not indicate that the infant is color blind, has retinopathy of prematurity, or has a mature macula.
3	This finding would not indicate that the infant is color blind, has retinopathy of prematurity, or has a mature macula. All infants have an immature macula for the first year of life.
4	The absence of the red reflex when assessing an infant’s eyes could indicate congenital cataracts or retinal detachment.

 

 

PTS:     1          CON:   Sensory Perception