Medical Surgical Nursing Assessment and Management of Clinical Problems, 10th Edition by Sharon L. Lewis
Medical Surgical Nursing Assessment and Management of Clinical Problems, 10th Edition by Sharon L. Lewis
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Chapter 20: Assessment of Visual and Auditory Systems
Complete Chapter Questions With Answers
Sample Questions Are Posted Below
MULTIPLE CHOICE
| a. | A Tono-Pen will be applied to the surface of the eye. |
| b. | The test involves reading a Snellen chart from 20 feet. |
| c. | Medications will be used to dilate the pupils for the test. |
| d. | The examination involves checking the pupil’s reaction to light. |
ANS: A
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: Apply (application) REF: 351
TOP: Nursing Process: Implementation MSC: NCLEX: Health Promotion and Maintenance
| a. | The patient’s sclerae are light yellow. |
| b. | The patient reports persistent photophobia. |
| c. | The pupil recovers slowly after responding to a bright light. |
| 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 in assessment and would not be unusual in a 76-yr-old patient.
DIF: Cognitive Level: Apply (application) REF: 357
TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity
| a. | shining a light into the patient’s eye causes pupil constriction in the opposite eye. |
| b. | a blink reaction follows touching the patient’s pupil with a piece of sterile cotton. |
| c. | covering one eye for 1 minute and noting pupil constriction as the cover is removed. |
| d. | the pupils constrict while fixating on an object being moved toward the patient’s eyes. |
ANS: D
Accommodation is defined as the ability of the lens to adjust to various distances. The pupils constrict while fixating on an object that is being moved from far away to near the eyes. The other responses may also be elicited as part of the eye examination, but they do not indicate accommodation.
DIF: Cognitive Level: Apply (application) REF: 351
TOP: Nursing Process: Assessment MSC: NCLEX: Health Promotion and Maintenance
| a. | History of hyperthyroidism |
| b. | Unequal pupil size and shape |
| c. | Blurred vision and light sensitivity |
| d. | Loss of peripheral vision in both eyes |
ANS: C
Classic signs of cataracts include blurred vision and light sensitivity. Thyroid problems are a major cause of exophthalmos. Unequal pupil is not indicative of cataracts. Loss of peripheral vision is a sign of glaucoma.
DIF: Cognitive Level: Apply (application) REF: 357
TOP: Nursing Process: Assessment MSC: NCLEX: Health Promotion and Maintenance
| a. | OS 20/50; OD 20/40 | c. | OD 20/40; OS 20/50 |
| b. | OU 20/40; OS 50/20 | 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 patient’s visual acuity.
DIF: Cognitive Level: Understand (comprehension) REF: 358
TOP: Nursing Process: Assessment MSC: NCLEX: Health Promotion and Maintenance
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