NURS624 Case Study: Sensory Function
Exam With Complete Solutions
During the initial interview, the nurse inspects the external anatomy of the eye.
The nurse notes that the cornea looks cloudy and an arcus senilis is seen
around the cornea.
Which action should the nurse take first?
A. Prepare to assist the HCP in obtaining ocular pressures.
B. Assess the client's retinal structures.
C. Assess whether the cornea looks thickened and raised and document the
finding.
D. Document any report of tearing or a burning sensation. - ANSWER C
As the lipid accumulates, the cornea may look thickened and raised. The
assessment finding should be documented in the electronic medical record.
During the assessment of the client's hearing, the nurse performs a series of
tests, including the client's ability to hear whispered and conversational tones.
How would the nurse assess for the presence of tinnitus?
A. Discrimination testing.
B. Ask the client if he ever hears ringing in his ears.
C. Use a tympanometry to assess the middle ear.
D. Hold the auricle up and back and observe the ear canal. - ANSWER B
Tinnitus is the presence of ringing in the ears, which is often associated with
hearing loss.
The client seems nervous and asks for a glass of water. After taking a drink, the
client attempts to set the glass down, but places the glass on the edge of the
counter, causing it to crash to the floor.
To follow up on this situation, which assessment would provide the most useful
data?
A. Mini mental status exam.
B. Vital signs and level of consciousness.
C. Visual field and depth perception.
D. Pupil size and accommodation. - ANSWER C
, Under or over reaching for objects is an indication of a visual deficit.
Assessment of visual field and depth perception will provide the most useful
data related to this situation.
The client's visual acuity is measured using a Snellen chart. The reading
obtained is 20/200 in the right eye and 20/80 in the left eye.
How should the nurse explain these findings to the client?
A. Results reflect far-sightedness, especially in the left eye.
B. Results reflect nearsightedness, especially in the right eye.
C. Results reflect macular degeneration in the right eye.
D. Results reflect the need for a corneal transplant. - ANSWER B
The larger the denominator (bottom number), the poorer the visual acuity. This
is commonly referred to as being near-sighted. Standing at 20 feet (6 m), the
client can read what the person with normal vision can read at further distances,
such as 80 feet (24 m) (left eye) or 200 feet (61 m) (right eye). Nearsightedness
(myopia) occurs when the eye overbends the light and images converge in front
of the retina where near vision is normal, but distance vision is poor.
As the interview continues, the nurse notes that the client is very pleasant and
nods their head in agreement with all of the nurse's statements, but does not
respond to simple requests during the assessment.
Which nursing problem is best supported by the data available?
A. Noncompliance.
B. Situational low self-esteem.
C. Impaired memory.
D. Disturbed sensory alteration (auditory). - ANSWER D
Clients with impaired hearing often smile and nod in agreement with the person
conversing even though they are unable to clearly hear the conversation.
Appearing to be inattentive, speaking loudly, and difficulty following directions
are other indications of a disturbance in auditory sensory function.
In identifying this problem, the nurse clusters the subjective and objective
assessment data and compares it with which information?
A. Defining characteristics of the problem.
B. Nursing actions related to the problem.
C. Outcome criteria.
D. Medical diagnosis. - ANSWER A
Exam With Complete Solutions
During the initial interview, the nurse inspects the external anatomy of the eye.
The nurse notes that the cornea looks cloudy and an arcus senilis is seen
around the cornea.
Which action should the nurse take first?
A. Prepare to assist the HCP in obtaining ocular pressures.
B. Assess the client's retinal structures.
C. Assess whether the cornea looks thickened and raised and document the
finding.
D. Document any report of tearing or a burning sensation. - ANSWER C
As the lipid accumulates, the cornea may look thickened and raised. The
assessment finding should be documented in the electronic medical record.
During the assessment of the client's hearing, the nurse performs a series of
tests, including the client's ability to hear whispered and conversational tones.
How would the nurse assess for the presence of tinnitus?
A. Discrimination testing.
B. Ask the client if he ever hears ringing in his ears.
C. Use a tympanometry to assess the middle ear.
D. Hold the auricle up and back and observe the ear canal. - ANSWER B
Tinnitus is the presence of ringing in the ears, which is often associated with
hearing loss.
The client seems nervous and asks for a glass of water. After taking a drink, the
client attempts to set the glass down, but places the glass on the edge of the
counter, causing it to crash to the floor.
To follow up on this situation, which assessment would provide the most useful
data?
A. Mini mental status exam.
B. Vital signs and level of consciousness.
C. Visual field and depth perception.
D. Pupil size and accommodation. - ANSWER C
, Under or over reaching for objects is an indication of a visual deficit.
Assessment of visual field and depth perception will provide the most useful
data related to this situation.
The client's visual acuity is measured using a Snellen chart. The reading
obtained is 20/200 in the right eye and 20/80 in the left eye.
How should the nurse explain these findings to the client?
A. Results reflect far-sightedness, especially in the left eye.
B. Results reflect nearsightedness, especially in the right eye.
C. Results reflect macular degeneration in the right eye.
D. Results reflect the need for a corneal transplant. - ANSWER B
The larger the denominator (bottom number), the poorer the visual acuity. This
is commonly referred to as being near-sighted. Standing at 20 feet (6 m), the
client can read what the person with normal vision can read at further distances,
such as 80 feet (24 m) (left eye) or 200 feet (61 m) (right eye). Nearsightedness
(myopia) occurs when the eye overbends the light and images converge in front
of the retina where near vision is normal, but distance vision is poor.
As the interview continues, the nurse notes that the client is very pleasant and
nods their head in agreement with all of the nurse's statements, but does not
respond to simple requests during the assessment.
Which nursing problem is best supported by the data available?
A. Noncompliance.
B. Situational low self-esteem.
C. Impaired memory.
D. Disturbed sensory alteration (auditory). - ANSWER D
Clients with impaired hearing often smile and nod in agreement with the person
conversing even though they are unable to clearly hear the conversation.
Appearing to be inattentive, speaking loudly, and difficulty following directions
are other indications of a disturbance in auditory sensory function.
In identifying this problem, the nurse clusters the subjective and objective
assessment data and compares it with which information?
A. Defining characteristics of the problem.
B. Nursing actions related to the problem.
C. Outcome criteria.
D. Medical diagnosis. - ANSWER A
