Chapter 20: Assessment of Visual and
Auditory Systems Lewis:
Medical-Surgical Nursing, 10th Edition
A sixty five-year-vintage affected person is being evaluated for glaucoma. Which data given via
the affected person has implications for the patient's treatment plan?
A. "I take metoprolol (Lopressor) for angina."
b. "I take aspirin when I have a sinus headache."
c. "I even have had common episodes of conjunctivitis."
d. "I actually have not had an eye fixed exam for 10 years." - ANS-ANS: A
It is critical to notice whether the patient takes any -adrenergic blockers because this type of
medicines is also used to treat glaucoma, and there may be an growth in adverse
consequences. The use of aspirin does no longer growth intraocular pressure and is secure for
sufferers with glaucoma. Although older patients should have every year eye examinations, the
remedy for this patient will no longer be laid low with the 10-year hole in eye care. Conjunctivitis
does not growth the hazard for glaucoma.
A patient arrives within the emergency department complaining of eye itching and ache after
dozing with touch lenses in region. To facilitate further exam of the attention, fluorescein
angiography is ordered. The nurse will teach the affected person to
a. Maintain a card and fixate on the middle dot.
B. Report any burning or ache on the IV web page.
C. Remain nevertheless while the cornea is anesthetized.
D. Permit the examiner realize while images proven seem clean. - ANS-ANS: B
Fluorescein angiography involves injecting IV dye. If extravasation occurs, fluorescein is toxic to
the tissues. The affected person must be informed to report any signs and symptoms of
extravasation consisting of ache or burning. The nurse have to carefully screen the IV website
as nicely. The cornea is anesthetized at some point of ultrasonography. Refractometry involves
measuring visual acuity and asking the patient to select lenses which might be the sharpest; it's
miles a painless take a look at. The Amsler grid check involves using a hand-held card with grid
strains. The affected person fixates at the center dot and facts any abnormalities of the grid
traces.
A affected person complains of dizziness while bending over and of nausea and dizziness
associated with physical sports. The nurse will plan to train the affected person approximately
a. Tympanometry.
B. Rotary chair trying out.
C. Natural-tone audiometry.
D. Bone-conduction checking out. - ANS-ANS: B
, The patient's medical manifestations of dizziness and nausea advocate a disease of the
labyrinth, which controls balance and consists of three semicircular canals and the vestibule.
Rotary chair checking out is used to test vestibular function. The different checks are used to
test for problems with hearing.
A affected person who underwent eye surgery is required to wear an eye patch until the
scheduled postoperative clinic visit. Which nursing diagnosis will the nurse encompass in the
plan of care?
A. Disturbed body picture associated with eye trauma and eye patch
b. Risk for falls related to brief lower in stereoscopic imaginative and prescient
c. Ineffective health protection associated with inability to see surroundings
d. Ineffective coping associated with inability to confess the impact of the eye harm - ANS-ANS:
B
The loss of stereoscopic imaginative and prescient created with the aid of the attention patch
impairs the affected person's capacity to see in 3 dimensions and to judge distances. It also
increases the danger for falls. There is not any proof in the evaluation records for useless
fitness preservation, disturbed body image, or ineffective denial.
Assessment of a affected person's visual acuity reveals that the left eye can see at 20 ft what
someone with normal vision can see at 50 feet and the right eye can see at 20 ft what someone
with regular imaginative and prescient can see at 40 toes. The nurse information which finding?
- ANS-ANS: A
When documenting visible acuity, the primary number shows the usual (for normal vision) of 20
ft and the second wide variety indicates the road that the affected person is capable of examine
while status 20 toes from the Snellen chart. OS is the abbreviation for left eye, and OD is the
abbreviation for proper eye. The closing three answers do now not correctly describe the
patient's visual acuity.
The rate nurse ought to interfere at once if watching a nurse who's being concerned for a patient
with vestibular ailment
a. Going through the affected person without delay when talking.
B. Talking slowly and exceedingly to the affected person.
C. Administering each the Rinne and Weber assessments.
D. Encouraging the affected person to ambulate independently. - ANS-ANS: D
Vestibular sickness impacts stability, so the nurse should screen the affected person all through
activities that require balance. The different moves might be used for sufferers with listening to
issues.
The nurse in the attention health center is examining a sixty seven-year-antique patient who
says, "I see small spots that flow around in front of my eyes." Which motion will the nurse take
first?
A. Immediately have the ophthalmologist evaluate the patient.
B. Explain that spots and "floaters" are a everyday part of growing old.
C. Warn the patient that these spots may also indicate retinal damage.
D. Use an ophthalmoscope to look at the posterior eye chambers. - ANS-ANS: D
Although "floaters" are typically because of vitreous liquefaction and are common in ageing
sufferers, they can be because of hemorrhage into the vitreous humor or with the aid of retinal
tears, so the nurse's first action might be to examine the retina and posterior chamber. Although
Auditory Systems Lewis:
Medical-Surgical Nursing, 10th Edition
A sixty five-year-vintage affected person is being evaluated for glaucoma. Which data given via
the affected person has implications for the patient's treatment plan?
A. "I take metoprolol (Lopressor) for angina."
b. "I take aspirin when I have a sinus headache."
c. "I even have had common episodes of conjunctivitis."
d. "I actually have not had an eye fixed exam for 10 years." - ANS-ANS: A
It is critical to notice whether the patient takes any -adrenergic blockers because this type of
medicines is also used to treat glaucoma, and there may be an growth in adverse
consequences. The use of aspirin does no longer growth intraocular pressure and is secure for
sufferers with glaucoma. Although older patients should have every year eye examinations, the
remedy for this patient will no longer be laid low with the 10-year hole in eye care. Conjunctivitis
does not growth the hazard for glaucoma.
A patient arrives within the emergency department complaining of eye itching and ache after
dozing with touch lenses in region. To facilitate further exam of the attention, fluorescein
angiography is ordered. The nurse will teach the affected person to
a. Maintain a card and fixate on the middle dot.
B. Report any burning or ache on the IV web page.
C. Remain nevertheless while the cornea is anesthetized.
D. Permit the examiner realize while images proven seem clean. - ANS-ANS: B
Fluorescein angiography involves injecting IV dye. If extravasation occurs, fluorescein is toxic to
the tissues. The affected person must be informed to report any signs and symptoms of
extravasation consisting of ache or burning. The nurse have to carefully screen the IV website
as nicely. The cornea is anesthetized at some point of ultrasonography. Refractometry involves
measuring visual acuity and asking the patient to select lenses which might be the sharpest; it's
miles a painless take a look at. The Amsler grid check involves using a hand-held card with grid
strains. The affected person fixates at the center dot and facts any abnormalities of the grid
traces.
A affected person complains of dizziness while bending over and of nausea and dizziness
associated with physical sports. The nurse will plan to train the affected person approximately
a. Tympanometry.
B. Rotary chair trying out.
C. Natural-tone audiometry.
D. Bone-conduction checking out. - ANS-ANS: B
, The patient's medical manifestations of dizziness and nausea advocate a disease of the
labyrinth, which controls balance and consists of three semicircular canals and the vestibule.
Rotary chair checking out is used to test vestibular function. The different checks are used to
test for problems with hearing.
A affected person who underwent eye surgery is required to wear an eye patch until the
scheduled postoperative clinic visit. Which nursing diagnosis will the nurse encompass in the
plan of care?
A. Disturbed body picture associated with eye trauma and eye patch
b. Risk for falls related to brief lower in stereoscopic imaginative and prescient
c. Ineffective health protection associated with inability to see surroundings
d. Ineffective coping associated with inability to confess the impact of the eye harm - ANS-ANS:
B
The loss of stereoscopic imaginative and prescient created with the aid of the attention patch
impairs the affected person's capacity to see in 3 dimensions and to judge distances. It also
increases the danger for falls. There is not any proof in the evaluation records for useless
fitness preservation, disturbed body image, or ineffective denial.
Assessment of a affected person's visual acuity reveals that the left eye can see at 20 ft what
someone with normal vision can see at 50 feet and the right eye can see at 20 ft what someone
with regular imaginative and prescient can see at 40 toes. The nurse information which finding?
- ANS-ANS: A
When documenting visible acuity, the primary number shows the usual (for normal vision) of 20
ft and the second wide variety indicates the road that the affected person is capable of examine
while status 20 toes from the Snellen chart. OS is the abbreviation for left eye, and OD is the
abbreviation for proper eye. The closing three answers do now not correctly describe the
patient's visual acuity.
The rate nurse ought to interfere at once if watching a nurse who's being concerned for a patient
with vestibular ailment
a. Going through the affected person without delay when talking.
B. Talking slowly and exceedingly to the affected person.
C. Administering each the Rinne and Weber assessments.
D. Encouraging the affected person to ambulate independently. - ANS-ANS: D
Vestibular sickness impacts stability, so the nurse should screen the affected person all through
activities that require balance. The different moves might be used for sufferers with listening to
issues.
The nurse in the attention health center is examining a sixty seven-year-antique patient who
says, "I see small spots that flow around in front of my eyes." Which motion will the nurse take
first?
A. Immediately have the ophthalmologist evaluate the patient.
B. Explain that spots and "floaters" are a everyday part of growing old.
C. Warn the patient that these spots may also indicate retinal damage.
D. Use an ophthalmoscope to look at the posterior eye chambers. - ANS-ANS: D
Although "floaters" are typically because of vitreous liquefaction and are common in ageing
sufferers, they can be because of hemorrhage into the vitreous humor or with the aid of retinal
tears, so the nurse's first action might be to examine the retina and posterior chamber. Although
