Chapter 13: Care of the Patient with a Sensory Disorder
MULTIPLE CHOICE
1. The nurse is aware that the patient has 20/40 vision. This means that the patient can see at 20
feet what the normal eye can see at _______ feet.
a. 10
b. 20
c. 30
d. 40
ANS: B
The Snellen Eye Chart tests visual acuity. A vision evaluation of 20/40 means that the patient
can see at 20 feet what the person with normal vision can see at 40 feet.
DIF: Cognitive Level: Application REF: Page 625 OBJ: 7
TOP: Snellen evaluation KEY: Nursing Process Step: I Assessment
MSC: NCLEX: Physiological Integrity
2. The patient tells the nurse that he is legally blind. How would this information impact the
nurse’s plan of care for this patient?
a. The patient would be considered totally blind.
b. This patient probably has some light perception, but no usable vision.
c. This patient has some usable vision, which enables function at an acceptable level.
d. The nurse would need to determine how this patient’s visual impairment affects
normal functioning.
ANS: D
“Legal blindness” refers to individuals with a maximum visual acuity of 20/200 with
corrective eyewear and/or visual field sight capacity reduced by 20 degrees. Categories have
been established to help determine the exact extent of the vision loss and what assistive
measures are appropriate for the individual. The nurse will need more information as to the
exact extent of the vision loss for this patient.
DIF: Cognitive Level: Analysis REF: Page 626 OBJ: N/A
TOP: Legal blindness KEY: Nursing Process Step: Planning
MSC: NCLEX: Physiological Integrity
3. One of the housekeepers splashes a chemical in the eyes. What should be the first priority?
a. Transport to a physician immediately
b. Cover the eyes with a sterile gauze
c. Irrigate with H2O for 5 minutes
d. Irrigate with normal saline solution for 20 minutes
ANS: D
Burns are medically treated with a prolonged, 15- to 20-minute or longer normal saline flush
immediately after burn exposure.
DIF: Cognitive Level: Analysis REF: Page 646 OBJ: 11
TOP: Chemical burn of eye KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
, 4. What does a tympanoplasty correct?
a. Conductive hearing loss
b. Sensorineural hearing loss
c. Congenital hearing loss
d. Functional hearing loss
ANS: A
Tympanoplasty can correct a conductive hearing loss.
DIF: Cognitive Level: Knowledge REF: Page 664 OBJ: 17
TOP: Tympanoplasty KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
5. The 62-year-old home health patient who is recovering from eye surgery complains of a
feeling of “grittiness” in the eye and is having blurred vision. The eyes are reddened and have
stringy mucus. What do these complaints indicate?
a. Sjögren syndrome
b. Early cataracts
c. Macular degeneration
d. Retinal detachment
ANS: A
The Sjögren syndrome of “dry eye” frequently appears after eye surgery. There is insufficient
production of tears. Excessive use of antihistamines, antidepressants, and decongestants may
cause this syndrome to appear.
DIF: Cognitive Level: Application REF: Page 633 OBJ: 8
TOP: Sjögren syndrome KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
6. Four hours after a stapedectomy the patient complains that hearing has not improved at all.
What knowledge would the nurse use to shape a response?
a.A large percentage of stapedectomies are not successful
b.It will take at least 10 days for the graft to heal
c.Hearing will not return until edema subsides
d.Hearing will improve after irrigation of the ear
ANS: C
Hearing improvement will not be noted until edema subsides and the packing is removed.
DIF: Cognitive Level: Application REF: Page 662 OBJ: 17
TOP: Stapedectomy KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
7. What is a common mistake that hinders communication when communicating with the
hearing impaired?
a. Overaccentuating words
b. Facing the patient when speaking
c. Speaking in conversational tones
d. Speaking into the ear with the hearing aid
MULTIPLE CHOICE
1. The nurse is aware that the patient has 20/40 vision. This means that the patient can see at 20
feet what the normal eye can see at _______ feet.
a. 10
b. 20
c. 30
d. 40
ANS: B
The Snellen Eye Chart tests visual acuity. A vision evaluation of 20/40 means that the patient
can see at 20 feet what the person with normal vision can see at 40 feet.
DIF: Cognitive Level: Application REF: Page 625 OBJ: 7
TOP: Snellen evaluation KEY: Nursing Process Step: I Assessment
MSC: NCLEX: Physiological Integrity
2. The patient tells the nurse that he is legally blind. How would this information impact the
nurse’s plan of care for this patient?
a. The patient would be considered totally blind.
b. This patient probably has some light perception, but no usable vision.
c. This patient has some usable vision, which enables function at an acceptable level.
d. The nurse would need to determine how this patient’s visual impairment affects
normal functioning.
ANS: D
“Legal blindness” refers to individuals with a maximum visual acuity of 20/200 with
corrective eyewear and/or visual field sight capacity reduced by 20 degrees. Categories have
been established to help determine the exact extent of the vision loss and what assistive
measures are appropriate for the individual. The nurse will need more information as to the
exact extent of the vision loss for this patient.
DIF: Cognitive Level: Analysis REF: Page 626 OBJ: N/A
TOP: Legal blindness KEY: Nursing Process Step: Planning
MSC: NCLEX: Physiological Integrity
3. One of the housekeepers splashes a chemical in the eyes. What should be the first priority?
a. Transport to a physician immediately
b. Cover the eyes with a sterile gauze
c. Irrigate with H2O for 5 minutes
d. Irrigate with normal saline solution for 20 minutes
ANS: D
Burns are medically treated with a prolonged, 15- to 20-minute or longer normal saline flush
immediately after burn exposure.
DIF: Cognitive Level: Analysis REF: Page 646 OBJ: 11
TOP: Chemical burn of eye KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
, 4. What does a tympanoplasty correct?
a. Conductive hearing loss
b. Sensorineural hearing loss
c. Congenital hearing loss
d. Functional hearing loss
ANS: A
Tympanoplasty can correct a conductive hearing loss.
DIF: Cognitive Level: Knowledge REF: Page 664 OBJ: 17
TOP: Tympanoplasty KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
5. The 62-year-old home health patient who is recovering from eye surgery complains of a
feeling of “grittiness” in the eye and is having blurred vision. The eyes are reddened and have
stringy mucus. What do these complaints indicate?
a. Sjögren syndrome
b. Early cataracts
c. Macular degeneration
d. Retinal detachment
ANS: A
The Sjögren syndrome of “dry eye” frequently appears after eye surgery. There is insufficient
production of tears. Excessive use of antihistamines, antidepressants, and decongestants may
cause this syndrome to appear.
DIF: Cognitive Level: Application REF: Page 633 OBJ: 8
TOP: Sjögren syndrome KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
6. Four hours after a stapedectomy the patient complains that hearing has not improved at all.
What knowledge would the nurse use to shape a response?
a.A large percentage of stapedectomies are not successful
b.It will take at least 10 days for the graft to heal
c.Hearing will not return until edema subsides
d.Hearing will improve after irrigation of the ear
ANS: C
Hearing improvement will not be noted until edema subsides and the packing is removed.
DIF: Cognitive Level: Application REF: Page 662 OBJ: 17
TOP: Stapedectomy KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
7. What is a common mistake that hinders communication when communicating with the
hearing impaired?
a. Overaccentuating words
b. Facing the patient when speaking
c. Speaking in conversational tones
d. Speaking into the ear with the hearing aid
