AVN 2035 MED SURG 3 MIDTERM EXAM QUESTIONS
WITH CORRECT ANSWERS
The nurse is providing health promotion teaching to a group of older adults.
Which information will the nurse include about routine glaucoma testing? -
ANSWER A Tono-pen will be applied to the surface of the eye.
Rationale: Glaucoma is caused by an increase in intraocular pressure, which
would be measured using the Tono-pen; normal range is 10-21 mmHg.
The nurse is performing an eye examination on a 76 year old patient. The nurse
should refer the patient for a more extensive assessment based on which
finding? - ANSWER The patient reports persistent photophobia.
Rationale: Photophobia is not a normally occurring change with aging and would
require further assessment.
The nurse performing an eye examination will document normal findings for
accommodation when .. - ANSWER The pupils constrict while fixating on an
object being moved closer to the patient's eyes.
Rationale: Accommodation is defined as the ability of the lens to adjust to
various distances. The pupils constrict while fixating on an object being moved
far away to near the eyes.
Which assessment finding alerts the nurse to provide patient teaching about
cataract development? - ANSWER Blurred vision and light sensitivity
Rationale: Classic signs of cataracts include blurred and light sensitivity.
Proteins in the lens deteriorate and clump together causing the lens to
thicken/harden obstructing the passage of light through the lens to the retina.
Assessment of a patients visual acuity reveals that the left eye can see at 20 feet
what a person with normal vision can see at 50 feet and the right eye can see at
20 feet what a person with normal vision can see at 40 feet. The nurse records
which finding? - ANSWER a. OS 20/50; OD 20/40
Rationale : OS = left eye, OD "ojo derecho" = right eye, OU= both eyes. When
documenting for 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.
, When assessing a patients consensual pupil response, the nurse should -
ANSWER Shine a light into one pupil and observe the response of both pupils.
The nurse is observing a student who is preparing to perform an ear
examination for a 30 year old patient. The nurse will need to intervene if the
student .. - ANSWER Chooses a speculum larger than the ear canal.
Rationale: The speculum should be smaller than the ear canal so it can be
inserted without damage to the external ear canal.
The nurse is assessing a 65 year old patient for presbyopia. Which instruction
will the nurse give the patient before the test? - ANSWER "Hold this card and
read the print out loud."
Rationale: The Jaeger card is used to assess near vision problems and
presbyopia in persons over 40 years old age. The card should be held 14 inches
away from the eyes while the patient reads words in various print sizes.
When the nurse is taking a health history of a new patient at the ear clinic, the
patient states, "I have to sleep with the television on." Which follow-up question
is most appropriate to obtain more information about possible hearing
problems? - ANSWER "Have you noticed ringing in your ears?"
Rationale: Patients with tinnitus may use masking techniques, such as playing a
radio, to block out the ringing in the ears.
When the patient turns his head quickly during the admission assessment, the
nurse observes nystagmus. What is the indicated nursing action? - ANSWER
Place a fall-risk bracelet on the patient.
Rationale: Problems with balance related to vestibular function may present ass
nystagmus or vertigo and indicate an increased risk for falls.
The nurse recording health histories in the outpatient clinic would plan a
focused hearing assessment for adult patients taking which medication? -
ANSWER Ibuprofen (Advil) taken for 20 years to treat osteoarthritis
Rationale: NSAIDs are potentially ototoxic when taken for long periods of time.
The charge nurse must intervene immediately if observing a nurse who is caring
for a patient with vestibular disease does which of the following actions? -
ANSWER Encourages the patient to ambulate independently
Rationale: Vestibular disease affects balance, so the nurse should monitor the
patient during activities that require balance.
WITH CORRECT ANSWERS
The nurse is providing health promotion teaching to a group of older adults.
Which information will the nurse include about routine glaucoma testing? -
ANSWER A Tono-pen will be applied to the surface of the eye.
Rationale: Glaucoma is caused by an increase in intraocular pressure, which
would be measured using the Tono-pen; normal range is 10-21 mmHg.
The nurse is performing an eye examination on a 76 year old patient. The nurse
should refer the patient for a more extensive assessment based on which
finding? - ANSWER The patient reports persistent photophobia.
Rationale: Photophobia is not a normally occurring change with aging and would
require further assessment.
The nurse performing an eye examination will document normal findings for
accommodation when .. - ANSWER The pupils constrict while fixating on an
object being moved closer to the patient's eyes.
Rationale: Accommodation is defined as the ability of the lens to adjust to
various distances. The pupils constrict while fixating on an object being moved
far away to near the eyes.
Which assessment finding alerts the nurse to provide patient teaching about
cataract development? - ANSWER Blurred vision and light sensitivity
Rationale: Classic signs of cataracts include blurred and light sensitivity.
Proteins in the lens deteriorate and clump together causing the lens to
thicken/harden obstructing the passage of light through the lens to the retina.
Assessment of a patients visual acuity reveals that the left eye can see at 20 feet
what a person with normal vision can see at 50 feet and the right eye can see at
20 feet what a person with normal vision can see at 40 feet. The nurse records
which finding? - ANSWER a. OS 20/50; OD 20/40
Rationale : OS = left eye, OD "ojo derecho" = right eye, OU= both eyes. When
documenting for 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.
, When assessing a patients consensual pupil response, the nurse should -
ANSWER Shine a light into one pupil and observe the response of both pupils.
The nurse is observing a student who is preparing to perform an ear
examination for a 30 year old patient. The nurse will need to intervene if the
student .. - ANSWER Chooses a speculum larger than the ear canal.
Rationale: The speculum should be smaller than the ear canal so it can be
inserted without damage to the external ear canal.
The nurse is assessing a 65 year old patient for presbyopia. Which instruction
will the nurse give the patient before the test? - ANSWER "Hold this card and
read the print out loud."
Rationale: The Jaeger card is used to assess near vision problems and
presbyopia in persons over 40 years old age. The card should be held 14 inches
away from the eyes while the patient reads words in various print sizes.
When the nurse is taking a health history of a new patient at the ear clinic, the
patient states, "I have to sleep with the television on." Which follow-up question
is most appropriate to obtain more information about possible hearing
problems? - ANSWER "Have you noticed ringing in your ears?"
Rationale: Patients with tinnitus may use masking techniques, such as playing a
radio, to block out the ringing in the ears.
When the patient turns his head quickly during the admission assessment, the
nurse observes nystagmus. What is the indicated nursing action? - ANSWER
Place a fall-risk bracelet on the patient.
Rationale: Problems with balance related to vestibular function may present ass
nystagmus or vertigo and indicate an increased risk for falls.
The nurse recording health histories in the outpatient clinic would plan a
focused hearing assessment for adult patients taking which medication? -
ANSWER Ibuprofen (Advil) taken for 20 years to treat osteoarthritis
Rationale: NSAIDs are potentially ototoxic when taken for long periods of time.
The charge nurse must intervene immediately if observing a nurse who is caring
for a patient with vestibular disease does which of the following actions? -
ANSWER Encourages the patient to ambulate independently
Rationale: Vestibular disease affects balance, so the nurse should monitor the
patient during activities that require balance.
