NUR 3306 Final Study Guide: Quizzes 5-11[Verified Answers]

When testing for accommodation, what reaction would you expect to see?ANSWERS-CorrectD. Pupils converge and constrict Response Feedback: You test for accommodation by asking the patient to focus on an object (finger or pen, for example) as you move it towards the patient's nose. You would expect the pupils to constrict and for eyes to cross (convergence). A nurse is admitting a client to the hospital. When reviewing the client's medical record, the nurse notes that this client had abnormal findings during the Weber test. What would the nurse know this means?ANSWERS-CorrectD. The client has unilateral hearing loss Response Feedback: The whisper test evaluates loss of high-frequency sounds. The Weber test helps to differentiate the cause of unilateral hearing loss. In the Rinne test, use of a tuning fork helps the nurse determine if hearing is equal in both ears and if there is either a conductive or a sensorineural hearing loss by allowing the nurse to compare the difference in bone conduction (BC) versus air conduction (AC). Remember AC has less resistance than BC. Option D is a distracter for this question. A mother brings her 2-year-old child to the clinic stating that the child is cross-eyed. What test would the nurse perform to test for strabismus?ANSWERS-CorrectB. Corneal light reflex Response Feedback: The corneal light reflex tests for strabismus. The cover test is for presence and amount of ocular deviation. A low light level with no direct light sources shining in the patient's eyes is ideal. At rest, the extraocular muscles have very little activity. The assessment referred to as cardinal fields of gaze allows nurses to detect muscle defects that cause misalignment or uncoordinated eye movements. The static test can help the nurse detect gross differences in all four quadrants of the visual field. The Allen test tests a toddler's visual acuity. What components of sound does the cochlea interpret? (Select all that apply.)ANSWERS-Answers: CorrectA. Frequency CorrectB. Amplitude Response Feedback: The cochlea interprets two components of sound: amplitude (volume) and frequency (pitch). The cochlea does not interpret tone, direction, or decibel. The nurse is caring for a client with an eye injury. The client asks about the eye, and the nurse explains its structures and functions. What would the nurse tell the client is the largest chamber of the eye?ANSWERS-CorrectA. Vitreous Response Feedback: The interior eye has three chambers: anterior, posterior, and vitreous. The anterior chamber is the space between the cornea in the front and the iris and lens in the back. It contains aqueous humor, produced by the ciliary body; the amount varies to maintain pressure in the eye. The posterior chamber starts behind the iris and goes to the lens. It is also filled with aqueous humor that helps to nourish the cornea and lens. The largest vitreous chamber is adjacent to the inner retinal layer and lens. This chamber is filled with vitreous humor, which is gel-like, holds the retina in place, and maintains the shape of the eyeball. Corneal is a distracter for this question. Student nurses are spending time in the laboratory learning the proper use of an otoscope. What technique would these students learn for best visualization of the tympanic membrane in an adolescent?ANSWERS-CorrectD. Hold the ear at the helix and lift up and back Response Feedback: Hold the adolescent's ear at the helix and lift up and back to align the canal for best visualization of the tympanic membrane. In children younger than 3 years, the nurse would pull down and back to visualize the tympanic membrane. The nurse always lifts from the helix, not the auricle (pinna) and never from the tragus. The nurse is assessing a client and notes dullness to percussion in the lowest point of the abdomen. When rolling the client to the left, the nurse notes that there is now dullness on the left side. This indicates ascites, which can be caused byANSWERS-CorrectA. Cirrhosis and nephrosis Response Feedback: Ascites is the accumulation of fluid in the abdomen. The fluid descends with gravity, resulting in dullness to percussion in the lowest point of the abdomen based on client position. Changing the client's position should move the fluid shift to the most dependent point. Ascites occurs in cirrhosis of the liver, congestive heart failure, nephrosis, peritonitis, and metastatic neoplasms. The other options are distracters to the question. When assessing the tympanic membrane, where would the nurse expect to visualize the malleus?ANSWERS-CorrectB. Near the center Response Feedback: The tympanic membrane adheres through its concave shape to the malleus near the center. The other options are distracters for the question. Which assessment techniques would a nurse use on the external ear? (Select all that apply)ANSWERS-Correct Palpation Correct Inspection The nurse is performing visual acuity testing on an older adult who has fallen and fractured their femur. What finding would be considered normal for this client? (Select all that apply.)ANSWERS-CorrectA. Arcus senilis CorrectD. Decreased tear production CorrectE. Cataract Response Feedback: Findings related to aging include loss of adipose tissue in the orbit, decreased tear production, and decreased pupillary response. Arcus senilis, a gray/white circle that circumscribes the limbus and results from the deposition of lipid, is a common cloudiness that appears around the corneas of older adults. Cataracts are common in the older adult. Increased tear production and increased pupillary response are distracters for this question. A teenager is brought to the clinic for a sports physical examination. The client states plans to play goalie on the community soccer team. What is the most important teaching opportunity presented for this client?ANSWERS-CorrectB. Use of safety equipment Response Feedback: The nurse should assess with each client the use of safety equipment when playing sports. Proper eye protection can prevent many sports-related eye injuries. All options are points for client teaching for this client; however, the most important opportunity involves the use of safety equipment. The open space between the eyelids is called what?ANSWERS-CorrectC. The palpebral fissure Response Feedback: The palpebral fissure is the almond-shaped open space between the eyelids. The limbus is the border of the cornea and the sclera. Eyeball and lacrimal fissure are distracters for the question. A client complains, "I feel like the whole room is spinning around me, and it makes me nauseous sometimes." What term should the nurse use to document the client's symptom?ANSWERS-CorrectB. Vertigo Response Feedback: Vertigo, the sensation of the room spinning, indicates dysfunction of the bony labyrinth in the inner ear. Dizzines indicates that the client feels like he/she is spinning in the room. Tinnitus, a sensation of buzzing in the ear, is thought to be an inability to filter internal noise from the external input of sound. Otalgia is ear pain. The eustachian tube is a passage between the middle ear and the nasopharynx. What is the function of the eustachian tube?ANSWERS-CorrectD. Helps to regulate pressure in the middle ear Response Feedback: The eustachian tube, a conduit that connects the middle ear to the nasopharynx, allows for pressure regulation of the middle ear. The other options are distracters for the question. Which of the following scores for distance vision indicates the patient with the poorest vision?ANSWERS-20/200 A client tells the nurse that his eyes "are not working right." When the nurse asks what the client means, the client states, "It is like one eye is moving faster than the other." What test would be most appropriate for the nurse to use to assess this client?ANSWERS-CorrectD. Cardinal fields Response Feedback: The cardinal fields of gaze allow the nurse to detect muscle defects that cause misalignment or uncoordinated movement of the eyes. Kinetic and static confrontation tests are used to test peripheral vision. The cover test is for accommodation. Normal movement of the eye involves what cranial nerves? (Mark all that apply.)ANSWERS-CorrectA. VI CorrectB. IV CorrectD. III Response Feedback: As the nurse inspects and palpates the eye, he or she assesses for the sensory and motor functions of four cranial nerves: Cranial nerve II, optic nerve, visual acuity, visual fields, fundoscopic examination; cranial nerve III, oculomotor, cardinal fields of gaze, eyelid inspection, pupil reaction (direct/consensual/ accommodation); cranial nerve IV, trochlear, cardinal fields of gaze; and cranial nerve VI, abducens, cardinal fields of gaze. Cranial nerve V, known as the trigeminal nerve, is a nerve responsible for sensation in the face and certain motor functions such as biting and chewing. When assessing risk factors for eye and vision problems, the nurse knows that genetics can play a role. What major eye problem are clients most likely at increased risk for if a first-degree relative has it?ANSWERS-CorrectC. Glaucoma Response Feedback: Glaucoma in a first-degree relative increases the client's risk for the same problem two to three times. Retinoblastoma can be inherited from either parent but does not have increased incidence if a first-degree relative has the disease. Retinitis pigmentosa is also a genetic disease, but a client's risk of the disease is not increased if a first-degree relative is affected. Strabismus is not genetic. A nurse caring for a client admitted 2 days ago following a cerebral vascular accident. The nurse notes that the client is frequently coughing, has food falling from the mouth while eating, and frequently chokes. What would be the most pertinent nursing diagnosis for this client?ANSWERS-CorrectD. Impaired swallowing Response Feedback: Impaired swallowing is associated with problems in oral, pharyngeal, or esophageal structure or function. Related findings include delayed swallowing; gurgly voice; frequent coughing, choking, or gagging; inability to clear oral cavity; and food falling from the mouth. The scenario described does not mention impaired dentition, alteration in mobility, or altered cerebral perfusion. The autonomic nervous system innervates the salivary glands along with which cranial nerves? (Select all that apply.)ANSWERS-CorrectC. VII CorrectD. IX CorrectE. XII Response Feedback: The autonomic nervous system and cranial nerves VII (facial) and IX (glossopharyngeal) innervate secretions of the major and minor salivary ducts. Cranial nerve XII (hypoglossal) innervates the submandibular glands. Cranial nerves VIII and X are not involved. What is the purpose of the tongue? (Select all that apply.)ANSWERS-CorrectB. Manipulates solids and liquids when eating and drinking CorrectC. Helps with the identification of sweet, sour, salty, and bitter tastes CorrectD. Assists in speech production Response Feedback: The tongue manipulates solids and liquids in chewing and swallowing. It is also involved in speech production and taste. The anterior two thirds of the tongue surface contain taste buds known as vallate papillae, which identify sweet, sour, salty, and bitter tastes. The other options are distracters for the question. The nurse is caring for an adult client who presents at the clinic with reports of general malaise and fatigue. Physical assessment reveals that the client's lips are dry and cracked. What might this indicate?ANSWERS-CorrectC. Inadequate hydration Response Feedback: Dryness or cracking may indicate inadequate hydration. Lesions or aphthous ulcers may represent a viral infection. Swelling or edema of the lips suggests allergy. Heat stroke is a distracter for this question. Which information in the client's history is a priority safety concern?ANSWERS-CorrectC. Recent immigrant complains of cough Response Feedback: Incidence of tuberculosis is approximately nine times higher among U.S. immigrants (W.H.O., 2013). Diminished senses of smell and taste may produce safety risks but are not as high priority as the immediate threat of tuberculosis, which is contagious. Lack of smell and tast are not contagious conditions. Removal of a cancerous lesion in the past does not pose an immediate concern like tuberculosis. Cleft lip and palate surgery are not immediate safety concerns like tuberculosis. When doing a risk assessment of the nose, sinuses, mouth, and throat, what finding might indicate an allergy?ANSWERS-CorrectC. Frequent childhood infections D. Family history of diabetes Response Feedback: Frequent upper respiratory infections in childhood should raise the nu