Health Assessment Eyes and Ears questions with
verified answers
A nurse is teaching a class on the pathology and physiology of the eye.
Which statement by the nurse about eversion of the eyelids during
physical examination is accurate? Ans✓✓✓"The lashes need to be
grasped between the examiner's thumb and forefinger."
During the eversion of the upper lid, the lashes should be grasped
between the thumb and forefinger and gently pulled down and outward.
The patient should keep both eyes open and look down; closing the eyes
would tense the orbicularis muscle. The upper lid should be slid up
along the bony orbit to lift up the eyelashes. Eversion of the upper lid is
done to inspect the conjunctiva of the upper lid. That is the reason the
applicator stick should be placed on the upper lid above the level of the
internal tarsal plates.
A patient develops sudden clouding of vision, severe eye pain, and halos
around light. What should be the nurse's first intervention?
Ans✓✓✓Report this to the primary health care provider.
Sudden clouding of vision, severe eye pain, and halos around light may
indicate primary angle-closure glaucoma. It is caused by a sudden
increase in the intraocular pressure from a blocked outflow from the
anterior chamber. Such symptoms should be reported immediately to the
primary health care provider, because a delay in getting medical
attention may lead to blindness. Analgesics, referring the patient to the
optician, and making the patient rest in a dark room will not relieve the
obstruction of the outflow from the anterior chamber of the eye.
,A patient has a beady nodule protruding from the eyelid. The nurse
discovers the presence of swelling over the nodule that moves freely.
What should the nurse infer from these findings? Ans✓✓✓The patient
has a chalazion
A chalazion refers to a beady protruding nodule over the eyelid.
Retention or infection cyst of the meibomian gland may lead to the
formation of a chalazion. The patient who has a chronic chalazion may
have a swelling over the freely moving nodule. Blepharitis is the clinical
manifestation of seborrheic dermatitis. Blepharitis does not manifest as a
nodule on the eyelid. The presence of swelling and pain at the inner
canthus along with purulent discharge indicates dacryocystitis. It may
occur due to the infection or blocking of the nasolacrimal duct. A
hordeolum is an acute localized staphylococcal infection of an eyelash
hair follicle.
A patient has decreased visual acuity and decreased color vision. The
nurse observes a grayish discoloration on the optic disc. Which
abnormality will the nurse most likely find in the patient?
Ans✓✓✓optic atrophy
Grayish discoloration of the optic disc may occur due to optic atrophy.
Optic atrophy happens as a result of partial or complete death of the
optic nerve. The patient with optic atrophy may experience a decrease in
visual acuity and color vision and decreased contrast sensitivity.
Congestion and elevation of the optic disc results in papilledema. The
patient with papilledema would not have a decrease in color vision.
Narrowing of the artery decreases the diameter of the artery, thereby
,decreasing the light reflex. However, a narrowed artery may not result in
grayish discoloration of the optic disc. The arteriovenous crossing
disrupts the blood flow to the eye. Less blood flow results in thickening
of the arterial wall and makes it opaque in appearance. Grayish
discoloration of the optic disc does not characterize the arteriovenous
crossing.
A patient is experiencing conductive hearing loss and is given an exam.
What structure would not be examined because of its location and
disassociation with conductive hearing loss? Ans✓✓✓Cochlea
Conductive hearing loss involves a mechanical dysfunction of the
external or middle ear. This is considered a partial loss because the
person can hear if the sound amplitude is increased enough to reach the
inner ear. The cochlea is located in the inner ear; its impairment would
lead to sensorineural hearing loss. Otosclerosis, a decrease in the
mobility of the ear ossicles, may cause conductive hearing loss. A
perforated tympanic membrane or impacted cerumen in the ear canal
may also lead to conductive hearing loss.
A patient reports spinning and whirling sensations to the nurse. Which
part of the ear does the nurse suspect to be damaged in this patient?
Ans✓✓✓Labyrinth
A patient reports to the nurse that he is having trouble seeing nearby
objects. Which type of reflex is associated with this type of adaptation?
Ans✓✓✓Accommodation
, A person who has a problem adapting the eyes to see objects nearby may
have a problem in accommodation. Accommodation is adaptation of the
eye for near vision. It is done by increasing the curvature of the lens
through movement of the ciliary muscles. When one of the pupils is
exposed to a bright light, a direct light reflex causes constriction of that
pupil, and a consensual light reflex causes simultaneous constriction of
the other pupil. Fixation is a reflex direction of the eye toward an object
attracting our attention.
A patient tells the nurse, "I feel a throbbing pain in my eyes when I look
at bright light." The nurse sees a dull red halo around the iris and cornea
of the patient's eye. Which condition does this patient likely have?
Ans✓✓✓iritis
The presence of a dull red halo around the iris and cornea indicates that
the patient has iritis. The patient with iritis may have the symptoms of
marked photophobia and throbbing pain. The presence of a dull halo
around the iris and cornea does not indicate glaucoma, conjunctivitis, or
a corneal abrasion in the patient. A patient with glaucoma may have a
headache, pain in the eyes, oval and dilated pupils, a steamy cornea, and
a shallow anterior chamber. A bacterial or viral infection may cause
conjunctivitis in the patient. A patient with conjunctivitis may have red
beefy-looking vessels around the iris, which are more prominent at the
periphery. A patient with a corneal abrasion will feel intense pain in the
eyes and may have a scar on the cornea, but not a dull halo around the
iris.
A patient tells the nurse, "I got an eye injury while playing baseball."
The nurse notices blood in the anterior chamber of the eye. What should
verified answers
A nurse is teaching a class on the pathology and physiology of the eye.
Which statement by the nurse about eversion of the eyelids during
physical examination is accurate? Ans✓✓✓"The lashes need to be
grasped between the examiner's thumb and forefinger."
During the eversion of the upper lid, the lashes should be grasped
between the thumb and forefinger and gently pulled down and outward.
The patient should keep both eyes open and look down; closing the eyes
would tense the orbicularis muscle. The upper lid should be slid up
along the bony orbit to lift up the eyelashes. Eversion of the upper lid is
done to inspect the conjunctiva of the upper lid. That is the reason the
applicator stick should be placed on the upper lid above the level of the
internal tarsal plates.
A patient develops sudden clouding of vision, severe eye pain, and halos
around light. What should be the nurse's first intervention?
Ans✓✓✓Report this to the primary health care provider.
Sudden clouding of vision, severe eye pain, and halos around light may
indicate primary angle-closure glaucoma. It is caused by a sudden
increase in the intraocular pressure from a blocked outflow from the
anterior chamber. Such symptoms should be reported immediately to the
primary health care provider, because a delay in getting medical
attention may lead to blindness. Analgesics, referring the patient to the
optician, and making the patient rest in a dark room will not relieve the
obstruction of the outflow from the anterior chamber of the eye.
,A patient has a beady nodule protruding from the eyelid. The nurse
discovers the presence of swelling over the nodule that moves freely.
What should the nurse infer from these findings? Ans✓✓✓The patient
has a chalazion
A chalazion refers to a beady protruding nodule over the eyelid.
Retention or infection cyst of the meibomian gland may lead to the
formation of a chalazion. The patient who has a chronic chalazion may
have a swelling over the freely moving nodule. Blepharitis is the clinical
manifestation of seborrheic dermatitis. Blepharitis does not manifest as a
nodule on the eyelid. The presence of swelling and pain at the inner
canthus along with purulent discharge indicates dacryocystitis. It may
occur due to the infection or blocking of the nasolacrimal duct. A
hordeolum is an acute localized staphylococcal infection of an eyelash
hair follicle.
A patient has decreased visual acuity and decreased color vision. The
nurse observes a grayish discoloration on the optic disc. Which
abnormality will the nurse most likely find in the patient?
Ans✓✓✓optic atrophy
Grayish discoloration of the optic disc may occur due to optic atrophy.
Optic atrophy happens as a result of partial or complete death of the
optic nerve. The patient with optic atrophy may experience a decrease in
visual acuity and color vision and decreased contrast sensitivity.
Congestion and elevation of the optic disc results in papilledema. The
patient with papilledema would not have a decrease in color vision.
Narrowing of the artery decreases the diameter of the artery, thereby
,decreasing the light reflex. However, a narrowed artery may not result in
grayish discoloration of the optic disc. The arteriovenous crossing
disrupts the blood flow to the eye. Less blood flow results in thickening
of the arterial wall and makes it opaque in appearance. Grayish
discoloration of the optic disc does not characterize the arteriovenous
crossing.
A patient is experiencing conductive hearing loss and is given an exam.
What structure would not be examined because of its location and
disassociation with conductive hearing loss? Ans✓✓✓Cochlea
Conductive hearing loss involves a mechanical dysfunction of the
external or middle ear. This is considered a partial loss because the
person can hear if the sound amplitude is increased enough to reach the
inner ear. The cochlea is located in the inner ear; its impairment would
lead to sensorineural hearing loss. Otosclerosis, a decrease in the
mobility of the ear ossicles, may cause conductive hearing loss. A
perforated tympanic membrane or impacted cerumen in the ear canal
may also lead to conductive hearing loss.
A patient reports spinning and whirling sensations to the nurse. Which
part of the ear does the nurse suspect to be damaged in this patient?
Ans✓✓✓Labyrinth
A patient reports to the nurse that he is having trouble seeing nearby
objects. Which type of reflex is associated with this type of adaptation?
Ans✓✓✓Accommodation
, A person who has a problem adapting the eyes to see objects nearby may
have a problem in accommodation. Accommodation is adaptation of the
eye for near vision. It is done by increasing the curvature of the lens
through movement of the ciliary muscles. When one of the pupils is
exposed to a bright light, a direct light reflex causes constriction of that
pupil, and a consensual light reflex causes simultaneous constriction of
the other pupil. Fixation is a reflex direction of the eye toward an object
attracting our attention.
A patient tells the nurse, "I feel a throbbing pain in my eyes when I look
at bright light." The nurse sees a dull red halo around the iris and cornea
of the patient's eye. Which condition does this patient likely have?
Ans✓✓✓iritis
The presence of a dull red halo around the iris and cornea indicates that
the patient has iritis. The patient with iritis may have the symptoms of
marked photophobia and throbbing pain. The presence of a dull halo
around the iris and cornea does not indicate glaucoma, conjunctivitis, or
a corneal abrasion in the patient. A patient with glaucoma may have a
headache, pain in the eyes, oval and dilated pupils, a steamy cornea, and
a shallow anterior chamber. A bacterial or viral infection may cause
conjunctivitis in the patient. A patient with conjunctivitis may have red
beefy-looking vessels around the iris, which are more prominent at the
periphery. A patient with a corneal abrasion will feel intense pain in the
eyes and may have a scar on the cornea, but not a dull halo around the
iris.
A patient tells the nurse, "I got an eye injury while playing baseball."
The nurse notices blood in the anterior chamber of the eye. What should
