b. between the lens and the retina. Show
(The posterior chamber lies between the anterior surface of the lens and the posterior surface of the iris. The posterior cavity lies in the large space behind the lens and in front of the retina.) In a patient who has a hemorrhage in the posterior cavity of the eye, the nurse knows that blood is accumulating a. in the aqueous humor. d. increased production of aqueous humor by the ciliary process. (Excess aqueous humor production or decreased outflow can elevate intraocular pressure above the normal 10 to 21 mm Hg; this condition is called glaucoma.) Increased intraocular pressure may occur as a result of a. edema of the corneal stroma. c. a history of heart or lung disease. (Assess whether the patient is taking -adrenergic blockers, because these drugs can be potentiated by the β-adrenergic blockers used to treat glaucoma. Many preparations for colds contain a form of epinephrine (i.e., pseudoephedrine) that can cause the pupils to dilate, and antihistamines or decongestants can cause ocular dryness.) Question patients using eyedrops to treat their glaucoma about a. use of corrective
lenses. a. visual acuity. (Always assess and record the patient's visual acuity for medical and legal reasons.) Always assess the patient with an ophthalmic problem for a. visual acuity. c. midline tone heard equally in both ears. (Normal findings of physical assessment of the auditory system include symmetry of the ears in location and shape; nontenderness and no lesions of auricles and tragus; clearness of the canal; pearl-gray color of tympanic membrane with landmarks and light reflex intact; ability of the patient to hear low whisper at a distance of 30 cm; better Rinne test results for air conduction than for bone conduction (AC > BC); and no lateralization according to the Weber test results.) During an assessment of hearing, the nurse would expect to find normal finding of a. absent cone of light. a, c, d (Age-related changes include increased production of drier cerumen, atrophic changes of tympanic membrane, and neuron degeneration in auditory nerve and central pathways.) Age-related changes in the auditory system commonly include (select all that apply) a. drier cerumen. a, d (Fluorescein dye sometimes causes nausea or vomiting, and the dye may cause a transient yellow-orange discoloration of urine and skin. Extravasation of the dye causes tissue toxicity. Systemic allergic reactions to the dye are rare, but the nurse should be familiar with emergency equipment and procedures.) Before injecting fluorescein for angiography, it is important for the nurse to (select all that apply) a. obtain an emesis basin. B. Drooping of the upper lid margin in one or both eyes (Ptosis is the term used to describe drooping of the upper lid margin, which may be either unilateral or bilateral. Ptosis can be a result of mechanical causes, such as an eyelid tumor or excess skin, or from myogenic causes such as myasthenia gravis.) A patient has ptosis resulting from myasthenia gravis. Which assessment finding would the nurse expect to see in this patient? A. Redness and swelling of the conjunctiva C. Gently pull the auricle up and backward to straighten the canal. (When examining a patient's external ear canal and tympanum, ask the patient to tilt the head toward the opposite shoulder. Grasp and gently pull the auricle up and backward to straighten the canal. A healthy, normal tympanic membrane will appear pearl gray, white, or pink and have a cone-shaped light reflex.) When assessing an adult patient's external ear canal and tympanum, what should the nurse do? A. Ask the patient to tip his or her head toward the nurse. B. Hypertension and diabetes mellitus (Hypertension and diabetes frequently contribute to visual pathologies. The other cited health problems are less likely to have a direct, deleterious effect on a patient's vision.) What aspects of the patient's medical history are most likely to have potential consequences for the patient's visual system? A. Hypothyroidism and polycythemia D. "Have you noticed any change in your hearing in recent months and years?" (Presbycusis is an age-related change in auditory acuity. Ringing in the ears is termed tinnitus whereas dizziness and falls are related to balance and the function of the vestibular system. Presbycusis is not associated with pain during chewing and swallowing.) The nurse is assessing an 86-year-old female who has just been transferred to the long-term care facility. Which assessment question will best allow the nurse to assess the woman for the presence of presbycusis? A. "Do you ever experience any ringing in your ears?" c. Monitoring of the growth (An exostosis is a bony growth into the ear canal that normally does not require intervention or correction.) Otoscopic examination of the patient's left ear indicates the presence of an exostosis. What does the nurse prepare to teach the patient about regarding the growth? a. Surgery A. Do you wear contacts? (College students frequently wear contact lenses and will be up late or all night studying for finals. If the student wears contacts, the wearing of them while studying, care of them, and length of wear time will be assessed before looking for a corneal abrasion from extended wear with fluorescein dye. There are no manifestations of allergies, diplopia, or visual changes mentioned.) A college student has gone to the nurse complaining of eye pain after studying for finals. What assessment should the nurse make first in determining the possible etiology of this eye pain? A. Do you wear contacts? A. Amsler grid test (The Amsler grid test is self-administered and regular testing is necessary to identify any changes in macular function. B-scan ultrasonography is used to diagnose ocular pathologic conditions (e.g., intraocular foreign bodies or tumors, vitreous opacities, retinal detachments). Fluorescein angiography is used to diagnose problems related to the flow of blood through pigment epithelial and retinal vessels. Intraocular pressure testing with a Tono-pen is done to test for glaucoma.) The patient has described a loss of central vision. What test should the nurse teach the patient about to identify changes in macular function? A. Amsler grid test B. Swimmer's ear (Swimmer's ear or an infection of the external ear is probably the cause of the discharge and pain. Asking the patient about swimming, ear protection, and exposure to types of water can identify contact with contaminated water. After clearing the discharge, the tympanic membrane can be assessed for otitis media. A sebaceous cyst and metabolic disorders would not cause drainage or discomfort in the external ear canal.) When examining the patient's ear with an otoscope, there is discharge in the canal and the patient noted pain with the examination. What should the nurse next assess the patient for? A. Sebaceous cyst C. Check the medication list (The nurse should evaluate the patient's medication list to identify agents that can contribute to dry eyes so follow-up nursing care can be planned. Dry eyes aggravate wearing contact lenses but contact lenses do not normally cause dry eyes. The nurse should not suggest saline eye drops until the etiology of the dry eyes is determined. Eyeglasses do not cause dry eyes.) During the course of an interview to assess vision, a patient complains of dry eyes. What should the nurse implement next? A. Assess for contact lenses C. Presbyopia (Presbyopia is a loss of accommodation causing an inability to focus on near objects. This occurs as a normal part of aging process starting around age 40. Myopia is nearsightedness (near objects are clear and far objects are blurred). Astigmatism results in visual distortion related to unevenness in the cornea. Hyperopia is farsightedness (near objects are blurred and far objects are clearly seen)) During a health history, a 43-year-old teacher complains of increasing difficulty reading printed materials for the past year. What change related to aging does the nurse suspect? A. Myopia B. "What do you take if you have allergy symptoms"? (Anithistamines or decongestants taken for allergies or colds can cause ocular dryness. Ginkgo biloba is an herbal product and has been used to treat asthma and tinnitus. Side effects of ginkgo may include headache, nausea, gastrointestinal upset, diarrhea, dizziness, allergic skin reactions, and increased bleeding. β-adrenergic blockers can potentiate drugs used to treat glaucoma. Long-term use of prednisone (corticosteroids) may contribute to the development of glaucoma or cataracts.) A patient complains of intermittent eye dryness. Which question should the nurse ask the patient to determine the etiology of this symptom? A. "Do you take ginkgo to treat asthma or tinnitus"? C. Dizziness (Dizziness is a sensation of being off balance that occurs when standing or walking; it does not occur when lying down. Nystagmus is an abnormal eye movement that may be observed as a twitching of the eyeball or described by the patient as a blurring of vision with head or eye movement. Vertigo is a sense that the person or objects around the person are moving or spinning and is usually stimulated by movement of the head. Syncope is a brief lapse in consciousness accompanied by a loss in postural tone (fainting).) A 44-year-old woman who works in a noisy factory reports being off balance when standing or walking but not while lying down. What term will the nurse use to document this patient's symptoms? A. Vertigo A. Eat a light meal before the procedure. (Instruct patient to eat a light meal before the test to avoid nausea. Results of vestibular tests can be altered by use of caffeine, other stimulants, sedatives, and antivertigo drugs.) A patient reporting frequent vertigo is scheduled for electronystagmography to test vestibular function. Which instructions should the nurse provide to the patient before the procedure? A. Eat a light meal
before the procedure. C. Increased production of aqueous humor or blocked drainage increases pressure. (Intraocular pressure is increased in glaucoma as a result of excess aqueous humor production or decreased outflow. Cardiac or cerebral circulation changes do not cause glaucoma. Lacrimal anomalies do not affect aqueous humor production.) A 64-year-old man newly diagnosed with glaucoma asks the nurse what has made the pressure in his eyes so high. Which is the nurse's most accurate response? A. Back pressure from cardiac congestion causes corneal edema. a. Look for cerumen in the ear. (Gerontologic differences in the assessment of the auditory system include increased production of and drier cerumen, which can become impacted in the ear canal and contribute to hearing loss. Conductive hearing loss with impacted cerumen may lead to speaking softly as the patient's voice conducted through bone seems loud to the patient. Although increased hair growth occurs, it will not impact the hearing. Presbycusis may be occurring, but it should not be assumed. There is no reason to ask the patient if he has fallen because dizziness and vertigo are not a normal change of aging of the ear.) An older adult patient states they don't seem to hear well and have to ask people to repeat themselves. What should the nurse do first to determine the cause of the hearing loss? a. Look for cerumen in the ear. b. Assess for increased hair growth in the ear. c. Tell the patient it is probably related to aging. d. Ask the patient if he has fallen because of dizziness. What is in the posterior cavity of the eye? a.
Zonules c. Protective white outer layer of the eyeball What is the function of the sclera? a. Secrete aqueous humor c. Transparent mucous membrane lining the eyelids What accurately describes the conjunctiva? a. Junction of the upper and lower eyelids Which tissue nourishes the ciliary body, iris, and part of the retina? a. Pupil When obtaining a health history from a patient with cataracts, what is most important for the nurse to ask about the use of? D. Constriction of the pupils when an object is brought closer to the The nurse documents PERRLA following assessment of a patient's eyes. What is one finding that supports this statement? a. A slightly oval shape of the pupils In which individuals should the nurse expect to find a yellow cast to the sclera? a. Infants To determine the presence of corneal abrasions or defects in a patient with an eye injury, what would the nurse provide?
a. A tonometer What are possible abnormal assessment findings when assessing the eyelid (select all that apply)? a. Ptosis C. Protrusion of the eyeball When the patient has a diagnosis of hyperthyroidism, which abnormal assessment of the eye could be found? a. Light intolerance C. A break in the retina at the site of the macula When examining the patient's eye with an ophthalmoscope, which finding would be of most concern to the nurse? a. Depression at the center of the optic disc B. Involves IV dye injection to evaluate blood flow through epithelial and retinal blood vessels To prepare a patient for a fluorescein angiography, what should the nurse explain about the test? a. Measures curvature of the cornea What is the organ of balance and equilibrium? a. Cochlea C. Allows for equalization of pressure in the middle ear How does the eustachian tube assist the auditory system? a. Transmits sound stimuli
to the brain A. Atrophy of the eardrum Which changes of aging can impair hearing in the older adult (select all that apply)? a. Atrophy of eardrum (middle ear)
D. A decrease in the ability to hear high-pitched sounds The nurse suspects a patient has presbycusis when she says she has a. ringing in the ears. A. Major landmarks of the tympanic membrane include the umbo, handle of malleus, and cone of light What accurately describes an assessment of the ear? a. Major landmarks of the tympanic membrane include the umbo, handle of malleus, and cone of light. A. Positive Rinne Test What indicates sensorineural hearing loss (select all that apply)? a. Positive Rinne test B. Speak at a normal speed and volume with the patient Results of an audiometry indicate that a patient has a 10-dB hearing loss at 8000 Hz. What is the most appropriate action by the nurse? a. Encourage the patient to start learning to lip-read B. No nystagmus is elicited with application of water in the external ear When does caloric testing indicate disease of the vestibular system of the ear? a. Hearing is improved with irrigation of the external ear canal Which cranial nerve is responsible for opening the eyelids? Which cranial nerve is responsible for closing the eyelids? Which cranial nerve is responsible for pupil constriction? Which cranial nerve is responsible for pupil dilation? Which cranial nerve is responsible for visual acuity? vitreous liqufication and retinal holes or tears What is the cause of the following assessment finding? floaters What is the cause of the following assessment finding? ectropion chronic exposure to UV light of other environmental irritants What is the cause of the following assessment finding? pinguecula cholesterol deposits in the peripheral cornea What is the cause of the following assessment finding? arcus senilis What is the cause of the following assessment finding? yellowish sclera decreased tear secretion or composition What is the cause of the following assessment finding? dry irritated eyes increased rigidity of iris What is the cause of the following assessment finding? decreased pupil size What is the cause of the following assessment finding? changes in color perception Which cognitive function would likely be affected when the patient's temporal lobe is injured?Damage to the temporal lobes can result in:
Difficulty learning and retaining new information. Impaired factual and long-term memory. Persistent talking.
Which lobe of the cerebrum would the nurse suspect has been affected when a patient has difficulty making decisions?Which area of the cerebrum is most likely affected? The frontal lobe is involved in communication, concentration, decision making and memory. A nurse has been assigned to an accident patient whose temporal lobe area is suspected to be injured.
Which response would the nurse make to a patient who has an equilibrium deficit and does not want to walk at home because of fear of falling?A patient with an equilibrium deficit is afraid to walk at home because of fear of falling. What is an appropriate response by the nurse? "Use a cane or a walker when you are ambulating for stability." "Focusing on your feet when you are walking will decrease dizziness."
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Which assessment finding should cause the nurse to suspect an older patient has presbycusis
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