The Eyes

Question 1
Type: MCSA
A patient recovering from a stroke is reporting vision changes. The nurse realizes that these changes are occurring
because:
1. the stroke occurred in the optic region of the patient’s brain.
2. the brain interprets information received through the eyes.
3. the patient is experiencing another stroke.
4. the patient is unable to talk because of the stroke.
Correct Answer: 2
Rationale 1: The information provided is inadequate to determine the location of the infarct.
Rationale 2: The primary functions of the eye are to encode the patterns of light from the environment through
photoreceptors and to carry the coded information from the eyes to the brain. The brain gives meaning to the
coded information, and interprets what is seen.
Rationale 3: The patient’s clinical manifestations are not consistent with another stroke.
Rationale 4: There is no indication of the patient’s verbal abilities.
Global Rationale: The primary functions of the eye are to encode the patterns of light from the environment
through photoreceptors and to carry the coded information from the eyes to the brain. The brain gives meaning to
the coded information and interprets what is seen. The information provided is inadequate to determine the
location of the infarct. The patient’s clinical manifestations are not consistent with another stroke. There is no
indication of the patient’s verbal abilities.
Cognitive Level: Analyzing

Client Need: Physiological Integrity
Client Need Sub: Physiological Adaptation
QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care
AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological,
spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using
developmentally and culturally appropriate approaches
NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health
assessments and interventions
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 1. Describe the anatomy, physiology, and functions of the eye and the ear.
MNL Learning Outcome: 9.2.1. Explain the causes, risk factors, incidence, and pathophysiology of eye
disorders.
Page Number: 1474
Question 2
Type: MCSA
While exiting a burning building, a patient’s eyebrows and lashes were burned. The nurse recognizes that this
patient might experience:
1. wound infections.
2. fluid and electrolyte imbalance.
3. foreign bodies in the eyes.
4. itchiness as the hair grows back.
Correct Answer: 3
Rationale 1: The lack of eyelashes and eyebrows would not increase the patient’s risk of developing a wound
infection.
Rationale 2: The lack of eyelashes and eyebrows would not lead to fluid and electrolyte imbalance.
Rationale 3: The eyebrows shade the eyes and prevent perspiration from entering the eyes. When stimulated, the
eyelashes cause the blink reflex, which serves to protect the eyes from foreign bodies.
Rationale 4: Some discomfort might be experienced as the hair grows back, but this is a minor concern compared
to another possibility.
Global Rationale: The eyebrows shade the eyes and prevent perspiration from entering the eyes. When
stimulated, the eyelashes cause the blink reflex, which serves to protect the eyes from foreign bodies. The lack of
eyelashes and eyebrows would not increase risk of wound infection or lead to fluid and electrolyte imbalance.
Some discomfort might be experienced as the hair grows back, but this is a minor concern compared to another
possibility.

MNL Learning Outcome: 9.2.1. Explain the causes, risk factors, incidence, and pathophysiology of eye
disorders.
Page Number: 1474
Question 3
Type: MCSA
A patient has sustained an injury to the inner layer of the left retina. The nurse realizes that this patient will have
difficulty with:
1. tear production.
2. blinking.
3. reading.
4. peripheral vision and color perception.
Correct Answer: 4
Rationale 1: Tear production is not controlled by the inner retina.
Rationale 2: Blinking is not controlled by the inner retina.
Rationale 3: Reading will still be possible with this type of injury.
Rationale 4: The retina is the innermost lining of the eyeball. It has a pigmented outer layer and an inner neural
layer. The transparent inner layer is made up of millions of light receptors in structures called rods and cones.
Rods enable vision in dim light as well as peripheral vision. Cones enable vision in bright light and the perception
of color.
Global Rationale: The retina is the innermost lining of the eyeball. It has a pigmented outer layer and an inner
neural layer. The transparent inner layer is made up of millions of light receptors in structures called rods and
cones. Rods enable vision in dim light as well as peripheral vision. Cones enable vision in bright light and the
perception of color. Tear production and blinking are not controlled by the inner retina. Reading will still be
possible with this type of injury.

Learning Outcome: 5. Identify abnormal findings that may indicate impairment in the function of the eye and the
ear.
MNL Learning Outcome: 9.2.2. Differentiate the manifestations of eye disorders.
Page Number: 1475
Question 4
Type: MCSA
A patient with an injury to the right eye has received an eye patch. The nurse understands that this patient might
experience difficulty with:
1. depth perception.
2. reading.
3. light perception.
4. color perception.
Correct Answer: 1
Rationale 1: Depth perception depends on visual input from two eyes that function well.
Rationale 2: Reading may be contraindicated if the treatment plan warns against moving the eyes.
Rationale 3: Light will still be discernible to the “good” eye.
Rationale 4: Color will still be discernible to the “good” eye.
Global Rationale: Depth perception depends on visual input from two eyes that function well. Reading may be
contraindicated if the treatment plan warns against moving the eyes. Light and color will still be discernible to the
“good” eye.

ear.
MNL Learning Outcome: 9.2.3. Examine the diagnosis and treatment of eye disorders.
Page Number: 1476
Question 5
Type: MCSA
The nurse positions a patient for an eye examination. After repeated attempts, the patient is able to read all the
letters on the Snellen chart without difficulty at a distance of 15 feet. From this finding the nurse determines that
the patient:
1. has normal 20/20 vision.
2. has normal reading vision.
3. has visual impairments.
4. has a normal pupillary reflex.
Correct Answer: 3
Rationale 1: For people with normal vision, the distance from the viewed object at which the eyes require no
accommodation is 20 feet.
Rationale 2: This test is not used to assess reading vision.
Rationale 3: The patient must stand closer than normal to read the chart. For people with normal vision, the
distance from the viewed object at which the eyes require no accommodation is 20 feet.
Rationale 4: This test is not used to assess pupillary reflex.
Global Rationale: The patient must stand closer than normal to read the chart. For people with normal vision, the
distance from the viewed object at which the eyes require no accommodation is 20 feet. This test is not used to
assess reading vision or pupillary reflex.

Client Need: Health Promotion and Maintenance
Client Need Sub:
ear.
Page Number: 1478
Question 6
Type: MCSA
A patient is found to need corrective lenses. Which diagnostic test was most likely used to determine this finding?
1. computed tomography (CT) scan
2. tonometry
3. refractometry
4. response to atropine eye drops
Correct Answer: 3
Rationale 1: A computed tomography (CT) scan is used to assess structures.
Rationale 2: Tonometry is used to assess ocular pressure.
Rationale 3: Refractive errors, with prescription for corrective lenses, are evaluated by retinoscopy and/or
refractometry. Pupils must be dilated for accurate diagnosis.
Rationale 4: The patient’s response to atropine drops would not be used to evaluate the need for corrective
lenses.
Global Rationale: Refractive errors, with prescription for corrective lenses, are evaluated by retinoscopy and/or
refractometry. Pupils must be dilated for accurate diagnosis. A computed tomography (CT) scan is used to assess
structures. Tonometry is used to assess ocular pressure. The patient’s response to atropine drops would not be
used to evaluate the need for corrective lenses.
Cognitive Level: Applying

Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Evaluation
Page Number: 1477
Question 7
Type: MCSA
The nurse is assessing a patient’s visual fields by covering the right eye with an opaque covering. The nurse
should then perform which action?
1. cover own right eye
2. cover own left eye
3. keep both eyes uncovered
4. turn the lights on in the room before conducting this examination
Correct Answer: 2
Rationale 1: This action will not help assess the patient’s visual fields.
Rationale 2: The nurse asks the patient to cover one eye with the opaque cover while the nurse covers his or her
own eye opposite the patient’s. For example, if the patient covers the right eye, the nurse should cover the left eye.
The nurse must have normal fields of vision to perform this examination.
Rationale 3: This action will not help assess the patient’s visual fields.
Rationale 4: Turning on the lights will not help assess the patient’s visual fields.
Global Rationale: The nurse asks the patient to cover one eye with the opaque cover while the nurse covers his
or her own eye opposite the patient’s. For example, if the patient covers the right eye, the nurse should cover the
left eye. The nurse must have normal fields of vision to perform this examination. Covering the same eye, not
covering either eye, or turning on the lights will not help assess the patient’s visual fields.

Client Need Sub:
Learning Outcome: 2. Identify specific topics for consideration during a health history interview of the patient
with health problems involving the eye or ear.
MNL Learning Outcome: 9.2.4. Utilize the nursing process in care of client.
Page Number: 1479
Question 8
Type: MCSA
A 20-year-old patient is experiencing difficulty with near vision. The nurse realizes that this finding is:
1. consistent with the aging process.
2. normal in a 20-year-old patient.
3. evidence of presbyopia.
4. evidence of hyperopia.
Correct Answer: 4
Rationale 1: Changes in near vision, especially in patients over 45, can indicate presbyopia, which is impaired
near vision that results from a loss of elasticity of the lens related to aging.
Rationale 2: This is not a normal finding in a 20-year-old.
Rationale 3: Changes in near vision, especially in patients over 45, can indicate presbyopia, which is impaired
near vision that results from a loss of elasticity of the lens related to aging.
Rationale 4: Changes in near vision in younger patients is referred to as hyperopia or farsightedness.
Global Rationale: Changes in near vision, especially in patients over 45, can indicate presbyopia, which is
impaired near vision that results from a loss of elasticity of the lens related to aging. In younger patients, this
condition is referred to as hyperopia or farsightedness. This is not a normal finding in a 20-year-old.

Client Need Sub:
ear.
Page Number: 1479
Question 9
Type: MCSA
When performing the cover test, the nurse notes that a patient’s left eye deviates inward when focusing on an
object. What should this finding suggest to the nurse?
1. presbyopia
2. hyperopia
3. weakness
4. myopia
Correct Answer: 3
Rationale 1: Presbyopia is impaired near vision resulting from a loss of elasticity of the lens related to aging.
Rationale 2: Presbyopia is impaired near vision resulting from a loss of elasticity of the lens related to aging. In
younger patients, this condition is referred to as hyperopia (farsightedness).
Rationale 3: The movement of an eye with the cover test indicates weakness of the eye muscles.
Rationale 4: Myopia is the term for nearsightedness.
Global Rationale: The movement of an eye with the cover test indicates weakness of the eye muscles.
Presbyopia is impaired near vision resulting from a loss of elasticity of the lens related to aging. In younger
patients, this condition is referred to as hyperopia (farsightedness). Myopia is the term for nearsightedness.

Client Need Sub:
ear.
Page Number: 1480
Question 10
Type: MCSA
A patient who is using atropine eyedrops is found to have a poor consensual light response. The nurse recognizes
that this finding is considered:
1. abnormal and should be reported to the physician.
2. normal because of the eyedrops.
3. evidence of retinal degeneration.
4. evidence of optic nerve damage.
Correct Answer: 2
Rationale 1: This is a normal response and does not need to be reported to the physician.
Rationale 2: Some eye medications may cause unequal dilation, constriction, or inequality of pupil size.
Morphine and narcotic drugs may cause small, unresponsive pupils, and anticholinergic drugs such as atropine
may cause dilated, unresponsive pupils.
Rationale 3: Retinal degeneration is evidenced by an inability of the pupils to respond appropriately to light.
Rationale 4: Damage to the optic nerve would likely produce visual disturbances.
Global Rationale: Some eye medications may cause unequal dilation, constriction, or inequality of pupil size.
Morphine and narcotic drugs may cause small, unresponsive pupils, and anticholinergic drugs such as atropine
may cause dilated, unresponsive pupils. This is a normal response and does not need to be reported to the
physician. Retinal degeneration is evidenced by an inability of the pupils to respond appropriately to light.
Damage to the optic nerve would likely produce visual disturbances.

Client Need Sub: Pharmacological and Parenteral Therapies
ear.
Page Number: 1480
Question 11
Type: MCMA
During the assessment of a patient’s outer eyes, the nurse suspects that the patient has a hair follicle infection.
What did the nurse most likely assess in this patient?
1. xanthelasma
2. ptosis
3. exophthalmos
4. sty
Correct Answer: 4
Rationale 1: Yellow plaques noted most often on the lid margins are referred to as xanthelasma and have
cosmetic significance only.
Rationale 2: Ptosis, or drooping of the eyelid, may be congenital or may be associated with stroke or
neuromuscular disorders.
Rationale 3: Exophthalmos is an abnormal prominence of the eye and is associated with thyroid disease.
Rationale 4: An acute localized inflammation of a hair follicle is known as a hordeolum or a sty and is generally
caused by staphylococcal organisms.
Global Rationale: An acute localized inflammation of a hair follicle is known as a hordeolum or a sty and is
generally caused by staphylococcal organisms. Yellow plaques noted most often on the lid margins are referred to
as xanthelasma and have cosmetic significance only. Ptosis, or drooping of the eyelid, may be congenital in nature
or may be associated with stroke, neuromuscular disorders. Exophthalmos is an abnormal prominence of the eye
and is associated with thyroid disease.

ear.
Page Number: 1481
Question 12
Type: MCSA
The patient assessment reveals absence of the fovea centralis. The next examination that may be anticipated by
the nurse would be:
1. inspection of the red reflex.
2. inspection of the retina.
3. inspection of the macula.
4. inspection of the optic disc.
Correct Answer: 3
Rationale 1: The red reflex should be visible when using the ophthalmoscope if it is properly positioned. It is not
related to the absence of the fovea centralis.
Rationale 2: Inspection of the retina would not provide any further information concerning the absent fovea
centralis.
Rationale 3: Absence of the fovea centralis is common in older patients. It may indicate macular degeneration, a
cause of loss of central vision. During the inspection of the macula, the macula should be visible on the temporal
side of the optic disc.
Rationale 4: Inspection of the optic disc would not provide any further information concerning the absent fovea
centralis.
Global Rationale: During the inspection of the macula, the macula should be visible on the temporal side of the
optic disc. Absence of the fovea centralis is common in older patients; however, it may indicate macular
degeneration, which is a common cause of loss of central vision. The red reflex should be visible when using the
ophthalmoscope if it is properly positioned. It is not related to the absence of the fovea centralis. Inspection of the
retina and optic disc would not provide any further information concerning the absent fovea centralis.

Client Need Sub: Reduction of Risk Potential
Learning Outcome: 4. Describe normal variations in assessment findings for the older adult.
MNL Learning Outcome: 9.1.2. Differentiate the manifestations of age-related eye disorders.
Page Number: 1481
Question 13
Type: MCSA
A patient with a sore throat is complaining of “trouble with hearing.” The nurse realizes that this patient might be
experiencing:
1. a sinus infection.
2. a middle ear infection.
3. infected tonsils.
4. an inner ear infection.
Correct Answer: 2
Rationale 1: The manifestations of a sinus infection would not include auditory compromise.
Rationale 2: The mucous membrane lining the middle ear is continuous with the mucous membranes lining the
pharynx.
Rationale 3: The manifestations of tonsillitis would not include auditory compromise.
Rationale 4: The inner ear is not implicated in this scenario.
Global Rationale: The mucous membrane lining the middle ear is continuous with the mucous membranes lining
the pharynx. The manifestations of a sinus infection or tonsillitis would not include auditory compromise. The
inner ear is not implicated in this scenario.

ear.
MNL Learning Outcome: 9.3.2. Differentiate the manifestations of ear disorders.
Page Number: 1484
Question 14
Type: MCSA
During a Weber test, a patient is found to have increased hearing in the right ear. The nurse realizes that this
finding is consistent with:
1. normal aging.
2. conductive hearing loss in the right ear.
3. possible buildup of cerumen or otitis media in the left ear.
4. perforated left eardrum.

Correct Answer: 2
Rationale 1: Lateralization is not associated with normal aging.
Rationale 2: The sound will be louder on the impaired side with a conductive hearing loss; in this case, the right
ear.
Rationale 3: A buildup of cerumen or an infection such as otitis media can cause conductive hearing loss. If this
were the case, the patient would have a buildup of cerumen or otitis media in the right ear.
Rationale 4: Perforation of the eardrum can cause conductive hearing loss. If this were the case, the patient would
have a perforated eardrum of the right ear.
Global Rationale: During the Weber test, sound heard in, or lateralized to, one ear indicates either a conductive
loss in that ear or a sensorineural loss in the other ear. The sound will be louder on the impaired side with a
conductive hearing loss; in this case, the right ear. Lateralization is not associated with normal aging. A buildup of
cerumen, an infection such as otitis media, or perforation of the eardrum can cause conductive hearing loss. For
this patient, the affected ear is the right ear.

ear.
Page Number: 1488
Question 15
Type: MCSA
A patient is found to have small, raised lesions on the rim of the ear. The nurse realizes that this finding is
consistent with which health problem?
1. hypertension
2. gout
3. heart disease
4. kidney failure
Correct Answer: 2
Rationale 1: These lesions are not associated with hypertension.

Rationale 2: Small, raised lesions on the rim of the ear are known as tophi and may indicate gout. Tophi are the
result of uric acid crystal buildup.
Rationale 3: These lesions are not associated with heart disease.
Rationale 4: These lesions are not associated with kidney failure.
Global Rationale: Small, raised lesions on the rim of the ear are known as tophi and may indicate gout. Tophi are
the result of uric acid crystal buildup. These lesions are not associated with hypertension, heart disease, or kidney
failure.

ear.
Page Number: 1489
Question 16
Type: MCSA
An older patient says, “I seem to be talking so much louder these days and I don’t know why!” The nurse realizes
that this patient might be experiencing:
1. loss of hair cells in the middle ear.
2. cochlear atrophy.
3. impacted cerumen.
4. stiffening of the middle ear structures.
Correct Answer: 4
Rationale 1: Loss of hair cells in the middle ear would not produce the perception that the patient is speaking
more loudly.
Rationale 2: Cochlear atrophy would not produce the perception that the patient is speaking more loudly.
Rationale 3: Impacted cerumen would not produce the perception that the patient is speaking more loudly.
Rationale 4: One age-related change of the middle ear is the weakening and stiffening of muscles and ligaments,
which decreases the acoustic reflex. Sounds made from one’s own body and speech are louder and may further
interfere with hearing, speech, and communication.
Global Rationale: One age-related change of the middle ear is the weakening and stiffening of muscles and
ligaments, which decreases the acoustic reflex. Sounds made from one’s own body and speech are louder and may
further interfere with hearing, speech, and communication. Loss of hair cells in the middle ear, cochlear atrophy,
and impacted cerumen would not produce the perception that the patient is speaking more loudly.

Client Need Sub:
Page Number: 1486
Question 17
Type: MCMA
A patient is scheduled for diagnostic tests to determine the cause of a hearing and balance disorder. For which
diagnostic tests should the nurse prepare this patient?
Standard Text: Select all that apply.
1. tonometry
2. computed tomography (CT) scan
3. electronystagmography (ENG)
4. auditory evoked potentials (AEP)
5. auditory brainstem response (ABR)
Correct Answer: 3, 4, 5
Rationale 1: Tonometry is used to measure intraocular pressures.
Rationale 2: CT scan would note abnormalities in organ structure but would not be helpful in identifying hearing
and balance issues.
Rationale 3: Electronystagmography (ENG) is used to detect eye movements (nystagmus) in response to changes
in head position or stimulation of balance sensors in the inner ear using warm and cool water or air. It may be
used to evaluate vertigo or help diagnose Ménière disease.
Rationale 4: The auditory evoked potential test is a diagnostic test used to help determine hearing and balance
disorders.
Rationale 5: The auditory brainstem response test is a diagnostic test used to help determine hearing and balance
disorders.
Global Rationale: Diagnostic tests used to determine hearing and balance disorders include audiometry, auditory
evoked potential (AEP), auditory brainstem response (ABR), and electronystagmography (ENG). Tonometry is
used to measure intraocular pressures. CT scan would note abnormalities in organ structure but would not be
helpful in identifying hearing and balance issues.

AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for
managing the acute and chronic care of patients and promoting health across the lifespan
Nursing/Integrated Concepts: Nursing Process: Implementation
ear.
MNL Learning Outcome: 9.3.3. Examine the diagnosis and treatment of ear disorders.
Page Number: 1486
Question 18
Type: FIB
A patient receiving an eye exam has to stand 20 feet from the chart to read a line that a person with normal vision
could read 100 feet from the chart. The nurse would document this as ______ vision.
Standard Text: Write the answer as a fraction.
Correct Answer: 20/100
Rationale: Changes in distant vision are most commonly the result of myopia (nearsightedness). For example, a
reading of 20/100 indicates impaired distance vision. The person has to stand 20 feet from the chart to read a line
that a person with normal vision could read 100 feet from the chart.
Global Rationale:

ear.
Page Number: 1478
Question 19
Type: SEQ
The nurse is preparing to perform an otoscopic exam of the ear. The patient is restless but has agreed to the exam.
List in order of priority the steps the nurse would perform.
Standard Text: Click and drag the options below to move them up or down.
Choice 1. Explain the procedure to the patient.
Choice 2. Grasp the superior portion of the auricle and pull up, out, and back to straighten the auditory canal.
Choice 3. Hold the handle of the otoscope in the dominant hand, otoscope handle upward.
Choice 4. Wash the hands.
Choice 5. Turn on the otoscope light.
Choice 6. Rest the hand holding the otoscope against the patient’s head.
Correct Answer: 1, 4, 5, 3, 6, 2
Rationale 1: The nurse should first explain the procedure to the patient.
Rationale 2: The last step is to grasp the superior portion of the auricle and pull up, out, and back to straighten the
auditory canal.
Rationale 3: The fourth step is to hold the handle of the otoscope in the dominant hand with the otoscope handle
upward.
Rationale 4: The second step is to wash the hands.
Rationale 5: The third step is to prepare to use the otoscope.
Rationale 6: The fifth step is to rest the hand holding the otoscope on the patient’s head.
Global Rationale: The correct procedure for an otoscopic ear exam is: Explain the procedure to the patient. Wash
the hands; wear disposable gloves if the patient has any drainage from the ears. Turn on the otoscope light. Ask
the patient to tip the head slightly toward the shoulder opposite the ear being examined. When the patient is in this
position, the auditory canal is aligned with the speculum. Hold the handle of the otoscope in the dominant hand. If
the patient is restless, hold the otoscope handle upward, resting the hand against the patient’s head. If the patient is
cooperative, hold the handle downward. For adult patients, grasp the superior portion of the auricle and pull up,
out, and back to straighten the auditory canal.

Client Need Sub:
Page Number: 1487
Question 20
Type: MCHS
When assessing the external features of the eye, the nurse should be able to identify each accessory eye structure.
Which part of the eye should the nurse focus on when assessing the sclera? Place an X on the area that indicates
the sclera.
Correct Answer:
Rationale: The white sclera, the outer fibrous layer of the eyeball, protects and gives shape to the eyeball. The
sclera gives way to the cornea over the iris and pupil.
Global Rationale:

Client Need Sub:
Page Number: 1474
Question 21
Type: MCSA
The nurse is conducting an assessment of a patient’s hearing. Which test is the nurse conducting, as demonstrated
in the picture?
1. Rinne test
2. tympanogram
3. auditory precision test
4. Weber test
Correct Answer: 4
Rationale 1: In the Rinne test, a vibrating tuning fork is placed on the patient’s mastoid bone to determine the
conduction of sound by bone and air conduction.
Rationale 2: In a tympanogram, a measuring device is inserted into the ear canal to measure the pressure of the
middle ear and observe the tympanic membrane’s response to waves of pressure.
Rationale 3: In the auditory precision test, the patient sits in a soundproof room and raises a hand when sounds
are heard.
Rationale 4: The Weber test is performed by placing the base of a vibrating tuning fork on the midline vertex of
the patient’s head. Sound is normally heard equally in both ears. If the sound is not heard equally, the cause may
be a buildup of cerumen, an infection such as otitis media, or perforation of the eardrum.
Global Rationale: Tuning forks are used to determine whether a hearing loss is conductive or perceptive. The
Weber test is performed by placing the base of a vibrating tuning fork on the midline vertex of the patient’s head.
Sound is normally heard equally in both ears. If the sound is not heard equally, the cause may be a buildup of
cerumen, an infection such as otitis media, or perforation of the eardrum. In the Rinne test, a vibrating tuning fork
is placed on the patient’s mastoid bone to determine the conduction of sound by bone and air conduction. In a
tympanogram, a measuring device is inserted into the ear canal to measure the pressure of the middle ear and
observe the tympanic membrane’s response to waves of pressure. In the auditory precision test, the patient sits in
a soundproof room and raises a hand when sounds are heard.

Client Need Sub:
ear.
Page Number: 1488
Question 22
Type: MCSA
Before assessing an older adult patient, the nurse reviews the age-related changes in the ear. (See accompanying
box.) After the assessment, the nurse recognizes which priority concern related to the finding of vestibular
degeneration?
1. skin breakdown
2. fall prevention
3. nausea
4. low night vision
Correct Answer: 2
Rationale 1: Skin breakdown is not a consequence of age-related changes that may occur in the ear.
Rationale 2: Degeneration and atrophy of inner ear structures involved in balance and equilibrium, such as the
vestibule, increase the risk for falls.
Rationale 3: Nausea is not a consequence of age-related changes that may occur in the ear.
Rationale 4: Reduced night vision is not a consequence of the age-related changes that may occur in the ear. It is
an age-related change in the eyes.
Global Rationale: Degeneration and atrophy of inner ear structures involved in balance and equilibrium, such as
the vestibule, increase the risk for falls. Skin breakdown and nausea are not consequences of age-related changes
that may occur in the ear. Reduced night vision is an age-related change in the eyes.

Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Planning
Page Number: 1486
Question 23
Type: MCSA
A patient is experiencing dizziness and disequilibrium with head movements. For which problem should the nurse
plan care?
1. imbalanced fluids
2. difficulty adjusting to life changes
3. problems with coping
4. potential to fall
Correct Answer: 4
Rationale 1: Not enough information is given in the question to determine whether the symptoms of dizziness
and disequilibrium are due to a fluid imbalance.
Rationale 2: It is unlikely adjustment difficulties are caused by dizziness and disequilibrium with head
movements.
Rationale 3: It is unlikely that coping problems are caused by dizziness and disequilibrium with head
movements.
Rationale 4: Dizziness and disequilibrium are caused by changes within the vestibule and semicircular canals of
the inner ear, which give the sensation of starting, stopping, and head position in relation to gravitational pull.
Dizziness and disequilibrium create a risk for potential injury from falling because of loss of balance.
Global Rationale: Dizziness and disequilibrium are caused by changes within the vestibule and semicircular
canals of the inner ear, which give the sensation of starting, stopping, and head position in relation to gravitational
pull. Dizziness and disequilibrium create a risk for potential injury from falling because of loss of balance. Not
enough information is given in the question to determine whether the symptoms of dizziness and disequilibrium
are due to a fluid imbalance. It is unlikely that adjustment difficulties or coping problems are caused by dizziness
and disequilibrium with head movements.

Page Number: 1484
Question 24
Type: MCSA
The nurse suspects that a patient has bone-conductive hearing loss. Which assessment technique should the nurse
use to differentiate between bone conduction loss and air conduction loss?
1. Rinne test
2. Weber test
3. assessment of balance and body position
4. palpation of mastoid process
Correct Answer: 1
Rationale 1: A Rinne test is a hearing test that compares air conduction of sound to bone conduction. In
conductive hearing loss, bone conduction is equal to or greater than air conduction.
Rationale 2: A Weber test identifies hearing loss by lateralization (increase in sound) to the ear with a conductive
hearing loss. Thus this test would be helpful to identify a difference between left and right ear changes that might
be related to a conductive hearing loss.
Rationale 3: Balance and body position changes would reflect a disturbance in the inner ear and possible nerve
damage. If balance and body position are affected, this information does not differentiate between conductive
hearing loss, nerve loss, and a combination of both types of losses.
Rationale 4: Palpation of the mastoid process would assess for pain or swelling, which can indicate inflammation
of the external auditory canal and mastoid sinuses. Mastoiditis can lead to fluid or scarring within the middle ear,
which could interfere with sound conduction from the external to the inner ear. This assessment would be helpful
to identify a source for conduction hearing loss.
Global Rationale: A Rinne test is a hearing test that compares air conduction of sound to bone conduction. In
conductive hearing loss, bone conduction is equal to or greater than air conduction. A Weber test identifies a
hearing loss by lateralization (increase in sound) to the ear with a conductive hearing loss. Thus this test would be
helpful to identify a difference between left and right ear changes that might be related to a conductive hearing
loss. Balance and body position changes would reflect a disturbance in the inner ear and possible nerve damage. If
balance and body position are affected, this information does not differentiate between conductive hearing loss,
nerve loss, and a combination of both types of losses. Palpation of the mastoid process would assess for pain or
swelling, which can indicate inflammation of the external auditory canal and mastoid sinuses. Mastoiditis can lead
to fluid or scarring within the middle ear, which could interfere with sound conduction from the external to the
inner ear. This assessment would be helpful to identify a source for conduction hearing loss.

Page Number: 1488
Question 25
Type: MCSA
A patient has a tonometer test result of 28 mmHg. Which explanation by the nurse about this pressure reading is
most accurate?
1. The pressure in the eye has been measured and is too low. Medication will be required to increase the pressure
and prevent blindness from retinal damage.
2. The pressure in the inner ear has been measured to evaluate the semicircular canals’ function related to nerve
damage and is within the normal range.
3. The pressure in the middle ear that builds up with mastoiditis has been measured. The condition needs to be
treated with surgical insertion of tubes to drain the fluid behind the tympanic membrane.
4. The pressure in the eye has been measured and is above normal. This condition could lead to possible retinal
changes if not treated.
Correct Answer: 4
Rationale 1: A measurement of 28 mmHg is above the normal range of 10–22 mmHg.
Rationale 2: A tonometer measures eye pressure, not ear pressure.
Rationale 3: Typanometry is performed to evaluate the response of the tympanic membrane to changes in air
pressure and middle ear function.
Rationale 4: Tonometry is used to diagnose increased intraocular pressure in glaucoma. A handheld tonometer or
computerized device may be used. The cornea is anesthetized prior to being touched with the device. The normal
range is 10–22 mmHg.
Global Rationale: Tonometry is used to diagnose increased intraocular pressure in glaucoma. A handheld
tonometer or computerized device may be used. The cornea is anesthetized prior to being touched with the device.
The normal range is 10–22 mmHg. A tonometer measures eye pressure, not ear pressure. Typanometry is
performed to evaluate the response of the tympanic membrane to changes in air pressure and middle ear function.

AACN Essentials Competencies: IX.4. Communicate effectively with all members of the healthcare team,
including the patient and the patient’s support network
Page Number: 1477
Question 26
Type: MCSA
The nurse is assessing a 75-year-old patient. Which patient report would require immediate action by the nurse?
1. occasional presence of floaters
2. greater need for additional light and reading glasses
3. development of a white circle around the iris
4. frequent falls from tripping over items on the floor
Correct Answer: 4
Rationale 1: Floaters are often seen by older patients and are related to debris or condensation when the vitreous
body pulls away from the retina. Unless excessive, with vision suddenly greatly impaired, floaters are not an
urgent problem.
Rationale 2: Near vision accommodation is gradually lost as elasticity declines and presbyopia (a common
problem in older patients) develops with aging. This is not an urgent problem.
Rationale 3: White circles around the iris of the eye (arcus senilis) are caused by lipid deposits through a gradual
process that does not require immediate care.
Rationale 4: Excessive falling can represent changes in vision sufficient to alter the field of vision. Depth
perception changes and adaptation to changes in light represent a need for immediate additional assessments.
Global Rationale: Excessive falling down can represent changes in vision sufficient to alter the field of vision.
Depth perception changes and adaptation to changes in light represent a need for immediate additional
assessments. Floaters are often seen by older patients and are related to debris or condensation when the vitreous
body pulls away from the retina. Unless excessive, with vision suddenly greatly impaired, floaters are not an
urgent problem. Near vision accommodation is gradually lost as elasticity declines and presbyopia (a common
problem in older patients) develops with aging. This is not an urgent problem. White circles around the iris of the
eye (arcus senilis) are caused by lipid deposits through a gradual process that does not require immediate care.

Client Need Sub:
MNL Learning Outcome: 9.1.2. Differentiate the manifestations of age-related eye disorders.
Page Number: 1479
Question 27
Type: MCMA
The nurse is assessing a patient for neurological changes after a head trauma. Which eye assessment should the
nurse perform?
1. ptosis
2. extraocular movements
3. accommodation
4. color of iris
5. nystagmus
Correct Answer: 1, 2, 3, 5
Rationale 1: Ptosis refers to the drooping one eyelid and may indicate cranial nerve damage.
Rationale 2: Failure of one or both eyes to follow an object in any given direction may reflect cranial nerve
dysfunction.
Rationale 3: Accommodation is the bending of light rays at the lens so that they focus on one point on the retina.
Failure of accommodation, along with lack of pupil response to light, may signal a neurologic problem.
Rationale 4: The color of the iris does not reflect neurologic changes or deficits in cranial nerves.
Rationale 5: Nystagmus is the involuntary rhythmic movement of the eyes that occurs with neurologic disorders
and the use of some medications.
Global Rationale: Ptosis refers to the drooping one eyelid and may indicate cranial nerve damage. Failure of one
or both eyes to follow an object in any given direction may reflect cranial nerve dysfunction. Accommodation is
the bending of light rays at the lens so that they focus on one point on the retina. Failure of accommodation, along
with lack of pupil response to light, may signal a neurologic problem. Nystagmus is the involuntary rhythmic
movement of the eyes that occurs with neurologic disorders and the use of some medications. The color of the iris
does not reflect neurologic changes or deficits in cranial nerves.

ear.
Page Number: 1480

Question 28
Type: MCSA
The nurse is assessing a patient for a possible conductive hearing loss. What should the nurse perform first?
1. external ear exam
2. Weber test
3. Rinne test
4. tympanogram
Correct Answer: 1
Rationale 1: Visual inspection of the external ear will give information about possible obstruction by cerumen,
drainage, redness, swelling, or objects present in the external canal. Visual inspection can also show the condition
of the tympanic membrane (intact or ruptured), swelling, redness, and scarring. Pain also might be identified when
using the otoscope to visualize the structures in the external canal.
Rationale 2: A Weber test is done to identify the equality of sound heard in both ears. This would be the next step
in the assessment process. Normally, sound is heard equally in both ears.
Rationale 3: A Rinne test is done to identify the difference between bone and air conduction of sound by each
ear. This is the third step. Normally, sound can be heard twice as long by air conduction as by bone conduction.
Rationale 4: Tympanograms are done to measure the pressure of the middle ear by evaluating the tympanic
membrane’s response to waves of pressure. This test would be done last, only if other symptoms were noted or
indicated by the nurse’s findings.
Global Rationale: Visual inspection of the external ear will give information about possible obstruction by
cerumen, drainage, redness, swelling, or objects present in the external canal. Visual inspection can also show the
condition of the tympanic membrane (intact or ruptured), swelling, redness, and scarring. Pain also might be
identified when using the otoscope to visualize the structures in the external canal. A Weber test is done to
identify the equality of sound heard in both ears. This would be the next step in the assessment process. Normally,
sound is heard equally in both ears. A Rinne test is done to identify the difference between bone and air
conduction of sound by each ear. This is the third step. Normally, sound can be heard twice as long by air
conduction as by bone conduction. Tympanograms are done to measure the pressure of the middle ear by
evaluating the tympanic membrane’s response to waves of pressure. This test would be done last, only if other
symptoms were noted or indicated by the nurse’s findings.

ear.
Page Number: 1485
Question 29
Type: MCMA
The nurse is performing the Weber test when assessing a patient’s hearing. For which abnormalities does this
technique assess?
1. conductive hearing loss
2. sensorineural hearing loss
3. otitis media
4. degree of hearing loss
5. tumor of the middle ear
Rationale 1: Tuning forks are used to determine whether a hearing loss is conductive or sensorineural. The sound
will be louder on the impaired side with a conductive hearing loss.
Rationale 2: Tuning forks are used to determine whether a hearing loss is conductive or sensorineural. The sound
will be softer on the impaired side with a sensorineural hearing loss.
Rationale 3: If the sound is not heard equally in both ears, the cause may be an infection such as otitis media.
Rationale 4: This test cannot measure degree of hearing loss.
Rationale 5: The Rinne test is not used to assess for the presence of a tumor in the middle ear.
Global Rationale: Tuning forks are used to determine whether a hearing loss is conductive or sensorineural. The
sound will be louder on the impaired side with a conductive hearing loss. The sound will be softer on the impaired
side with a sensorineural hearing loss. If the sound is not heard equally in both ears, the cause may be an infection
such as otitis media. The test cannot measure degree of hearing loss. The Rinne test is not used to assess for the
presence of a tumor in the middle ear.

ear.
Page Number: 1488
Question 30
Type: MCHS
The nurse is preparing to assess a patient’s corneal reflex. Place an X on the site where the nurse may lightly
touch the eye with a wisp of cotton.
Correct Answer:
Rationale: The white sclera lines the outside of the eyeball and protects and gives shape to the eyeball. The sclera
gives way to the cornea over the iris and pupil. The cornea is transparent, avascular, and sensitive to touch. It
forms a window that allows light to enter the eye and is a part of its light-bending apparatus. When the cornea is
touched, the eyelids blink (the corneal reflex) and tears are secreted.
Global Rationale:

Client Need Sub:
Page Number: 1474, 1476, 1481

Question 31
Type: MCMA
The nurse is performing an assessment of an 82-year-old patient’s eyes. Which patient statements should the
nurse expect based on the patient’s age?
1. “I’ve been having some drainage from the inside corner of my eye.”
2. “My eyes feel so dry most of the time.”
3. “I have almost fallen several times at home going down our basement stairs.”
4. “I have this white circle around the color of my eyes.”
5. “I have a hard time driving at night.”
Rationale 1: Drainage from the puncta may indicate an infectious process and is not a normal age-related change.
Rationale 2: The lacrimal apparatus within the older patient’s eye produces fewer tears. The eyes may look and
feel dry.
Rationale 3: The older patient has an increased risk of falls as a result of changes in depth perception and
adaptation to changes in light.
Rationale 4: A partial or complete white circle may form around the cornea (arcus senilis).
Rationale 5: With aging the lens loses elasticity, with reduced ability to change shape and focus light. The lens
loses clarity and becomes thicker and increasingly opaque.
Global Rationale: The lacrimal apparatus within the older patient’s eye produces fewer tears. The eyes may look
and feel dry. The older patient has an increased risk of falls as a result of changes in depth perception and
adaptation to changes in light. A partial or complete white circle may form around the cornea (arcus senilis). With
aging the lens loses elasticity, with reduced ability to change shape and focus light. The lens loses clarity and
becomes thicker and increasingly opaque. Drainage from the puncta may indicate an infectious process and is not
a normal age-related change.

Client Need Sub:
Page Number: 1479
Question 32
Type: MCHS
A patient with complaints of dizziness states, “When I’m walking through our house, I sometimes have to hold on
to furniture to keep from falling.” The physician has determined that the patient has an ear disorder. Place an “X”
over the area of the ear that is most likely responsible for the patient’s symptom.
Correct Answer:
Rationale: As a sensory organ, the ears have two primary functions: hearing and maintaining equilibrium.
Anatomically, each ear is divided into three areas: the external ear, the middle ear, and the inner ear. All three are
involved in hearing, but only the inner ear is involved in equilibrium. The vestibule is the central portion of the
inner ear, one side of which is a bony wall containing the oval window. Two sacs within the vestibule (the saccule
and the utricle) join the vestibule with the cochlea and the semicircular canals. The saccule and the utricle contain
receptors for equilibrium that respond to changes in gravity and changes in head position.
Global Rationale:

ear.
Page Number: 1483, 1484

Question 33
Type: MCSA
The nurse is assessing the ears of a patient who is African American. Which assessment finding should the nurse
identify as abnormal?
1. During the Rinne test, the patient hears the sound by air conduction for an equal amount of time as by bone
conduction.
2. The patient is able to hear whispers from 18 inches away.
3. The patient’s cerumen is dark gray.
4. The patient’s tympanic membrane is pearly gray.
Correct Answer: 1
Rationale 1: This patient has some conductive hearing loss. The patient with no conductive hearing loss hears the
sound twice as long by air conduction as by bone conduction.
Rationale 2: The patient should normally be able to hear the nurse whispering from 1–2 feet away.
Rationale 3: People with darker skin tend to have darker cerumen. This is a normal finding.
Rationale 4: The tympanic membrane should look pearly gray. This is a normal finding.
Global Rationale: This patient has some conductive hearing loss. The patient with no conductive hearing loss
hears the sound twice as long by air conduction as by bone conduction. The patient should normally be able to
hear the nurse whispering from 1–2 feet away. People with darker skin tend to have darker cerumen. This is a
normal finding. The tympanic membrane should look pearly gray. This is a normal finding.

ear.
Page Number: 1488
Question 34
Type: MCMA
The nurse is reviewing the physiology of the ear with a patient with a hearing disorder. What should the nurse
explain about the function of the inner ear?
1. It coordinates visual pathways.
2. It integrates efferent neuron messages.
3. It provides information about head position.
4. It maintains middle ear structure and function.
5. It conducts sound.
Correct Answer: 3, 5
Rationale 1: The inner ear is not involved with visual pathways.
Rationale 2: The inner ear does not integrate efferent neuron messages.
Rationale 3: Receptors within the inner ear maintain equilibrium by responding to changes in head position in
order to coordinate body movements and balance.
Rationale 4: The inner ear does not maintain middle ear structure and function.
Rationale 5: The inner ear is a maze of bony chambers. The membranous labyrinth, a delicate network of
interconnected fluid-filled tubes, lies within this maze. Perilymph, a fluid similar to cerebrospinal fluid, flows
between the bony and the membranous labyrinth. Within the chambers of the membranous labyrinth is a fluid
called endolymph. These fluids conduct sound vibrations.
Global Rationale: The inner ear is a maze of bony chambers. The membranous labyrinth, a delicate network of
interconnected fluid-filled tubes, lies within this maze. Perilymph, a fluid similar to cerebrospinal fluid, flows
between the bony and the membranous labyrinth. Within the chambers of the membranous labyrinth is a fluid
called endolymph. These fluids conduct sound vibrations. Receptors within the inner ear maintain equilibrium by
responding to changes in head position in order to coordinate body movements and balance. The inner ear is not
involved with visual pathways. It does not integrate efferent neuron messages or maintain middle ear structure
and function.

AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage,
age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in
their care
MNL Learning Outcome: 9.3.1. Explain the causes, risk factors, incidence, and pathophysiology of ear
disorders.
Page Number: 1484
Question 35
Type: MCMA
The nurse is preparing to assess an older patient’s ears. Which techniques should the nurse consider when
conducting this assessment?
1. whisper test
2. Rinne test
3. Weber test
4. electronystagmography (ENG)
5. audiometer
Rationale 1: The examiner can whisper a word 1 or 2 feet behind the patient, asking the patient to repeat the
word; this may provide a rough estimate of hearing acuity.
Rationale 2: The Rinne test measures hearing loss.
Rationale 3: The Weber test measures hearing loss.
Rationale 4: Electronystagmography (ENG) is used to detect eye movements (nystagmus) in response to changes
in head position or stimulation of balance sensors in the inner ear using warm and cool water or air. It may be
used to evaluate vertigo or help diagnose Ménière disease.
Rationale 5: Audiometry is used to evaluate and diagnose conductive and sensorineural hearing loss.
Global Rationale: The examiner can whisper a word 1 or 2 feet behind the patient, asking the patient to repeat
the word; this may provide a rough estimate of hearing acuity. The Rinne and Weber tests measure hearing loss.
Audiometry is used to evaluate and diagnose conductive and sensorineural hearing loss. Electronystagmography
(ENG) is used to detect eye movements (nystagmus) in response to changes in head position or stimulation of
balance sensors in the inner ear using warm and cool water or air. It may be used to evaluate vertigo or help
diagnose Ménière disease.

Page Number: 1486, 1488
Question 36
Type: MCMA
The nurse determines that an older patient has age-related changes in the vestibular structures of the ear. What
should the nurse identify as risks for this patient?
1. infection
2. falls
3. medication errors
4. food intolerance
5. problems communicating
Rationale 1: Infection is unrelated to vestibular changes.
Rationale 2: Degeneration and atrophy of inner ear structures involved in balance and equilibrium increase the
risk for falls.
Rationale 3: Medication errors are unrelated to vestibular changes.
Rationale 4: Food intolerance is unrelated to vestibular changes.
Rationale 5: With the loss of high-frequency sounds, speech may be distorted, contributing to a risk for problems
with communication.
Global Rationale: Degeneration and atrophy of inner ear structures involved in balance and equilibrium increase
the risk for falls. With the loss of high-frequency sounds, speech may be distorted, contributing to a risk for
problems with communication. Infection, medication errors, and food intolerance are unrelated to vestibular
changes.

Page Number: 1486
Question 37
Type: MCMA
A patient has a tonometry measurement of 29 mmHg. What additional assessment findings should the nurse
identify that indicate this patient has glaucoma?
1. narrowing visual fields

2. loss of definition of the optic disc
3. areas of hemorrhage, exudate, and white patches
4. narrowing of the vein where an arteriole crosses over
5. displaced blood vessels from the center of the optic disc
Rationale 1: Narrowing of visual fields may indicate an eye disorder such as glaucoma.
Rationale 2: Loss of definition of the optic disc is seen in papilledema from increased intracranial pressure.
Rationale 3: Areas of hemorrhage, exudate, and white patches may be a result of diabetes or longstanding
hypertension.
Rationale 4: Hypertension may cause a narrowing of the vein where an arteriole crosses over.
Rationale 5: Glaucoma may cause displacement of blood vessels from the center of the optic disc due to
increased intraocular pressure.
Global Rationale: Narrowing of visual fields may indicate an eye disorder such as glaucoma. Glaucoma may
cause displacement of blood vessels from the center of the optic disc due to increased intraocular pressure. Loss
of definition of the optic disc is seen in papilledema from increased intracranial pressure. Areas of hemorrhage,
exudate, and white patches may be a result of diabetes or longstanding hypertension. Hypertension may cause a
narrowing of the vein where an arteriole crosses over.

Learning Outcome: 3. Give examples of genetic disorders in vision and hearing.
Page Number: 1478, 1479, 1481
Question 38
Type: MCMA
The nurse is assessing a patient with retinitis pigmentosa. Which findings should the nurse identify as consistent
with this health problem?
1. loss of visual acuity

2. loss of peripheral vision
3. progressive night blindness
4. one dilated, unresponsive pupil
5. reduced perception of blue-green tones
Rationale 1: Retinitis pigmentosa results in loss of visual acuity.
Rationale 2: Retinitis pigmentosa results in loss of peripheral vision.
Rationale 3: Retinitis pigmentosa results in progressive night blindness.
Rationale 4: A patient who has one dilated and unresponsive pupil may have paralysis of the oculomotor nerve.
Rationale 5: A change in blue-green perception is an age-related change caused by the atrophy of photoreceptor
cells in the eyes.
Global Rationale: Retinitis pigmentosa results in progressive night blindness, with loss of visual acuity and
peripheral vision. A patient who has one dilated and unresponsive pupil may have paralysis of the oculomotor
nerve. A change in blue-green perception is an age-related change caused by the atrophy of photoreceptor cells in
the eyes.

Page Number: 1478
Question 39
Type: MCMA
During a health history interview the nurse becomes concerned that a patient is at risk for a genetic hearing
disorder. On what information did the nurse base this clinical decision?
1. The patient’s mother, age 76, uses hearing aids.

2. The patient’s father had tubes in the ears as a child.
3. The patient’s brother lost his hearing because of a thyroid disorder.
4. The patient’s sister was treated for ear drainage after swimming.
5. The patient’s nephew had surgery to remove a tumor on the acoustic nerve.
Rationale 1: Hereditary hearing impairment (HHI) is believed to account for more than 50% of childhood hearing
loss and can also manifest later in life. Most HHI follows an autosomal recessive inheritance pattern. Heredity is
also increasingly recognized as a contributor to presbycusis.
Rationale 2: Tubes in the ears may have been used to treat ear infections. This does not increase the patient’s risk
for a genetic hearing loss.
Rationale 3: Pendred syndrome is an inherited disorder that accounts for as much as 10% of hereditary deafness.
The deafness is usually accompanied by a thyroid goiter.
Rationale 4: Ear drainage is an indication of infection. This does not increase the patient’s risk for a genetic
hearing loss.
Rationale 5: Neurofibromatosis, a rare inherited disorder, is characterized by the development of acoustic

neuromas, or benign tumors of the auditory nerve.
Global Rationale: Hereditary hearing impairment (HHI) is believed to account for more than 50% of childhood
hearing loss and can also manifest later in life. Most HHI follows an autosomal recessive inheritance pattern.
Heredity is also increasingly recognized as a contributor to presbycusis. Pendred syndrome is an inherited
disorder that accounts for as much as 10% of hereditary deafness. The deafness is usually accompanied by a
thyroid goiter. Neurofibromatosis, a rare inherited disorder, is characterized by the development of acoustic
neuromas or benign tumors of the auditory nerve. Tubes in the ears may have been used to treat ear infections; ear
drainage is an indication of an infection. These situations do not increase the patient’s risk for a genetic hearing
loss.

MNL Learning Outcome: 9.3.1. Explain the causes, risk factors, incidence, and pathophysiology of ear
disorders.
Page Number: 1485
Question 40
Type: MCMA
During an assessment the nurse suspects that a victim of a motor vehicle crash is a narcotic substance user. Which
assessment findings would confirm the nurse’s suspicion?
1. small pupils
2. dilated pupils
3. unequal pupil size
4. poor pupillary response to light
5. one dilated and unresponsive pupil
Rationale 1: The use of morphine and narcotic drugs may cause small pupils.
Rationale 2: The use of anticholinergic drugs such as atropine may cause dilated pupils.
Rationale 3: Pupils that are unequal in size may indicate previous eye surgery or a serious neurologic problem,
such as increased intracranial pressure.
Rationale 4: The use of morphine and narcotic drugs may cause poor pupillary response to light.
Rationale 5: One dilated and unresponsive pupil may indicate paralysis of the oculomotor nerve.
Global Rationale: The use of morphine and narcotic drugs may cause small pupils with poor response to light.
The use of anticholinergic drugs such as atropine may cause dilated, poorly responsive pupils. Pupils that are
unequal in size may indicate previous eye surgery or a serious neurologic problem, such as increased intracranial
pressure. One dilated and unresponsive pupil may indicate paralysis of the oculomotor nerve.

Page Number: 1480

The Eyes

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The Eyes

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Question 1

1. the stroke occurred in the optic region of the patient’s brain.

2. the brain interprets information received through the eyes.

3. the patient is experiencing another stroke.

4. the patient is unable to talk because of the stroke.

Rationale 4: There is no indication of the patient’s verbal abilities.

Cognitive Level: Analyzing

2. fluid and electrolyte imbalance.

3. foreign bodies in the eyes.

4. itchiness as the hair grows back.

Cognitive Level: Analyzing

4. peripheral vision and color perception.

Rationale 1: Tear production is not controlled by the inner retina.

Rationale 2: Blinking is not controlled by the inner retina.

Rationale 3: Reading will still be possible with this type of injury.

Cognitive Level: Analyzing

Rationale 3: Light will still be discernible to the “good” eye.

Rationale 4: Color will still be discernible to the “good” eye.

Cognitive Level: Analyzing

1. has normal 20/20 vision.

2. has normal reading vision.

3. has visual impairments.

4. has a normal pupillary reflex.

Rationale 2: This test is not used to assess reading vision.

Rationale 4: This test is not used to assess pupillary reflex.

Cognitive Level: Analyzing

1. computed tomography (CT) scan

4. response to atropine eye drops

Rationale 1: A computed tomography (CT) scan is used to assess structures.

Rationale 2: Tonometry is used to assess ocular pressure.

Cognitive Level: Applying

1. cover own right eye

2. cover own left eye

3. keep both eyes uncovered

4. turn the lights on in the room before conducting this examination

Cognitive Level: Applying

1. consistent with the aging process.

2. normal in a 20-year-old patient.

Rationale 2: This is not a normal finding in a 20-year-old.

Rationale 4: Changes in near vision in younger patients is referred to as hyperopia or farsightedness.

Cognitive Level: Analyzing

Rationale 4: Myopia is the term for nearsightedness.

Cognitive Level: Analyzing

1. abnormal and should be reported to the physician.

2. normal because of the eyedrops.

3. evidence of retinal degeneration.

4. evidence of optic nerve damage.

Cognitive Level: Analyzing

Cognitive Level: Analyzing

1. inspection of the red reflex.

2. inspection of the retina.

3. inspection of the macula.

4. inspection of the optic disc.

Cognitive Level: Applying

2. a middle ear infection.

4. an inner ear infection.

Rationale 3: The manifestations of tonsillitis would not include auditory compromise.

Rationale 4: The inner ear is not implicated in this scenario.

Cognitive Level: Analyzing

2. conductive hearing loss in the right ear.

3. possible buildup of cerumen or otitis media in the left ear.

4. perforated left eardrum.

Rationale 1: Lateralization is not associated with normal aging.