When the patient turns his head quickly during the admission assessment, the nurse observes nystagmus. What is the indicated nursing action?
a. Assess the patient with a Rinne test.
b. Place a fall-risk bracelet on the patient.
c. Ask the patient to watch the mouths of staff when they are speaking.
d. Remind unlicensed assistive personnel to speak loudly to the patient.
Question 2The nurse is assessing a 65-year-old patient for presbyopia. Which instruction will the nurse give the patient before the test?
a. Hold this card and read the print out loud.
b. Cover one eye at a time while reading the wall chart.
c. You'll feel a short burst of air directed at your eyeball.
d. A light will be used to look for a change in your pupils.
Question 3A patient arrives in the emergency department complaining of eye itching and pain after sleeping with contact lenses in place. To facilitate further examination of the eye, fluorescein angiography is ordered. The nurse will teach the patient to
a. hold a card and fixate on the center dot.
b. report any burning or pain at the IV site.
c. remain still while the cornea is anesthetized.
d. let the examiner know when images shown appear clear.
Question 4A patient who underwent eye surgery is required to wear an eye patch until the scheduled postoperative clinic visit. Which nursing diagnosis will the nurse include in the plan of care?
a. Disturbed body image related to eye trauma and eye patch
b. Risk for falls related to temporary decrease in stereoscopic vision
c. Ineffective health maintenance related to inability to see surroundings
d. Ineffective denial related to inability to admit the impact of the eye injury
Question 5Which information will the nurse provide to the patient scheduled for refractometry?
a. You will need to wear sunglasses for a few hours after the exam.
b. The surface of your eye will be numb while the doctor does the exam.
c. You should not take any of your eye medicines before the examination.
d. The doctor will shine a bright light into your eye during the examination.
Question 6A 65-year-old patient is being evaluated for glaucoma. Which information given by the patient has implications for the patient's treatment?
a. I use aspirin when I have a sinus headache.
b. I have had frequent episodes of conjunctivitis.
c. I take metoprolol (Lopressor) daily for angina.
d. I have not had an eye examination for 10 years.
Question 7The nurse is observing a student who is preparing to perform an ear examination for a 30-year-old patient. The nurse will need to intervene if the student
a. pulls the auricle of the ear up and posterior.
b. chooses a speculum larger than the ear canal.
c. stabilizes the hand holding the otoscope on the patient's head.
d. stops inserting the otoscope after observing impacted cerumen.
Question 8The nurse is testing the visual acuity of a patient in the outpatient clinic. The nurse's instructions for this test include asking the patient to
a. stand 20 feet from the wall chart.
b. follow the examiner's finger with the eyes only.
c. look at an object far away and then near to the eyes.
d. look straight ahead while a light is shone into the eyes.
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