Chapter 23: Nursing Assessment: Visual and Auditory Systems
Lewis: Medical-Surgical Nursing in Canada, 4th Canadian Edition
MULTIPLE CHOICE
1. The nurse is teaching a client about routine glaucoma testing. Which of the following
information should the nurse include in the teaching plan?
a. The test involves reading a Snellen chart at a distance of 6 m.
b. Application of a Tono-pen to the surface of the eye will be needed.
c. The examination includes checking the pupil’s reaction to a bright light.
d. Medications to dilate the pupil will be used before testing for glaucoma.
ANS: B
Glaucoma is caused by an increase in intraocular pressure, which would be measured
using the Tono-pen. The other techniques are used in testing for other eye disorders.
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
MSC: NCLEX: Health Promotion and Maintenance
2. Which assessment information obtained by the nurse when performing an eye
examination for an older-adult client indicates that more extensive examination of the
eyes is needed?
a. The client’s sclerae are light yellow in colour.
b. The client complains of persistent photophobia.
c. The pupil recovers slowly after being stimulated by a penlight.
d. There is a whitish gray ring encircling the periphery of the iris.
ANS: B
Photophobia is not a normally occurring change with aging and would require further
assessment. The other assessment data are common age-related differences and would
not be unusual in an older-adult client.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Assessment
3. The nurse is performing an eye examination on a client and is assessing for
accommodation. Which of the following actions should the nurse implement?
a. Cover one eye for 1 minute and note the pupil reaction when the cover is removed.
b. Shine a light into the client’s eye and assess the pupil response in the opposite eye.
c. Observe the pupils when the client focuses on a close object and then on a distant
object.
d. Touch the client’s pupil with a small piece of sterile cotton and watch for a blink
reaction.
ANS: C
Accommodation is defined as the ability of the lens to adjust to various distances. The
other nursing actions also may be part of the eye examination, but they do not test for
accommodation.
DIF: Cognitive Level: Application
TOP: Nursing Process: Assessment
MSC: NCLEX: Health Promotion and Maintenance
4. The nurse is delivering a health-promotion session at the eye clinic and advises all
clients to wear sunglasses that protect the eyes from ultraviolet light. Which of the
following conditions is associated with ultraviolet sunlight exposure?
a. Cataracts
b. Glaucoma
c. Anisocoria
d. Exophthalmos
ANS: A
Ultraviolet light exposure is associated with the accelerated development of cataracts.
Glaucoma is caused by increased intraocular pressure, exophthalmos is associated with
hyperthyroidism, and anisocoria can occur normally in a small percentage of the
population or may be caused by injury or central nervous system disorders.
DIF: Cognitive Level: Comprehension TOP: Nursing Process: Implementation
MSC: NCLEX: Health Promotion and Maintenance
5. The nurse’s assessment of a client’s visual acuity reveals that the left eye can see at 20
feet what a person with normal vision can see at 40 feet and the right eye can see at 20
feet what a person with normal vision can see at 50 feet. Which of the following findings
should the nurse document?
a. Left eye 20/40; right eye 20/50
b. OU 20/40; OS 50/20
c. Right eye 20/40; left eye 20/50
d. OS 20/40; OD 20/50
ANS: A
When documenting visual acuity, the first number indicates the standard (for normal
vision) of 20 feet and the second number indicates the line that the client is able to read
when standing 20 feet from the Snellen chart. Nurses should avoid using the
abbreviations OS for left eye, OD for right eye, and OU for both eyes when documenting
in client charts. The remaining three answers do not correctly describe the client’s visual
acuity.
DIF: Cognitive Level: Comprehension TOP: Nursing Process: Assessment
MSC: NCLEX: Health Promotion and Maintenance
6. The nurse is conducting a vision assessment on a client and is assessing the client’s
visual field. Which of the following actions should the nurse include?
a. Position the client 20 feet from the Snellen chart.
b. Have the client cover one eye while facing the nurse.
c. Instruct the client to follow a moving object using only the eyes.
d. Shine a light into one pupil and observe the response for both pupils.
ANS: B
To perform confrontation visual field testing, the client faces the examiner and covers
one eye, then counts the number of fingers that the examiner brings into the visual field.
The other actions are needed to test for visual acuity, extraocular movements, and
consensual pupil response.
DIF: Cognitive Level: Application
TOP: Nursing Process: Assessment
MSC: NCLEX: Health Promotion and Maintenance
7. The nurse is observing a student who is preparing to perform an ear examination of an
adult client. Which of the following actions by the student should cause the nurse to
intervene in the assessment?
a. Chooses a speculum smaller than the ear canal
b. Pulls the auricle of the ear down and backward
c. Stabilizes the hand holding the otoscope on the client’s head
d. Stops inserting the otoscope after observing impacted cerumen
ANS: B
The auricle should be pulled up and back when assessing an adult. The other actions are
appropriate when performing an ear examination.
DIF: Cognitive Level: Application
TOP: Nursing Process: Assessment
MSC: NCLEX: Health Promotion and Maintenance
8. The nurse is obtaining a health history from a middle-aged adult client. Which of the
following client statements is most important to communicate to the health care
provider?
a. “My vision seems blurry now when I read.”
b. “I have noticed that my eyes are drier now.”
c. “It is hard for me to see when I drive at night.”
d. “The peripheral part of my vision is decreased.”
ANS: D
The decrease in peripheral vision may indicate glaucoma, which is not a normal visual
change associated with aging and requires rapid treatment. The other client statements
indicate visual problems (presbyopia, dryness, and lens opacity) that are considered a
normal part of aging.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Assessment
9. The nurse is obtaining a health history from an older-adult client, who is new to the eye
clinic and who has glaucoma. Which of the following information given by the client
will have the most implications for the client’s treatment?
a. “I use aspirin when I have a sinus headache.”
b. “I have had frequent episodes of conjunctivitis.”
c. “I take metoprolol daily for angina.”
d. “I have not had an eye examination for 10 years.”
ANS: C
It is important to note whether the client takes any â-adrenergic blockers because this
category of medications also is used to treat glaucoma, and there may be an increase in
adverse effects. The use of aspirin does not increase intraocular pressure and is safe for
clients with glaucoma. Although older clients should have yearly eye examinations, the
treatment for this client will not be affected by the 10-year gap in eye care.
Conjunctivitis does not increase the risk for glaucoma.
DIF: Cognitive Level: Analysis
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Assessment
10. The nurse is preparing to assess the visual acuity for a client in the outpatient clinic.
Which of the following supplies should the nurse obtain to prepare for this assessment?
a. Penlight
b. Amsler grid
c. Snellen chart
d. Ophthalmoscope
ANS: C
The Snellen chart is used to check visual acuity. An ophthalmoscope, penlight, and
Amsler grid also may be used during an eye examination, but they are not helpful in
assessing visual acuity.
DIF: Cognitive Level: Comprehension TOP: Nursing Process: Assessment
MSC: NCLEX: Health Promotion and Maintenance
11. The nurse is admitting a client to the hospital who has an eye patch in place and tells the
nurse “I had a recent eye injury, so I need to wear this patch for a few weeks.” Which of
the following nursing diagnoses will the nurse include in the plan of care?
a. Risk for falls as evidenced by impaired vision (decrease in stereoscopic vision)
b. Ineffective health maintenance related to impaired decision-making (inability to
see surroundings)
c. Disturbed body image related to alteration in self-perception
d. Ineffective denial related to threat of unpleasant reality
ANS: A
The loss of stereoscopic vision created by the eye patch impairs the client’s ability to see
in three dimensions and to judge distances. It also increases the risk for falls. There is no
evidence in the assessment data for ineffective denial, disturbed body image, or
ineffective health maintenance.
DIF: Cognitive Level: Application
TOP: Nursing Process: Diagnosis
MSC: NCLEX: Safe and Effective Care Environment
12. The nurse is preparing a client in the eye clinic for refractometry. Which of the
following information should the nurse include in client teaching?
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.”
ANS: A
The pupil is dilated by using cycloplegic medications during refractometry. This effect
will last several hours and cause photophobia. The other teaching would not be
appropriate for a client who was having refractometry.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
13. The nurse is assessing an older-adult client for the presence of presbyopia. Which of the
following equipment will the nurse need to obtain before the examination?
a. Penlight
b. Tono-pen
c. Jaeger chart
d. Snellen chart
ANS: C
Presbyopia is the normal loss of near vision that occurs with age and is assessed using a
Jaeger chart. This assessment should begin after 40 years of age. The Snellen chart,
penlight, and the Tono-pen are used when assessing for other visual disorders.
DIF: Cognitive Level: Application
TOP: Nursing Process: Assessment
MSC: NCLEX: Health Promotion and Maintenance
14. The nurse is caring for a client in the emergency department with symptoms of eye
itching and pain caused by sleeping with contact lenses in place. Which of the following
equipment should the nurse anticipate preparing to facilitate further examination of the
client’s eye?
a. Tonometer
b. Eye patch
c. Refractometer
d. Fluorescein dye
ANS: D
Eye itching and pain suggest a possible corneal abrasion or ulcer, which can be
visualized using fluorescein dye. The other items listed would not be helpful in
determining the cause of this client’s symptoms.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Planning
15. The nurse is obtaining a nursing history from a client when the client indicates
symptoms of dizziness when bending over and nausea and dizziness associated with
physical activities. Which of the following topics should the nurse include in this client’s
teaching plan?
a. Tympanometry
b. Rotary chair testing
c. Pure-tone audiometry
d. Bone-conduction testing
ANS: B
The client’s clinical manifestations of dizziness and nausea suggest a disorder of the
labyrinth, which controls balance and contains three semicircular canals and the
vestibule. Rotary chair testing is used to test vestibular function. The other tests are used
to test for problems with hearing.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Planning
16. The nurse is taking a health history of a new client at the ear clinic and the client states,
“I always sleep with the radio on.” Which of the following questions is most appropriate
to obtain more information about possible hearing problems?
a. “Do you grind your teeth at night?”
b. “What time do you usually fall asleep?”
c. “Have you noticed any ringing in your ears?”
d. “Are you ever dizzy when you are lying down?”
ANS: C
Clients with tinnitus may use masking techniques, such as playing a radio, to block out
the ringing in the ears. The responses “Do you grind your teeth at night?” and “Have you
noticed any ringing in your ears?” would be used to obtain information about other ear
problems, such as vestibular disorders and referred temporo-mandibular joint (TMJ)
pain. The response “What time do you usually fall asleep?” would not be helpful in
assessing problems with the client’s ears.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Assessment
17. The nurse is admitting a client to the hospital preoperatively. Which of the following
findings may indicate that the client is at risk for falls while hospitalized?
a. Lateralization with Weber’s test
b. Positive result for Rinne’s testing
c. Inability to hear a low-pitched whisper
d. Nystagmus when head is turned rapidly
ANS: D
Nystagmus suggests that the client may have problems with balance related to disease of
the vestibular system. The other tests are used to check hearing; abnormal results for
these do not indicate potential problems with balance.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Assessment
18. The nurse is conducting a health history with a new client in the outpatient clinic. Which
of the following medications in the health history may indicate the need to perform a
focused hearing assessment?
a. Salbutamol for acute asthma
b. Atenolol to prevent angina
c. Acetaminophen frequently for headaches
d. Ibuprofen for 20 years to treat arthritis
ANS: D
Nonsteroidal anti-inflammatory drugs (NSAIDs) are potentially ototoxic.
Acetaminophen, atenolol, and salbutamol are not associated with hearing loss. Other
drugs that are potentially ototoxic include aminoglycosides, any other antibiotics,
salicylates, antimalarial agents, chemotherapeutic drugs, and diuretics.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Assessment
19. Which of the following actions should the nurse include in the plan of care for a client
who has vestibular disease?
a. Check Rinne’s and Weber’s tests.
b. Face the client when speaking.
c. Enunciate clearly when speaking.
d. Monitor the client’s ability to ambulate safely.
ANS: D
Vestibular disease affects balance so the nurse should monitor the client during activities
that require balance. The other action might be used for clients with hearing disorders.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Planning
20. The nurse in the eye clinic is examining an older-adult client who says “I see small spots
that move around in front of my eyes.” Which of the following actions should the nurse
take first?
a. Immediately have the ophthalmologist evaluate the client.
b. Explain that spots and “floaters” are a normal part of aging.
c. Inform the client that these spots may indicate damage to the retina.
d. Use an ophthalmoscope to examine the posterior chamber of the eyes.
ANS: D
Although “floaters” are usually caused by vitreous liquefaction and are common in aging
clients, they can be caused by hemorrhage into the vitreous humur or by retinal tears, so
the nurse’s first action will be to examine the retina and posterior chamber. Although the
ophthalmologist will examine the client, the presence of spots or floaters in a
65-year-old is not an emergency. The spots may indicate retinal damage, but the nurse
should assess the eye further before discussing this with the client.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
21. The nurse is assessing a client’s auditory canal and tympanic membrane. Which of the
following findings is a priority to report to the health care provider?
a. There is a cone of light visible.
b. The tympanum is bluish-tinged.
c. Cerumen is present in the auditory canal.
d. The skin in the ear canal is dry and scaly.
ANS: B
A bluish-tinged tympanum can occur with acute otitis media, which requires immediate
care to prevent perforation of the tympanum. Cerumen in the ear canal may need to be
removed before proceeding with the examination but is not unusual or pathological. The
presence of a cone of light on the eardrum is normal. Dry and scaly skin in the ear canal
may need further assessment but does not require urgent care.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Assessment
MULTIPLE RESPONSE
1. The nurse is caring for a child who has a perforated eardrum. Which of the following are
possible causes? (Select all that apply.)
a. Chronic otitis media
b. Mastoiditis
c. Eustachian tube blockage
d. Serous otitis media
e. Acute otitis media
ANS: A, B, E
Perforation of the eardrum, central or marginal, can be caused by chronic otitis media
and mastoiditis. Acute otitis media may also be the cause of a perforation, but more
commonly it is bulging red or blue with an acute infection. Eustachian tube blockage
could be the cause of a retracted eardrum. Serous otitis media presents as hairline fluid
level, yellow-amber bubbles above the fluid line.
DIF: Cognitive Level: Comprehension
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Assessment
2. The nurse is conducting an auditory assessment with a client. Which of the following
findings should the nurse document as normal? (Select all that apply.)
a. Ability to hear low whisper at 30 cm
b. Rinne’s test results: bone conduction is better than air conduction
c. Weber’s test results- no lateralization
d. Curved cone light reflex
e. Symmetrical location of ears
ANS: A, C, E
Normal findings in the physical assessment of the auditory system include ears
symmetrical in location and shape; auricles and tragus nontender, without lesions; clear
canal and tympanic membrane intact, landmarks and light reflect intact; ability to hear
low whispers at 30 cm and no lateralization Weber’s test result. Rinne’s test result for a
normal finding is that air conduction is better than bone conduction.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation