ATI LPN
Timby's Introductory Medical-Surgical Nursing Thirteenth, North American Edition
Chapter 41 : Introduction to the Sensory System Questions
Question 1 of 5
A client comes to the occupational health nurse complaining of eye irritation. The client works in a dusty, outdoor environment. Why should the nurse advise periodic blinking to this client?
Correct Answer: C
Rationale: Periodic blinking clears the dust and particles from the surface of the eyes. The eyelids also spread tears over the surface of the eye, which helps bathe and lubricate the surface. The eyelids protect against foreign bodies and adjust the amount of light that enters the eye, whereas the eyelashes trap foreign debris.
Question 2 of 5
The nurse is performing a Weber test on a client. During this test, where should the nurse place the tuning fork?
Correct Answer: B
Rationale: The Weber test is performed by striking the tuning fork and placing its stem in the midline of the client's skull or in the center of the forehead. In the Rinne test, the tuning fork is struck and placed on the mastoid process behind the ear. The tuning fork is not placed near the external meatus of each ear or under the bridge of the nose.
Question 3 of 5
The nurse is conducting hearing tests at the local junior high school. Which of the following indicates normal hearing in a child?
Correct Answer: A
Rationale: The lowest level of sound that normal persons may first perceive is 20 dB. The painful sounds occur at 120 dB. The hearing acuity is determined by measuring the intensity at which a person first perceives sound.
Question 4 of 5
A client is having problems with dizziness and complains of the 'room spinning.' The physician performs the caloric stimulation test. The nurse knows that a diminished response in one eye during the caloric stimulation test is indicative of what?
Correct Answer: A
Rationale: During the caloric stimulation test, a diminished response in one eye is significant for an inner ear disorder such as M?©ni?¨re disease. It does not signify a middle ear disorder, an outer ear disorder, or age-related macular degeneration.
Question 5 of 5
A client has been referred to an ophthalmologist for suspected macular degeneration. The nurse knows to prepare what test for the physician to give the client?
Correct Answer: C
Rationale: Clients with macular problems are tested with an Amsler grid. It is made up of a geometric grid of identical squares with a central fixation point. The examiner instructs the client to stare at the central fixation spot on the grid and report if they see any distortion of the squares. Clients with macular problems may say some of the squares are faded or wavy. An Ishihara polychromatic plate, visual field, or slit lamp test will not diagnose macular degeneration.