ATI LPN
Timby's Introductory Medical-Surgical Nursing Thirteenth, North American Edition
Chapter 41 : Introduction to the Sensory System Questions
Question 1 of 5
The nurse is assessing a client for objective symptoms of hearing difficulties. Which sign leads the nurse to take alternate measures to ensure client understanding of teaching?
Correct Answer: C
Rationale: The nurse assesses objective signs of leaning forward and turning the head as indicative of difficulty hearing. The nurse would use alternate formats of teaching to reinforce key points. Asking to repeat information is a subjective indication of hearing difficulty. Responding appropriately and reading instructional literature does not indicate a hearing difficulty.
Question 2 of 5
The nurse is obtaining a visual history from a client who has noted an increase in glare and changes in color perception. Which assessment would the nurse anticipate to confirm a definitive diagnosis?
Correct Answer: A
Rationale: The client states an increased glare and changes in color perception, which indicates a cataract. Identification of opacities on the lens confirms that diagnosis. A white circle around the cornea and a yellowish aging spot are also symptoms of aging but with different symptoms. Redness of the sclera indicates irritation.
Question 3 of 5
The nurse is caring for a client with increased fluid accumulation in the eye. When assessing the client, which structure within the eye is noted to drain fluid from the anterior chamber?
Correct Answer: C
Rationale: The canal of Schlemm drains the anterior chamber of the eye. By draining the fluid, it decreases the fluid amount and pressure in the eye. The other options have no draining ability.
Question 4 of 5
A client states having difficulty noting details on faces or television. Which of the following structures of the eye allows for detailed vision?
Correct Answer: D
Rationale: The macula lutea is composed entirely of cones and allows for detailed vision. It lies in the center of the retina. This client could potentially have macular degeneration. The iris is the highly vascular, pigmented portion of the eye surrounding the pupil that adjusts in response to light. The cornea covers the anterior portion of the eyeball.
Question 5 of 5
A nurse is assessing a pediatric client in a public health clinic. The parent states that the client has been sneezing and rubbing the eyes. The nurses observes the client's eyes and documents objective symptoms of watery and red eyes. When reporting the assessment findings to the health care provider, which description is appropriate?
Correct Answer: A
Rationale: Conjunctivitis often stems from an allergy causing inflammation of the conjunctiva, which is a thin, transparent mucous membrane. Conjunctivitis can cause symptoms of itchiness, redness, and watery eyes. Ptosis is drooping of the upper eyelid. Proptosis is an extended and upper eyelid that delays in closing or remains partially open. Nystagmus is an uncontrolled oscillating movement of the eyeball.