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's hearing using the Rinne test. When providing instruction to elicit client feedback, which instruction is essential?
Correct Answer: B
Rationale: It is essential to provide clear directions on when the client is to notify the nurse of client response. The information gleaned from the response is what the nurse uses to interpret the test. The correct time to induce feedback is when the vibration is heard.
Question 2 of 5
The nurse is assisting with the administration of a caloric stimulation test. Which client response would the nurse document as an expected response?
Correct Answer: C
Rationale: A caloric stimulation test assesses vestibular reflexes of the inner ear that control balance. Warm or cool water or air is instilled into the external meatus of the ear separately. Nystagmus, a quivering movement of the eyes, is the expected response. Slight dizziness may be experienced but is not the expected response. Headache and double vision are not expected responses.
Question 3 of 5
The client is consulting with a physician regarding a potential diagnosis of M?©ni?¨re disease. The nurse is assisting in positional testing and documentation. Which diagnostic test would the nurse anticipate to obtain a more precise evaluation of vestibular function?
Correct Answer: B
Rationale: The electronystagmography is a more precise method for evaluation vestibular function. It is performed in conjunction with caloric stimulation. When the fluid is instilled in the ear, a machine records the duration and velocity of eye movements with electrodes attached around the eye. Audiometry measures hearing acuity. The Romberg test measures balance.
Question 4 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 5 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.