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Chapter 51. Sensory System Function, Assessment, and Therapeutic
Measures: Vision and Hearing
Multiple Choice
Identify the choice that best completes the statement or answers the
question.
1. The nurse is giving instructions to a patient who is scheduled for an
electronystagmogram due to a diagnosis of vertigo and ringing in the ears.
Which finding regarding the patient’s medical history will cause the nurse to
notify the prescribing health care provider (HCP) for cancellation of the
test?
1. The patient has a history of alcohol abuse.
2. The patient has a pacemaker.
3. The patient takes tranquilizers.
4. The patient lives alone.
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2. The nurse is collecting information about a patient’s auditory system
during a physical examination. Which process will the nurse perform first?
1. Observation
2. Inspection
3. Palpation
4. Auscultation
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3. The nurse is conducting an initial screening to determine a patient’s
gross hearing acuity as part of a complete physical. Which test does the
nurse include in the assessment?
1. Romberg
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2. Calorie test
3. Whisper voice
4. Otoscopic examination
3 4. The nurse is collecting information about the eyes of an older adult
patient. Which finding is unexpected during the examination?
1. The lenses of the eyes are slightly opaque in appearance.
2. The patient states that the glare of the pen light is too bright.
3. The best color discrimination is between blue, green, and purple.
4. The patient has needed reading glasses since the age of 45 years.
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5. The nurse is explaining how the retina works to a patient who is
experiencing visual changes. Which factor shared by the nurse is correct?
1. The retina reacts to chemical stimulation from rods and cones.
2. The rods and cones are stimulated by chemical stimulation of the
retina.
3. The fovea centralis is located directly behind the center of the lens
and contains cones.
4. The rods of the retina are most sensitive to light and are most
responsible for color vision.
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6. The nurse is assisting with a patient who is having a test to measure
intraocular pressure. Which equipment should the nurse expect to be
used?
1. A tonometer
2. Ultrasonography
3. An ophthalmoscope
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4. A slit-lamp microscope
7. A patient has an injury resulting in major damage to the pinna of the right
ear. The patient expresses fear about hearing loss in the damaged ear.
Which statement by the nurse will alleviate the patient’s fear?
1. “The left ear will become over-sensitive to sound.”
2. “The impulses for hearing come from the middle and inner ear.”
3. “The outside of your ear will need to be surgically restructured.”
4. “This much damage to the outer ear also indicates severe damage
internally.”
4 8. A patient is scheduled to have cataract surgery. Which structure of
the patient’s eye does the nurse explain will be involved in the procedure?
1. The iris
2. The fibrous tunic
3. The ciliary body
4. The lens
9. The nurse is attending while the HCP performs an otoscopic examination
of a patient’s ears. The nurse is aware that the examination is performed
primarily for which purpose?
1. To examine the eardrum
2. To look for foreign objects
3. To remove excessive earwax
4. To obtain a sample of drainage
10. The nurse is preparing a patient with diabetes mellitus for fluorescein
angiography. For which reason does the nurse understand the
performance of this test?
1. To find leakage or damage to the blood vessels of the retina
2. To identify the dry form of macular degeneration
3. To find the amount of vision damage related to glaucoma
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4. To find abnormalities of the eye structure from hypoglycemia
11. The nurse performs a visual assessment of a patient and documents
the findings using the acronym
PERRLA. Which assessment finding does PERRLA indicate?
1. Palpebral angle rigid, right and left angles
2. Patient’s eyes round, regular, lively, active
3. Pupils equilateral, regular, round, little accommodation
4. Pupils equal, round, and reactive to light and accommodation
12. The nurse is conducting a hearing acuity evaluation on a patient using
the Rinne test. The test involves the use of a tuning fork. Which test result
will be validated with the documentation “AC greater than BC”?
1. The patient hears the tuning fork twice as long when it is placed on
the mastoid bone.
2. The patient is unable to hear the tuning fork when it is lifted away
from the mastoid bone.
3. The patient continues to hear the tuning fork for twice as long when it
is lifted from the mastoid bone.
4. The patient stops hearing the tuning fork when it is moved from in
front of the ear and placed on the mastoid bone.
13. The nurse is preparing to administer eye medication as prescribed by
the HCP after eye surgery for cataract removal. The HCP prescribes one
drop with punctual occlusion. Which action will the nurse perform when
administering this medication?
1. Have the nonmedicated eyelid held closed during medication
administration.
2. Place the index finger on the corner of the eye and apply pressure
against the nose bone.
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3. Instruct the patient to squeeze the eye tightly shut once the drop is
administered.
4. Tilt the head back, apply the drop, ask the patient to blink twice, and
blot any leakage.
14. A patient’s Snellen chart findings are 20/60. Which explanation does
the nurse provide to the patient regarding this finding?
1. “Your vision is better than normal.”
2. “You must be at 60 feet to see what normal vision sees at 20 feet.”
3. “You must be at 20 feet to see what normal vision sees at 60 feet.”
4. “You are considered legally blind, even though with prescription
glasses you’ll be able to see.”
15. The nurse is assisting with the preparation of a patient for a cochlear
implant due to profound deafness. Which teaching will the nurse reinforce
for this patient?
1. Preparation instructions for surgery
2. Care of the external equipment
3. The impact of hearing for the first time
4. Physical limitations after the procedure
16. The nurse is working at a summer camp for preadolescent children.
One of the children comes to the nurse rubbing an eye and stating pain
from getting sand in the eye. After the child is effectively treated, which
teaching is the nurse prompted to provide to all the attendees?
1. It is dangerous to throw sand at each other.
2. Wear sunglasses if it is windy at the beach.
3. Do not rub your eye if it has something in it.
4. Remove the sand with any available fluid.
17. The nurse in an HCP’s office is assisting a patient who has purulent
drainage from the ear. Which action by the HCP does the nurse expect?
1. Flushing of the drainage from the ear canal
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2. Packing the ear lightly to absorb the drainage
3. Excising the eardrum to promote drainage
4. Obtaining a swab of the drainage for culture
18. During a physical examination of a patient, pupillary reflexes are
checked. A light is shone into the right eye while it is observed. Pupillary
reaction and pupil size are noted. Then a light is shone into the left eye as
the right eye is still observed. Which response occurs during the second
step of the test?
1. Direct response
2. Indirect response
3. Consensual response
4. Accommodation response
19. While checking a patient’s pupils, the nurse notes that the left pupil
constricts when a light is shone into the right eye. Which information does
this finding suggest to the nurse?
1. Tropia present
2. Esotropia absent
3. Accommodation absent
4. Consensual response present
20. The National Eye Institute has performed research regarding the impact
of nutrition on eye diseases. Which factor does the nurse recognize as an
incorrect conclusion from this research?
1. A diet high in green, leafy vegetables lowers the risk of age-related
macular degeneration (AMD).
2. With intensive glycemic control, patients with diabetes mellitus do not
experience retinopathy.
3. Supplements containing vitamins and minerals will reduce the risk of
developing advanced AMD.
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4. There is no benefit of supplemented omega-3 fatty acids on AMD;
eating fish lowers the rate.
Multiple Response
Identify one or more choices that best complete the statement or answer
the question.
1,2,3,4
21. The nurse determines that a patient is experiencing common age-
related changes in vision and hearing. Which findings does the nurse
identify in the patient? (Select all that apply.)
1. Presbycusis
2. Yellowing of the lens
3. Distorted depth perception
4. Decreased lacrimal secretions
5. Increased pupil size and response to light
1,2,3,4
22. The nurse places eyedrops for a patient with an injured eye and covers
the eye with a patch as prescribed. Discharge instructions are given to the
patient. Which patient statements indicate further instruction is needed?
(Select all that apply.)
1. “I should exercise my patched eye four times daily.”
2. “I can watch television without moving my eye too much.”
3. “I should apply pressure to the tear duct of the eye every 5 minutes.”
4. “I should try to open my eyelid under the patch hourly while awake.”
5. “I can listen to music or an audiotaped book, but should not read or
watch television.”
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23. The nurse has reinforced teaching with a patient about diagnostic tests
that evaluate eye muscle balance. Which tests identified by the patient
indicate teaching has been effective? (Select all that apply.)
1. Cover test
2. Corneal light reflex
3. Tonometer readings
4. Electroretinography
5. Computed tomography
6. Fluorescein angiography
2,3,4,5
24. During a health history, the nurse suspects that a patient is at risk for a
vision problem. Which information within the family history does the nurse
use to make this decision? (Select all that apply.)
1. Asthma
2. Diabetes
3. Cataracts
4. Blindness
5. Glaucoma
1,2
25. Before measuring a patient’s hearing, the nurse obtains a tuning fork.
Which hearing tests is the nurse preparing to conduct? (Select all that
apply.)
1. Rinne test
2. Weber test
3. Caloric test
4. Tympanometry
5. Electronystagmogram
