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Chapter16:Ears
MULTIPLECHOICE
1.Thenurseneedstopulltheportionoftheearthatconsistsofmovablecartilageandskindownandback
whenadministeringeardrops.Thisportionoftheeariscalledthe:
a.Auricle.
b.Concha.
c.Outermeatus.
d.Mastoidprocess.
ANS:A
Theexternaleariscalledtheauricleorpinnaandconsistsofmovablecartilageandskin.
DIF:CognitiveLevel:Remembering(Knowledge)
MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptation
2.Thenurseisexaminingapatientsearsandnoticescerumenintheexternalcanal.Whichofthesestatements
aboutcerumeniscorrect?
a.Stickyhoney-coloredcerumenisasignofinfection.
b.Thepresenceofcerumenisindicativeofpoorhygiene.
c. Thepurposeofcerumenistoprotectandlubricatetheear.
d.Cerumenisnecessaryfortransmittingsoundthroughtheauditorycanal.
ANS:C
Theearislinedwithglandsthatsecretecerumen,whichisayellowwaxymaterialthatlubricatesandprotects
theear.
DIF:CognitiveLevel:Remembering(Knowledge)
MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptation
3.Whenexaminingtheearwithanotoscope,thenursenotesthatthetympanicmembraneshouldappear:
a.Lightpinkwithaslightbulge.
b.Pearlygrayandslightlyconcave.
c.Pulledinatthebaseoftheconeoflight.
TestBank-PhysicalExaminationandHealthAssessment8e(byJarvis)211
NURSINGTB.COM
PHYSICAL EXAMINATION AND HEALTH ASSESSMENT 8TH EDITION JARVIS TEST BANK
This article will explain how to perform an assessment of the eyes as a nurse. This assessment is part of the nursing head-to-toe assessment you have to perform in nursing school and on the job. The eye assessment includes: Inspect the eyes, eye lids, pupils, sclera, and conjunctivaVideo Demonstration on the Eye Assessment
- Is the conjunctiva pink NOT red and swollen?
- Look for Strabismus and Aniscoria:
- Strabismus: Do the eyes line up with another?
- Aniscoria: Are the pupils equal in size…or is one pupil larger than the other?
- Are the pupils
clear…not cloudy?
- Normal pupil size should be 3 to 5 mm and equal
Test cranial nerves III (oculomotor), IV (trochlear), VI (abducens)
- Have the patient follow your pen light by moving it 12-14 inches from the patient’s face in the six cardinal fields of gaze (start in the midline)
- Watch for any nystagmus (involuntary movements of the eye)
- Reactive to light?
- Dim the lights and have the patient look at a distant object (this dilates the pupils)
- Shine the light in from the side in each eye.
- Note the pupil response: The eye with the light shining in it should constrict (note the dilatation size and response size (ex: pupil size goes from 3 to 1 mm) and the other side should constrict as well.
- Accommodation?
- Make the lights normal and have patient look at a distant object to dilate pupils,
and then have patient stare at pen light and slowly move it closer to the patient’s nose.
- Watch the pupil response: The pupils should constrict and equally move to cross.
- Make the lights normal and have patient look at a distant object to dilate pupils,
and then have patient stare at pen light and slowly move it closer to the patient’s nose.
If all these findings are normal you can document PERRLA.
More nursing skill videos.