Sensory Exam Flashcards
(129 cards)
1
Q
Most common changes in the aging eye are those in the ___.
what happens?
A
lens partially or totally opaque loses elasticity peripheral vision losses depth perception decreases
2
Q
what is Snellen’s chart
A
Used to test visual acuity
3
Q
what does 20/20 vision mean
A
the patient can read at 20 feet what the normal eye can read at 20 feet
4
Q
visual impairment starts at what number/
A
20/70
5
Q
how to test intraocular pressure
A
puff of air
6
Q
what is the whisper voice test
A
plug one ear, whisper in the other
7
Q
what is the Rinne test
A
differentiates between conductive and sensorineural hearing loss. Place an activated tuning fork to mastoid process and in front of the ear
8
Q
What is the Weber test
A
place tuning fork on top of head and see if they can hear the same from both ears
9
Q
What is Romber’s test
A
have the patient stand with eyes open and then closed. Observe for swaying. Some swaying is ok!
10
Q
what is Audiometric testing
A
When the patient is placed in a sound proof room with head phones and raises hand when sounds are heard
11
Q
What is tympanometry
A
Used to measure compliance of the tympanic membrane and determine problems of the middle ear. It determines the amount of pressure in the middle ear.
12
Q
What is a caloric test
A
Warm or cold water is irrigated into the ears.
Nystagmus is a normal response. If no nystagmus, it is indicative of Menier’s disease
13
Q
S/S of any eye disorder
A
visual disturbances, pain, redness, secretions, itchiness, sensation of pressure in the eyes
14
Q
possible Nursing Dx for eye disorders
A
acute pain
anxiety r/t visual-sensory deficit
deficient knowledge
15
Q
define conjunctivitis
A
inflammation of conjunctiva due to a virus or bacteria
contagious (whether bacterial or viral)
aka pink eye
16
Q
s/s of conjunctivitis
A
redness
crusting exudate
itching
17
Q
define Blepharitis
A
chronic inflammation of eyelid margins
2 types seborrheic and ulcerative
18
Q
define hordeolum
A
a sty, staph abscess in the sebaceous gland at base of eyelash
19
Q
define keratitis
A
inflammation of cornea
20
Q
s/s of keratitis
A
Pain inflammation Decreased vision photophobia spasms If untreated, patient may suffer loss of vision
21
Q
define Hyperopia
A
farsightedness
light rays focused behind retina
22
Q
define myopia
A
nearsightedness
light rays focused in front of the retina
23
Q
define astigmatism
A
unequal curvatures in the shape of cornea which causes blurred vision.
24
Q
define presbyopia
A
crystalline lenses lose elasticity, causing decrease ability to focus on close objects
25
s/s of refractive errors
Difficulty reading or seeing objects
Eyestrain causing headaches
Myopia – holding reading material close to eyes
Hyperopia – holding reading materials farther from eyes
26
Therapeutic interventions for refractive errors
Corrective lenses
Laser assisted in situ keratomileus (LASIK)
Photorefractive keratectomy (PRK) – laser
27
causes of blindness
Trauma
Complications of diseases (HTN, Diabetes, cataracts, glaucoma, malnutrition, infection)
Caused when the ray of light on their way to the optic nerve is obstructed or by disease of the optic nerve
28
Dx test for blindness
```
Visual field exam
Tonometry
Slit-lamp microscope exam
Retinal angiography
Ultrasonography
```
29
Define diabetic retinopathy
Vascular changes in retinal blood vessels
It’s due to the excess glucose, changes in the retinal walls, and formation of microaneurisms and constriction of blood vessels
30
define retinal detachment and name s/s
Separation of retina from choroid layer of eye which allows for fluid to enter the space between the layers
Signs & Sx: sudden change in vision, Flashing lights or floaters
31
Dx test of retinal detachment
indirect ophthalmoscopy
| visualization of the retina
32
complications of retinal detachment
Increased intraoccular pressure and posses threat for further detachments
33
Define glaucoma
Group of diseases characterized by abnormal pressure within the eyeball
Pressure causes damage to cells of the optic nerve
Types:
Acute angle closure glaucoma
Primary open able glaucoma
34
s/s of acute angle closure glaucoma
```
ophthalmic emergency
unilateral, rapid onset
severe pain
blurred vision
rainbows around lights
eye redness
steamy-appearing cornea
Photophobia
tearing
```
35
s/s of primary open able glaucoma
```
bilateral, gradual onset
painless at times
mild aching
headaches
halo around lights
frequent visual changes not corrected with eyeglasses
```
36
Dx test for glaucoma
tonometry: used to detect increased IOP
| Normal IOP – 12 to 20 mm Hg
37
eye drop treatment for glaucoma
1st line treatment is focused on opening the aqueous flow using cholinergic agents (miotics) which constrict the pupil causing the iris to pull away from the drainage canal, allowing aqueous fluid to flow freely.
2nd type of medication used to slow production of aqueous fluid
Steroids may also be ordered to decrease inflammation
38
surgical management of glaucoma
Used when medication not able to control IOP
Focused on creating an area for aqueous humor to flow freely thus preventing increased intraocular pressure
Cataracts are painless
39
define cataract
Opacity in the lens of the eye that may cause a loss of visual acquity
Vision diminished because light rays are unable to get to retina through clouded lens
40
factors contributing to cataract development
```
Age
UV radiation
Diabetes
Smoking
Steroids
Alcohol
Nutrition
Intraocular Infections
Trauma
Congenital Defects
```
41
surgical treatment for cataracts
Only treatment
| Removal of cloudy lens one eye at a time
42
complications of cataract surgery
```
Inflammation
Increased IOP
Macular edema
Retinal detachment
Vitreous loss
```
43
risk factors for macular degeneration
```
Older than 60 years old
Family history of macular degeneration
Diabetes
Smoking
Frequent exposure to UV light
Caucasian
```
44
s/s of macular degeneration
Dry type is slow, progressive loss of central & near vision
Usually both eyes, but can be affected differently
```
Wet type – onset sudden of visual loss
Blurred vision
Distortion of straight lines
Dark or empty spots
Decreased ability to distinguish colors
```
45
types of macular degeneration
Dry (atrophic)
| Wet (exudative)
46
therapeutic interventions for DRY (ATROPHIC) macular degeneration
No treatment
Most do not lose peripheral vision or become totally blind
Most are classified as legally blind
Special low-vision lenses can enhance remaining vision
47
therapeutic interventions for WET (EXUDATE) macular degeneration
If diagnosed early – laser photocoagulation can seal the leaking blood vessels, which will slow rate of vision loss
Meds: antiangiogenic – prevents new blood vessels from forming
48
```
define each type of eye trauma
Foreign body
Burns
abrasions/lacerations
penetrating wounds
```
Foreign bodies – most common cause of corneal injury (dust in eyes, then rub eyes causing further irritation)
Burns – chemical, UV and direct heat
Abrasions & Lacerations – due to something dragging across the eye
Penetrating wounds – most serious due to eye structures may be permanently damaged
49
therapeutic intervention for foreign body trauma
NS flush to irrigate object out of eye or to a point where it can be taken out with a swab; topical antibiotic ointment for infection prevention
50
therapeutic intervention for chemical burn eye trauma
15 to 20 minute irrigation (the sooner the better) of tap water is fine to use at work site; sterile solution used in the hospital; topical antibiotic ointment for infection prevention
51
therapeutic intervention for abrasions and lacerations to eye
anti-infective ointments or drops after cleansing the eye with NS
52
therapeutic intervention for penetrating wounds to the eye
eye specialist will treat these; cover both eyes to prevent ocular movement; stabilize any protruding objects; DO NOT REMOVE OBJECT
53
most common disability in the US
hearing loss
| acquired or congenital
54
define conductive hearing loss
Any interference with the conduction of sound impulses through the external auditory canal, eardrum, or middle ear.
Caused by the interference with the sound wave ability to reach the inner ear
This is a mechanical problem
55
correction for conductive hearing loss
Infection, foreign bodies and impacted cerumen can be corrected
Hearing devices may improve hearing loss if cause cannot be corrected
56
define sensory hearing loss
originates in the cochlea & involves hair cells & nerve endings
57
define sensorineural hearing loss
Results from disease or trauma to the sensory or neural components of the inner ear
58
define presbycusis hearing loss
hearing loss caused by the aging process
59
causes of sensorineural hearing loss
```
Complications of infections (measles, mumps, meningitis)
Ototoxic drugs
Trauma
Noise
Neuromas
Arteriosclerosis
Aging process
```
60
define external otitis and its cause
Caused due to exposure to moisture, contamination or trauma
Perfect environment for pathological growth
Staphylococci most common causative organism
most common infection
61
define ear infection
Localized infection
ear canal furuncle or abscess due to hair follicle infected
Carbuncle forms when several hair follicles involved in forming the abscess
Most furuncles and carbuncles erupt and drain spontaneously
62
s/s of ear infection
```
Ear pain (early indication if pain with gentle pull on pinna) – pain may occur with jaw movement or otoscope insertion
Pruritus
Inflammation present
Redness
Drainage
Fever is a possibility
```
63
Dx test of ear infection
CBC (WBC elevation)
Cultures of drainage
Rinne’s test and weber’s test to detect hearing loss
64
therapeutic interventions for ear infection
Topical (drops/ointment) or systemic antibiotics
Topical or systemic steroids
Thoroughly cleanse ear before topical treatment
65
risk factors for impacted cerumen
```
Large amounts of ear hair
Work in dusty or dirty environments
Improper cleaning
Older age
Hearing aids
```
66
s/s of impacted cerumen
Hearing loss
Feeling of fullness
Feeling of blocked ear
Otoscopic exam shows cerumen blocking ear canal
67
Dx test for impacted cerumen
```
Otoscopy
Audiometric testing
conductive loss in affected ear
Whisper voice
Rinne’s test
conductive loss in affected ear
Weber test
conductive loss in affected ear
```
68
makes found in the ear
Benign masses are usually Sebaceous gland cysts
| Malignant tumors such as basal cell carcinoma on the pinna and squamous cell in the ear anal may develop and spread
69
s/s of masses in the ear
```
Changes in appearance of skin
Impaired conductive or sensorineural hearing loss
Pain
Ear drainage
Facial paralysis (progressed)
Visualization of mass during otoscopy
```
70
Dx studies for masses in ear
```
Otoscopy
Biopsy
Imaging
Audiometric studies
Demonstrates hearing impairment
```
71
s/s of trauma to ear
```
Lacerations
Contusions
Hematomas
Abrasions
Erythema
Blistering
Itching
Decreased hearing
Pain
Swelling
```
72
Dx studies for trauma to the ear
```
Otoscopic examination – use caution not to push foreign object farther in
Imaging studies – to determine extent
Evaluate conductive hearing loss:
Audiometric test
Whisper voice test
Rinne’s test
Weber’s test
```
73
therapeutic interventions for trauma to the ear
debridement, surgical repair, or application of protective covering
74
Therapeutic measures for external ear disorders
Topical or systemic antibiotics
Analgesics are used to control pain
Steroids are used to treat inflammation
Make sure the ear is thoroughly cleaned prior to topical treatment
Cerumen may be removed with installations or irrigation
Do not irrigate if patient has history of perforated eardrum
75
define otis media
Most common disease of middle ear
General term for inflammation of middle ear, mastoid, & Eustachian tube
Commonly follows URI
Nasopharyngeal mucosa becomes edematous & discharge produced
Fluid, pus, or air builds up in the middle ear and the Eustachian tube becomes blocked which impairs middle ear ventilation
76
s/s of otis media
```
Fever
Earache
Feeling of fullness in ear
Purulent drainage
Pain
Conductive hearing loss
N/V
Redness on otoscopic exam
```
77
Dx tests for otis media
```
CBC (elevated WBC)
Ear cultures
Imaging studies
Conductive hearing loss present on
Audiometric studies
Rinne’s test
Weber’s test
Whisper test
```
78
complications of otis media
Spontaneous perforation of tympanic membrane
Pain with perforation
Hearing loss
Cholesteatoma, Tympanosclerosis, and Mastoiditis
Due to Repeated infections
79
therapeutic interventions for otis media
```
Antibiotics
Oral analgesics
Ear drops (for pain)
Surgical
Myringotomy – with tubes
Myringoplasty – reconstruction of perforated tympanic membrane
```
80
define Otosclerosis
Hardening of the ear
Due to formation of new bone along the stapes
Causes the stapes to become immobile and causes conductive hearing loss
81
s/s of otosclerosis
Progressive hearing loss
Bilateral conductive hearing loss (soft, low tones)
Tinnitus
Otoscopic exam – pinkish/orange tympanic membrane
82
Dx studies for otosclerosis
```
Audiometric testing
Imaging studies
Whisper voice test
Rinne’s test
Weber’s test
```
83
therapeutic interventions for otosclerosis
```
No cure
Hearing aids
Ossiculoplasty
Total or partial ossicular replacement (prosthesis)
Stapedectomy
```
84
nursing management for otosclerosis
```
Operative ear upward when lying in bed
Ear plug (keep area aseptic)
Activity as ordered
Use caution d/t dizziness
Instruct not to cough, sneeze, blow nose, vomit, fly in plane, lift heavy objects or shower
```
85
Nursing Dx for Middle Ear, Tympanic Membrane & Mastoid Disorders
Risk for infection r/t broken skin, pressure necrosis, chronic disease, or surgical procedure
Acute pain r/t fluid accumulation, inflammation, or infection
Fear r/t hearing loss
86
define Labyrinthitis
Inflammation or infection of inner ear
Caused by Viral or bacterial pathogens
87
s/s of labyrinthitis
```
Vertigo
Tinnitus
Sensorineural hearing loss
Pain
Fever
N/V
```
88
nursing management of labyrinthitis
Symptom management
Safety education while on sedatives and bedrest
Avoid turning head quickly
89
define Meniere’s Disease
Balance disorder
Cause unknown
disturbance in fluid physiology of the endolymphatic system
90
s/s of Meniere's Disease
```
Triad of Symptoms:
Vertigo
Hearing loss
Tinnitus
can also have n/v
```
91
Dx test for Meniere's Disease
audiometric, neurological, radiographs
92
therapeutic interventions for Meniere's disease
symptomatic management and prophyloactic treatment between attacks
Salt restriction, Avoid caffeine, alcohol & tobacco
Surgical Treatment – only when medical management has failed
93
Name the proper sequence as they are involved in the process of producing a visual image from beginning to end
```
cornea
aqueous humor
lens
vitreous humor
retina
optic nerve
occipital lobe
```
94
name the proper sequence in the process of hearing when sound waves enter the ear canal
```
eardrum
malleus
incus
stapes
oval window
fluid in the cochlea
hair cells in the organ or court
eighth cranial nerve
temporal lobes
```
95
define nystagmus
constant involuntary cyclical eyeball movement
96
define tropia
deviation of the eye away from the visual axis
97
define accommodation
adjustment of the eye for distance to focus the image on the retina by changing lens curvature
98
define ptosis
drooping of the upper eyelid as a resolute of paralysis
99
define arcus senilus
opaque white ring around the periphery of the cornea in aged persons from deposits of fat
100
Name purpose of test and normal test results
| Snellen chart
visual acuity
| 20/20 for both eyes
101
Name purpose of test and normal test results
| visual fields
peripheral vision
| equal to examiner's
102
Name purpose of test and normal test results
| cardinal fields of gaze
extraocular movement
| follows in all fields without nystagmus
103
Name purpose of test and normal test results
| accommodation
pupillary response to near and far distance
| eyes turn inward and pupils constrict when focusing on a near object
104
Name purpose of test and normal test results
| Rinne
differentiate between conductive and sensorineural hearing loss
air conductive greater than bone conduction
105
Name purpose of test and normal test results
| Weber
hearing acuity
| heard equally
106
Name purpose of test and normal test results
| Romberg's
balance/vestibular function
| able to maintain standing position without loss of balance
107
Which of the following would indicate that the patient has a normal corneal light reflex?
- the eye focuses the image in the center of the pupil
- the eyes converge to focus on the light
- constriction of both pupils occurs in response to bright light
- light is reflected at the same spot in both eyes
-light is reflected at the same spot in both eyes
symmetrical eye muscle strength keeps the eyes in the same position, and the light is reflected in exactly the same place
108
When testing visual fields, the nurse examines which of the following parts of vision?
- peripheral vision
- near vision
- distance vision
- central vision
peripheral vision
109
Which of the following terms would indicate to the nurse that a substance is toxic to the ear?
- otoplasty
- otalgia
- ototoxic
- tinnitus
ototoxic
otoplasty is ear repair
otalgia is ear pain
tinnitus is ringing in the ears
110
Which of the following tests would the nurse use as an initial screening test to determine hearing loss?
- Romberg's test
- Otoscopic examination
- Caloric test
- Whisper voice test
Whisper voice test
111
Which of the following would the nurse use to document a finding that the patient's ear is draining?
- Otorrhea
- Otalgia
- Ototoxic
- tinnitus
otorrhea
112
Which of the following terms indicates that the patient has a hearing loss caused by aging?
- otoplasty
- otalgia
- presbycusis
- tinnitus
presbycusis
which is loss of high pitched sounds due to aging
113
Which of the following explanations would the nurse give to the patient who had a Snellen chart finding of 20/80?
- You can see at 80 feet what those with normal vision can see at 20 feet.
- You can see at 20 feet what those with normal vision see at 80 feet.
- You can see four times farther than those with normal vision can see
- Your vision is normal
You can see at 20 feet what those with normal vision see at 80 feet
the first distance recorded when conducting the Snellen test is the distance from which the patient can clearly read the alphabetical line on the chart. The second distance recorded is the distance from which a person with normal vision can see the same alphabetical line
114
In planning safe care for the older adult, which of the following conditions does the nurse recognize would cause visual problems? SATA
- glaucoma
- cataracts
- arcus senilis
- macular degeneration
- estropia
- presbycusis
glaucoma
cataracts
macular degeneration
estropia
115
In which of the following statements does the nurse understand is true concerning air conduction of sound in the ear?
- it is caused by the vibration of bones in the skull
- it is less efficient than bone conduction
- it is heard longer than bone conduction
- it is caused by transmission of heat through the air
-it is heard longer than bone conduction
116
Which of the following statements would the nurse understand is true when checking normal auditory acuity using the Rinne test?
- The patient perceives sound equality in both ears
- Air conduction is heard longer than bone conduction in both ears
- Bone conduction is heard longer than bone conduction in both ears
- The patient's left ear will perceive the sound better than the right ear
Air conduction is heard longer than bone conduction in both ears
117
Define Carbuncle
several hair follicles forming an abscess
118
Define Cholesteatoma
epithelial cyst like sac filled with skin and sebaceous material
119
define mastoiditis
complication of otis media
120
define barotrauma
pressure in the middle ear caused by atmospheric changes
121
Which of the following type of eyedrops is given to constrict the pupil, permitting aqueous humor to flow around the lens
- osmotic
- myotic
- mydriatic
- cycloplergic
myotic
mystics lower intraocular pressure by stimulating pupillary and ciliary sphincter muscles
122
which of the following procedures does the nurse understand is used to correct otosclerosis
- myringotomy
- myringoplasty
- mastoidectomy
- stapedectomy
stapedectomy
involves removing or replacing part of all the stapes with a prothesis
123
A nurse understands that labyrinthitis is treated primarily with which of the following drug categories
- antihistamines
- antispasmodics
- anti-inflammatories
- antiemetics
antihistamines
124
Which of the following types of hearing loss does the nurse understand is most improved with the use of a hearing aid?
- conductive
- sensorineural
- mixed
- central
conductive
125
which of the following would the nurse teach the patient is the most common site for ear infections
- outer ear
- inner ear
- middle ear
- semicircular canal
middle ear
126
Which of the following would e a symptom the nurse expects to find during examination of a patient with macular degeneration? SATA
- decreased ability to distinguish colors
- sudden loss of vision
- loss of near vision
- loss of central vision
- loss of peripheral vision
- increased periodic dizziness
decreased ability to distinguish colors
oss of near vision
loss of central vision
127
Which of the following would the nurse explain to the patient is the triad of symptoms associated with Meniere's disease?
- hearing loss, vertigo, and tinnitus
- nystagmus, headache, and vomiting
- nausea, vomiting, and pain
- nystagmus, vomiting, and pain
hearing loss, vertigo, and tinnitus
128
Which of the following is usually the first symptom of a cataract that the nurse would expect a patient to report during an examination?
- dry eyes
- eye pain
- blurring of vision
- loss of peripheral vision
blurring of vision
due to clouding of the lens
129
Which of the following is a symptom that the nurse would expect to find during assessment of a patient experiencing acute angle-closure glaucoma?
- flashing lights
- lens opacity
- halos around lights
- vertigo
halos around lights
