Sensory (Ch 51)

The nurse performs a visual assessment on a patient and documents the findings using the acronym PERRLA. Which assessment finding does PERRLA indicate?

• Palpebral angle rigid, right and left angles

• Patient’s eyes round, regular, lively, active

• Pupils equilateral, regular, round, little accommodation

• Pupils equal, round, and reactive to light and accommodation

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?

• The iris

• The fibrous tunic

• The ciliary body

• The lens

The nurse is collecting information about the eyes from an older adult patient. Which finding is unexpected during the examination?

• The lenses of the eyes are slightly opaque in appearance

• The patient states that the glare of the pen light is too bright.

• The best color discrimination is between blue, green, and purple.

• The patient has needed reading glasses since the age of 45 years.

The nurse is explaining how the retina works to a patient who is experiencing visual changes. Which factor shared by the nurse is correct?

• The retina reacts to chemical stimulation from rods and cones.

• The rods and cones are stimulated by chemical stimulation of the retina.

• The fovea centralis is located directly behind the center of the lens and contains cones.

• The rods of the retina are most sensitive to light and are most responsible for color vision.

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?

• Direct response

• Indirect response

• Consensual response

• Accommodation response

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?

• Romberg

• Calorie test

• Whisper voice

• Otoscopic examination

A patient has an injury resulting in a 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?

• “The left ear will become over sensitive to sound.”

• “The impulses for hearing come from the middle and inner ear.”

• “The outside of your ear will need to be surgically restructured.”

• “This much damage to the outer ear also indicates severe damage internally.”

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?

• To examine the eardrum

• To look for foreign objects

• To remove excessive earwax

• To obtain a sample of drainage

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?

• Preparation instructions for surgery

• Care of the external equipment

• The impact of hearing for the first time

• Physical limitations after the procedure

The nurse in an HCP’s office is providing assistance with a patient who has purulent drainage from the ear. Which action by the HCP does the nurse expect?

• Flushing of the drainage from the ear canal

• Packing the ear lightly to absorb the drainage

• Excising the eardrum to promote drainage

• Obtaining a swab of the drainage for culture