Sensory & GI Review (NUR 326)

A client hears the tuning fork louder in the affected ear during the Weber test. Which type of hearing loss is this?

• Sensorineural

• Conductive

• Mixed

• Normal

Answer explanation

Rationale: Conductive loss = sound heard louder in affected ear.

During their hearing tests, a client reports Air Conduction > Bone Conduction in both ears, but still has trouble hearing. What does this suggest?

• Normal hearing

• Sensorineural hearing loss

• Conductive hearing loss

• Otitis externa

Answer explanation

Rationale: Air Conduction > Bone Conduction but still reports hearing loss = Sensorineural

Which of the following is an expected finding in a patient with presbycusis (age-related hearing loss)?

• Weber lateralizes to left ear

• Rinne test shows BC > AC

• Rinne test shows AC > BC with decreased perception

• Weber test lateralizes to right ear

Answer explanation

Rationale: Presbycusis = sensorineural; AC > BC but decreased hearing

A client with early-stage cataracts would most likely report which initial symptom?

• Sudden, severe eye pain

• Loss of peripheral vision

• Blurred or cloudy vision

• Floating dark spots in the visual field

Answer explanation

Rationale: Blurred or cloudy vision is an early symptom of cataracts.

Additional symptoms include: Difficulty seeing at night, yellowish color, halos around lights and sensitivity to light.

A client arrives at the emergency department reporting a sudden onset of “flashes of light” and “a curtain coming down” over their right eye. What is the nurse’s priority action?

• Reassure the client and recheck vision in an hour

• Instruct the client to keep the affected eye covered

• Notify the provider immediately—possible retinal detachment

• Prepare the client for a CT scan

Answer explanation

Rationale:

Typically sudden onset of floaters/flashes of light and changes in field of vision (curtain vision). Usually PAINLESS but is an ophthalmic surgical EMERGENCY! Rapid surgical repair is required to prevent total vision loss in affected eye.

The nurse is assessing cranial nerve function. Asking the client to shrug their shoulders against resistance tests which cranial nerve?

• CN VII – Facial

• CN IX – Glossopharyngeal

• CN X – Vagus

• CN XI – Spinal Accessory

Answer explanation

CN XI is the Spinal Accessory nerve. It is involved in head and shoulder movement and is tested by asking the patient to shrug their shoulders and turn their head side to side (against resistance).

Which finding is commonly associated with sensorineural hearing loss?

• Soft spoken voice due to hearing sensitivity
• C. Bone conduction greater than air conduction on
• Congenital malformation of the stapes

• Difficulty understanding speech in noisy environments
  

Answer explanation

Rationale:

Sensorineural hearing loss presents with muffled hearing / difficulty hearing conversations in noisy environments, tinnitus, dizziness and anxiety/depression related to hearing deficits.

During a Rinne test, the nurse notes that a client hears the tuning fork louder when placed on the mastoid process than when it is near the ear canal. What does this finding indicate?

• Normal hearing

• Sensorineural hearing loss

• Conductive hearing loss

• Tinnitus

Answer explanation

Rationale: In conductive hearing loss, bone conduction > air conduction.

A client reports sudden onset of severe eye pain, blurred vision, and seeing halos around lights. The eye appears red, and the pupil is non-reactive to light. What is the nurse's priority?

• Reassure the client and reassess in 30 minutes

• Administer prescribed antibiotic eye drops

• Notify the provider immediately

• Ask about recent trauma to the eye

Answer explanation

Rationale: These are classic signs of acute angle-closure glaucoma, a medical emergency due to rapid IOP rise.

The provider should be notified as immediate intervention is necessary to prevent blindness.

Which of the following are risk factors for developing closed-angle glaucoma? (Select all)

• Hyperopia (farsightedness)

• Use of anticholinergic medications

• African American descent

• Sudden pupil dilation

• Shallow anterior chamber

Answer explanation

Rationale: Risk increases with hyperopia, anticholinergics (can trigger attacks), and anatomical predisposition like a shallow anterior chamber.