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Health and Illness Concepts I Nursing: N1210 > Sensory/Integumentary System (Exam One) > Flashcards

Sensory/Integumentary System (Exam One) Flashcards

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1
Q

What are the essential functions of the structures of the eye?

A
  • Protect the eye

- Prevent the eye from drying out

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2
Q

The vitreous humor gives the eyeball its what? How is the consistency of the vitreous humor described?

A
  • Gives the eyeball its shape

- Jelly like consistency

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3
Q

The aqueous humor encompasses which portion of the eyeball? How is the consistency of the aqueous humor described?

HINT: Think “aque” and “aqua” where “aqua” = water

A
  • Located in the frontal portion of the eyeball

- Water like consistency

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4
Q

Cones are responsible for what?

A

Colored vision

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5
Q

Rods are responsible for what?

A

Various shades of grey color

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6
Q

The optic nerve protrudes from which portion of the eyeball?

A

Posterior (back) portion of the eyeball

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7
Q

The optic nerve is known as which cranial nerve?

A

Cranial nerve II

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8
Q

What two tests assess visual acuity?

A
  • Snellen

- E-chart

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9
Q

How many feet away from the chart is the patient during the Snellen test? How would the nurse assess each eye individually?

A
  • 20 feet

- The patient will cover one eye with their hand

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10
Q

How far is the E-chart held from the face during testing?

A

14 inches

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11
Q

The E-chart is used for individual who struggle with this task.

A

Reading

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12
Q

The nurse should take note of which eye diseases when assessing family history? Why are these diseases specifically important?

A
  • Glaucoma
  • Diabetes
  • Blindness
  • Cataracts

-They are genetic

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13
Q

What is normal vision? How is this interpreted?

A
  • 20/20

- At 20 feet the patient can read what the normal eye can read at the same distance

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14
Q

Low vision occurs at what?

A

20/70

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15
Q

Legal blindness occurs at what?

A

20/200

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16
Q

How is the term ‘right eye’ written when documenting?

A

OD

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17
Q

How is the term ‘left eye’ written when documenting?

A

OS

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18
Q

How is the term ‘both eyes’ written when documenting?

A

OU

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19
Q

Besides the visual acuity, the nurse should include what in her documentation?

A

Whether visual acuity is achieved with/without corrective lenses

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20
Q

How is muscle balance and movement assessed in the eyeball?

A

Six Cardinal Field Test

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21
Q

The six cardinal field test assesses which cranial nerves?

A
  • Cranial nerve III (3)
  • Cranial nerve IV (4)
  • Cranial nerve VI (6)
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22
Q

Define esotropia.

A

Deviation of eye towards nose

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23
Q

Define exotropia.

A

Deviation of eye away from nose

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24
Q

Define hypotropia.

A

Deviation of eye downward

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25
Q

Define hypertropia.

A

Deviation of eye upward

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26
Q

What is ptosis? Ptosis is often seen in what disease?

A
  • Drooping of the eyelid

- Seen in stroke patients

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27
Q

The eyes should be ______.

A

Symmetrical

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28
Q

Yellowish discoloration of the eyes is indicative of what?

A

Jaundice

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29
Q

What is a tonometer? Tonometer assesses for which disease? Can this be performed by the nurse?

A
  • Checks intraocular pressure of the eyeball
  • Assesses for glaucoma

-Yes

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30
Q

Distorted depth perception puts the patient at an increased risk for what?

A

Falls

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31
Q

What is arcus senilis? What clinical manifestation is associated with arcus senilis?

A
  • Lipid deposit within the cornea

- White ring around the iris

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32
Q

List important vision changes within the older adult.

A
  • Yellowing of the lens
  • Distorted depth perception
  • Dry eyes
  • Arcus senilis
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33
Q

What should be obtained before a patient begins antibiotic treatment?

A

Culture

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34
Q

How often is an eye exam needed if the patients wears corrective lenses, has an eye disease, or experiences change in vision?

A

Annually

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35
Q

In what direction should the eye be wiped?

A

From the inner eye to the outer eye

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36
Q

What mechanism or method is used to irrigate the eyeball?

A
  • Morgan Lens

- IV tubing

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37
Q

The nurse should educate the patient to cover what when inserting eye drops or eye ointment? Why is this important?

A
  • Cover the punctum (tear duct)

- Prevents medications from being absorbed systemically

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38
Q

When administering medication to the eye, what should never come in contact with the eye itself?

A

The tip of the medicine dropper

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39
Q

How long should the patient wait between eye drop administration?

A

5 to 10 minutes

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40
Q

Eye ointment is always administer to which portion of the eye? In what direction should the ointment be applied?

A
  • The bottom eyelid

- Inner to outer

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41
Q

The nurse should encourage a patient with an eye patch to avoid which activities?

A
  • Watching television

- Reading

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42
Q

What is conjunctivitis?

A

Inflammation of the conjunctiva that is either bacterial or viral

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43
Q

Bacterial conjunctivitis is also referred to as what?

A

Pinkeye

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44
Q

What are the signs and symptoms of conjunctivitis?

A
  • Redness
  • Crusty exudate
  • Pain
  • Itching
  • Excessive tearing
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45
Q

What is the most effective method in preventing bacterial and bacterial transfer?

A

Handwashing!

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46
Q

What is a hordeolum? It is also known as what?

A
  • Abscess in the sebaceous gland at the eyelid

- Sty

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47
Q

What is a chalazion? How does it differ from hordeolum? What might a chalazion require?

A
  • Sty that is larger in size
  • Can cause pain and pressure to the cornea
  • May require I&D (incision and drainage)
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48
Q

What is blepharitis? Is it short-term or long-term? What is required with blepharitis?

A
  • Inflammation of eyelid
  • Long-term problem
  • Requires daily cleaning
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49
Q

What is keratitis?

A

Inflammation of the cornea

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50
Q

Patients with keratitis have a sensitivity to what?

A

Light

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51
Q

What is astigmatism? What does it cause?

A
  • Uneven curves of the cornea

- Causes blurry vision

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52
Q

Define hyperopia.

A

Farsightedness (can see far away)

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53
Q

Define myopia.

A

Nearsightedness (can see close)

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54
Q

What is presbyopia? At what age does this occur?

A
  • Age related changes to vision

- After 40 years old

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55
Q

How are refractive vision disorders generally treated?

A
  • Glasses

- Contact lenses

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56
Q

What is the nursing priority for visually impaired patients?

A

Safety

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57
Q

How might a patient describe their vision if they have diabetic retinopathy? What is diabetic retinopathy? What causes diabetic retinopathy?

A
  • Dark spots or strings floating in the vision

- Vascular change of retinal vessels caused by lack of blood sugar control

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58
Q

What might the patient experience if they suffer from retinal detachment?

A
  • Sudden vision changes
  • Loss of peripheral vision
  • Decreased visual acuity
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59
Q

Will retinal detachment cause pain? Why or why not?

A
  • No pain

- There are no sensory nerves in the retina

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60
Q

What are the treatment options for a patient with a detached retina?

A
  • Laser Surgery
  • Cryopexy
  • Pneumatic retinopexy
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61
Q

What is pneumatic retinopexy?

A

Injects air or gas into the chamber to hold the retina in place

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62
Q

What is the biggest issue regarding patients and retinal detachment surgeries?

A

Patient compliance

63
Q

What is glaucoma?

A
  • Damage to the optic nerve

- Silent, progressive and irreversible

64
Q

What are the two major forms of glaucoma?

A
  • Primary open angle glaucoma (POAG)

- Acute angle closure glaucoma (AACG)

65
Q

Which form of glaucoma has a unilateral rapid onset, is considered an emergency, and can result in blindness? What occurs in this form of glaucoma?

A
  • Acute angle closure glaucoma (AACG)

- Blocks flow of aqueous humor

66
Q

How would a patient with acute angle closure glaucoma describe their vision?

A
  • Blurred
  • Rainbows appear around light
  • Painful
67
Q

Which form of glaucoma is most common and considered silent, progressive, painless, and irreversible? Does it occur unilaterally or bilaterally?

A
  • Primary open angle glaucoma

- Occurs bilaterally

68
Q

What occurs in primary open angle glaucoma (POAG)?

A

Degeneration of the eye drainage system blocking the flow of aqueous humor

69
Q

Which medications are commonly prescribed to treat glaucoma?

HINT: Little word = little pupil

A

Miotic medications

70
Q

Which medications are contraindicated in patients with glaucoma?

HINT: Big word = big pupil

A

-Mydriatic medications:

-Anticholinergics: Atropine
-Antihistamines: Hydroxyzine
and Diphenhydramine

71
Q

What is a lifelong requirement for patients with glaucoma? What is the most prominent issue with this requirement?

A
  • Daily eye drops

- Compliance

72
Q

Patients with glaucoma should wear what? What is the importance of this?

A
  • Medical alert bracelet

- Prevents receiving contraindicated medication in the event of an emergency

73
Q

List possible nursing diagnosis for glaucoma.

A
  • Pain
  • Self care deficit
  • Anxiety
  • Risk for Injury
  • Knowledge deficit
74
Q

What are cataracts? Cataracts develop due to what?

A
  • Painless opacity (cloud formation) of the eye lens

- Develop due to aging

75
Q

What are the risk factors for developing cataracts?

A
  • Prolonged ultraviolet light
  • Diabetes
  • Smoking/Alcohol
  • Steroid use
76
Q

What are the signs and symptoms of cataracts?

A
  • Increased sensitivity to glare
  • Hazy or blurred vision
  • Double vision
  • Decreased color vision
77
Q

What are the treatment options for cataracts?

A
  • Implantation of lens (surgery)

- Performed on one eye at a time

78
Q

What is the leading cause of blindness in people over 50 years of age?

A

Age Related Macular Degeneration

79
Q

What are the two types of macular degeneration? Which type accounts for 70% to 90% of cases?

A
  • Dry accounts for 70% to 90% of cases

- Wet

80
Q

Who is most at risk for macular degeneration?

A
  • People over age of 60
  • Family history
  • Diabetes
  • Smoking
  • UV light exposure
  • Caucasians
81
Q

What education should the nurse provide to the patient in relation to UV light exposure?

A

Protective eye wear!

82
Q

What is the primary symptom of dry macular degeneration?

A

Slow progressive loss of central vision

83
Q

What is the primary symptom of wet macular degeneration?

A

Sudden severe loss of central vision

84
Q

_____ is key regarding macular degeneration.

A

Prevention

85
Q

How is macular degeneration prevented?

A
  • Healthy lifestyle
  • No smoking
  • Green/orange/yellow vegetables
  • Zinc
86
Q

What is an enucleation?

A

Removal of the eyeball

87
Q

What is the most common treatment for trauma to the eyeball?

A

Saline flush to wash the eye out

88
Q

What is strabismus? What can it cause?

A
  • Crossed-eyed appearance

- Double vision can cause children to appear clumsy

89
Q

What is the most common childhood eye problems?

A

Strabismus

90
Q

What are the treatment options for strabismus?

A
  • Eye patch applied to stronger eye
  • Glasses
  • Eye exercises
91
Q

Strabismus can lead to what condition?

A

Amblyopia

92
Q

What is amblyopia? What can it cause?

A
  • Lazy eye

- Causes reduction or loss of vision in one eye

93
Q

What is the chief cause of preventable vision loss in children?

A

Amblyopia

94
Q

Restoration of sight is unlikely in a patient with amblyopia if they are older than what age?

A

7 years of age

95
Q

The outer ear consists of what?

A

The visible, external portion of the ear to the ear drum

96
Q

The middle ear consists of what?

A

The eardrum to the beginning of the cochlea

97
Q

The inner ear consists of what?

A

Involves the cochlea

98
Q

What does the inner ear control?

A

Equilibrium

99
Q

Patients who present with inner ear problems are at an increased risk for what?

A

Falls

100
Q

What is the name of cranial nerve VIII? What is it responsible for?

A
  • Vestibulocochlear nerve

- Hearing

101
Q

What is the role of the eustachian tube?

A

Equalization of pressure within the ear

102
Q

What is presbycusis? What causes this?

A

-Age related hearing changes -Loss of hair cells and decreased blood supply

103
Q

Which frequency of hearing is generally lost first?

A

High frequencies

104
Q

What is otorrhea?

A

Discharge from the ear

105
Q

What is otalgia?

A

Ear pain

106
Q

List medications that are ototoxic.

A
  • Diuretics: Lasix or Bumex
  • Certain antibiotics: Vancomycin, Gentamycin
  • Aspirin
107
Q

The nurse should assess for which disease when asking the patient about a family history of hearing loss?

A

Meniere’s Disease

108
Q

Describe the whisper test.

A
  • Patient occludes one ear
  • Standing 1 or 2 feet away the provider will whisper a word
  • Patient should be able to repeat back the same word
109
Q

The Rinne and Weber test utilize what assistive device?

A

-Utilize tuning forks

110
Q

What is Romberg’s test? If excessive swaying is present what might this indicate?

A
  • Known as the fall test
  • Patient should exhibit minimal swaying when eyes are closed
  • Inner ear problem associated with excessive swaying
111
Q

What therapeutic medications are given for hearing problems?

A
  • Anti-infectives
  • Anti-inflammatories
  • Antihistamines
  • Decongestants
  • Cerumenolytics
  • Diuretics
112
Q

Cochlear implants are used for what type of ear problem? What population will benefit most from cochlear implants?

A
  • Sensorineural hearing loss

- Children

113
Q

What are safety measures that can be utilized by hearing impaired individuals?

A
  • Visual smoke detectors
  • Alarms that vibrate the bed
  • Hearing ear dog
114
Q

Ear drops should be kept at _____ _______.

A

Room temperature

115
Q

How are ear drops administered in an adult?

A

Pull ear back and up

116
Q

How are ear drops administered in a child?

A

Pull the ear down and back for infants and children under 3 years old

117
Q

How long should the patient remain in position after ear drops have been applied?

A

2 to 3 minutes

118
Q

What are the three types of hearing loss?

A
  • Conductive
  • Sensorineural
  • Mixed
119
Q

What is conductive hearing loss? Where does this occur?

A
  • Affects sound waves attempting to reach the ear

- Affects outer and middle ear

120
Q

What is sensorineural hearing loss? Where does this occur?

A
  • Involves the cochlea and hair cells

- Affects the nerve of the inner ear, specifically cranial nerve VIII

121
Q

What are the causes of conductive hearing loss?

A
  • Foreign body
  • Cerumen
  • Infection
  • Perforation
  • Trauma
122
Q

What are the causes of sensorineural hearing loss?

A
  • Measles
  • Mumps
  • Meningitis
  • Ototoxic drugs
  • Noise
  • Aging
123
Q

What are signs and symptoms of sensorineural hearing loss?

A
  • Tinnitus
  • Dizziness
  • Hearing loss
124
Q

What are the causes of mixed hearing loss?

A
  • Tumors

- Strokes

125
Q

What is the most common problem of the external ear?

A

Infection (i.e. Swimmer’s Ear)

126
Q

What is the most common bacteria associated with external ear infections?

A

Staphylococci

127
Q

How is impacted cerumen usually treated?

A

Ear irrigation

128
Q

The ear can only be irrigated if the patient has not had what?

A

Perforated ear drum

129
Q

What should not be put into a patients ear if they have had perforated ear drums?

A

Water

130
Q

What is the most common type of infection and overall most common disease?

A

Otitis media

131
Q

What is otitis media? What causes otitis media?

A
  • Inflammation of the middle ear

- Fluid, pus, or air builds up in middle ear canal blocking the eustachian tubes which prevents ventilation

132
Q

What are the complications of otitis media?

A

Perforation of eardrum

133
Q

When will pain be present if an eardrum ruptures or perforates?

A
  • Pain present before the rupture

- NO pain after the rupture

134
Q

Otitis media is most common after what other disease process?

A

Upper respiratory infection

135
Q

Why are children more prone to middle ear infections?

A
  • Shorter ear tubes
  • More horizontal ear tubes
  • More flaccid
  • Unable to drain well
136
Q

What are the signs and symptoms of otitis media?

A
  • Pulling at ears
  • Possible purulent drainage
  • Decreased appetite
  • Sucking will aggravate pain
  • Fever
137
Q

What is a myringoplasty?

A

Surgical repair of eardrum

138
Q

What is a myringotomy?

A

Surgical incision and placement of drainage tubes

139
Q

What is a mastoidectomy?

A

Removal of mastoid if infection has spread

140
Q

What is the only middle ear structure that can be seen from outside?

A

Tympanic membrane

141
Q

What is otosclerosis?

A
  • Hardening of the ear

- New bone formation of stapes

142
Q

What are possible sources of trauma to the middle ear?

A
  • Blunt force
  • Pressure changes
  • Blast injuries
143
Q

What is labyrinthitis?

A

Inflammation of the inner ear

144
Q

What are causes of labyrinthitis?

A
  • Virus
  • Bacteria
  • Drug intoxication
  • Alcohol
  • Allergies
145
Q

Why might a patient be placed on bedrest if they have labyrinthitis?

A

Safety precaution

146
Q

What is Meniere’s disease?

A

Balance disorder

147
Q

**What are the signs and symptoms of Meniere’s disease?

A
  • Vertigo
  • Tinnitus
  • Hearing loss

-N/V

148
Q

What maneuver is done to help relieve vertigo? What does this maneuver do?

A
  • Epley manuever

- Aids in the repositioning of canalith

149
Q

What are key concepts regarding the pediatric population and ear infections?

A
  • Handwashing

- Early detection

150
Q

What other system is often affected if a child has a hearing difficulty?

A

Speech problems

151
Q

Stuttering is normal for a child up to what age? Is it most common in males or females?

A
  • Age 5

- Most common in males

152
Q

What should be addressed first: hearing or language?

A

Hearing

153
Q

How is hearing enhanced in pediatric populations?

A
  • Encourage hearing aid use
  • Look directly at child
  • Avoid background use
  • Speak slowly
  • Use visual aids

Health and Illness Concepts I Nursing: N1210 (12 decks)

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