N109: Foundations in Nursing Practice

N109: Foundations in Nursing Practice Study Guide o Normal: Eyes are coordinated and move in unison o Deviations from normal: Nystagmus present, eye movements not coordinated, or eyes do not move in unison when following a penlight • Color correctness test: This test consists of color plates on which numbers are outlined in primary colors and surrounded by confusion colors. A person who is color blind is unable to recognize the figure. • Ask about presence or history of: o Hearing problems or deafness o History of ear surgery o Use of ear drops or medications o Signs or symptoms of ear or hearing problems (ringing in ears or drainage from ears) o Use of hearing aids • Assess hearing acuity: Speak in a normal tone of voice and assess hearing. Hold a ticking watch one inch from the patient’s ear and ask him what he can hear. o Normal: Able to hear normal voice tones and ticking watch o Deviations from normal: Unable to hear normal voice tones or ticking watch in one or both ears • The Weber test: A vibrating tuning fork (512 Hz) is placed in the middle of the forehead, chin, or head equidistant from the patient’s ears. The patient is asked to report in which ear the sound is heard louder. o Normal: Sound is heard equally in both ears or in the center o Sensorineural hearing loss: The unaffected ear perceives the sound as louder o Conductive hearing loss: The affected ear perceives the sound as louder • The Rinne test: The Rinne test is performed by placing a vibrating tuning fork (512 Hz) against the patient's mastoid bone and asking the patient to say when the sound is no longer heard. Time this interval of bone conduction with a watch, noting the number of seconds. Quickly position the still vibrating tines 1-2 cm from the auditory canal, and again ask the patient to say when the sound is no longer heard. Continue timing the interval of sound due to air conduction heard by the patient. Compare the number of seconds sound is heard by bone conduction versus air conduction. o Normal (positive Rinne): Air-conducted sound should be heard twice as long as bone- conducted sound (if bone-conducted sound is heard for 15 seconds, air-conducted sound should be heard for 30 seconds) o Deviations from normal (negative Rinne): Bone-conducted sound is greater than or equal to the air-conduction time • The Romberg test: This test is performed by having the patient stand erect with feet together and eyes closed. Remain close by in case the patient begins to sway. If the patient begins to sway this indicates a problem with proprioception, or the body’s sense of positioning. Analysis With the patient, family, and healthcare team, the nurse must analyze the assessment and formulate

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