Page 372 - Saunders Comprehensive Review For NCLEX-RN

i. The optic disc, retinal vessels, general
background, and macula can be
examined.
j. The optic disc should be creamy yellow-
orange to pink, round or oval shape
with distinct margins. Retinal vessels
should be visible without nicking and
engorgement. General background
varies from light red to dark brown
red, corresponding with the person’s
color.
13. Refer to Chapter 56 for diagnostic tests related to the
eye.

14. Client teaching

a. Instruct the client to notify the PHCP if
alterations in vision occur or any
redness, swelling, or drainage from the
eye is noted.
b. Inform the client of the importance of
regular eye examinations.
D. Ears: Includes inspection, palpation, hearing tests, vestibular
assessment, and the use of an otoscope
1. Subjective data: Difficulty hearing, earaches,

drainage from the ears, dizziness, ringing in the ears,
exposure to environmental noise, use of a hearing aid,
medications being taken, history of ear problems or
infections

2. Objective data

a. Inspect and palpate the external ear,
noting size, shape, symmetry, skin
color, and the presence of pain.
b. Inspect the external auditory meatus for
size, swelling, redness, discharge, and
foreign bodies; some cerumen
(earwax) may be present.
3. Auditory assessment
a. Sound is transmitted by air conduction
and bone conduction.
b. Air conduction takes 2 or 3 times longer
than bone conduction.
c. Hearing loss is categorized as
conductive, sensorineural, or mixed
conductive and sensorineural.
d. Conductive hearing loss is caused by

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