Chapter 53 Sensory Disorder

The nurse recognizes that the patient who is being evaluated for a visual impairment does not have glaucoma because the tonometry reveals an intraocular pressure of _____mmhg

18

The 60 year old patient who has had an enucleation ask when he can get his prosthesis fitted. The nurse responds that the prosthesis will be fitted by an optician in approximately ______ weeks

4

Why is otitis media found more frequently in children 6 to 36 months?

Eustachian tubes in children are shorter and straighter

Implementations that are appropriate in the care plan for a visually impaired person include

announcing your presence when you enter and leave the room

When the patient stares at the black dot on an Amsler grid, what should the nurse ask him to report?

any distortion of the grid

The nurse counsels the 16 year old boy that playing his music at high volume can result in impairment in hearing related to

damage of the fine hair cells in the organ of corti

When the patient in the emergency room complains of seeing flashing lights and a curtain down over his right eye, the nurse recognizes this as a symptom of which condition?

detached retina

Which complaint made by a 64 year old patient during a health interview would alert the nurse to the possibility of cataracts?

difficulty driving at night

The nurse will assess for _________ when the older adult home health patient complains that the entire right side of his head hurts and he cannot chew without pain.

external otitis

A nurse is performing an otoscopic examination of a client. Which of the following is an unexpected finding?

fluid bubble seen behind the TM

During the initial assessment of a very thin patient at the eye clinic, the nurse notes that the patient has very prominent eyes. The nurse should inquire about a history of

graves disease

The nurse takes into consideration that the Weber test indicated a conductive hearing loss in a patient because the patient reported hearing tone:

louder in his affected ear

A nurse is providing discharge instructions for a client following outpatient cataract surgery with insertion of a intraocular lens. Which of the following should the nurse include?

lying on the unaffected side can prevent complications

The nurse explains that the difference between open-angle and closed-angle glaucoma is that with closed-angled glaucoma

onset is acute

What is a common mistake that hinders communication when communicating with the hearing impaired?

over accentuating words

What must a patient do following a left vitrectomy?

position self in a face-down position for 4-5 days

What should a patient who has had a cataract repair avoid?

the lifting of heavy objects

What is the first indication of muscular degeneration?

the loss of central vision

The 62 year old home health patient who is recovering from eye surgery complains of a feeling of "grittiness" in the eye and is having blurred vision. The eyes are reddened and have stringy mucus. What do these complaints indicate?

sjogren syndrome

Why would the nurse encourage a group of teenagers to protect their eyes with dark sunglasses while using a UV lamp?

the lamp can cause cataracts

What is the process when the lens of the eye changes its curvature to focus on the retina?

accommodation

Upon performing an otoscope the nurse expects the light reflex to appear visible from:

auditory canal and the tympanic membrane

Which may contribute to otitis media? (Select all that apply.) a. Exposure to cigarette smoke b. Allergies c. Upper respiratory infections d. Swimming e. Trauma f. Prolonged exposure to loud noise

exposure to cigarette smoke allergies upper respiratory infections

The nurse considers in planing care for a patient with glaucoma that this disorder is caused by

increase in intraocular pressure

A patient tells the nurse he has hearing loss with occasional ringing in his ears. He states that the health care provider used another term. What term did the health care provider most likely use?

tinnitus

The nurse explains that the correct term to use for a patient with a vision disorder is

visually impaired

The newly diagnosed patient with macular degeneration flings her book at the television set and furiously says "I can't read this blasted book, and I can't see what is on the stupid TV!" The nurse recognizes this behavior as

anger stage of grieving

A patient who had an enucleation of the right eye has been admitted PACU. What should the nurse include in the plan of care?

apply a pressure dressing over the right eye socket

What should the nurse advise the 20 year old to do who has been put on cefaclor for a resistant otitis media?

avoid alcoholic beverages

The nurse clarifies that the difference between a photorefractive keratectomy (PRK) and a laser in-situ keratomileusis (LASIK) is that a LASIK:

removes some interal layers of the cornea

A nursing diagnosis for a visually impaired patient might include all of the following except

risk for delayed development

When the newly blind male home health patient asks the nurse how he might get assistance, who might the nurse suggest he contact?

American foundation for blind for a list of agencies

What does diabetes retinopathy result from?

Capillaries in retina hemorrhage

What should the nurse do when assisting a blind person to walk in an unfamiliar hospital environment? (Select all that apply) A. Discourage the use of the cane B. Advise the patient to walk quickly C. Describe the surroundings D. Encourage the patient to ask for verbal cues E. Place the patient hand on nurses shoulder or elbow

Describe the surroundings Encourage the patient to ask for verbal cues Place the patient hand on nurses shoulder or elbow

Four hours after stapedectomy, the patient complains that hearing has not improved at all. What knowledge would the nurse use to shape a response?

Hearing will not return until edema subsides

One of the housekeepers splashes a chemical in the eyes. What should be the first priority?

Irrigate with normal saline solution for 20 minutes

How should the nurse advise a patient who has severe vertigo from labyrinthitis?

Lie immobile and hold the hand in one position until the vertigo lessens

Which of the following are causes of cataracts? (Select all that apply) A. Long-term use of corticosteroids B. Hypotension C. Congenital from exposure to maternal rubella D. Diabetes mellitus E. Exposure to sand and dust F. Smoking

Long-term use of corticosteroids Congenital from exposure to maternal rubella Diabetes mellitus Smoking

The nurse notes that the PCP has documented a diagnosis of presbycusis on the history. Which explanation should the nurse give to the client to explain this condition?

a sensorineural hearing loss that occurs with aging

The patient tells the nurse that he is legally blind. How would this information impact the nurses plan of care for this patient?

The nurse would need to determine how this patient's visual impairment affects normal functioning.

How would the nurse explain the purpose of photocoagulation to a diabetic patient with diabetic retinopathy?

The procedure will destroy new blood vessels, seal leaking vessels help prevent renal edema

What would a nurse do when the patient arrives in the PACU after a left stapedectomy? (Select all that apply) A. Turn the patient to his right side B. Change the dressing as it becomes soiled C. Turn the patient every 2 hours D. Leave the bed flat E. Medicate immediately on the complaint of nausea

Turn the patient to his right side Leave the bed flat Medicate immediately on the complaint of nausea

What does the cataract treatment of phacoemulsification involve?

breaking the cataract with ultrasound

Select all the conditions that may cause conductive hearing loss. (Select all that apply.) a. Buildup of cerumen b. Foreign bodies c. Otosclerosis of external auditory canal d. Trauma e. Exposure to ototoxic drugs f. Otitis media with effusion

build up of cerumen foreign bodies otosclerosis of external auditory canal otitis media with effusion

When asked about his vision, the patient says that the last time he had it tested his vision was recorded as 20/50. This means that the patient

can read at 20 feet what a person with normal vision can read at 50 feet

What is the most interior part of the eye?

choroid

A nurse assessing the results of a Rinne test sees the notation of BC>AC. How should the nurse translate this result?

conductive hearing loss

What does a tympanoplasty correct?

conductive hearing loss

What do miotic eyedrops do for a patient with glaucoma?

constrict the pupil and open the canal of schlemm

Which is a sign of acute angle closure glaucoma (AACG)?

large fixed pupil

Which surgical implementation is most effective with retinal detachment?

scleral buckling

What should the nurse include in the plan of care following a tympanoplasty?

elevating head of the bed with operative side facing upward

The nurse explains that the portion of the eye that will make it possible for a person to see in a darkened environment is the

rods

The nurse explains to the patient who is to have a pneumatonometric study of the eye that his procedure requires that

his eye may be anesthetized

What is the first nursing intervention step for the immediate care of the patient with a penetrating wound of the eye?

lay the patient down flat

A nurse is collecting data from a client who has open-angle glaucoma. Which of the following findings should the nurse expect?

loss of peripheral vision

As the nurse you are aware that the retina requires 4 basic functions which include the following except

reflection

What should the nurse remind the hearing aid wearer to do when the nurse hears a whistling hearing aid?

reinsert the ear mold

When providing patient education about protecting vision, the nurse should tell the patient that

after 40 year of age, eye examinations should be performed every 2 years

A nurse is preparing a young adult client who has hearing impairment for surgery. Which of the following actions should the nurse take?

allow the client to keep her hearing aid in

The nurse instructs a family member how to guide a visually impaired person when ambulating by

allowing the visually impaired person to hold the helpers arm with the helper slightly ahead

The nurse is aware the extra ocular muscles control eye movement via the following cranial nerves which are

cranial nerves: ocular nerve III, trochlear nerve IV, abducens nerve VI

What factors must the nurse consider when assessing readiness to learn when teaching health promotion practices for the visually and hearing impaired (Select all that apply) A. Cultural beliefs B. Values C. Habits D. Income E. Occupation

cultural beliefs values habits