COTAC II - sensory powerpoint questions

A nurse is caring for a client who has right-sided acoustic neuroma resulting in impairment of cranial nerves IX and X. Which of the following actions should the nurse take? a)Place suction equipment at the client's bedside. b)Apply an eye patch to the client's right eye. c)Avoid the use of warm water to wash the client's face. d)Provide range-of-motion exercises to the client's neck and shoulders.

A Cranial nerves IX (glossopharyngeal) and X (vagus) innervate the muscles of the soft palate, larynx, and pharynx. Impairment of these nerves places the client at risk for aspiration, making it necessary for the nurse to have access to suction for the client. Cranial nerve III (Oculomotor) is responsible for eye movement, pupil constriction, and eyelid elevation. It is not affected by an acoustic neuroma. The temperature of the water does not affect clients with an acoustic neuroma and impairment of cranial nerves IX and X. The nurse should bathe the client with water at a temperature that promotes client comfort. Cranial nerve XI (Accessory) innervates the sternocleidomastoid and trapezius muscles. It is not affected by an acoustic neuroma.

A nurse is in a client's room when the client begins having a tonic-clonic seizure. Which of the following actions should the nurse take first? a)Turn the client's head to the side .b)Check the client's motor strength. c)Loosen the clothing around the client's waist. d)Document the time the seizure began.

A The first action the nurse should take when using the airway, breathing, circulation approach to client care is to turn the client's head to the side. This action keeps the client's airway clear of secretion to prevent aspiration. The nurse should check the client's motor strength as part of a neurovascular assessment following the seizure; however, there is another action the nurse should take first. The nurse should loosen the clothing around the client's waist to protect the client from injury; however, there is another action the nurse should take first. The nurse should document the time the seizure began and ended to provide information to the provider about the severity of the seizure; however, there is another action the nurse should take first.

A nurse has several tasks to delegate to an assistive personnel (AP). Which of the following tasks should the nurse ask the AP to perform first? a)Take an arterial blood gas (ABG) specimen to the laboratory. b)Transport a client to the radiology department for an x-ray. c)Pass fresh water to clients on the unit. d)Obtain a routine urine sample from a newly-admitted client.

A When using the urgent vs. nonurgent approach to client care, the nurse should determine the priority action is to take the ABG blood sample to the laboratory. ABG samples are placed on ice and must be transported to the laboratory immediately or the specimen will deteriorate, making any results inaccurate. It is appropriate to delegate this task to the AP, but there is another task that is the priority. It is appropriate to delegate this task to the AP, but there is another task that is the priority. It is appropriate to delegate this task to the AP, but there is another task that is the priority.

A nurse is triaging clients in an urgent care clinic. Which of the following clients should the nurse have the provider care for immediately? a)An adolescent female client who is belligerent and has slurred speech b)A toddler who has a laceration on his forehead and is screaming c)A middle adult male who is diaphoretic and reports epigastric pain d)A young adult with a painful sunburn of his face and arms

C When using the urgent vs. nonurgent approach to client care, the nurse should determine that caring for this client is the highest priority because diaphoresis and epigastric pain are manifestations of an acute myocardial infarction. This client is displaying the effects of excessive alcohol intake and needs care. However, there is another client who has a higher priority need and should be cared for by the provider first. The nurse should apply pressure to the site of laceration and work with the parent to decrease the toddler's anxiety. However, there is another client who has a higher priority need and should be cared for by the provider first. A sunburn is a superficial burn and the client needs to be cared for by the provider. However, there is another client who has a higher priority need and should be cared for by the provider first.

A nurse at an outpatient surgery center is providing discharge teaching to a client and his spouse following surgical removal of a cataract. Which of the following should the nurse include in the teaching? a)Take ibuprofen for eye discomfort. b)Creamy white drainage is an indication of infection. c)Notify the provider immediately if the operative eye itches. d)The client should wear dark glasses while outdoors.

D The nurse should instruct the client and his spouse that he should wear dark glasses when outside or in bright light until pupil reaction returns. The nurse should instruct the client to avoid NSAIDs, such as ibuprofen, as these can cause bleeding at the surgical site. The client should use acetaminophen, along with cool compresses, to treat discomfort. The nurse should instruct the client that creamy white drainage is an expected finding following cataract surgery. Drainage that is green or yellow in color should be reported to the provider immediately. The nurse should remind the client that mild itching is a normal occurrence following cataract surgery. The client should be instructed to contact the provider if eye pain occurs with nausea and vomiting as this can indicate an increase in intraocular pressure.

Which of the following instruments is used to record intraocular pressure? a)Goniometer b)Ophthalmoscope c)Slit lamp d)Tonometer

D A tonometer is a device used in glaucoma screening to record intraocular pressure. A goniometer measures joint movement and angles. An ophthalmoscope examines the interior of the eye, especially the retina. A slit lamp evaluates structures in the anterior chamber in the eye.

A nurse in an ophthalmology clinic is interviewing a client who was referred by his primary care provider for suspicion of cataracts. The nurse should expect the client to report a)loss of central vision. b)having a loss of peripheral vision. c)seeing bright flashes of light and floaters. d)having a decreased ability to perceive colors.

D Symptoms of cataracts include painless blurred vision and a decrease in the ability to perceive colors. Clients who have macular degeneration experience a loss of central vision. Loss of peripheral vision is an initial symptom of open angle glaucoma. Bright flashes of light, especially in the peripheral visual field, and floaters, which are translucent specks of various shapes in the visual field, are associated with retinal detachment.

The nurse working in the vision & hearing clinic receives telephone calls from several clients who want appointments in the clinic ASAP. Which client should be seen first? a)71-year-old who has noticed increasing loss of peripheral vision. b)74-year-old who has difficulty seeing well enough to drive at night c)60-year-old who has difficulty hearing clearly in a noisy environment d)64-year-old who has decreased hearing and ear "stuffiness" without pain.

A A increasing loss of peripheral vision is characteristic of glaucoma and the patient should be scheduled for an examination as soon as possible. The other patients have symptoms commonly associated with aging presbycusis, possible cerumen impaction, and impaired night vision.

The priority nursing diagnosis for a patient experiencing an acute attack with Meniere's disease is: a)Risk for falls related to dizziness b)Impaired verbal communication related to tinnitus c)Self-care deficit (bathing & dressing) related to vertigo d)Imbalanced nutrition: less than body requirements related to nausea

A All the nursing diagnoses are appropriate, but because sudden attacks of vertigo can lead to "drop attacks: the major focus of nursing care is to prevent injuries associated with dizziness.

The nurse is caring for a client following enucleation. The nurse notes the presence of bright red blood drainage on the dressing. Which nursing action is appropriate? a)Notify the physician b)Continue to monitor the drainage c)Document the finding d)Mark the drainage on the dressing and monitor for any increase in bleeding.

A If the nurse notes the presence of bright red drainage on the dressing, it must be reported to the physician because this indicates hemorrhage.

A nurse is caring for a client who is postoperative following a left corneal transplant. The nurse observes purulent drainage from the affected eye. Which of the following actions is the nurse's priority? a)Notify the surgeon .b)Instill an antibiotic solution in both eyes. c)Clean eye from inner to outer canthus. d)Apply a non-pressure patch to the affected eye.

A Purulent draining is a manifestation of infection and should be reported to the surgeon immediately. The client will likely have a prescription for antibiotic, but another action is the priority. The nurse should keep the eye clean. However, another action is the priority. A patch is often applied to the eye following surgery. However, another action is the priority.

The client arrives in the emergency room after sustaining a chemical eye injury from a splash of battery acid. The initial nursing action is to: a)Begin visual acuity testing b)Irrigate the eye with sterile normal saline c)Swab the eye with antibiotic ointment d)Cover the eye with a pressure patch.

B Emergency care following a chemical burn to the eye includes irrigating the eye immediately with sterile normal saline or ocular irrigating solution. In the emergency department, the irrigation should be maintained for at least 10 minutes. Following this emergency treatment, visual acuity is assessed.

A nurse is assessing a client who has an acoustic neuroma. Which of the following client manifestations should the nurse expect? a)Vertigo b)Dysphagia c)Diplopia d)Apraxia

B The nurse should expect a client who has an acoustic neuroma, a benign tumor of cranial nerve VIII, to manifest mild to moderate vertigo as time progresses. Dysphagia is difficulty swallowing, and the client who has an acoustic neuroma would display manifestations controlled by the cranial nerve VIII, including hearing and balance. Diplopia is double vision, and the client who has an acoustic neuroma would display manifestations controlled by the cranial nerve VIII, including hearing and balance. Apraxia is the inability to perform learned motor skills or commands, and the client who has an acoustic neuroma would display manifestations controlled by the cranial nerve VIII, including hearing and balance.

A patient who has undergone a left tympanoplasty should be instructed to: a)Remain on bed rest b)Keep the head of bed elevated c)Avoid blowing the nose d)Irrigate the left ear canal

C Coughing or blowing the nose increases pressure in the eustachian tube and middle ear cavity and disrupts postoperative healing. There is no postoperative need for prolonged bed rest, elevation of the head, or continuous antibiotic irrigation.

A nurse is teaching a class of older adults about the expected physiologic changes of aging. Which of the following changes should the nurse include in the discussion? (Select all that apply.) a)More difficulty seeing due to a greater sensitivity to glare b)Decreased cough reflex c)Decreased bladder capacity d)Decreased systolic blood pressure e)Dehydration of intervertebral discs

A, B, C, E More difficulty seeing due to a greater sensitivity to glare is correct. Older adults have an increased susceptibility to glare, greater difficulty in seeing at low levels of illumination, and alterations in color perception. Decreased cough reflex is correct. Older adults have a decreased cough reflex, increased airway resistance, fewer alveoli, and a greater risk for respiratory infections. Decreased bladder capacity is correct. Older adults have a decreased bladder capacity and a reduction in renal blood flow. Decreased systolic blood pressure is incorrect. Older adults have increased systolic blood pressure, thickening of blood-vessel walls, and decreased peripheral circulation. Dehydration of intervertebral discs is correct. Older adults have dehydration of intervertebral discs, decreased muscle strength and mass, and decalcification of bones.

A nurse at an ophthalmology clinic is providing teaching to a client who has open angle glaucoma and a new prescription for timolol eye drops. Which of the following instructions should the nurse provide? a)The medication is to be applied when the client is experiencing eye pain. b)The medication will be used until the client's intraocular pressure returns to normal. c)The medication should be applied on a regular schedule for the rest of the client's life. d)The medication is to be used for approximately 10 days, followed by a gradual tapering off.

C The client needs to take the medications daily to reduce intraocular pressure and preserve remaining eyesight. Treatment for open-angle glaucoma is to continue for life.

A nurse at an ophthalmology clinic is providing teaching to a client who has open-angle glaucoma and a new treatment regimen of timolol and pilocarpine eye drops. Which of the following instructions should the nurse provide? a)Administer the medications by touching the tip of the dropper to the sclera of the eye. b)Hold pressure on the conjunctiva sac for 2 min following application of drops. c)Administer the medications 5 min apart. d)It is not necessary to remove contact lenses before administering medications.

C The nurse should instruct the client that, if more than one ophthalmic medication is to be administered, they should be given 5 min apart. The nurse should teach the client that, to prevent contamination, the dropper should not touch the eye. The nurse should instruct the client to hold pressure for 1 to 2 min on the lacrimal sac following administration of the drops. This action prevents excessive systemic absorption of the medications. The nurse should teach the client that contact lenses should be removed prior to administering eye drops. The contacts may be reinserted 15 min following medication

A patient who received a corneal transplant 2 weeks ago calls to report that his vision hasn't improved with the transplant. Which action should the nurse take? a)Suggest the patient arrange a ride to the clinic immediately. b)Ask about the presence of "floaters" in the patient' visual field c)Remind the patient it may take months to restore vision after transplant d)Teach the patient to continue using prescribed pupil-dilating medications

C Vision may not be restored for up to a year after corneal transplant. Because the patient is not experiencing complication of the surgery, an emergency clinic visit is not needed. Because "floaters" are not associated with complications of corneal transplant, the nurse will not need to ask the patient about their presence. Corticosteroid drops, not mydriatic drops are used after corneal transplant surgery.

A 42-year-old woman with Meniere's disease is admitted with vertigo, nausea, and vomiting. Which nursing intervention will be included in the care plan? a)Dim the lights in the patient's room b)Encourage increased oral fluid intake c)Change the patient's position every 2 hours d)Keep the head of the bed elevated 30 degrees

A A darkened, quite room will decrease the symptoms of the acute attack of Meniere's disease. Because the patient will be nauseated during an acute attack, fluids are administered IV. Position changes will cause vertigo and nausea. The head of bed can be positioned for patient comfort.

A nurse is instructing the caregiver of a toddler who has bacterial conjunctivitis and a new prescription for an ophthalmic ointment. Which of the following instructions should the nurse provide? a)"Apply the ointment in a thin line into the conjunctival sac." b)"Ask the child to look down before applying the ointment." c)"Always wipe from the outer to the inner canthus when wiping away secretions." d)"Use a sterile glove and applicator to apply the antibiotic ointment."

A The medication should be administered (in a thin line) into the conjunctival sac, rather than being placed directly on the globe of the eye. This ensures that more of the medication comes in contact with the surfaces of the eye when the child blinks. If applied to the globe of the eye, most of the medication will end up in the child's lashes when the child closes her eye. The caregiver should position the child with the head extended, and ask the child to look up before applying the ointment. The caregiver should be taught to wipe from the inner canthus (closer to the nose) to the outer canthus (closer to the ear) to avoid cross-contamination of the unaffected eye and lacrimal duct with secretions. Use of a sterile glove and applicator is not necessary. Ophthalmic ointments are applied directly from the tube, using clean technique. The first bead of ointment should be discarded, as it is considered to be contaminated. The tube should not be allowed to touch the eye, and it should be recapped as soon as the ointment has been dispensed.

A nurse is providing education for a client who has glaucoma. Which of the following statements should the nurse include in the teaching? a)"Without treatment, glaucoma can cause blindness." b)"Double vision is a common symptom of glaucoma." c)"Glaucoma is caused by inadequate production of fluid within the eye." d)"Use of eye drops will improve vision over time."

A The nurse should explain that without treatment glaucoma can result in blindness due to irreversible damage to the retina and optic nerve. The nurse should explain that visual manifestations of glaucoma include a gradual loss of visual field, blurred vision, and seeing halos around lights. The nurse should explain that glaucoma is the result of increased intraocular pressure caused by a disruption in the drainage and reabsorption of aqueous humor. The nurse should explain that the client's vision will not be regained, but the use of medications will prevent further damage.

Which action could the register nurse (RN) who is working in the eye and ear clinic delegate to a licensed practical/vocational nurse (LPN/LVN)? a)Evaluate a patient ability to administer eye drops b)Use a Snellen chart to check a patient's visual acuity c)Teach a patient with otosclerosis about use of sodium fluoride and vitamins D. d)Check the patient's external ear for signs of irritation caused by a hearing aid.

B Using standard screening tests such as a Snellen chart to test visual acuity is included in LPN education and scope of practice. Evaluation, assessment and patient teaching are higher level skills that require an RN education and scope of practice.

Which information about a patient who had a stapedotomy yesterday is most important for the nurse to communicate to the health care provider? a)The patient complains of "fullness" in the ear. b)The patient's oral temperature is 100.8 F (38.1 C) c)The patient says "My hearing is worse now than it was right after surgery."" d)There is a small amount of dried bloody drainage on the patient's dressing.

B An elevated temperature may indicate a postoperative infection. Although the nurse would report all the data, bloody drainage on the dressing and a feeling of congestion (because of the accumulation of blood and drainage in the ear) are common after this surgery.

A nurse is caring for a client following cataract surgery. Which of the following comments from the client should the nurse report to the client's provider? a)"My eye really itches, but I'm trying not to rub it." b)"I need something for the pain in my eye. I can't stand it." c)"It's hard to see with a patch on one eye. I'm afraid of falling." d)"The bright light in this room is really bothering me."

B Severe eye pain after surgery might indicate increased intraocular pressure or hemorrhage. The client may find that exposure to bright light is uncomfortable after cataract surgery. Wearing sunglasses can prevent most of the client's discomfort. Itching is common after cataract surgery. The nurse should remind the client not to rub or place pressure on the eyes. Clients who wear an eye patch lose their depth perception and part of their peripheral vision, temporarily decreasing visual acuity. Following cataract surgery, the client should expect only mild pain and should immediately report any pain, decrease in vision, or increase in discharge from the eye.

The clinic nurse is preparing to test the visual acuity of a client using a Snellen chart. Which of the following identifies the accurate procedure for this visual acuity test? a)Both eyes are assessed together, followed by the assessment of the right and then the left eye. b)The right eye is tested followed by the left eye, and then both eyes are tested. c)The client is asked to stand at a distance of 40ft. from the chart and is asked to read the largest line on the chart. d)The client is asked to stand at a distance of 40ft from the chart and to read the line than can be read 200 ft away by an individual with unimpaired vision.

B Visual acuity is assessed in one eye at a time, and then in both eyes together with the client comfortably standing or sitting. The right eye is tested with the left eye covered; then the left eye is tested with the right eye covered. Both eyes then are tested together. Visual acuity is measured with or without corrective lenses and the client stands at a distance of 20ft. from the chart.

A clinic nurse is giving instructions to a mother on the proper technique of applying ophthalmic ointment to her preschool-age child who has conjunctivitis. Which of the following should the nurse include in the instructions? a)"Warm the ointment by placing the tube in glass of hot tap water." b)"Cleanse the eye with a wet cotton ball in a direction towards the inner canthus before applying the ointment." c)"Discard the first bead of ointment before each application." d)"Instruct your child to squeeze his eyes shut following application."

C The parent should discard the first bead of ointment from the tube because it is considered contaminated. Eye drops that are stored in the refrigerator should come to room temperature before instillation. The parent should not warm the ointment by placing it in glass of hot water. The parent should clean the eye in a direction from the inside canthus outward in order to prevent contamination of the lacrimal duct or the other eye. Closing the eyes spreads the medication over the eyeball, but squeezing the eyelid shut can force out some of the medication.

A nurse is assessing a client who reports ear pain for the past 3 days that has suddenly resolved. The client has a new onset of otorrhea (drainage from the ear). The nurse should recognize the client has manifestations of which of the following conditions? a)Mastoiditis b)Ménière's disease c)Acoustic neuroma d)Perforated tympanic membrane

D The client has manifestations of otitis media with a perforated tympanic membrane (eardrum). Ear pain is reduced when fluid and pus drain from the eardrum due to the perforation. Manifestations of mastoiditis include pain and swelling behind the ear, fever, hearing loss, and ear drainage. Manifestations of Ménière's disease include tinnitus, hearing loss, vertigo and nystagmus. Acoustic neuroma is a benign tumor of the eighth cranial nerve. Manifestations include tinnitus, and hearing loss.

A 72-year-old patient with age-related macular degeneration (AMD) has just had photodynamic therapy. Which statement by the patient indicated that the discharge teaching has been effective? a)"I will need to use bright light to read for at least the next week" b)"I will use drops to keep my pupils dilated until my appointment" c)"I will not use facial lotions near my eyes during the recovery period." d)"I will cover up with long-sleeved shirts and pants for the next 5 days."

D The photosensitizing drug used for photodynamic therapy is activated by exposure to bright light and can cause burns in areas exposed to light for 5 days after the treatment. {verteporfin (Visudyne) medication collects in the abnormal blood vessels under the macula. Laser light then activates the medication to form clots that block the abnormal vessels}

The nurse is assessing a patient who has recently been treated with amoxicillin for acute otitis media of the right ear. Which finding is a priority to report to the health care provider? a)The patient has a temperature of 100.6 F b)The patient complains of "popping" in the ear c)The patient frequently asks the nurse to repeat information d)The patient states that the right ear has a feeling of fullness.

A The fever indicates that the infection may not be resolved and the patient might need further antibiotic therapy. A feeling of fullness, "popping" of the ear, and decreased hearing are symptoms of otitis media with effusion. These symptoms are normal for weeks to months after an episode of acute otitis media and usually resolve without treatment.

A nurse is talking with a client who is scheduled for surgery to repair retinal detachment. Which of the following preoperative instructions should the nurse include? a)Keep both eyes patched. b)Restrict head movement. c)Eye drops to constrict the pupils will be prescribed. d)Apply cool compresses.

B The client should restrict head and eye movement to prevent further detachment prior to surgery. With retinal detachment, the client should wear an eye patch over the affected eye to limit its movement. Topical medications are administered preoperatively to prevent pupil constriction and accommodation. Retinal detachment is painless, so there is no need for comfort measures like cool compresses.

A nurse is reviewing discharge instructions with a client following a right cataract extraction. Which of the following instructions should the nurse include? a)Sleep on the abdomen to facilitate wound healing. b)Avoid lifting anything heavier than 4.5 kg (10 lb) for 1 week. c)Bend at the waist to pick objects up from the floor. d)Notify the surgeon if white drainage develops on the eyelids.

B The nurse should instruct the client to avoid activities that increase intraocular pressure. Therefore, the nurse should instruct the client to avoid lifting anything heavier than 4.5 kg (10 lb) for 1 week following surgery. The nurse should instruct the client to avoid activities that increase intraocular pressure, such as bending at the waist. The client should bend at the knees to pick objects up from the floor. White, crusty drainage on the eyelid is an expected finding. The client should notify the surgeon if she has green or yellow drainage on the eyelids or eyelashes. The client should be instructed to sleep on the back of the unaffected side to lessen pressure on the affected eye. Sleeping on the abdomen is not recommended.

A nurse is participating in a disaster simulation in which a toxic substance is released into a crowded stadium. Multiple clients are transported to the facility. Which of the following activities would be the lowest priority for the nurse? a)Preventing cross-contamination of clients b)Performing concise client assessment c)Transferring a client to the discharge location d)Maintaining a client tracking system

C Nursing care in a disaster setting focuses on essential care. The nurse should recognize nonskilled interventions, such as transferring a client to the discharge location, can be performed by nonmedical personnel. In a disaster, the nurse must be able to segregate clients to prevent contamination of a nonexposed client with an exposed client, and thereby limiting the spread of the unknown toxin. In the triage setting, the nurse provides essential care; therefore, the nurse must conduct concise client assessments for triage purposes. It is imperative for the nurse to maintain a client tracking system in a disaster situation. Disaster tags are numbered and include information such as triage priority, name, address, medications given, and treatments provided. These tags should remain with the client throughout his movement within the facility.