EYE, EAR ( Adult)
The student nurse is working with a registered nurse (RN) in the clinic. The RN is educating the student nurse on dysfunction in the area of the semicircular canals of the ear. Which statement by the student nurse indicates that the teaching has been effective? 1. "Tinnitus is common." 2. "Disturbance in balance occurs." 3. "Conduction hearing loss often happens." 4. "Sensorineural hearing loss is not unusual."
2. "Disturbance in balance occurs." The semicircular canals function to aid the client's sense of balance. These canals do not relate to hearing function or the presence of tinnitus.
The nurse has admitted to the hospital a client with a diagnosis of an acute attack of Ménière's disease. The nurse reviews the primary health care provider's prescriptions for the client. Which prescription should the nurse question? 1. Diazepam 2. Nicotinic acid 3. Diphenhydramine 4. Ambulation four times daily
4. Ambulation four times daily. Medical interventions during the acute phase of Ménière's disease include using diazepam as prescribed to decrease the autonomic nervous system function. Diphenhydramine may be prescribed for its antihistamine effects, and a vasodilator (nicotinic acid) also will be prescribed. The client will remain on bed rest during the acute attack. When allowed out of bed, the client will need assistance with walking, sitting, or standing.
A client is experiencing blockage of the eustachian tubes. The nurse educates the client on how the client may forcibly open the eustachian tube. Which statement by the client indicates that the teaching has been effective? 1. "I should tap the side of the head lightly." 2. "I should perform the Valsalva maneuver." 3. "I should use cotton-tipped applicators in the ears." 4. "I should chew food using exaggerated mouth movements."
2. "I should perform the Valsalva maneuver." The Valsalva maneuver is performed through forced exhalation against a closed airway. Performing the Valsalva maneuver increases pressure in the nasopharynx and may help open a blocked eustachian tube. The actions described in the other options will not accomplish this.
The nurse is educating a client on how to eliminate whistling from a hearing aid. The nurse recognizes that further teaching is needed when the client makes which statement? 1. "I will cleanse my ear mold." 2. "I will try reinserting the hearing aid." 3. "I will raise the volume of my hearing aid." 4. "I will make sure that my hair is not caught between the ear mold and canal."
3. "I will raise the volume of my hearing aid." To reduce or eliminate whistling from a hearing aid, it should be reinserted, making certain that no hair is caught between the ear mold and canal. The ear mold or ear can be cleansed, and lowering the volume of the aid might help.
The nursing student is caring for a client with a diagnosis of presbycusis. The nursing instructor determines that the student understands presbycusis when which statement is made? 1. "It's a loss of vision associated with aging." 2. "A loss of balance occurs with presbycusis." 3. "Presbycusis is a conductive hearing loss that occurs with aging." 4. "It's a sensorineural hearing loss that occurs with the aging process."
4. "It's a sensorineural hearing loss that occurs with the aging process." Presbycusis is a type of hearing loss that occurs with aging. It is a gradual sensorineural loss caused by nerve degeneration in the inner ear or auditory nerve. The statements in the remaining options are incorrect statements about this condition.
A client is diagnosed with glaucoma. Which piece of nursing assessment data identifies a risk factor associated with this eye disorder? 1. Cardiovascular disease 2. Frequent urinary tract infections 3. A history of migraine headaches 4. Frequent upper respiratory infections
1. Cardiovascular disease. Hypertension, cardiovascular disease, diabetes mellitus, and obesity are associated with the development of glaucoma. Options 2, 3, and 4 do not identify risk factors associated with this eye disorder.
A client is diagnosed with glaucoma. Which piece of nursing assessment data identifies a risk factor associated with this eye disorder? 1. Cardiovascular disease 2. A history of migraine headaches 3. Frequent urinary tract infections 4. Frequent upper respiratory infections
1. Cardiovascular disease. Hypertension, cardiovascular disease, diabetes mellitus, and obesity are associated with the development of glaucoma. Options 2, 3, and 4 do not identify risk factors associated with this eye disorder.
The nurse is caring for a client diagnosed with Ménière's disease. The nurse plans care, understanding that this disorder is characterized by which manifestation? 1. Dizziness 2. Photophobia 3. Hemianopsia 4. Blurred vision
1. Dizziness. Ménière's disease is a disorder of the inner ear characterized by dizziness and loss of balance. This requires the addition of safety to the care plan. The clinical manifestations in the remaining options are not found with Ménière's disease.
The nurse is caring for a hearing-impaired client. Which approach will facilitate communication? 1. Speak loudly. 2. Speak frequently. 3. Speak at a normal volume. 4. Speak directly into the impaired ear.
3. Speak at a normal volume. Speaking in a normal tone to the client with impaired hearing and not shouting are important. The nurse should talk directly to the client while facing the client and speak clearly. If the client does not seem to understand what is said, the nurse should express it differently. Moving closer to the client and toward the better ear may facilitate communication, but the nurse should avoid talking directly into the impaired ear.
The nurse in the health care clinic is providing instructions to a client regarding the use of a hearing aid. Which statement is most appropriate for the nurse to include? 1. "The hearing aid should not be worn if an ear infection is present." 2. "The ear mold for the hearing aid should be washed with mild soap and water once a month." 3. "The hearing aid should be removed from the ear at the end of the day and then turned off after removal." 4. "The hearing aid contains a lifelong battery, so you will not need to be concerned about changing batteries."
1. "The hearing aid should not be worn if an ear infection is present." The client should be instructed that the hearing aid should not be worn if an ear infection is present. The client should wash the ear mold frequently with mild soap and water and use a pipe cleaner to clean the cannula of the hearing aid. The client should be instructed to turn off the hearing aid before removing it from the ear to prevent any squealing feedback. The hearing aid should be turned off when not in use, and the client should keep extra batteries on hand at all times.
The nurse is providing discharge instructions to a client who had a fenestration procedure for the treatment of otosclerosis. The nurse should instruct the client to take which measure? 1. Avoid air travel. 2. Shower daily to prevent infection. 3. Resume all normal activities in 1 week. 4. Drink liquids through a straw for the next 2 to 3 weeks.
1. Avoid air travel. After ear surgery, the client needs to be instructed to avoid air travel, excessive coughing, and drinking through a straw for 2 to 3 weeks. In addition, the client should avoid straining when having a bowel movement and should avoid washing the hair, getting the head wet, or showering for 1 week. The client also needs to avoid rapidly moving the head, bouncing, and bending over for 3 weeks.
The nurse is providing discharge instructions to the client being discharged after a fenestration procedure for the treatment of otosclerosis. Which statement made by the client indicates a need for further instruction? 1. "I should use a straw to drink liquids for the next 2 to 3 weeks." 2. "I need to avoid washing my hair and showering for at least 1 week." 3. "I should avoid movements requiring bending over for at least 3 weeks." 4. "I should take stool softeners to avoid straining when having a bowel movement."
1. "I should use a straw to drink liquids for the next 2 to 3 weeks." After ear surgery, clients need to be instructed to avoid drinking with a straw for 2 to 3 weeks, to avoid air travel, and to avoid excessive coughing because these activities will increase pressure within the ear. The client should avoid getting the head wet, washing the hair, or showering for at least 1 week, and avoid rapidly moving the head, bouncing, and bending over for at least 3 weeks. The client also should be instructed to avoid straining when having a bowel movement and should be instructed to take stool softeners as prescribed.
A client is diagnosed with a problem involving the inner ear. Which is the most common client complaint associated with a problem involving this part of the ear? 1. Pruritus 2. Tinnitus 3. Hearing loss 4. Burning in the ear
2. Tinnitus. Tinnitus is the most common complaint of clients with otological problems, especially problems involving the inner ear. Symptoms of tinnitus range from mild ringing in the ear, which can go unnoticed during the day, to a loud roaring in the ear, which can interfere with the client's thinking process and attention span. Options 1, 3, and 4 are not associated specifically with problems of the inner ear.
The nurse is caring for a hearing-impaired client. Which approach will facilitate communication? 1. Speak loudly. 2. Speak frequently. 3. Speak at a normal volume. 4. Speak directly into the impaired ear.
3. Speak at a normal volume. Speaking in a normal tone to the client with impaired hearing and not shouting are important. The nurse should talk directly to the client while facing the client and speak clearly. If the client does not seem to understand what is said, the nurse should express it differently. Moving closer to the client and toward the better ear may facilitate communication, but the nurse should avoid talking directly into the impaired ear.
The nurse notes that the primary health care provider has documented a diagnosis of presbycusis on a client's chart. Based on this information, what action should the nurse take? 1. Speak loudly, but mumble or slur the words. 2. Speak loudly and clearly while facing the client. 3. Speak at normal tone and pitch, slowly and clearly. 4. Speak loudly and directly into the client's affected ear.
3. Speak at normal tone and pitch, slowly and clearly. Presbycusis is a type of hearing loss that occurs with aging. Presbycusis is a gradual sensorineural loss caused by nerve degeneration in the inner ear or auditory nerve. When communicating with a client with this condition, the nurse should speak at a normal tone and pitch, slowly and clearly. It is not appropriate to speak loudly, mumble or slur words, or speak into the client's affected ear.
A client with Ménière's disease is experiencing severe vertigo. Which instruction should the nurse give to the client to assist in controlling the vertigo? 1. Increase sodium in the diet. 2. Avoid sudden head movements. 3. Lie still and watch the television. 4. Increase fluid intake to 3000 mL a day.
2. Avoid sudden head movements. The nurse instructs the client to make slow head movements to prevent worsening of the vertigo. Dietary changes such as salt and fluid restrictions that reduce the amount of endolymphatic fluid are sometimes prescribed. Lying still and watching television will not control vertigo.
The nurse is planning care for a client with acute otitis media. To reduce pressure and allow fluid to drain, the nurse anticipates that which measure would most likely be recommended to the client? 1. Strict bed rest 2. A myringotomy 3. A mastoidectomy 4. Diphenhydramine
2. A myringotomy. A myringotomy is a surgical procedure that will allow fluid to drain from the middle ear and may be necessary to treat acute otitis media. Strict bed rest is not necessary, although activity may be restricted. Additionally, bed rest would not assist in reducing pressure or allowing fluid to drain. In some recurrent and persistent cases, the mastoid bone is removed or partially removed for chronic otitis media. Benadryl is an antihistamine with antiemetic properties.
A client with Meniere's disease is experiencing severe vertigo. Which instruction should the nurse give to the client to assist in controlling the vertigo? 1. Increase sodium in the diet. 2. Avoid sudden head movements. 3. Lie still and watch the television. 4. Increase fluid intake to 3000 mL a day.
2. Avoid sudden head movements. The nurse instructs the client to make slow head movements to prevent worsening of the vertigo. Dietary changes such as salt and fluid restrictions that reduce the amount of endolymphatic fluid are sometimes prescribed. Lying still and watching television will not control vertigo.
The nurse is preparing to provide care for a client who will need an ear irrigation to remove impacted cerumen. Which interventions should the nurse take when performing the irrigation? Select all that apply. 1. Apply some force when instilling the irrigation solution. 2. Position the client with the affected side down after the irrigation. 3. Warm the irrigating solution to a temperature that is close to body temperature. 4. Position the client to turn the head so that the ear to be irrigated is facing upward. 5. Direct a slow, steady stream of irrigation solution toward the upper wall of the ear canal.
2. Position the client with the affected side down after the irrigation. 3. Warm the irrigating solution to a temperature that is close to body temperature. 5. Direct a slow, steady stream of irrigation solution toward the upper wall of the ear canal. During the irrigation, the client is positioned so that the ear to be irrigated is facing downward because this allows gravity to assist in the removal of the earwax and solution. Delivery of irrigation solutions at temperatures that are not close to body temperature can cause discomfort for the client and may result in tissue injury, nausea, and vertigo. A slow, steady stream of solution should be directed toward the upper wall of the ear canal, not toward the tympanic membrane. After the irrigation, the client should lie on the affected side for a period of time that is necessary to allow the irrigating solution to finish draining (usually 10 to 15 minutes). Too much force could cause the tympanic membrane to rupture.
The nurse is observing an assistive personnel (AP) communicating with a client who is deaf. The nurse should intervene if which behavior is observed? 1. The AP is speaking directly to the client. 2. The AP overenunciates words when speaking. 3. The AP faces the client when speaking to the client. 4. The AP touches the client's arm to gain his or her attention.
2. The AP overenunciates words when speaking. Overenunciating words does not make lip reading easier and is demeaning to the deaf person. It is best to speak in a normal manner. The actions in the remaining options are appropriate communication strategies for the client who is deaf.
A client is diagnosed with a disorder involving the inner ear. Which is the most common client complaint associated with a disorder involving this part of the ear? 1. Pruritus 2. Tinnitus 3. Hearing loss 4. Burning in the ear
2. Tinnitus. Tinnitus is the most common complaint of clients with otological disorders, especially disorders involving the inner ear. Symptoms of tinnitus range from mild ringing in the ear, which can go unnoticed during the day, to a loud roaring in the ear, which can interfere with the client's thinking process and attention span. Options 1, 3, and 4 are not associated specifically with disorders of the inner ear.
The nurse is performing an assessment on a client with a diagnosis of Ménière's disease. The nurse anticipates that the client is most likely to report which symptom during an acute attack? 1. Fatigue 2. Tinnitus 3. Headache 4. Insomnia
2. Tinnitus. Ménière's disease results in a disturbance of the fluid of the endolymphatic system. The cause of the disturbance is not known. Attacks may be preceded by feelings of fullness in the ear or by tinnitus. Fatigue, headaches, and insomnia are not associated with this disorder.
The nurse educator is conducting an in-service education session for the nurses employed in the eye and ear surgical unit of a large trauma center. In discussing the topic of cochlear implants, the educator notes that this surgical procedure is contraindicated in which client? 1. A client with bilateral profound hearing loss 2. A client who communicates primarily by speech 3. A client who became deaf before learning to speak 4. A client who received no benefit from conventional hearing aids
3. A client who became deaf before learning to speak. Adults who were born deaf or became deaf before learning to speak usually are not candidates for this type of surgery. Criteria for a cochlear implant procedure are bilateral profound hearing loss, use of speech as the primary mode of communication, lack of benefit from conventional hearing aids, evidence of strong family and social support, and realistic client expectations for the outcome of the implant procedure.
The nurse instructs a client in the use of a hearing aid. The nurse should include which instruction? 1. Hearing aids do not require any care. 2. Leave the hearing aid in place while showering. 3. Check the battery to ensure that it is working before use. 4. A water-soluble lubricant is used on the hearing aid before insertion.
3. Check the battery to ensure that it is working before use. The battery of the hearing aid should be checked before use. The hearing aid should be removed for showering because it should not get excessively wet. It also should be put away in its case at night. It should be cleaned according to the manufacturer's directions, which usually consist of cleaning the ear mold with mild soap and water (avoiding excessive wetness), followed by thorough drying. Lubricants or other solvents are not used on the hearing aid.
A client makes an appointment with an ear specialist because of the frequent recurrence of middle ear infections. In performing an intake assessment of the client, the nurse should ask about which risk factor related to infection of the ears? 1. Occupational noise 2. Exposure to loud noise 3. Congenital abnormalities 4. Use of drilling and other power tools
3. Congenital abnormalities. Otitis media (middle ear infection) is associated with colds, allergies, sore throats, and blockages of the eustachian tube. Risk factors include young age (usually a childhood disease), congenital abnormalities, immune deficiencies, exposure to cigarette smoke, family history of otitis media, recent upper respiratory infections, and allergies. The remaining options are risk factors for hearing loss. Hearing loss can occur as a result of an acute loud noise (acoustic trauma) or as a result of chronic exposure to loud noise (noise-induced hearing loss).
The nurse is planning a presentation on noise prevention and ear protection for a display booth at a local health fair. The nurse plans to incorporate which important concept regarding hearing loss in the presentation? 1. Sitting near loud music is not harmful. 2. Prolonged ringing in the ears after loud noises is normal. 3. Cup the hands over the ears if loud noise is expected suddenly. 4. Ear plugs or other protectors are necessary only with the use of power tools.
3. Cup the hands over the ears if loud noise is expected suddenly. A variety of ear-protective devices are available commercially. These include disposable and reusable plugs, headbands, and foam-filled muffs. They should be used around any type of loud noise, such as from power tools, machinery, lawn mowers, chain saws, or other equipment. Sitting near loud music should be avoided whenever possible. If a loud noise is suddenly anticipated, the ears should be covered for protection. The client should see a primary health care provider for tinnitus or hearing loss after exposure to a loud noise.
The nurse is caring for a client following craniotomy for removal of an acoustic neuroma. Assessment of which cranial nerve would identify a complication specifically associated with this surgery? 1. Cranial nerve I, olfactory 2. Cranial nerve IV, trochlear 3. Cranial nerve III, oculomotor 4. Cranial nerve VII, facial nerve
4. Cranial nerve VII, facial nerve An acoustic neuroma (or vestibular schwannoma) is a unilateral benign tumor that occurs where the vestibulocochlear or acoustic nerve (cranial nerve VIII) enters the internal auditory canal. It is important that an early diagnosis be made, because the tumor can compress the trigeminal and facial nerves and arteries within the internal auditory canal. Treatment for acoustic neuroma is surgical removal via a craniotomy. Assessment of the trigeminal and facial nerves is important. Extreme care is taken to preserve remaining hearing and preserve the function of the facial nerve. Acoustic neuromas rarely recur following surgical removal.
A caloric test is prescribed for a client suspected of having disease of the labyrinth. The nurse should obtain which essential item in preparation for this test? 1. An otoscope 2. A tongue blade 3. An emesis basin 4. An ophthalmoscope
1. An otoscope. A caloric test is contraindicated if the client has a perforated tympanic membrane (air may be used as a substitute) or if the client has an acute disease of the labyrinth. An otoscopic examination should be performed before the caloric test to rule out perforation and to determine whether the ear canal contains cerumen, which must be removed before the test. An ophthalmoscope, a tongue blade, and an emesis basin are not essential items.
The nurse is preparing a teaching plan for a client who had a cataract extraction with intraocular implantation. Which home care measures should the nurse include in the plan? Select all that apply. 1. Avoid activities that require bending over. 2. Contact the surgeon if eye scratchiness occurs. 3. Take acetaminophen for minor eye discomfort. 4. Expect episodes of sudden severe pain in the eye. 5. Place an eye shield on the surgical eye at bedtime. 6. Contact the surgeon if a decrease in visual acuity occurs.
1. Avoid activities that require bending over. 3. Take acetaminophen for minor eye discomfort. 5. Place an eye shield on the surgical eye at bedtime. 6. Contact the surgeon if a decrease in visual acuity occurs. Following eye surgery, some scratchiness and mild eye discomfort may occur in the operative eye and usually is relieved by mild analgesics. If the eye pain becomes severe, the client should notify the surgeon because this may indicate hemorrhage, infection, or increased intraocular pressure (IOP). The nurse also would instruct the client to notify the surgeon of increased purulent drainage, increased redness, or any decrease in visual acuity. The client is instructed to place an eye shield over the operative eye at bedtime to protect the eye from injury during sleep and to avoid activities that increase IOP, such as bending over.
The nurse is preparing a teaching plan for a client who had a cataract extraction with intraocular implantation. Which home care measures should the nurse include in the plan? Select all that apply. 1. Avoid activities that require bending over. 2. Contact the surgeon if eye scratchiness occurs. 3. Take acetaminophen for minor eye discomfort. 4. Expect episodes of sudden severe pain in the eye. 5. Place an eye shield on the surgical eye at bedtime. 6. Contact the surgeon if a decrease in visual acuity occurs.
1. Avoid activities that require bending over. 3. Take acetaminophen for minor eye discomfort. 5. Place an eye shield on the surgical eye at bedtime. 6. Contact the surgeon if a decrease in visual acuity occurs. Following eye surgery, some scratchiness and mild eye discomfort may occur in the operative eye and usually is relieved by mild analgesics. If the eye pain becomes severe, the client should notify the surgeon, because this may indicate hemorrhage, infection, or increased intraocular pressure (IOP). The nurse also would instruct the client to notify the surgeon of increased purulent drainage, increased redness, or any decrease in visual acuity. The client is instructed to place an eye shield over the operative eye at bedtime to protect the eye from injury during sleep and to avoid activities that increase IOP, such as bending over.
The nurse creates a plan of care for a client with a diagnosis of Ménière's disease who is being admitted to the hospital. The priority nursing intervention in the plan of care should focus on which item? 1. Measures that will ensure safety 2. Determining any knowledge deficits 3. Assessing for any psychosocial needs 4. Asking the client about knowledge of the treatment plan
1. Measures that will ensure safety. Ménière's disease can cause severe vertigo in the client. The priority in the nursing care plan for the hospitalized client with Ménière's disease should be safety issues to prevent falls or injury. Although client knowledge and psychosocial needs may be components of the plan of care, safety is the priority issue.
The nurse creates a plan of care for a client with a diagnosis of Ménière's disease who is being admitted to the hospital. The priority nursing intervention in the plan of care should focus on which item? 1. Measures that will ensure safety 2. Determining any knowledge deficits 3. Assessing for any psychosocial needs 4. Asking the client about knowledge of the treatment plan
1. Measures that will ensure safety. Ménière's disease can cause severe vertigo in the client. The priority in the nursing care plan for the hospitalized client with Ménière's disease should be safety issues to prevent falls or injury. Although client knowledge and psychosocial needs may be components of the plan of care, safety is the priority issue.
The nurse is developing a plan of care for a client with a diagnosis of severe vertigo from Ménière's disease who is being admitted to the hospital. What is the priority nursing intervention in the plan of care? 1. Safety measures 2. Self-care measures 3. Food items to avoid 4. Knowledge about medication therapy
1. Safety measures Ménière's disease can cause severe vertigo in the client. The priority in the nursing care plan should focus on safety issues to prevent falls or injury to the client. Although self-care measures, dietary therapy, and medication therapy may be components of the plan of care, safety is the priority issue.
A client with a history of ear problems is going on vacation by aircraft. The nurse advises the client to include which activities to prevent barotrauma during ascent and descent of the airplane? Select all that apply. 1. Yawning 2. Humming 3. Swallowing 4. Chewing gum 5. Sucking on hard candy
1. Yawning 3. Swallowing 4. Chewing gum 5. Sucking on hard candy. Clients who are prone to barotrauma should perform any of a variety of mouth movements to equalize pressure between the ear and the atmosphere, particularly during ascent and descent of an aircraft. These can include yawning, swallowing, drinking, chewing, and sucking on hard candy. Valsalva maneuver also may be helpful. The client should avoid sitting with the mouth motionless during this time because the resulting lack of pressure change in the ear will contribute to pressure buildup behind the tympanic membrane. Humming does not affect pressure.
A client being prepared for a myringotomy asks the nurse about the procedure. The nurse should respond by making which statement? 1. "This procedure involves removing a bone from the ear." 2. "This procedure will reduce the pressure you feel in your ear and allow fluid to drain." 3. "This procedure involves removing the eardrum and inserting a mechanical bone in the ear." 4. "This procedure involves removal of middle ear and inserting a ring around the ear bones that will vibrate on sound to promote better hearing."
2. "This procedure will reduce the pressure you feel in your ear and allow fluid to drain." A myringotomy is a surgical procedure that allows fluid to drain from the middle ear. A small incision is created in the eardrum (tympanic membrane) to relieve pressure that may be caused by excessive buildup of fluid. A tympanostomy tube is inserted into the eardrum to keep the middle ear aerated and to prevent reaccumulation of fluid. A mastoidectomy, in which the mastoid bone is removed or partially removed, may be recommended to treat chronic otitis media that is resistant to other therapies. The tympanic membrane is a structure needed to transmit sound from the air to the ossicles inside the middle ear and then to the oval window in the fluid-filled cochlea. Thus, it ultimately converts and amplifies vibration in air to vibration in fluid.
The nurse has given a client who is at risk for motion sickness suggestions about medications that can prevent an occurrence. The nurse determines that the client has correctly learned the information if the client states that the medication is taken at what time before the triggering event? 1. At least 2 days before 2. At least 1 hour before 3. At least the day before 4. At least a half-day before
2. At least 1 hour before. To be maximally effective, medications to prevent motion sickness should be taken at least 1 hour before the triggering event. Medications that are commonly used for this purpose include dimenhydrinate, scopolamine, promethazine, and prochlorperazine. The time frames in the remaining options are incorrect.
The nurse is caring for a client who was recently diagnosed with primary open-angle glaucoma (POAG). Which assessment finding is specific to this type of glaucoma? 1. Client report of blurred vision 2. Client report of "tunnel vision" 3. Client report of ocular erythema 4. Client report of halos around lights
2. Client report of "tunnel vision". POAG results from obstruction to outflow of aqueous humor and is the most common type. Assessment findings include painless vision changes and "tunnel vision." Primary angle-closure glaucoma (PACG) is another type of glaucoma that results from blocking the outflow of aqueous humor into the trabecular meshwork. Assessment findings include blurred vision, ocular erythema, and halos around lights.
A client arrives at the emergency department with a foreign body in the left ear and tells the nurse that an insect flew into the ear. Which intervention should the nurse implement initially? 1. Irrigation of the ear 2. Instillation of mineral oil 3. Instillation of antibiotic eardrops 4. Instillation of corticosteroid ointment
2. Instillation of mineral oil. Insects are killed before removal unless they can be coaxed out by a flashlight or by a humming noise. Mineral oil or diluted alcohol may be instilled into the ear to suffocate the insect, which is then removed by using ear forceps. When the foreign object is vegetable matter, irrigation is not used because such material may expand with hydration, thereby worsening the impaction. Antibiotic eye drops and corticosteroid ointment are not initial nursing actions.
A client's vision is tested with a Snellen chart. The results of the tests are documented as 20/60. What action should the nurse implement based on this finding? 1. Provide the client with materials on legal blindness. 2. Instruct the client that he or she may need glasses when driving. 3. Inform the client of where he or she can purchase a white cane with a red tip. 4. Inform the client that it is best to sit near the back of the room when attending lectures.
2. Instruct the client that he or she may need glasses when driving. Vision that is 20/20 is normal-that is, the client is able to read from 20 feet (6 meters) what a person with normal vision can read from 20 feet (6 meters). A client with a visual acuity of 20/60 can only read at a distance of 20 feet (6 meters) what a person with normal vision can read at 60 feet (18 meters). With this vision, the client may need glasses while driving in order to read signs and to see far ahead. The client should be instructed to sit in the front of the room for lectures to aid in visualization. This is not considered to be legal blindness.
A client arrives at the emergency department stating that a mosquito flew into his ear and that he is hearing a constant buzzing noise. Which intervention should the nurse take first? 1. Initiate a consult for an ear specialist. 2. Look into the ear canal using a flashlight. 3. Irrigate the ear and try to drown the mosquito. 4. Use an ear forcep and try to pull the mosquito out.
2. Look into the ear canal using a flashlight. Insects are killed before removal unless they can be coaxed out by a flashlight or a humming noise. Therefore, the first action would be to look into the ear canal using a flashlight. Substances such as viscous lidocaine may be prescribed to be instilled into the ear to suffocate the insect, which then is removed with the use of ear forceps. Irrigation may be necessary to flush the ear canal once the mosquito is killed, but this would not be the first action.
The nurse is reviewing the primary health care provider's prescriptions for a client with Ménière's disease. Which diet would most likely be prescribed for the client? 1. Low-fat diet 2. Low-sodium diet 3. Low-cholesterol diet 4. Low-carbohydrate diet
2. Low-sodium diet. Dietary changes such as salt and fluid restrictions that reduce the amount of endolymphatic fluid are sometimes prescribed for a client with Ménière's disease. The diets in the remaining options are not specific to the client with Ménière's disease.
Tonometry is performed on a client with a suspected diagnosis of glaucoma. The nurse looks at the documented test results and notes an intraocular pressure (IOP) value of 23. What should be the nurse's initial action? 1. Apply normal saline drops. 2. Note the time of day the test was done. 3. Contact the primary health care provider (PHCP). 4. Instruct the client to sleep with the head of the bed flat.
2. Note the time of day the test was done. Tonometry is a method of measuring intraocular fluid pressure. Pressures between 10 and 21 mm Hg are considered within the normal range. However, IOP is slightly higher in the morning. Therefore, the initial action is to check the time the test was performed. Normal saline drops are not a specific treatment for glaucoma. It is not necessary to contact the PHCP as an initial action. Flat positions may increase the pressure.
Tonometry is performed on a client with a suspected diagnosis of glaucoma. The nurse looks at the documented test results and notes an intraocular pressure (IOP) value of 23. What should be the nurse's initial action? 1. Apply normal saline drops. 2. Note the time of day the test was done. 3. Contact the primary health care provider (PHCP). 4. Instruct the client to sleep with the head of the bed flat.
2. Note the time of day the test was done. Tonometry is a method of measuring intraocular fluid pressure. Pressures between 10 and 21 mm Hg are considered within the normal range. However, IOP is slightly higher in the morning. Therefore, the initial action is to check the time the test was performed. Normal saline drops are not a specific treatment for glaucoma. It is not necessary to contact the PHCP as an initial action. Flat positions may increase the pressure.
The nurse is developing a teaching plan for a client with glaucoma. Which instruction should the nurse include in the plan of care? 1. Avoid overuse of the eyes. 2. Decrease the amount of salt in the diet. 3. Eye medications will need to be administered for life. 4. Decrease fluid intake to control the intraocular pressure.
3. Eye medications will need to be administered for life. The administration of eye drops is a critical component of the treatment plan for the client with glaucoma. The client needs to be instructed that medications will need to be taken for the rest of her or his life. Options 1, 2, and 4 are not accurate instructions.
The nurse is developing a teaching plan for a client with glaucoma. Which instruction should the nurse include in the plan of care? 1. Avoid overuse of the eyes. 2. Decrease the amount of salt in the diet. 3. Eye medications will need to be administered for life. 4. Decrease fluid intake to control the intraocular pressure.
3. Eye medications will need to be administered for life. The administration of eye drops is a critical component of the treatment plan for the client with glaucoma. The client needs to be instructed that medications will need to be taken for the rest of his or her life. Options 1, 2, and 4 are not accurate instructions.
The nurse is assigned to care for a client after a mastoidectomy. Which nursing intervention would be a priority in the care of this client? 1. Maintain a supine position. 2. Change the ear dressing daily. 3. Monitor for signs of facial nerve injury. 4. Position the client on the affected side to promote drainage.
3. Monitor for signs of facial nerve injury. After mastoidectomy, the nurse should assess for signs of facial nerve injury (cranial nerve VII), such as facial drooping. The nurse should monitor vital signs and inspect the dressing for drainage or bleeding. The nurse also should monitor for signs of pain, dizziness, or nausea. The client should be instructed to lie on the unaffected side to prevent disruption of the surgical site. The head of the bed should be elevated at least 30 degrees. The client probably will have sutures, an outer ear packing, and a bulky dressing, which is removed on approximately the sixth day postoperatively.
The nurse notes that the primary health care provider has documented a diagnosis of presbycusis on a client's chart. Based on this information, what action should the nurse take? 1. Speak loudly but mumble or slur the words. 2. Speak loudly and clearly while facing the client. 3. Speak at normal tone and pitch, slowly and clearly. 4. Speak loudly and directly into the client's affected ear.
3. Speak at normal tone and pitch, slowly and clearly. Presbycusis is a type of hearing loss that occurs with aging. Presbycusis is a gradual sensorineural loss caused by nerve degeneration in the inner ear or auditory nerve. When communicating with a client with this condition, the nurse should speak at a normal tone and pitch, slowly and clearly. It is not appropriate to speak loudly, mumble or slur words, or speak into the client's affected ear.
The home care nurse is visiting a client who was recently diagnosed with a hearing impairment. The nurse should prepare to instruct the client's spouse in which measure that will facilitate communication? 1. Speak loudly to the client to facilitate hearing. 2. Speak directly into the impaired ear to facilitate hearing. 3. Speak in a normal tone and face the client when speaking. 4. Speak frequently to the client to provide sensory stimulation.
3. Speak in a normal tone and face the client when speaking. Measures that facilitate hearing in the client with a hearing impairment include speaking in a normal tone, avoiding shouting, talking directly to the client while facing the client, and speaking clearly. If the client does not seem to understand what is said, the statement should be expressed differently. Moving closer to the client and toward the better ear may facilitate communication, but talking directly into the impaired ear should be avoided.
The nurse is providing diet instructions to a client with Ménière's disease who is being discharged from the hospital after admission for an acute attack. Which statement, if made by the client, indicates an understanding of the dietary measures to take to help prevent further attacks? 1. "I need to restrict my carbohydrate intake." 2. "I need to drink at least 3 L of fluid per day." 3. "I need to maintain a low-fat and low-cholesterol diet." 4. "I need to be sure to consume foods that are low in sodium."
4. "I need to be sure to consume foods that are low in sodium." Dietary changes, such as salt and fluid restrictions, that reduce the amount of endolymphatic fluid are sometimes prescribed for the client with Ménière's disease. The client should be instructed to consume a low-sodium diet and restrict fluids as prescribed. Although helpful to treat other disorders, low-fat, low-carbohydrate, and low-cholesterol diets are not specifically prescribed for the client with Ménière's disease.
Which statement made by the client who had ear surgery to treat otosclerosis would indicate that the client understands postoperative home care instructions? 1. "It is okay to take a shower and wash my hair." 2. "I can resume my tennis lessons starting next week." 3. "I should drink liquids through a straw for the next 2 to 3 weeks." 4. "I will take stool softeners as prescribed by my primary health care provider."
4. "I will take stool softeners as prescribed by my primary health care provider." After ear surgery, the client needs to avoid straining when having a bowel movement. The client needs to be instructed to avoid drinking with a straw, air travel, and excessive coughing for 2 to 3 weeks. The client needs to avoid getting the head wet, washing the hair, and showering for 1 week and to avoid rapid movements of the head, bouncing, and bending over for 3 weeks.
The nurse is performing an otoscopic examination on a client with mastoiditis. On examination of the tympanic membrane, which finding should the nurse expect to observe? 1. A pink-colored tympanic membrane 2. A pearly colored tympanic membrane 3. A transparent and clear tympanic membrane 4. A red, dull, thick, and immobile tympanic membrane
4. A red, dull, thick, and immobile tympanic membrane. Otoscopic examination in a client with mastoiditis reveals a red, dull, thick, and immobile tympanic membrane, with or without perforation. Postauricular lymph nodes are tender and enlarged. Clients also have a low-grade fever, malaise, anorexia, swelling behind the ear, and pain with minimal movement of the head.
The nurse is performing an otoscopic examination on a client with mastoiditis. On examination of the tympanic membrane, which finding should the nurse expect to observe? 1. A pink-colored tympanic membrane 2. A pearly colored tympanic membrane 3. A transparent and clear tympanic membrane 4. A red, dull, thick, and immobile tympanic membrane
4. A red, dull, thick, and immobile tympanic membrane. Otoscopic examination in a client with mastoiditis reveals a red, dull, thick, and immobile tympanic membrane, with or without perforation. Postauricular lymph nodes are tender and enlarged. Clients also have a low-grade fever, malaise, anorexia, swelling behind the ear, and pain with minimal movement of the head. A normal tympanic membrane is pearly gray, intact, with a positive cone of light reflex.
The clinic nurse is performing an otoscopic examination on an adolescent who was hit in the ear with a basketball during a neighborhood game. A perforated eardrum is suspected. Which finding should the nurse expect to observe if the eardrum is perforated? 1. A red and bulging eardrum 2. Dense white patches on the eardrum 3. A colony of black dots on the eardrum 4. A round or oval darkened area on the eardrum
4. A round or oval darkened area on the eardrum. A round or oval darkened area on the eardrum would be seen in a client with a perforated eardrum. A red and bulging eardrum is indicative of acute purulent otitis media. Dense white patches are seen on the eardrum of a client with sequelae of repeated ear infections. A colony of black dots on the eardrum suggests a yeast or fungal infection.
The nurse is performing an admission assessment on a client with a diagnosis of detached retina. Which sign or symptom is associated with this eye disorder? 1. Total loss of vision 2. Pain in the affected eye 3. A yellow discoloration of the sclera 4. A sense of a curtain falling across the field of vision
4. A sense of a curtain falling across the field of vision. A characteristic manifestation of retinal detachment described by the client is the feeling that a shadow or curtain is falling across the field of vision. No pain is associated with detachment of the retina. Options 1 and 3 are not characteristics of this disorder. A retinal detachment is an ophthalmic emergency and even more so if visual acuity is still normal.
The nurse is performing an admission assessment on a client with a diagnosis of detached retina. Which sign or symptom is associated with this eye problem? 1. Total loss of vision 2. Pain in the affected eye 3. A yellow discoloration of the sclera 4. A sense of a curtain falling across the field of vision
4. A sense of a curtain falling across the field of vision. A characteristic manifestation of retinal detachment described by the client is the feeling that a shadow or curtain is falling across the field of vision. No pain is associated with detachment of the retina. Options 1 and 3 are not characteristics of this problem. A retinal detachment is an ophthalmic emergency, and even more so if visual acuity is still normal.
The nurse is performing an assessment on a client with a suspected diagnosis of cataract. Which clinical manifestation should the nurse expect to note in the early stages of cataract formation? 1. Diplopia 2. Eye pain 3. Floating spots 4. Blurred vision
4. Blurred vision. A gradual, painless blurring of central vision is the chief clinical manifestation of a cataract. Early symptoms include slightly blurred vision and a decrease in color perception. Options 1, 2, and 3 are not characteristics of a cataract.
The nurse is caring for a client in the postoperative period following enucleation. The nurse notes bloody staining on the surgical eye dressing. Which nursing action is most appropriate? 1. Document the finding. 2. Reinforce the dressing. 3. Mark the site and continue to monitor. 4. Contact the primary health care provider (PHCP).
4. Contact the primary health care provider (PHCP). After enucleation, if the nurse notes any staining or bleeding on the surgical dressing, the PHCP needs to be notified immediately. The remaining options are not appropriate nursing actions for this client.
The nurse is caring for a client following craniotomy for removal of an acoustic neuroma. Assessment of which cranial nerve would identify a complication specifically associated with this surgery? 1. Cranial nerve I, olfactory 2. Cranial nerve IV, trochlear 3. Cranial nerve III, oculomotor 4. Cranial nerve VII, facial nerve
4. Cranial nerve VII, facial nerve. An acoustic neuroma (or vestibular schwannoma) is a unilateral benign tumor that occurs where the vestibulocochlear or acoustic nerve (cranial nerve VIII) enters the internal auditory canal. It is important that an early diagnosis be made because the tumor can compress the trigeminal and facial nerves and arteries within the internal auditory canal. Treatment for acoustic neuroma is surgical removal via a craniotomy. Assessment of the trigeminal and facial nerves is important. Extreme care is taken to preserve remaining hearing and preserve the function of the facial nerve. Acoustic neuromas rarely recur following surgical removal. Due to the location of the repairs made during this surgery, the olfactory, trochlear, and oculomotor nerves are not typically affected.
A client with retinal detachment is admitted to the nursing unit in preparation for a repair procedure. Which prescription should the nurse anticipate? 1. Allowing bathroom privileges only 2. Elevating the head of the bed to 45 degrees 3. Wearing dark glasses to read or watch television 4. Placing an eye patch over the client's affected eye
4. Placing an eye patch over the client's affected eye. The nurse places an eye patch over the client's affected eye to reduce eye movement. Some clients may need bilateral patching. Depending on the location and size of the retinal break, activity restrictions may be needed immediately. These restrictions are necessary to prevent further tearing or detachment and to promote drainage of any subretinal fluid. Therefore, reading and watching television are not allowed. The client's position is prescribed by the primary health care provider; normally, the prescription is to lie flat.
The nurse provides dietary instructions to a client with Ménière's disease. The nurse should tell the client that which food or fluid item is acceptable to consume? 1. Tea 2. Coffee 3. Cold-cut meats 4. Sugar-free Jell-O
4. Sugar-free Jell-O. The underlying pathological changes of Ménière's disease include overproduction and defective absorption of endolymph. This increases the volume and pressure within the membranous labyrinth until distention results in rupture and mixing of the endolymph and perilymph fluids. Dietary therapy frequently is quite helpful in controlling the symptoms associated with Ménière's disease. The nurse encourages the client to follow a low-salt diet and to avoid caffeine, sugar, monosodium glutamate, and alcohol.
