MS2 quiz #10 Chapter 58, 59, 60

A nurse is providing discharge instructions for a client following outpatient cataract surgery with insertion of an intraocular lens. which of the following should the nurse include? a. eye drops can cause halos to appear around lights b. lying on the unaffected side can prevent complications c. surgery can cause temporary reduced visual acuity d. warm compresses over the surgical eye can reduce pain

ANS: B

A patient with glaucoma is taking a beta-adrenergic blocking agent, timolol (Timoptic). For which potential side effect should the nurse assess the patient? a. Wheezing b. Hypertension c. Sudden eye pain d. Blurred vision

ANS: A Beta-adrenergic blocking agents cause bronchospasm and tachycardia.

A nurse is evaluating discharge instructions for a client following a right cataract extraction. which of the following client statements indicates the teaching is effective? a. I will take a stool softener until my eye is healed b. I will expect to have moderately severe pain for 1-2 days c. I will refrain from cooking for 1 week d. I will bend at the waist to tie my shoes

ANS: A

A nurse is reinforcing preoperative teaching with a client who is scheduled for retinal detachment repair. Which of the following instructions should the nurse include in the teaching? A. Keep both eyes patched B. Restrict head movement C. Lie down as much as possible D. Apply cool compresses

ANS: B

A patient reports to a home health care nurse of having cloudy vision and seeing spots and halos around lights. What should the nurse suspect based on these patient symptoms? a. Cataracts b. Glaucoma c. Detached retina d. Macular degeneration

ANS: A Cataracts are the cause of cloudy vision and seeing spots or halos.

A nurse is reinforcing discharge teaching with a client following a cataract extraction. which of the following should the nurse include in the teaching? a. avoid bending at the waist b. remove the eye shield at bedtime c. limit the use of laxatives if constipated d. seeing flashes of light in an expected finding following extraction

ANS: A

Which surgical implementation is most effective with retinal detachment? a. Removing the lens b. Macular bonding c. Lasik surgery d. Scleral buckling

ANS: D Scleral buckling is used to hold the retinal repair in place. The band is left in place to keep together the layers of the eye tissue.

The nurse is reinforcing teaching provided to a patient recovering from a stapedectomy. Which patient statement indicates teaching has been effective? a. I will avoid airplane travel for 6 months. b. I will cough or sneeze with my mouth open. c. I will gently blow my nose with both sides open. d. I will keep the ear moist by packing it with cotton balls.

ANS: B It is important to prevent increased pressure to protect the graft site, so the mouth should be open when coughing or sneezing.

What should a nurse include when educating a patient with Ménière disease? a. "When you feel dizzy, just stay in bed and take your medications." b. "Decrease your sodium intake and take your diuretic medication between attacks." c. "Vestibular rehabilitation might help, and you can still drink your morning coffee." d. "Your vertigo will get better if you take your medications. You won't need any relaxation techniques."

ANS: B A low-sodium diet and diuretic medications between attacks will prevent edema, which could cause an attack.

When being interviewed, a 50-year-old patient says that he cannot see the newspaper as well as he used to. What is the reason this patient vision has changed from near to far? a. The ciliary muscle changes the pupil size. b. The lens of the eye changes shape as the ciliary muscle contracts and relaxes. c. Nearsightedness has set in. d. Clouding of the vitreous humor has occurred.

ANS: B Accommodation or adjustment of the lens by contraction and expansion of the ciliary muscle allows an individual to see far or near.

1. A 60-year-old patient who has had an enucleation asks when he can get his prosthesis fitted. In approximately how many weeks should this patient expect to be fitted? a. 2 b. 4 c. 8 d. 12

ANS: B After an enucleation, the patient is fitted with a prosthesis in 1 month.

What is the cause of glaucoma? a. Cloudiness in the lens b. Increase in intraocular pressure c. Failed eye surgery d. Retinal tears

ANS: B Glaucoma is caused by an increase in intraocular pressure.

A nurse is contributing to the plan of care for a client who has labyrinthitis. which of the following interventions should the nurse include in the plan? a. Limit fluid intake b. Monitor client's cardinal fields of vision c. Encourage ambulation d. Ensure the room is brightly lit

ANS: B

A nurse is collecting data from a client who has open-angle glaucoma. which of the following findings should the nurse expect? a. Loss of peripheral vision b. Headache c. Halos around lights d. Discomfort in the eyes

ANS: A

The nurse is caring for a client with a diagnosis of detached retina. Which assessment sign would indicate that bleeding has occurred as a result of the retinal detachment? A. Complaints of a burst of black spots or floaters B. A sudden sharp pain in the eye C. Total loss of vision D. A reddened conjunctiva

ANS: A

How does closed-angle glaucoma differ from open-angle glaucoma? a. The onset is acute. b. Trabeculectomy is the initial treatment. c. Treatment can be conservative. d. Intraocular pressure drops suddenly.

ANS: A Closed-angle glaucoma has an acute onset with eye pain and other systemic symptoms, such as nausea and vomiting. Reducing the intraocular pressure is an ocular emergency.

A 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!" How should the nurse define this behavior? a. Anger stage of grieving b. Poor impulse control c. Ineffective management of a therapeutic regimen d. Psychotic reaction to loss

ANS: A Frequently, a grieving process accompanies the realization that deteriorating vision and ultimate blindness are inevitable with macular degeneration.

A young woman being admitted to the clinic service states that all the members of her family have been hard of hearing. She says her hearing loss became more pronounced when she was pregnant. What term explains this type of hearing loss? a. Otosclerosis b. Ototoxicity c. Otalgia d. Otitis media

ANS: A Otosclerosis is hereditary, develops in young women, and worsens with pregnancy.

Which intraocular pressure reading obtained by tonometry indicates a patient being evaluated for a visual impairment does not have glaucoma? a. 18 mm Hg b. 28 mm Hg c. 45 mm Hg d. 52 mm Hg

ANS: A The normal intraocular pressure is between 12 and 21 mm Hg. If the patient had glaucoma, the intraocular pressure would be abnormally high.

A nurse is reinforcing teaching with a client who has glaucoma. which of the following statements should the nurse make? a. Without treatment, glaucoma can cause blindness b. Double vision is a common symptom of glaucoma c. Glaucoma results from the inadequate production of fluid within the eye d. You will need to treatment glaucoma by instilling eye drops once a week

ANS: A The nurse should explain that without treatment glaucoma can result in blindness due to the irreversible damage to the retina and optic nerve

26. A nurse assesses an 80-year-old patient for age-related changes to the eye. What potential changes should the nurse anticipate? (Select all that apply.) a. Decreased tear production b. Eyeball sunk deep in orbit c. Hyperopia d. Eye lashes diminished e. Arcus senilis

ANS: A, B, C, E Eyelash diminution is not a consistent finding in older adults. All of the other options are common eye changes related to advancing age.

A home health nurse is assisting with the plan of care for an older adult client who had cataract surgery recently. which of the following information should the nurse include in the plan of care? a. Remain on bed rest for at least 2 days b. Rest in semi-Fowler's position c. Deep-breathe a d cough four times a day d. Lie on the side of the surgery when in bed

ANS: B

A nurse collecting data from a client who has Meniere's disease? which of the following is an expected finding for this client? a. bilateral ear pain b. gradual hearing loss c. o,[acted cerumen d. retracted eardrum

ANS: B

A nurse is collecting data from a client who has a suspected cataract. the nurse should collect data from which of the following areas to confirm the diagnosis? a. the posterior pharynx of the client's throat b. the lens of the client's eye c. the client's eyelid d. the client's tongue

ANS: B

A 75-year-old patient has normal age-related changes in his ear. What change should not be considered a normal change in the aging patient? a. Dry and wrinkled skin on the auricle b. Otitis externa c. Dry cerumen d. Hair in the ear canal

ANS: B Otitis externa is an outer ear infection and therefore an exception. The other three options are normal age-related changes.

Which nursing diagnosis is not appropriate for a visually impaired patient? a. Impaired sensory perception b. Risk for delayed development c. Self-care deficit d. Ineffective coping

ANS: B Patients with a visual impairment are not at risk for delayed development. They will have a nursing diagnosis of "Impaired sensory perception," "Ineffective coping," and "Self-care deficit."

A 75-year-old patient reports having difficulty hearing in crowds but can hear just fine at home with his wife. What hearing disorder should the nurse suspect? a. Otitis media b. Presbycusis c. Ototoxicity d. Central deafness

ANS: B Presbycusis is a conductive hearing loss associated with normal aging and is caused by changes in the cochlea.

A patient in the emergency department complains of severe pain in his eye and is seeing halos around lights and feeling nauseous. Which diagnosis should the nurse suspect? a. Open-angle glaucoma b. Angle-closure glaucoma c. Cataracts d. Retinal detachment

ANS: B Sudden onset of acute eye pain with nausea and vomiting and halos around lights are all symptoms of angle-closure glaucoma. The acute pain is caused by sudden blockage of the fluid channels in the eye.

What is an appropriate nursing action to implement when performing eye irrigation? a. Ask the patient to tip up her head and run the irrigation fluid over her open eye. b. Direct the irrigating fluid from the inner canthus to the outer canthus. c. Not allow the patient to blink. d. Place the irrigating syringe directly onto the corner of the eye and allow the fluid to move across the eye.

ANS: B The direction of the flow should be from the inner canthus to the outer canthus.

What information should a nurse include when providing information to a patient using topical eye medications? a. Look upward and drop the medication into the inner canthus. b. Pull the lower eyelid down and drop the medication into the conjunctival sac. c. Hold both eyelids open and drop the medication onto the sclera. d. Tilt the head to the side and drop the medication into the outer canthus.

ANS: B The eye drops should be dropped into the lower eyelid, and the nurse should press the tear duct to slow absorption.

What information should a nurse stress when teaching a patient with Ménière disease about managing the disorder? a. Limiting fluid intake b. Avoiding the use of alcohol and tobacco c. Using antiemetic medications sparingly d. Staying active during the day

ANS: B The use of alcohol and tobacco products affects the amount of fluid in the middle ear, worsening the symptoms of Ménière disease. The patient with Ménière disease should drink adequate fluid, use antiemetic medications as needed, and conserve energy during the day.

A patient who has had surgery this morning for cataracts is now going home. What should the nurse include when providing discharge instructions? (Select all that apply.) a. Sleep on the affected side. b. Use stool softeners. c. Avoid bending over. d. Avoid lifting anything heavier than 5 lb. e. Do not wear an eye shield at night.

ANS: B, C, D After cataract surgery, the patient should sleep on the unaffected side with the eye shield in place. He or she should avoid heavy lifting and use stool softeners to prevent straining.

A nurse is caring for the client who has Meniere's disease. when asked by the client if he is allowed to ambulate independently. which of the following responses should the nurse make? a. you are free to move around your room as you wish, but you should avoid the hallways b. you are on strict bed rest and must not be up c. please call for assistance when you wish to get out of bed d. why would we not allow you to walk if you wanted?

ANS: C

A nurse is reinforcing discharge teaching with a client who is postoperative following a cataract extraction from the left eye with the placement of an intraocular lens implant. which of the following statements by the client indicates a need for further teaching? a. my eye may feel a little itchy for a while after surgery, but that's normal b. i may have white drainage around my eye but its's not necessary to notify my surgeon about it c. i will change my eye patch dressing every other day d. my vision might be better by tomorrow

ANS: C

A patient comes to the primary care clinic complaining of a head cold and ear pain with drainage. What should the nurse suspect this patient is experiencing? a. Otitis externa b. Hearing loss c. Acute otitis media d. Mastoiditis

ANS: C Acute otitis media is connected with colds and drainage from the ear. A hearing loss may be experienced as well, but the pain and drainage place the need to intervene for the infection first.

How should a nurse assist a visually impaired patient to ambulate? a. Hold the visually impaired person by his or her nondominant arm and walk side by side. b. Hold the nondominant hand, wrap the arm around his or her waist, and walk side by side. c. Allow the visually impaired person to hold the helper's arm, with the helper slightly ahead. d. Allow the visually impaired person to hold the shoulder of the helper and walk slightly behind the helper.

ANS: C Allowing the visually impaired person to walk slightly behind the helper and holding the helper's arm is the most effective way to guide someone who is visually impaired.

A nurse reads in a patient's history that the patient has experienced otalgia. How should the nurse interpret this term? a. Difficulty hearing b. Buildup of cerumen c. Ear pain d. Ringing in the ears

ANS: C Otic- is the root word for ear, and -algia is the root term for pain of any type.

A 52-year-old patient reports that he must hold his paper farther and farther away from his face to read it. What is the nurse's most informative response? a. "You are describing myopia. Glasses will help you read." b. "You may have astigmatism, but your eyes will finally adjust." c. "You have presbyopia. Nonprescription reading glasses will help you." d. "An eye infection may be the problem. Check with your physician for medication."

ANS: C Presbyopia is a normal age-related change. Changes in the ciliary muscles cause the condition. Corrective lenses such as bifocals are used to correct this visual change.

A 94-year-old patient is receiving gentamicin sulfate (Garamycin) in a continuous intravenous (IV) infusion. The nurse adds to the nursing care plan the diagnosis "Risk for injury." What nursing action should be implemented? a. Pull side rails in place. b. Assist with ambulation. c. Measure intake and output. d. Provide for a possible seizure.

ANS: C Reduced urine output would cause the drug to stay in the system rather than being excreted, which could result in a drug saturation. Gentamicin is ototoxic and can cause hearing impairment.

The nurse is assisting with the auditory assessment phase of the physical examination for a high school swimming team. The nurse identifies a student who has pain and itching of the ear. The nurse would anticipate treatment for which of these disorders? a. Otitis media b. Furunculosis c. External otitis d. Chronic mastoiditis

ANS: C Swimmer's ear caused by scratching or cleaning wax with sharp object (Staphylococci or Strepto or Fungal)

A nurse is reinforcing teaching with a client who has been newly diagnosed with chronic open-angle glaucoma. which of the following statements by the client indicates an understanding of the teaching? a. When my vision improves, I will be able to stop taking the eye drops b. If I forget to take my eye drops, I should wait until the next time they are due c. I should call the clinic before taking any over the counter medication d. Every two years I will need to have my vision checked by an eye doctor.

ANS: C Taking over-the-counter (OTC) medications that dilate the pupil could cause the client who has chronic open-angle glaucoma to experience an increase in intraocular pressure. A client who has glaucoma should always check with the provider before using OTC medications.

What significant instruction should a nurse include to a patient being discharged after ear surgery? a. Use stool softeners with caution. b. Assume your usual activities. c. Avoid blowing your nose. d. Shampoo your hair with baby shampoo.

ANS: C The patient should avoid blowing the nose to prevent back pressure in the eustachian tube. The patient should take stool softeners, limit activity until balance returns, and delay shampooing.

A patient receiving chemotherapy has been told he has thrombocytopenia. He is getting ready to do his morning care. Which is an appropriate teaching measure to include? a. "Take an aspirin before beginning; it will help with your pain." b. "Trim your toenails close to prevent infection." c. "Use an electric shaver." d. "Be sure to scrub your teeth vigorously."

ANS: C The patient should be taught to use an electric shaver. Thrombocytopenia is a reduction in the number of circulating platelets, due to the depression of the bone marrow. When the platelet count is less than 20,000/mm3, spontaneous bleeding can occur.

The nurse is administering timolol Eyedrops to a client who has glaucoma. Which of the following actions should the nurse take? A) apply pressure to the bridge of the nose after administering B) wipe the eye from the outer campus to the inner canthus before installation C) drop the prescribed amount of medication into the conjunctiva sac D) protect the distal portion of the eyedropper using clean technique

ANS: C With the dominant hand resting on the clients four head, gold filled medication eyedropper or the ophthalmic solution approximately 1 to 2 cm above the conjunctiva sack. And still prescribe number of medication drops into the conjunctiva sack. After instilling the drops, ask the client to close his eyes gently. If the client is to receive more than one eye medication to the same I, we at least five minutes before administering the next medication

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

ANS: D

A nurse is reinforcing preoperative teaching with a client who is scheduled for cataract surgery. which of the following statements should the nurse make? a. you should report bloodshot eyes on the day of surgery b. you should apply warm compresses to the eye 3 times daily c. you should expect bro pain for 3 days after the procedure d. you should expect your vision to improve within 2 weeks of the surgery

ANS: D

A nurse is reinforcing teaching about a tonometry examination with a client who has manifestations of glaucoma. which of the following statements should the nurse include in the teaching? a. tonometry is performed to evaluate peripheral vision b. this test will diagnose the type of your glaucoma c. tonometry will allow inspection of the optic disc for signs of degeneration d. this test will measure the intraocular pressure of the eye

ANS: D

A patient with diabetes says that he needs a hearing aid because he cannot hear well, and everything sounds garbled and distant. What type of hearing loss should the nurse suspect? a. Mixed hearing loss b. Conductive hearing loss c. Central hearing loss d. Sensorineural hearing loss

ANS: D A patient with long-term diabetes may have a sensorineural hearing loss that is not helped by hearing aids.

What is the correct term to use for a patient with a vision disorder? a. Blind b. Handicapped c. Partially blind d. Visually impaired

ANS: D The term visual impairment is a medically accepted term to use for patients with a vision loss.

A nurse is assisting with a caloric test and notes that the specific patient response that indicates a hearing disorder is a problem in the labyrinth. Which response did the nurse witness? a. Blinking b. Grimacing c. Headache d. Nystagmus

ANS: D When warm or cold water is introduced into the ear, the appearance of nystagmus is a positive indication that the hearing problem has its cause in the labyrinth.

When planning care for a patient who cannot perceive or interpret sounds, a nurse takes into consideration that the patient may have a(n) _____ hearing loss.

ANS:central The inability to perceive or interpret sounds is referred to as a central hearing loss.

A nurse is assisting with the plan of care for a client who is postoperative following repair of a detached retina. Which of the following interventions should the nurse include in the plan of care?

Apply an eye shield during naps and at bedtime.