NCLEX: Week 3

A client reporting recent right eye discomfort is diagnosed with chalazion of the right eye. The nurse reinforces instructions to the client regarding care to the eye. Which statement by the client indicates an understanding of the measures?

"I should apply warm packs to my eye."

The nurse is assigned to care for a client with a diagnosis of Ménière's disease. After reinforcing discharge instructions, which client statement indicates a need for further teaching?

"I will become totally deaf if I don't follow instructions."

The nurse is assisting with performing an otoscopic examination on a client with mastoiditis. On examination of the tympanic membrane, which finding would the nurse expect to observe?

A red, dull, thick, and immobile tympanic membrane

The nurse is reviewing the preoperative prescriptions of a client scheduled for a keratoplasty. Which prescriptions noted in the client's chart would the nurse question?

Administer medication to dilate the affected pupil.

A client who has sustained an eye injury has been prescribed corticosteroid eye drops. The nurse would most carefully monitor for side effects of this medication if the client has which health problem listed on the medical record?

Diabetes mellitus

The nurse is assisting in developing a teaching plan for a client with glaucoma. Which instruction would the nurse include in the plan of care?

Eye medications will need to be administered for life.

The nurse has reinforced instructions to a client regarding the method for instilling eye drops into the left eye. The nurse determines that the client needs further teaching if the client does which during a return demonstration?

Lies supine, pulls up on the upper lid, and puts the drop in the upper lid

A client is experiencing blockage of the eustachian tubes. The nurse informs the client that which activity by the client may forcibly open the eustachian tube?

Performing the Valsalva maneuver

The nurse is caring for a hearing-impaired client. Which approach will facilitate communication?

Speak at a normal volume.

A client's vision is tested with a Snellen chart. The results of the test are documented as 20/60. How would the nurse interpret this result?

The client can read at a distance of 20 feet what a client with normal vision can read at 60 feet.

The nurse is assisting in preparing to test the visual acuity of a client using a Snellen chart. Which identifies the accurate procedure for this visual acuity test?

The right eye is tested, followed by the left eye, and then both eyes are tested.

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?

Tinnitus

Which instruction is appropriate for the nurse to provide to a client who reports via telephone that they are certain an insect has flown into the ear because they can hear it "buzzing"?

Use a flashlight to coax the insect out of the ear.

An adult client with a history of ear infections reports a right earache accompanied by a sensation of fullness. The client also reports nausea and has a temperature of 100.6° F. The nurse questions the client about which aspect of the client's history?

Whether the client has had a recent upper respiratory infection (URI)

A perforated eardrum is suspected in a client who was hit in the ear with a basketball. A tympanoplasty was performed. The nurse is giving the client discharge instructions. Which client statement indicates a need for further teaching?

"I will drink from the plastic bottle mouth since I can't use drinking straws."

The nurse is reinforcing discharge instructions to a client following right eye corneal transplantation surgery. The nurse determines that the client understands the instructions if the client makes which statement?

"I will lie on my back or left side."

The nurse is giving home care instructions to a client with conjunctivitis. Which client statement indicates a need for further teaching?

"I will use a sterile gauze to rub any matter from my eyes."

In teaching a client who is experiencing hearing loss, the nurse is explaining how sound is conducted from the middle ear to the inner ear. What is the order of structures conducting sound waves from the middle ear to the inner ear? Arrange the structures in the order that they would occur. All options must be used.

1: Tympanic membrane 2: Malleus, incus, stapes 3: Oval window 4: Cochlea 5: Organ of Corti

A client with Ménière's disease is experiencing severe vertigo. Which instruction would the nurse reinforce giving to the client to assist in controlling the vertigo?

Avoid sudden head movements.

The nurse has reinforced instructions to a client following a right keratoplasty. Which statement by the client indicates a need for further teaching?

"In 1 week, I'll return to have the sutures removed."

The nurse is reinforcing discharge instructions to a client who just underwent a myringotomy with placement of a polyethylene tube in the left ear. Which statement by the client indicates a need for further teaching? Select all that apply.

-"I will irrigate the ear with gentle pressure." -"I can expect to feel pressure inside the ear." -"I may wash my hair tomorrow."

The nurse is reviewing the health care record of a client with a diagnosis of otosclerosis. Which signs and symptoms would the nurse note? Select all that apply.

-Difficulty hearing voices of others -Bone conduction better than air conduction -Tinnitus

The nurse is reviewing the health care record of a client suspected of having mastoiditis. Which documented findings would the nurse expect to note if this disorder is present? Select all that apply.

-Headache -Elevated white blood cell count -Swelling behind the ear on affected ear

A nursing student is preparing to assist with an ear irrigation on an assigned client who has a buildup of cerumen in the left ear. The nursing instructor asks the student about the procedure for the irrigation. The student nurse would perform the procedure in which correct order? Arrange the actions in the order that they would be used. All options must be used.

1: Warm the prescribed solution to body temperature (95° F to 105° F). 2: Have the client sit up, holding an emesis basin under the ear to be irrigated with a drape under the basin. 3: Straighten the external canal of an adult by pulling the auricle up and back. 4: Select an irrigating syringe or bulb syringe with a tip that is smaller than the canal. 5: Direct the solution toward the top of the canal in a steady stream, not toward the eardrum.

The nurse is assigned to the care of a client who is being admitted to an assisted living facility. The nurse notes which observations as indications that the client likely has a hearing deficit? Select all that apply.

-The client does not respond to a person unless facing the speaker. -The client states that they have quit attending social events. -The client answers questions incorrectly.