Sensory System
The client with a detached retina undergoes a scleral buckling procedure.Postoperatively, which client problem should be the nurses highest priority?
Vomiting (increases IOP)
Which of the following statements by a nurse is correct in information the client of how to manage a nonsevere sty
Warm soaks every 4 hours for at least 30 minutes
At age 40-60 when should you get an eye exam ?
every two years
The nurse is assisting with developing a teaching plan for the client with glaucoma.Which instruction should the nurse suggest to include in the plan of care?
eye medication may need to be administered for the rest of your life
hyperopia
farsightedness
surgery for myopia
flatten
What is Meniere's disease?
fluctuating sensorineural hearing loss in adults dizzy spells fullness in ear tinnitus
conjuctivitis
inflammation of the conjunctiva
blepharitis
inflammation of the glands and eyelash follicles along the margin of the eyelids
otoscope
instrument used for visual examination of the ear
A client sustains a chemical eye injury from a splash of battery acid. The nurse prepares the client for which immediate measure?
irrigate the eye with sterile normal saline
how do tears flow
lacrimal gland, small ducts in the inner canthus, lacrimal sac, nasolacrimal duct, nasal cavity
The nurse is assigned to care for a client hospitalized with menieres disease. the nurse expects that which would most likely be prescribed for the client
low sodium diet
When a client with Otis media complains of tenderness behind the ear, the nurse is aware this may be a sign of which of the following condition ?
mastoiditis
Betaxolol hydrochloride eyedrops have been prescribed for the client with glaucoma.Which nursing action is most appropriate related to monitoring for the side/adverse effects of this medication?
monitoring blood pressure
Atropine Sulfate
mydriatic and cycloplegia medication, and its use is contraindicated in clients with glaucoma
myopia
nearsightedness
macular degeneration
progressive damage to the macula of the retina
Pilocarpine hydrochloride is prescribed for the client with glaucoma. Which medication should the nurse plan to have available in the event of systemic toxicity ?
Atropine sulfate
The nurse is caring for a client with glaucoma which medication prescribed for the client should the nurse question ?
Atropine sulfate
Which of the following instructions should the nurse give a client with glaucoma ?
Avoid heavy lifting
A client with menieres disease is experiencing severe vertigo. The nurse reinforces instructions to the client to do which to assist with controlling the vertigo?
Avoid sudden head movements
hordeolum
(stye) red, painful pustule that is a localized infection of hair follicle at eyelid margin
When caring for a client who is visually impaired, what are the best techniques for communication? SATA
2.Explain where items are on the dinner tray 3.Priovide a visual description of the room
When the client reports first perceiving sound at. dB, the nurse determine that the client's hearing acuity is normal.
20
The nurse is preparing to reinforce a teaching plan for a client who is undergoing cataract extraction with intraocular implant.Which home care measures should the nurse include in the plan? SATA
1.Avoid activities that require bending over. 3.To take acetaminophen for minor eye discomfort 4.To place an eye shield on the surgical eye at bedtime 6.To contact the surgeon if a decrease in visual acuity occurs
A nurse is reviewing manometer measurements on four clients. The nurse correctly identifies which of the following as normal intraocular pressure (IOP)?
11 mm Hg
What font size do we use for older people ?
22 or larger
What advice would the nurse give too a client who has just undergone fluorescein angiography? SATA
4. Expect skin to appear slightly yellow for the 6 to 8 hours 5.Expect urine to appear bright yellow for 24 to 36 hours
Base line comprehensive screening should be done at what age
40
Eustachian tube
A narrow tube between the middle ear and the throat that serves to equalize pressure on both sides of the eardrum
The nurse notes that they primary health care provider (PHCP) has documented a diagnosis of presbycusis on the clients chart. Which explanation should the nurse give to the client explain this condition
A sensorineural hearing loss that occurs with aging
The client is receiving an eyedrops and an eye ointment to the right eye.Which action should the nurse take?
Administer the eyedrops first, followed by the eye ointment
What medications are ototoxic
Aminoglycosides, salicylates, furosemide
A client sustains a contusion of the eyeball after a traumatic injury with a blunt object. The nurse should take which immediate action?
Apply ice to the affected eye
In addition to assessing the degree of the client's impairment, which of the following types of information should a nurse obtain from a client who has recently turned blind?
Ask about how the client is coping with the visual problems
A client is visually impaired and is admitted to the hospital.Which of the following interventions can help the visually impaired client to achieve independence?
Ask client's preference for where to store hygiene articles and other objects needed for self-care
the nurse in the clinic is aware that which of the following is the first symptom that a client with dry macular degeneration may report?
Blurred vision
A client is diagnosed with glaucoma. Which data gathered by the nurse indicate a risk factor associated with glaucoma
Cardiovascular disease
A nurse needs to test a clients ab slitty to read small print and asks the client to hold a Jaegar chart.Which of the following instructions is the most appropriate?
Cover one eye while reading the smallest print with the other
a client arrives at an urgent care clinic and states that a chemical was inadvertently splashed in the right eye. What is the first action the nurse should initiate ?
Flush the eye with normal saline solution
The nurse is providing teaching for a client with blepharitis.Which of the following would the nurse be most likely to recommend?
Frequently wash the face and hair
A 24 year old client asks the nurse when is the best time to have an eye exam.there is not any personal history of eye problems, or any family history of eye disease.What is the nurses best recommendation?
Have the first complete eye exam in your 20s
At an annual checkups client complains of persistent itching in the right eye.What questions does the nurse need to include as part of the assessment ? SATA
How long have you had this problem? Is there any drainage?
A nurse is testing a clients hearing with a weber test.Which statement by the client confirms the nurses assessment that the client hearing is normal
I am able to hear the same sound in both ears
The nurse is assessing a client who reports a history of cataracts. Which of the following findings would indicate the client is experiencing cataracts ?
The client reports that the visual image is blurred or cloudy
Which of the following symptoms should the nurse closely monitor for and report immediately in a. client who has just undergone cataract surgery ?
Intense pain in the eye or near the brown
Which of the following actions should the nurse first carry out in client with a chemical splash in the eye?
Irrigate the eyes with tap water
The nurse is checking a client's color vision.Which of the following charts does the nurse use to check this?
Ishihara polychromatic plates
A nurse is instructing a client about the eyedrops prescribed for the new diagnosis of open-angle glaucoma. Which of the following statements indicates a need for further teaching?
It is all right if I skip a dose every now and then
A client arrives at the emergency department with a foreign body on the left ear that has been determined to be an insect.Which initial intervention should the nurse anticipate to be prescribed?
KILL THE INSECT FIRST!! Instillation of mineral oil or diluted alcohol (suffocates the insect)
a nurse is giving a lecture to a group of nursing students on blindness.Which of the following best defines a client's blindness in terms of the best corrected visual acuity ?
Less than 20/200 even with correction
a client arrives at the emergency department after an insect has entered the ear. which of the following solutions would the nurse instill into the clients ear to smother the insect?
Mineral oil
Which of the following nursing actions is helpful for older clients who are experiencing lens changes associated with aging?
Offer teaching aids with large sized letters
A nurse hears the physician explain to the client that the surgical procedure involves removing the epithelial layer (top surface ) of the cornea while a laser sculpts the cornea to correct refractive error. The nurse recognizes that this procedure is which of the following?
Photorefractive keratectomy (PRK)
The nurse is preparing to administer eardrums to an adult client.The nurse administers the teardrops by which technique?
Pulling the pinna up and back
Which of the following strategies should the nurse encourage for older clients with hearing impairments to prevent disorientation?
Reorient the client frequently
in preparation for cataract surgery, the nurse is to administer cyclopnetolate eyedrops. The nurse administers the eyedrops knowing that which is the purpose of this medication
To dilate the pupil of the operative eye
A nurse needs to irrigate a client's ear to remove wax.In which direction does the nurse hold the syringe when irrigating the ear?
Toward the roof of the canal
A client with glaucoma that has not been treated. Which of the following symptoms caused by chronic progression of the disease is the client most likely to report to the nurse?
Tunnel vision
Which of the following instructions should a nurse give a client who has been prescribed hearing aids and fears that wearing a hearing aid is a stigma?
Use a hearing aid that fits almost unnoticeably in the ear
a nurse caring for a client with a sensorineural hearing loss is aware that this condition was most likely caused by which go the following?
Vascular conditions
The nurse is assigned to care for a client with a detached retina. Which finding should the nurse expect to be documented in the clients record?
a sense of a curtain falling across the field of vision
Which of the following should the nurse closely monitor in a client who has undergone surgery for otosclerosis ?
abnormal facial nerve function
What is prebycusis?
age related hearing loss
Risk factors of ear disorders
aging process infection medications ototoxicity trauma tumors
Which of the following symptoms would a nurse suspect a client to have accompanied a medical diagnosis of acoustic neuroma?
altered facial sensation
Romberg test
assesses ability of vestibular apparatus in inner ear to help maintain standing balance
What is hyphema?
blood in the anterior chamber of the eye
What is the function of the outer ear
collects sound waves and directs them into the ear
Cones
color vision
astigmatism
defective curvature of the cornea or lens of the eye
caloric stimulation test
test that uses different water temperatures to assess the vestibular portion of the nerve of the inner ear (acoustic nerve) to determine if nerve damage is the cause of vertigo MENIERE DISEASE
A client has undergone the snellen eye chart and has 20/40 vision. The nurse correctly interprets this as which of the following description
the client sees letter at 20 feet that others can read at 40 feet
vertigo
the sensation of dizziness
What is the vitreous humor?
the transparent jellylike tissue filling the eyeball behind the lens.
what nerve controls the ear
vestibular cochlear
The nurse is assigned to care for a client with a diagnosis of detached retina.Which findings would indicate that bleeding has occurred as a result of retinal detachment ?SATA
vision may be cloudy, complaints of burst of black spots or floaters
The nurse assists with preparing the client for ear irrigation as prescribed by the primary health care provider(PHCP).Which action should the nurse plan to take ?
warm the irrigating solution to 98 degrees
In what disease process does irreversible hearing loss?
Meniere's disease
a 65 year old client asks the nurse why his vision is not as sharps it once was.What is the nurses best response?
The lens in an older adults eyes accommodate more slowly
How does the lens change shape?
contraction/relaxation of the surrounding ciliary muscles and suspensory ligaments
What is mydriasis?
dilation of the pupil (anticholinergics are given)
A nurse is caring for a client just diagnosed with emmetropia .What is the nurse's best explanation for this disorder for the client?
emmetropia is a term used for normal vision
What medications affect the clients hearing ?
gentamicin, furosemide, aspirin
otosclerosis
hardening of the bony tissue of the middle ear
mastoditis
inflammation of the mastoid process
Prebysopia
lens loss of ability
The nurse is caring for a client after enucleation and notes the presence of bright red drainage on the dressing. The nurse should take which appropriate action?
Report the finding to the registered nurse (RN)
Running fork test
Rinne and Weber
Which of the following tests would a nurse use to test whether air conduction or bone conduction is greater in a client with hearing loss?
Rinne test
A nurse is performing a health history on a client and determines that the client has some hearing loss. when reviewing medications the client has taken, which ones might have contributed to the hearing loss?
Salicylates
What symptom may the client report with age related macular degeneration
loss of central vision
a client is seen in an eye clinic complaining of burning and irritation after being struck in the eye by a pine branch.The nurse anticipates the client will need which of the following eye examinations?
Slit-lamp examination
What causes nystagmus?
Stimulated semicircular canals when the head is not moving
A client has a Romberg test done. which of the following results should the nurse recognize as abnormal
Swaying,losing balance, or arm drifting
Snellen test
Test visual Acuity. Pt stands 20 ft reads letters.
A new nurse is receiving instructions on the best method for screening a clients hearing.Which statement by the new nurse indicates that more teaching is required?
I will say something in a normal voice with my back to the client and ask the client to repeat the statement
A client arrives in the emergency department after an automobile accident. The clients forehead hit the steering wheel ana hyphen has been diagnosed.Which position should the nurse prepare to position the client?
on bed rest in semi fowlers position
During an ophthalmic assessment, which of the following is the nurse expected to observe carefully
pupil responses
Rods
retinal receptors that detect black, white, and gray; necessary for peripheral and twilight vision, when cones don't respond
When assessing a client for otitis media, what should the nurse expect for signs and symptoms ?
signs of swelling and pus
what test for abrasions on the cornea
slit lamp test
The nurse correctly advises a client being treated for menieres's disease that which of the following is contraindicated ?
smoking
The nurse is caring for a client who is hearing impaired and should take which approach to facilitate communication ?
speak in a normal tone
Whisper test assesment
stand behind patient 4ft away & whisper to see if they can hear you
Amsler grid
test to assess central vision and to assist in the diagnosis of age-related macular degeneration
LASIK
use of an excimer laser to correct errors of refraction
