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4. The nurse is assessing a client who had a stroke in the right cerebral hemisphere. Which neurologic deficit does the nurse assess for in this client? a. Impaired proprioception b. Aphasia c. Agraphia d. Impaired olfaction

ANS: A A stroke to the right cerebral hemisphere causes impaired visual and spatial awareness. The client may present with impaired proprioception and may be disoriented as to time and place. The right cerebral hemisphere does not control speech, smell, or the client's ability to write. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology) MSC: Integrated Process: Nursing Process (Assessment)

17. In the emergency department, the nurse is caring for a client diagnosed with a hyphema. Which statement by the client indicates a need for further teaching? a. "When I get home, I can lie flat in bed and turn from side to side." b. "For a few days, I cannot even read a book or watch television." c. "I will need to protect the eye with a patch and shield." d. "I need to stay on bedrest and will try not to make any sudden movement."

ANS: A A hyphema is a hemorrhage in the anterior chamber of the eye due to blunt force such as a motor vehicle accident. For management of this condition, the client must be on bedrest but must remain in a semi-Fowler's position to prevent accumulation of blood around the optical center of the cornea. The client cannot lie flat in bed and rotate from side to side. The client cannot read a book or watch television and must protect the eye if paralytic eyedrops were used. The client needs to be as still as possible to prevent further bleeding. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Safe and Effective Care Environment (Safety and Infection Control—Home Safety) MSC: Integrated Process: Teaching/Learning

10. During assessment, the nurse notes that a client's right pupil is 2 mm larger than the left pupil. Which is the nurse's first action? a. Ask the client how long this condition has been present. b. Attempt to elicit a red reflex in both eyes. c. Document the finding as the only action. d. Identify the medications that the client is taking.

ANS: A Although both pupils are normally the same size and a difference in size can indicate various pathologies, approximately 5% of people have a noticeable difference in the size of their pupils. The nurse should first determine whether this condition represents a change or has been present for a long time. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Health Promotion and Maintenance (Health Screening) MSC: Integrated Process: Nursing Process (Assessment)

5. The nurse is caring for a client who will undergo electronystagmography testing the following day. Which instruction does the nurse provide for the client? a. "You should drink only caffeine-free beverages the day of and the day before the test." b. "Do not chew gum or clean your ears for 24 hours after the test is completed." c. "You may feel flushed as the contrast dye is injected through your IV for the test." d. "You will be sedated for the test, so you need someone to drive you home."

ANS: A Caffeinated drinks may interfere with the test results, so the client should be sure to drink only decaffeinated beverages during the 24 to 48 hours before the test. Clients may chew gum or clean their ears after the test, if desired. Neither IV contrast nor sedation is used for the test. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiologic Integrity (Reduction of Risk Potential—Diagnostic Tests) MSC: Integrated Process: Teaching/Learning

12. Several clients come to the emergency department following an accident. Which client does the nurse assess first? a. Client with clear watery drainage from the ear canals b. Client who reports tinnitus and pain in the right ear c. Client with a deep, 1-inch laceration to the pinna d. Client who has had severe difficulty hearing since the accident

ANS: A Clear watery drainage from the ears following trauma suggests a basal skull fracture and should be assessed immediately. Tinnitus and pain, lacerations, and hearing loss all may be assessed by the nurse in a timely manner, after the possible skull fracture. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—System-Specific Assessments) MSC: Integrated Process: Nursing Process (Assessment)

11. The nurse is assessing a client who wishes to be considered as a potential donor for corneal transplantation. Which medical diagnosis at the time of death excludes the client from consideration? a. Small cell lung cancer b. Chronic heart failure c. Profound nearsightedness d. History of detached retina

ANS: A Clients of any age may donate corneas as long as the corneas are clear and the client is free from infectious disease or cancer at the time of death. The other problems would not keep a client from donating corneas. DIF: Cognitive Level: Comprehension/Understanding REF: p. 1059 TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications from Surgical Procedures and Health Alterations) MSC: Integrated Process: Nursing Process (Assessment)

5. A client has paralysis of the right medial rectus muscle of the right eye. Which assessment finding assists the nurse in validating this diagnosis? a. Client is unable to turn the eye in toward the nose. b. Client is unable to lift the upper eyelid. c. Client cannot look downward. d. Client cannot look upward.

ANS: A Contraction of the medial rectus muscle turns the eye toward the nose. The superior oblique muscle pulls the eye downward, and the inferior oblique muscle pulls the eye upward. The ocular muscles do not lift the upper eyelid. DIF: Cognitive Level: Comprehension/Understanding REF: Table 48.1, p.1042 TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology) MSC: Integrated Process: Nursing Process (Assessment)

2. Which is the most important information for the nurse to teach a client who is receiving cycloplegic drug therapy? a. "Do not drive or operate machinery until the drug wears off." b. "Use at least a 30 SPF sunscreen agent when going outdoors." c. "Remain on bedrest for 24 hours in a prone position." d. "Turn up the lights because acuity will be decreased in low-light environments."

ANS: A Cycloplegic agents prevent accommodation of the iris, resulting in a widely dilated pupil. The pupil cannot accommodate to bright light, causing eye discomfort and pain. Turning up the lights will not assist the client to see more clearly. Bedrest and sunscreen are not measures needed for this drug. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Health Promotion and Maintenance (Self-Care) MSC: Integrated Process: Teaching/Learning

22. The nurse is caring for a client who is disoriented as the result of a stroke. Which action does the nurse implement to help orient this client? a. Ask the family to bring in pictures familiar to the client. b. Turn on the television to a 24-hour news station. c. Maintain a calm and quite environment by minimizing visitors. d. Provide auditory and visual stimulation simultaneously.

ANS: A For the client with disorientation, the nurse can request that the family bring in pictures or objects that are familiar to the client. The nurse explains what the object or picture represents in simple terms. These stimuli can be presented several times daily. Visitors can also be familiar stimuli to reorient the client. Too much stimuli and constant stimuli can lead to further confusion. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Illness Management) MSC: Integrated Process: Nursing Process (Implementation)

2. The nurse is performing an ear assessment on an older adult. Which assessment finding does the nurse document in the client's chart as an expected age-related change? a. Coarse hair is seen in the auditory canal. b. Tympanic membrane is intact and bulging. c. Impacted cerumen is present in the auditory canal. d. Small, painless nodules are noted on the helix of the pinna.

ANS: A Growth of coarse hair in the auditory canal occurs in some older men and women. It does not interfere with hearing and is considered a normal variation related to aging

6. The nurse notes that the left arm of a client who has experienced a brain attack is in a contracted, fixed position. Which complication of this position does the nurse monitor for in this client? a. Shoulder subluxation b. Flaccid hemiparesis c. Pathologic fracture d. Neglect syndrome

ANS: A Hypertonia causing contracture or flaccidity can predispose the client to subluxation of the shoulder. Contractures are stiff and immobile—not flaccid. Contractures are not caused by fractures or neglect syndrome. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Alterations in Body Systems) MSC: Integrated Process: Nursing Process (Analysis)

19. A client comes to the emergency department with periorbital ecchymosis of the right eye. Which is the nurse's priority action? a. Apply an ice pack to the affected eye. b. Patch the eye to prevent eye movement. c. Assess the client's vision in both eyes. d. Irrigate the affected eye with normal saline.

ANS: A Ice will cause capillary vasoconstriction, thereby decreasing swelling and capillary oozing. Treatment with ice begins at the time of injury. Whenever the eye or surrounding tissue is injured, visual acuity is assessed next. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Safe and Effective Care Environment (Management of Care—Establishing Priorities) MSC: Integrated Process: Nursing Process (Implementation)

20. The nurse is preparing to administer prescribed mannitol (Osmitrol) to a client with a severe head injury. Which precaution does the nurse take before administering this medication? a. Draw up the medication using a filtered needle. b. Have injectable naloxone (Narcan) prepared and ready at the bedside. c. Prepare to hyperventilate the client before drug administration. d. Discontinue a barbiturate-induced coma before drug administration.

ANS: A Mannitol (Osmitrol) must be drawn up using a filtered needle to eliminate microscopic crystals. Narcan does not reverse the effects of mannitol. Hyperventilation does not affect administration of this drug, and clients can be given mannitol while in a barbiturate-induced coma. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies—Medication Administration) MSC: Integrated Process: Nursing Process (Implementation)

14. A client is scheduled for a caloric test to evaluate the vestibular portion of the inner ear. Which statement by the client leads the nurse to conclude that more teaching is necessary? a. "I can eat a hearty breakfast before the procedure." b. "I will have to stay in bed after the procedure to prevent nausea." c. "Warm water will be infused into my affected ear." d. "I may experience dizziness after the water is inserted."

ANS: A The client usually is asked to fast for several hours before the caloric test. A hearty breakfast is not a good idea because nausea and vomiting is a common reaction following the test. Fasting will lower the risk of aspiration. The other responses demonstrate adequate knowledge of this procedure and its follow-up care. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiologic Integrity (Reduction of Risk Potential—Diagnostic Tests) MSC: Integrated Process: Nursing Process (Evaluation)

10. A client who first experienced symptoms related to a confirmed thrombotic stroke 2 hours ago is brought to the intensive care unit. Which prescribed medication does the nurse prepare to administer? a. Tissue plasminogen activator b. Heparin sodium c. Gabapentin (Neurontin) d. Warfarin (Coumadin)

ANS: A The client who has had a thrombotic stroke has a 3-hour time frame from the onset of symptoms to receive recombinant tissue plasminogen activator (rt-PA) to dissolve the cerebral artery occlusion and re-establish blood flow. Clients must meet eligibility criteria for administration of this therapy. The other medications do not assist in the re-establishment of blood flow for a client with a confirmed thrombotic stroke. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies—Expected Actions/Outcomes) MSC: Integrated Process: Nursing Process (Implementation)

13. A client has experienced a stroke resulting in damage to Wernicke's area. Which clinical manifestation does the nurse monitor for? a. Inability to comprehend spoken words b. Communication with rote speech only c. Slurred speech d. Inability to make sounds

ANS: A The client with damage to Wernicke's area cannot understand spoken or written words. If the client speaks, the language is meaningless, with the client using made-up words. Damage to Wernicke's area does not cause slurred speech, nor will the client communicate with habitual speech only. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Psychosocial Integrity (Sensory/Perceptual Alterations) MSC: Integrated Process: Nursing Process (Analysis)

Chapter 48: Assessment of the Eye and Vision Test Bank MULTIPLE CHOICE 1. Why is the optic disc considered to be a blind spot? a. This area does not contain photoreceptors. b. Light rays are unable to focus on this location. c. Blood vessels form a meshwork and interfere with vision. d. This area is heavily pigmented and light rays are absorbed.

ANS: A The optic nerve enters the eyeball at this point and contains no photoreceptors. The other responses are incorrect. DIF: Cognitive Level: Knowledge/Remembering REF: p. 1040 TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology) MSC: Integrated Process: Nursing Process (Assessment)

10. The nurse notes reddened areas behind both ears. What does the nurse ask the client? a. "Do you wear eyeglasses?" b. "Do you have any allergies?" c. "Do you use dandruff shampoo?" d. "Have you been around anyone with lice?

ANS: A The presence of reddened areas behind both ears strongly suggests constant pressure, such as that incurred from wearing eyeglasses or sunglasses. Dandruff shampoo, allergies, and lice would not cause reddened areas only behind the ears. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—System-Specific Assessments) MSC: Integrated Process: Nursing Process (Assessment)

4. The nurse performs an assessment of a client's extraocular movement and notes no difficulty. Which additional assessment data assist in confirming this finding? a. No episodes of double vision b. Synchronized blinking movements c. No reports of headaches and dizziness d. Both pupils constricting equally in response to light

ANS: A The voluntary muscles of the orbit rotate the eye and coordinate eye movements to ensure that the retina of each eye receives an image at the same time, so that only a single image is perceived. If the client has reported double vision, this would indicate a problem with this coordination. The other answers are not related to extraocular eye movements. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Health Promotion and Maintenance (Health Screening) MSC: Integrated Process: Nursing Process (Assessment)

2. A client with aphasia presents to the emergency department with a suspected brain attack. Which clinical manifestation leads the nurse to suspect that this client has had a thrombotic stroke? a. Two episodes of speech difficulties in the last month b. Sudden loss of motor coordination c. A grand mal seizure 2 months ago d. Chest pain and nuchal rigidity

ANS: A Thrombotic stroke is characterized by a gradual onset of symptoms that often are preceded by transient ischemic attacks (TIAs), causing a focal neurologic dysfunction. Two episodes of speech difficulties would correlate with TIAs. The other manifestations are not related to a thrombotic stroke. DIF: Cognitive Level: Comprehension/Understanding REF: Table 47-1, p. 1006 TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology) MSC: Integrated Process: Nursing Process (Analysis)

15. The nurse is providing discharge teaching for a client with posterior uveitis. Which is the most important precaution for the nurse to teach the client? a. Correct technique for eyedrop instillation b. Clinical manifestations of retinal hemorrhage c. Correct technique for insertion of contact lenses d. Proper timing of opioid analgesics

ANS: A Treatment of posterior uveitis is symptomatic, with eyedrops used to dilate the pupil and decrease the inflammatory response. The client may have to instill eyedrops as frequently as every hour. This condition consists of inflammation of the retina—not a hemorrhage. Opioids are not prescribed to lessen the pain, but cool or warm compresses may be used for ocular pain. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Health Promotion and Maintenance (Self-Care) MSC: Integrated Process: Teaching/Learning

MULTIPLE RESPONSE 1. A client is admitted for evaluation of a cerebral tumor. Which clinical manifestations does the nurse assess this client for? a. Hemiplegia b. Aphasia c. Hearing loss d. Behavior changes e. Nystagmus

ANS: A, B, D If the tumor affects the cerebral hemispheres, hemiplegia, aphasia, and behavioral changes are common. Hearing loss and nystagmus are found with brainstem lesions. DIF: Cognitive Level: Comprehension/Understanding REF: Chart 47-10, p. 1032 TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology) MSC: Integrated Process: Nursing Process (Assessment)

2. Which statements by a client alert the nurse that the client may have some psychosocial issues with impaired hearing? (Select all that apply.) a. "I get so angry when I cannot hear what my daughter says." b. "When I use my hearing aids, I hear the choir so clearly." c. "I don't mind sitting in my chair all day long and not playing bingo." d. "My family never seems to visit anymore because their voices all seem so distant." e. "No one asks my opinion because I cannot hear their question." f. "My grandchildren do not think that I am funny anymore because I cannot hear their jokes."

ANS: A, C, D, E, F The client may become angry, frustrated, and depressed by an inability to hear and may respond appropriately. The inability to hear often isolates the client from the world, as depicted by sitting in a chair all day long, the perception of the family being distant, and no one asking for an opinion or joking around. The nurse must be sensitive to the depression resulting from the sensory isolation of hearing loss. If hearing aids are working so that the client can clearly hear a choir, psychosocial issues may be less of a problem. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Psychosocial Integrity (Grief and Loss) MSC: Integrated Process: Nursing Process (Assessment)

2. The nurse is teaching a postoperative client who had a keratoplasty. Which responses by the client require further teaching about safety in the home? (Select all that apply.) a. "We use throw rugs in the bathroom." b. "Our neighbors will be bringing food for a week." c. "We may have two extension cords in the living room." d. "Most of the furniture is placed against the wall, except for one rocking chair." e. "Every room has at least one window." f. "The hallway has low lighting."

ANS: A, C, D, F Throw rugs pose a danger of slipping or tripping. The client cannot see if the rug is flat or elevated. Extension cords should be placed under or behind the furniture to decrease the possibility of tripping. Furniture should be out of the normal walking pathway. Low lighting in the hallway may pose a problem when the client has a patch and shield over the operated eye. Lighting from a window should not be a problem. When neighbors bring food, the chance of burns occurring while cooking with limited vision is reduced. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Health Promotion and Maintenance (Self-Care) MSC: Integrated Process: Nursing Process (Evaluation)

MULTIPLE RESPONSE 1. The nurse is caring for an older client who presents with dizziness and difficulty hearing. Which of the nurse's assessment findings will require collaboration with the client's primary health care provider? (Select all that apply.) a. Tympanic membrane is retracted, with multiple air bubbles. b. The client reports inability to hear high-frequency voices and sounds. c. Clear watery drainage is present in the ear canal and is positive for glucose. d. Tympanic membrane is shiny and translucent, with light reflex noted. e. Hearing test indicates positive Rinne test, with AC > BC noted bilaterally. f. The client reports dizziness after taking naproxen (Aleve) for arthritis pain.

ANS: A, C, F Aleve can cause ototoxicity, which can present as dizziness. Retraction of the tympanic membrane with air bubbles indicates an ear infection, which may be treated with antibiotics. Clear, watery, glucose-positive drainage from the ear canal suggests a basal skull fracture. An inability to hear high-frequency voices and sounds are commonly found in older adults as normal age-related changes. A shiny, translucent, tympanic membrane with a light reflex is a normal assessment finding, as is a positive Rinne test with AC > BC noted bilaterally. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Alterations in Body Systems) MSC: Integrated Process: Nursing Process (Assessment)

11. The nurse is assessing the blink reflex in a client who is blind. Which is the best technique to use? a. Ask the client to blink first with one eye and then with the other. b. Expel a syringe of air toward the client's eyes. c. Shine a bright light at the client's pupils one at a time. d. Suddenly bring a finger toward the client's face.

ANS: B A blind client cannot respond with a blink reflex to visually threatening movements such as bright light or bringing a finger toward the client. Air blowing suddenly at the eye should elicit the blink reflex as a protective response. Asking the client to blink first with one eye and then with the other will not elicit the blink reflex. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—System-Specific Assessments) MSC: Integrated Process: Nursing Process (Assessment)

6. A client is recovering from cataract surgery and needs medication to prevent a potential eye infection. Which drug does the nurse question administering to the client? a. Tobramycin (Tobrex) b. Apraclonidine (Iopidine) c. Gentamicin (Genoptic) d. Ciprofloxacin (Ciloxan)

ANS: B Apraclonidine is an adrenergic agonist that binds to eye receptors to reduce the amount of aqueous humor in the eye, resulting in decreased intraocular pressure. This medication usually is administered to clients with glaucoma. Tobramycin, gentamicin, and ciprofloxacin are anti-infectives. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies—Expected Actions/Outcomes) MSC: Integrated Process: Nursing Process (Implementation)

4. Which statement indicates that the client understands teaching about the use of aspirin post-cataract surgery? a. "It may increase intraocular pressure after cataract surgery." b. "It changes the ability of the blood to clot and increases the risk of bleeding." c. "It reduces inflammation and might mask any symptoms of infection." d. "It can cause nausea and vomiting and may increase intraocular pressure."

ANS: B Aspirin disrupts platelet aggregation and increases the risk for bleeding after surgery. Aspirin may decrease inflammation but would not mask symptoms of infection. Aspirin does not cause increased intraocular pressure, nor does it typically cause nausea and vomiting. Aspirin should not mask signs of infection. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies—Adverse Effects/Contraindications/Side Effects/Interactions) MSC: Integrated Process: Nursing Process (Evaluation)

21. The nurse is assessing a client's eyes. Which is the first step for the nurse in this procedure? a. Explain the procedure. b. Wash the hands. c. Assess for infections. d. Use the Snellen chart.

ANS: B Before examining a client's eyes, the examiner should wash his or her hands. This is done to prevent contamination of the eye and structures. The nurse could then proceed to explain any procedure, assess infection, or assess visual acuity using the Snellen chart. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Safe and Effective Care Environment (Safety and Infection Control—Standard Precautions/Transmission-Based Precautions/Surgical Asepsis) MSC: Integrated Process: Nursing Process (Implementation)

7. The nurse is caring for a client who has experienced a stroke. Which nursing intervention for nutrition does the nurse implement to prevent complications from cranial nerve IX impairment? a. Turn the client's plate around halfway through the meal. b. Place the client in high Fowler's position. c. Order a clear liquid diet for the client. d. Verbalize the placement of food on the client's plate.

ANS: B Cranial nerve IX, the glossopharyngeal nerve, controls the gag reflex. Clients with impairment of this nerve are at great risk for aspiration. The client should be in high Fowler's position and should drink thickened liquids if swallowing difficulties are present. The client would not have vision problems. Turning the plate around would not prevent a complication, nor would limiting the client's diet to clear liquids. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications from Surgical Procedures and Health Alterations) MSC: Integrated Process: Nursing Process (Implementation)

18. A teenager is admitted to the emergency department with a possible fracture of the left orbit after getting hit in the face with a baseball. All tests are negative and the client is being discharged. Which is important for the nurse to teach the client? a. "Keep an eye patch on the eye for 48 hours." b. "Always wear protective equipment to prevent eye damage." c. "Take aspirin if a headache should occur." d. "Do not do any heavy lifting for a week."

ANS: B If all tests are negative, restrictions on heavy lifting are not needed. An eye patch does not have to be worn. Acetaminophen (Tylenol) would be a better choice for a headache because aspirin promotes bleeding. The client and the family should be taught about protective equipment while playing sports (helmet and goggles). DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Health Promotion and Maintenance (Principles of Teaching/Learning) MSC: Integrated Process: Teaching/Learning

25. The nurse is assessing a client who was recently diagnosed with a meningioma. Which statement indicates that the client correctly understands the diagnosis? a. "This is the worst type of brain tumor, and surgery is not an option." b. "My tumor can be removed, but I can still have damage because of pressure in my brain." c. "Even after the surgery, I will need chemotherapy to decrease the spread of the tumor." d. "Radiation is never used on brain tumors because of possible nerve damage."

ANS: B Meningiomas arise from the coverings of the brain (the meninges) and are the most common type of benign tumor. This tumor is encapsulated, globular, and well demarcated, and causes compression and displacement of nearby brain tissue. Although complete removal of the tumor is possible, it tends to recur and causes irreversible damage to the brain. The tumor is not treated by chemotherapy or radiation. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Psychosocial Integrity (Therapeutic Communication) MSC: Integrated Process: Nursing Process (Evaluation)

20. The nurse is teaching a client how to apply eye medication. Which is the correct technique for applying ointment into the eye? a. From the middle out b. From the inner canthus to the outer canthus c. From the outer canthus to the inner canthus d. Against the inner aspect of the eyelid

ANS: B Ointment should be applied by pulling down the lower lid and forming a pocket. Application should proceed from the inner canthus toward the outer canthus, with the client tilting the head backward and looking up at the ceiling. DIF: Cognitive Level: Knowledge/Remembering REF: Chart 49-1, p. 1053 TOP: Client Needs Category: Safe and Effective Care Environment (Safety and Infection Control—Standard Precautions/Transmission-Based Precautions/Surgical Asepsis) MSC: Integrated Process: Nursing Process (Implementation)

24. The nurse assesses periorbital edema and ecchymosis around both eyes of a client who is 6 hours postoperative for craniotomy. Which intervention does the nurse implement for this client? a. Position the client with the head of the bed flat. b. Apply an ice pack to the affected area. c. Assess arterial blood pressure. d. Notify the health care provider.

ANS: B Periorbital edema and ecchymosis are expected after a craniotomy. The nurse should attempt to increase the client's comfort by reducing the swelling with application of ice. The provider does not need to be notified. Lowering the head of the bed and assessing blood pressure will not decrease inflammation. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications from Surgical Procedures and Health Alterations) MSC: Integrated Process: Nursing Process (Implementation)

12. The nurse assesses several clients. Which one is most likely to have secondary open-angle glaucoma? a. Client with gradual onset of blurred vision b. Client who has recently had eye surgery c. Client who sees halos around lights d. Client with reactive pupils and clear sclera

ANS: B Secondary open-angle glaucoma results from another condition that interferes with drainage of the aqueous humor such as recent eye surgery. Cataracts usually start with a slow onset of blurred vision but do not lead to secondary open-angle glaucoma. A late manifestation of primary open-angle glaucoma is seeing halos around lights

20. A client is told that he has 20/10 vision when tested on the Snellen chart. How does the nurse explain this finding to the client? a. "You can read at 10 feet what others can read at 20 feet." b. "You can read at 20 feet what others can read at 10 feet." c. "This demonstrates normal vision." d. "You are considered legally blind."

ANS: B The "20" is the point at which the client can see from the chart, and the "10" is the point at which a healthy eye can see from the chart. Normal vision is 20/20. DIF: Cognitive Level: Comprehension/Understanding REF: p. 1046 TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Diagnostic Tests) MSC: Integrated Process: Nursing Process (Assessment)

3. Which teaching is essential for a client who is going to have intraocular pressure measurement with a slit lamp? a. "The test causes temporary blindness." b. "The test is quick and a local anesthetic is used." c. "The test does cause a little pain, but it is over quickly." d. "The test causes some tearing, but no pain."

ANS: B The IOP test done with a slit lamp must have direct eye contact, which could cause discomfort, so a local anesthetic is used. The test is quick but does not cause temporary blindness. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Health Promotion and Maintenance (Health Screening) MSC: Integrated Process: Teaching/Learning

8. A client who had a brain attack was admitted to the intensive care unit yesterday. The nurse observes that the client is becoming lethargic and is unable to articulate words when speaking. What does the nurse do next? a. Check the client's blood pressure and apical heart rate. b. Elevate the back rest to 30 degrees and notify the health care provider. c. Place the client in a supine position with a flat back rest, and observe. d. Assess the client's white blood cell count and differential.

ANS: B The client is experiencing signs of increased intracranial pressure (ICP). Raising the head of the bed would help decrease ICP. The health care provider should then be notified immediately so that other interventions to reduce ICP can be instituted. Assessing vital signs and white blood cell count is not the priority at this time. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications from Surgical Procedures and Health Alterations) MSC: Integrated Process: Nursing Process (Implementation)

Chapter 50: Assessment of the Ear and Hearing Test Bank MULTIPLE CHOICE 1. The nurse notes that a client's tympanic membrane moves in response to air injected into the external canal. What is the nurse's best action? a. Notify the health care provider. b. Document the finding. c. Prepare to wash the external ear canal. d. Immediately remove the otoscope.

ANS: B The healthy ear should have a tympanic membrane that is mobile when air is injected into the external canal. This normal finding should be documented in the client's chart. Because the mobile tympanic membrane is an expected finding, the nurse does not need to remove the otoscope immediately from the client's ear canal. No cerumen is impacting the ear canal, so irrigation is not appropriate. The physician does not need to be notified about a normal finding. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—System-Specific Assessments) MSC: Integrated Process: Nursing Process (Assessment)

8. The nurse is performing vision screenings. Which client is at greatest risk for developing vision problems? a. Postpartum woman with no complications b. Young client who has diabetes mellitus c. Middle-aged adult who takes aspirin daily d. Older client with chronic dry eye syndrome

ANS: B The hyperglycemia that characterizes diabetes mellitus causes numerous vascular problems in the eye and damages the nerves. Although good control of blood glucose levels delays visual problems, it does not eliminate these problems in the diabetic population. Daily aspirin therapy does not place a client at risk for vision problems. Dry eyes are a common finding with older clients because tear production is decreased, but this does not necessarily interfere with the client's vision. Postpartum women should not be at risk for vision problems. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Health Promotion and Maintenance (Health Screening) MSC: Integrated Process: Nursing Process (Assessment)

13. The nurse is assessing a client for the possibility of a lens opacity. Which assessment finding confirms this problem? a. Increased intraocular pressure b. Absence of a red reflex c. Decreased central vision d. Positive corneal staining

ANS: B The red reflex is elicited with an ophthalmoscope and represents reflection of the ophthalmoscopic light through the lens onto the vascular retina. The absence of a red reflex strongly indicates a lens opacity that does not allow light to penetrate through to the retina. The other answers are not related to a lens opacity. Increased intraocular pressure is measured by tonometry and could indicate glaucoma. Decreased central vision is measured by a Snellen chart and a Jaeger card and indicates decreased visual acuity. Positive corneal staining with topical dye could indicate corneal abrasion. DIF: Cognitive Level: Comprehension/Understanding REF: p. 1049 TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology) MSC: Integrated Process: Nursing Process (Assessment)

16. The nurse is caring for a client admitted to the intensive care unit after incurring a basilar skull fracture. Which complication of this injury does the nurse monitor for? a. Aspiration b. Hemorrhage c. Pulmonary embolus d. Myocardial infarction

ANS: B This type of fracture may cause hemorrhage from damage to the internal carotid artery. The other problems are not complications of this injury. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications from Surgical Procedures and Health Alterations) MSC: Integrated Process: Nursing Process (Analysis)

12. The nurse is caring for a client who is immobile from a recent stroke. Which intervention does the nurse implement to prevent complications in this client? a. Position the client with the unaffected side down. b. Apply sequential compression stockings. c. Instruct the client to turn the head from side to side. d. Teach the client to touch and use both sides of the body.

ANS: B To avoid complications of immobility, such as deep vein thrombosis, the nurse applies sequential compression stockings or pneumatic compression boots. Efforts are made to mobilize the client as much as possible, and the client should be repositioned frequently. The other interventions will not prevent complications of immobility. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications from Surgical Procedures and Health Alterations) MSC: Integrated Process: Nursing Process (Implementation)

14. Which clinical manifestation alerts the nurse to the possibility of a vitreous humor hemorrhage? a. Presence of a red reflex b. Reddened whites of the eye c. Red haze or floaters in the line of vision d. Swelling of the upper and lower eyelids

ANS: C Mild seepage of blood into the vitreous humor causes the client's vision to have an overall red haze or floaters. With a vitreous humor hemorrhage, the red reflex is reduced. Reddened whites of the eye and swelling of the eyelids would indicate irritation and infection of the eye. DIF: Cognitive Level: Comprehension/Understanding REF: p. 1067 TOP: Client Needs Category: Health Promotion and Maintenance (Health Screening) MSC: Integrated Process: Nursing Process (Assessment)

15. The nurse is evaluating a client's technique for instilling eyedrops. Which behavior indicates that the client needs more teaching? a. Closing they eye after the drops are in b. Touching the eye with the tip of the dropper c. Allowing the drops to spread across the eye surface d. Getting the drops into the conjunctival pocket

ANS: B Touching the eye with the tip of the dropper contaminates the dropper and the medication. If the client has an infection in the eye that is touched, the dropper cannot even be used on the client's other eye. The other answers indicate correct technique. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies—Medication Administration) MSC: Integrated Process: Nursing Process (Evaluation)

6. The nurse is caring for a client who may have an ear infection. Which intervention is used to prevent spread of the infection to other clients? a. A new sterile otoscope speculum is used to examine each of the client's ears. b. The nurse washes his hands after removing hearing aids from the client's ears. c. Hearing aids are cleaned with alcohol before they are re-inserted into the client's ears. d. The tuning fork is cleaned with hydrogen peroxide before and after use with the client.

ANS: B Washing hands after removal of a hearing aid should prevent any spread of infection between clients. Hearing aids may harbor infectious microorganisms, especially in clients who may have an ear infection. The other answers pertain to the possible spread of infection from one ear to the other—not to other clients. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Safe and Effective Care Environment (Safety and Infection Control—Standard Precautions/Transmission-Based Precautions/Surgical Asepsis) MSC: Integrated Process: Nursing Process (Implementation)

10. The nurse assesses a client post-cataract surgery and finds white, dry, crusty drainage on the client's eyelid and lashes. What does the nurse do next? a. Obtain a specimen of the drainage for culture. b. Clean away the drainage and apply the prescribed drops. c. Contact the physician for an antibiotic order. d. Arrange for the client to be seen by the ophthalmologist today.

ANS: B White, dry, crusty drainage on the eyelid and lashes is expected after cataract surgery. Because the drainage is white and no other symptoms of infection are noted, a culture does not need to be done and an antibiotic will not be needed. Urgency is not an issue because this is an expected effect from the trauma of surgery. The physician does not need to be called. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications from Surgical Procedures and Health Alterations) MSC: Integrated Process: Nursing Process (Implementation)

MULTIPLE RESPONSE 1. The nurse is assessing the eye changes in an older adult. Which changes lead the nurse to consult with the health care provider? (Select all that apply.) a. Increasing difficulty perceiving greens, blues, and violets b. Increasing redness in the eyes c. Acute pain in the eyes d. Sudden change in acuity e. Need for additional lighting for reading f. Need to hold newspaper farther away to read

ANS: B, C, D Increasing redness, acute pain, and sudden changes in acuity represent manifestations that might be indicative of a more serious complication and need the provider's evaluation. Delay could cause harm. The other signs are associated with the aging process and do not require immediate evaluation. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Health Promotion and Maintenance (Health Screening) MSC: Integrated Process: Nursing Process (Implementation)

3. A blind client is admitted to the hospital unit. Orientation to the unit includes which information? (Select all that apply.) a. Introduce the staff to the client. b. Describe the room to the client using one reference point. c. Walk the client to the bathroom and describe it. d. Tell the client to use the call light if he or she wants to go to the bathroom. e. Explain the routine of the unit and how to operate the bed controls. f. Assist in putting the client's belongings away.

ANS: B, C, E, F The client needs to know where everything is located to be independent and safe from falls. Clients need to be shown where things are and how to do things such as turn on the call light and raise the head of the bed. The client should be introduced to the staff, not the reverse, and should first be shown how to use the call light. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Safe and Effective Care Environment (Safety and Infection Control—Accident/Injury Prevention) MSC: Integrated Process: Nursing Process (Implementation)

14. A client is scheduled for electroretinography. Which statement indicates that the client understands the teaching about this procedure? a. "I will wear dark glasses in sunlight to prevent eye pain." b. "I am going to drink at least 3 liters of water to flush the dye out of my system." c. "I will avoid rubbing my eyes until the anesthetic drops have worn off." d. "I will not drive for the first 24 hours after the procedure."

ANS: C A local anesthetic agent is used for this procedure because an electrode is placed on the cornea. The client could inadvertently scratch or harm the eye by touching or rubbing it while the anesthetic effect is present. No eye pain should be noted with this procedure, no dye is used, and restricting driving for 24 hours is not necessary. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Diagnostic Tests) MSC: Integrated Process: Teaching/Learning

23. A client just underwent a keratoplasty. Which activity does the nurse suggest that the client begin possibly 1 week after surgery? a. Continue with salsa dance lessons. b. Jog only one-half mile versus the usual 2 miles. c. Return to employment as a receptionist. d. Help the family move furniture from room to room.

ANS: C Activities that raise the intraocular pressure (e.g., jogging, dancing, any movement that can cause jerky head motion) should be discouraged for at least 3 weeks after surgery. No heavy lifting should be done for 6 to 8 weeks. A sedentary job such as a receptionist can be tolerated a week after surgery. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Health Promotion and Maintenance (Self-Care) MSC: Integrated Process: Teaching/Learning

13. Which statement made by a client after corneal transplantation indicates a need for further teaching? a. "I will wear an eye shield at night for at least 1 month." b. "I will avoid bending at the waist and straining when moving my bowels." c. "I won't worry if I have increased tearing, because it is normal." d. "I'll notify the ophthalmologist if any signs of rejection occur."

ANS: C Aqueous humor can leak from the incision site if wound closure is incomplete. Any fluid coming from the eye in the early postoperative period needs to be checked by the provider. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications from Surgical Procedures and Health Alterations) MSC: Integrated Process: Nursing Process (Evaluation)

Chapter 47: Care of Critically Ill Patients with Neurologic Problems Test Bank MULTIPLE CHOICE 1. The nurse is obtaining a health history for a client admitted to the hospital after experiencing a brain attack. Which disorder does the nurse identify as a predisposing factor for an embolic stroke? a. Seizures b. Psychotropic drug use c. Atrial fibrillation d. Cerebral aneurysm

ANS: C Clients with a history of hypertension, heart disease, atrial fibrillation, diabetes, obesity, and hypercoagulopathy are at risk for embolic stroke. The other disorders are not risk factors for an embolic stroke. DIF: Cognitive Level: Knowledge/Remembering REF: p. 1012 TOP: Client Needs Category: Health Promotion and Maintenance (Health Screening) MSC: Integrated Process: Nursing Process (Assessment)

11. A client who had a stroke is receiving clopidogrel (Plavix). Which adverse effect does the nurse monitor for in this client? a. Repeated syncope b. New-onset confusion c. Spontaneous ecchymosis d. Abdominal distention

ANS: C Clopidogrel (Plavix) is an antiplatelet medication that can cause bleeding, bruising, and liver dysfunction. The nurse should be alert for signs of bleeding, such as ecchymosis, bleeding gums, and tarry stools. Plavix does not cause syncope, confusion, or abdominal distention. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies—Adverse Effects/Contraindications/Side Effects/Interactions) MSC: Integrated Process: Nursing Process (Evaluation)

11. Which statement indicates that a client needs additional teaching about ear hygiene? a. "I will wash my hands before I put in my earplugs at work." b. "I will clean my ears with plain warm water and a washcloth every day." c. "I will use a cotton swab to get the extra water out of my ears after I swim." d. "I can rinse my ears with half-strength hydrogen peroxide if ear wax builds up."

ANS: C Cotton swabs should not be inserted into the ear canal because injury to the tympanic membrane can result. The cotton swab can push cerumen deeper into the ear canal, possibly resulting in impaction. Hands should always be washed before earplug insertion to prevent ear infection. Ears should be cleaned with plain warm water and a washcloth to prevent irritation of the ear canal. The ears may be safely rinsed with half-strength hydrogen peroxide to remove excess ear wax within the ear canal. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Health Promotion and Maintenance (Self-Care) MSC: Integrated Process: Nursing Process (Evaluation)

9. Which is the best assessment question for the nurse to ask a client with tinnitus? a. "How exactly do you clean your ears?" b. "Have you had your hearing checked lately?" c. "Do you have ringing in both ears or in only one ear?" d. "Does the ringing make it hard for you to sleep at night?"

ANS: C Determining whether the tinnitus is in one or both ears provides valuable information about the cause of the problem. Tinnitus is not related to how the client cleans his or her ears. Asking about the last hearing check will not help determine the cause of the tinnitus. Asking about nighttime tinnitus is helpful but is less important than asking if the problem is present in one or both ears. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Alterations in Body Systems) MSC: Integrated Process: Nursing Process (Assessment)

23. The nurse is planning the discharge of a client who has sustained a moderate head injury and is experiencing personality and behavior changes. The client's wife states, "I am concerned about how different he is. What can I do to help with the transition back to our home?" How does the nurse respond? a. "Be firm and let him know when his behavior is unacceptable." b. "Minimizing the number of visitors will help stabilize his personality." c. "Developing a routine will help provide him with a structured environment." d. "He will return to his normal emotional functioning in 6 to 12 months."

ANS: C Developing a home routine that provides structure and repetition is recommended because clients with personality and behavior problems respond best to this type of environment. The client's personality and emotional functioning will never return to normal. The client may be aggressive, and family members must be aware of potential client reactions. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Psychosocial Integrity (Family Dynamics) MSC: Integrated Process: Teaching/Learning

9. The nurse is caring for a client who had a stroke. Which nursing intervention does the nurse implement during the first 72 hours to prevent complications? a. Administer prescribed analgesics to promote pain relief. b. Cluster nursing procedures together to avoid fatiguing the client. c. Monitor neurologic and vital signs closely to identify early changes in status. d. Position with the head of the bed flat to enhance cerebral perfusion.

ANS: C Early detection of neurologic, blood pressure, and heart rhythm changes offers an opportunity to intervene in a timely fashion. Evidence is not yet sufficient to recommend a specific back rest elevation after stroke. Analgesics are often held during the first 72 hours to ensure that the client's neurologic status is not altered by pain medications. Preventing fatigue is not a priority in the first 72 hours. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications from Surgical Procedures and Health Alterations) MSC: Integrated Process: Nursing Process (Analysis)

7. The nurse is caring for a client who is hard of hearing. Which intervention best helps the client with communication? a. Speaking loudly and adding extra inflections to the tone of voice b. Bending over the client so that he or she can see the nurse's lips more easily c. Closing the door to the room and making sure that lighting is adequate d. Asking the client's spouse to answer questions that are not heard by the client

ANS: C Environmental noise decreases the hearing-impaired client's ability to hear conversation. The room should be adequately lit so the client can read supplemental written notes. Bending down to the client may be seen as condescending or offensive. Speaking loudly, with extra inflections, can actually make it harder for the client to understand the nurse. The nurse should not bend over the client and should instead sit to meet the client's eye level. The client's spouse should be used only as a last resort if no other means of communication are possible. DIF: Cognitive Level: Comprehension/Understanding REF: p. 1080 TOP: Client Needs Category: Psychosocial Integrity (Therapeutic Communication) MSC: Integrated Process: Communication and Documentation

16. The nurse is educating a client about the instillation of eyedrops. Which client statement indicates the need for additional teaching? a. "Squeezing my eye tightly after I put the drops in may force the drops out of my eye too quickly." b. "If the drops are kept in the refrigerator, I will be able to tell when they are in my eye because they will feel cold." c. "My sister has the same prescription, so we can use the same bottle of eyedrops." d. "I will wash my hands before I use these eyedrops."

ANS: C Eyedrops or eye ointment should never be shared because of the risk of spreading infection. The other answers indicate correct technique. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies—Medication Administration) MSC: Integrated Process: Nursing Process (Evaluation)

3. Which client is at highest risk for hearing loss? a. Client with heart failure receiving digoxin (Lanoxin), 0.125 mg orally daily b. Client with asthma receiving high-dose methylprednisolone (Solu-Medrol) therapy c. Client with osteomyelitis receiving IV gentamicin (Garamycin) d. Client with hyperkalemia being treated with intravenous glucose and insulin

ANS: C Gentamicin is an aminoglycoside that can cause ototoxicity. Assessment of hearing should be done before and during therapy. Digoxin, methylprednisolone, and insulin do not put the client at risk for hearing loss. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies—Adverse Effects/Contraindications/Interactions/Side Effects) MSC: Integrated Process: Nursing Process (Assessment)

6. The nurse is assessing extraocular eye movements (EOMs) in an older adult client and finds that the client is unable to sustain an upward gaze for longer than 2 seconds. What does the nurse do next? a. Repeat the test while holding the client's head in a fixed position. b. Perform a cover-uncover eye test. c. Document the finding and continue assessing. d. Assess for additional signs of impending brain attack.

ANS: C In the older adult, decreased muscle tone impairs the ability to maintain an upward gaze and to sustain convergence. Therefore, this finding is normal for an older adult client. The nurse would not repeat the test or hold the client's head in a fixed position. The nurse would document the finding and continue to assess. This would not be a cause for concern, nor would it be a symptom of impending brain attack. The cover-uncover test is used for determining the degree of peripheral vision. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Alterations in Body Systems) MSC: Integrated Process: Nursing Process (Assessment)

22. A client is having intraocular pressure measured for both eyes. Which response by the client best indicates that the client understands why this is necessary every year? a. "Elevated eye pressure can cause high blood pressure." b. "If eye pressure is too high, your eyes will dry out." c. "Elevated eye pressure can press on blood vessels in the eye." d. "Increased eye pressure causes the tear ducts to become blocked."

ANS: C Intraocular pressure is the pressure generated by the fluids inside the globe of the eye. As intraocular pressure increases to above normal, it compresses the blood vessels and the optic nerves. As the blood vessels are compressed, oxygenation to the internal eye structures, including the nerves and photoreceptors, is diminished. The nerves and photoreceptors require a constant supply of oxygen and will die if blood flow is inadequate, leading to blindness. The other statements are inaccurate. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Diagnostic Tests) MSC: Integrated Process: Teaching/Learning

Chapter 49: Care of Patients with Eye and Vision Problems Test Bank MULTIPLE CHOICE 1. A client is using an ophthalmic beta-blocking agent for the treatment of glaucoma. Which instruction does the nurse give to the client to prevent orthostatic hypotension? a. "Change positions quickly after administering the drops." b. "Take your pulse at least four times daily." c. "Apply pressure to the inside corner of your eye when administering the drops." d. "Lay down for 10 minutes after administering the drops."

ANS: C Nasal punctal occlusion during eyedrop instillation keeps the drug in contact with the eye structures longer and decreases systemic absorption and side effects. Systemic distribution of the drug is what may cause orthostatic hypotension. The other answers will not help prevent orthostatic hypotension. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies—Adverse Effects/Contraindications/Side Effects/Interactions) MSC: Integrated Process: Nursing Process (Implementation)

12. The nurse is performing an eye assessment on a client. Which finding confirms normal accommodation during visual assessment? a. Both pupils constrict when a light is shined at one eye. b. The client blinks in response to a threatening movement. c. Both pupils constrict when focusing on an object being moved in toward the nose. d. The client is able to hold an upward gaze without moving the head for 15 seconds.

ANS: C Normal accommodation is seen when the client's eyes converge. The pupils constrict when the client focuses on an object that is being moved from about 18 cm from the client's nose in closer toward the nose. Consensual response occurs when both pupils constrict after a light is shined at one eye. The blink reflex occurs in response to a sudden movement. Extraocular muscle function is tested when the client is asked to hold an upward gaze while keeping the head still. DIF: Cognitive Level: Comprehension/Understanding REF: p. 1046 TOP: Client Needs Category: Health Promotion and Maintenance (Health Screening) MSC: Integrated Process: Nursing Process (Assessment)

17. A client with presbyopia asks her nurse about corrective lenses. Which is the nurse's best response? a. "This type of problem cannot be helped with corrective lenses." b. "Corrective lenses are needed for both near and distance vision." c. "Corrective lenses can be used for reading and close work." d. "Corrective lenses are needed for distance only."

ANS: C Presbyopia is caused by stiffening of the lens as a result of water loss as the lens ages. Consequently, the lens does not refract as well and light waves converge behind the retina—a condition similar to farsightedness (hyperopia). The condition makes near vision blurry. Corrective lenses for presbyopia increase light wave refraction and are used for reading or close work. Therefore the other answers are incorrect. Presbyopia can be helped with corrective lenses but only for near vision, not for distance vision. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Alterations in Body Systems) MSC: Integrated Process: Nursing Process (Implementation)

17. A client who has a head injury is transported to the emergency department. Which assessment does the emergency department nurse perform immediately? a. Pupil response b. Motor function c. Respiratory status d. Short-term memory

ANS: C Respiratory derangements (e.g., hypoxemia, hypercarbia, alterations in pH) can contribute to secondary brain injury in this scenario. Therefore, the important priority is assessment of respiratory status so that secondary brain injury conditions are avoided. The other assessments should be performed after effective respiratory functions have been established. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications from Surgical Procedures and Health Alterations) MSC: Integrated Process: Nursing Process (Assessment)

4. The nurse is caring for an older adult client with sensorineural hearing loss. Which assessment finding does the nurse correlate with the client's health history? a. History of frequent ear infections b. Swims frequently c. Worked in a sawmill for the last 20 years d. Had a tumor removed from his left eardrum last year

ANS: C Sensorineural hearing loss is caused by damage to the cochlear hair cells. This damage may be caused by exposure to loud noises, including noise from machinery in factories or sawmills. Tumor removal from the eardrum, swimming, and ear infections do not increase the risk for sensorineural hearing loss because conduction of sound through the nerves is not affected. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—System-Specific Assessments) MSC: Integrated Process: Nursing Process (Assessment)

13. A client asks the nurse why there is "waxy yellow stuff" on the cotton swab when he cleans his ears. Which is the nurse's best response? a. "The yellow ear wax helps transmit sound to your middle ear." b. "The yellow ear wax indicates that you have an infection in your ears." c. "The yellow ear wax helps protect and lubricate the inside of your ear canal." d. "The yellow ear wax builds up when you don't clean your ears often enough."

ANS: C The ear canal is lined with ear wax (cerumen), which offers protection and lubrication. Ear wax does not help with sound transmission and does not indicate ear infection or buildup because of infrequent cleaning. DIF: Cognitive Level: Comprehension/Understanding REF: p. 1078 TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology) MSC: Integrated Process: Teaching/Learning

14. A client who has had a stroke with left-sided hemiparesis has been referred to a rehabilitation center. The client asks, "Why do I need rehabilitation?" How does the nurse respond? a. "Rehabilitation will reverse any physical deficits caused by the stroke." b. "If you do not have rehabilitation, you may never walk again." c. "Rehabilitation will help you function at the highest level possible." d. "Your doctor knows best and has ordered this treatment for you."

ANS: C The goal of rehabilitation is to maximize the client's abilities in all aspects of life. The other responses do not answer the client's question appropriately. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Health Promotion and Maintenance (Principles of Teaching/Learning) MSC: Integrated Process: Teaching/Learning

18. The nurse is caring for a client who has a moderate head injury. The client's sister asks, "Will my brother return to his normal functioning level when his brain heals?" How does the nurse respond? a. "You should expect a full recovery in all ways by the time of discharge." b. "Usually, someone with this type of injury returns to baseline within 6 months." c. "Your brother may experience many changes in personality and cognitive abilities." d. "Learning complex new skills may be more difficult, but you can expect other functions to return to normal."

ANS: C Those with moderate to severe head injuries are never the same as before the injury. They can experience changes in cognition such as memory loss, difficulty learning new information, and limited concentration. Personality alterations such as outbursts of temper and depression also may occur. The other responses do not correctly answer the question and can give false hope. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Psychosocial Integrity (Therapeutic Communication) MSC: Integrated Process: Nursing Process (Implementation)

15. The nurse is teaching bladder training to a client who is incontinent after a stroke. Which instruction does the nurse include in this client's teaching? a. "Decrease your oral intake of fluids to 1 liter per day." b. "Use a Foley catheter at night to prevent accidents." c. "Plan to use the commode every 2 hours during the day." d. "Hold your bladder as long as possible to restore bladder tone."

ANS: C To begin a bladder training program, teach the client to use the commode, bedpan, or urinal every 2 hours. If used frequently enough, this will prevent accidents and establish a routine. Fluid intake should be restricted at night, and a Foley catheter should be used only for urine retention. The client should empty his or her bladder when the urge occurs and should not hold the bladder. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Illness Management) MSC: Integrated Process: Teaching/Learning

19. A client who has a severe head injury is placed in a drug-induced coma. The client's husband states, "I do not understand. Why are you putting her into a coma?" How does the nurse respond? a. "These drugs will prevent her from experiencing pain when positioning or suctioning is required." b. "This medication will help her remain cooperative and calm during the painful treatments." c. "This medication will decrease the activity of her brain so that additional damage does not occur." d. "This medication will prevent her from having a seizure and will reduce the need for monitoring intracranial pressure."

ANS: C When intracranial pressure cannot be controlled by other means, clients may be placed in a barbiturate coma to decrease cerebral metabolic demands, decrease formation of vasogenic edema, and produce a more uniform blood supply to the brain. The other responses do not correctly explain the reason for a medication-induced coma. Pain medication should be administered when the client is comatose. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Illness Management) MSC: Integrated Process: Teaching/Learning

MULTIPLE RESPONSE 1. A client with acute-angle glaucoma has several medications ordered. Which medications does the nurse question? (Select all that apply.) a. Acetazolamide (Diamox) b. Pilocarpine (Pilocar) c. Atropine (Isopto Atropine) d. Latanoprost (Xalatan) e. Timolol (Timoptic) f. Epinephrine

ANS: C, F Atropine and epinephrine are mydriatics, which decrease the outflow of aqueous humor, resulting in increased intraocular pressure (IOP). Diamox is a carbonic anhydrase inhibitor that decreases the formation of aqueous humor. Pilocar is a miotic that enhances outflow of aqueous humor. Xalatan is a prostaglandin agonist that improves outflow, and Timoptic is a beta blocker that decreases the formation of aqueous humor. All these help decrease IOP. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies—Expected Actions/Outcomes) MSC: Integrated Process: Nursing Process (Implementation)

9. A client relates that the vision in the left eye is greatly decreased from the day before. What does the nurse do first? a. Assess current medications. b. Patch the left eye. c. Notify the ophthalmologist. d. Perform an in-depth interview.

ANS: D A client with a sudden or persistent loss of vision needs to undergo a complete history and assessment first to identify the possible cause. Information such as current medications must be available before the ophthalmologist is called. The nurse cannot patch the left eye without completing an interview first. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Diagnostic Tests) MSC: Integrated Process: Nursing Process (Assessment)

22. The nurse is triaging clients in the emergency department. Which clients require immediate attention by an ophthalmologist? a. Older client with an intraocular pressure (IOP) of 15 b. Confused client in need of an ophthalmoscopic examination c. Young client with dry drainage from one eye d. Middle-aged client with recent onset of eye pain

ANS: D A client with abrupt onset of eye pain should be the priority because of possible underlying pathology causing the symptom. An IOP of 15 is within the normal range (10 to 21)

19. An anxious adult client asks why she needs to have intraocular pressure tested every year. What is the best response from the nurse? a. "Many changes can occur because of aging." b. "If the pressure is too low, you will be blind." c. "If the pressure is too high, blood will not flow through the eye." d. "Loss of vision can occur if the pressure is too high or too low."

ANS: D Although all responses are somewhat correct, explaining the outcome of abnormal pressure is to the point and is done at the client's level of understanding, especially if she is anxious about the test. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Diagnostic Tests) MSC: Integrated Process: Teaching/Learning

3. An older adult client who has a mature cataract in the right eye states, "Now I have lost the sight in my right eye because I waited too long for treatment." How does the nurse best respond to the client? a. "Yes, this type of blindness could have been prevented by earlier treatment." b. "It is fortunate you came for treatment in time to save the sight of your other eye." c. "Nothing you could have done would have made any difference." d. "Surgery can still save the sight in your eye with removal of the cataract."

ANS: D Although sight is increasingly impaired as a cataract matures, no other damage is done to the eye by waiting. Removal of the cataract will result in improved vision, regardless of how long the cataract has been present. No indication suggests that the client will develop a cataract in the other eye. The other statements are inaccurate. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Psychosocial Integrity (Grief and Loss) MSC: Integrated Process: Nursing Process (Caring)

9. A client has been educated about activities that can increase intraocular pressure. Which statement indicates that the client requires further teaching? a. "I will avoid wearing tight shirt collars and ties." b. "I will take stool softeners daily to prevent straining." c. "I will try not to sneeze, cough, or blow my nose." d. "I will not put my arms above my head."

ANS: D Arm position does not influence intraocular pressure. All other activities listed decrease the incidence of increased intraocular pressure. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications from Surgical Procedures and Health Alterations) MSC: Integrated Process: Nursing Process (Evaluation)

5. Which assessment alerts the nurse to the possible presence of a cataract in a client? a. Loss of central vision b. Loss of peripheral vision c. Dull aching in the eye and brow areas d. Blurred vision and reduced color perception

ANS: D As the lens becomes opaque and less able to refract light appropriately, the client experiences blurred vision and a reduced ability to distinguish among different colors. The development of a cataract does not typically cause loss of peripheral or central vision, nor does it result in aching in the brow area. DIF: Cognitive Level: Comprehension/Understanding REF: p. 1060 TOP: Client Needs Category: Health Promotion and Maintenance (Health Screening) MSC: Integrated Process: Nursing Process (Assessment)

21. A client has conjunctivitis in both eyes and is being treated with topical antibiotics. Which statement by the client indicates a need for further teaching? a. "I'll avoid sharing washcloths or towels with other family members." b. "I will wash my hands after applying the eye ointment to each eye." c. "I will call the ophthalmologist if the drainage continues after the antibiotics are started." d. "I'll use the same tube of topical ointment for each infected eye."

ANS: D Bacterial conjunctivitis is highly contagious

5. A client who had a stroke combs her hair only on the right side of her head and washes only the right side of her face. How does the nurse interpret these actions? a. Poor left-sided motor control b. Paralysis or contractures on the right side c. Limited visual perception of the left fields d. Unawareness of the existence of her left side

ANS: D Clients who have experienced a right hemisphere stroke often have neglect syndrome, in which they are unaware of the existence of the paralyzed side, or the left side. This injury would not have an effect on the client's sight. This is not related to poor motor control or paralysis. DIF: Cognitive Level: Comprehension/Understanding REF: p. 1011 TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Potential for Alterations in Body Systems) MSC: Integrated Process: Nursing Process (Analysis)

3. The nurse is caring for an 80-year-old client who presented to the emergency department in a coma. Which question does the nurse ask the client's family to help determine whether the coma is related to a brain attack? a. "How many hours does your mother usually sleep at night?" b. "Did your mother complain recently of weakness in her lower extremities?" c. "Is any history of seizures known among your mother's immediate family?" d. "Does your mother drink any alcohol or take any medications?"

ANS: D Conditions such as drug or alcohol intoxication, as well as hypoxemia and metabolic disturbances, can cause profound changes in level of consciousness (LOC) when accompanied by a brain attack. Alcohol abuse and medication toxicity can be especially problematic in older adults. The other manifestations are related to a stroke but would not increase the client's risk of coma. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology) MSC: Integrated Process: Nursing Process (Assessment)

8. The nurse is teaching a client about home care after cataract surgery. Which statement indicates that the client requires further teaching? a. "I am glad that I don't need an eye patch after the surgery." b. "I will try a cool compress to decrease the swelling around the operated eye." c. "Dark sunglasses will be necessary when I am in the sun." d. "Pain, nausea, and vomiting are normal after this surgery."

ANS: D Eye pain accompanied by nausea and vomiting is an indication of increased intraocular pressure and/or hemorrhage. This is an emergent situation and the surgeon must be contacted by the client. The other responses are correct. The client will not need an eye patch, cool compresses will decrease the slight swelling, and dark glasses are necessary outdoors until the pupil responds to sunlight. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications from Surgical Procedures and Health Alterations) MSC: Integrated Process: Nursing Process (Evaluation)

2. During assessment of an older adult, which finding does the nurse immediately report to the health care provider? a. Yellowing or bluing of the sclera b. Lack of discrimination between green and violet c. An opaque, bluish-white ring within the outer edge of the cornea d. Pupil constriction in response to light occurring in 2 seconds

ANS: D In an older client, it is normal for the sclera to turn yellow or blue with aging. It is also common for the older adult to have problems discriminating between the colors of green, blue, and violet. Arcus senilis, an opaque, bluish-white ring on the edge of the cornea, is a common occurrence in the older adult. This does not cause vision loss. Pupil constriction as a reaction to light should occur in less than 1 second. If pupil constriction takes longer, then the reaction is considered sluggish and should be reported to the provider. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Alterations in Body Systems) MSC: Integrated Process: Nursing Process (Assessment)

16. A client with macular degeneration would like to watch television. Where does the nurse place the television for best visualization of the screen? a. As close to the client's face as possible b. As far away as possible, with low lights c. Directly in front of the client d. On either side of the client

ANS: D Macular degeneration decreases central vision but usually does not affect peripheral vision. Clients looking straight ahead can see people and objects off to the side. Therefore the television should be placed on either side of the client. The other options would not help the client with macular degeneration to see the screen. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Health Promotion and Maintenance (Self-Care) MSC: Integrated Process: Teaching/Learning

21. A client with a head injury is being given midazolam (Versed) while on mechanical ventilation. Which action does the nurse implement for this client? a. Monitor for seizures. b. Assess for urinary output. c. Provide a clear liquid diet. d. Administer an analgesic.

ANS: D Midazolam (Versed) is a benzodiazepine agent and has no analgesic effect. It should be given with pain medication. This medication does not increase the risk of seizures and does not decrease urinary output. Clients should not be fed when being mechanically ventilated. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies—Expected Actions/Outcomes) MSC: Integrated Process: Nursing Process (Implementation)

8. Which statement indicates that a client needs additional teaching about protecting the ears and preventing hearing loss? a. "I will start a smoking cessation program and will take a multivitamin every day." b. "I will wear earplugs whenever I cut the grass or use my snow blower." c. "I will blow my nose gently, one nostril at a time, whenever I get a cold or the flu." d. "I will take Motrin (ibuprofen) instead of Tylenol (acetaminophen) for pain."

ANS: D Motrin (ibuprofen) can be ototoxic. Its use should be avoided to help prevent additional hearing loss. Blowing the nose gently can help prevent damage to the tympanic membrane. Smoking reduces oxygen supply to the cochlea, possibly increasing damage to the sensory cells, and should be avoided. Clients should use earplugs whenever they are exposed to loud noises to help prevent cochlear hair cell damage. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Health Promotion and Maintenance (Health and Wellness) MSC: Integrated Process: Nursing Process (Evaluation)

18. A client has just returned from having surgery, and sulfahexafluoride gas was used intraocularly. How does the nurse position the client? a. Completely supine, with sandbags beside the head b. On the nonoperative side in the Trendelenburg position c. On the operative side in the Trendelenburg position d. On the abdomen, with the affected eye up

ANS: D Sulfahexafluoride gas has a lower specific gravity than the vitreous humor. It will float to the highest position. The client should be positioned so that the gas will float up and against the newly reattached retina. The other positions are incorrect after this procedure. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications from Surgical Procedures and Health Alterations) MSC: Integrated Process: Nursing Process (Implementation)

7. Which statement indicates that a client understands why his cataract surgery is being done first on the eye with the poorest vision? a. "Insurance reimbursement dictates the timing of surgeries." b. "The eye with poorer vision is at greater risk for permanent damage." c. "The pressure in the poorer eye could increase, causing permanent damage." d. "If a complication arises in that eye, I will still have some vision in the better eye."

ANS: D The eye with the better sight is left alone until the outcome of the first surgery is known to reduce the chance that the client will lose sight in both eyes if complications arise from the surgery. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications from Surgical Procedures and Health Alterations) MSC: Integrated Process: Nursing Process (Evaluation)

7. The nurse is assessing an older adult client whose irises no longer fully dilate. What is the best intervention for the nurse to suggest? a. "Wear dark glasses whenever you are outside." b. "Use eyedrops on a regular basis to prevent dryness." c. "Avoid rubbing your eyes to prevent corneal abrasions." d. "Turn up room lights when reading or doing close work."

ANS: D With increasing age, the iris has less ability to dilate and clients have difficulty adapting to a darker environment. Older adult clients may need additional light for reading. Wearing dark glasses will not assist the client, and no indication suggests that the client's eyes are dry. Rubbing the eyes should not cause corneal abrasions. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Alterations in Body Systems) MSC: Integrated Process: Teaching/Learning