Chapter 52: Care of the Patient with a Sensory Disorder

46. What is the first nursing intervention step for the immediate care of a patient with a penetrating wound of the eye? A. Assess eye, do not remove object B. Cover both eyes with an eye shield or cup C. Lay the patient down flat D. Check for the irregularity of the pupil E. Obtain medical attention immediately

ANS. C. Lay the patient down flat

45. What is the most interior part of the eye? A. Choroid B. Córnea C. Aqueous humor D. Retina E. Lens F. Iris

ANS: A. Choroid

43. Arrange the parts of the eye from the exterior to the most interior. (Separate letters by a comma and space as follows: A, B, C, D) a. Choroid b. Cornea c. Aqueous humor d. Retina e. Lens f. Iris

ANS: B, C, F, E, D, A The cornea is the outermost, followed by the aqueous humor, iris, lens, retina, and the choroid. PTS: 1 DIF: Cognitive Level: Application REF: Page 1840, Figure 52-1 OBJ: 2 TOP: Eye structure KEY: Nursing Process Step: Assessment

44. Place the nursing intervention in appropriate order for the immediate care of a patient with a penetrating wound of the eye. (Separate letters by a comma and space as follows: A, B, C, D) a. Assess eye, do not remove object b. Cover both eyes with an eye shield or cup c. Lay the patient down flat d. Check for the irregularity of the pupil e. Obtain medical attention immediately

ANS: C, A, D, B, E The patient should be placed on his back to prevent loss of the aqueous humor, assessment of the eye for the location of the object and whether the pupil is regular, cover the eye to prevent movement, and obtain medical attention immediately. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 1870, Safety Alert OBJ: 10 TOP: Penetrating wound of the eye KEY: Nursing Process Step: Implementation

38. The home health patient complains of tearing and a feeling of dryness in the right eye. The nurse assesses that the eyelid is turned inward and the sclera is red. The nurse documents the presence of a(n) .

ANS: entropion An entropion is the abnormal turning in of the eyelid, causing irritation and tearing of the eye. PTS: 1 DIF: Cognitive Level: Application REF: Page 1859 OBJ: 8 TOP: Entropion KEY: Nursing Process Step: Assessment

40. The total removal of an eye is a(n) .

ANS: enucleation The surgical removal of the eyeball is an enucleation. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 1869 OBJ: 9 TOP: Enucleation KEY: Nursing Process Step: Assessment

39. The nurse explains that a pneumatic retinopexy is a repair of a retinal detachment using a bubble of to put pressure on the damaged retina.

ANS: gas A pneumatic retinopexy uses a bubble of gas to put pressure on the damaged retina. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 1866 OBJ: 11 TOP: Pneumatic retinopexy KEY: Nursing Process Step: Implementation

41. The surgical incision into the eardrum with either a knife or a heated wire loop to relieve pressure in the middle ear is a(n) .

ANS: myringotomy The opening of the eardrum with a specialized knife or a heated wire loop to relieve pressure in the middle ear is a myringotomy. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 1883 OBJ: 17 TOP: Myringotomy KEY: Nursing Process Step: Assessment

14. What does diabetes retinopathy result from? a. Capillaries in retina hemorrhage b. Long-term overdosing of insulin c. Retinal detachment d. Aging

ANS: A Retinopathy is caused when the capillaries in the retina have aneurysms or hemorrhage. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 1861 OBJ: 9 TOP: Glaucoma KEY: Nursing Process Step: Assessment

29. Why is otitis media found more frequently in children 6 to 36 months? a. Eustachian tubes in children are shorter and straighter. b. Infection descends via the eustachian tube to the throat. c. Children's eustachian tubes are more vertical and longer. d. Otitis media is seen equally in both children and adults.

ANS: A Children's shorter and straighter eustachian tubes provide easier access of the organisms from the nasopharynx to travel to the middle ear. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 1881 OBJ: 16 TOP: Otitis media KEY: Nursing Process Step: Evaluation

7. What is a common mistake that hinders communication when communicating with the hearing impaired? a. Overaccentuating words b. Facing the patient when speaking c. Speaking in conversational tones d. Speaking into the ear with the hearing aid

ANS: A Do not overaccentuate words. Speak in a normal tone; do not shout or raise the pitch of voice. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 1870, Health Promotion OBJ: 14 TOP: Communication KEY: Nursing Process Step: Implementation

28. Which is a sign of acute angle closure glaucoma (AACG)? a. Large fixed pupil b. Nystagmus c. Bluish color in sclera d. Drooping eyelid

ANS: A Signs of AACG would be eye pain, large fixed pupil with reddened sclera, decreased vision, nausea, and vomiting. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 1867 OBJ: 9 TOP: Glaucoma KEY: Nursing Process Step: Assessment

5. The 62-year-old home health patient who is recovering from eye surgery complains of a feeling of "grittiness" in the eye and is having blurred vision. The eyes are reddened and have stringy mucus. What do these complaints indicate? a. Sjögren syndrome b. Early cataracts c. Macular degeneration d. Retinal detachment

ANS: A The Sjögren syndrome of "dry eye" frequently appears after eye surgery. There is insufficient production of tears. Excessive use of antihistamines, antidepressants, and decongestants may cause this syndrome to appear. PTS: 1 DIF: Cognitive Level: Application REF: Page 1858 OBJ: 8 TOP: Sjögren syndrome KEY: Nursing Process Step: Assessment

8. What is the process when the lens of the eye changes its curvature to focus on the retina? a. Accommodation b. Constriction c. Convergence d. Refraction

ANS: A The ability of the lens to alter its curvature as it focuses on the retina is accommodation. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 1849 OBJ: 16 TOP: Accommodation KEY: Nursing Process Step: Implementation

30. Why would the nurse encourage a group of teenagers to protect their eyes with dark sunglasses while using a UV lamp? a. The lamp can cause cataracts. b. The lamp can cause presbycusis. c. The lamp can cause keratitis. d. The lamp can cause ectropion.

ANS: A The proteins in the lens of the eye are vulnerable to UV light and can develop cataracts. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 1890 OBJ: 9 TOP: Health promotion KEY: Nursing Process Step: Implementation

15. When the patient in the emergency room complains of seeing flashing lights and a curtain down over his right eye, the nurse recognizes this as a symptom of which condition? a. Detached retina b. Macular degeneration c. Early sign of cataract d. Diabetic retinopathy

ANS: A The standard complaint of a detached retina is the report of seeing flashing lights and having a curtain being drawn over the eyes. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 1865 OBJ: 9 TOP: Detached retina KEY: Nursing Process Step: Assessment

18. What should the nurse remind the hearing aid wearer to do when the nurse hears a whistling hearing aid? a. Reinsert the ear mold b. Change the battery c. Recharge the hearing aid d. Wash the ear mold with warm water

ANS: A The whistling hearing aid is usually caused by a poor fit of the ear mold. Reinsertion of the ear mold usually stops the whistling. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 1880, Box 52-3 OBJ: 13 TOP: Hearing aid KEY: Nursing Process Step: Implementation

4. What does a tympanoplasty correct? a. Conductive hearing loss b. Sensorineural hearing loss c. Congenital hearing loss d. Functional hearing loss

ANS: A Tympanoplasty can correct a conductive hearing loss. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 1889 OBJ: 17 TOP: Tympanoplasty KEY: Nursing Process Step: Implementation

34. What factors must the nurse consider when assessing readiness to learn when teaching health promotion practices for the visually and hearing impaired? (Select all that apply.) a. Cultural beliefs b. Values c. Habits d. Income e. Occupation

ANS: A, B, C The nurse must consider the patient's culture, beliefs, values, and habits, as well as the special needs of the older adult. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 1891 OBJ: N/A TOP: Health promotion KEY: Nursing Process Step: Assessment

32. Select all the conditions that may cause conductive hearing loss. (Select all that apply.) a. Buildup of cerumen b. Foreign bodies c. Otosclerosis of external auditory canal d. Trauma e. Exposure to ototoxic drugs f. Otitis media with effusion

ANS: A, B, C, F Common causes of conductive hearing loss are buildup of cerumen and otitis media with effusion (escape of effusion). Other conditions that may result in conductive hearing loss are foreign bodies, otosclerosis, and stenosis of the external auditory canal. Sensorineural hearing loss is usually due to trauma, infectious processes, or exposure to ototoxic drugs. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 1878 OBJ: 12 TOP: Hearing loss KEY: Nursing Process Step: Assessment

35. Which of the following are causes of cataracts? (Select all that apply.) a. Long-term use of corticosteroids b. Hypotension c. Congenital from exposure to maternal rubella d. Diabetes mellitus e. Exposure to sand and dust f. Smoking

ANS: A, C, D, F Among the many causes of cataracts are long-term corticosteroid use, maternal rubella, diabetes mellitus, and smoking. PTS: 1 DIF: Cognitive Level: Application REF: Page 1859 OBJ: 9 TOP: Cataracts KEY: Nursing Process Step: Assessment

36. What would a nurse do when the patient arrives in the PACU after a left stapedectomy? (Select all that apply.) a. Turn the patient to his right side b. Change dressing as it becomes soiled c. Turn patient every 2 hours d. Leave the bed flat e. Medicate immediately on the complaint of nausea

ANS: A, D, E The bed is left in the flat position and the patient is positioned with the operated side facing up, the patient is not turned, and the dressing is not changed by the nurse. The patient should be medicated immediately on complaint of nausea to prevent vomiting and possible disruption of graft. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 1887 OBJ: 17 TOP: Stapedectomy KEY: Nursing Process Step: Implementation

24. A patient who had an enucleation of the right eye has been admitted PACU. What should the nurse include in the plan of care? a. Turn, cough, and deep breathe every 3 hours b. Apply a pressure dressing over the right eye socket c. Document dressing assessment every 2 hours d. Turn on the affected side

ANS: B A pressure dressing will be applied to the right eye socket and the dressing should be checked every hour for the first 24 hours. PTS: 1 DIF: Cognitive Level: Application REF: Page 1872 OBJ: 11 TOP: Infections/inflammatory disorders KEY: Nursing Process Step: Assessment

12. Which complaint made by a 64-year-old patient during a health interview would alert the nurse to the possibility of cataracts? a. Pain in the eyes b. Difficulty driving at night c. Loss of peripheral vision d. Dry eyes

ANS: B Blurring of vision and difficulty driving at night is often the first subjective symptom reported by a patient who has cataracts. PTS: 1 DIF: Cognitive Level: Application REF: Page 1860 OBJ: 9 TOP: Cataracts KEY: Nursing Process Step: Assessment

25. What must a patient do following a left vitrectomy? a. Remain flat in bed for 48 hours b. Position self in a face-down position for 4 to 5 days c. Assume a side-lying position with the left side down for 3 days d. Keep head upright and cushioned with pillows for 24 hours

ANS: B Following a vitrectomy, the patient must assume a face-down position or turn the face to the right side for 4 to 5 days. PTS: 1 DIF: Cognitive Level: Application REF: Page 1874 OBJ: 11 TOP: Vitrectomy KEY: Nursing Process Step: Planning

23. When the patient stares at the black dot on an Amsler grid, what should the nurse ask him to report? a. Any color visible on the grid b. Fading of the edges of the grid c. Any distortion of the grid d. Movement of the black dot

ANS: C Amsler grid, a diagnostic tool for retinal disorders, requires that the patient look at the dot on the grid and report any distortion in the grid lines. PTS: 1 DIF: Cognitive Level: Application REF: Page 1850, Figure 52-3 OBJ: 9 TOP: Aging KEY: Nursing Process Step: Assessment

31. The nurse counsels the 16-year-old boy that playing his music at high volume can result in impairment in hearing related to: a. damaged tympanic membrane. b. protective buildup of cerumen. c. damage of the fine hair cells in the organ of Corti. d. rupture of the oval window.

ANS: C Long-term exposure to loud noises can damage the fine hair cells in the organ of Corti, which causes a conductive hearing loss. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 1890 OBJ: 12 TOP: Health promotion KEY: Nursing Process Step: Assessment

2. The patient tells the nurse that he is legally blind. How would this information impact the nurse's plan of care for this patient? a. The patient would be considered totally blind. b. This patient probably has some light perception, but no usable vision. c. This patient has some usable vision, which enables function at an acceptable level. d. The nurse would need to determine how this patient's visual impairment affects normal functioning.

ANS: D "Legal blindness" refers to individuals with a maximum visual acuity of 20/200 with corrective eyewear and/or visual field sight capacity reduced by 20 degrees. Categories have been established to help determine the exact extent of the vision loss and what assistive measures are appropriate for the individual. The nurse will need more information as to the exact extent of the vision loss for this patient. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 1851 OBJ: N/A TOP: Legal blindness KEY: Nursing Process Step: Planning

21. What do miotic eyedrops do for a patient with glaucoma? a. Dilate the pupil and sharpen vision b. Lubricate and moisten the dry eye c. Irrigate the surface of the eye d. Constrict the pupil and open the canal of Schlemm

ANS: D Miotic eyedrops allow the pupil to constrict and open the canal of Schlemm to drain the excess fluid. PTS: 1 DIF: Cognitive Level: Application REF: Page 1868 OBJ: 4 TOP: Aging KEY: Nursing Process Step: Assessment

42. Progressive deafness caused by the ankylosis of the stapes is the condition of .

ANS: otosclerosis Progressive deafness related to the ankylosis of the stapes is diagnosed as otosclerosis. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 1885 OBJ: 16 TOP: Otosclerosis KEY: Nursing Process Step: Assessment

27. What is the first indication of macular degeneration? a. The loss of peripheral vision b. The loss of central vision c. The loss of color discrimination d. Eye fatigue

ANS: B Macular degeneration is characterized by the slow loss of central and near vision. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 1864 OBJ: 9 TOP: Macular degeneration KEY: Nursing Process Step: Assessment

9. When the newly blind male home health patient asks the nurse how he might get assistance, who might the nurse suggest he contact? a. American Red Cross b. American Foundation for the Blind for a list of agencies c. Local hospital social worker d. The public health department

ANS: B The American Foundation for the Blind has lists of agencies to assist and educate the visually impaired patient. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 1852 OBJ: 15 TOP: Medications KEY: Nursing Process Step: Implementation

1. The nurse is aware that the patient has 20/40 vision. This means that the patient can see at 20 feet what the normal eye can see at feet. a. 10 b. 20 c. 30 d. 40

ANS: B The Snellen Eye Chart tests visual acuity. A vision evaluation of 20/40 means that the patient can see at 20 feet what the person with normal vision can see at 200 feet. PTS: 1 DIF: Cognitive Level: Application REF: Page 1850 OBJ: 7 TOP: Snellen evaluation KEY: Nursing Process Step: Assessment

16. The nurse will assess for when the older adult home health patient complains that the entire right side of his head hurts and he cannot chew without pain. a. mumps b. external otitis c. otitis media d. labyrinthitis

ANS: B The symptoms of painful head, painful chewing, and pain when the auricle is moved all indicate external otitis, frequently caused by compacted cerumen. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 1880 OBJ: 16 TOP: External otitis KEY: Nursing Process Step: Assessment

17. The nurse takes into consideration that the Weber test indicated a conductive hearing loss in a patient because the patient reported hearing the tone: a. equally in both ears. b. as a shrill noise. c. louder in his affected ear. d. very faintly.

ANS: C A conductive hearing loss can be diagnosed by the Weber test. A person with a conductive loss will hear the noise louder in his affected ear. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 1885 OBJ: 16 TOP: Weber test KEY: Nursing Process Step: Assessment

19. What should the nurse advise the 20-year-old to do who has been put on cefaclor (Ceclor) for a resistant otitis media? a. Store suspension at room temperature b. Discontinue drug when symptoms abate c. Avoid alcoholic beverages d. Take with meals only

ANS: C Drinking alcohol is discouraged while on Ceclor. The drug should be taken in its entirety and stored in the refrigerator. The drug can be taken with or without meals. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 1880, Table 52-5 OBJ: 16 TOP: Ceclor KEY: Nursing Process Step: Implementation

6. Four hours after a stapedectomy the patient complains that hearing has not improved at all. What knowledge would the nurse use to shape a response? a. A large percentage of stapedectomies are not successful b. It will take at least 10 days for the graft to heal c. Hearing will not return until edema subsides d. Hearing will improve after irrigation of the ear

ANS: C Hearing improvement will not be noted until edema subsides and the packing is removed. PTS: 1 DIF: Cognitive Level: Application REF: Page 1887 OBJ: 17 TOP: Stapedectomy KEY: Nursing Process Step: Implementation

13. What should a patient who has had a cataract repair avoid? a. The use of eye patches b. The use of sunglasses c. The lifting of heavy objects d. Reading for long periods of time

ANS: C Postcataract patients should avoid any activity that increases the intraocular pressure, such as lifting heavy objects, stooping, and bending. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 1860 OBJ: 11 TOP: Blindness KEY: Nursing Process Step: Planning

10. The nurse clarifies that the difference between a photorefractive keratectomy (PRK) and a laser in-situ keratomileusis (LASIK) is that a LASIK: a. reshapes the central cornea. b. makes partial-thickness radial incisions in the cornea. c. removes some internal layers of the cornea. d. implants intracorneal rings.

ANS: C The LASIK procedure removes some of the internal layers of the cornea affecting the central zone of vision. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 1853 OBJ: 11 TOP: Visual acuity KEY: Nursing Process Step: Implementation

37. What should the nurse do when assisting a blind person to walk in an unfamiliar hospital environment? (Select all that apply.) a. Discourage the use of the cane b. Advise the patient to walk quickly c. Describe the surroundings d. Encourage the patient to ask for verbal cues e. Place patient hand on nurse's shoulder or elbow

ANS: C, D, E The patient should be given verbal cues about the environment. Allow the patient to hold the nurse's shoulder or elbow while the nurse walks in front, and encourage the use of a cane to let the patient "examine" the boundaries and obstacles. PTS: 1 DIF: Cognitive Level: Application REF: Page 1851 OBJ: N/A TOP: Assisting blind to walk KEY: Nursing Process Step: Implementation

3. One of the housekeepers splashes a chemical in the eyes. What should be the first priority? a. Transport to a physician immediately b. Cover the eyes with a sterile gauze c. Irrigate with H2O for 5 minutes d. Irrigate with normal saline solution for 20 minutes

ANS: D Burns are medically treated with a prolonged, 15- to 20-minute or longer normal saline flush immediately after burn exposure. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 1871 OBJ: 11 TOP: Chemical burn of eye KEY: Nursing Process Step: Implementation

20. How should the nurse advise a patient who has severe vertigo from labyrinthitis? a. Lean against a wall and not head forward until vertigo lessens. b. Bend at the waist and take several deep breaths. c. Drink an iced drink slowly. d. Lie immobile and hold the head in one position until the vertigo lessens.

ANS: D Lying immobile and holding the head in one position will lessen vertigo. PTS: 1 DIF: Cognitive Level: Application REF: Page 1880, Patient Teaching OBJ: 16 TOP: Vertigo KEY: Nursing Process Step: Implementation

11. What does the cataract treatment of phacoemulsification involve? a. "Drying" the cataract with hypertonic saline b. Removing the lens through the anterior capsule c. The insertion of a new lens d. Breaking the cataract with ultrasound

ANS: D Phacoemulsification uses ultrasound to break up the cataract. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 1860 OBJ: 11 TOP: Infectious/inflammatory disorders KEY: Nursing Process Step: Planning

26. How would the nurse explain the purpose of photocoagulation to a diabetic patient with diabetic retinopathy? a. The procedure will destroy the retina, which is not getting enough blood supply. b. The procedure will reduce edema in the macula of the eye. c. The procedure will vaporize fatty deposits that appear in the retina. d. The procedure will destroy new blood vessels, seal leaking vessels, and help prevent retinal edema.

ANS: D Photocoagulation is useful in diabetic retinopathy to cauterize hemorrhaging vessels and to destroy new vessels. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 1863 OBJ: 9 TOP: Diabetic retinopathy KEY: Nursing Process Step: Implementation

22. What should the nurse include in the plan of care following a tympanoplasty? a. Elevating head of bed with operative side facing upward b. Enforcing bed rest for 72 hours c. Frequent turning, coughing, and deep breathing d. Continuous irrigation of the ear canal with antibiotic solutions

ANS: A Postoperative management for patients who have had a tympanoplasty consists of bed rest until the next morning. The head of the bed is elevated 40 degrees, and the operative side faces upward. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 1889 OBJ: 17 TOP: Otitis media KEY: Nursing Process Step: Implementation

33. Which may contribute to otitis media? (Select all that apply.) a. Exposure to cigarette smoke b. Allergies c. Upper respiratory infections d. Swimming e. Trauma f. Prolonged exposure to loud noise

ANS: A, B, C Otitis media is usually caused by an upper respiratory infection with gram-negative bacteria, such as Proteus, Klebsiella, and Pseudomonas. In addition, allergy, exposure to cigarette smoke, mycoplasma, and several viruses may be factors. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 1881 OBJ: 16 TOP: Otitis media KEY: Nursing Process Step: Assessment