Eye/Ear Nclex
Essential feature of glaucoma is: A. Optic neuropathy B. Raised intraocular pressure C. Reduced vision D. Painful eye
A
The client arrives in the emergency room after sustaining a chemical eye injury from a splash of battery acid. The initial nursing action is to: A. Begin visual acuity testing B. Irrigate the eye with sterile normal saline C. Swab the eye with antibiotic ointment D. Cover the eye with a pressure patch
B Emergency care following a chemical burn to the eye includes irrigating the eye immediately with sterile normal saline or ocular irrigating solution. In the emergency department, the irrigation should be maintained for at least 10 minutes. Following this emergency treatment, visual acuity is assessed.
The nurse has conducted discharge teaching for a client who had a fenestration procedure for the treatment of otosclerosis. Which of the following, if stated by the client, would indicate that teaching was effective? A. "I can resume my tennis lessons starting next week." B. "I should drink liquids through a straw for the next 2-3 weeks." C. "It's ok to take a shower and wash my hair." D."I will take stool softeners as prescribed by my doctor."
D
What should the nurse do for a client who just had cataract surgery? 1 Instruct the client to avoid driving for several weeks. 2 Teach the client coughing and deep-breathing techniques. 3 Advise the client to refrain from vigorous brushing of the teeth and hair. 4 Encourage the client to perform eye exercises to strengthen the ocular musculature.
3 Activities such as rigorous brushing of hair and teeth cause increased intraocular pressure and may lead to hemorrhage in the anterior chamber. 1 This is unnecessary; clients are usually permitted to drive before this time. 2 Coughing and deep breathing can increase intraocular pressure and should be avoided. 4 Weakening of the eye musculature is not related to cataracts.
A client with glaucoma asks a nurse about future treatment and precautions. What information should the nurse's explanation include? 1 Avoidance of cholinergics 2 Surgical replacement of lens 3 Continuation of therapy for life 4 Prevention of high blood pressure
3 Therapy must be continued for life to prevent damage to the optic nerve from increased intraocular pressure. 1 These are used in the treatment of glaucoma; anticholinergics are contraindicated. 2 This is the treatment for cataracts. 4 There is an increase in intraocular pressure with glaucoma; the blood pressure may be unaffected.
Which desired effect of therapy should the nurse explain to the client who has primary angle-closure glaucoma? 1 Dilating the pupil 2 Resting the eye muscles 3 Preventing secondary infection 4 Controlling intraocular pressure
4 Glaucoma is a disease in which there is increased intraocular pressure resulting from narrowing of the aqueous outflow channel (canal of Schlemm). This can lead to blindness, caused by compression of the nutritive blood vessels supplying the rods and cones. 1 Pupil dilation increases intraocular pressure because it narrows the canal of Schlemm. 2 Intraocular pressure is not affected by activity of the eye. 3 Although secondary infections are not desirable, the priority is to maintain vision by controlling the pressure.
Tonometry is performed on the client with a suspected diagnosis of glaucoma. The nurse analyzes the test results as documented in the client's chart and understands that normal intraocular pressure is: A. 2-7 mmHg B. 10-21 mmHg C. 22-30 mmHg D. 31-35 mmH
B Tonometry is the method of measuring intraocular fluid pressure using a calibrated instrument that indents or flattens the corneal apex. Pressures between 10 and 21 mmHg are considered within normal range.
A nurse is caring for a client who is scheduled for surgery for a detached retina. Which goal of surgery identified by the client indicates that the preoperative teaching was effective? 1 Promote growth of new retinal cells 2 Adhere the sclera to the choroid layer 3 Graft a healthy piece of retina in place 4 Create a scar that aids in healing retinal holes
4 Scar formation seals the hole and promotes attachment of the two retinal surfaces. 1 The retina is part of the nervous system; it does not regenerate or grow new cells. 2 The sclera is not involved; the retina adjoins and is nourished by the choroid. 3 This is not the treatment used; treatment includes the formation of a scar by the use of lasers or surgical "buckling."
For a client having an episode of acute narrow-angle glaucoma, a nurse expects to give which of the following medications? A. Acetazolamide (Diamox) B. Atropine C. Furosemide (Lasix) D. Urokinase (Abbokinase
A Acetazolamide, a carbonic anhydrase inhibitor, decreases intraocular pressure (IOP) by decreasing the secretion of aqueous humor. Atropine dilates the pupil and decreases outflow of aqueous humor, causing further increase in IOP. Lasix is a loop diuretic, and Urokinase is a thrombolytic agent; they aren't used for the treatment of glaucoma.
For a client complaining of periocular aching after a surgical repair of a detached retina, which medication would be the most appropriate analgesic? A. Acetaminophen B. Codeine C. Meperidine D. Morphine
A Because the discomfort is typically mild after surgery to repair a detached retina, a mild analgesic such as acetaminophen would be used. Codeine is constipating and may lead to straining and increased intraocular pressure (IOP). Meperidine often causes nausea and vomiting, further adding to the client's level of discomfort, and vomiting may lead to increased IOP. Morphine causes nausea, vomiting, and constipation, which should be avoided after surgery.
The nurse is performing an assessment in a client with a suspected diagnosis of cataract. The chief clinical manifestation that the nurse would expect to note in the early stages of cataract formation is: A. Eye pain B. Floating spots C. Blurred vision D. Diplopia
C A gradual, painless blurring of central vision is the chief clinical manifestation of a cataract. Early symptoms include slightly blurred vision and a decrease in color perception.
A nurse in the outpatient unit is preparing a client who is scheduled for a laser trabeculoplasty for the treatment of primary open-angle glaucoma. Which of the following instructions should the nurse provide to the client? a) the procedure takes about 2 hours b) activities can be resumed following the procedure immediately c) you may return to work 1 to 2 days following the procedure d) your vision loss will be restored following the procedure
C - Laser trabeculoplasty is performed in the outpatient setting and requires about 30 minutes. The client will experience little discomfort and may resume all normal activities including returning to work within 1 to 2 days. The treatment prevents further visual loss, but the lost vision cannot be restored.
Which of the following instruments is used to record intraocular pressure? A. Goniometer B. Ophthalmoscope C. Slit lamp D. Tonometer
D A tonometer is a device used in glaucoma screening to record intraocular pressure. A goniometer measures joint movement and angles. An ophthalmoscope examines the interior of the eye, especially the retina. A slit lamp evaluates structures in the anterior chamber in the eye.
Aling Martha, a 73-year-old widow, tells to the nurse during the admission process that she was recently diagnosed with age-related hearing loss. Upon receiving such information, the nurse is correct if he suspects: A. Ménière's disease B. Otalgia C. Otitis media D. Presbycusis
D The term presbycusis refers to sensorineural hearing impairment in elderly individuals.
Ben is diagnosed with a retinal detachment at the inner aspect of the right eye. Into which position would the nurse place the client? A. Fowler's position B. Supine with a small pillow C. Right-side lying D. Left-side lying
D When retinal detachment occurs, the client is positioned so that the area of detachment is dependent. For this client, the left-side lying position is used. Positioning the client in the Fowler, supine, or right-side lying position would not place the detached area in a dependent position.
male client has just had a cataract operation without a lens implant. In discharge teaching, the nurse will instruct the client's wife to: A. Feed him soft foods for several days to prevent facial movement B. Keep the eye dressing on for one week C. Have her husband remain in bed for 3 days D. Allow him to walk upstairs only with assistance
D Without a lens, the eye cannot accommodate. It is difficult to judge distance and climb stairs when the eyes cannot accommodate. Therefore, the client should walk up and down stairs only with assistance.
Which clinical indicator is the nurse most likely to identify when exploring the history of a client with open-angle glaucoma? 1 Constant blurring 2 Abrupt attacks of acute pain 3 Sudden, complete loss of vision 4 Impairment of peripheral vision
4 Open-angle glaucoma has an insidious onset, with increased intraocular pressure causing pressure on the retina and blood vessels in the eye. Peripheral vision is decreased as the visual field progressively diminishes. 1 This may occur with untreated acute angle-closure glaucoma. 2 Pain occurs in acute angle-closure, not open-angle, glaucoma. 3 Occlusions of the central retinal artery or retinal detachment will cause a sudden loss of vision
Cataract surgery results in aphakia. Which of the following statements best describes this term? A. Absence of the crystalline lens B. A "keyhole" pupil C. Loss of accommodation D. Retinal detachment
A Aphakia means without lens, a keyhole pupil results from iridectomy. Loss of accommodation is a normal response to aging. A retinal detachment is usually associated with retinal holes created by vitreous traction.
Mang Isko, a 68-year-old widower, has been stricken with cataracts about year ago. Which assessment date would the nurse expect when collecting the nursing history from the client? A. Blurred vision B. Eye pain C. Floaters D. Eye redness
A Cataracts lead to progressive worsening and blurring of vision. Eye pain and redness, common with glaucoma, are not present with cataracts. Floaters are characteristics of retinal detachment.
The nurse is caring for a client with a diagnosis of detached retina. Which assessment sign would indicate that bleeding has occurred as a result of the retinal detachment? A. Complaints of a burst of black spots or floaters B. A sudden sharp pain in the eye C. Total loss of vision D. A reddened conjunctiva
A Complaints of a sudden burst of black spots or floaters indicate that bleeding has occurred as a result of the detachment.
The nurse is caring for a client following enucleation. The nurse notes the presence of bright red blood drainage on the dressing. Which nursing action is appropriate? A. Notify the physician B. Continue to monitor the drainage C. Document the finding D. Mark the drainage on the dressing and monitor for any increase in bleeding.
A If the nurse notes the presence of bright red drainage on the dressing, it must be reported to the physician because this indicated hemorrhage.
The nurse has notes that the physician has a diagnosis of presbycusis on the client's chart. The nurse plans care knowing the condition is: A. A sensorineural hearing loss that occurs with aging B. A conductive hearing loss that occurs with aging. C. Tinnitus that occurs with aging D. Nystagmus that occurs with aging
A Presbycusis is a type of hearing loss that occurs with aging. Presbycusis is a gradual sensorineural loss caused by nerve degeneration in the inner ear or auditory nerve.
During the early postoperative period, the client who had a cataract extraction complains of nausea and severe eye pain over the operative site. The initial nursing action is to: A. Call the physician B. Administer the ordered main medication and antiemetic C. Reassure the client that this is normal. D. Turn the client on his or her operative side
A Severe pain or pain accompanied by nausea is an indicator of increased intraocular pressure and should be reported to the physician immediately. The other options are inappropriate.
Which of the following symptoms would occur in a client with a detached retina? A. Flashing lights and floaters B. Homonymous hemianopia C Loss of central vision D. Ptosis
A Signs and symptoms of retinal detachment include abrupt flashing lights, floaters, loss of peripheral vision, or a sudden shadow or curtain in the vision. Occasionally visual loss is gradual.
The client with glaucoma asks the nurse is complete vision will return. The most appropriate response is: A. "Although some vision as been lost and cannot be restored, further loss may be prevented by adhering to the treatment plan." B. "Your vision will return as soon as the medications begin to work." C. "Your vision will never return to normal." D. "Your vision loss is temporary and will return in about 3-4 weeks."
A Vision loss to glaucoma is irreparable. The client should be reassured that although some vision has been lost and cannot be restored, further loss may be prevented by adhering to the treatment plan. Option C does not provide reassurance to the client.
A clinic nurse is providing instructions to a client with glaucoma regarding the prescribed treatment measures for the disorder. The nurse prepares the instructions based on the primary objective of: a) maintaining intraocular pressure at a reduced level b) producing mydriasis c) increasing the formation of aqueous humor d) promoting dilation of the pupils of the eyes
A - The principle of treatment of the client with glaucoma is to maintain intraocular pressure at a reduced level to prevent further damage to intraocular structures. Medications are used to create miosis (constriction of the pupil) and reduce formation of the aqueous humor by the ciliary body.
The nurse is performing a voice test to assess hearing. Which of the following describes the accurate procedure for performing this test? A. Stand 4 feet away from the client to ensure that the client can hear at this distance. B. Whisper a statement and ask the client to repeat it. C. Whisper a statement with the examiners back facing the client. D. Whisper a statement while the client blocks both ears
B The examiner stands 1-2 feet away from the client and asks the client to block one external ear canal. The nurse whispers a statement and asks the client to repeat it. Each ear is tested separately.
The nurse is performing an admission assessment on a client with a diagnosis of detached retina. Which of the following is associated with this eye disorder? A. Pain in the affected eye B. Total loss of vision C. A sense of a curtain falling across the field of vision D. A yellow discoloration of the sclera
C A characteristic manifestation of retinal detachment described by the client is the feeling that a shadow or curtain is falling across the field of vision. No pain is associated with detachment of the retina. Options B and D are not characteristics of this disorder. A retinal detachment is an ophthalmic emergency and even more so if visual acuity is still normal.
In preparation for cataract surgery, the nurse is to administer prescribed eye drops. The nurse reviews the physicians orders, expecting which type of eye drops to be instilled? A. An osmotic diuretic B. A miotic agent C. A mydriatic medication D. A thiazide diuretic
C A mydriatic medication produces mydriasis or dilation of the pupil. Mydriatic medications are used preoperatively in the cataract client. These medication act by dilating the pupils. They also constrict blood vessels. An osmotic diuretic may be used to decrease intraocular pressure. A miotic medication constricts the pupil. A thiazide diuretic is not likely to be prescribed for a client with a cataract.
After the nurse instills atropine drops into both eyes for a client undergoing ophthalmic examination, which of the following instructions would be given to the client? A. "Be careful because the blink reflex is paralyzed." B. "Avoid wearing your regular glasses when driving." C. "Be aware that the pupils may be unusually small." D. "Wear dark glasses in bright light because the pupils are dilated.
D Atropine, an anticholinergic drug, has mydriatic effects causing pupil dilation. This allows more light onto the retina and may cause photophobia and blurred vision. Atropine doesn't paralyze the blink reflex or cause miosis (pupil constriction). Driving may be contraindicated to blurred vision.
Nurse Jairuz Roy is carrying out his preoperative teachings for an older client who will have cataract surgery on the right eye. The nurse concludes that the client needs further understanding about the teachings if he says: A. "I will sleep on my left side after the surgery." B. "I will wipe my nose gently if it is congested after surgery." C. "I will call my physician if I have sharp and sudden pain or a fever after surgery." D. "I will bend below my waist frequently to increase circulation after surgery."
D Immediately after the procedure, the client should avoid bending over, to prevent putting extra pressure on the eye.
The client's vision is tested with a Snellen's chart. The results of the tests are documented as 20/60. The nurse interprets this as: A. The client can read at a distance of 60 feet what a client with normal vision can read at 20 feet. B. The client is legally blind. C. The client's vision is normal D. The client can read only at a distance of 20 feet what a client with normal vision can read at 60 feet.
D Vision that is 20/20 is normal, that is, the client is able to read from 20 feet what a person with normal vision can read from 20 feet. A client with a visual acuity of 20/60 only can read at a distance of 20 feet of what a person with normal vision can read at 60 feet.
The part of the ear that contains the receptors for hearing is the: A. Utricle B. Cochlea C. Middle ear D. Tympanic cavity
B The dendrites of the cochlear nerve terminate on the hair cells of the organ of Corti in the cochlea.
When using a Snellen alphabet chart, the nurse records the client's vision as 20/40. Which of the following statements best describes 20/40 vision? A. The client has alterations in near vision and is legally blind. B. The client can see at 20 feet what the person with normal vision can see at 40 feet. C. The client can see at 40 feet what the person with normal vision sees at 20 feet. D. The client has a 20% decrease in acuity in one eye, and a 40% decrease in the other eye
B The numerator refers to the client's vision while comparing the normal vision in the denominator.
During the nursing history, which assessment data would the nurse expect the client scheduled for surgical correction of chronic open-angle glaucoma to report? A. Seeing flashes of lights and floaters B. Recent motor vehicle crash while changing lanes C. Complaints of headaches, nausea, and redness of the eyes D. Increasingly frequent episodes of double vision
B Typically, the client with chronic open-angle glaucoma experiences a gradual loss in peripheral vision leading to tunnel vision. Being involved in a motor vehicle crash while changing lanes suggests the disorder. The client may experience insidious blurring, decreased accommodation, mild aching eyes and, eventually, halos around the lights as intraocular pressure increases. Flashes of light and floaters are characteristic of retinal detachment. Nausea, headache, and eye redness are seen with an episode of acute (sudden) closed-angle closure. Double vision occurs when one eye has a lens and other is aphakic.
The clinic nurse is preparing to test the visual acuity of a client using a Snellen chart. Which of the following identifies the accurate procedure for this visual acuity test? A. Both eyes are assessed together, followed by the assessment of the right and then the left eye. B. The right eye is tested followed by the left eye, and then both eyes are tested. C. The client is asked to stand at a distance of 40ft. from the chart and is asked to read the largest line on the chart. D. The client is asked to stand at a distance of 40ft from the chart and to read the line than can be read 200 ft away by an individual with unimpaired vision.
B Visual acuity is assessed in one eye at a time, and then in both eyes together with the client comfortably standing or sitting. The right eye is tested with the left eye covered; then the left eye is tested with the right eye covered. Both eyes then are tested together. Visual acuity is measured with or without corrective lenses and the client stands at a distance of 20ft. from the chart.
The clinic nurse notes that the following several eye examinations, the physician has documented a diagnosis of legal blindness in the client's chart. The nurse reviews the results of the Snellen's chart test expecting to note which of the following? A. 20/20 vision B. 20/40 vision C. 20/60 vision D. 20/200 vision
D Legal blindness is defined as 20/200 or less with corrected vision (glasses or contact lenses) or visual acuity of less than 20 degrees of the visual field in the better eye.
A nurse provides a list of instructions to a client with glaucoma regarding measures that will prevent an increase in intraocular pressure in the eyes. Which statement by the client indicates a need for further instructions? a) I can move objects weighing 20 pounds or more by pushing the object on the floor using my feet b) I can tie my shoelaces by bending over slowly c) I need to consume a diet high in fiber and bulk d) I need to maintain an intake of six to eight glasses of water a day
B - Activities such as bending over or straining at stool will increase intraocular pressure. The client needs to be instructed to maintain a diet high in bulk and fiber and to consume a high intake of liquids, unless contraindicated, to prevent constipation and straining at stools. The client should tie shoelaces by bending the knee, raising the thigh, and bringing the foot within reach. Objects weighing 20 pounds or more can be moved by pushing the object on the floor by using the feet or a mechanical dolly.
A client reports to the health care clinic for an eye examination, and a diagnosis of primary open-angle glaucoma is suspected. Which of the following nursing assessment questions will elicit information regarding the initial clinical manifestations associated with this disorder? a) do you have any pain in your eyes? b) have you had difficulty with peripheral vision? c) do bright lights causes a glare? d) is your central vision blurred?
B - Because glaucoma is usually symptom free, the client may first note changes in peripheral visual acuity. If pain occurs with glaucoma, it is usually late in the course of structural changes, with an intraocular pressure of 40 to 50 mm Hg or higher. Severe pain is characteristic of absolute glaucoma (total vision loss). Glare from bright lights is a complaint of a client with a cataract. Blurred central vision occurs with macular degeneration.
The client arrives in the emergency room with a penetrating eye injury from wood chips while cutting wood. The nurse assesses the eye and notes a piece of wood protruding from the eye, what is the initial nursing action? A. Remove the piece of wood using a sterile eye clamp B. Apply an eye patch C. Perform visual acuity tests D. Irrigate the eye with sterile saline
C If the laceration is the result of a penetrating injury, an object may be noted protruding from the eye. This object must never be removed except by the ophthalmologist because it may be holding ocular structures in place. Application of an eye patch or irrigation of the eye may disrupt the foreign body and cause further tearing of the sclera. (The only option that will prevent further disruption is to assess visual acuity.)
During a hearing assessment, the nurse notes that the sound lateralizes to the clients left ear with the Weber test. The nurse analyzes this result as: A. A normal finding B. A conductive hearing loss in the right ear C. A sensorineural or conductive loss D. The presence of nystagmus
C In the Weber tuning fork test the nurse places the vibrating tuning fork in the middle of the client's head, at the midline of the forehead, or above the upper lip over the teeth. Normally, the sound is heard in equally in both ears by bone conduction. If the client has a sensorineural hearing loss in one ear, the sound is heard in the other ear. If the client has a conductive hearing loss in one ear, the sound is heard in that ear.
Which of the following procedures or assessments must the nurse perform when preparing a client for eye surgery? A. Clipping the client's eyelashes B. Verifying the affected eye has been patched 24 hours before surgery C. Verifying the client has been NPO since midnight, or at least 8 hours before surgery. D. Obtaining informed consent with the client's signature and placing the forms on the chart.
C Maintaining NPO status for at least 8 hours before surgical procedures prevents vomiting and aspiration. There is no need to patch an eye before most surgeries or to clip the eyelashes unless specifically ordered by the physician. The physician is responsible for obtaining informed consent; the nurse validates that the consent is obtained.
The client is being discharged from the ambulatory care unit following cataract removal. The nurse provides instructions regarding home care. Which of the following, if stated by the client, indicates an understanding of the instructions? A. "I will take Aspirin if I have any discomfort." B. "I will sleep on the side that I was operated on." C. "I will wear my eye shield at night and my glasses during the day." D. "I will not lift anything if it weighs more that 10 pounds."
C The client is instructed to wear a metal or plastic shield to protect the eye from accidental and is instructed not to rub the eye. Glasses may be worn during the day. Aspirin or medications containing aspirin are not to be administered or taken by the client and the client is instructed to take acetaminophen as needed for pain. The client is instructed not to sleep on the side of the body on which the operation occurred. The client is not to lift more than 5 pounds.
The nurse is developing a plan of care for the client scheduled for cataract surgery. The nurse documents which more appropriate nursing diagnosis in the plan of care? A. Self-care deficit B. Imbalanced nutrition C. Disturbed sensory perception D. Anxiety
C The most appropriate nursing diagnosis for the client scheduled for cataract surgery is Disturbed sensory perception (visual) related to lens extraction and replacement. Although the other options identify nursing diagnoses that may be appropriate, they are not related specifically to cataract surgery.
The client sustains a contusion of the eyeball following a traumatic injury with a blunt object. Which intervention is initiated immediately? A. Notify the physician B. Irrigate the eye with cold water C. Apply ice to the affected eye D. Accompany the client to the emergency room
C Treatment for contusion begins at the time of injury. Ice is applied immediately. The client then should be seen by a physician and receive a thorough eye examination to rule out the presence of other eye injuries.
When developing a teaching session on glaucoma for the community, which of the following statements would the nurse stress? A. Glaucoma is easily corrected with eyeglasses B. White and Asian individuals are at the highest risk for glaucoma. C. Yearly screening for people ages 20-40 years is recommended. D. Glaucoma can be painless and vision may be lost before the person is aware of a problem
D Open-angle glaucoma causes a painless increase in intraocular pressure (IOP) with loss of peripheral vision. A variety of miotics and agents to decrease IOP and occasional surgery are used to treat glaucoma. Blacks have a threefold greater chance of developing with an increased chance of blindness than other groups. Individuals older than 40 should be screened.
The nurse is caring for a client that is hearing impaired. Which of the following approaches will facilitate communication? A. Speak frequently B. Speak loudly C. Speak directly into the impaired ear D. Speak in a normal tone
D Speaking in a normal tone to the client with impaired hearing and not shouting are important. The nurse should talk directly to the client while facing the client and speak clearly. If the client does not seem to understand what is said, the nurse should express it differently. Moving closer to the client and toward the better ear may facilitate communication, but the nurse should avoid talking directly into the impaired ear.
During eyedrop instillation, which intervention would the nurse perform to prevent systemic adverse effects from drug absorption? A. Applying pressure on the eyelid rim B. Having the client close his eyes tightly C. Placing the client in the supine position for a few minutes D. Applying pressure on the inner canthus
D Systemic absorption and subsequent adverse effects may occur if the medication enters the nasolacrimal canal. The nurse therefore applies pressure to the inner canthus, causing occlusion of this canal and minimizing the risk for systemic adverse effects. Applying pressure on the eyelid rim would not occlude this canal. Having the client close his eyes tightly may cause some of the medication to be expelled. Positioning has no effect on the blood flow of medication into the nasolacrimal canal and subsequent absorption.
The nurse is developing a teaching plan for the client with glaucoma. Which of the following instructions would the nurse include in the plan of care? A. Decrease fluid intake to control the intraocular pressure B. Avoid overuse of the eyes C. Decrease the amount of salt in the diet D. Eye medications will need to be administered lifelong
D The administration of eye drops is a critical component of the treatment plan for the client with glaucoma. The client needs to be instructed that medications will need to be taken for the rest of his or her life.
