eyes and ears

37. The nurse is caring for a client postoperatively after removal of an acoustic neuroma using surgery. Which client symptom does the nurse related to the physician? A) Temperature of 100.2° F and discomfort B) Restlessness and confusion C) Redness and inflammation at incision site D) Hearing loss and discomfort

Ans: B Feedback: After surgery, the nurse closely monitors the client for increased intracranial pressure including restlessness and confusion. The physician would be notified immediately if symptoms occurred. The physician would not be notified of the other options because they are either expected following surgery or not significant at the present time.

25. Which nursing suggestion would be most helpful to the client with recurrent otitis externa? A) Use a cotton applicator to ensure that the ear canal is dry. B) Place ear plugs into the ears before swimming. C) Flush the ear with hydrogen peroxide. D) Avoid lying on the side of the affected ear.

Ans: B Feedback: The nurse instructs the client to carry out the medical treatment and provides health teaching to prevent recurrence. For example, he or she advises swimmers to wear soft plastic ear plugs to prevent trapping water in the ear. A cotton tip applicator should not be placed into the ear canal because it could perforate the eardrum. Above all, the nurse advises the client to avoid the use of nonprescription remedies unless they have been approved by the physician and to contact the physician if symptoms are not relieved in a few days.

4. A nurse is doing preoperative and postoperative teaching with a client who is undergoing cataract surgery. What is an important teaching point the nurse should teach the client about? A) Feelings of depression B) Increased urine output C) Eat soft, easily chewed food until healing is complete D) Development of a "black" eye

Ans: C Feedback: Advise clients who have had cataract surgery to eat soft, easily chewed foods until healing is complete to avoid tearing from excessive facial movements. Clients who undergo cataract surgery do not become depressed, have increased urine output, or develop a "black" eye.

31. The nurse is caring for a client with increased fluid accumulation in the eye. When assessing the client, which structure within the eye is noted to drain fluid from the anterior chamber? A) Fovea centralis B) Canthus C) Canal of Schlemm D) Choroid

Ans: C Feedback: The canal of Schlemm drains the anterior chamber of the eye. By draining the fluid, it decreases the fluid amount and pressure in the eye. The other options have no draining ability.

28. The nurse is assessing a client for objective symptoms of hearing difficulties. Which symptom leads the nurse to take alternate measures to ensure client understanding of teaching? A) The client interrupts by asking the nurse to repeat instruction. B) The client is quiet and responds appropriately. C) The client leans forward and turns the head. D) The client quietly reads the instructional literature.

Ans: C Feedback: The nurse assesses objective symptoms of leaning forward and turning the head as symptoms of having difficulty hearing. The nurse would use alternate formats of teaching to reinforce key points. Asking to repeat information is a subjective indication of hearing difficulty. Responding appropriately and reading instructional literature does not indicate a hearing difficulty.

30. Which of the following nursing diagnosis is most appropriate when caring for a client with deteriorating vision? A) Risk for Injury B) Hopelessness C) Impaired Adjustment D) Altered Sensory Perceptions

Ans: D Feedback: When caring for a client with deteriorating vision, the most appropriate nursing diagnosis focuses on the alteration in sensory perceptions. A "Risk for" diagnosis is appropriate when no current diagnosis is available.

26. Which of the following teaching items would be a priority in maintaining normal pressure range in the eye? A) Increase fiber in the diet. B) Avoid reading. C) East small meals. D) Treat allergy symptoms promptly.

Ans: A Feedback: Adding fiber to the diet will increase ease of bowel movements and prevent constipation and straining, which can inadvertently increase intraocular pressure. Eating small meals is insignificant in maintaining intraocular pressure. Avoid over-the-counter treatment of cold and allergy symptoms if contains cholinergic blockers. Reading is not significant in changing intraocular pressure, but eye strain should be avoided.

7. An eight-grade boy tells the school nurse that the eye doctor told him he had astigmatism and that meant his eyeball wasn't shaped right. The boy says he went home and looked in the mirror and both eyes looked just alike. What is the school nurse's best response? A) "Astigmatism means that the cornea of the eye is shaped differently than the cornea in most eyes." B) "Astigmatism means that the eye is shaped more like an olive than most eyes." C) "Astigmatism means that the inside of the eye is shaped differently than the inside of most eyes." D) "Astigmatism means that the lens of the eye is more of an oval shape than the lens in most eyes."

Ans: A Feedback: Astigmatism is visual distortion caused by an irregularly shaped cornea. Many people have both astigmatism and myopia or hyperopia. Options B, C, and D are incorrect because they are not the best answer.

1. A client is diagnosed with blepharitis. What symptoms should a nurse monitor in this client? A) Patchy flakes clinging to the eyelashes B) A red pustule in the internal tissue of the eyelid C) Redness surrounding the conjunctival sac D) A halo around the pupil

Ans: A Feedback: Blepharitis is an inflammation of the lid margins. The nurse monitors visible patchy flakes clinging to the eyelashes and about the lids. The condition does not cause redness or a halo around the pupil. In case of a sty, the nurse would observe a red pustule in the internal tissue of the eyelid.

11. The nurse is caring for a client experiencing hearing loss. The nurse uses the otoscope to assess the ear canal and tympanic membrane and notes a significant accumulation of cerumen. Which documentation of hearing loss type would be most accurate? A) Conductive B) Mixed C) Central D) Sensorineural

Ans: A Feedback: Conductive hearing loss occurs from an obstruction in the outer or middle ear such as from cerumen. Mixed hearing loss is a combination of conductive and sensorineural problems. Central hearing loss involves injury or damage to the nerves or the nuclei of the central nervous system. Sensorineural involves damage to the inner ear.

33. A nurse is assessing a pediatric client in a public health clinic. The parent states that the client has been sneezing and rubbing the eyes. The nurse looks at the client's eyes and documents objective symptoms of watery and red eyes. When reporting to the physician the assessment findings, which word is appropriate? A) Conjunctivitis B) Ptosis C) Nystagmus D) Proptosis

Ans: A Feedback: Conjunctivitis often stems from an allergy causing inflammation of the conjunctiva, which is a thin, transparent mucous membrane. Conjunctivitis can cause symptoms of itchiness, redness, and watery eyes. Ptosis is drooping of the upper eyelid. Proptosis is an extended and upper eyelid that delays in closing or remains partially open.

5. A client is having problems with dizziness and complains of the "room spinning." The physician performs the caloric stimulation test. The nurse knows that a diminished response in one eye during the caloric stimulation testis indicative of what? A) Inner ear disorder B) Middle ear disorder C) Outer ear disorder D) Age-related macular degeneration

Ans: A Feedback: During the caloric stimulation test, a diminished response in one eye is significant for an inner ear disorder such as Ménière's disease. It does not signify a middle ear disorder, an outer ear disorder, or age-related macular degeneration.

15. While cleaning gutters, a client reports getting debris in the eyes. On inspection, no obvious foreign object is noted. Which of the following diagnostic evaluation techniques would be most beneficial for this client? A) Administer fluorescein dye. B) Obtain an x-ray for orbital fractures. C) Assess intraocular movements. D) Assess with tonometer.

Ans: A Feedback: Fluorescein dye stains the eye and helps to identify minute foreign body or abrasions in the cornea. X-ray of the eye orbit would be done if a blow to the area preceded the visit. Assessment of intraocular movements (cranial nerves III, IV, and VI) would not be indicated. Tonometry is done for assessment of intraocular pressure and would not be indicated.

18. A client has exhibited repeated return of hordeolum (sty). Which assessment finding is most important in determining care for this client? A) Use of mascara B) Low blood sugar C) Use of disposable wash cloths D) Antibacterial facial wash

Ans: A Feedback: Hordeolum is an infection usually caused by Staphylococcus aureus. To avoid transferring microorganisms, the use of eye cosmetics should be eliminated or at least products frequently replaced. Clients with high blood sugar are more likely to develop hordeolum. Use of disposable wash cloths, antibacterial cleansers, and good hygiene practices are preventable techniques.

5. The nurse is caring for a client who underwent surgery for a retinal detachment. The surgery included the injection of an air bubble to promote contact between the retina and choroids. What position should the nurse keep the client in? A) With the face parallel to the floor B) With the client's head slightly elevated C) With the client lying in a high Fowler's position D) With the client in an upright position

Ans: A Feedback: If an air bubble is instilled to promote contact between the retina and sclera, the client is positioned with the face parallel to the floor so that the bubble floats to the posterior of the eye. The client is asked to be on complete bed rest for several days with the head immobilized and to avoid any physical movements.

2. A client comes to the walk-in clinic complaining of a "bug in my ear." What action should be taken when there is an insect in the ear? A) Instillation of mineral oil B) Instillation of carbamide peroxide C) Instillation of hot water D) Use of a small forceps

Ans: A Feedback: Mineral oil is instilled into the ear to smother an insect. Carbamide peroxide is used to soften dried cerumen, and small forceps are used to remove solid objects. Hot liquids cause dizziness and should not be instilled in the ear.

20. The nurse is obtaining a history from a client complaining of ear pain and dizziness. Which assessment finding is the best evidence that the client has a perforated eardrum? A) Fluid draining in the external canal B) Pain has resolved C) Elevated white blood cell count D) Inflammation and a reddened eardrum

Ans: A Feedback: Noting the actual fluid in the ear canal alerts the nurse to the fact that there is a perforation in the tympanic membrane. The other options are also signs of a perforation but also signs of otitis media without perforation

22. The nurse is instilling an antibiotic solution into the ear of an adult with otitis media. Which nursing action is most correct to ensure that the medication travels down the ear canal? A) Pull the auricle upward and back to instill the medication. B) Place a cotton ball in the ear canal to keep the medication in place. C) Pull the auricle downward and back to instill the medication. D) Use a cotton tip applicator to spread the medication deep in the canal.

Ans: A Feedback: The best nursing action is to straighten the ear canal by pulling the auricle upward and back. This action allows the medication to progress down the canal. In a child, the auricle should be pulled downward and back. The child's canal is straighter than the adults. The cotton ball will keep the medication in place but does not ensure that the medication in traveling down the canal. A cotton tip applicator should not be placed into

29. The nurse is obtaining a visual history from a client who has noted an increased in glare and changes in color perception. Which assessment would the nurse anticipate to confirm a definitive diagnosis? A) Identification of opacities on the lens B) Identification of white circle around the cornea C) Identification of yellowish aging spot on the retina D) Identification of redness of the sclera

Ans: A Feedback: The client states an increased glare and changes in color perception, which indicates a cataract. Identification of opacities on the lens confirms that diagnosis. A white circle around the cornea and a yellowish aging spot are also symptoms of aging but with different symptoms. Redness of the sclera indicates irritation.

23. A 24-year-old female client is diagnosed with otosclerosis. Which teaching is most accurate? A) Symptoms may be accelerated by pregnancy. B) Medications can interfere with birth control pills. C) Menstrual periods may be longer and more severe. D) Females otosclerosis is linked with infertility.

Ans: A Feedback: The etiology of otosclerosis is unknown; however, it is more common in females than males and usually occurs in the second or third decade of life. It is accurate to instruct females that symptoms of otosclerosis seem to be accelerated during pregnancy.

8. The nursing student hopefuls are taking a pre-nursing anatomy and physiology class. What anatomical structure equalizes air pressure in the middle ear? A) Eustachian tube B) The malleus C) The pinna D) The meatus

Ans: A Feedback: The eustachian tube extends from the floor of the middle ear to the pharynx and is lined with mucous membrane. It equalizes air pressure in the middle ear. Options B, C, and D do not equalize pressure in the middle ear.

22. The nurse is caring for a client who just returned from a trip requiring an airline flight. The client commented on how his ears hurt upon descent. The nurse is correct in stating which site as being the pressure equalizer in the ear? A) Eustachian tube B) Auricle C) Tympanic membrane D) Labyrinth

Ans: A Feedback: The eustachian tube extends from the floor of the middle ear to the pharynx. It equalizes air pressure in the middle ear. The auricle is the fleshy portion of the outer ear which funnels sound waves to the inner ear.

11. The nurse is assessing client's eyes as part of the inspection part of the assessment process. For which reason does the nurse identify a normal variation in the angle of the lateral and medial canthus? A) Ethnic differences B) Chromosomal differences C) Structural changes D) Cosmetic alterations

Ans: A Feedback: The line between the lateral and medial canthus is usually horizontal. Variations are noted abnormally in children with Down syndrome and normally in individuals of Asian descent. Structural changes and cosmetic variations are not considered normal changes noted on assessment.

4. You are doing hearing tests at the local junior high school. Which of the following indicates normal hearing in a child? A) A client who first perceives sound at 20 dB B) A client who first perceives sound at 40 dB C) A client for whom the painful sound occurs at 80 dB D) A client for whom the painful sound occurs at 100 dB

Ans: A Feedback: The lowest level of sound that normal persons may first perceive is 20 dB. The painful sounds occur at 120 dB. The hearing acuity is determined by measuring the intensity at which a person first perceives sound.

32. The nurse is instructing a client's family members on the most incapacitating symptom of Ménière's disease. Which nursing instruction associated with the symptom is most helpful? A) Assist the client when ambulating. B) Keep a bucket beside the bed. C) Ensure low lighting in the room. D) Sit in front of the client when speaking.

Ans: A Feedback: The most incapacitating symptom of Ménière's disease is vertigo. When the client is experiencing vertigo or dizziness, the gate is unsteady. Having a person assist the client when ambulating is most helpful in preventing falls. Keeping a bucket at the bedside is helpful if the client is experiencing nausea. Photophobia is not a main symptom of Ménière's disease. If the client experiences hearing loss, being able to see the client's lips may be helpful.

36. The nurse is caring for a client diagnosed with an acoustic neuroma. Which assessment finding does the nurse anticipate when receiving shift report that is not related to hearing? A) Impaired facial movement and numbness and tingling B) Stroke like symptoms with bilateral facial droop C) Difficulty swallowing D) Inability to smell scents

Ans: A Feedback: The nurse anticipates that the previous shift nurse will report assessment findings of symptoms of impaired facial movement and possibly symptoms of facial numbness and tingling. Symptoms related to hearing include hearing loss, tinnitus, and vertigo.

19. The nurse is evaluating the client while taking the color vision test. Which response would the nurse anticipate when caring for a client with normal color vision? A) The nurse would anticipate the client identifying numbers and shapes. B) The nurse would anticipate a cross-eyed appearance. C) The nurse would anticipate responding to the color names in the pictures. D) The nurse would anticipate no differentiation in between colors.

Ans: A Feedback: The nurse is correct to anticipate the client being able to identify numbers and shapes dictated by different color codes. The other options do not test for color vision or indicate an inability to differentiate colors.

22. The client with chronic open-angle glaucoma is receiving timolol (Timoptic) eye drops. Which evaluation finding would indicate to the nurse the treatment is working? A) Intraocular pressure 15 mm Hg B) Reduced peripheral vision C) Halos around lights D) Decrease in nausea and vomiting

Ans: A Feedback: Timoptic is a beta-blocker that is used topically to decrease the flow rate of aqueous humor in the eye. As flow rate decreases, the intraocular pressure decreases. IOP of 12 to 21 mm Hg is within normal range. Reduced peripheral vision, halos around lights, and blurred vision are all symptoms of open-angle glaucoma. Nausea and vomiting are more likely to occur with acute angle-closure glaucoma.

27. An elderly client is scheduled for cataract surgery and asks the nurse, "Will I need to wear pop-bottle lenses after surgery?" Which is the most appropriate response from the nurse? A) "An implanted lens has replaced the need for corrective glasses." B) "Contact lenses are preferred by most clients after this surgery." C) "They can make corrective lenses much thinner now." D) "No lens is necessary with cataract surgery."

Ans: A Feedback: Vision is usually restored after cataract surgery with an intraocular lens implant. Contact lenses can be used but can be burdensome for the elderly. Corrective glass lenses can cause a distortion of peripheral vision and only required one lens (over operative eye). To restore vision after cataract surgery, a lens is required.

20. A client presents to the emergency room with symptoms of blurred vision. Which type of question would be best to ask first? A) "Have you ever had these symptoms before?" B) "Did these symptoms come on abruptly?" C) "Do you have a family history of vision problems?" D) "Do you have any other diseases?"

Ans: A Feedback: When a client presents with unusual symptoms, a first question assesses if he or she has ever had these symptoms before. This prepares a starting place for the assessment. If the client did have these symptoms before, questions regarding the specific nature and similarities of that experience guide the assessment.

9. A nursing instructor is teaching pre-nursing students in a pathophysiology class. What would the instructor teach the students about Ménière's disease? A) It is referred to as endolymphatic hydrops. B) It originates in the middle ear. C) It is referred to as lymphatic hydrops. D) It originates in the outer ear.

Ans: A Feedback: When a person moves his or her head, the endolymph also moves, and nerve receptors within the membranous labyrinth send signals to the brain about the movement. In Ménière's disease, an increase in endolymph causes the membranous labyrinth to dilate like a balloon; this is referred to as endolymphatic hydrops. Ménière's disease does not originate in either the middle or the outer ear, and it is not referred to as lymphatic

25. An elderly client is admitted with the diagnosis of retinal detachment and is scheduled for laser surgery and scleral buckling procedure. The nurse anticipates which of the following symptoms to be exhibited in this client? Select all that apply. A) Flashing lights B) Cobwebs in vision field C) Complete loss of vision in both eyes D) Loss of central vision E) Eye pain F) Arcus senilis

Ans: A, B Feedback: Many clients with detached retina experience a sensation of a curtain or veil lowering over vision field, flashing of lights, floaters, cobwebs, or spots. Complete vision loss can occur in the affected eye. Loss of central vision, eye pain, and arcus senilis is not indicated in this disorder.

27. The nurse is working in a long-term care facility. Which clues does the nurse note which suggests that the client is not hearing what the nurse said? Select all that apply. A) The client does not want to be social. B) The client responds inappropriately. C) The client asks for surrounding sounds be increased. D) The client nods the head and smiles. E) The client withdraws from activity.

Ans: A, B, D, E Feedback: A nurse notices clues that the client is having difficulty hearing. Clues include not wanting to be social because interaction is difficult, responding/answering questions inappropriately, nodding and smiling no matter what the answer is, and withdrawing from activity to name a few. Increasing the surrounding sounds makes it more difficult to hear.

24. The nurse is employed in an ear, nose, and throat (ENT) physician's office, obtaining a client history. The nurse documents the following client statements. Which symptoms may indicate a diagnosis of otosclerosis? Select all that apply. A) "It seems that I increasingly could not hear my kids talk to me." B) "I woke up on Monday and had ear pain with a marked decrease in hearing." C) "I now notice a ringing in my ears especially when I lay down to sleep at night." D) "I can hear better when someone speaks in low tones." E) "I can hear best when you put the tuning fork behind my ear."

Ans: A, C, E Feedback: Although the cause of otosclerosis is unknown, there are specific symptoms because of the interference of the vibrations in the ear. The symptoms of diagnosis of otosclerosis include a progressive, bilateral hearing loss; tinnitus especially noted at night; and the outcome of the Rinne test as being that sound is heard best with the tuning fork behind the ear. The nurse would not identify an abrupt onset of hearing loss or improvement of

15. The nurse is obtaining subjective data from a client with difficulty hearing. In order to assist the client in hearing the nurse's voice, which adjustments are made? Select all that apply. A) Speak in a clear voice B) Use high-pitched tones C) Clearly articulate D) Speak in a louder volume E) Speak in a lower tone F) Face the client when speaking

Ans: A, C, E, F Feedback: To obtain data from the client, the nurse must be able to communicate with the client. In a client with hearing difficulty, the nurse is correct to speak in a clear voice and articulate the words clearly. Also, speaking in lower tones is better for hearing. Facing the client enables the client to focus on interpreting lipreading to compare with hearing the words. High-pitched tones and speaking in a loud volume are more difficult for word interpretation.

12. When caring for a client with a foreign object removed from the eye, the nurse is most correct to assess the eye protective functions of which structures? Select all that apply. A) Eyelids and lashes B) Aqueous humor C) Superior and inferior oblique muscles D) Conjunctiva E) Sclera F) Tears

Ans: A, F Feedback: The nurse is correct to assess the eyelids and lashes and also tears as the protective structures. The eyelids protect against foreign bodies and adjust the amount of light that enters the eye. The eyelashes trap foreign debris. Periodic blinking clears dust and particles from the surface of the eyes. The aqueous humor and sclera are intraocular structures. Oblique muscles move the eye left and right. The conjunctiva is a sensitive transparent mucous membrane that alerts the individual to a foreign object in the eye.

3. You are teaching a class on diseases of the ear. What would you teach the class is the most characteristic symptom of otosclerosis? A) The client being distressed in the mornings B) A progressive, bilateral loss of hearing C) A red and swollen ear drum D) The client describing a recent upper respiratory infection

Ans: B Feedback: A progressive, bilateral loss of hearing is the characteristic symptom of otosclerosis. Tinnitus appears as the loss of hearing progresses; it is especially noticeable at night, when surroundings are quiet, and may be quite distressing to the client. The eardrum appears pinkish-orange from structural changes in the middle ear. The client often describes a history of having had a recent upper respiratory infection i

13. The occupational nurse is advising a customer service representative client on assistive devices for hearing because the client has progressive hearing loss. In discussing the options with the client, which type would be the last option offered by the nurse? A) Battery-operated hearing aid B) American sign language C) Headsets with amplifiers D) Text-based telecommunications

Ans: B Feedback: Although the American sign language is an asset to use for communication, a client with an occupation of customer service representative needs accommodations to be able to understand the spoken word.

17. A client is diagnosed with uveitis. Which assessment finding is most important in determining likelihood of recurrence? A) Chemical exposure B) Ankylosing spondylitis C) Glaucoma D) Extended contact use

Ans: B Feedback: Although the cause of uveitis is unknown, it is detected with frequency among clients with autoimmune disorders (such as ankylosing spondylitis). Chemical exposure and extended contact use are not indicated with uveitis.

3. A client is diagnosed with keratitis. What advice should the nurse give this client? A) Use warm soaks frequently. B) Use dark glasses. C) Wash the face and hair frequently. D) Massage the surrounding area.

Ans: B Feedback: Dark glasses are recommended for a client with keratitis to relieve photophobia. Treatment for keratitis does not require use of warm soaks and massages or washing of the face and hair.

7. There are several types of hearing loss. Which type of hearing loss benefits most from the use of a hearing aid? A) Sensorineural B) Conductive C) Genetic D) Acquired

Ans: B Feedback: Diminished hearing results from a conductive loss, sensorineural loss, or both. Clients with a conductive hearing loss benefit more from the use of a hearing aid because the structures that convert sound into energy and facilitate perception of sound in the brain continue to function. Genetic and acquired are not types of hearing loss.

9. A client has just been diagnosed with glaucoma. What teaching should the nurse include with this client? A) How long they have to wear dark glasses B) Maintain regular bowel habits C) What vegetables to eat D) When they can read again

Ans: B Feedback: Instructions for the client with glaucoma include the following: Obtain assistance from a family member, relative, or friend if you have trouble instilling eye drops. Avoid all drugs that contain atropine. Check with physician or pharmacist before using any nonprescription drug. preparations for cold or allergy symptoms may contain an atropine-like drug. Maintain regular bowel habits; straining at stool can raise IOP. Avoid heavy lifting and emotional upsets (especially crying) because they increase IOP. Eating vegetables and reading do not increase IOP.

23. The nurse is assessing a client's hearing using the Rinne test. When providing instruction to elicit client feedback, which instruction is essential? A) Raise your hand when you hear the vibration. B) Raise your hand when you no longer hear sound. C) Raise your hand when the vibration exceeds the sound. D) Raise your hand when the sound exceeds the vibration.

Ans: B Feedback: It is essential to provide clear directions on when the client is to notify the nurse of client response. The information gleaned from the response is what the nurse uses to interpret the test. The correct time to induce feedback is when the vibration is held.

5. A nursing student is presenting a report on Ménière's disease to other members of the class. What symptom would the student list? A) Pinkish-orange eardrum B) Nystagmus of the eyes C) Enlarged lymph nodes behind the ear D) Swelling and redness in the auditory canal

Ans: B Feedback: Nystagmus of the eyes may occur in a client with Ménière's disease caused by an imbalance in vestibular control of eye movements. Pinkish-orange eardrums, enlarged lymph nodes, or swelling and redness in the auditory canal are not observed in a client with Ménière's disease.

35. The nurse is caring for a client with symptoms of ototoxicity from aminoglycoside administration. On which structure does the medication produce the ototoxic effect? A) The auditory canal B) The eighth cranial nerve C) The tympanic membrane D) The cochlear nerve

Ans: B Feedback: Ototoxicity describes the detrimental effect of aminoglycosides on the eighth cranial nerve. Signs and symptoms include tinnitus and sensorineural hearing. The other options are not related to the ototoxic effects.

11. Following an ophthalmologic exam, an anxious client asks the nurse, "How serious is a refraction error?" Which of the following is the best response from the nurse? A) "It is nothing serious." B) "It means corrective lenses are required." C) "Simple surgery can fix this problem." D) "This is normal for anyone your age."

Ans: B Feedback: Refractive errors can be corrected with glasses or contact lenses. Telling a client that "nothing is serious" does not provide the necessary information to help alleviate fears. The word surgery can increase fears. If the refractive error is associated with aging, this is a normal finding but does not provide information to the condition.

28. Which nursing goal is a priority when caring for a client newly diagnosed with vertigo? A) Patient will maintain therapeutic medication schedule. B) Patient will remain safe while ambulating in the home. C) Patient will have a caretaker with him or her in the home. D) Patient will closes eyes as needed to reduce symptoms.

Ans: B Feedback: Safety is always a concern when a client is experiencing vertigo. The goal of the nurse's instruction and care is for the client to remain safe. Maintaining a therapeutic medication schedule and caretaker and establishing strategies to reduce symptoms are important but not of highest priority.

12. The nurse is obtaining a history from a client who indicates hearing loss due to drug toxicity. Which type of hearing loss is noted? A) Conductive B) Sensorineural C) Mixed D) Central

Ans: B Feedback: Sensorineural hearing loss involves damage to the inner ear from etiologies including drug toxicity. Conductive hearing loss occurs from an obstruction in the middle to outer ear. Mixed hearing loss includes a combination of conductive and sensorineural hearing loss. Central hearing loss involves injury or damage to the nerv

3. The client is having a Weber test. During a Weber test, where should the tuning fork be placed? A) On the mastoid process behind the ear B) In the midline of the client's skull or in the center of the forehead C) Near the external meatus of each ear D) Under the bridge of the nose

Ans: B Feedback: The Weber test is performed by striking the tuning fork and placing its stem in the midline of the client's skull or in the center of the forehead. In the Rinne test, the tuning fork is struck and placed on the mastoid process behind the ear.

21. A client splashes bleach into the right eye and requires irrigation of the eye. Which nursing action is most important to prevent extension of chemical irritation? A) Use only saline solution. B) Turn head with right side lower than the left. C) Tilt head backward and irrigate both eyes. D) Direct solution toward the nasolacrimal duct.

Ans: B Feedback: The chemical in the right eye can drain into the left eye causing additional damage. To avoid the drainage from affected eye to unaffected eye requires careful positioning during irrigation. Saline solution is usually used, but water can be used for emergency flushing.

26. The nurse is evaluating the independent care of a client recovering from a stapedectomy. Which action, made by the client, indicates a need for further teaching? A) The client turns head slowly when family approaches. B) The client uses clean technique to clean the wound. C) Taking antibiotics on a convenient schedule D) Ensure assistance upon ambulation.

Ans: B Feedback: The client needs further instructions on using aseptic technique when completing wound care. Using aseptic technique reduces the introduction and transmission of microorganisms and protects the clie

26. The client is consulting with a physician regarding a potential diagnosis of Ménière's disease. The nurse is assisting in positional testing and documentation. Which diagnostic test would the nurse anticipate to obtain a more precise evaluation of vestibular function? A) Audiometry B) Electronystagmography C) Caloric stimulation test D) Romberg test

Ans: B Feedback: The electronystagmography is a more precise method for evaluation vestibular function. It is performed in conjunction with caloric stimulation. When the fluid is instilled in the ear, a machine records the duration and velocity of eye movements with electrodes attached around the eye. Audiometry measures hearing acuity. The Romberg test measures balance.

21. The nurse is caring for a client with recurrent ear infections. The nurse assesses the client for further infectious processes traveling deeper into the tissue and becoming more lethal. Which infection, originated in the ear, is of most concern? A) Mastoiditis B) Meningitis C) Sinusitis D) Labyrinthitis

Ans: B Feedback: The infection stemming for the ear may extend to the meninges, causing meningitis, or a brain abscess could occur. This could be life threatening. The other options are also potential complications of an ear infection.

16. The nurse is establishing a visual test using the Snellen chart for a client experiencing visual changes. At which distance should the nurse instruct the client to stand? A) A 10-feet distance B) A 20-feet distance C) A 30-feet distance D) A 40-feet distance

Ans: B Feedback: The nurse is correct in instructing the client to stand at a 20-feet distance from the Snellen chart. Often, the nurse places tape on the floor to denote the correct distance for

18. The nurse is assisting the eye surgeon in completing an examination of the eye. Which piece of equipment would the nurse provide to the physician to examine the fundus and interior of the eye? A) Retinoscope B) Ophthalmoscope C) Tonometer D) Amsler grid

Ans: B Feedback: The nurse is correct to provide an ophthalmoscope to the surgeon for examination of the fundus or interior of the eye. A retinoscope is used to determine errors in refraction. A tonometer measures intraocular pressure. An Amsler grid tests for problems with the macula.

20. When caring for a client with progressive macular degeneration, which teaching measure is primary for client safety? A) Patch the affected eye. B) Turn head side to side when walking. C) Avoid bending over. D) Avoid straining the eyes.

Ans: B Feedback: To expand the visual field, the client should be taught to turn the head from side to side when walking. This effort can assist in improving vision field and decrease risk of injury from tripping and falls. This technique helps to maximize the partial sight. A patch may assist with symptoms of dizziness associated with hemianopia but not significant for safety. Bending over can increase intracranial pressure but not significant with macular degeneration. Straining the eyes with close work and reading can increase blurring of vision in macular degeneration but not significant for safety

8. You are teaching a parent how to instill drops in their 12-year-old son's eyes. Which action would you teach the parent is accomplished first? A) Close the eye gently. B) Tilt the head slightly backward. C) Instill the prescribed number of drops into the conjunctival pocket. D) Do not allow the tip of the container to touch the eye.

Ans: B Feedback: To instill eye drops, tilt the head slightly backward and toward the eye in which the medication is to be instilled. Do not allow the tip of the container to touch the eye. Instill the prescribed number of drops into the conjunctival pocket or apply a thin ribbon of ointment directly into the conjunctival pocket, beginning at the inner corner and moving outward. Close the eye gently. Options A, C, and D are not the first action in instilling eye drops.

33. The nurse is assisting the client in planning care during exacerbations of Ménière's disease. Which diet would the nurse identify as appropriate at this time? A) A high-protein diet B) A low-sodium diet C) A low-fat diet D) A calorie-controlled diet

Ans: B Feedback: Treatment for Ménière's disease is related to reducing fluid production in the inner ear, facilitating its drainage, and treating the symptoms that accompany the attack. A low-sodium and sodium-free diet lessens edema.

2. A client, diagnosed with a cataract, comes into the clinic. What assessment should the nurse observe in this client? A) A burning sensation and the sensation of an object in the eye B) Blurred or cloudy visual image C) Inability to produce sufficient tears D) A swollen lacrimal caruncle

Ans: B Feedback: When a cataract forms, the light is blocked from reaching the macula, and the visual image becomes blurred or cloudy. The client does not experience any burning or the sensation of an object in the eye, an inability to produce sufficient tears, or a swollen lacrimal caruncle.

29. The nurse on a cruise ship is assessing clients for motion sickness. Which of the following is a common misconception? A) Repeated motion is the cause. B) Once symptoms occur, they will always be present. C) Medications help the symptoms. D) Pallor and diaphoresis is a first symptom.

Ans: B Feedback: When the client experiences motion sickness, the client will use that data to avoid further symptoms in the future. The client can use medication, change location or position, and recognize symptoms earlier for symptom management. The other options are correct and teachable statements.

17. The nurse is supervising a family member who instilling ear drops into the client's ear. Which of the following statements, made by the family member, would require further nursing instruction? A) "Turn your head to the side so I can put these drops in." B) "These drops are cold from being on the window seal." C) "Let me put this cotton ball in your ear because I put the drop in." D) "I squeeze the dropper to put a drop of medicine in the ear."

Ans: B Feedback: When the family member states that the drops are cold, the nurse would encourage the family member to place the bottle in a warm bath or warm the bottle in their hands. Cold or hot liquids, instilled in the ear, may cause dizziness and potential for injury.

14. Which technique would be most beneficial for ambulation of a client who is visually impaired? A) Speak before touching the client. B) Provide a detailed description of the room and walkway. C) Allow client to follow your lead. D) Provide the client with a see-eye guide dog.

Ans: C Feedback: A blind person feels more secure and safe when assisted by someone who is sighted. The nurse should walk slightly ahead while allowing the client to hold onto the upper arm or elbow of the nurse. Speaking before touching is an important care item in dealing with clients who have impaired vision but does not assist in ambulation. Providing a detailed description of the room may allow the client an image of the surroundings but not as helpful in initial ambulation. Finding a perfect fit between guide dog and client is a lengthy process and should be pursued upon request of client.

25. The nurse is assisting with the administration of a caloric stimulation test. Which client response would the nurse document as an expected response? A) Dizziness B) Headache C) Nystagmus D) Double vision

Ans: C Feedback: A caloric stimulation test assesses vestibular reflexes of the inner ear that control balance. Warm or cool water or air is instilled into the external meatus of the ear separately. Nystagmus, a quivering movement of the eyes, is the expected response. Slight dizziness may be experienced but is not the expected response.

30. Miotic eye solutions are often ordered in the treatment of glaucoma. Which is the best nursing rationale for the use of this medication? A) Constricts intraocular vessels B) Paralyzes ciliary muscles C) Constricts pupil D) Dilates the pupil

Ans: C Feedback: A miotic agent works by constricting the pupil and pulling the iris away from the drainage channels so that the aqueous fluid can escape. These medications increase outflow and decrease intraocular pressure. Cycloplegics paralyze the ciliary muscles of the eye. Mydriatics drugs are used to dilate the pupil and are contraindicated in glaucoma.

10. The nurse is instructing a nursing student when a new client comes to the eye clinic. The client explains that he thinks he has a corneal abrasion. The nurse should explain what to the student nurse? A) "To detect corneal abrasions, an ophthalmoscope is used." B) "To detect corneal abrasions, ultrasonography is used." C) "To detect corneal abrasions, a slit lamp is used." D) "To detect corneal abrasions, retinal angiography is used."

Ans: C Feedback: A slit lamp is a binocular microscope that magnifies the surface of the eye. A beam of light, narrowed to a slit, is directed at the cornea, facilitating an examination of structures and fluid in the anterior segment of the eye. This examination is used to identify disorders such as corneal abrasions, iritis, conjunctivitis, and cataracts. Options A, B, and D are not used to detect corneal abrasions.

9. Audiometry is testing that measures hearing acuity precisely. Who does the nurse know can perform audiometric testing? A) School nurse B) Hearing aide salesperson C) Audiologist D) Office nurse

Ans: C Feedback: Audiometry is done by an audiologist. Audiometric testing measures hearing acuity precisely. Options A, B, and D can screen hearing, but they cannot do audiometric testing.

6. A client has been referred to an ophthalmologist for suspected macular degeneration. The nurse knows to prepare what test for the physician to give the client? A) Ishihara polychromatic plates B) Visual field C) Amsler grid D) Slit lamp

Ans: C Feedback: Clients with macular problems are tested with an Amsler grid. It is made up of a geometric grid of identical squares with a central fixation point. The examiner instructs the client to stare at the central fixation spot on the grid and report if they see any distortion of the squares. Clients with macular problems may say some of the squares are faded or wavy. An Ishihara polychromatic plate, visual field, or slit lamp test will

28. Immediately following cataract removal, which symptom would be most alarming to the nurse? A) Irritation in the operative eye B) Dilation of the pupil C) Dry, tickling cough D) Fever

Ans: C Feedback: Coughing can rise the intraocular pressure and should be avoided. A cough suppressant can be prescribed. The pupil was intentionally dilated during the surgical approach and will resolve. The client may complain of mild eye irritation in the immediate postoperative period. Fever can be a complication of cataract surgery but not expected in the immediate period postoperatively.

34. The nurse is caring for a client being treated for Ménière's disease. Which medication is monitored closely due to its addictive properties? A) Meclizine (Antivert) B) Hydrochlorothiazide C) Diazepam (Valium) D) Promethazine (Phenergan)

Ans: C Feedback: Diazepam (Valium) is used to treat the client with Ménière's disease to help control vertigo. Diazepam is a tranquilizer that has addictive properties. The other options, used in the treatment of Ménière's disease, do not have any or significant addictive properties.

6. During a pharmacology class, the students are told that some drugs need to be closely monitored. What aspect should the nurse closely monitor for in clients who have been administered salicylates, loop diuretics, quinidine, quinine, or aminoglycosides? A) Signs of hypotension B) Reduced urinary output C) Tinnitus and sensorineural hearing loss D) Impaired facial movement

Ans: C Feedback: It is important that nurses are knowledgeable about the ototoxic effects of certain medications such as salicylates, loop diuretics, quinidine, quinine, and aminoglycosides. Signs and symptoms of ototoxicity include tinnitus and sensorineural hearing loss. Hypotension, reduced urinary output, and impaired facial movement are not signs of

23. A client with chronic open-angle glaucoma is now presenting with eye pain and intraocular pressure of 50 mm Hg. An immediate iridotomy is scheduled. Which of the following describes the desired effects of this procedure? A) Reverse optic nerve damage B) Restore vision C) Improve outflow drainage D) To relieve pain

Ans: C Feedback: Laser iridotomy or standard iridotomy is a surgical procedure that provides additional outlet drainage of aqueous humor. This is done to lower the IOP as quickly as possible since permanent vision loss can occur in 1 to 2 days. Once optic nerve damage occurs, it cannot be reversed, and vision is not restored. Pain that occurs with rising IOP will be

1. A client comes to the occupational health nurse complaining of eye irritation. The client works in a dusty, outdoor environment. Why should the nurse advise periodic blinking to this client? A) To control the amount of sunlight that enters the eye B) To minimize the impact of the wind on the eye and to trap foreign debris C) To clear the dust and particles from the surface of the eyes D) To prevent the collection of tears over the surface of the eye

Ans: C Feedback: Periodic blinking clears the dust and particles from the surface of the eyes. The eyelids also spread tears over the surface of the eye, which helps bathe and lubricate the surface. The eyelids protect against foreign bodies and adjust the amount of light that enters the eye, whereas the eyelashes trap foreign debris.

12. A middle-aged client reports increasing difficulty reading the newspaper print. Which of the following nursing explanations best describes this type of refractive error? A) Client is nearsighted. B) Lens has become cloudy and thick. C) Loss of elasticity of the ciliary processes D) Floaters in the eye increase with age

Ans: C Feedback: Presbyopia is a result of poor accommodation due to a loss of elasticity of the ciliary muscles and lens. Nearsighted refers to myopia. Cloudiness of lens is also associated with the aging process and does interfere with vision as a result of cataract formation. Floaters in the eyes are more apparent with aging but appear as dark spots.

8. What kind of otitis media is a pathogen-free fluid behind the tympanic membrane, resulting from irritation associated with respiratory allergies and enlarged adenoids? A) Purulent otitis media B) Infectious otitis media C) Serous otitis media D) Sterile otitis media

Ans: C Feedback: Serous otitis media, a collection of pathogen-free fluid behind the tympanic membrane, results from irritation associated with respiratory allergies and enlarged adenoids. Options B and D are distractors for this question. Purulent otitis media usually results from the spread of microorganisms from the eustachian tube to the middle ear during upper respiratory infections.

14. The nurse is obtaining a history on a client stating the inability to read the newspaper and even seeing detail when looking at an image. Which assessment test would add additional data for a diagnosis? A) Assess if the pupils are equal and reactive to light. B) Assess vision on the Snellen chart. C) Assess peripheral vision. D) Assess color vision.

Ans: C Feedback: The client states symptoms of the inability to discriminate letters, words, and details of an image, indicating the degeneration of the macula. If the macula is damaged, the client will only have the ability to see movement and gross objects in the peripheral fields. Assessing the peripheral vision will add essential information. The other visual tests are not as important at this time.

18. The nurse is caring for an 8-year-old and anticipates that the client has otitis externa from symptoms stated on the history. Which symptoms, from the history and physical examination, would confirm the diagnosis? A) Discomfort in the ear B) Difficulty hearing C) Pus noted in the ear canal D) Inflammation around the tympanic membrane

Ans: C Feedback: The diagnosis of otitis externa (inflammation of the tissue of the outer ear) is confirmed by the presence of pus in the ear canal. The inflammation is usually caused by an overgrowth of pathogens. The other symptoms are also common in otitis media.

16. The nurse is instructing the client with dried cerumen blocking the ear canal on potential methods to reduce symptoms. Which at home methods of cerumen removal is discouraged? A) Instilling 1 to 2 drops of half-strength peroxide in the ear B) Using warm glycerin or mineral oil to soften the cerumen C) Removing the cerumen by means of a cotton tip applicator D) Irrigating the ear with warm water and a rubber-bulb syringe

Ans: C Feedback: The nurse is an important resource person to consult when a client has an issue with the ear structure or hearing. The nurse is correct to discourage placing anything down the ear canal that could push the cerumen deeper toward or puncture the tympanic membrane. The other options are appropriate to soften and lubricate the cerumen or to irrigate the cerumen from the ear.

21. The nurse is caring for a client ordered multiple eye screening. Following which procedure will the nurse instruct the client on a yellow coloring to the skin and urine as being normal? A) Ultrasonography B) Retinal Imaging C) Retinal Angiography D) Retinoscopy

Ans: C Feedback: The nurse is most correct to instruct the client that his skin and urine may turn yellow following a retinal angiography. Sodium fluorescein is a water-soluble dye that is injected into a vein. The dye then travels to the retinal arteries and capillaries, where pictures are obtained of the vascular supply. The other options do not include a dye injection.

6. A client has undergone enucleation. What complication of enucleation should be addressed by the nurse? A) Hypotension B) Nausea and vomiting C) Hemorrhage D) Pneumonia

Ans: C Feedback: The nurse should take measures to prevent hemorrhage, a complication of enucleation, by applying a pressure dressing. Nausea and vomiting may be common side effects of

13. The nurse is assisting in providing coordination of services between the physician's office and vision specialist's office for a client who is being referred for potential retinal surgery. Which eye care specialist will the nurse make the referral to? A) Optician B) Optometrist C) Ophthalmologist D) Ophthalmic technician

Ans: C Feedback: The ophthalmologist is a physician who performs surgery on clients with eye disorders. The optician makes eyeglasses or contact lenses. The optometrist tests vision and prescribes corrective lenses. The ophthalmic technician assists in selective eye tests and procedures.

31. Which of the following assessment findings is least helpful in identifying a cause of Ménière's disease? A) Family history B) Allergic reactions C) Food intolerance D) Head injury

Ans: C Feedback: There is no evidence that a food intolerance is an identifying cause of Meniere's disease. The other options are attributed to the disease.

10. You are caring for a client with open-angle glaucoma. You know that this disease causes which of the following? Select all that apply. A) Atrophy of nerve fibers in the central area of the retina B) Edema of the lens C) Degeneration of the optic nerve D) Edema of the cornea E) Atrophy of nerve fibers in the peripheral areas of the retina

Ans: C, D, E Feedback: Open-angle glaucoma occurs when structures in the drainage system (i.e., trabecular meshwork and canal of Schlemm) degenerate, and the exit channels for aqueous fluid become blocked. As the IOP rises, it causes edema of the cornea, atrophy of nerve fibers in the peripheral areas of the retina, and degeneration of the optic nerve. This makes options A and B incorrect.

17. The nurse is completing a corneal light reflex test using a penlight. Which result would indicate a normal test result? A) The pupils have reaction to light. B) The eyes follow the light in all four directions. C) The client can see the light using peripheral vision. D) The light reflection is in the same spot on each eye.

Ans: D Feedback: A normal corneal light reflex test is when the light reflex is even, reflecting the light at the same spot on both eyes. If the light reflex is uneven, it indicates deviated alignment of the eyes, possibly due to muscle weakness or paralysis.

10. You are caring for a client who is poststapedectomy. What would you include in your nursing care? A) Place the client on the operative side. B) Keep the affected ear packed with cotton. C) Encourage the client to exercise within 24 hours. D) Assess the facial nerve.

Ans: D Feedback: After surgery, the nurse positions the client on the nonoperative side. He or she takes care to prevent dislodgment of the prosthesis as a result of coughing, sneezing, or vomiting. Nausea and dizziness are common problems. The nurse assesses facial nerve function by checking symmetry when the client smiles or frowns. The nurse does not keep the ear packed with cotton or encourage the client to exercise.

19. The nurse is instructing the mother of an infant diagnosed with otitis media. The mother states, "Why is my child getting recurrent ear infections?" Which assessment question is best? A) "Do you cover the child's ears when going outdoors?" B) "Do you administer the child's vitamins on a daily basis?" C) "Do have other children with similar symptoms?" D) "Do you allow the infant to hold or prop the bottle during feeding?"

Ans: D Feedback: Allowing the bottle to be held by the infant or propped by a towel, enables the formula to leak/drip from the child's mouth and flow to the ears where the formula can proceed down the eustachian tube, causing otitis media. It is a common practice to cover the child's ears and take daily vitamins. An ear infection is not typically a contagious

24. Which assessment finding would contraindicate the use of atropine in a client scheduled for general anesthesia? A) Detached retina B) Cerebrovascular accident C) Cataracts D) Glaucoma

Ans: D Feedback: Cholinergic blockers (such as atropine) are often used preoperatively to dry up secretions. Use of these drugs results in dilation of pupils, which increases IOP. Clients with glaucoma should avoid use of atropine in an effort to maintain normal range of IOP. Detached retina, CVA, and cataracts are insignificant in the use of cholinergic blockers.

16. The nurse is instructing the client on use of ophthalmic eye ointment for treatment of an eye disorder. The ointment is ordered once daily. When is the best time to apply the ointment? A) Before arising in the morning B) After breakfast C) After dinner D) At bedtime

Ans: D Feedback: Eye ointments should be instilled when the client can lie back and allow the ointment to dissolve and bathe the eye. This is best accomplished at bedtime.

29. Following cataract removal, discharge instructions will be provided to the client. Which of the following instructions is most important? A) Apply protective patch to both eyes at bedtime. B) Only sleep on back. C) Avoid washing face and eyes for first 24 hours. D) Avoid any activity that can increase intraocular pressure

Ans: D Feedback: For approximately 1 week, the client should avoid any activity that can cause an increase in intraocular pressure. Clients may sleep on back or unaffected side. Clients may use a clean damp cloth to remove eye discharge and wash face. An eye shield is often ordered for the first 24 hours and during the night to prevent rubbing or trauma to the operative eye.

30. The nurse is working in the triage section of a walk-in clinic. Which triad of common symptoms, when placed together, indicate Ménière's disease? A) Blurred vision, vertigo, nausea B) Syncope, vertigo, ear pain C) Disorientation, vertigo, nausea D) Hearing loss, vertigo, tinnitus

Ans: D Feedback: Hearing loss, vertigo, and tinnitus are common symptoms of many disease processes but, when placed together, indicate Ménière's disease. The other options do not include the accurate triad of symptoms.

1 You are teaching the daughter how to instill ear drops of her father to remove impacted cerumen. What is important to teach this woman? A) Insert the irrigating syringe deeply. B) Direct the flow of the ear drops toward the eardrum. C) Refrigerate before instillation. D) Place the container in warm water before instillation.

Ans: D Feedback: If irrigation or instillation of liquids is ordered, the nurse should warm the liquid to body temperature by placing the container in warm water. Cold or hot liquids cause dizziness, and the potential for injury exists if the liquid is hot. The nurse should avoid inserting the irrigating syringe too deeply so as not to close off the auditory canal. The nurse should direct the flow toward the roof of the canal, rather than the eardrum.

2. A nurse is assessing a client for a fracture to the bony orbit. What would the nurse document if her assessment for fracture was positive? A) There is excessive tearing. B) The client's vision is blurred. C) A rust ring is seen around the pupil. D) The client has diplopia.

Ans: D Feedback: If the bony orbit is fractured, the eyes may appear asymmetric, and the client has diplopia or double vision. Excessive tearing, presence of rust rings, or blurry vision does not indicate a fractured bony orbit.

13. At morning report, the nurse learns the assigned client is blind. Which question should the nurse ask the client upon initial assessment? A) "Have you always been blind?" B) "What caused your vision problem?" C) "Are you dependent with your care?" D) "Can you perceive light and motion?"

Ans: D Feedback: Many people who are considered blind perceive light and motion. Establishing this fact can help in developing a plan of care for this client. Establishing cause and length of time for visual impairment is not required for initial care. Asking the client about dependence is important, but the new environment could provide safety issues (even if independent) if no perception of light is identified.

27. The client has been diagnosed with objective vertigo. Which symptom would the nurse relate to the tentative diagnosis? A) Frequency of a headache B) Pain in the outer ear C) Hearing ability fluctuations D) A sensation of things moving

Ans: D Feedback: Objective vertigo includes the sensation that the environment is moving or a sense that things are moving around oneself. The symptoms do not include a headache, pain in the

24. The nurse is working in the emergency department when a physician asks for help as the client is performing a Romberg test. In which position would the nurse stand to be most helpful? A) The nurse would stand directly in front of the client. B) The nurse would stand between the client and physician. C) The nurse would stand across the room but in direct alignment from the client. D) The nurse would stand laterally to the client, opposite side to where the physician is standing.

Ans: D Feedback: The Romberg test is used to evaluate a person's ability to sustain balance. The client stands with the feet together and arms extended. In the event that the client begins to sway (an abnormal result), the nurse is most helpful to stand on the lateral side of the client, opposite side to where the physician is standing to ensure that the client does not fall.

4. You are admitting a client with an acoustic neuroma to your unit. What would you include during the assessment of this client? A) Measure the client's urine output. B) Note the client's height and weight. C) Test the client's ability to sustain balance. D) Test for facial sensation.

Ans: D Feedback: The assessment of a client with an acoustic neuroma includes evaluating hearing function, observing the client's facial movements, and testing for facial sensation. The client's urine output, height and weight, and ability to sustain balance, although important, are not as essential as testing for facial sensation.

15. The nurse is caring for geriatric clients stating that they are prescribed reading glasses. Some individuals state needing assistance with seeing writing far away, and others need assistance with closer vision. The nurse is correct to understand that the aging visual changes relate to which of the following? A) Changes in refraction B) Changes in the visual field C) Changes in central vision D) Changes in accommodation

Ans: D Feedback: The changes that occur in vision during aging, which include difficulty reading and the need for reading glasses, include changes in accommodation. Accommodation occurs when the ciliary muscles contract or relax to focus an image on the retina.

7. What is located in the cochlea of the inner ear? A) Semicircular canals B) Labyrinth C) Vestibulocochlear nerve D) Organ of Corti

Ans: D Feedback: The fluid motion created by the vibrating stapes excites the nerve endings in the sensitive sound receptors of the organ of Corti located in the cochlea. The labyrinth is the name for the inner ear, and the semicircular canals and vestibulocochlear nerves are other components of the inner ear.

32. A client states having difficulty noting details on faces or television. Which of the following structures of the eye allows for detailed vision? A) The pupil B) The iris C) The cornea D) The macula lutea

Ans: D Feedback: The macula lutea is composed entirely of cones and allows for detailed vision. It lies in the center of the retina. This client could potentially have macular degeneration. The iris is the highly vascular, pigmented portion of the eye surrounding the pupil that adjusts in response to light. The cornea covers the anterior portion of the eyeball.

14. The nurse is instructing a client on the benefits of a cochlear implant. The client asks, "How am I able to interpret sound?" The nurse credits which of the following as significant in the production of hearing? A) External microphone B) Internal processor C) Amplifier D) Auditory nerve

Ans: D Feedback: The nurse credits stimulation of the auditory nerve in the transmission of the electrical signals to the brain for interpretation. The external processor and internal processor bring the sounds from the environment and send them to the internal processor, which converts to the electrical signal. An amplifier is used with typical hearing aids.

19. An elderly client with macular degeneration has received injections of angiogenesis inhibitors. Which assessment finding would indicate the condition is worsening? A) Blurred vision B) Burning sensation of the eyes C) Loss of peripheral field vision D) Central vision impairment

Ans: D Feedback: When the macula becomes irreparably damaged, central vision is lost and the client can only see images via peripheral field. Blurred vision is the initial symptom of the disease and does not signify worsening. Burning sensation is a common adverse reaction to the treatment injection.