NCLEX Sensory

The nurse is preparing to administer eyedrops. Which interventions should the nurse take to administer the drops? Select all that apply.

1. Wash hands. 2. Put on gloves. 3. Place the drop in the conjunctival sac. 4. Pull the lower lid down against the cheekbone. To administer eye medications, the nurse would wash hands and put on gloves. The client is instructed to tilt the head backward, open the eyes, and look up. The nurse pulls the lower lid down against the cheekbone and holds the bottle like a pencil, with the tip downward. Holding the bottle, the nurse gently rests the wrist of the hand on the client's cheek and squeezes the bottle gently to allow the drop to fall into the conjunctival sac. The client is instructed to close the eyes gently and not to squeeze the eyes shut to prevent the loss of medication.

A client arrives at the emergency department following an eye injury in which an acid used to clean the brick on the fireplace splashed into the eye. Which question should the nurse ask initially

"Did you flush the eye following the injury?"

The nurse reinforces 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 teaching

"I can tie my shoelaces by bending over slowly."

The nurse is reinforcing instructions to a client following a cataract extraction on the right eye. Which statement by the client indicates a need for further teaching?

"I need to wear an eye shield all the time."

A client reporting recent right eye discomfort is diagnosed with chalazion of the right eye. The nurse reinforces instructions to the client regarding care to the eye. Which statement by the client indicates an understanding of the measures?

"I should apply warm packs to my eye."

A clinic nurse is reinforcing instructions to a client regarding the use of a hearing aid. Which statement by the client indicates a need for further teaching?

"I should turn the hearing aid off after removing it from my ear."

A client is brought to the ambulatory care department by the spouse one day following a cataract extraction procedure. A diagnosis of hyphema is made, which occurred as a result of the surgical procedure. The nurse reinforces instructions to the client and spouse regarding the treatment for the complication and makes which statement?

"Maintain bed rest and patching of both eyes."

Prescriptive eyeglasses are prescribed for a client with bilateral aphakia. When reinforcing teaching instructions regarding the eyeglasses, the nurse determines the need for further teaching when the client makes which statement?

"My peripheral vision will not be distorted."

The nurse is providing discharge instructions to a client following a keratoplasty. Which statement by the client indicates the need for further teaching?

"Sutures are removed in 2 weeks."

The nurse interprets that a client diagnosed with glaucoma needs information about the expected effects of this condition when the client makes which statement?

"Taking my daily walk right around dusk each evening has proven to be so enjoyable."

The nurse is assisting a client who has just been given a hearing aid to wear for the first time. When reinforcing client teaching, the nurse should include which instruction?

"The hearing aid should not be worn if an ear infection is present."

A miotic medication has been prescribed for the client with glaucoma. The client asks the nurse about the purpose of the medication. The nurse should tell the client which?

"The medication causes the pupil to constrict and will lower the pressure in the eye." Miotics cause pupillary constriction and are used to treat glaucoma. They lower the intraocular pressure, thereby increasing blood flow to the retina and decreasing retinal damage and loss of vision. Miotics cause a contraction of the ciliary muscle and a widening of the trabecular meshwork. Options 1, 2, and 4 are incorrect.

A client with glaucoma has suffered significant eye damage before diagnosis and now has impaired vision. The nurse determines that the client needs further assistance in adapting to this situation if the client makes which statement?

"There is no difficulty driving at dusk."

The 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 instructions should the nurse reinforce to the client?

"You may return to work 1 or 2 days following the procedure."

The nurse is reviewing the results of an eye examination on a client. Which tests can detect glaucoma? Select all that apply.

1,2

A client has sought treatment in the ambulatory care clinic after an insect has become trapped in the external ear canal. The nurse prepares to assist the health care provider to instill which acceptable solutions into the ear to remove the insect? Select all that apply.

1,2,3

The nurse is preparing to instill an otic solution into the adult client's right ear. The nurse should include which action while performing this procedure? Select all that apply.

1,2,3,4

Which nursing interventions are appropriate for a client recovering from surgery for retinal detachment? Select all that apply

1,2,3,4,6

Which nursing interventions are appropriate for a client recovering from surgery for retinal detachment? Select all that apply.

1,2,3,4,6

The nurse is providing client and family instructions for a client who has been recently diagnosed with glaucoma. Which statement indicates that the client's family member needs further teaching regarding the eye drop application of pilocarpine hydrochloride (Isopto Carpine)? Select all that apply.

1,3,5

The nurse is providing client teaching regarding glaucoma. Which instructions are important to include in the teaching plan? Select all that apply.

1,4

Tonometry is performed on the client with a suspected diagnosis of glaucoma. The nurse reviews the test and determines that the intraocular pressure is normal if which result is noted?

15 mm Hg Tonometry is the method of measuring intraocular fluid pressure using a calibrated instrument that indents or flattens the corneal apex. Pressures between approximately 10 and 21 mm Hg are considered within the normal range; therefore, the other options are incorrect.

Surgery has been recommended for the client with otosclerosis. The client tells the nurse that she would prefer not to have surgery and asks the nurse about alternative methods to improve hearing. The nurse should make which appropriate response to the client?

A hearing aid may improve your hearing.

A perforated eardrum is suspected in a client who was hit in the ear with a basketball. Which documented observation concerning an otoscopic examination supports this suspicion?

A round or oval darkened area on the eardrum

The nurse is assigned to care for a client with a detached retina. Which finding should the nurse expect to be documented in the client's record?

A sense of a curtain falling across the field of vision A characteristic clinical manifestation of retinal detachment described by clients is the feeling that a shadow or curtain is falling across the field of vision. There is no pain associated with detachment of the retina. A retinal detachment is an ophthalmic emergency and even more so if visual acuity is still normal. Options 1 and 3 are not specifically associated with a detached retina.

The nurse is reviewing the medication list for an assigned client. Which medication is the only one on the client's prescription sheet that does not have an ototoxic effect?

Acetaminophen (Tylenol)

The nurse is reviewing the preoperative prescriptions of a client scheduled for a keratoplasty. Which prescriptions noted in the client's chart should the nurse question?

Administer medication to dilate the affected pupil.

A client has a diagnosis of presbycusis. The nurse interprets that which behavior indicates that the client has successfully adapted to this disorder?

Agrees to use a prescribed hearing aid, especially when home alone

A caloric test is prescribed for a client suspected of having a disease of the labyrinth. The nurse obtains which essential item in preparation for this test?

An otoscope

The nurse is listening to a health care provider explain the results of an eye examination to a client. The health care provider states that the client has glaucoma resulting from a congenitally narrow anterior chamber angle, which has suddenly become blocked by the base of the iris. The nurse interprets that the health care provider is describing which type of glaucoma?

Angle-closure glaucoma

The nurse is reinforcing instructions to a client with a diagnosis of hordeolum regarding the treatment plan. Which instruction should the nurse include in the teaching plan for the client?

Apply a warm compress for 15 minutes four times daily.

The nurse is assisting in developing a plan of care for a client following the surgical removal of an acoustic neuroma. Which assessment will be included in the plan of care for this specific intervention?

Assessment of cranial nerve VII (facial)

A client with Ménière's disease is experiencing severe vertigo. The nurse reinforces instructions to the client to do which to assist in controlling the vertigo?

Avoid sudden head movements. The nurse instructs the client to make slow head movements to prevent worsening of the vertigo. Dietary changes such as salt and fluid restrictions that reduce the amount of endolymphatic fluid are sometimes prescribed. Watching television can increase the vertigo.

A client is experiencing double vision, or diplopia. The nurse interprets that this client is experiencing a loss of which normal function of the eye?

Binocular vision

The nurse collects data from a client with a diagnosis of macular degeneration of the eye. The nurse should expect the client to report which symptom?

Blurred central vision

A nursing student is caring for a client in the health care clinic who has been diagnosed with glaucoma. The nursing instructor asks the student to describe the types of medication that will likely be prescribed for the client to treat the eye disorder. Which drug classification will facilitate the outflow of aqueous humor?

Cholinergic miotic agents

The nurse is developing a poster to use in teaching clients about the prevention of hearing loss. The nurse should diagram which structure as part of the inner ear?

Cochlea

The nurse is assigned to care for a client with a diagnosis of detached retina. Which finding would indicate that bleeding has occurred as a result of retinal detachment?

Complaints of a burst of black spots or floaters Complaints of a sudden burst of black spots or floaters indicate that bleeding has occurred as a result of the detachment. Options 1, 2, and 3 are not specifically associated with bleeding as a result of detached retina.

The nurse caring for a client in the postoperative period following an enucleation notes bloody staining on the surgical eye dressing. Which is the appropriate nursing action?

Contact the health care provider.

The nurse is caring for a client following craniotomy for removal of an acoustic neuroma. The nurse understands that assessment of which cranial nerve should identify a complication specifically associated with this surgery?

Cranial nerve VII, facial nerve

The nurse should check for vision loss in a client with which condition?

Diabetes mellitus

The nurse is collecting data from a client who has a history of untreated cataracts. The nurse checks the client for which associated manifestation?

Difficulty with driving a car at night

A client who has undergone cataract removal without an intraocular lens implant is visibly upset because his vision is still blurry. Which action should the nurse perform to provide realistic reassurance to this client?

Explain that vision will improve with adjustment to aphakic lenses.

After an eye examination, a client has been diagnosed with acute angle-closure glaucoma. The nurse collecting data from the client asks the client about an accompanying history of which sign/symptom?

Eye pain

The nurse in a health care clinic is assisting to test the client for accommodation. The nurse should ask the client to perform which initial action?

Focus on a distant object.

The nurse is assisting the health care provider with performing a Weber tuning fork test on a client. What does this test assess for?

Hearing loss

A client with a diagnosis of otosclerosis is admitted to the ambulatory care unit for stapedectomy, and the nurse reinforces instructions to the client regarding home care following the procedure. Which statement by the client indicates a need for further teaching?

I need to avoid air travel for at least 6 months."

The nurse is providing discharge instructions for a client who has had a fenestration procedure for the treatment of otosclerosis. Which statement by the client indicates an understanding of the instructions?

I will take stool softeners as prescribed by my doctor."

The nurse is caring for a client with acute otitis media. The nurse plans care knowing which treatment for this problem is likely to be included?

Myringotomy

An adult client has increased fluid in the middle ear, which is causing vertigo. The nurse checks this client for which associated signs and symptoms of this condition?

Nausea and vomiting

The nurse is assisting the health care provider in performing a caloric test on a client. Following instillation of cool water into the ear, the nurse observes the presence of nystagmus. The nurse should document the findings of this test as indicative of which result?

Normal

The client has undergone funduscopic examination of the eye. The documented results indicate that the blood vessels are without tortuosity, narrowing, pulsation, or nicking. The nurse interprets that this report indicates which finding?

Normal retinal examination

A client who sustained an eye injury arrives at the emergency department. Which is the initial nursing action?

Obtain a history regarding the cause of the injury.

A clinic nurse is reviewing the record of a client recently diagnosed with a cataract. Which clinical manifestation associated with this disorder should the nurse expect to be documented in the client's record?

Painless, progressive loss of vision

A client is experiencing blockage of the eustachian tubes. The nurse teaches the client that which activities by the client may forcibly open the eustachian tube?

Performing the Valsalva maneuver

The nurse is assisting a health care provider in performing a caloric test on a client. Following instillation of warm water into the ear, the nurse notes that nystagmus does not occur. The nurse should document the findings of this test as indicative of which result?

Positive

The nurse is attempting to inspect the lacrimal apparatus of a client's eye. Because of its anatomical location the nurse should do which action?

Retract the upper eyelid and ask the client to look down.

The nurse is explaining how sound is conducted from the middle ear to the inner ear in teaching a client who is experiencing hearing loss. The nurse plans to use a diagram that illustrates how which bones connects to the cochlea at the oval window?

Stapes

The nurse is reviewing the health care record of a client suspected of having mastoiditis. Which finding does the nurse expect to note if this disorder is present?

Swelling behind the ear

A client is being discharged from the ambulatory care unit following cataract removal. Which instruction from the discharge teaching plan should the nurse reinforce?

Take acetaminophen (Tylenol) if any discomfort occurs.

A client susceptible to motion sickness asks the nurse about the use of medication to prevent an occurrence. The nurse plans to incorporate into the discussion that the medication works effectively if which guideline is followed?

Taking the medication 1 hour before a triggering event.

The nurse is assisting to perform a Romberg test on a client being seen in the clinic. The nurse performs this test to make which determination?

The ability of the vestibular apparatus in the inner ear

The nurse is assisting in performing a confrontation test on a client seen in the clinic. The nurse understands that this test is performed to check which client ability?

The ability to demonstrate effective peripheral vision

The nurse notes that the client's physical examination record states the client's eyes moved normally through the six cardinal fields of gaze. The nurse makes which interpretation?

The client has normal ocular movements.

A client diagnosed with primary open-angle glaucoma has been prescribed pilocarpine ophthalmic drops. When the client asks the nurse how this medication lowers intraocular pressure, which information does the nurse tell the client?

The medication increases the outflow of aqueous humor.

A client has been newly diagnosed with glaucoma. As part of the discharge instructions, the nurse should plan to reinforce which information?

The need for lifelong medication therapy

Which instruction is appropriate for the nurse to provide to a client who reports via telephone that he is certain an insect has flown into his ear because he can hear it "buzzing"?

Use a flashlight to coax the insect out of the ear.

The nurse is speaking with a client with a hearing impairment. The nurse refrains from doing which least likely helpful action when communicating with this client?

Using many exaggerated hand gestures while talking

The nurse is reinforcing instructions to a client regarding the use of ice packs to treat an eye injury. The nurse instructs the client to do which action?

Wrap a plastic bag filled with ice with a pillowcase and place it on the eye.

The nurse notes that the client's eyes are reddened, and the client states that an eye infection has been diagnosed. The nurse interprets that the client is most likely referring to infection of which structure that provides a protective covering for the eye?

Conjunctiva

The nurse has been assigned to a client with a hearing impairment. To enhance nurse-client communication, the nurse should plan to communicate with the client by speaking in which manner?

In a normal tone while facing the client

A client arrives at the emergency department after experiencing a traumatic blow to the eye and a hyphema is diagnosed. In which position should the nurse place the client?

In semi-Fowler's position

The nurse is reinforcing home care instructions to a client following a fenestration procedure for the treatment of otosclerosis. Which instruction should the nurse give the client?

Increase fluids and take a stool softener daily

A client arrives in the emergency department with an eye injury caused by metal fragments that hit the eye while the client was drilling into metal. The nurse checks the eye and notes small pieces of metal floating on the eyeball. Which action should the nurse plan to assist with first?

Irrigate the eye with sterile saline.

A client arrives in the emergency department with an eye injury resulting from metal fragments that hit the eye while the client was drilling into metal. The nurse checks the eye and notes small pieces of metal floating on the eyeball. Which action should the nurse take first?

Irrigate the eye with sterile saline.

The nurse is communicating with a client who is hard of hearing in both ears. To facilitate communication with this client, the nurse should perform which?

Lower the voice pitch and face the client when speaking.

A client has been diagnosed with glaucoma. The nurse who is teaching the client principles of self-care should encourage the client to limit or refrain from which usual activity on a repeated basis?

Picking objects up off the floor

The nurse is preparing a plan of care for a client being admitted to the hospital with a diagnosis of retinal detachment. Which measure should the nurse include in the plan of care?

Place an eye patch over the affected eye.

The nurse is assisting in preparing a teaching plan for a client with Ménière's disease. The nurse places highest priority on teaching the client information related to which information?

Safety

The nursing student is developing information for use in a clinical conference about hearing disorders. In the presentation, the student plans to include the statement that the ear is housed in which bones of the skull?

Temporal

The nurse is reviewing the health care provider's prescriptions for a client admitted to the hospital with a diagnosis of an acute attack of Ménière's disease. Which prescription noted on the client's chart should the nurse question?

The administration of a vasoconstrictor

A client has had same-day surgery to insert a ventilating tube in the tympanic membrane. The nurse reinforces to the client to be sure to perform which action until the postoperative assessment by the health care provider?

Use a shower cap to protect the ears if taking a shower.

A nursing student is preparing to assist with an ear irrigation on an assigned client who has a buildup of cerumen in the left ear. The nursing instructor asks the student about the procedure for the irrigation. The student nurse should perform the procedure in which correct order? Arrange the actions in the order that they should be used. All options must be used.

Warm the prescribed solution to body temperature (95° F to 105° F). Have the client sit up holding an emesis basin under the ear to be irrigated with a drape under the basin. Straighten the external canal of an adult by pulling the auricle up and back. Select an irrigating syringe or bulb syringe with a tip that is smaller than the canal. Direct the solution toward the top of the canal in a steady stream, not toward the eardrum.

A client with glaucoma and an acute exacerbation of chronic obstructive pulmonary disease (COPD) has a new prescription to receive carteolol HCl (Ocupress) eye drops. Which action by the nurse is most appropriate?

Withhold the dose and notify the registered nurse.

A client arrives in the emergency department with a chemical eye injury. The nurse immediately performs which action?

Irrigates the eye with copious amounts of sterile normal saline

A client reports to the health care clinic for an eye examination, and a diagnosis of primary open-angle glaucoma is suspected. Which question will elicit information regarding the signs/symptoms associated with this disorder?

"Have you had difficulty with peripheral vision?"

The nurse is reinforcing home-care instructions to a client and family regarding care after cataract removal from the right eye. Which statement made by the client indicates an understanding of the instructions?

"I should not sleep on my right side." After cataract surgery, the client should not sleep on the side of the body that was operated on. Clients should be instructed not to take aspirin or any medications that contain aspirin because of their antiplatelet properties that can increase the risk of bleeding. Acetaminophen (Tylenol) can be taken as needed for pain. Clients may wear their glasses.

The nurse is reinforcing instructions to a client regarding the use of a hearing aid. Which statement by the client indicates a need for further teaching?

"I should turn the hearing aid off after removing it from my ear." Nurses should have a basic knowledge of the care of a hearing aid to assist the client in its use. The client should be instructed to turn the hearing aid off before removing it from the ear to prevent squealing feedback. The hearing aid should be turned off when not in use, and the client should keep an extra battery available at all times. The client should wash the ear mold frequently with mild soap and water, using a pipe cleaner to cleanse the cannula. The client should not wear the hearing aid during an ear infection.

A client is being discharged from the ambulatory care unit following cataract removal, and the nurse provides instructions regarding home care. Which statement by the client indicates an understanding of the instructions?

"I will wear my eye shield at night and my glasses during the day."

Prescriptive glasses are prescribed for a client with bilateral aphakia, and the nurse reinforces instructions to the client regarding the use of the glasses. Which statement by the client indicates the need for further teaching?

"The prescriptive glasses will correct my visual field of sight."

When the nurse documents the results of a Snellen vision test as 20/80 vision, the client asks the nurse to describe what these numbers mean. Which statement is the appropriate response?

"You can read at a distance of 20 feet what a client with normal vision can read at 80 feet."

The nurse is assigned to administer the prescribed eye drops for a client preparing for cataract surgery. Which type of eye drops should the nurse expect to be prescribed?

A mydriatic medication A mydriatic medication produces mydriasis or dilation of the pupil. Mydriatic medications are used preoperatively in the cataract client. These medications act by dilating the pupils. They also constrict blood vessels. A miotic agent would constrict the pupil. An osmotic agent would act to decrease intraocular pressure. A thiazide diuretic would promote the excretion of body fluid. A thiazide diuretic is not likely to be prescribed for a client with a cataract.

The client is receiving an eyedrop and an eye ointment to the right eye. Which action should the nurse take?

Administer the eyedrop first, followed by the eye ointment. When an eyedrop and an eye ointment is scheduled to be administered at the same time, the eyedrop is administered first. Options 2, 3, and 4 are incorrect.

Pilocarpine hydrochloride (Isopto Carpine) is prescribed for the client with glaucoma. Which medication should the nurse plan to have available in the event of systemic toxicity?

Atropine sulfate Systemic absorption of pilocarpine hydrochloride can produce toxicity and includes manifestations of vertigo, bradycardia, tremors, hypotension, and seizures. Atropine sulfate must be available in the event of systemic toxicity. Pindolol, timolol maleate, and carteolol hydrochloride are β-blockers.

The nurse is caring for a client following enucleation. Which postsurgical observation requires immediate attention by the nurse?

Bright red drainage on the dressing

The nurse is assisting in developing a teaching plan for the client with glaucoma. Which instruction should the nurse suggest to include in the plan of care?

Eye medications will need to be administered for the rest of your life. The administration of eyedrops 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. Limiting fluids and reducing salt will not decrease intraocular pressure. Option 3 is not necessary.

The nurse determines that the client diagnosed with Ménière's disease understands the reinforced dietary instructions when the client states that which food will be avoided in the diet?

Hot dogs

A client sustains a chemical eye injury from a splash of battery acid. The nurse should prepare the client for which immediate measure?

Irrigating the eye with sterile normal saline Emergency care after a chemical burn to the eye includes irrigating the eye immediately with sterile normal saline or ocular irrigating solution. The irrigation should be maintained for at least 10 minutes. After this emergency treatment, visual acuity is assessed. Options 2 and 3 are not immediate measures.

The nurse has reinforced instructions to a client who is scheduled for a cataract extraction. Which statement by the client indicates a need for further teaching?

No eating or drinking for at least 18 hours before the surgery."

The nurse in the ambulatory care unit is caring for a client following cataract extraction. The client suddenly complains of nausea and severe eye pain in the surgical eye. The nurse should take which action?

Notify the registered nurse.

The nurse is caring for a client following enucleation. On data collection, the nurse notes staining and bleeding on the dressing. The nurse should take which action?

Notify the registered nurse.

A client with retinal detachment is admitted to the outpatient nursing unit in preparation for a scleral buckling procedure. Which prescription should the nurse anticipate?

Placing an eye patch over the client's affected eye

The nurse is preparing to administer eardrops to an adult client. The nurse administers the eardrops by which technique?

Pulling the pinna up and back The nurse tilts the client's head slightly away and pulls the pinna up and back. Asking the client to stand and lean to one side is inappropriate and unsafe.

During the early postoperative stage, the cataract extraction client complains of nausea and severe eye pain over the operative site. Which action should the nurse implement?

Report the client's complaints. Severe pain or pain accompanied by nausea is an indicator of increased intraocular pressure and should be reported to the registered nurse and health care provider immediately. The remaining options are incorrect.

The nurse is reviewing the health care record of a client with a diagnosis of otosclerosis. The nurse should expect to note documentation of which early symptom of this disorder?

Ringing in the ears Otosclerosis involves the formation of spongy bone in the capsule of the labyrinth of the ear, often causing the auditory ossicles to become fixed and less able to vibrate when sound enters the ear. An early symptom is ringing in the ears, but the most noticeable symptom is progressive hearing loss. The remaining options are not associated with this condition.

While at home, the nurse receives a telephone call from a neighbor, who reports that while accidentally breaking a mirror, a piece of glass flew into her eye. Which is the appropriate initial nursing action after observing that the large glass shard is protruding from the neighbor's eye?

Secure a paper cup over the affected eye.

The nurse is assisting in developing a plan of care for the client scheduled for cataract surgery. The nurse makes suggestions regarding the plan, knowing that which problem is specifically associated with this type of surgery?

Sensory perceptual alteration The most specific associated problem for the client scheduled for cataract surgery is sensory perceptual alteration (visual) related to lens extraction and replacement. Self-care deficit and imbalanced nutrition should also be concerns but occur as a result of a sensory perceptual alteration. Anxiety can occur with any type of surgical procedure.

The nurse is caring for a client who is hearing-impaired and should take which approach to facilitate communication?

Speak in a normal tone. It is important to speak in a normal tone to the client with impaired hearing and avoid shouting. The nurse should talk directly to the client while facing the client and should 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 it is important to avoid talking directly into the impaired ear.

The nurse is inserting soft contact lenses into the eyes of a client. Which direction does the nurse tell the client to look?

Straight ahead

The nurse is caring for a client who will be undergoing surgical treatment for Ménière's disease. The nurse plans care based on which expected outcome?

The surgery relieves pressure from accumulation of inner ear fluid in the endolymphatic sac.

A client is diagnosed with a disorder involving the inner ear. The nurse caring for the client understands that which is the most common client complaint associated with a disorder involving the inner ear?

Tinnitus Tinnitus is the most common complaint of clients with otological disorders, especially disorders involving the inner ear. Symptoms of tinnitus range from mild ringing in the ear that can go unnoticed during the day, to a loud roaring in the ear that can interfere with the client's thinking process and attention span. Hearing loss may or may not occur. Pruritus and burning in the ear are not specifically associated with inner ear problems.

Which intervention should be implemented for the older client with presbycusis who has a hearing loss?

Use low-pitched tones. Presbycusis refers to the age-related, irreversible, degenerative changes of the inner ear that lead to decreased hearing acuity. As a result of these changes, the older client has a decreased response to high-frequency sounds. Low-pitched tones of voice are more easily heard and interpreted by the older client. Speaking softly or slowly is not helpful

The nurse assists to prepare the client for ear irrigation as prescribed by the health care provider. Which action should the nurse plan to take?

Warm the irrigating solution to 98° F. Irrigation solutions that are not close to the client's body temperature can be uncomfortable and may cause injury, nausea, and vertigo. The client is positioned so that the ear to be irrigated is facing downward, because this allows gravity to assist in the removal of the ear wax and solution. After the irrigation, the client is to lie on the affected side to finish draining the irrigating solution. A slow, steady stream of solution should be directed toward the upper wall of the ear canal and not toward the eardrum. Too much force could cause the tympanic membrane to rupture.

A client arrives at the emergency department with a foreign body in the left ear that has been determined to be an insect. Which initial intervention should the nurse anticipate to be prescribed?

instillation of mineral oil or diluted alcohol Insects are killed before removal unless they can be coaxed out by a flashlight or a humming noise. Mineral oil or diluted alcohol is instilled into the ear to suffocate the insect, which is then removed by using ear forceps. When the foreign object is vegetable matter, irrigation is not used because this material expands with hydration and the impaction becomes worse. Options 1, 2, and 3 may be prescribed after the initial treatment if necessary and if inflammation or infection is a concern.

A client with glaucoma asks the nurse if complete vision will return. The nurse should make which response to the client?

"Although some vision has been lost and cannot be restored, further loss may be prevented by adhering to the treatment plan."

A myringotomy is performed on a client in the ambulatory care center. The ambulatory care nurse calls the client 24 hours after the procedure to evaluate the status of the client. The client reports to the nurse that a small amount of brownish drainage has been coming from the ear. Which instruction should the nurse provide to the client?

"Continue to monitor the drainage because this is normal and may occur for 24 to 48 hours following the surgery."

The nurse provides discharge instructions to the client who was hospitalized for an acute attack of Ménière's disease. Which statement made by the client indicates a need for further teaching?

"It is not necessary to restrict salt in my diet." Management during remission of Ménière's disease includes diuretics to decrease the fluid and thereby decrease pressure in the endolymphatic system. Antihistamines, vasodilators, and diuretics may be prescribed for the client. A low-salt diet may also be prescribed for the client to reduce fluid retention. The major goal of treatment is to preserve the client's hearing; careful medical management helps achieve this in most clients with Ménière's disease.

The nurse is caring for a client hospitalized with an acute attack from Ménière's disease. The client verbalizes concern because the client has experienced a hearing loss as a result of the attack. Which response should the nurse make to the client regarding the hearing loss?

"The attack leaves a hearing loss in the involved ear."

The nurse is reinforcing discharge instructions with a client who is being discharged following a fenestration procedure for the treatment of otosclerosis. Which should be included on the list of instructions prepared for the client?

"You need to avoid air travel."

The nurse notes that the health care provider has documented a diagnosis of presbycusis on the client's chart. The nurse understands that this condition is accurately described as which?

A sensorineural hearing loss that occurs with aging Presbycusis is a type of hearing loss that occurs with aging. It is a gradual sensorineural loss caused by nerve degeneration in the inner ear or auditory nerve. Options 1, 2, and 3 are not accurate descriptions.

A client was just admitted to the hospital to rule out a gastrointestinal (GI) bleed. The client has brought several bottles of medications prescribed by different specialists. During the admission assessment, the client states, "Lately, I have been hearing some roaring sounds in my ears, especially when I am alone." Which medication should the nurse determine to be the cause of the client's complaint?

Acetylsalicylic acid (aspirin) Aspirin is contraindicated for gastrointestinal bleed and is potentially ototoxic. The client should be advised to notify the prescribing health care provider so the medication can be discontinued and/or a substitute that is less toxic to the ear can be taken instead. Options 1, 3, and 4 do not have side effects that are potentially associated with hearing difficulties.

A client who was hit in the eye with a baseball bat sustains a contusion of the eyeball. The emergency department nurse implements which immediate action?

Applies ice to the affected eye

A client arrives at the emergency department following a blow to the eye from a softball. Which intervention should be implemented by the nurse initially?

Apply ice to the affected eye.

The nurse is caring for a client with glaucoma. Which medication prescribed for the client should the nurse question?

Atropine sulfate (Isopto Atropine) Options 1, 2, and 4 are miotic agents used to treat glaucoma. Option 3 is a mydriatic and cycloplegic medication, and its use is contraindicated in clients with glaucoma. Mydriatic medications dilate the pupil and can cause an increase in intraocular pressure in the eye.

A client is diagnosed with glaucoma. Which data gathered by the nurse indicate a risk factor associated with glaucoma?

Cardiovascular disease Hypertension, cardiovascular disease, diabetes mellitus, and obesity are associated with the development of glaucoma. Smoking, ingestion of caffeine or large amounts of alcohol, illicit drugs, corticosteroids, altered hormone levels, posture, and eye movements may cause varying transient increases in intraocular pressure.

The nurse is assigned to care for a client hospitalized with Ménière's disease. The nurse expects that which would most likely be prescribed for the client?

Low-sodium diet Dietary changes such as salt and fluid restrictions that reduce the amount of endolymphatic fluid are sometimes prescribed. Options 1, 3, and 4 are not specific dietary prescriptions for this condition.

The nurse is providing instructions to a client who will be self-administering eyedrops. To minimize the systemic effects that eyedrops can produce, the client is instructed to perform which?

Occlude the nasolacrimal duct with a finger over the inner canthus for 30 to 60 seconds after instilling the drops.

A client arrives in the emergency department after an automobile crash. The client's forehead hit the steering wheel, and a hyphema has been diagnosed. Which position should the nurse prepare to position the client?

On bed rest in a semi-Fowler's position A hyphema is the presence of blood in the anterior chamber. It is produced when a force is sufficient to break the integrity of the blood vessels in the eye. It can be caused by direct injury, such as penetrating injury from a BB pellet, or indirectly, such as from striking the forehead on a steering wheel during an accident. The client is treated by bed rest in a semi-Fowler's position to assist gravity in keeping the hyphema away from the optical center of the cornea

The nurse in the recovery room area is preparing to care for a client following cataract extraction of the right eye. Which position does the nurse prepare to place the client?

On the left side with the head of the bed elevated

The nurse is caring for a client after enucleation and notes the presence of bright red drainage on the dressing. The nurse should take which appropriate action?

Report the finding to the registered nurse (RN). If the nurse notes the presence of bright red drainage on the dressing, it must be reported to the registered nurse because this can indicate hemorrhage. Options 1, 2, and 4 will delay necessary treatment.

The nurse is preparing to communicate with an older client who is hearing impaired. Which intervention should be implemented initially?

Stand in front of the client. The nurse would ensure that the hearing-impaired client can see the nurse when the nurse is speaking by providing adequate lighting and standing in front of the client. The nurse should enunciate words clearly but not exaggerate lip movements. If the client is profoundly hearing impaired and uses signing, a sign-language interpreter should be obtained. If a client cannot understand by reading lips, the nurse would try using gestures, pantomiming, or writing notes.

The nurse is reinforcing preoperative instructions to a client scheduled for cataract surgery and prepares a written list of instructions for the client. Which statement by the client indicates a need for further teaching?

"I can drink any liquids that I want to on the morning of the surgery.

The nurse reinforces home care instructions to a client after cataract removal and placement of an intraocular implant in the right eye. Which statement by the client indicates a need for further teaching?

"I need to remove the eye dressing as soon as I get home and place a warm pack on my eye."

The nurse has reinforced discharge instructions to the client who has had ocular surgery of the right eye. The nurse determines that the client needs further teaching if the client states which?

"I will call the health care provider if a temperature of 99° F is present.

Which statement by the nurse indicates an understanding of the diagnosis of presbycusis?

"It is a sensorineural type of hearing loss that occurs with aging."

The nurse is preparing to reinforce a teaching plan for a client who is undergoing cataract extraction with intraocular implant. Which home care measures should the nurse include in the plan? Select all that apply.

1. To avoid activities that require bending over 3. To place an eye shield on the surgical eye at bedtime 5. To contact the surgeon if a decrease in visual acuity occurs 6. To take acetaminophen (Tylenol) for minor eye discomfort After eye surgery, some scratchiness and mild eye discomfort may occur in the operative eye and is usually relieved by mild analgesics. If the eye pain becomes severe, the client should notify the surgeon because this may indicate hemorrhage, infection, or increased intraocular pressure. The nurse would also instruct the client to notify the surgeon of purulent drainage, increased redness, or any decrease in visual acuity. The client is instructed to place an eye shield over the operative eye at bedtime to protect the eye from injury during sleep and to avoid activities that increase intraocular pressure such as bending over.

The nurse is reviewing the plan of care developed by a nursing student for a client scheduled for keratoplasty. The nurse discusses the plan with the student if which incorrect intervention is listed in the plan?

Administering medications that will dilate the pupil

A client sustains a contusion of the eyeball after a traumatic injury with a blunt object. The nurse should take which immediate action?

Apply ice to the affected eye. Treatment for a contusion begins at the time of injury. Ice is applied immediately. The client should receive a thorough eye examination to rule out the presence of other eye injuries. Eye irrigation is not indicated in a contusion. Options 1 and 4 will delay immediate treatment. After the application of ice, the HCP would be notified.

In preparation for cataract surgery, the nurse is to administer cyclopentolate (Cyclogyl) eyedrops. The nurse administers the eyedrops knowing that the purpose of this medication is which?

Dilate the pupil of the operative eye. Cyclopentolate is a rapidly acting mydriatic and cycloplegic medication. Cyclopentolate is effective in 25 to 75 minutes, and accommodation returns in 6 to 24 hours. Cyclopentolate is used for preoperative mydriasis.

The nurse is assigned to care for a client following a cataract extraction. The nurse plans to place the client in which position?

On the nonoperative side Postoperatively, cataract extraction clients should be positioned on their backs in a semi-Fowler's position or on the nonoperative side to prevent edema in the surgical site. The remaining positions are incorrect and will cause swelling at the surgical site.

The nurse provides dietary instructions to a client with Ménière's disease. The nurse tells the client that which food or fluid item is acceptable to consume?

Sugar-free Jell-O

The nurse is reinforcing discharge instructions to a client following right eye cataract surgery about ways to avoid strain on the operative eye. The nurse determines that the client needs further teaching if the client makes which statement?

"I can lie on my right side."

The nurse is reinforcing discharge instructions to a client who has had ocular surgery of the left eye. Which statement by the client indicates a need for further teaching

"I need to call the doctor if I develop any fever."

A clinic nurse is reinforcing home care instructions to a client with a diagnosis of glaucoma. Which statement by the client indicates an understanding of the treatment plan for glaucoma?

"I need to take my eye drops for the rest of my life."

Immediately following cataract repair, the client's affected conjunctiva and eyelids are edematous. Which statement by the nurse accurately characterizes these findings for the client?

"The edema is normal and should subside within 3 days."

The nurse administers meclizine hydrochloride (Antivert) to a client diagnosed with an attack of Ménière's disease. Which observations demonstrate to the nurse that the medication is effective? Select all that apply.

2,3

The nurse is gathering data from a client with a history of untreated cataracts. The nurse asks the client about the presence of which sign of a cataract?

Difficulty with driving at night and blurred vision

The nurse is reinforcing home care instructions to a client who has a hordeolum (sty) of the right eye. Which statement by the client indicates an understanding of the instructions?

I should apply antibiotic ointment as prescribed."

The nurse is assisting the health care provider in performing a caloric test on a client. Following instillation of warm water into the ear, the client complains of vertigo. The nurse documents the findings of this test as indicative of which result?

Normal

The nurse is reinforcing discharge instructions to a client going home after same-day eye surgery. During the postoperative period, the nurse stresses that the client may safely perform which activity?

Watch television.

After a routine eye examination, a client has been told there are refractive errors in both eyes. The nurse explains to the client that this problem is primarily treated with which intervention?

Prescription of corrective lenses

An adult client with a history of ear infections reports a right earache accompanied by a sensation of fullness. The client also reports nausea and has a temperature of 100.6° F. The nurse questions the client about which aspect of the client's history?

Whether the client has had a recent upper respiratory infection (URI)

The nurse has reinforced instructions to a client following a right keratoplasty. Which statement by the client indicates a need for further teaching?

"In 1 week, I'll return to have the sutures removed."

A client with a history of ear problems telephones the ambulatory care nurse to cancel an appointment because he will be away on business. The client mentions that he will be flying during this trip. The nurse advises the client to engage in which activity to prevent barotrauma during takeoff and landing? Select all that apply.

1,2,3,5

The nurse is reinforcing discharge instructions to a client who just underwent a myringotomy with placement of a polyethylene tube in the left ear. Which statement by the client indicates a need for further teaching? Select all that apply.

1,4,5

The nurse is reinforcing discharge teaching to a client following right eye cataract surgery. The nurse determines that the client needs further teaching about ways to avoid strain on the operative eye when the client makes which statements? Select all that apply.

2,5

The nurse assigned to care for a hearing-impaired client should use which approach to communication in order to enhance communication and preserve the client's self-esteem? Select all that apply.

2,3,5

A nursing instructor asks a student about cochlear implants. The student understands that which clients are candidates for such a procedure? Select all that apply.

2,4

A client, who frequently experiences hearing loss due to built-up cerumen in the ears, asks the nurse about ways to deal with the problem including irrigating the ears. Which information is correct for the nurse to include in the teaching plan? Select all that apply.

2,4,6

A client arrives at the emergency department for treatment of an injury to the eye after being hit by a baseball bat. On data collection, the nurse notes that the eye is bleeding. Which nursing action is appropriate?

Cover the eye with cold, sterile saline gauze.

A client is diagnosed with hyphema after experiencing a traumatic blow to the eye. The nurse explains to the client that which activity limitation needs to be implemented following this type of injury?

Bed rest with the head in semi-Fowler's position

A client who had previously undergone cataract surgery tells the nurse that she has begun seeing flashing lights and floaters in the eye. Based on the client's history, the nurse interprets that the client is at risk for which?

Detached retina

The nurse is reinforcing education to a client who has just obtained a hearing aid about its use and maintenance. The nurse tells the client that it is helpful to follow which practice?

Keep an extra battery readily available.

The nurse assesses that a client with glaucoma has vision that is lost because of obstruction of aqueous humor flow by the trabecular meshwork. The nurse interprets that this client is suffering from which disorder?

Primary open-angle glaucoma

A client arrives in the emergency department following an eye injury from a chemical solution. Which is the initial nursing action?

Test the eye pH with litmus paper.

The nurse is observing an unlicensed assistive personnel (UAP) talk to a client who is hearing impaired. The nurse should intervene if which action is performed by the UAP during communication with the client?

The UAP speaks directly into the impaired ear.

A client has been diagnosed with open-angle glaucoma and asks the nurse to repeat the health care provider's explanation of the disorder. The nurse should offer the client which explanation?

The pressure increases within the eye from excess fluid or blocking of drainage.

When reinforcing information to a client regarding how to appropriately care for a new hearing aid, the nurse should provide the client with which instruction?

To check the battery regularly to ensure that it is working before use

The nurse is reviewing the health record of a client diagnosed with a cataract. The initial sign/symptom that the nurse should expect to note in the early stages of cataract formation is which?

Blurred vision A gradual, painless blurring of central vision is the chief sign/symptom of a cataract. Early symptoms include slightly blurred vision and a decrease in color perception. The incorrect options are not specifically associated with a cataract.

The nurse is preparing to reinforce instructions to a client with glaucoma regarding the prescribed treatment measures for the disorder. The nurse prepares the instructions based on which treatment goal?

Maintaining intraocular pressure at a reduced level

The nurse is assigned to care for a client with a diagnosis of Ménière's disease. Which part of the ear is affected with Ménière's disease?

Inner ear

The nurse is reviewing the record of a client with mastoiditis. The nurse should expect to note which documented characteristic regarding the results of the otoscopic examination?

Red, dull, thick, and immobile tympanic membrane Otoscopic examination in a client with mastoiditis reveals a red, dull, thick, and immobile tympanic membrane with or without perforation. Postauricular lymph nodes are tender and enlarged. Clients also have a low-grade fever, malaise, anorexia, swelling behind the ear, and pain with minimal movement of the head. The remaining options are not findings that would be noted in an otoscopic examination in the client with mastoiditis.

The nurse is attempting to communicate with a hearing-impaired client. Which strategy by the nurse would be least helpful when talking to this client?

Smiling continuously during conversation Hearing-impaired clients rely on visual cues to help them comprehend the conversation of others. Smiling continuously is the least helpful strategy, because the smile distorts the appearance of the mouth if the client is trying to read lips. When beginning the conversation, it helps to reduce background noise such as turning off or lowering the volume of the television. Facing the client and standing so there is light on the nurse's face are helpful strategies, because it assists the client to lip-read. Taking care not to show frustration or annoyance with the client's impairment is also helpful to preserve the client's self-esteem.

A clinic nurse notes that following several eye examinations the health care provider has documented a diagnosis of legal blindness in the client's chart. Which should the nurse expect to note documented as the result of the Snellen chart test?

20/200 vision

Betaxolol hydrochloride (Betoptic) eyedrops have been prescribed for the client with glaucoma. Which nursing action is most appropriate related to monitoring for the side/adverse effects of this medication?

Monitoring blood pressure Hypotension, dizziness, nausea, diaphoresis, headache, fatigue, constipation, and diarrhea are systemic effects of the medication. Nursing interventions include monitoring the blood pressure for hypotension and assessing the pulse for strength, weakness, irregular rate, and bradycardia. Options 1, 3, and 4 are not specifically associated with this medication.