ADH II Test 3

24. For a client having an episode of acute narrow-angle glaucoma, a nurse expects to give which of the following medications? 1. Acetazolamide (Diamox) 2. Atropine 3. Furosemide (Lasix) 4. Urokinase (Abbokinase)

ANS: 1 Acetazolamide, a carbonic anhydrase inhibitor, decreases intraocular pressure (IOP) by decreasing the secretion of aqueous humor. Atropine dilates the pupil and decreases outflow of aqueous humor, causing further increase in IOP. Lasix is a loop diuretic, and Urokinase is a thrombolytic agent; they aren't used for the treatment of glaucoma.

The nurse is caring for a client being treated for fat embolus after multiple fractures. Which data would the nurse evaluate as the most favorable indication of resolution of the fat embolus? 1.Clear mentation 2.Minimal dyspnea 3.Oxygen saturation of 85% 4.Arterial oxygen level of 78 mm Hg (10.3 kPa)

ANS: 1 An altered mental state is an early indication of fat emboli; therefore, clear mentation is a good indicator that a fat embolus is resolving. Eupnea, not minimal dyspnea, is a normal sign. Arterial oxygen levels should be 80-100 mm Hg (10.6-13.33 kPa). Oxygen saturation should be higher than 95%.

22. Cataract surgery results in aphakia. Which of the following statements best describes this term? 1. Absence of the crystalline lens 2. A "keyhole" pupil 3. Loss of accommodation 4. Retinal detachment

ANS: 1 Aphakia means without lens, a keyhole pupil results from iridectomy. Loss of accommodation is a normal response to aging. A retinal detachment is usually associated with retinal holes created by vitreous traction.

A client is diagnosed with glaucoma. Which piece of nursing assessment data identifies a risk factor associated with this eye disorder? 1.Cardiovascular disease 2.Frequent urinary tract infections 3.A history of migraine headaches 4.Frequent upper respiratory infections

ANS: 1 Hypertension, cardiovascular disease, diabetes mellitus, and obesity are associated with the development of glaucoma. Options 2, 3, and 4 do not identify risk factors associated with this eye disorder.

The nurse is developing a plan of care for a client with a diagnosis of severe vertigo from Ménière's disease who is being admitted to the hospital. What is the priority nursing intervention in the plan of care? 1.Safety measures 2.Self-care measures 3.Food items to avoid 4.Knowledge about medication therapy

ANS: 1 Ménière's disease can cause severe vertigo in the client. The priority in the nursing care plan should focus on safety issues to prevent falls or injury to the client. Although self-care measures, dietary therapy, and medication therapy may be components of the plan of care, safety is the priority issue.

8. During the early postoperative period, the client who had a cataract extraction complains of nausea and severe eye pain over the operative site. The initial nursing action is to: 1. Call the physician 2. Administer the ordered main medication and antiemetic 3. Reassure the client that this is normal. 4. Turn the client on his or her operative side

ANS: 1 Severe pain or pain accompanied by nausea is an indicator of increased intraocular pressure and should be reported to the physician immediately. The other options are inappropriate.

The nurse in the health care clinic is providing instructions to a client regarding the use of a hearing aid. Which statement is most appropriate for the nurse to include? 1."The hearing aid should not be worn if an ear infection is present." 2."The ear mold for the hearing aid should be washed with mild soap and water once a month." 3."The hearing aid should be removed from the ear at the end of the day and then turned off after removal." 4."The hearing aid contains a lifelong battery, so you will not need to be concerned about changing batteries."

ANS: 1 The client should be instructed that the hearing aid should not be worn if an ear infection is present. The client should wash the ear mold frequently with mild soap and water and use a pipe cleaner to clean the cannula of the hearing aid. The client should be instructed to turn off the hearing aid before removing it from the ear to prevent any squealing feedback. The hearing aid should be turned off when not in use, and the client should keep extra batteries on hand at all times.

The nurse is caring for a client who has had spinal fusion, with insertion of hardware. The nurse would be most concerned with which assessment finding? 1.Temperature of 101.6°F (38.7°C) orally 2.Complaints of discomfort during repositioning 3.Old bloody drainage outlined on the surgical dressing 4.Discomfort during coughing and deep-breathing exercises

ANS: 1 The nursing assessment conducted after spinal surgery is similar to that done after other surgical procedures. For this specific type of surgery, the nurse assesses the neurovascular status of the lower extremities, watches for signs and symptoms of infection, and inspects the surgical site for evidence of cerebrospinal fluid leakage (drainage is clear and tests positive for glucose). A mild temperature is expected after insertion of hardware, but a temperature of 101.6°F (38.7°C) should be reported.

The nurse is completing a physical assessment on a client with possible fibromyalgia. To support the diagnosis of​ fibromyalgia, the nurse must assess and document pain upon palpation on how many standard tender​ points? 1. Eleven 2. Nine 3. Five 4. Seven

ANS: 1 To assist with the diagnosis of​ fibromyalgia, the client must have pain upon palpation at 11 or more of the 18 standard tender​ points, not​ nine, seven, or five of the standard tender points.

10. The client with glaucoma asks the nurse is complete vision will return. The most appropriate response is: 1. "Although some vision as been lost and cannot be restored, further loss may be prevented by adhering to the treatment plan." 2. "Your vision will return as soon as the medications begin to work." 3. "Your vision will never return to normal." 4. "Your vision loss is temporary and will return in about 3-4 weeks."

ANS: 1 Vision loss to glaucoma is irreparable. The client should be reassured that although some vision has been lost and cannot be restored, further loss may be prevented by adhering to the treatment plan. Option C does not provide reassurance to the client.

The nurse is caring for a client who has had spinal fusion, with insertion of hardware. The nurse would be most concerned with which assessment finding? 1. Temperature of 101.6°F (38.7°C) orally 2. Complaints of discomfort during repositioning 3. Old bloody drainage outlined on the surgical dressing 4. Discomfort during coughing and deep-breathing exercises

ANS: 1 The nursing assessment conducted after spinal surgery is similar to that done after other surgical procedures. For this specific type of surgery, the nurse assesses the neurovascular status of the lower extremities, watches for signs and symptoms of infection, and inspects the surgical site for evidence of cerebrospinal fluid leakage (drainage is clear and tests positive for glucose). A mild temperature is expected after insertion of hardware, but a temperature of 101.6°F (38.7°C) should be reported.

The nurse is preparing a teaching plan for a client who had a cataract extraction with intraocular implantation. Which home care measures should the nurse include in the plan? Select all that apply. 1.Avoid activities that require bending over. 2.Contact the surgeon if eye scratchiness occurs. 3.Take acetaminophen for minor eye discomfort. 4.Expect episodes of sudden severe pain in the eye. 5.Place an eye shield on the surgical eye at bedtime. 6.Contact the surgeon if a decrease in visual acuity occurs.

ANS: 1, 3, 5, 6 Following eye surgery, some scratchiness and mild eye discomfort may occur in the operative eye and usually is 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 (IOP). The nurse also would instruct the client to notify the surgeon of increased 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 IOP, such as bending over.

A healthcare provider prescribes duloxetine​ (Cymbalta) for a client diagnosed with fibromyalgia. The client asks the nurse why this medication is being prescribed. The nurse will base the response on which​ rationale? 1. To reduce neuropathic pain 2. To increase levels of dopamine and serotonin 3. To decrease joint pain and swelling 4. To relax the client and promote sleep

ANS: 2 Duloxetine​ (Cymbalta) is prescribed to a client with fibromyalgia to increase serotonin and norepinephrine levels. This medication is not prescribed to reduce neuropathic​ pain, decrease swelling to​ joints, or relax the client to promote sleep. Pregabalin​ (Lyrica) is prescribed to reduce neuropathic pain. Nonsteroidal​ anti-inflammatory drugs are prescribed to decrease swelling to joints. Fluoxetine​ (Prozac) and paroxetine​ (Paxil) are medications prescribed to promote sleep.

A student nurse is asking questions about fibromyalgia. The nurse educates the student that this disorder closely resembles what other​ disorder? 1. Osteoarthritis 2. Chronic fatigue syndrome 3. Muscular dystrophy​ 4. Sjögren syndrome

ANS: 2 Fibromyalgia closely resembles chronic fatigue​ syndrome, with the exception of the musculoskeletal pain typically associated with fibromyalgia. Fibromyalgia does not closely resemble​ Sjögren syndrome, muscular​ dystrophy, or osteoarthritis.

The nurse is performing an assessment on a client with a diagnosis of Ménière's disease. The nurse anticipates that the client is most likely to report which symptom during an acute attack? 1.Fatigue 2.Tinnitus 3.Headache 4.Insomnia

ANS: 2 Ménière's disease results in a disturbance of the fluid of the endolymphatic system. The cause of the disturbance is not known. Attacks may be preceded by feelings of fullness in the ear or by tinnitus. Fatigue, headaches, and insomnia are not associated with this disorder.

The nurse is caring for a client who was recently diagnosed with primary open-angle glaucoma (POAG). Which assessment finding is specific to this type of glaucoma? 1.Client report of blurred vision 2.Client report of "tunnel vision" 3.Client report of ocular erythema 4.Client report of halos around lights

ANS: 2 POAG results from obstruction to outflow of aqueous humor and is the most common type. Assessment findings include painless vision changes and "tunnel vision." Primary angle-closure glaucoma (PACG) is another type of glaucoma that results from blocking the outflow of aqueous humor into the trabecular meshwork. Assessment findings include blurred vision, ocular erythema, and halos around lights.

The nurse is creating a plan of care for a client in skin traction. The nurse should monitor for which priority finding in this client? 1.Urinary incontinence 2.Signs of skin breakdown 3.The presence of bowel sounds 4.Signs of infection around the pin sites

ANS: 2 Skin traction is achieved by Ace wraps, boots, or slings that apply a direct force on the client's skin. Traction is maintained with 5 to 8 lb (2.3 to 3.6 kg) of weight, and this type of traction can cause skin breakdown. Urinary incontinence is not related to the use of skin traction. Although constipation can occur as a result of immobility and monitoring bowel sounds may be a component of the assessment, this intervention is not the priority assessment. There are no pin sites with skin traction.

Tonometry is performed on a client with a suspected diagnosis of glaucoma. The nurse looks at the documented test results and notes an intraocular pressure (IOP) value of 23. What should be the nurse's initial action? 1.Apply normal saline drops. 2.Note the time of day the test was done. 3.Contact the health care provider (HCP). 4.Instruct the client to sleep with the head of the bed flat.

ANS: 2 Tonometry is a method of measuring intraocular fluid pressure. Pressures between 10 and 21 mm Hg are considered within the normal range. However, IOP is slightly higher in the morning. Therefore, the initial action is to check the time the test was performed. Normal saline drops are not a specific treatment for glaucoma. It is not necessary to contact the HCP as an initial action. Flat positions may increase the pressure.

Tonometry is performed on the client with a suspected diagnosis of glaucoma. The nurse analyzes the test results as documented in the client's chart and understands that normal intraocular pressure is: 1. 2-7 mmHg 2. 10-21 mmHg 3. 22-30 mmHg 4. 31-35 mmHg

ANS: 2 Tonometry is the method of measuring intraocular fluid pressure using a calibrated instrument that indents or flattens the corneal apex. Pressures between 10 and 21 mmHg are considered within normal range.

The nurse is assigned to care for a client in traction. The nurse creates a plan of care for the client and should include which action in the plan? 1.Ensure that the knots are at the pulleys. 2.Check the weights to ensure that they are off of the floor. 3.Ensure that the head of the bed is kept at a 45- to 90-degree angle. 4.Monitor the weights to ensure that they are resting on a firm surface.

ANS: 2 To achieve proper traction, weights need to be free-hanging, with knots kept away from the pulleys. Weights should not be kept resting on a firm surface. The head of the bed is usually kept low to provide countertraction.

The nurse is preparing to provide care for a client who will need an ear irrigation to remove impacted cerumen. Which interventions should the nurse take when performing the irrigation? Select all that apply. 1.Apply some force when instilling the irrigation solution. 2.Position the client with the affected side down after the irrigation. 3.Warm the irrigating solution to a temperature that is close to body temperature. 4.Position the client to turn the head so that the ear to be irrigated is facing upward. 5.Direct a slow, steady stream of irrigation solution toward the upper wall of the ear canal.

ANS: 2,3,5 During the irrigation, 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 earwax and solution. Delivery of irrigation solutions at temperatures that are not close to body temperature can cause discomfort for the client and may result in tissue injury, nausea, and vertigo. A slow, steady stream of solution should be directed toward the upper wall of the ear canal, not toward the tympanic membrane. After the irrigation, the client should lie on the affected side for a period of time that is necessary to allow the irrigating solution to finish draining (usually 10 to 15 minutes). Too much force could cause the tympanic membrane to rupture.

Which risk factor associated with fibromyalgia should the nurse inquire about while taking a client​'s health​ history? 1. Age​ 60-75 years 2. History of osteoarthritis 3. Family history 4. Male gender

ANS: 3 A family history of fibromyalgia is a risk factor for developing fibromyalgia.​ Female, not​ male, gender is a risk factor for developing​ fibromyalgia. Being diagnosed with another rheumatic disorder such as rheumatoid arthritis​ (not osteoarthritis) or systemic lupus erythematosus are risk factors associated with developing fibromyalgia. A risk factor for developing fibromyalgia is an age between 20 and 50 years​ old, not between 60 and 75 years old.

6. The nurse is performing an assessment in a client with a suspected diagnosis of cataract. The chief clinical manifestation that the nurse would expect to note in the early stages of cataract formation is: 1. Eye pain 2. Floating spots 3. Blurred vision 4. Diplopia

ANS: 3 A gradual, painless blurring of central vision is the chief clinical manifestation of a cataract. Early symptoms include slightly blurred vision and a decrease in color perception.

7. In preparation for cataract surgery, the nurse is to administer prescribed eye drops. The nurse reviews the physicians orders, expecting which type of eye drops to be instilled? 1. An osmotic diuretic 2. A miotic agent 3. A mydriatic medication 4. A thiazide diuretic

ANS: 3 A mydriatic medication produces mydriasis or dilation of the pupil. Mydriatic medications are used preoperatively in the cataract client. These medication act by dilating the pupils. They also constrict blood vessels. An osmotic diuretic may be used to decrease intraocular pressure. A miotic medication constricts the pupil. A thiazide diuretic is not likely to be prescribed for a client with a cataract.

The nurse is caring for an older adult who has been placed in Buck's extension traction after a hip fracture. On assessment of the client, the nurse notes that the client is disoriented. What is the best nursing action based on this information? 1.Apply restraints to the client. 2.Ask the family to stay with the client. 3.Place a clock and calendar in the client's room. 4.Ask the laboratory to perform electrolyte studies.

ANS: 3 An inactive older adult may become disoriented because of lack of sensory stimulation. The most appropriate nursing intervention would be to reorient the client frequently and to place objects such as a clock and a calendar in the client's room to maintain orientation. Restraints may cause further disorientation and should not be applied unless specifically prescribed; agency policies and procedures should be followed before the application of restraints. The family can assist with orientation of the client, but it is inappropriate to ask the family to stay with the client. It is not within the scope of nursing practice to prescribe laboratory studies.

A client is complaining of low back pain that radiates down the left posterior thigh. The nurse should ask the client if the pain is worsened or aggravated by which factor? 1.Bed rest 2.Ibuprofen 3.Bending or lifting 4.Application of heat

ANS: 3 Low back pain that radiates into 1 leg (sciatica) is consistent with herniated lumbar disk. The nurse assesses the client to see whether the pain is aggravated by events that increase intraspinal pressure, such as bending, lifting, sneezing, and coughing, or by lifting the leg straight up while supine (straight leg-raising test). Bed rest, heat (or sometimes ice), and nonsteroidal antiinflammatory drugs (NSAIDs) usually relieve back pain.

21. Which of the following procedures or assessments must the nurse perform when preparing a client for eye surgery? 1. Clipping the client's eyelashes 2. Verifying the affected eye has been patched 24 hours before surgery 3. Verifying the client has been NPO since midnight, or at least 8 hours before surgery. 4. Obtaining informed consent with the client's signature and placing the forms on the chart.

ANS: 3 Maintaining NPO status for at least 8 hours before surgical procedures prevents vomiting and aspiration. There is no need to patch an eye before most surgeries or to clip the eyelashes unless specifically ordered by the physician. The physician is responsible for obtaining informed consent; the nurse validates that the consent is obtained.

The home care nurse is visiting a client who was recently diagnosed with a hearing impairment. The nurse should prepare to instruct the client's spouse in which measure that will facilitate communication? 1.Speak loudly to the client to facilitate hearing. 2.Speak directly into the impaired ear to facilitate hearing. 3.Speak in a normal tone and face the client when speaking. 4.Speak frequently to the client to provide sensory stimulation.

ANS: 3 Measures that facilitate hearing in the client with a hearing impairment include speaking in a normal tone, avoiding shouting, talking directly to the client while facing the client, and speaking clearly. If the client does not seem to understand what is said, the statement should be expressed differently. Moving closer to the client and toward the better ear may facilitate communication, but talking directly into the impaired ear should be avoided.

The nurse is developing a teaching plan for a client with glaucoma. Which instruction should the nurse include in the plan of care? 1.Avoid overuse of the eyes. 2.Decrease the amount of salt in the diet. 3.Eye medications will need to be administered for life. 4.Decrease fluid intake to control the intraocular pressure.

ANS: 3 The administration of eye drops is a critical component of the treatment plan for the client with glaucoma. The client needs to be instructed that medications will need to be taken for the rest of his or her life. Options 1, 2, and 4 are not accurate instructions.

9. The client is being discharged from the ambulatory care unit following cataract removal. The nurse provides instructions regarding home care. Which of the following, if stated by the client, indicates an understanding of the instructions? 1. "I will take Aspirin if I have any discomfort." 2. "I will sleep on the side that I was operated on." 3. "I will wear my eye shield at night and my glasses during the day." 4. "I will not lift anything if it weighs more that 10 pounds."

ANS: 3 The client is instructed to wear a metal or plastic shield to protect the eye from accidental and is instructed not to rub the eye. Glasses may be worn during the day. Aspirin or medications containing aspirin are not to be administered or taken by the client and the client is instructed to take acetaminophen as needed for pain. The client is instructed not to sleep on the side of the body on which the operation occurred. The client is not to lift more than 5 pounds.

5. The nurse is developing a plan of care for the client scheduled for cataract surgery. The nurse documents which more appropriate nursing diagnosis in the plan of care? 1. Self-care deficit 2. Imbalanced nutrition 3. Disturbed sensory perception 4. Anxiety

ANS: 3 The most appropriate nursing diagnosis for the client scheduled for cataract surgery is Disturbed sensory perception (visual) related to lens extraction and replacement. Although the other options identify nursing diagnoses that may be appropriate, they are not related specifically to cataract surgery.

The nurse is evaluating a client in skeletal traction. When evaluating the pin sites, the nurse would be most concerned with which finding? 1.Redness around the pin sites 2.Pain on palpation at the pin sites 3.Thick, yellow drainage from the pin sites 4.Clear, watery drainage from the pin sites

ANS: 3 The nurse should monitor for signs of infection such as inflammation, purulent drainage, and pain at the pin site. However, some degree of inflammation, pain at the pin site, and serous drainage would be expected; the nurse should correlate assessment findings with other clinical findings, such as fever, elevated white blood cell count, and changes in vital signs. Additionally, the nurse should compare any findings to baseline findings to determine if there were any changes.

The nurse is performing an assessment on a client with a suspected diagnosis of cataract. Which clinical manifestation should the nurse expect to note in the early stages of cataract formation? 1.Diplopia 2.Eye pain 3.Floating spots 4.Blurred vision

ANS: 4 A gradual, painless blurring of central vision is the chief clinical manifestation of a cataract. Early symptoms include slightly blurred vision and a decrease in color perception. Options 1, 2, and 3 are not characteristics of a cataract.

19. Which of the following instruments is used to record intraocular pressure? 1. Goniometer 2. Ophthalmoscope 3. Slit lamp 4. Tonometer

ANS: 4 A tonometer is a device used in glaucoma screening to record intraocular pressure. A goniometer measures joint movement and angles. An ophthalmoscope examines the interior of the eye, especially the retina. A slit lamp evaluates structures in the anterior chamber in the eye.

20. After the nurse instills atropine drops into both eyes for a client undergoing ophthalmic examination, which of the following instructions would be given to the client? 1. "Be careful because the blink reflex is paralyzed." 2. "Avoid wearing your regular glasses when driving." 3. "Be aware that the pupils may be unusually small." 4. "Wear dark glasses in bright light because the pupils are dilated."

ANS: 4 Atropine, an anticholinergic drug, has mydriatic effects causing pupil dilation. This allows more light onto the retina and may cause photophobia and blurred vision. Atropine doesn't paralyze the blink reflex or cause miosis (pupil constriction). Driving may be contraindicated to blurred vision.

A client with a hip fracture asks the nurse about Buck's (extension) traction that is being applied before surgery and what is involved. The nurse should provide which information to the client? 1.Allows bony healing to begin before surgery and involves pins and screws 2.Provides rigid immobilization of the fracture site and involves pulleys and wheels 3.Lengthens the fractured leg to prevent severing of blood vessels and involves pins and screws 4.Provides comfort by reducing muscle spasms, provides fracture immobilization, and involves pulleys and wheels

ANS: 4 Buck's (extension) traction is a type of skin traction often applied after hip fracture before the fracture is reduced in surgery. Traction reduces muscle spasms and helps to immobilize the fracture. Traction does not allow for bony healing to begin or provide rigid immobilization. Traction does not lengthen the leg for the purpose of preventing blood vessel severance. This type of traction involves pulleys and wheels, not pins and screws.

The nurse is caring for a client with suspected fibromyalgia. Which diagnostic tool does the nurse anticipate will be used to properly diagnose this​ client? 1. Blood tests for neurotransmitter levels 2. Abnormalities on a thyroid panel 3. Failure of a cardiac stress test 4. A widespread pain index

ANS: 4 Fibromyalgia is a diagnosis of exclusion and based largely on client​ feedback, such as responding to questions on a screening tool like the widespread pain index. There is no laboratory or diagnostic study that establishes the diagnosis.

The nurse has admitted to the hospital a client with a diagnosis of an acute attack of Ménière's disease. The nurse reviews the health care provider's prescriptions for the client. Which prescription should the nurse question? 1.Diazepam 2.Nicotinic acid 3.Diphenhydramine 4.Ambulation four times daily

ANS: 4 Medical interventions during the acute phase of Ménière's disease include using diazepam as prescribed to decrease the autonomic nervous system function. Diphenhydramine may be prescribed for its antihistamine effects, and a vasodilator (nicotinic acid) also will be prescribed. The client will remain on bed rest during the acute attack. When allowed out of bed, the client will need assistance with walking, sitting, or standing.

When planning care for a client affected by​ fibromyalgia, the nurse addresses the potential problem of activity intolerance. What will the nurse recommend to the client in order to most effectively address this​ problem? 1. Daily meditation and guided imagery 2. NSAID medications taken on a regular schedule 3. Referral to physical therapy for an assistive device 4. A program of​ regular, mild to moderate exercise

ANS: 4 Meditation and guided imagery can reduce anxiety. NSAIDs address the problem of pain. Assistive devices do not increase conditioning or activity tolerance in the absence of injury or neurologic deficits.​ Regular, mild to moderate exercise improves conditioning and activity tolerance.

23. When developing a teaching session on glaucoma for the community, which of the following statements would the nurse stress? 1. Glaucoma is easily corrected with eyeglasses 2. White and Asian individuals are at the highest risk for glaucoma. 3. Yearly screening for people ages 20-40 years is recommended. 4. Glaucoma can be painless and vision may be lost before the person is aware of a problem.

ANS: 4 Open-angle glaucoma causes a painless increase in intraocular pressure (IOP) with loss of peripheral vision. A variety of miotics and agents to decrease IOP and occasional surgery are used to treat glaucoma. Blacks have a threefold greater chance of developing with an increased chance of blindness than other groups. Individuals older than 40 should be screened.

The nursing student is caring for a client with a diagnosis of presbycusis. The nursing instructor determines that the student understands presbycusis when which statement is made? 1."It's a loss of vision associated with aging." 2."A loss of balance occurs with presbycusis." 3."Presbycusis is a conductive hearing loss that occurs with aging." 4."It's a sensorineural hearing loss that occurs with the aging process."

ANS: 4 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. The statements in the remaining options are incorrect statements about this condition.

11. The nurse is developing a teaching plan for the client with glaucoma. Which of the following instructions would the nurse include in the plan of care? 1. Decrease fluid intake to control the intraocular pressure 2. Avoid overuse of the eyes 3. Decrease the amount of salt in the diet 4. Eye medications will need to be administered lifelong.

ANS: 4 The administration of eye drops is a critical component of the treatment plan for the client with glaucoma. The client needs to be instructed that medications will need to be taken for the rest of his or her life.