Exam 5 sensory questions

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The nurse needs to assess the patient for color blindness. Which assessment tool will the nurse use? a. ishihara chart b. confrontation test c. snellen chart d. rosenberg pocket vision screener

the patient is diagnosed with BIL eye infection and receives a prescription for two bottles of the same antibiotic solution. what instructions should the nurse give to the patient? a. obtain one bottle from the pharmacy and return for the second if the infection does not clear b. obtain and use one bottle for both eyes; the second bottle is not necessary c. obtain both bottles and label one for the right eye and the other for the left eye d. obtain both bottles but save the second one because the infection will probably recur

One of the expected changes of the eyes associated with aging is the decreased ability of the iris to dilate. How will this affect the patient's eyes or vision? a. difficulty with tear production resulting in dry eyes b. decreased ability to see objects that are close c. difficulty distinguishing blues, greens, or violets d. increased difficulty seeing in dark environments

the older patient has reduced visual sensory perception and is newly admitted to the med-surg unit. what instructions should the nurse give to UAP about assisting the patient with ADLs? a. "when entering and exiting the room, be very quiet so the patient is not disturbed." b. "put personal belongings in the closet so the patient knows where they are." c. "during mealtimes, sit with the patient and explain how he should eat and drink." d. "when walking with the patient, offer your arm and walk a step ahead."

The nurse is teaching a client about visual changes that occur with age. Which statement does the nurse include? A. "It may take your eyes longer to adjust in a darkened room." B. "Most visual changes occur before age 40." C. "When the sclera starts to turn yellow, this means you might have problems with your liver." D. "You probably will have to move reading materials closer to your eyes."

A The nurse teaches the client that, "It may take your eyes longer to adjust in a dark room." With increasing age, the iris has less ability to dilate, which leads to difficulty in adapting to dark environments.Adults older than 40 years are at increased risk for both glaucoma and cataract formation. Presbyopia also commonly begins in the 40s. The sclera appears yellow or blue as a process of aging, and this condition should not be used to assess for jaundice in the older adult. The near-point of vision (the closest distance at which the eye can see an object clearly) increases with aging. Near objects (especially reading material) must be placed farther from the eye to be seen clearly.

While reading a client's optical chart, the nurse notices that the client has emmetropia. Which corrective equipment does the nurse expect to see this client wearing? A. Bilateral eye patches B. Contact lenses C. Nothing; this is normal D. Reading glasses

C Emmetropia is perfect refraction (bending of light rays from the outside world into the eye) of the eye. Emmetropia is a normal (and ideal) condition that does not require any treatment.Bilateral eye patches inhibit the client's vision. Contact lenses are used to correct under refraction of the eye. Reading glasses are used to correct over refraction of the eye.

The nurse providing education on eye protection suggests the special need for protective eyewear for which clients? A. Cab driver B. College student C. Lifeguard D. Racquetball player E. Registered nurse

C Lifeguards are in need of eye protection from ultraviolet (UV) A and UVB rays because of exposure to the sun. People who play racquetball need to wear protective eyewear to prevent possible eye injury.Cab drivers may require eyewear for corrective purposes but are not at high risk and in need of protective eyewear. College students are generally not at high risk. Although an RN would need eye protection at certain times, RNs do not routinely require protective eyewear for general work.

Which assessment finding warrants further investigation by the nurse in the ophthalmology clinic? A. Snellen eye examination result is 20/50 for a client who normally wears corrective lenses but does not have them at the time of the examination. B. When six cardinal positions of gaze of the left eye are assessed, the client exhibits nystagmus when looking to the left lower and upper fields. C. The pupil exhibits miosis when exposed to light from the ophthalmoscope during examination and mydriasis when the light is removed from the pupil. D. When assessing the cornea, the nurse notes cloudiness and the client reports pain when the ophthalmoscope light shines into the pupil.

D Cloudiness in the cornea and pain from a light shined into the pupil is an abnormal finding that requires further assessment and possible intervention and/or referral.A Snellen eye examination result of 20/50 for the client who normally wears corrective lenses but does not have them at the time of the examination is normal given the client's baseline and considering that he or she wears corrective lenses. It can be a normal finding for the client to exhibit nystagmus when looking to the left lower and upper fields during assessment of the six cardinal positions of gaze of the left eye. It is normal for the pupil to exhibit miosis when exposed to light from the ophthalmoscope during examination and mydriasis when the light is removed from the pupil.

A client who is using eye drops in both eyes develops a viral infection in one eye and asks the nurse what to do. What is the nurse's best response? A. "As long as you don't touch the eyes with the dropper, it will be OK." B. "Just wash your hands between eyes and put drops in the uninfected eye first." C. "The other eye will probably get infected anyway." D. "You will need to use a separate bottle of drops for each eye."

D The best response is that the client will need a separate bottle of eye drops for each eye. Because of the risk of transmitting the infection to the uninfected eye, clients would receive two bottles of drops labeled "right" and "left" to use in the correct eyes.There is still a risk of transmitting the infection when the dropper is kept from contacting the eye or when hands are washed. With proper technique, transmission of infection to the other eye can be prevented.

When performing an eye or vision assessment, which comment by the client alerts the nurse that immediate care by an ophthalmologist is needed? A. "One eye is green and the other eye is blue." B. "My eyes are red and itchy." C. "My vision has been getting worse gradually." D. "Something hit my eye while I was cutting grass."

D The client who is experiencing trauma, a foreign body in the eye, sudden ocular pain, or sudden redness should be seen immediately by an ophthalmologist.Heterochromia is an ocular condition, usually genetically inherited, that causes the iris to vary in color. This is not an emergency. Itching and redness can be caused by allergies, irritation, or ocular drug effects but do not require immediate attention. Gradual vision loss could be caused by uncontrolled hypertension and diabetes but does not require immediate care by an ophthalmologist.

The patient is being treated for an eye infection. The drug therapy may continue for 3 or more weeks; eye drops are required at night, and the patient is not allowed to wear contact lenses for weeks to months until the infection is completely cleared. Which patient statement indicates that the patient understands the goal of therapy? a. "stopping the infection can save the vision in my infected eye." b. "i'll never have to worry about cataracts once this infection clears" c. "antibiotic drops are easier than surgery, so I guess i'll use them." d. "three weeks is a long time, but I have a spare pair of eyeglasses."

What is the pathophysiology that underlies the development of glaucoma? a. pressure on retinal vessels decreases blood flow so photoreceptors and nerve fibers become hypoxic b. decreased muscle tone reduces ability to keep the gaze focused on a single object c. cornea flattens, and the surface becomes irregular with worsening of astigmatism and blurred vision d. the lens hardens, shrinks, and loses elasticity, and cataracts begin to form

Which intervention would be best to use for a patient with presbyopia? a. encouragement to get a prescription for reading glasses b. administration of the prescribed eye medications c. reinforcement to wear sunglasses for protection against UV light d. reminder to have annual examination for early detection of glaucoma

a 46 yo patient calls the clinic and reports sudden "floating dark spots" in her vision. what should the nurse say to the patient? a. advise the patient to immediately call her ophthalmologist b. advise the patient that this Is normal for her age c. ask the patient if the spots were accompanied by pain d. tell the patient to mention this during her annual eye appointment

the nurse hears in shift report that the patient will have phacoemulsification for treatment for eye problems. what does the nurse anticipate in the care of this patient? a. patient will be discharged within an hour of surgery b. patient is likely to mourn the loss of the body part c. patient will need opioid medication for severe pain d. patient should be closely observed for postoperative bleeding

A client has a bilateral corneal disorder and must instill anti-infective eye drops every hour for the first 24 hours. Which comment by the client indicates a need for further instruction by the nurse? a. "I have two bottles of eye drops in case I run out." b. "I won't be able to wear my contacts for a while." c. "I must apply the drops throughout the night." d. "I must wash my hands before, between, and after eye applications."

a If both eyes are infected, separate bottles of drugs are needed for each eye. The client must be taught to clearly label the bottles "right eye" and "left eye" and to not switch the drugs from eye to eye.The client would not wear contact lenses during the entire time that these drugs are being used because the eye then has fewer protections against infection or injury. In addition, the drugs can cloud or damage contact lenses. If the drugs are to be instilled every hour for the first 24 hours, the client will have to wake up every hour during the night to apply the drops. The client would completely care for one eye, wash the hands, and by using the drugs for the remaining eye, care for that eye. As always, handwashing must be done before and after eye care.

A bedridden client with reduced vision has been admitted. Which nursing interventions will ease the client's hospital stay? a. Announce name and purpose when entering the client's room. b. Explain food positions on the tray using a clock face as the example. c. Orient the client to the location of the call light, and keep it in that place. d. Orient the client to the room surroundings and equipment. e. Speak in a loud, clear voice.

a, b, c, d Staff would always introduce themselves to clients, with or without visual issues. Using a standard clock face to explain food locations on the tray will assist the client with self-feeding. Providing room orientation to the client is important to improve his or her ability for self-care. Orienting the client to the room and equipment in the room will allow him or her to have increased comfort with surroundings.This client has visual issues, not hearing issues, so speaking louder is not necessary.

what questions would the nurse ask to assess auditory sensory perception? select all that apply. a. "do you have a hearing problem now?" b. "have you ever had any ear trauma or surgery?" c. "what kind of music does you like to listen to?" d. "have you ever been exposed to loud noises?" e. "have you had problems with excessive earwax?" f. "are you having any pain or itching in your ears?"

a, b, d, e, f

What is included in the correct procedure for instilling ophthalmic drops in a patient's eyes? select all that apply a. check the name, strength, and expiration date of the solution b. have the patient tilt the head backward and look down c. release drops into the conjunctival pocket d. avoid contaminating the tip of the bottle e. rest the wrist holding the bottle against the patient's cheek f. after instilling a drop, tell patient to tightly close eyelids

a, c, d, e

Which assessment findings of the eye are normal? select all that apply a. presbyopia in a 45 yo woman b. ptosis of the eyelids c. yellow sclera with small pigmented dots in a dark-skinned person d. pupil constriction in response to accommodation e. pupil constriction within 1 minute in response to light f. nystagmus in the far lateral gaze

a, c, d, f

The nurse is providing discharge instructions to a client with glaucoma. Which activities does the nurse instruct the client to avoid? Select all that apply. a. Bending over to tie shoes b. Sitting with legs elevated c. Sleeping on more than two pillows d. Blowing the nose frequently e. Lifting objects weighing more than 10 pounds (4.5 kg)

a, d, e Any action that would increase pressure in the eye needs to be avoided, such as bending over, excessive blowing of the nose, and lifting heavy objects that weigh more than 10 pounds (4.5 kg).Sitting with the legs elevated or sleeping on more than two pillows is not contraindicated in clients with glaucoma.

What is the nursing care priority for a deceased patient who is a corneal donor? a. instill saline solution into the eyes b. instill antibiotic drops into the eyes c. lay the deceased in a flat supine position d. apply loose patches moistened with saline

a patient has had cataract surgery and is ready to go home. during the discharge education, what does the nurse tell the patient about activities? a. driving int he daylight is okay, but do not drive at night b. meal preparation and doing dishes are acceptable activities c. vacuuming and mopping are okay, but do not bend over to scrub d. exercises, such as jogging or swimming, can be done at a slow pace

in caring for a patient who was recently diagnosed with dry age-related macular degeneration, which teaching point would the nurse emphasize? a. importance of adhering to the exact schedule for eye drops b. dietary modifications to slow progression of vision loss c. avoiding activities that cause rapid or jerking head movements d. good handwashing and keeping the tip of the eyedropper clewan

the nurse is teaching a patient about self-medication with eye drops for glaucoma. which intervention does the nurse suggest to prevent systemic absorption of the medication? a. wait 15 mins between instilling different eye drops b. place pressure on the corner of the eye near the nose c. place all eye medications in one eye and then the other d. blink rapidly after instilling drops and keep head upright

the nurse is working at an ophthalmology specialty center and has just received a handoff report. Which patient needs to be assessed and managed first? a. patient needs postprocedural care after phacoemulsification b. patient was just diagnosed with primary angle-closure glaucoma c. patient requires therapy for exudative macular degeneration d. patient is resting quietly, with probable retinal detachment

A client has recently been diagnosed with 20/200 vision bilaterally and tells the nurse he is "legally blind." How does the nurse best offer increased support? a. Provides instructions in a loud, clear voice b. Refers the family to local services for the blind c. Tells the client to find a support group d. Writes instructions down in very large print

b Because the client is considered legally blind, referring the family to local services for the blind is the best way for the nurse to offer increased support.Talking in a loud, clear voice demonstrates insensitivity on the part of the nurse because speaking louder does not have any impact on vision. The client needs more specific assistance than just being told to find a support group. The client with 20/200 vision will not be able to distinguish large print.

A client with visual limitations has been admitted to the intensive care unit (ICU). Which action is most important to implement for this client? a. Allowing the client's seeing-eye dog in the unit b. Making all health care team members aware of the client's visual limitations c. Keeping the client bedridden for safety d. Addressing the client in a loud, clear voice

b It is most important to be sure all health care team members are aware of the client's visual limitations and need for assistance.All health care team members must be made aware of the client's visual limitations and need for assistance. Seeing-eye dogs are not usually allowed in the ICU. It is not necessary to keep the client bedridden. The client would be addressed in a normal tone of voice, because the client's hearing is not affected.

What is the action of miotic drugs that constrict the pupils in the client with glaucoma? a. Decrease the inflammatory process b. Enhance aqueous circulation to site of absorption c. Increase the production of vitreous humor d. Vasoconstrict the blood vessels in the eye

b Miotics are used to improve the flow of fluid (aqueous humor) and circulation and decrease intraocular pressure in clients with glaucoma.Steroid drops, not miotics, decrease the inflammatory process. Vitreous humor fills the space between the lens and the retina, is stagnant, and is not replenished as the aqueous humor is. Miotics make the pupil smaller, which creates more room between the iris and the lens.

Which client is most in need of immediate examination by an ophthalmologist? a. A 58-year-old with glasses who reports an inability to see colors well and is feeling as though the glasses are always smudged b. A 40-year-old with glasses and a reddened sclera who reports brow pain, headache, and seeing colored halos around lights c. A 76-year-old with seborrhea of the eyebrows and eyelids who reports burning and itching of the eyes d. A 39-year-old with contacts who reports an inability to tolerate bright lights and has visible purulent drainage on eyelids and eyelashes

b The 40-year-old client with glasses and a reddened sclera who reports brow pain, headache, and seeing colored halos around lights is most in need of an ophthalmologic examination. This client is exhibiting signs and symptoms of increased intraocular pressure (IOP). This is a priority because the optic nerve can be damaged, which can cause possible blindness. Acute angle-closure glaucoma can occur in people 40 years of age and older.The 58-year-old client reporting an inability to see colors well is exhibiting early signs of cataracts and will need to be seen, but this is not the priority. The 76-year-old with seborrhea of the eyebrows and eyelids is exhibiting signs and symptoms of blepharitis and will need to be seen, but this is also not the priority. The 39-year-old with contacts is exhibiting signs and symptoms of corneal abrasion, possibly from cataracts, and will need to be seen soon, but the client exhibiting increased IOP is still the priority.

The nurse is teaching the mother of a teenage client with conjunctivitis how to administer eye ointment. Which statement by the mother indicates a correct understanding of the nurse's instruction? a. "My child should look down at the floor during instillation." b. "I will place the ointment in the lower lid." c. "My child should rub the eye gently after instillation to increase absorption." d. "I will press gently on the inner canthus for 1 minute."

b The mother's statement that she will place the ointment in the lower lid indicates that she understands the nurse's instruction correctly. After the lower lid is gently pulled down to form a small pocket, eye ointment would be placed in the lower lid.For instillation of eye ointment, the client would tilt the head backward and look up at the ceiling. After closing the eye, the client may gently wipe away any excess ointment with a tissue, but the eye would never be rubbed. Pressing on the inner canthus is a technique reserved for the instillation of glaucoma drops.

A client has sustained damage to the optic nerve (cranial nerve II) after a traumatic injury. Which intervention does the nurse anticipate to accommodate for this injury? a. Artificial tears b. Identifying food on the client's plate using the clock method c. Daily eye assessment of the six cardinal positions of gaze d. Ensuring that the client wears sunglasses when the curtains are open or when the room light is on

b The optic nerve (cranial nerve [CN] II) controls sight. Using the clock method helps the client with impaired vision or loss of vision locate food on his or her plate.Artificial tears are used when tear production is decreased due to the aging process. The six cardinal positions of gaze assess CN III, IV, and VI. Sunglasses are used when the pupils are artificially dilated for assessment purposes, or when medications are used that cause dilation of the pupil.

The nurse is performing preoperative teaching for an older adult client who will be having a cataract removed. Which instructions does the nurse include? select all that apply. a. "You will need to wear a patch on your eye for several weeks after the surgery." b. "Several different types of eye drops are requested after surgery, and they have to be taken several times a day for up to 4 weeks." c. "You will receive a medication to help you relax. Then you will receive eye drops to dilate your pupils and paralyze the lens." d. "Bring sunglasses with you on the day of your procedure." e. "You might experience a lot of bruising and swelling around the eye."

b, c, d The client will have multiple eye drops to use after surgery and needs to be made aware of this before the procedure to understand the importance. Providing information on what to expect, such as telling the client about the medication that will be administered and the eye drops that will dilate and paralyze the lens, helps the client prepare for the day of surgery. The client will need to have sun protection after the procedure.A patch is required after surgery only if a risk for injury is present. Cataract surgery does not cause bruising and swelling postsurgery.

which factors can decrease blood supply to the ear in an older patient? select all that apply. a. osteoporosis b. diabetes c. smoking d. heart disease e. HTN f. cerumen

b, c, d, e

The nurse reads in the patient's chart that the patient's visual acuity is 20/40. What is the correct interpretation of this documentation? a. patient has 50% of the ideal 20/20 visual acuity b. patient stood 40 feet from the chart rather than 20 fee from the chart c. patient sees at 20 feet from the chart what a healthy eye sees at 40 feet d. patient stood 20 feet from the chart and sees 40% of the letters

The patient underwent a fluorescein angiography. What postprocedure instructions will the nurse give the patient? a. you may see a yellow haze for several days b. use OTC artificial tears to flush the eye c. drink fluids to help eliminate the dye from the body d. wear BIL eye patches for 24 hours to rest eyes

What would be an important point to include in the documentation of a patient's IOP? a. patient's body position during IOP measurement b., IOP measurement performed in a darkened room c. type and time of IOP measurement d. time of mydriatric drops and response to IOP measurement

Which method would the nurse use to perform a corneal assessment? a. inspect the corneas to determine if they are equal distance from the nose b. quickly and unexpectedly bring a hand toward the patient's cornea c. use a penlight and direct the light on the cornea from the side d. ask the patient to open and close eyelids, and observe the cornea

Which patient has the greatest risk for cataracts and needs an annual eye examination? a. 25 yo who was treated for an episode of eye infection b. 16 yo who was struck in the face by a basketball c. 57 yo with no history of eye problems or vision changes d. 35 yo who is pregnant with her first child

a young patient was hit in the left eye with a baseball. there is discoloration around the eye. which treatment does the nurse expect to give this patient? a. eye patch to rest the eye b. warm, moist compresses c. small ice application to area d. bedrest in semi-fowler's position

after a scleral buckling procedure, the patient is advised to avoid reading, writing, or close work, such as sewing. what is the rationale for avoiding these activities? a. they cause increased IOP b. close, fine work is likely to cause pain c. they cause rapid eye movement d. close work or fine print will be blurry

for a patient who had a keratoplasty, which discharge instruction will the nurse give? a. sleep on the operative side to reduce IOP b. keep eye covered for 1 week with the initial dressing and shield c. wear the shield at night for the first month after surgery d. apply a small cloth-covered ice pack to reduce swelling

which patient behavior would prompt the nurse to suggest that the patient should see an ophthalmologist about the possible development of a cataract? a. patient frequently wipes a creamy white, dry, crusty drainage from the eyelids b. patient has tearing and a reddened sclera after instilling prescribed eye drops c. patient frequently removes eyeglasses and repeatedly cleans the lenses d. patient rubs eyelids because of itching, mild swelling, and irritation

A client has recently had cataract surgery. The nurse will instruct the client to notify the health care provider immediately if which symptom occurs? a. Increased tearing b. Itching of the eye c. Reduction in vision d. Swollen eyelid

c A reduction in vision after cataract surgery indicates a problem, and the client would notify the provider immediately.Increased tearing, itching of the eye, and a swollen eyelid all are expected after cataract surgery.

The nurse is providing postmortem care to a client who will donate a cornea. Which action is appropriate for the nurse to implement? a. Apply a warm pack to the eyes. b. Elevate the lower extremities. c. Instill antibiotic drops into the eyes. d. Contact the recipient family.

c Antibiotic eye drops, such as Neosporin (polymyxin B, neomycin, bacitracin) or tobramycin, is appropriate to instill into the corneal donor's eyes to prevent infection.Small cold packs, not warm packs, should be applied to the donor's closed eyes. Raising the head of the bed 30 degrees prevents blood from pooling in the eye region of the deceased client. Raising the lower extremities is not appropriate. The nurse is not the person to contact the recipient family. The donor organization will complete all the communication to the parties involved.

A client is returning home after cataract surgery with a patch over the affected eye. Which statement by the client's spouse indicates a need for further instruction on providing a safe home environment? a. "I will get some books on tape for entertainment." b. "I will be sure to pick up all clutter and loose carpets from the floor." c. "I will rearrange the furniture for better flow before my spouse gets home." d. "I will place a nonslip mat in the bathtub."

c The statement by the spouse that the furniture will be rearranged indicates the need for further instruction. Changes in item location would not be made without input from the client with reduced vision.Books on tape are a good diversion for recuperating clients with reduced vision. Any objects that may present a tripping hazard would be removed at once. A nonslip mat may be used to prevent falls in the bathtub.

The home health nurse is interviewing a patient and discovers that there may be a previously undiagnosed vision problem. The nurse does not have a Jaeger card available at the patient's house to assess the suspected problem. Which item would serve as the best temporary substitute for a Jaeger card? a. flashlight b. ophthalmoscope c. snellen chart d. newspaper

What would be included in the procedure for using an ophthalmoscope? a. the nurse comes toward the patient's eye from 6 inches away b. the test should be done in a brightly lit room to enhance visibility c. have an assistant firmly hold a confused patient during the examination d. the nurse stands on the same side as the eye being examined

Which food would the nurse recommend, that would be particularly good for eye health? a. whole grain cereal b. low fat milk c. raw almonds d. fresh tomatoes

Why might the HCP order a CT scan to examine the eye? a. to validate the function of extraocular muscles b. to verify IOP c. to determine the degree of peripheral vision d. to detect an ocular tumor In the orbital space

a 23 yo athlete suffered a traumatic eye injury and enucleation was required. the nurse is trying to do discharge teaching, but the patient verbalizes anger and hopelessness, saying "what the point of learning about how to take care of this stupid empty hole in my face?" what is the nurse's first response? a. "let's just take things one step at a time. I'll come back later." b. "would you like information about joining a support group?" c. "preventing infection will prevent further disfigurement and problems." d. "you are frustrated. tell me how this accident will affect your life."

a patient who works on the tarmac at a busy airport is being seen for a routine examination. what protection measures for hearing does the nurse suggest to the patient? a. wear cotton ball ear inserts b. listen to music to mask noise c. wear a hat with ear covers d. wear an over-the-ear headset

a patient with myopia tells the nurse that he forgot to bring his glasses to the hospital and that his wife will bring them later when she comes to see him. which activity is the patient most likely to have difficulty with while he is waiting for his glasses? a. eating his lunch b. looking at a brochure c. using his cell phone d. watching television

during mealtimes, the nursing student is assisting an older patient who has reduced vision. when would the nursing instructor intervene to help the student to improve the quality of care? a. student opens sealed packages and removes the lids from cups and bowls b. student describes food placement on the plate in terms of a clock face c. student asks the charge nurse how much assistance the patient needs during meals d. student places meal tray on a table and tells the patient to call for help prn

the nurse is using an ophthalmoscope to examine the lens of a patient with a mature cataract. Which finding does the nurse expect to see? a. dilated pupil b. yellow tinge to sclera c. enlarged retina d. bluish-white pupil

what is the priority for a patient with impaired vision? a. self-care b. communication c. mobility d. safety

which traumatic injury is most likely to cause loss of vision in the injured eye? a. metal shavings on the cornea b. contusion to periorbital soft tissue c. laceration to the margin of the eyelid d. wood splinter embedded in eyeball

A client with glaucoma is being assessed for new symptoms. Which symptom indicates a high priority need for reassessment of intraocular pressure? a. Burning in the eye b. Inability to differentiate colors c. Increased sensitivity to light d. Gradual vision changes

d Gradual vision changes are an indication of increased intraocular pressure and indicate a high priority for reassessment.A burning sensation in the eye usually indicates inflammation and/or infection. An inability to differentiate colors is an early sign of cataracts. An increased sensitivity to light might be a sign of a corneal abrasion.

for a person who is just beginning to notice some hearing loss, which sounds would be the most difficult to clearly hear? a. woman singing in the soprano range b. toddler who is angry and screaming c. cell phone ringing with low-frequency tones d. gunfire shots on a television show

for which ear condition might a myringotomy be recommended? a. labyrinthitis b. acoustic neuroma c. otitis media d. presbycusis

an adult patient with a history of otitis media states that his left ear pain is better. now, the patient has noticed some pus with blood in the affected ear. what does the nurse suspect has happened? a. antibiotics are resolving the infection b. the eardrum has perforated c. the infection has worsened d. the ear is permanently damaged

tympanometry is helpful in distinguishing which disorder? a. middle ear infection b. external ear infection c. hearing loss for low-pitched tones d. indurated lesions on the pinna

what is an early S/S of macular degeneration? a. mild blurring b. decreased tear production c. loss of central vision d. difficulty with activities of daily living

what is the normal response to caloric testing? a. vertigo and nystagmus within 20-30 sec b. vertigo and nystagmus immediately c. vertigo and nystagmus within 5 minutes d. nystagmus with no vertigo

which disorder of the ear/hearing is more commonly found among men aged 20-50 years old? a. Meniere's disease b. ostosclerosis c. excessive cerumen d. labyrinthitis

which patient is most likely to have the lowest threshold for hearing tones and speech? a. 25 yo patient with no previous hearing problems b. 76 yo patient with significant hearing loss c. 43 yo patient who is well adapted to a hearing aid d. 6o yo patient with no known health problems

Which method is used to measure IOP? a. corneal staining b. tonometry c. slit lamp examination d. electroretinography

a 30 yo patient has cerumen in the left ear. when irrigating the ear, the nurse uses which amount of fluid? a. 10-30 mL b. 50-70 mL c. 60-100 mL d. 150-200 mL

sequentially order the events that allow for hearing. use 1 for the first step and 6 for the final step. __ a. sound waves are transferred to the malleus __ b. sound waves are transferred to the incus and the stapes __ c. vibrations are transmitted to the cochlea __ d. neural impulses are conducted by the auditory nerve __ e. sound waves strike the mastoid and the movable tympanic membrane __ f. sound is processed and interpreted by the brain

2, 3, 4, 5, 1, 6

Clients with a family history of which eye disorder may have problems with increased intraocular pressure (IOP), requiring additional assessment? A. Anisocoria B. Presbyopia C. Diabetic retinopathy D. Glaucoma

D Glaucoma can be caused by increased IOP, which reduces blood flow to the eyes. Adults with a family history of glaucoma should have their IOP measured once or twice a year.Anisocoria is characterized by unequal pupil size, which normally affects about 5% of the population. This condition is not a sign of increased IOP. Presbyopia is a condition related to aging with a progressive loss of the ability to focus on near objects. Increased IOP is not a factor. Diabetic retinopathy is microvascular damage caused by uncontrolled diabetes, not by increased IOP.

The nurse is teaching a client about administering eye drops to treat open-angle glaucoma. Which statement by the client indicates a need for further instruction? a. "I must wait 10 to 15 minutes between different eye drop medications." b. "I must press on the inside of my eye to prevent washout." c. "It is important to not skip a dose." d. "These eye drops will not cure my glaucoma."

Pressing on the inside of the eye after instillation of eye medication prevents systemic absorption of the drug.To avoid washout, the client must wait 10 to 15 minutes between eye drop medications. Skipping a dose will not exacerbate the client's glaucoma. Medication will not cure glaucoma, but it will control its progression.

a patient underwent electronystagmography and results showed failure of nystagmus to occur with cerebral stimulation. which action is the nurse most likely to take because of the test results? a. initiate fall precautions b. use a whiteboard prn c. give an antiemtic medication d. speak slowly to patient

an adult patient has otitis media. what does the nurse expect the patient's main concern to be? a. ear pain b. rhinitis c. drainage d. swelling

during physical assessment of an older patient, the nurse notes a small, crusted ulceration on the pinna. what should the nurse do first? a. ask the patient how long the sore has been there b. teach the patient how to clean the ears to prevent infection c. ask the HCP to check for the ear for cancer d. document the finding and mention it at shift change

the nurse immediately stops irrigating the ear if the patient reports which symptom? a. persistent pain b. sensation of fullness c. tingling sensation d. feelings of fatigue

the nurse is on a camping trip, and one of the camper's reports, "I think there is an insect in my ear. I can hear it and feel it moving around inside my ear canal." what should the nurse try first? a. shine a flashlight in the canal and try to coax the insect to come out b. instill cooking oil into the ear to suffocate the insect, then flush the canal with water c. apply a thing coating of antibiotic ointment to the external canal and pinna d. instruct the camper to tilt head downwards and vigorously shake the head

which patient is the most likely candidate to benefit fromt he rinne tuning fork test? a. patient requires differentiation of hearing b. patient has mental disability and is unable to follow instructions for audiometry or other tests c. patient has a fam hx of sensorineural hearing loss and genetic mutation in gene GJB2 d. patient is unable to identify and report which ear has the greater hearing loss

Which type of hearing loss is most likely to be reversible when treated appropriately? a. Conductive hearing loss b. Sensorineural hearing loss c. Mixed conductive-sensorineural hearing loss d. Central hearing loss

a Conductive hearing loss is most likely to be reversible when treated appropriately. This type of hearing loss is often the result of an obstruction in the ear canal or a retracted or bulging tympanic membrane.Sensorineural loss is the result of damage to the eighth cranial nerve, a defect in the cochlea, or damage in the brain. Mixed conductive sensorineural hearing loss is the result of both conductive and sensorineural hearing loss. Central hearing loss results when the brain is unable to process signals from the ear. None of these types of hearing loss is likely to be reversible.

Which test best determines hearing acuity? a. Audiometry b. Electronystagmography c. Otoscope d. Snellen test

a Audiometry is the best test for determining hearing acuity.Electronystagmography is a test that is sensitive for detecting central and peripheral disease of the vestibular system in the ear. An otoscope is used to inspect the ear canal. The Snellen test is a vision acuity test.

The nurse is teaching a client about ear protection. Which statement by the client indicates that teaching was effective? a. "I wear foam ear inserts at works where it is noisy." b. "I listen to music with foam ear inserts." c. "My ears ring after a rock concert, but it goes away." d. "The machinery is loud at work, but I get used to it."

a Foam ear inserts or over-the-ear headsets protect against potential ear damage from loud noises.If the client's work environment is noisy, the client will have to turn up the volume significantly to hear music played through ear inserts. A ringing in the ears (tinnitus) may be a sign of injury. Clients should wear earplugs in environments with loud music. Not wearing ear protection around noisy machinery will cause damage to the ear. "Getting used to" the noise is a sign that damage has occurred.

An older adult client reports ear pain. Otoscopic examination for otitis media by the nurse practitioner (NP) reveals a dull and retracted membrane. What does the NP do next? a. Continues further assessment b. Irrigates the ear c. Prescribes antibiotics for probable otitis media d. Tests hearing acuity

a The NP needs to perform further assessments. A dull and retracted membrane is not the only indication of otitis media for the older adult client. This finding may be a normal age-related change.Irrigating the ear is not indicated for this client. Further assessment is needed to determine whether the client has otitis media; therefore, antibiotics would not be prescribed. Auditory assessment is the last part of an ear examination after the otoscopic examination.

The nurse is preparing a client for electronystagmography. Which statement by the client indicates that teaching was effective? a. "I can't drink caffeine 24 to 48 hours before the test." b. "I should drink more fluids 4 hours before the test." c. "I'll be placed in a soundproof booth for the test." d. "I'll be sedated for the test."

a The client must avoid caffeine-containing beverages for 24 to 48 hours before the test. Electronystagmography (ENG) is a test to assess for central and peripheral disease of the vestibular system in the ear by detecting and recording nystagmus (involuntary eye movements). This response is accurate because the eyes and ears depend on each other for balance.The client must fast for several hours before electronystagmography. Fluids are carefully introduced after the test is completed to prevent nausea and vomiting. The client is placed in a soundproof booth for an audiometry test. Sedation is not given for the test. The examiners will ask the client to name names or do simple math problems during the test to ensure that he or she stays alert.

An older adult client comes in for a routine visit. During the assessment he is irritable and says, "Speak up and quit mumbling!" How will the nurse respond? a. Apologizes and speaks louder and clearer b. Asks whether the client has a hearing loss c. Shout to ensure that the client can hear d. Suggests that the client move to a soundproof examination room to improve his hearing

a The nurse would repeat and speak more clearly first and then determine whether further assessment is needed.It would not be assumed that the client has a hearing loss; this suggestion may make the client more irritable, especially if the client is in denial. Shouting is not recommended because it can make understanding more difficult. Soundproof rooms are used for hearing tests, not to improve hearing.

The nurse is performing an otoscopic examination of a client's ear and notes greenish-white drainage. What does the nurse do next? a. Disposes of the otoscope tip and washes the hands before examining the other ear b. Reports the finding to the health care provider immediately c. Sends a specimen for culture d. Suctions out the drainage

a The nurse's next step is to dispose of the otoscope tip and wash the hands before examining the other ear. To prevent cross-contamination, Contact Precautions must be used with any client who has drainage from the ear canal.The health care provider will be notified after the ear examination is complete. After an otoscopic examination, the nurse must perform an auditory assessment. A specimen is obtained only if the nurse is examining the external meatus region, but this is not the first step. The nurse must assess the second ear and compare. Suctioning an ear that is infected is not done because this causes trauma to the tissue.

an adult patient has been diagnosed with Meniere's disease. which points does the nurse include in the teaching plan for this patient? select all that apply. a. move or turn head very slowly b. reduce the intake of salt c. stop smoking d. take vitamin supplements e. avoid caffeine f. irrigate ears frequently to decrease cerumen

a, b, c

Which clients are at high risk for developing hearing problems? Select all that apply. a. Airline mechanic b. Client with Down syndrome c. Drummer in a rock band d. Teenager listening to music using ear buds e. Telephone operator

a, b, c, d Clients who are at high risk for hearing problems include an airline mechanic who is exposed to excessive noise, a client with Down syndrome, (a genetic condition associated with frequent hearing problems), a drummer in a rock band due to exposure to loud noise, and a teenager listening to music using ear buds. Ear buds are known risk factors for increasing potential hearing loss among people who use them on a regular basis with elevated noise levels.A telephone operator is not at risk for hearing problems simply because he or she may wear headphones or audio equipment.

which treatments are used for external otitis? select all that apply. a. application of heat b. oral analgesics c. topical antibiotics d. myringotomy e. minimizing head movements to reduce pain f. ear irrigation with warm water

a, b, c, e

what interventions can the nurse use to enhance communication with a hearing-impaired patient? select all that apply. a. have conversations in a quiet room with minimal distractions b. use appropriate hand motions c. stand in front of a bright light or a window d. get the patient's attention before speaking e. face the patient while speaking f. sit side by side to access the patient's better ear

a, b, d, e

which S/S should a patient who has had cataract surgery report to the HCP? select all that apply a. sharp, sudden pain in the eye b. decreased vision c. mild eye itching d. green or yellow thick discharge e. flashes of light f. lid swelling

a, b, d, e, f

what are the nurse's instructions to a patient after a myringotomy? select all that apply. a. report excessive drainage to your HCP b. avoid washing hair for 1 week c. use a straw for drinking liquids d. leave ear dressing in place until the next office visit e. blow the nose gently with the mouth open f. stay away from people with respiratory infections

a, b, e, f

what changes in the ear are related to aging? select all that apply. a. tympanic membrane may appear dull and retracted b. pinna becomes shorter and thickened c. cerumen is drier and impacts more easily d. cochlear nerve cells degenerate e. high frequency sounds are lost first f. hair in the canal is very sparse or absent

a, c, d, e

after a scleral buckling procedure, which aspect of postoperative care is affected if gas or oil has been placed in the eye? a. type of eye path b. position of the head c. eye drop schedule d. effects of anesthesia

lymph node tenderness is most likely to be a symptom of which disorder? a. meniere's disease b. mastoiditis c. otosclerosis d. cerumen impaction

the home health nurse is visiting the patient for the frist time. the nurse notices that the patient frequently tilts his head and gives odd answers to simple questions. the nurse has a stethoscope, a digital watch, a pen, and a BP cuff in her supply bag. which method would the nurse use to test hearing during this visit? a. hold the watch about 5 inches from each ear and ask the patient what he hears b. stand 2 feet away, have patient block one ear, whisper a sentence, and ask patient to repeat It c. apply the BP cuff and ask if patient can hear the separation of the velcro fastener d. have the patient don the stethoscope and listen to and count his own heartbeat

the nurse is assessing a patient who was admitted to the unit after undergoing a stapedectomy. the patient's face has an asymmetric appearance, and there is drooping of features on the affected side. what should the nurse do first? a. tell the patient that this is a temporary condition related to anesthesia b. ask the patient about sensations of taste and touch on the affected side c. notify the surgeon because it is likely that there is cranial nerve damage d. call the RRT because the patient may be having a stroke

the nurse uses irrigating fluid that is 98.6 F to irrigate a patient's ear to remove cerumen. what is the best rationale for using fluid at this temperature? a. EBP guides the selection of temperature b. it reduces the chance of stimulating the vestibular sense c. it is less painful than hotter or colder temperatures d. it potentiates the melting and mobilization of cerumen

the patient is taking meclizine. which question will the nurse ask to determine if the medication is having the desired therapeutic effect? a. "on a scale of 1-10, which number represents your current level of pain?" b. "do you feel the medication helped to relieve the dizziness and nausea?" c. "do you feel the medication decreased the buzzing sound that you reported?" d. "do you think that your hearing has improved after completing the medication?"

the patient tells the nurse that he has unpredictable episodes of vertigo. What instructions are the most important to give to the UAP who is assisting the patient with ADLs? a. "face the patient directly whenever speaking to him" b. "there is high risk for falls, so use a gait belt during ambulation" c. "noise from the television or hallway should be minimized" d. "patient's pain is likely to escalate, so report any discomfort"

which S/S is the most common early clinical manifestation of retinitis pigmentosa? a. cataracts b. night blindness c. HA d. vit A deficiency

which action could prevent ear trauma? a. holding the nose when sneezing to reduce pressure b. not using small objects to clean the external ear canal c. occluding one nostril when blowing the nose d. not using soap or water around the external ear and canal

which patient has the greatest risk for potential life-threatening complications? a. patient with DM needs treatment for external otitis b. patient who is immunosuppressed develops necrotizing otitis c. patient who is homeless has limited opportunities for hygiene and has tinnitus d. patient who works as a lifeguard frequently has problems with "swimmer's ear"

which technique would the nurse use to perform otoscopic assessment? a. the patient's head should be tilted slightly toward the nurse b. the nurse holds the otoscope upside down, like a large pen c. the pinna is pulled downwards and backwards d. the internal ear is visualized while the speculum is slowly inserted

which precautions does the nurse instruct a patient to take after having ear surgery? select all that apply. a. avoid air travel for 5-7 days b. stay away from people with colds c. do not drink through a straw for 2-3 weeks d. keep your ear dry for 6 weeks e. avoid straining when having a bowel movement f. avoid rapidly moving head, bouncing, or bending over for 2-3 days

b, c, d, e

Which technique is correct when instilling ear drops? a. Maintain the head in the same position for 2 minutes after instillation. b. Place the medication bottle in a bowl of warm water before instillation. c. Rinse the ear canal with hydrogen peroxide before instillation. d. Check to see whether the eardrum is intact before instillation.

b The correct way to instill eardrops is to first place the bottle (with the top on tightly) in a bowl of warm water for 5 minutes. This warms the medication and makes instillation more comfortable for the client.The head would be gently moved back and forth five times after instillation to ensure proper distribution. It is not necessary to rinse the ear canal with hydrogen peroxide or check to see whether the eardrum is intact before instillation.

tinnitus may be caused by which factors? select all that apply. a. tophi of the pinna b. otosclerosis c. continuous exposure to loud noise d. medications e. meiere's disease f. excessive cleaning of ears

b, c, d, e

before performing a physical examination, what assessments related to the patient's hearing can be done while observing the patient? select all that apply. a. observe the patient's clothes and hygiene b. observe the patient's body posture and position c. observe if that patient is anxious or overly talkative d. notice if the patient asks for questions to be repeated e. notice whether the patient tilts the head toward the examiner f. notice the patient's response when not looking in direction of sound

b, d, e, f

An adult patient has external otitis. after the inflammation resolves, which action should the patient avoid? a. using earplugs during swimming or other water sports b. dropping diluted alcohol in the ear to prevent recurrence c. inserting cotton-tipped applicator into ears after bathing d. using analgesics and warm compresses for pain relief

The results of an audiometry test indicate that the patient hears about 50% of the time at 0 decibels. based on these results, which action is the nurse most likely to take? a. prepare a brochure about different types of hearing aids b. explain the purpose and procedure of caloric testing c. use normal conversation speech when speaking to the patient d. ask the patient which ear is better and direct voice toward that side

an adult patient is having problem with hearing. which of the patient's medications is ototoxic? a. vit B12 b. digoxin c. furosemide d. levothyroxine

during the physical assessment, the nurse identifies a defect of the patient's external ear. based on knowledge of embryonic development, which question will the nurse ask to identify potential problems in a body system that developed concurrently with the external ear? a. "have you ever had problems with your heart?" b. "do you notice shortness of breathe with minor exertion?" c. "have you had any problems with your kidneys or urination?" d. "do you have episodes of headaches with confusion?"

how would the nurse use body position and the surrounding environment when conducting an interview with a patient who may have a hearing problem? a. conduct the interview in a quiet, darkened room without distractions b. sit bedside the patient and speak indirectly into the patient's ear c. sit directly in front of the patient in a room with adequate lighting d. stand over the patient and use hand motions for emphasis

the HCP asks the nurse to obtain a pneumatic otoscope so that the external canal can be inspected. what specific assessment finding is this instrument used for? a. to detect infection or inflammation b. to gently elicit pain or discomfort c. to detect mobility of the eardrum d. to verify the patency of the eardrum

the HCP tells the nurse that the patient was informed about the diagnosis of acoustic neuroma and was also given information about the prognosis, treatment, and possible complications. which patient statement indicates that the patient understood the information? a. "the tumor is benign, so I am not going to worry about it" b. "I am not sure if i want chemotherapy and radiation" c. "the tumor is benign, but neurologic damage sounds scary" d. "hearing loss in one ear is not too bad, if that's the worst complication"

the nurse hears in shift report that a patient suffers from hyperacusis. which intervention is the nurse most likely to use in the care of this patient? a. supply a writing tablet and pen b. speak loudly and carefully enunciate c. control or reduce environmental noise d. instruct the patient to sit up slowly

the nurse is assisting an inexperienced HCP who is trying to perform an otoscopic examination on an older patient who is being treated for delirium caused by infection. What should the nurse do? a. quietly talk to the patient to distract him as the provider inserts the speculum b. gently hold the patient's head to prevent movement during the examination c. suggest that the otoscopic examination be deferred until the delirium resolves d. suggest using a rinne tuning fork test instead of otoscopic examination

the nurse reads in the patient's chart that the weber tuning fork test showed that the patient had lateralization to the right. based on this information, what would the nurse do while caring for the patient? a. instruct the patient to turn his head to the right if he is having trouble hearing b. ask the patient in which ear the sound is louder, because the test is inconclusive c. position self to the patient's right, so that voice travels directly to the right ear d. lateralization indicates normal hearing, so the nurse would perform routine care

what is the nurse most likely to notice if the patient has problems with auditory sensory perception? a. patient frequently looks away when being spoken to b. patient feigns disinterest or annoyance when spoken to c. patient frequently asks speaker to repeat statements d. patient often seeks out others for assistance

what should the nurse teach a patient who is learning to use a hearing aid? a. soak the hearing aid in a solution of mild soap and water b. plug the hearing aid into an electrical source when not in use c. avoid exposing the hearing aid to extreme temperatures d. adjust volume to the highest setting to maximize hearing

which child is most likely to develop hearing loss in adulthood? a. 1 yo with ear infections related to "night bottles" b. 2 yo who stumbles and bumps his head on a table c. 5 yo who is diagnosed with down syndrome d. 10 yo with a grandparent who has hearing problems

which condition requires extra caution when patients are prescribed ototoxic drugs? a. chronic HF b. chronic pancreatitis c. chronic glomerulonephritis d. COPD

which step is a correct part of the procedure for instilling eardrops? a. gently irrigate the ear if the membrane is not intact b. place the bottle of eardrops in a bowel of hot water for 10 mins c. tilt the patient's head in the opposite direction of the affected ear d. perform hand hygiene and use sterile gloves during the procedure

The nurse is teaching a client with impaired hearing about audiometric testing. Which statement by the nurse effectively communicates information about the procedure to the client? a. "Here is a picture of how the test is done. See how your bad ear will be tested first? You will be alone in the soundproof booth, so you will need to watch for lights flashing on and off as your cues." b. "Here is a video of the procedure. Please watch and feel free to ask me any questions." c. "I will sit right in front of you in the soundproof booth and give you instructions on what types of sounds you will hear and how you'll need to respond." d. "You will be in a soundproof booth and the sounds will be piped in. When you first hear the loudest sound, put your hand down. When you stop hearing the sound, put your hand up to stop."

c An effective statement by the nurse regarding audiometric testing involves informing the client that the nurse will be sitting in front of the hearing-impaired client while providing instructions. This allows the client to read lips.Pictures help the client with impaired hearing, but the good ear is tested first. The client wears earphones and listens for sounds, not flashing lights. Showing a hearing-impaired client a video is ineffective because of tone and frequency differences in the video, which make it difficult to read lips and understand the instructions. During the test, earphones are placed on the client. The client will raise her or his hand up when hearing the first sound and will lower the hand when the sound first disappears.

An older adult client reports nausea during irrigation of the ear canal to remove impacted cerumen. What does the nurse do next? a. Administer an antiemetic. b. Call the health care provider. c. Stop irrigation immediately. d. Use less water to irrigate.

c If nausea, vomiting, or dizziness develops in the client, the nurse needs to next stop the irrigation immediately. The client's nausea may be a sign of vertigo.Antiemetics would not be administered immediately in this case. The client's nausea may be a symptom of vertigo, and further assessment is required first. The health care provider would not be notified before further assessment of the client is done by the nurse. Using less water will not alleviate the client's nausea.

The nurse has just received change-of-shift report about these clients. Which client needs to be assessed first? a. Client with Ménière's disease who is reporting severe nausea and is requesting an antiemetic b. Client who has had removal of an acoustic neuroma and has complete hearing loss on the surgical side c. Client with labyrinthitis who has a temperature of 102.4° F (39.1° C) and a headache d. Client who has acute otitis media and is reporting drainage from the affected ear

c The client with an elevated temperature and headache with labyrinthitis must be assessed first. This may indicate that the client has developed meningitis requiring immediate intervention.Severe nausea is an expected finding with Ménière's disease. Complete hearing loss on the surgical side is an expected postoperative finding after an acoustic neuroma. Drainage from the affected ear can be an expected finding with otitis media.

The nurse is caring for a client who is admitted with mastoiditis. Which assessment data obtained by the nurse requires the most immediate action? a. The eardrum is red, thick-appearing, and immobile. b. The lymph nodes are swollen and painful to touch. c. The client reports a headache and a stiff neck. d. The client's oral temperature is 100.1° F (37.8° C).

c The most immediate action is required when the client reports a headache and a stiff neck. These complaints may indicate meningitis, which is a serious illness requiring further assessment and immediate intervention.The eardrum being red, thick-appearing, and immobile is an expected finding for a client with an ear infection. Lymph nodes that are swollen and painful to touch are an expected finding for a client with an active infection of the mastoid area. An oral temperature of 100.1° F (37.8° C) is also an expected finding for a client with an active infection.

Which type of drug therapy does the nurse anticipate giving to a client with Ménière's disease to decrease endolymph volume? a. Antihistamines b. Antipyretics c. Diuretics d. Nicotinic acid

c Mild diuretics are prescribed to decrease endolymph volume. Ménière's disease causes an excess of endolymphatic fluid that distorts the entire inner-canal system. This distortion decreases hearing by dilating the cochlear duct, causes vertigo because of damage to the vestibular system, and stimulates tinnitus.Antihistamines help reduce the severity of or stop an acute attack, and antipyretics control fever and pain, but they do not decrease endolymph volume. Nicotinic acid has been found to be useful because of its vasodilatory effect, but it does not decrease endolymph volume.

The nurse is assessing a client with recent changes in hearing. After taking a medication history, which drugs does the nurse identify as possible causes of the client's hearing change? select all that apply. a. Acetaminophen (Tylenol) b. Beta blockers c. Erythromycin d. Ibuprofen (Advil) e. Insulin f. Furosemide (Lasix)

c, d, f The nurse identifies erythromycin, ibuprofen, and furosemide (Lasix) as medications known to increase the risk for hearing change related to ototoxicity and hearing problems.Acetaminophen, beta blockers, and insulin are not known ototoxic drugs.

a patient is having problems with speech discrimination. what is the nurse most likely to observe? a. patient speaks very loudly during a conversation b. patient can hear high tones but not low tones c. patient cannot accurately repeat two-syllable words d. patient repeats back "say" when the nurse says "stay"

a sensorineural hearing loss results from impairment of which structure? a. mobility of bony ossicles b. first cranial nerve c. patency of external canal d. eighth cranial nerve

for a patient with meiere's disease, what is the purpose of the recommended nutrition therapy? a. to ensure an adequate intake of nutrients to slow progression of the disease b. to reduce harmful lipid accumulation in the acoustic-vestibular system c. to improve general overall health and strengthen the immune system d. to stabilize body fluid and prevent excess endolymph accumulation

the nurse gently taps over the patient's mastoid process, and the patient reports tenderness. this finding may indicate which condition? a. excessive cerumen b. hyperacusis c. ruptured eardrum d. inflammatory process

what is a contraindication for a patient having electronystagmography (ENG)? a. dental problems b. previous ENG c. prosthetic hip d. pacemaker

what is an early S/S of a cataract? a. double vision b. photophobia c. decreased depth perception d. decreased color perception

which patient is most likely to benefit by having music playing during sleeping hours? a. patient has frequent episodes of acute otitis media b. patient reports an odd sensation of "whirling in space" c. patient has a hearing aid and reports excessive background noise d. patient reports tinnitus that contributes to emotional disturbance

which person has the highest risk for developing hearing problems related to occupation? a. nurse who works night shift in an ED b. coach who instructs a high school swim team c. bus driver who picks up elementary school children d. bartender who works in a nightclub with live music

An older adult client reports ear pain. To differentiate the cause, which clinical manifestation is more indicative of otitis media? a. Dry, flaky cerumen b. Pain on movement of the tragus c. Ringing in the ears d. Dizziness

d Dizziness is more indicative of otitis media due to pressure as the middle ear pushes against the inner ear.Dry, flaky cerumen is normal with aging. Pain on movement of the tragus is indicative of external otitis. Ringing in the ears is more likely with Ménière's disease.

The nurse is reviewing postoperative instructions with a client undergoing stapedectomy. Which statement by the client indicates a need for further teaching? a. "I may have problems with vertigo after the surgery." b. "I should not drink from a straw for several weeks." c. "I will have to take antibiotics after the surgery." d. "I will be able to hear as soon as my dressing is removed."

d Further teaching is necessary if the client states that he will be able to hear as soon as the dressing is removed. Hearing is initially worse after a stapedectomy. The client would be informed that improvement in hearing may not occur until 6 weeks after surgery. At first, the ear packing interferes with hearing, and swelling in the ear after surgery reduces hearing, but these conditions are temporary.Vertigo, nausea, and vomiting are common after surgery because of the nearness of the surgical site to inner ear structures. Clients must not drink through a straw for 2 to 3 weeks after surgery. Antibiotics are used to reduce the risk for infection.

The nurse is talking to a client about cerumen removal from the ear canal. Which statement by the client indicates a need for further teaching? a. "I dry my ears using my fingertip and a towel." b. "I may irrigate my ears with tap water." c. "I should not use an ear candle to soften the wax." d. "I use a cotton swab to remove earwax."

d Further teaching is needed when the client states, "I use a cotton swab to remove earwax." Nothing smaller than the client's own fingertip should be inserted into the ear canal. Use of a cotton swab can scrape the skin of the canal, push cerumen up against the eardrum, and even puncture the eardrum.Using the fingertip and a towel and irrigating the ear canal with tap water are acceptable. Clients would be discouraged from using ear candles.

What is the proper technique for assessing an adult client's ear with an otoscope? a. Hold the otoscope right side up when inserting it into the ear canal. b. Maintain distance between the otoscope and the client's head. c. Place the otoscope in the nondominant hand. d. Pull the pinna up and back with the nondominant hand.

d In the adult, pulling the pinna up and back with the nondominant hand allows the ear canal to straighten. The otoscope should be held upside down, like a large pen.The otoscope would not be held right side up. Holding the otoscope upside down permits the hand to lie against the client's head for support. The otoscope would not be held in the nondominant hand.

The nurse is teaching a client who will soon be fitted for a hearing aid about proper care and use. Which statement by the client indicates that teaching was effective? a. "Background noises will be difficult for me to hear." b. "I should wear my hearing aid only to work at first." c. "I should just get a smaller hearing aid because I don't have much money." d. "Listening to the radio and television will help me get used to new sounds."

d Teaching was effective if the client states that listening to television and the radio and reading aloud will help the client to get used to new sounds.With hearing aids, background noises are amplified, so the client must learn to concentrate and filter out background noises. The client would start using the hearing aid slowly, at first wearing it only at home and only during part of the day. The cost of smaller hearing aids is actually greater than for larger ones.

A client recently diagnosed with Ménière's disease is struggling with tinnitus. How does the nurse provide support to this client? a. Provide further assessment. b. Suggest a quiet environment. c. Suggest temporary removal of a hearing aid. d. Refer the client to the American Tinnitus Association.

d The best action by the nurse is to refer the client to the American Tinnitus Association. This group assists clients in coping with tinnitus when other therapy is unsuccessful.Reassessment of the client's diagnosis is not needed; this will only waste the client's and the nurse's time. A quiet environment and removal of the hearing aid will not be helpful. Background noise masks the tinnitus while quiet conditions exacerbate it. Ear-mold hearing aids can amplify sounds to drown out tinnitus during the day.

The nurse is teaching a client with vertigo about safety precautions for fall prevention. Which statement by the client indicates a need for further instruction? a. "I may need to use a cane." b. "I should keep my grandkids' toys out of the hallway." c. "Moving more slowly may help the vertigo subside." d. "Taking my medication will allow me to drive my car again."

d The client's statement about taking medication and driving a car indicates further teaching is needed. Medications for vertigo may cause drowsiness, so the client must not drive or operate machinery while taking these drugs.The client with vertigo may need to use a cane for balance. Clients need to maintain a safe, uncluttered environment to prevent accidents during periods of vertigo. Restricting head motion and moving more slowly may help clients reduce occurrences of vertigo.

A client is in the immediate postoperative period after tympanoplasty. How does the nurse position the client? a. On the affected side b. Supine, with eyes toward the ceiling c. With the head elevated 60 degrees d. With the affected ear facing up

d The nurse keeps the client flat, with the head turned to the side and the operative ear facing up, for at least 12 hours after surgery.Laying the client on the affected side is the opposite side of where the client should be placed. Laying the client in a supine position is incorrect. Raising the head places undue pressure on the surgical site.

A client has purulent drainage in the inner canthus of the eye. Before examining the eye, what must the nurse do first? a. Administer a Snellen test. b. Obtain an informed consent c. Instill antibiotic drops. d. Put on gloves.

d The nurse must first put on gloves. Gloves must be worn in the presence of drainage and would be put on before examining the eye. Administering a Snellen test or instilling antibiotic eye drops is not the first thing that the nurse should do before examining the client's eye. Obtaining informed consent is not necessary for an eye examination.Administering a Snellen test or instilling antibiotic eye drops is not the first thing that the nurse would do before examining the client's eye. Obtaining informed consent is not necessary for an eye examination.

When preparing to examine an ear with drainage, what does the nurse do first? a. Begins testing at 1000 Hz b. Reassures the client that the ear drainage is normal c. Tilts the client's head away slightly d. Dons clean gloves

d The nurse needs to don clean gloves first to prevent infection, Contact Precautions need to be used when assessing drainage from a client's ear canal.Testing for hearing loss (1000 Hz) is not used when examining an ear for drainage. Ear drainage is not normal and must be investigated. Tilting the client's head is not the first action among the options given that the nurse needs to do.

A client is having a stapedectomy. Which form of postoperative communication is most effective for the nurse to use? a. Gesturing b. Sign language c. Speaking d. Writing

d Writing is the most effective way to communicate with the client who has undergone a stapedectomy.Gesturing can be vague and imprecise. Sign language requires training. It is hoped that the client will not be hearing-impaired long enough for this to be a viable option. The client will not be able to hear for the first 6 weeks after surgery.

Light waves pass through each of the eye structures listed below to reach the retina. Place them in sequence using hte numbers 1-5, with number 1 being the outermost structure and number 5 being the innermost structure. __ a. vitreous humor __ b. aqueous humor __ c. lens __ d. cornea __ e. retina

d, b, c, a ,e

What does a normal tympanic membrane look like with an otoscope?

shiny, transparent, or opaque and pearly/gray

the nurse is providing the immediate postoperative care for a patient who had a keratoplasty. which assessment will the nurse perform to identify the most likely complication? a. assess for bleeding b. assess for photosensitivity c. monitor for respiratory depression d. monitor for HTN

A patient is diagnosed with arcus senilis. Which intervention will the nurse use in caring for this patient? a. assist the patient in activities that require near vision b. teach the patient how to instill the prescribed eye drops c. reassure the patient the vision is not affected d. instruct the consistent use of sunglasses prevents worsening

A patient reports not being able to see objects in his peripheral vision. Which method is used to evaluate this symptom? a. jaeger card b. six cardinal positions of gaze c. confrontation test d. corneal light reflex test

A 45 yo patient has DM. Which information about vision protection does the nurse include in the teaching plan? a. people with DM have an increased incidence of ocular melanoma b. fluctuating blood glucose levels are undesirable but do not cause vision problems c. use OTC eye drops every day to flush potential infective organisms d. annual eye examinations are recommended for patients with DM

A client is admitted to the emergency department with metal shards in the right eye. Which test is contraindicated for this client? A. Magnetic resonance imaging (MRI) B. Ophthalmoscopy C. Radioisotope scanning D. Snellen chart

A Because the client has metal in the eye, MRI is an absolute contraindication.Ophthalmoscopy is used to assess the eye for interior and exterior damage and is not contraindicated for this client. Radioisotope scanning assesses the eye for tumors or lesions and is not contraindicated. The Snellen chart measures distance vision and is not contraindicated.

An older patient reports a sensation of eye dryness. The nurse would teach the patient to use saline eye drops and to increase the humidity in the house to reduce the risk for which eye disorder? a. corneal abrasion b. presbyopia c. hyperopia d. yellowing of the sclera

which cranial nerve is the nurse testing when performing a bedside hearing test? a. V b. VI c. VIII d. IX

the patient tells the nurse that he had LASIK surgery several years ago. which question is the nurse most likely to ask? a. "what was the IOP prior to having LASIK performed?" b. "did you have LASIK for nearsightedness, farsightedness, or astigmatism?" c. "in addition to LASIK, are you getting sufficient antioxidants, vitamin B12, and carotenoids?" d. "after LASIK, did you see 'shooting stars' or thin 'lightning streak' or 'floaters'?"

Which medications can adversely affect the eyes and vision? select all that apply a. heparin b. decongestants c. oral contraceptives d. acetaminophen e. corticosteroids f. antibiotics

b, c, e, f

A 29 yo patient tells the nurse that he spends a great deal of time in the sun and rarely wears sunglasses. The patient's behavior increases the risk for which eye disorder? a. hyperopia b. ptosis c. ocular melanoma d. exophthalmos

A patient who works in a machine shop has a suspected metal foreign body in the eye. Which test is contraindicated for this patient? a. corneal staining b. CT scan c. MRI d. U/S

The nurse is teaching a client who is scheduled for an ultrasonography of the eye. Which statement by the client indicates a need for further instruction? A. "I'll have to wear a bandage over my eye after the test." B. "I will be awake during this test." C. "I won't hear the high-frequency sound waves." D. "This test will help determine whether my retina is detached."

A The client does not have to wear a bandage after the test because no special follow-up care is needed after an ultrasonography of the eye. However, the client should be reminded not to rub or touch the eye until the effects of the anesthetic drops have worn off.The test is noninvasive and painless, and the client remains awake during the test. The high-frequency sound waves that are bounced through the eye cannot be heard. Ultrasonography aids in the diagnosis of trauma, intraorbital tumor, proptosis, and choroidal or retinal detachment.

Which systemic disorders may affect the eye and vision and require yearly eye examination by an ophthalmologist? A. Anemia B. Diabetes mellitus C. Hepatitis D. Hypertension E. Multiple sclerosis (MS)

B Clients who are diabetic are at risk for diabetic retinopathy and are in need of annual eye examinations. Clients with elevated blood pressure need to have annual eye examinations because of the increased risk for retinal damage. Clients with MS should have annual examinations because of changes that occur with the neurologic effects of MS that impact visual acuity.Anemia does not require eye examination on a routine basis. Hepatitis does not increase eye risk and is not indicated as a disorder requiring annual examinations.

Which eye procedure requires informed consent from the client? A. Eye drop instillation B. Fluorescein angiography C. Ophthalmoscopy D. Snellen test

B Fluorescein angiography is an invasive test and requires informed consent from the client.Eye drop instillation, ophthalmoscopy, and the Snellen test are not invasive procedures and do not require informed consent from the client.

A client says, "I have problems reading signs when I am driving." Which test does the nurse use to best assess this client's problem? A. Confrontation test B. Ishihara chart C. Rosenbaum Pocket Vision Screener or a Jaeger card D. Snellen chart

B The Snellen chart test best assesses the client's distance vision, which is the type of vision used while driving.The confrontation test assesses the client's visual field. The Ishihara chart assesses the client's color vision. The Rosenbaum Pocket Vision Screener or Jaeger card assesses the client's near vision.

A client reports "something scratching on the inside of my eyelid." Before examining the eyelid, what does the nurse do first? A. Administer a Snellen test. B. Obtain an informed consent. C. Wash the hands. D. Put on sterile gloves.

C Always wash hands before touching the external eye structures to prevent infection.A Snellen test may be done but is not the first thing that should be done by the nurse. An informed consent or sterile gloves are not needed for the nurse to examine the client's eye.

Which proper technique does the nurse use for eye drop instillation? A. Instilling the drops into the inner canthus B. Opening the eye by raising the upper eyelid C. Placing the eye drop in the lower lid pocket D. Touching the bottle tip to the eyeball

C To instill eye drops, the lower eyelid is gently pulled down against the cheek to form a pocket, and the medication is instilled.Instilling drops into the inner canthus causes the medication to enter the punctum and be absorbed systemically. The upper eyelid is larger than the lower eyelid and is used to protect the eye and keep the cornea moist; it should not be used to create a pocket to instill medication. Touching the bottle tip to any part of the eye could potentially contaminate the eye.

If the superior rectus muscle is damaged or not functioning properly, the patient would have difficulty with which eye movement? a. looking upwards b. looking downwards c. gazing inwards to the nose d. gazing outwards to the ear

A client with new-onset diminished vision is being discharged and is concerned about living independently. Which nursing technique best facilitates independent self-care for the client? a. Building on the remaining vision. b. Keeping the floor free of clutter c. Suggesting a seeing-eye animal companion d. Teaching Braille

a Using large-print books, talking clocks, and telephones with large, raised block numbers are examples of building on the client's remaining vision, and best facilitates the client's independent self-care.Keeping the floor free of clutter is important but is too specific. A seeing-eye animal companion may be assigned to those who are legally blind, not to those with diminished vision. Braille is used by clients who are legally blind. This client will still be able to read using a magnification device such as a visualizer.

Age is important because cataracts are most prevalent in the older adult. In addition, the nurse would ask about which predisposing factors? select all that apply a. exposure to radioactie materials, x-rays, or UV light b. fam Hx of cataracts c. fam Hx of rheumatoid arthritis d. systemic disease (e.g., DM, hypoparathyroidism) e. recent or past trauma to the eye f. prolonged use of corticosteroids, chlorpromazine, beta-blockers, or miotic drugs

a, b, d, e, f

Which conditions or diseases can adversely affect a patient's eyes and vision? select all that apply a. pregnancy b. inflammatory bowel disease c. diabetes d. HTN e. osteoarthritis f. thyroid problems

a, c, d, f

The nurse reads PERRLA in the patient's chart as noted by the nurse who worked the previous shift. What does the nurse do to determine if the patient still displays PERRLA or if the patient's status has changed? a. assess for presence, relief, or reduction of pain b. checks pupils, retina, and light refraction c. assesses the size, shape, and reactivity of pupils d. checks for signs of presbyopia or retinal detachment

The nurse reads in the patient's chart that he has anisocoria. Which assessment of the eye will reveal this variation that is considered normal in 5% of the population? a. corneal assessment b. scleral assessment c. pupillary assessment d. eye movement assessment

A neighbor calls the nurse for advice because he thinks he may have got some metal shavings in his eye while working on a home improvement project. What advice should the nurse give? a. rinse the eye with water and then don protective eyewear b. immediately notify his HCP or ophthalmologist c. mentioned the incident during the annual eye examination d. resting the eye is sufficient unless there is pain or loss of vision

Although the older patient denies any problems with his vision, the nurse frequently observes that he closes one eye when trying to look at his meal tray or personal items on the bedside table. What does the nurse expect? a. patient has arcus senilis b. patient has DM c. patient has dry eye syndrome d. patient has a small cataract

In assessing the corneal light reflex of the older patient's eye, the nurse notes an asymmetric reflex. What is the clinical significance of this assessment finding? a. this is a normal finding for an older adult b. eye is deviating because of possible muscle weakness c. the reflex is asymmetrical because of a cataract d. eye strain and eye fatigue can alter the reflex

The nurse is assessing a patient who is unable to see the 20/400 characters on the Snellen chart. Which assessment will the nurse try first? a. Ask the patient to detect stationary, left-right, or up-down hand movements. b. ask the patient to count the number of fingers held up in front of the eyes c. ask the patient to report "on" or "off' when detecting light in a darkened room d. ask the patient to self-select a distance from Snellen chart where 20/400 is visible.

The patient has an IOP greater than 21 mmHg. The patient's use of which OTC product should be brought to the immediate attention of the ophthalmologist? a. aspirin b. antihistamine c. vit supplement d. artificial tear eye drops

What is an early sign of primary open-angle glaucoma? a. sudden severe pain around the eyes b. gradual loss of visual fields c. seeing halos around lights d. brow pain with nausea and vomiting

Which activity is most likely to be very difficult for the patient if the visual function of accommodation is not working correctly? a. reading a newspaper b. playing tennis c. watching a sunset d. walking in a dark hallway

The home health nurse is visiting an older patient who was discharged to home yesterday after cataract surgery. the patient reports pain during the evening with nausea and vomiting that started this morning. the home health nurse decides to contact the health care provider for suspicion of which complication? a. dry eye syndrome b. tissue graft rejection c. corneal infection d. increased IOP

The nurse asks the patient to open and close his eyelids. Which cranial nerve is the nurse assessing? a. cranial nerve II optic b. cranial nerve III oculomotor c. cranial nerve V trigeminal d. cranial nerve VII facial

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