Med Surg CH 80

A client sustains a contusion of the eyeball after a traumatic injury with a blunt object. The nurse should take which immediate action? a. Apply ice on the affected eye b. Irrigate the eye with cool water c. Notify the primary healthcare provider (PHCP) d. Accompany the client to the emergency department

a. Apply ice on the affected eye

A client is diagnosed with glaucoma. Which data gathered by the nurse indicate a risk factor associated with glaucoma? a. Cardiovascular disease b. A history of migraine headaches c. Frequent urinary tract infections d. Frequent upper respiratory infections

a. Cardiovascular disease (Hypotension, heart disease, diabetes mellitus, are associated with the development of glaucoma. As well as smoking, ingestion of caffeine or large amounts of alcohol, illicit drugs, corticosteroids, altered hormone levels, posture, and eye movements may cause an increase in intraocular pressure)

The nurse is preparing to administer eardrops to an adult client. The nurse administers the eardrops by which technique? a. Pulling the pinna up and back b. Pulling the earlobe down and back c. Tilting the clients head forward and down d. Instructing the client to stand and lean to one side

a. Pulling the pinna up and back

The nurse preparing to reinforce a teaching plan for a client who is undergoing cataract extraction with intraocular implant. Which home care measures should the nurse include in the plan? Select all that apply. a. To avoid activities that require bending over b. To contact the surgeon if eye scratchiness occurs c. To take acetaminophen for eye discomfort d. To place an eye shield on the surgical eye at bedtime e. That episodes of sudden severe pain in the eye are expected f. To contact the surgeon if a decrease in visual acuity occurs

a. To avoid activities that require bending over c. To take acetaminophen for eye discomfort d. To place an eye shield on the surgical eye at bedtime f. To contact the surgeon if a decrease in visual acuity occurs

The nurse assists to prepare the client for ear irrigation as prescribed by the health care provider. Which action should the nurse plan to take? a. Warm the irrigation solution to 98 F (36.6 C) b. Position the client with the affected side up after the irrigation c. Direct a slow, steady stream of irrigation solution toward the eardrum d. Assist the client with turning his or her head so that the ear to be irrigated is facing upward

a. Warm the irrigation solution to 98 F (36.6 C)

The nurse is preparing to administer eyedrops. Which interventions should the nurse take to administer the drops? Select all that apply a. Wash hands. b. Put on gloves. c. Place the drop in the conjunctival sac. d. Pull the lower lid down against the cheekbone e. Instruct the client to squeeze the eyes shut after instilling the eyedrop f. Instruct the client to lean the head forward, open the eyes and look down

a. Wash hands. b. Put on gloves. c. Place the drop in the conjunctival sac. d. Pull the lower lid down against the cheekbone

A nurse is reviewing the health record of a client who has severe otitis media. Which of the following are expected findings? Select all that apply. a. enlarged adenoids b. report of recent colds c. client prescription for daily furosemide d. light reflex visible on otoscopic exam in the affected ear e. ear pain relieved by meclizine

a. enlarged adenoids b. report of recent colds e. ear pain relieved by meclizine

A nurse is providing teaching for a client who has a new diagnosis of dry macular degeneration. Which of the following instructions should the nurse include in the teaching? a. increase intake of deep yellow and orange vegetables b. administer eye drops twice daily c. avoid bending at the waist d. wear an eye patch at night

a. increase intake of deep yellow and orange vegetables (Rationale: the nurse should instruct the client to increase dietary intake of carotenoids and antioxidants to slow the progression of macular degeneration)

A nurse in a clinic is caring for a client who has been experiencing mild to moderate vertigo due to benign paroxysmal vertigo for several weeks. Which of the following actions should the nurse recommend to help control the vertigo? Select all that apply. a. reduce exposure to bright lighting b. move head slowly when changing positions c. do not eat fruit high in potassium d. plan evenly-spaced daily fluid intake e. avoid fluids containing caffeine

a. reduce exposure to bright lighting b. move head slowly when changing positions d. plan evenly-spaced daily fluid intake e. avoid fluids containing caffeine

A nurse is completing discharge teaching to a client following middle ear surgery. Which of the following statements by the client indicates understanding of the teaching? a."I should restrict rapid movements and avoid bending from the waist for several weeks" b."I should wait until the day after surgery to wash my hair" c. "I will remove the dressing behind my ear in 7 days" d. "my hearing should be back to normal right after my surgery"

a."I should restrict rapid movements and avoid bending from the waist for several weeks" (Rationale: avoid it three weeks following ear surgery)

A miotic medication has been prescribed for the client with glaucoma. The client asks the nurse about the purpose of the medication. The nurse should tell the client which? a. "The medication will help dilate the eye to prevent an increase in eye pressure." b. "The medication causes the pupil to constrict and will lower the pressure in the eye." c. "The medication will relax the muscles of the eyes and prevent blurred vision." d. "The medication will help block responses that are sent to the muscles in the eye."

b. "The medication causes the pupil to constrict and will lower the pressure in the eye."

Pilocarpine hydrochloride (Isopto Carpine) is prescribed for the client with glaucoma. Which medication should the nurse plan to have available in the event of systemic toxicity? a. Metopranolol b. Atropine sulfate c. Timolol maleate d. Carteolol hydrochloride

b. Atropine sulfate

Betaxolol hydrochloride (Betoptic) eyedrops have been prescribed for the client with glaucoma. Which nursing action is most appropriate related to monitoring for the side/adverse effects of this medication? a. Monitoring temperature b. Monitoring blood pressure c. Checking peripheral pulses d. Checking the blood glucose level

b. Monitoring blood pressure

A client arrives in the emergency department after an automobile crash. The client's forehead hit the steering wheel, and a hyphema has been diagnosed. Which position should the nurse prepare to position the client? a. Flat on bed rest b. On bedrest on semi-Fowler's c. In lateral position on the unaffected side d. In the lateral position on the affected side

b. On bedrest on semi-Fowler's

In preparation for cataract surgery, the nurse is to administer cyclopentolate (Cyclogyl) eyedrops. The nurse administers the eyedrops knowing that the purpose of this medication is which? a. To produce miosis of the operative eye b. To dilate the pupil of the operative eye c. To provide lubrication to the operative eye d. To constrict the pupil of the operative eye

b. To dilate the pupil of the operative eye

The nurse is assigned to care for a client with a diagnosis of detached retina. Which finding would indicate that bleeding has occurred as a result of retinal detachment? Select all that apply. a. Total loss of vision b. Vision may be cloudy c. A reddened conjunctiva d. A sudden sharp pain in the eye e. Complaints of a burst of black spots or floaters f. Vision is clear straight ahead but not to the right

b. Vision may be cloudy e. Complaints of a burst of black spots or floaters

A nurse is caring for an older adult client who has diabetes mellitus and reports a gradual loss of peripheral vision. The nurse should recognize this as a manifestation of which of the following diseases? a. cataracts b. open-angle glaucoma c. macular degeneration d. angle-closure glaucoma

b. open-angle glaucoma

The nurse is caring for a client with glaucoma. Which medication prescribed for the client should the nurse question? a. Betaxolol b. Pilocarpine c. Atropine sulfate d. Pilocarpine hydrochloride

c. Atropine sulfate

A client with Ménière's disease is experiencing severe vertigo. The nurse reinforces instructions to the client to do which to assist in controlling the vertigo? a. Increase in sodium diet b. Lie still and watch television c. Avoid sudden head movements d. Increase fluid intake 3000 mL/day.

c. Avoid sudden head movements

A nurse is collecting data for a client who has a new diagnosis of cataracts. Which of the following manifestations should the nurse expect? Select all that apply. a. Eye pain b. Floating spots c. Blurred vision d. White pupils e. Bilateral red reflexes

c. Blurred vision d. White pupils

The nurse is caring for a client after enucleation and notes the presence of bright red drainage on the dressing. The nurse should take which appropriate action? a. Document the finding b. Continue to monitor vital signs c. Report the finding to the registered nurse (RN) d. Mark the drainage on the dressing and monitor for any increase in bleeding

c. Report the finding to the registered nurse (RN) (can indicate hemorrage)

A nurse is providing postoperative teaching to a client following cataract surgery. Which of the following statements should the nurse include in the teaching? a. "you can resume playing golf in 2 days" b. "you need to tilt your head back when washing your hair" c. "you can get water in your eyes in 1 day" d. "you need to limit your housekeeping activities"

d. "you need to limit your housekeeping activities"

The nurse is assigned to care for a client with a detached retina. Which finding should the nurse expect to be documented in the client's record? a. Blurred vision b. Pain in the affected eye c. A yellow discoloration of the sclera d. A sense of a curtain falling across the field of vision

d. A sense of a curtain falling across the field of vision

The nurse notes that the health care provider has documented a diagnosis of presbycusis on the client's chart. The nurse understands that this condition is accurately described as which? a. Tinnitus that occurs with aging b. Nystagmus that occurs with aging c. A conductive hearing loss that occurs with aging d. A sensorineural hearing loss that occurs with aging

d. A sensorineural hearing loss that occurs with aging

The nurse is assisting in developing a teaching plan for the client with glaucoma. Which instruction should the nurse suggest to include in the plan of care? a. Decrease the amount of salt in the diet b. Decrease fluid intake to control the intraocular pressure c. Avoid reading the newspaper and watching television d. Eye medication may need to be administered for the rest of your life

d. Eye medication may need to be administered for the rest of your life

A client arrives at the emergency department with a foreign body in the left ear that has been determined to be an insect. Which initial intervention should the nurse anticipate to be prescribed? a. Irrigation of the ear b. Installation of antibiotic eyedrops c. Installation of corticosteroid ointment d. Installation of mineral oil or diluted alcohol

d. Installation of mineral oil or diluted alcohol

A client sustains a chemical eye injury from a splash of battery acid. The nurse should prepare the client for which immediate measure? a. Checking visual acuity b. Covering the eye with a pressure patch c. Swabbing the eye with antibiotic ointment d. Irrigating the eye with sterile normal saline

d. Irrigating the eye with sterile normal saline

The nurse is providing instructions to a client who will be self-administering eyedrops. To minimize the systemic effects that eyedrops can produce, the client is instructed to perform which action? a. Eat before instilling eyedrops b. Swallow several times after instilling eyedrops c. Blink vigorously to encourage tearing after instilling the eyedrops d. Occlude the nasolacrimal duct with a finger over the inner canthus for 30 to 60 seconds after instilling eyedrops

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

The nurse is assigned to care for a client hospitalized with Ménière's disease. The nurse expects that which would most likely be prescribed for the client? a. Low fat-diet b. Low-sodium diet c. Low-cholesterol diet d. Low carbohydrate-diet

b. Low-sodium diet

A nurse is performing an otoscopic examination of a client. Which of the following is an unexpected finding? a. pearly gray tympanic membrane (TM) b. malleus visible behind the TM c. presence of soft cerumen in the external canal d. fluid or bubbles seen behind the TM

d. fluid or bubbles seen behind the TM ( is not an expected finding)

A nurse is caring for a client who has suspected Meniere's Disease. Which of the following is an expected finding? a. presence of a purulent lesion in the external ear canal b. feeling of pressure in the ear c. bulging, red bilateral tympanic membranes d. unilateral hearing loss

d. unilateral hearing loss

A nurse is collecting data for a male older adult who has a new diagnosis of glaucoma. Which of the following should the nurse recognize as risk factors with this disease? Select all that apply. a. Gender b. Genetic predisposition c. Eye/ Trauma--Hypertension d. Age e. Diabetes mellitus

b. Genetic predisposition c. Eye/ Trauma--Hypertension d. Age e. Diabetes mellitus

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

C. Acetylsalicylic acid (asprin)

The client is receiving an eyedrop and an eye ointment to the right eye. Which action should the nurse take? a. Administer the eyedrop first, followed by the eye ointment b. Administer the eye ointment first, followed by eyedrop c. Administer the eyedrop, wait 10 min and administer eye ointment d. Administer the eye ointment, wait 10 min and administer eyedrop

a. Administer the eyedrop first, followed by the eye ointment

The nurse is caring for a client who is hearing-impaired and should take which approach to facilitate communication? a. Speak loudly b. Speak in normal tone c. Speak frequently d. Speak directly into the impaired client

b. Speak in normal tone