MED SURG Ear, Eye SAUNDERS QUESTIONS

1. Call the health care provider (HCP).

741. During the early postoperative period, a client who has undergone a cataract extraction complains of nausea and severe eye pain over the operative site. What should be the initial nursing action

3. Eye medications will need to be administered for life.

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

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

743. The nurse is performing an admission assessment on a client with a diagnosis of detached retina. Which sign or symptom is associated with this eye disorder?

4. A red, dull, thick, and immobile tympanic membrane

744. The nurse is performing an otoscopic examination on a client with mastoiditis. On examination of the tympanic membrane, which finding should the nurse expect to observe?

2. Tinnitus

745. A client is diagnosed with a disorder involving the inner ear. Which is the most common client complaint associated with a disorder involving this part of the ear?

4. Blurred vision

746. The nurse is performing an assessment on a client with a suspected diagnosis of cataract. Which clinical manifestation should the nurse expect to note in the early stages of cataract formation?

2. A semi-Fowler's position

747. A client arrives in the emergency department following an automobile crash. The client's forehead hit the steering wheel and a hyphema is diagnosed. The nurse should place the client in which position?

1. Apply ice to the affected eye.

748. The client sustains a contusion of the eyeball following a traumatic injury with a blunt object. Which intervention should be initiated immediately?

2. Perform visual acuity tests.

749. A client arrives in the emergency department with a penetrating eye injury from wood chips that occurred while cutting wood. The nurse assesses the eye and notes a piece of wood protruding from the eye. What is the initial nursing action?

3. Notify the health care provider (HCP).

750. The nurse is caring for a client following enucleation and notes the presence of brightred drainage on the dressing. Which action should the nurse take at this time?

1. Irrigate the eyes with water.

751. A woman was working in her garden. She accidentally sprayed insecticide into her right eye. She calls the emergency department, frantic and screaming for help. The nurse should instruct the woman to take which immediate action?

1. Avoid activities that require bending over. 3. Take acetaminophen for minor eye discomfort. 5. Place an eye shield on the surgical eye at bedtime. 6. Contact the surgeon if a decrease in visual acuity occurs.

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

2. Note the time of day the test was done.

753. Tonometry is performed on a client with a suspected diagnosis of glaucoma. The nurse looks at the documented test results and notes an intraocular pressure (IOP) value of 23. What should be the nurse's initial action?

4. Cranial nerve VII, facial nerve

754. The nurse is caring for a client following craniotomy for removal of an acoustic neuroma. Assessment of which cranial nerve would identify a complication specifically associated with this surgery?

3. Speak at normal tone and pitch, slowly and clearly.

755. The nurse notes that the health care provider has documented a diagnosis of presbycusis on a client's chart. Based on this information, what action should the nurse take?

2. Avoid sudden head movements.

756. A client with Meniere's disease is experiencing severe vertigo. Which instruction should the nurse give to the client to assist in controlling the vertigo?

1. The right eye is tested, followed by the left eye, and then both eyes are tested.

757. The nurse is preparing to test the visual acuity of a client, using a Snellen chart. Which identifies the accurate procedure for this visual acuity test?

2. Instruct the client that he or she may need glasses when driving.

758. A client's vision is tested with a Snellen chart. The results of the tests are documented as 20/60. What action should the nurse implement based on this finding?

3. Speak at a normal volume.

759. The nurse is caring for a hearing-impaired client. Which approach will facilitate communication?