Nursing 121 More Eye/Ear

An older client with diabetes mellitus complains of blurred vision with difficulty reading and driving at night. On the basis of the client's history, the nurse interprets that these changes most likely indicate the development of which condition? 1. Cataracts 2. Glaucoma 3. Papilledema 4. Detached retina

1. Cataracts

A client with increased intraocular pressure is experiencing excessive production of aqueous humor of the eye in relation to the speed of outflow. The nurse plans care, knowing that which part of the eye is responsible for the production of aqueous humor? 1. Ciliary body 2. Anterior chamber 3. Posterior chamber 4. Trabecular meshwork

1. Ciliary body

A nurse conducting an eye examination notes that the client exhibits rapid, involuntary oscillating movements of the eyeball when looking at the nurse. The nurse documents this finding as which condition? 1. Nystagmus 2. Photophobia 3. Unequal pupils 4. Consensual response

1. Nystagmus

A nurse conducting an eye examination notes that the client exhibits rapid, involuntary, oscillating movements of the eyeball when looking at the nurse. The nurse documents this finding as which condition? 1. Nystagmus 2. Photophobia 3. Unequal pupils 4. Impaired consensual response

1. Nystagmus

A nurse is told that a client with glaucoma has experienced vision loss as a result of obstruction of aqueous humor flow by the trabecular meshwork. The nurse plans care, knowing that this client has which type of glaucoma? 1. Primary open-angle glaucoma 2. Angle-closure glaucoma 3. Low-tension glaucoma 4. Secondary glaucoma

1. Primary open-angle glaucoma

A nurse who is collecting data from a client notes that the client's left eyelid is drooping. The nurse documents that the client is exhibiting which condition? 1. Ptosis 2. Arcus senilis 3. Abnormal corneal reflex 4. Blockage of the lacrimal duct

1. Ptosis

A nurse who is collecting data from a client notes that the client's left-sided eyelid is drooping. The nurse documents that the client is exhibiting which condition? 1. Ptosis 2. Arcus senilis 3. Abnormal corneal reflex 4. Blockage of the lacrimal duct

1. Ptosis

The nurse is caring for a client who has undergone intravenous fluorescein angiography of the eye. What activity should the nurse tell the client to avoid immediately after the procedure? 1. Reading 2. Lying down 3. Listening to music 4. Watching a large-screen television

1. Reading

A client who had surgery for treatment of glaucoma is at risk for injury. The client's home care nurse determines that the problem is unresolved if the client performs which action? 1. Removes the eye shield applied for use during sleep 2. Scans the environment, turning the head side to side 3. Takes in sufficient fluid and fiber to avoid constipation 4. Uses grab bars in the bathroom or holds the wall for added stability

1. Removes the eye shield applied for use during sleep

A clinic nurse notes that a client's visual acuity has been documented as 20/200. Which statement is a correct interpretation of the test result? 1. The client is legally blind. 2. The client requires the use of reading glasses. 3. The client requires the use of glasses at all times. 4. The client is partially blind and will need both contact lenses and glasses to see objects.

1. The client is legally blind.

A client with a history of ear problems is going on vacation by aircraft. The nurse advises the client to include which activities to prevent barotrauma during ascent and descent of the airplane? Select all that apply. 1. Yawning 2. Humming 3. Swallowing 4. Chewing gum 5. Sucking on hard candy

1. Yawning 3. Swallowing 4. Chewing gum 5. Sucking on hard candy

After cataract surgery a client is taught to avoid strain on the operated eye. Which statement, if made by the client, would alert the nurse that further teaching is needed? 1. "I cannot rub my eye." 2. "I can lie on my operated side." 3. "I can't lift more than 5 pounds." 4. "I need to take stool softeners to prevent straining."

2. "I can lie on my operated side."

After cataract surgery, a client is taught to avoid strain on the operative eye. Which statement by the client alerts the nurse that further teaching is needed? 1. "I cannot rub my eye." 2. "I can lie on my operative side." 3. "I can't lift more than 5 pounds." 4. "I need to take stool softeners to prevent straining."

2. "I can lie on my operative side."

A client reports to the health care clinic because of recent right eye discomfort. The health care provider diagnoses chalazion of the right eye. The clinic nurse provides instructions to the client regarding care to the eye. Which statement by the client indicates an understanding of the measures? 1. "I should apply cold packs to my eye." 2. "I should apply warm packs to my eye." 3. "I should irrigate my eye with cool water daily." 4. "I should use separate washcloths and towels to prevent spreading the infection to others."

2. "I should apply warm packs to my eye."

A nurse is listening to a health care provider (HCP) explain the results of an eye examination to a client. The HCP states that the client has glaucoma because of a congenitally narrow anterior chamber angle, which suddenly has become blocked by the base of the iris. The nurse understands that the HCP is describing which type of glaucoma? 1. Primary open-angle glaucoma 2. Angle-closure glaucoma 3. Low-tension glaucoma 4. Secondary glaucoma

2. Angle-closure glaucoma

An older client is seen in the health care clinic, and an eye examination is performed. The client is diagnosed with a refraction error. The nurse anticipates that which treatment will most likely be prescribed? 1. Contact lenses 2. Corrective lenses 3. Surgical keratoplasty 4. Eye drops to lower intraocular pressure

2. Corrective lenses

The long-term care nurse is performing assessments on several of the residents. Which are normal age-related physiological changes the nurse expects to note? Select all that apply. 1. Increased heart rate 2. Decline in visual acuity 3. Decreased respiratory rate 4. Decline in long-term memory 5. Increased susceptibility to urinary tract infections 6. Increased incidence of awakening after sleep onset

2. Decline in visual acuity 5. Increased susceptibility to urinary tract infections 6. Increased incidence of awakening after sleep onset

A nurse notes during assessment that an older client is exhibiting a number of visual changes. The nurse determines that which assessment findings are associated with normal age-related changes of the eye? Select all that apply. 1. Photophobia 2. Decreased visual acuity 3. Loss of peripheral vision 4. Decreased tolerance of glare 5. Decreased ability to adapt to dark and light

2. Decreased visual acuity 3. Loss of peripheral vision 4. Decreased tolerance of glare 5. Decreased ability to adapt to dark and light

The nurse is reviewing the results of a tonometry test performed on a client and notes that the results indicate an intraocular pressure (IOP) of 30 mm Hg. The nurse determines that the client most likely has which condition? 1. Cataracts 2. Glaucoma 3. Normal vision 4. Decreased IOP

2. Glaucoma

A clinic nurse is reviewing the record of a client with a diagnosis of a cataract. Which clinical manifestation is associated with this disorder? 1. Eye pain 2. Opacity of the lens 3. Loss of central vision 4. Inability to identify the color red on an eye examination

2. Opacity of the lens

A client reports to the health care clinic for an eye examination, and a diagnosis of macular degeneration is made. Which nursing assessment question will most specifically elicit information regarding the clinical manifestations associated with this disorder? 1. "Do bright lights bother you?" 2. "Do you have any pain in your eye?" 3. "Have you had any blurred vision?" 4. "Are you having difficulty seeing things out of the sides of your eyes?"

3. "Have you had any blurred vision?"

The nurse has provided instructions to a client with glaucoma regarding measures that will prevent an increase in intraocular pressure. Which statement, if made by the client, would indicate a need for further teaching? 1. "I should eat foods that are high in fiber." 2. "I should avoid lifting objects that weigh more than 20 pounds." 3. "I should limit my fluid intake to prevent an increase in pressure." 4. "I should move objects by using my feet and pushing them along the floor, rather than by lifting them."

3. "I should limit my fluid intake to prevent an increase in pressure."

Corrective eyeglasses are prescribed for a client with bilateral aphakia, and the clinic nurse provides instructions to the client regarding the eyeglasses. Which statement by the client indicates a need for further instruction? 1. "My central vision will be corrected." 2. "It may be difficult to judge distances." 3. "My peripheral vision will be very clear." 4. "Approximately 30% of my central vision will be magnified."

3. "My peripheral vision will be very clear."

The nurse is reviewing the preoperative prescriptions for a client scheduled for keratoplasty. Which prescription, if noted in the client's chart, should be questioned by the nurse? 1. Cut the client's eyelashes. 2. Administer prescribed antibiotic eye medication. 3. Administer prescribed medication to dilate the pupil. 4. Obtain a swab of the conjunctival fluid for culture and sensitivity testing.

3. Administer prescribed medication to dilate the pupil.

A client arrives at the hospital emergency department for treatment of an injury to the eye after being hit by a baseball bat. On assessment the nurse notes that the eye is bleeding. The nurse should take which action initially? 1. Irrigate the eye. 2. Apply pressure to the eye. 3. Cover the eye with cold sterile saline gauze. 4. Send the client to the radiograph department for a skull series.

3. Cover the eye with cold sterile saline gauze.

The nurse in the ambulatory care unit is preparing a plan of care for a client scheduled for cataract surgery. The nurse prioritizes the care plan components and plans interventions to address which client problem? 1. Inability to care for self 2. Decreased peripheral circulation 3. Interruption in sensory perception 4. Lack of knowledge regarding surgical procedure

3. Interruption in sensory perception

A client is experiencing dysfunction of the rods of the eye. The nurse plans care, knowing that this client will most likely exhibit which disturbances in vision? 1. Farsightedness 2. Nearsightedness 3. Night blindness 4. Color blindness

3. Night blindness

The nurse in the recovery area is caring for a client after cataract extraction in the right eye. The nurse should assist the client to which position? 1.On the right side 2. Supine on the left side 3. On the left side with the head of the bed elevated 4. On the right side with the head of the bed elevated

3. On the left side with the head of the bed elevated

A client with retinal detachment is admitted to the nursing unit in preparation for a scleral buckling procedure. What should the nurse anticipate will be prescribed? 1. Bathroom privileges only 2. Elevating the head of the bed to 45 degrees 3. Placing an eye patch over the client's affected eye 4. Wearing dark glasses to read or to watch television

3. Placing an eye patch over the client's affected eye

A nurse is attempting to inspect the lacrimal apparatus of the client's eye. Because of the anatomical location of this structure, the nurse should take which action? 1. Retract the lower eyelid and ask the client to look up. 2. Retract the upper eyelid and ask the client to look up. 3. Retract the upper eyelid and ask the client to look down. 4. Retract the lower eyelid and ask the client to look down.

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

The nurse is conducting a health screening clinic for glaucoma. A client reports to the clinic for an eye examination, and the nurse performs a tonometry test on the client. The results of the test indicate an intraocular pressure of 24 mm Hg. On the basis of this finding, what information should the nurse provide to the client? 1. The pressure is low. 2. The pressure is normal. 3. The pressure is elevated, necessitating follow-up treatment. 4. The test will need to be repeated because the findings are inconclusive

3. The pressure is elevated, necessitating follow-up treatment.

The nurse is providing instructions to the unlicensed assistive personnel (UAP) regarding care of an older client with hearing loss. Which should the nurse tell the UAP about older clients with hearing loss? 1. They are often distracted 2. They have middle ear changes 3. They respond to low-pitched tones 4. They develop moist cerumen production

3. They respond to low-pitched tones

The nurse has provided instructions to a client who has had a right keratoplasty. Which statement by the client indicates a need for further instruction? 1."I should lie on my left side to sleep." 2. "I need to wear an eye shield at bedtime." 3. "I need to faithfully apply antibiotic medication." 4. "If I see light flashes or floaters in my eye, it is nothing to worry about."

4. "If I see light flashes or floaters in my eye, it is nothing to worry about."

A nursing instructor asks a nursing student to describe the optic disc. The student responds correctly when she makes which statement? 1. "The optic disc is responsible for color perception." 2. "The optic disc is responsible for depth perception." 3. "The optic disc helps to produce sharp focusing of images." 4. "The optic disc has no visual ability and is the blind spot of the eye

4. "The optic disc has no visual ability and is the blind spot of the eye."

The nurse notes that the health care provider has documented a diagnosis of presbycusis on a client's chart. The nurse understands that which describes this condition? 1. Tinnitus that occurs with aging 2. Nystagmus that occurs with aging 3. A conductive hearing loss that occurs with aging 4. A sensorineural hearing loss that occurs with aging

4. A sensorineural hearing loss that occurs with aging

A nurse who is assessing a client's eyes notes that the pupil gets larger when looking at an object in the distance and gets smaller when looking at a near object. The nurse documents this finding as which condition? 1. Myopia 2. Hyperopia 3. Photophobia 4. Accommodation

4. Accommodation

A nurse notes during assessment and history taking that an older client exhibits visual changes. Which are normal age-related changes of the eye? Select all that apply. 1. Unequal pupil size 2. Corneal thickening 3. Ptosis of the eyelids 4. Decreased visual acuity 5. Decreased peripheral vision 6. Decreased tolerance of glare

4. Decreased visual acuity 5. Decreased peripheral vision 6. Decreased tolerance of glare

A client has undergone cataract removal but has not received an intraocular implant. The client is obviously upset because her vision is blurry. Which approach should the nurse take to provide emotional support to the client? 1. Explore the meaning of the new permanent vision loss. 2. Determine whether any relatives have lost vision permanently. 3. Reassure the client that disability benefits will definitely apply. 4. Explain that vision will improve with adjustment to aphakic lenses

4. Explain that vision will improve with adjustment to aphakic lenses

The client arrives in the emergency department after sustaining a chemical eye injury from a splash of battery acid. Which is the initial nursing action? 1. Begin visual acuity testing. 2. Cover the eye with a pressure patch. 3. Swab the eye with antibiotic ointment. 4. Irrigate the eye with sterile normal saline.

4. Irrigate the eye with sterile normal saline.

The home care nurse is visiting a client with glaucoma who is receiving acetazolamide (Diamox) daily. Which finding would indicate to the nurse that the client is experiencing an adverse effect related to the medication? 1. Diarrhea 2. Irritability 3. Lacrimation 4. Low back pain

4. Low back pain

A client who sustained an eye injury arrives at the hospital emergency department. Which initial action should the nurse take? 1. Instill an antibiotic solution. 2. Place an ice pack on the eye. 3. Flush the eye with sterile saline solution. 4. Obtain a history regarding the cause of the injury.

4. Obtain a history regarding the cause of the injury.

A client's physical examination record states that the client's eyes moved normally through the six cardinal fields of gaze. This exam measures which function? 1. Central vision 2. Corneal reflexes 3. Peripheral vision 4. Ocular movements

4. Ocular movements

Timolol (Timoptic) ophthalmic drops have been prescribed for a client with primary open-angle glaucoma. The client asks the nurse how this medication works. The nurse explains that the medication lowers intraocular pressure by which mechanism? 1. Constricting the pupil 2. Reducing intracranial pressure 3. Increasing contractions of the ciliary muscle 4. Reducing the production of aqueous humor

4. Reducing the production of aqueous humor

During a routine visit to the health care provider's office, an older client complains to the nurse of vision changes. The client describes vision as foggy, complains of mild aching in the eyes, and reports the need to change eye glass prescriptions frequently. Given these symptoms, the nurse most likely suspects which condition? 1. Cataracts 2. Glaucoma 3. Papilledema 4. Detached retina

2. Glaucoma

A client is scheduled to begin therapy with acetazolamide (Diamox Sequels) for the management of glaucoma. Before initiating therapy, the nurse should ask the client about a history of allergy or sensitivity to which type of medication? 1. Penicillin 2. Sulfa drugs 3. Corticosteroids 4. Nonsteroidal anti-inflammatory agents (NSAIDs)

2. Sulfa drugs

A client arrives at the hospital emergency department after an eye injury from a chemical solution. Which action is the initial nursing action? 1. Irrigate the eye. 2. Test the eye pH with litmus paper. 3. Place a pressure dressing on the eye. 4. Cover the eye with sterile saline solution, and contact the health care provider (HCP).

2. Test the eye pH with litmus paper.

The nurse is caring for a hearing-impaired client. Which approach will facilitate communication? 1. Speak loudly. 2. Speak frequently. 3. Speak at a normal volume. 4. Speak directly into the impaired ear.

3. Speak at a normal volume.

The nurse is caring for an older client in a long-term care facility. Which action contributes to encouraging autonomy in the client? 1. Planning meals 2. Decorating the room 3. Scheduling hair-cut appointments 4. Allowing the client to choose social activities

4. Allowing the client to choose social activities

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? 1. Cranial nerve I, olfactory 2. Cranial nerve IV, trochlear 3. Cranial nerve III, oculomotor 4. Cranial nerve VII, facial nerve

4. Cranial nerve VII, facial nerve

A nurse is providing instructions to a client and family regarding home care following cataract removal from the left eye. The nurse should plan to teach the client which piece of information about positioning in the postoperative period? 1. Avoid sleeping on the left side. 2. Sleep only on the left side or the back. 3. Bend below the waist as often as possible. 4. Lower the head between the knees three times a day.

1. Avoid sleeping on the left side.

A client is experiencing double vision, or diplopia. The nurse plans care, knowing that this client is experiencing a loss of which normal function of the eye? 1. Binocular vision 2. Depth perception 3. Optic nerve function 4. Ocular muscle control

1. Binocular vision

The nurse is administering eye care to a client with an artificial eye. The nurse first separates the upper and lower eyelids with the dominant hand and cups the nondominant hand under the eye. The nurse then removes the artificial eye by applying pressure with the index finger between the eye and which structure? 1. Brow 2. Lower lid 3. Inner canthus 4. Outer canthus

1. Brow

A client is experiencing visual difficulties and has been told that a previous vision test showed that the light rays entering the eye are falling in front of the retina. The nurse understands that this client is experiencing which visual disturbance? 1. Myopia 2. Hyperopia 3. Astigmatism 4. Exophthalmos

1. Myopia

The nurse is providing medication instructions to an older client who is taking digoxin (Lanoxin) daily. The nurse notes that which age-related body change could place the client at risk for digoxin toxicity? 1. Decreased muscle strength and loss of bone density 2. Decreased cough efficiency and decreased vital capacity 3. Decreased salivation and decreased gastrointestinal motility 4. Decreased lean body mass and decreased glomerular filtration rate

4. Decreased lean body mass and decreased glomerular filtration rate

A nurse conducting an eye examination notes protruding of the client's eyeballs. The nurse should document this finding as which condition? 1. Ptosis 2. Nystagmus 3. Scleral icterus 4. Exophthalmos

4. Exophthalmos

A nurse is attempting to inspect the lacrimal apparatus of the client's eye. Because of its anatomical location, the nurse should take which action? 1. Retract the upper eyelid, and ask the client to look up. 2. Retract the lower eyelid, and ask the client to look up. 3. Retract the lower eyelid, and ask the client to look down. 4. Retract the upper eyelid, and ask the client to look down.

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

A nurse is assessing a client's eyes. The nurse notes that the client's pupil gets larger when the client is looking at an object in the distance and gets smaller when the client is looking at a near object. The nurse documents this as which finding 1. Myopia 2. Hyperopia 3. Photophobia 4. Accommodation

2. Hyperopia

A client has been diagnosed as having bilateral cataract formation. The nurse plans care, knowing that this client has altered structure of which parts of the eye? 1. Iris 2. Lens 3. Pupil 4. Cornea

2. Lens

A nurse in the outpatient eye surgery center is teaching a nursing student about the anatomy and physiology of the eye. The nurse asks the student to identify the structures in the uveal tract. The student needs further education when she responds that which eye component is associated with the uveal tract? 1. Iris 2. Lens 3. Choroid 4. Ciliary body

2. Lens

An ambulatory care nurse has provided instructions to a client who is scheduled for a cataract extraction. Which statement by the client indicates a need for further instruction? 1. "I cannot eat or drink anything for 24 hours before the surgery." 2. "I need to wash my face thoroughly on the morning of surgery." 3. "A sedative may be prescribed to help me sleep the night before surgery." 4. "I may need to wash around the operative eye with antiseptic prescribed solution for 1 or more days before surgery."

1. "I cannot eat or drink anything for 24 hours before the surgery."

An ambulatory care nurse is providing instructions to a client who underwent a laser trabeculoplasty for the treatment of primary open-angle glaucoma. Which statement, if made by the client, would indicate an understanding of the postprocedure instructions? 1. "I need to avoid activities that cause straining." 2. "I should have the vision that I lost back within 1 week." 3. "I may lift objects as long as they do not weigh more than 35 pounds." 4. "I'm so glad that I had this type of surgery because I can resume all my activities immediately."

1. "I need to avoid activities that cause straining."

A client with glaucoma asks the nurse if complete vision will return. Which is the most appropriate response by the nurse? 1. "Your vision will never return to normal." 2. "Your vision will return as soon as the medication begins to work." 3. "Your vision loss is temporary and will return in about 3 to 4 weeks." 4. "Although some vision has been lost and cannot be restored, further loss may be prevented by adhering to the treatment plan."

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

The visiting nurse observes that the older male client is confined by his daughter-in-law to his room. When the nurse suggests that he walk to the den and join the family, he says, "I'm in everyone's way; my daughter-in-law needs me to stay here." Which is the most important action for the nurse to take? 1. Say to the daughter-in-law, "Confining your father-in-law to his room is inhumane." 2. Suggest to the client and daughter-in-law that they consider a nursing home for the client. 3. Say nothing, because it is best for the nurse to remain neutral and wait to be asked for help. 4. Suggest appropriate resources to the client and daughter-in-law, such as respite care and a senior citizens' center.

4. Suggest appropriate resources to the client and daughter-in-law, such as respite care and a senior citizens' center.

A client who underwent cataract extraction returns to the surgical care unit after the procedure. The client is resting on the back in a semi-Fowler's position and asks to be repositioned. The nurse should place the client in which position? 1. Prone 2. Supine 3. Operated side 4. Unoperated side

4. Unoperated side

A client returns to the ambulatory care unit 1 day after cataract removal surgery for follow-up care. The nurse checks the client's cornea with a flashlight, expecting which finding? 1. Clear 2. Cloudy 3. Spotted 4. Sanguineous

1. Clear

A client with Ménière's disease is experiencing severe vertigo. Which instruction should the nurse give to the client to assist in controlling the vertigo? 1. Increase sodium in the diet. 2. Avoid sudden head movements. 3. Lie still and watch the television. 4. Increase fluid intake to 3000 mL a day.

2. Avoid sudden head movements.

The nurse is caring for a client who had surgery for glaucoma and teaches the client to avoid activities that increase intraocular pressure (IOP). What activity should the nurse tell the client to avoid? 1. Watching television 2. Bending at the waist 3. Reading books with larger-type print 4. Reading books with smaller-type print

2. Bending at the waist

A client arrives at the hospital emergency department and tells the nurse that there is something in his eye. Which is the appropriate initial nursing action? 1. Irrigate the eye with normal saline. 2. Check the client's cornea and conjunctiva. 3. Tell the client that the object will work its way out. 4. Tell the client that a surgeon will need to be called.

2. Check the client's cornea and conjunctiva

An older client is seen in the health care clinic, and an eye examination is performed. The client is diagnosed with a refraction error. The nurse anticipates that which treatment will most likely be prescribed for this client? 1. Contact lenses 2. Corrective lenses 3. A surgical keratoplasty 4. Eye drops to lower intraocular pressure

2. Corrective lenses

The results of a client's eye examination indicate that he or she has an abnormal shape to the curvature of the cornea, which is impairing the ability to see clearly. The nurse determines that the client has which eye condition? 1. Myopia 2. Hyperopia 3. Astigmatism 4. Exophthalmos

3. Astigmatism

The nurse is performing an assessment on an older client who is having difficulty sleeping at night. Which statement by the client indicates the need for further teaching regarding measures to improve sleep? 1. "I swim three times a week." 2. "I have stopped smoking cigars." 3. "I drink hot chocolate before bedtime." 4. "I read for 40 minutes before bedtime."

3. "I drink hot chocolate before bedtime."

A client comes to the hospital emergency department complaining of redness and pain on the lower eyelid. A diagnosis of hordeolum is made. The nurse provides instructions to the client regarding measures to treat the disorder. Which statement made by the client would best indicate an understanding of these home care treatment measures? 1. "Antibiotic ointments will not help this condition." 2. "I should apply cool compresses to the eye three times a day." 3. "I should apply warm compresses to the eye for 15 minutes four times a day." 4. "When the hordeolum comes to a head, I should try to press it to make it open and drain."

3. "I should apply warm compresses to the eye for 15 minutes four times a day

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? 1. A pink-colored tympanic membrane 2. A pearly colored tympanic membrane 3. A transparent and clear tympanic membrane 4. A red, dull, thick, and immobile tympanic membrane

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

The nurse is caring for a client with a diagnosis of detached retina. Which assessment finding, if present in the client, would indicate that bleeding has occurred as a result of the retinal detachment? 1. Total loss of vision 2. A reddened conjunctiva 3. A sudden sharp pain in the eye 4. Complaints of a burst of black spots or floaters

4. Complaints of a burst of black spots or floaters

A nurse notes that a client's eyes are reddened, and the client states that an eye infection has been diagnosed. The nurse understands that the client most likely is referring to infection of which structure, which provides a protective covering for the eye? 1. Iris 2. Lens 3. Cornea 4. Conjunctiva

4. Conjunctiva

Pilocarpine hydrochloride (Isopto Carpine) is prescribed for a client with glaucoma. Which medication should the nurse plan to have available in case of systemic toxicity? 1. Atropine sulfate 2. Pindolol (Visken) 3. Protamine sulfate 4. Naloxone hydrochloride (Narcan

1. Atropine sulfate

The nurse is performing an assessment on an older adult client. Which assessment data would indicate a potential complication associated with the skin? 1. Crusting 2. Wrinkling 3. Deepening of expression lines 4. Thinning and loss of elasticity in the skin

1. Crusting

The nurse obtains the vital signs on an older client and notes that the client's heart rate is 60 beats/min and the respiratory rate is 20 breaths per minute. What should the nurse do? 1. Document the findings. 2. Check the client for signs of infection. 3. Recheck the heart and respiratory rates in 30 minutes. 4. Contact the health care provider to report the heart and respiratory rates

1. Document the findings

A client with a history of hypertension was seen in the clinic for treatment of glaucoma. The nurse notes that the client has a history of peptic ulcer disease. The nurse should be most concerned if which medication was noted in the health care provider's prescriptions? 1. Flurbiprofen (Ocufen) 2. Pilocarpine hydrochloride 3. Timolol maleate (Timoptic) 4. Phenylephrine hydrochloride (Neo-Synephrine)

1. Flurbiprofen (Ocufen

Immediately after cataract repair, a nurse notes that the conjunctiva and eyelids on the client's operated eye are edematous. The nurse should make which interpretation about this finding? 1. Normal and should subside within 3 days 2. Grossly abnormal and should be reported at once 3. Abnormal because only the eyelids should be affected 4. Abnormal because the conjunctiva should not be affected

1. Normal and should subside within 3 days

A clinic nurse is providing instructions to a client with a diagnosis of conjunctivitis. Which statement by the client indicates a need for further instruction? 1. "Sharing washcloths and towels is acceptable because this condition is not contagious." 2. "I can use saline eye irrigations before instilling the antibiotics in my eye if drainage is present." 3. "I should apply warm compresses before instilling the antibiotic drops if purulent drainage is present in my eye." 4. "If I have any eye discomfort, I can use the eye analgesic ointment that my health care provider has prescribed."

1. "Sharing washcloths and towels is acceptable because this condition is not contagious."

The nurse is providing home care instructions to a client who has a hordeolum (stye) of the right eye. Which statement by the client indicates an understanding of the instructions? 1. "I should apply antibiotic ointment as prescribed." 2. "When the eyelid turns white, I should try to squeeze the stye." 3. "I should press on the eye when I apply the warm compresses." 4. "I need to apply cool compresses to the eye for 15 minutes four times daily."

1. "I should apply antibiotic ointment as prescribed."

A client has sustained significant eye damage as a result of glaucoma and has impaired vision. The nurse interprets that the client demonstrates a need for further instruction in adapting to this impairment if the client makes which statement? 1. "I won't have difficulty seeing if I drive at night." 2. "Night lights have been placed in the hallways at home." 3. "It's important for me to have periodic eye examinations." 4. "My family will drive me to my eye doctor's office when eye examinations are needed."

1. "I won't have difficulty seeing if I drive at night."

A client has just had an eye examination and states that the vision test indicated that the focal point of the light rays entering the eyes is behind the retina. The nurse understands that this client is referring to which visual disturbance? 1. Myopia 2. Hyperopia 3. Astigmatism 4. Exophthalmos

2. Hyperopia

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? 1. Pruritus 2. Tinnitus 3. Hearing loss 4. Burning in the ear

2. Tinnitus

The nurse has given discharge instructions to a client who had surgery on the right eye. The nurse determines that further instruction is needed if the client makes which statement? 1. "I need to wear an eye shield at night." 2. "I need to wear sunglasses during the day." 3. "It is important that I sleep on the back or left side." 4. "I need to call my eye doctor if my temperature is 99° F."

4. "I need to call my eye doctor if my temperature is 99° F."

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

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

The results of a complete eye examination indicate that a client is color blind. The nurse plans care, knowing that which structures of the eye is affected? 1. Iris 2. Lens 3. Rods 4. Cones

4. Cones

A client arrives at the hospital emergency department and tells the nurse that there is something in his eye. The nurse looks into the client's eye and notes that the foreign body is visible and is not embedded. Which nursing action is appropriate? 1. Irrigate the eye with normal saline. 2. Tell the client that the object will work its way out. 3. Tell the client that the surgeon will need to be called. 4. Touch the object gently with a cotton swab and lift it out.

4. Touch the object gently with a cotton swab and lift it out.