sensory
what should a patient who has had a cataract repair avoid? a.the use of eye patches b. the use of sunglasses c. the lifting of heavy objects d. reading for long period of time
ANS: C the lifting of heavy objects
The priority nursing diagnosis for a patient with Ménière's disease who is experiencing an acute attack is a. risk for falls related to dizziness. b. impaired verbal communication related to tinnitus. c. self-care deficit (bathing and dressing) related to vertigo. d. imbalanced nutrition: less than body requirements related to nausea.
A All the nursing diagnoses are appropriate, but because sudden attacks of vertigo can lead to "drop attacks," the major focus of nursing care is to prevent injuries associated with dizziness.
Which of these nursing activities is appropriate for the RN working in the eye clinic to delegate to experienced nursing assistive personnel (NAP)? a. Application of a warm compress to a patient's hordeolum b. Assessment of a patient with possible bacterial conjunctivitis c. Instruction about hand washing for a patient with herpes keratitis d. Administration of antiviral drops to a patient with a corneal ulcer
ANS: A Application of cold and warm packs is included in NAP education and the ability to accomplish this safely would be expected for a nursing assistant working in an eye clinic. Medication administration, patient teaching, and assessment are high-level skills appropriate for the education and legal practice level of the RN.
A patient is scheduled for a right cataract extraction and intraocular lens implantation at an ambulatory surgical center in 2 weeks. During the preoperative assessment of the patient in the physician's office, it is most important for the nurse to assess a. the visual acuity of the patient's left eye. b. for a white pupil in the patient's right eye. c. how long that the patient has had the cataract. d. for a history of reactions to general anesthetics.
ANS: A Because it can take several weeks before the maximum improvement in vision occurs in the right eye, patient safety and independence are determined by the vision in the left eye. Cataract surgery is done using local anesthetics rather than general anesthetics. A white pupil in the operative eye would not be unusual for a patient scheduled for cataract removal and lens implantation. The length of time that the patient has had the cataract will not impact on the perioperative care.
Why is otitis media found more frequently in children 6 to 36 months? a. Eustachian tubes in children are shorter and straighter. b. Infection descends via the eustachian tube to the throat. c. Children's eustachian tubes are more vertical and longer. d. Otitis media is seen equally in both children and adults.
ANS: A Children's shorter and straighter eustachian tubes provide easier access of the organisms from the nasopharynx to travel to the middle ear.
What does a tympanoplasty correct? a.Conductive hearing loss b.Sensorineural hearing loss c.Congenital hearing loss d.Functional hearing loss
ANS: A Tympanoplasty can correct a conductive hearing loss
The nurse at the eye clinic advises all patients to wear sunglasses that protect the eyes from ultraviolet light because ultraviolet sunlight exposure is associated with the development of a.cataracts. b.glaucoma. c.anisocoria. d.exophthalmos
ANS: A Ultraviolet light exposure is associated with the accelerated development of cataracts. Glaucoma is caused by increased intraocular pressure, exophthalmos is associated with hyperthyroidism, and anisocoria can occur normally in a small percentage of the population ormay be caused by injury or central nervous system disorders
Which action should the RN who is working in the eye and ear clinic delegate to an LPN/LVN? a. Use a Snellen chart to check a patient's visual acuity. b. Evaluate a patient's ability to insert soft contact lenses. c. Teach a patient with otosclerosis about use of sodium fluoride and vitamin D. d. Assess the external auditory canal for signs of irritation caused by a hearing aid.
ANS: A Using standardized screening tests such as a Snellen chart to test visual acuity is included in LPN education and scope of practice. Evaluation, assessment, and patient education are higher level skills that require RN education and scope of practice.
Assessment of a patient's visual acuity reveals that the left eye can see at 20 feet what a person with normal vision can see at 40 feet and the right eye can see at 20 feet what a person with normal vision can see at 50 feet. The nurse records which of the following findings as visual acuity? a. OS 20/40; OD 20/50 b. OU 20/40; OS 50/20 c. OD 20/40; OS 20/50 d. OU 40/20; OD 50/20
ANS: A When documenting visual acuity, the first number indicates the standard (for normal vision) of 20 feet and the second number indicates the line that the patient is able to read when standing 20 feet from the Snellen chart. OS is the abbreviation for left eye and OD is the abbreviation for right eye. The remaining three answers do not correctly describe the patient's visual acuity.
The nurse counsels the 16-year-old boy that playing his music at high volume can result in impairment in hearing related to: a.damaged tympanic membrane. b.protective buildup of cerumen. c.damage of the fine hair cells in the organ of Corti. d.rupture of the oval window.
ANS: C damage of the fine hair cells in the organ of Corti.
The nurse at the outpatient surgery unit obtains all of this information about a patient who is scheduled for cataract extraction and implantation of an intraocular lens. Which information has the most immediate implications for the patient's care? a. The patient has not eaten anything for 8 hours. b. The patient takes three antihypertensive medications. c. The patient gets nauseated with general anesthesia. d. The patient has had blurred vision for several years
ANS: B Mydriatic medications used for pupil dilation are sympathetic nervous system stimulants and may increase heart rate and blood pressure. Using punctal occlusion when administering the mydriatic and monitoring of blood pressure are indicated for this patient. Patients are expected to be NPO for 6 to 8 hours before the surgical procedure. Blurred vision is an expected finding with cataracts. Cataract extraction and intraocular lens implantation are done using local anesthesia.
An adult client has increased fluid in the middle ear, which is causing vertigo. The nurse checks this client for which associated signs and symptoms of this condition? a.Headaches and flushing b. nausea and vomiting c. ear pain and tinnitus d. hearing loss and difficulty in swallowing
ANS: B NAUSEA AND VOMITING
To determine whether treatment is effective for a patient with primary open-angle glaucoma (POAG), the nurse will evaluate the patient for improvement in a. eye pain. b. visual field. c. blurred vision. d. depth perception.
ANS: B POAG develops slowly and without symptoms except for a gradual loss of visual field. Acute closed-angle glaucoma may present with excruciating pain, colored halos, and blurred vision. Problems with depth perception are not associated with POAG.
The nurse is caring for a patient who is having difficulty understanding written and spoken word? The nurse suspects the patient has _____ aphasia. a. Expressive b. Receptive c. Broca's d. Wernicke's
ANS: B Receptive aphasia occurs when patients have difficulty understanding spoken and written word. Expressive aphasia is seen when the patient has difficulty speaking or writing words. Broca and Wernicke refer to areas of the brain where language is processed
To evaluate the effectiveness of the prescribed bifocals for a patient with myopia and presbyopia, the nurse in the eye clinic will check the patient for a. strength of the eye muscles. b. both near and distant vision. c. cloudiness in the eye lenses. d. intraocular pressure changes.
ANS: B The lenses are prescribed to correct the patient's near and distant vision. The nurse also may assess for cloudiness of the lenses, increased intraocular pressure, and eye movement, but these data will not evaluate whether the patient's bifocals are effective.
A patient who has bacterial endophthalmitis in the left eye is restless, frequently asking whether the eye is healing and whether removal of the eye will be necessary. Based on the assessment data, which nursing diagnosis is appropriate? a. Grieving related to current loss of functional vision b. Anxiety related to the possibility of permanent vision loss c. Situational low self-esteem related to loss of visual function d. Risk for falls related to inability to see environmental hazards
ANS: B The patient's restlessness and questioning of the nurse indicate anxiety about the future possible loss of vision. Because the patient can see with the right eye, functional vision is relatively intact and the patient is not at a high risk for falls. There is no indication of impaired self-esteem at this time.
The nurse notes that nursing assistive personnel (NAP) perform all the following actions when caring for a patient with Ménière's disease who is experiencing an acute attack. Which action by NAP indicates that the nurse should intervene immediately? a. NAP raise the side rails on the bed. b. NAP turn on the patient's television. c. NAP turn the patient to the right side. d. NAP place an emesis basin at the bedside.
ANS: B Watching television may exacerbate the symptoms of an acute attack of Ménière's disease. The other actions are appropriate.
A client arrives in the emergency department with an eye injury caused by metal fragments that hit the eye while the client was drilling into metal. The nurse checks the eye and notes small pieces of metal floating on the eyeball. Which action should the nurse plan to assist with first? a. perform a complete visual acuity test b. irrigate the eye with sterile saline c. remove the objects using a sterile eye clamp d. apply an eye patch
ANS: B Irrigate the eye with sterile saline.
The nurse is explaining how sound is conducted from the middle ear to the inner ear in teaching a client who is experiencing hearing loss. The nurse plans to use a diagram that illustrates how which bones connects to the cochlea at the oval window?a. Malleus b. Hammer c. stapes d. incus
ANS: C stapes
The home health nurse observes a patient taking these actions when self-administering eardrops. Which patient action indicates a need for more teaching? a. The patient leaves the ear wick in place while administering the drops. b. The patient lies down before and for 2 minutes after administering the drops. c. The patient gets the eardrops out of the refrigerator just before administering the drops. d. The patient holds the tip of the dropper 1 cm above the ear while administering the drops.
ANS: C Administration of cold eardrops can cause dizziness because of stimulation of the semicircular canals. The other patient actions are appropriate
When the patient stares at the black dot on an Amsler grid, what should the nurse ask him to report? a.Any color visible on the grid b.Fading of the edges of the grid c.Any distortion of the grid d.Movement of the black dot
ANS: C Amsler grid, a diagnostic tool for retinal disorders, requires that the patient look at the dot on the grid and report any distortion in the grid lines
A patient with chronic otitis media is scheduled for a tympanoplasty. Before surgery, the nurse teaches the patient that postoperative expectations include a. keeping the head elevated. b. the need for prolonged bed rest. c. avoidance of coughing or blowing the nose. d. continuous antibiotic irrigation of the ear canal.
ANS: C Coughing or blowing the nose increases pressure in the eustachian tube and middle ear cavity and disrupts postoperative healing. There is no postoperative need for prolonged bed rest, elevation of the head, or continuous antibiotic irrigation.
What should the nurse advise the 20-year-old to do who has been put on cefaclor (Ceclor) for a resistant otitis media? a.Store suspension at room temperature b.Discontinue drug when symptoms abate c.Avoid alcoholic beverages d.Take with meals only
ANS: C Drinking alcohol is discouraged while on Ceclor. The drug should be taken in its entirety and stored in the refrigerator. The drug can be taken with or without meals.
A patient with external otitis has an ear wick placed and a new prescription for antibiotic otic drops. After the nurse provides patient teaching, which patient statement indicates that more instruction is needed? a. "I may use aspirin or acetaminophen (Tylenol) for pain relief." b. "I should apply the eardrops to the cotton wick in my ear canal." c. "I should clean my ear canal daily with a cotton-tipped applicator." d. "I may use warm compresses to the outside of my ear for comfort."
ANS: C Insertion of instruments such as cotton-tipped applicators into the ear should be avoided. The other patient statements indicate that the teaching has been successful.
A nurse is caring for a patient who is experiencing vertigo. Which nursing intervention would assist the patient in controlling the vertigo? a. Increasing fluid intake to 3 liters a day b. Watching television instead of reading books c. Avoiding riding in vehicles and making sudden motions d. Placing several antiemetic patches on the patient
ANS: C Sudden motions and motorized travel can worsen vertigo; avoiding these will lessen the severity of the vertigo. Increasing fluid intake, avoiding reading books, and using antiemetic patches do not affect vertigo.
In order to assess the visual acuity for a patient in the outpatient clinic, the nurse will need to obtain a (an) a. penlight. b. Amsler grid. c. Snellen chart. d. ophthalmoscope.
ANS: C The Snellen chart is used to check visual acuity. An ophthalmoscope, penlight, and Amsler grid also may be used during an eye examination, but they are not helpful in assessing visual acuity.
The nurse is caring for a patient who is a well-known surgeon at the hospital. Because of his status, all the hospital's physicians want to be sure to pay him a visit. The nurse notices the patient becoming more agitated and withdrawn with each group of visitors. The nurse asks the patient if he would like a "Do not disturb" sign placed on the door. A few hours later, the nurse notices a physician who is not involved in the patient's care attempting to enter the room. Which response by the nurse is most appropriate? a. Allowing the physician to enter because he has higher authority than the nurse b. Calling for security to remove the visitor c. Firmly explaining that the patient does not wish to have visitors at this time, so do not enter the room d. Scolding the physician for not obeying the signs on the door and respecting the patient's wishes.
ANS: C The nurse acts as an advocate for the patient (who is experiencing sensory overload and would benefit from a quiet environment) by firmly and politely asking the visitor to leave regardless of position in the hospital. The nurse should not allow anyone to enter unless the patient approves it. Security is not a necessary measure at this time. The nurse should handle herself with professionalism when addressing the visitor; scolding the visitor is not appropriate
To decrease the risk for future hearing loss, which action should the nurse who is working with college students at the on-campus health clinic implement? a. Arrange to include otoscopic examinations for all patients. b. Administer influenza immunizations to all students at the clinic. c. Discuss the importance of limiting exposure to amplified music. d. Perform tympanometry on all patients between the ages of 18 to 24.
ANS: C The nurse should discuss the impact of amplified music on hearing with young adults and discourage listening to very amplified music, especially for prolonged periods. Tympanometry measures the ability of the eardrum to vibrate and would not help prevent future hearing loss. Although students are at risk for the influenza virus, being vaccinated does not help prevent future hearing loss. Otoscopic examinations are not necessary for all patients.
A patient with a head injury after a motor vehicle accident arrives in the emergency department (ED) complaining of shortness of breath and severe eye pain. Which action will the nurse take first? a. Elevate the head to 45 degrees. b. Administer the ordered analgesic. c. Check the patient's oxygen saturation. d. Examine the eye for evidence of trauma
ANS: C The priority action for a patient after a head injury is to assess and maintain airway and breathing. Because the patient is complaining of shortness of breath, it is essential that the nurse assess the oxygen saturation. The other actions also are appropriate but are not the first action the nurse will take.
the patient tell the nurse that he is legally blind. how would this information impact the nurse plan of care for this patient? a. the patient would be considered totally blind. b. the patient probably has gone some light perception, button unable vision. c. the patient has some usable vision, which enables functions at an acceptable level. d. the nurse would need to determine how this patient visual impairment affects normal functioning .
ANS: D "Legal blindness" refers to individuals with a maximum visual acuity of 20/200 with corrective eyewear and/or visual field sight capacity reduced by 20 degrees. Categories have been established to help determine the exact extent of the vision loss and what assistive measures are appropriate for the individual. The nurse will need more information as to the exact extent of the vision loss for this patient.
The nurse is developing a poster to use in teaching clients about the prevention of hearing loss. The nurse should diagram which structure as part of the inner ear? a. malleus b.hammer c. stapes d. Cochlea
ANS: D Cochlea
A nurse is caring for a patient with right-sided weakness following a stroke. Which nursing action would be least effective in promoting positive adaptation of the patient's sensory deficit? a. Placing the patient's belongings on the affected side b. Approaching the patient from the affected side c. Teaching the patient how to create a safe environment d. Completing sentences that the patient cannot finish
ANS: D Completing the patient's sentences is not beneficial to the patient; instead provide the patient with plenty of time and opportunity to begin speaking. Creating a safe environment is important to reduce risk of injury. Placing objects on the patient's affected side and approaching the patient from the affected side cause the patient to be aware of the affected side and to learn to adapt and incorporate the affected part of the body. If the patient does not acknowledge the affected side, it will become neglected, and risk of injury will increase
Which teaching will the nurse implement for a patient who has just been diagnosed with viral conjunctivitis? a. Explain the purpose of antiviral eyedrops. b. Show how to perform eye irrigation safely. c. Instruct about how to insert soft contact lenses. d. Demonstrate appropriate hand-washing technique
ANS: D Hand washing is the major means to prevent the spread of conjunctivitis. Antiviral drops and eye irrigation will not be helpful in shortening the disease process. Contact lenses should not be used when patients have conjunctivitis because they can further irritate the conjunctiva.
How should the nurse advise a patient who has severe vertigo from labyrinthitis? a.Lean against a wall and not head forward until vertigo lessens. b.Bend at the waist and take several deep breaths. c.Drink an iced drink slowly. d.Lie immobile and hold the head in one position until the vertigo lessens
ANS: D Lying immobile and holding the head in one position will lessen vertigo
What do miotic eyedrops do for a patient with glaucoma? a.Dilate the pupil and sharpen vision b.Lubricate and moisten the dry eye c.Irrigate the surface of the eye d.Constrict the pupil and open the canal of Schlemm
ANS: D Miotic eyedrops allow the pupil to constrict and open the canal of Schlemm to drain the excess fluid.
The nurse is caring for a patient with expressive aphasia from a traumatic brain injury. Which desired outcome should be included in the plan of care? a. Patient will recover full use of speech vocabulary in 1 week. b. Patient will carry a pen and a pad of paper around for communication. c. Patient will thicken drinks to prevent aspiration. d. Patient will communicate nonverbally
ANS: D Patients with expressive aphasia may take a prolonged time to regain speech function, depending on the cause of the incident. To adapt to expressive aphasia, the nurse and the patient need to work on ways to communicate nonverbally through means such as pointing and gestures. A patient who has expressive aphasia may not be able to speak or write words. Thickening drinks prevents aspiration risk and is not included in a plan of care for this patient.
How would the nurse explain the purpose of photocoagulation to a diabetic patient with diabetic retinopathy? a.The procedure will destroy the retina, which is not getting enough blood supply. b.The procedure will reduce edema in the macula of the eye. c.The procedure will vaporize fatty deposits that appear in the retina. d.The procedure will destroy new blood vessels, seal leaking vessels, and help prevent retinal edema.
ANS: D Photocoagulation is useful in diabetic retinopathy to cauterize hemorrhaging vessels and to destroy new vessels.
A client has been diagnosed with glaucoma. The nurse who is teaching the client principles of self-care would encourage the client to limit or refrain from which of the following usual activities on a repeated basis? a. ironing b. folding clothes on a laundry table c. peeling vegetables d.Picking objects up off the floor
ANS: D Picking objects up off the floor
The nurse is teaching a mother to instill drops in her infant's ear. The nurse explains that to give the eardrops correctly, the mother needs to take which action? A. Pull up and back on the earlobe and direct the solution toward the eardrum. B. Pull down and back on the auricle and direct the solution toward the eardrum. C. Pull up and back on the auricle and direct the solution toward the wall of the canal. D. Pull down and back on the earlobe and direct the solution toward the wall of the canal.
ANS: D Pull down and back on the earlobe and direct the solution toward the wall of the canal.
Which action should the nurse take when assisting a totally blind patient to walk to the bathroom? a. Take the patient by the arm and lead the patient slowly to the bathroom. b. Have the patient place a hand on the nurse's shoulder and guide the patient. c. Stay beside the patient and describe any obstacles on the path to the bathroom. d. Walk slightly ahead of the patient and allow the patient to hold the nurse's elbow.
ANS: D When using the sighted-guide technique, the nurse walks slightly in front and to the side of the patient and has the patient hold the nurse's elbow. The other techniques are not as safe in assisting a blind patient.
The nurse is reviewing the medication list for an assigned client. Which medication is the only one on the client's prescription sheet that does not have an ototoxic effect? a. furosemide (lasix) b. vancomycin hydrochloride(vancocin) c. accetylsalicylic acid (aspirin) d. acetaminophen (tylenol)
ANS: D acetaminophen (tylenol)
One of the housekeepers splashes a chemical in the eyes. What should be the first priority? a.Transport to a physician immediately b.Cover the eyes with a sterile gauze c.Irrigate with H2O for 5 minutes d.Irrigate with normal saline solution for 20 minutes
ANS: DBurns are medically treated with a prolonged, 15- to 20-minute or longer normal saline flush immediately after burn exposure.
A client with chronic glaucoma is being started on medication therapy with acetazolamide (Diamox). The nurse teaches the client that which can occur early with the use of this medication? A. Fatigue B. Diuresis C. Headache D. Loss of libido
ANS:B Diuresis
The nurse has been assigned to a client with a hearing impairment. To enhance nurse-client communication, the nurse should plan to communicate with the client by speaking in which manner? a. directly into the impaired ear b. in a normal tone while facing the client c. on a more frequent basis d. very loudly to the client
ANS:B In a normal tone while facing the client
a nurse is concerned that a client may experience systemic effect from carterolol hydrochloride ophthalmic solution. the nurse observes the client self administer the medication to be the sure that the client a. instills the eye drops after a meal b. swallows at least five times after instillation c. blinks quickly to form tears after instillation d.applies digital pressure to the lacrimal sac for 1 to 2 minutes after instillation
ANS:D applies digital pressure to the lacrimal sac for 1 to 2 minutes after instillation
These medications are prescribed by the health care provider for a patient who has just been admitted to a hospital with acute angle-closure glaucoma. Which medication should the nurse give first? a. morphine sulfate 4 mg intravenously b. betaxolol (Betoptic) 1 drop in each eye c. acetazolamide (Diamox) 250 mg orally d. mannitol (Osmitrol) 100 mg intravenously
D The most immediate concern for the patient is to lower intraocular pressure, which will occur most rapidly with IV administration of a hyperosmolar diuretic such as mannitol. The other medications also are appropriate for a patient with glaucoma but would not be the first medication administered.