Sensory Disorder Chapter 52
What is the ability of the eye to focus on objects at various distances?
Accommodation
A 68-year-old African American patient visits the clinic complaining of eye pain. On further questioning, the patient states, "I feel like I have tunnel vision. I've been running into things when I walk from outside into a darkened room. Also, every time I look at the TV or a lamp, I see a halo around the light." The patient is found to have increased intraocular pressure. The nurse anticipates which therapy will be prescribed? Scleral buckling Trabeculectomy Pneumatic retinopexy Administration of betaxolol hydrochloride (Betoptic)
Administration of betaxolol hydrochloride (Betoptic)
Cataracts, glaucoma, and macular degeneration are common complications of
Advanced Aging
What is the visual disorder characterized by slow, progressive loss of central and near vision?
Age-related macular degeneration (ARMD)
What factors have been associated with the formation of cataracts? Select all that apply Aging Smoking Loud music Ultraviolet light Diabetes mellitus History of eye surgery Exposure to maternal rubella
Aging Smoking Ultraviolet light Diabetes mellitus Exposure to maternal rubella
Disturbances in central vision
Amsler Grid test
Defect in the curvature of the eyeballsurface
Astigmatism
Nearsightedness.
Myopia
The nurse is caring for a patient with conjunctivitis and notices that the eye is edematous. Which intervention suggested by the nurse would best comfort the patient? "Wear eye pads to cover your eyes at night." "Do not irrigate the eyes with normal saline." "Use contact lenses cleaned with tap water." "Apply cold saline compresses around the eye.
"Apply cold saline compresses around the eye.
What important safety measure should the nurse include while repeating instructions to a patient with glaucoma? Stop using the eye drops after the symptoms subside." "Do not keep extra opened bottles of glaucoma eye drops." "Do not drive for 1 to 2 hours after instilling miotic eye drops." "Apply pressure on the conjunctiva after instilling the eye drops
"Do not drive for 1 to 2 hours after instilling miotic eye drops."
Hordeolum, Chalazion, & Blepharitis Diagnostic Test:
vision disturbance, eyelid observations, drainage, culture and sensitivity test
Contact Lens Care Steps
-Wash/rinse hands before handling -Fingernails short/clean -Remove lenses from one at time and place on eye -Use proper lens care products/clean lenses per manufacture. Daily wear/dispose on daily basis -Keep lens storage kit clean -Wear daily and follow wearing schedule -Remove lens if uncomfortable -If eye infection, dispose of lenses -Avoid corneal abrasion -Report signs of photophobia, dryness, burning, tearing -Keep appts with eye doctor DO NOT -Use soap contain cream/perfume for cleaning -Let fingernails touch lenses -Mix up lenses -Exceed prescribed wear time -Use saliva to wet lenses -Use homemade solution/tap water to wet/clean -Borrow lens case/solution from others
Normal interocular eye pressure
10-20
A nurse is caring for a patient who has had functional blindness for 10 years. Which statement is true? A comprehensive approach to patient care is essential with blind patients. Pain is not associated with blindness, because the pain receptors have been destroyed. Because the patient's blindness is functional, not total, the patient is not considered to be legally blind. Because this patient has been blind for a number of years, the patient is in the acceptance phase of the illness.
A comprehensive approach to patient care is essential with blind patients.
six cardinal fields of gaze
A test to evaluate extraocular muscle function; performed by having the patient visually track an object in six visual fields in an H pattern.
The nurse is caring for a patient who is about to have corrective eye surgery. What instructions should be given to the patient to ensure effectiveness of the surgery? Avoid wearing lenses for 1-2 weeks before surgery. Instill some lubricating eye drops if the pain persists. Refrain from wearing glasses while driving at night. Visit the primary health care provider every year
Avoid wearing lenses for 1-2 weeks before surgery.
Inflammation of the eyelid, pruritus, erythema, pain, photophobia, tearing, and matting
Blepharitis
A patient arrives in the clinic with conjunctivitis after a respiratory virus. The nurse knows it is vital to treat the conjunctivitis quickly and effectively because it can lead to which serious complication? Blindness Eyelid scarring Reinfection with a respiratory virus No treatment is necessary, conjunctivitis is self-limiting
Blindness
Loss of visual acuity from partial to total loss of sight
Blindness
The otoscopic examination of a patient showed excessive secretion of cerumen in the left ear canal. Which medication should the nurse expect the primary health care provider (PHP) to prescribe? Cefaclor (Ceclor) Hydrocortisone (Cortisporin) Dimenhydrinate (Dramamine) Carbamide peroxide (Debrox)
Carbamide peroxide (Debrox)
A patient visits the clinic complaining of blurry vision, difficulty driving at night, and sensitivity to light. On assessment, the nurse notes that bilaterally the pupils look opaque and milky. The nurse anticipates which diagnosis?
Cataracts
A patient developed hearing loss following a stroke. Which type of hearing loss would the nurse expect the patient to have? Central hearing loss Functional hearing loss Conductive hearing loss Sensorineural hearing loss
Central hearing loss
Inflammatory cyst on eyelid, discomfort, edema, pressure felt when eyelid closes, and visual disturbance
Chalalazion
-Announce presence room -Talk in normal tone of voice -Do not try to avoid common phases in speech, "See what I mean?" -Introduce yourself with each contact -Explain activity occurring in room -Announce when leaving the room
Communicating with the Blind
Causes may be bacterial or viral infection, allergies, or environmental factors of the eye which causes erythema, edema, and mucopurulent crusting discharge, spreads rapidly to unaffected eye
Conjunctivitis
Is a common complication of long-term diabetes
Diabetic Retinopathy
One or both eyes turn toward nose
Esotropia
One or both eyes turn away from nose
Exotropia
Swimmer's ear
External Otitis
What instructions should the practical nurse reinforce when reviewing hearing aid care with a patient? Select all that apply. Extra batteries and a cord should always be kept available. The hearing aid should always stay on even when not in use. The ear mold should be reinserted if the hearing aid whistles. The hearing aid should be washed daily with mild soap and water. The ear mold or plug should be dried thoroughly before reconnecting
Extra batteries and a cord should always be kept available. The ear mold should be reinserted if the hearing aid whistles. The ear mold or plug should be dried thoroughly before reconnecting
Myopia Management
Eyeglasses/contact lenses or laser repair
Hyperopia Management
Eyeglasses/contacts
Slit-lamp can help to elevate intraocular pressure by tonometry to detect what?
Glaucoma
A nurse is preparing a patient for surgery to remove bilateral cataracts. Which statement, if made by the patient, indicates a need for further teaching? "I should wear a protective patch at night for several days." "I will require corticosteroid eye drops for the rest of my life." "Because the surgeon is using the intracapsular method, my healing time will be short." "I should expect a change in my corrective lens prescription after the surgery. In fact, I may not need glasses at all."
"I will require corticosteroid eye drops for the rest of my life."
observe ability to perform ADLS, be aware of treatment/rehab, impact on family, Braille
Nursing Interventions for Vision Loss
What is the thick, white, opaque connective tissue that is part of the outermost layer of the eyeball?
Sclera
Commonly known as "Pinkeye"
Conjunctivitis
Management: warm compresses, eye drops, good hygiene
Conjunctivitis
Stye
Hordeolum
Inability of eyes to focus in same direction; cross-eyed
Strabismus
A nurse is providing education to a patient with bacterial conjunctivitis. How should the nurse best determine the patient's ability to perform the necessary treatments? "Do you understand how to irrigate the infected eye and administer the medications?" "Please show me how you will irrigate the infected eye and administer the medications." "Please explain to me how you will irrigate the infected eye and administer the medications." "Do you have any questions on how to irrigate the infected eye and administer the medications?"
"Please show me how you will irrigate the infected eye and administer the medications."
A nurse is providing education to a patient with bacterial conjunctivitis. How should the nurse best determine the patient's ability to perform the necessary treatments?Do you understand how to irrigate the infected eye and administer the medications?" "Please show me how you will irrigate the infected eye and administer the medications." "Please explain to me how you will irrigate the infected eye and administer the medications." "Do you have any questions on how to irrigate the infected eye and administer the medications?
"Please show me how you will irrigate the infected eye and administer the medications."
A 7-year-old patient tells the nurse, "I am afraid of having this otoscopy." What should the nurse say to reassure the child? Select all that apply. "The test does not cause any pain." "The test will take only 1 to 2 minutes." "The ear is pulled slightly down and backward." "The ear is pulled slightly upward and backward." "The ear is pulled slightly backward and upward.
"The test does not cause any pain." "The test will take only 1 to 2 minutes." "The ear is pulled slightly down and backward."
Normal vision is
- 20/20 - Top # distance from the chart in feet - Bottom # distance that the average eye can read the chart
Myopia Nursing Interventions
-If surgery, eye patch, photosensitivity, blurred vision initially, keep up appts. -Do not touch eye and wash hands to prevent infection -Experience glare or halos from lights, may require glasses for night driving
The nurse is collecting data on a patient who tested positive with Schirmer's test. What conditions would the nurse observe in the patient? The patient has nearsightedness. The patient has a corneal inflammation. The patient has keratoconjunctivitis sicca. The patient has a stye on the upper eye lid
The patient has keratoconjunctivitis sicca.
The nurse is collecting data from a patient who is undergoing a visual acuity test for hyperopia. What assessment findings should the nurse expect to notice in the patient?
The patient is unable to read a newspaper.
A nurse who is preparing to care for a newly admitted patient learns the patient has myopia. The nurse understands this has which effect on the patient's sensory perception?
The patient is unable to see objects at a distance.
The nurse is caring for a patient with Ménière disease who reports recurrent episodes of vertigo, nausea, vomiting, and tinnitus. What interventions should the nurse perform to relieve the symptoms? Select all that apply. Limit fluid intake Administer diuretics Provide a low-salt diet Encourage ambulation Promote caffeine intake
Limit fluid intake Administer diuretics Provide a low-salt diet
first treatment is corrective eyewear, medications, canes, dogs, magnifying, and voice activation systems. Surgical correction(laser and transplants)
Management of Vision Loss
A patient comes to the clinic and is diagnosed with otitis media. The nurse understands that proper treatment is vital to prevent the spread of infection to which structure? Stapes Maxillary sinus Mastoid process
Mastoid process
A patient comes to the clinic and is diagnosed with otitis media. The nurse understands that proper treatment is vital to prevent the spread of infection to which structure? Stapes Maxillary sinus Mastoid process Semicircular canal
Mastoid process
Convergence
Medial movement of both eyes allows light rays from an object to hit the same point on both retinas
Inability to see objects at a distance
Myopia
A nurse caring for a patient with non-neovascular macular degeneration knows to prepare the patient for which therapy? Photodynamic therapy Bevacizumab (Avastin) injections Intravenous verteporfin (Visudyne) None. There is no treatment
None. There is no treatment
What is a Snellen Test?
Assesses the patient's visual acuity.
A nurse who is preparing to care for a newly admitted patient learns the patient has myopia. The nurse understands this has which effect on the patient's sensory perception? The patient is unable to see objects at a distance. The patient is unable to see objects that are too close. The patient was born with a form of congenital hearing loss. The patient has developed hearing loss from lifestyle choices
The patient is unable to see objects at a distance.
Which patient is at higher risk of developing secondary Sjögren syndrome? Select all that apply. The patient who has a diagnosis of scleroderma The patient who has cluster migraine headaches The patient who has developed acute otitis media The patient who has systemic lupus erythematosus The patient who has a history of rheumatoid arthritis
The patient who has a diagnosis of scleroderma The patient who has systemic lupus erythematosus The patient who has a history of rheumatoid arthritis
Constriction
The size of the pupil regulates the amount of light entering the eye
Inflammation of the conjunctiva
Conjunctivitis (pink eye)
Nursing interventions: Reinforce teaching to use individual wash clothes and towels, good hand washing to prevent spread of infection. Proper use of eye drops/ointment
Conjunctivitis (pink eye)
A positive Schirmer's test indicates decreased lacrimal secretions or dry eye, or called
Keratoconjunctivitis sicca
Individuals with a maximum visual acuity of 20/200 with corrective lenses
Legal Blindness
A home health nurse is collecting data and contributing to care planning for a 76-year-old female patient who lives alone with two cats and has a positive history of myopia, cataracts, hearing loss, and osteoarthritis. The nurse knows interventions to prevent which condition would be most important for this patient? Falls Infection Depression Skin breakdown
Falls
Acute infection (abscess),swelling of eyelid and glands of eyelashes. warm, redness, tender,painful, blurred vision, and scratching sensation in the eye
Hordeolum
Farsightedness; unable to visualize things that are close up
Hyperopia
Inablity to see objects at close range
Hyperopia
A nurse is caring for a 75-year-old patient who has experienced some sensory deficits. What change might be explained by age-related changes of the sensory system? Decreased sensitivity to glare Inability to hear low-frequency sounds Increased difficulty focusing on close objects Difficulty with red-orange color discrimination
Increased difficulty focusing on close objects
External Otitis
Inflammation of the external ear, or infection , of the external canal or auricle of the external ear
The nurse is caring for a visually impaired patient. What should the nurse do to reduce the risk of injury and anxiety in the patient?
Inform every time before touching the patient
Inflammation of the cornea
Keratits
What eye safety measures does the nurse keep in mind while caring for patients? Select all that apply Eye inflammation can be self-treated with eye drops. Ophthalmic solutions that are cloudy should not be used. Hands should be washed before and after touching the eyes. Any object that penetrated the eye should be removed immediately. Dark glasses should be worn during prolonged exposure to bright light
Ophthalmic solutions that are cloudy should not be used. Hands should be washed before and after touching the eyes. Any object that penetrated the eye should be removed immediately. Dark glasses should be worn during prolonged exposure to bright light
A 3-year-old patient is brought to the clinic with ear pain. The patient's mother reports that the patient gets swimmer's ear often during the summer. The nurse should document this as which condition? Mastoiditis Otitis media Labyrinthitis Otitis externa
Otitis externa
is revealed by conductive loss of hearing through the Weber test, Rinne test and tympanometry. Conductive hearing loss produces lateralization of sound in the deaf (affected) ear in the Weber test. Tympanometry reveals evidence of stiffness in the patient's sound conduction system. The Rinne test shows that bone-conducted sounds are heard longer than air-conducted sounds.
Otosclerosis
A mother of a 3-year-old asks the nurse why her child develops recurrent ear infections. What is the best response on the part of the nurse?
Parts of the throat and the inner and middle ear are covered in a continuous mucous membrane, which allows for easy communication of organisms from the child's throat to the middle ear."
A nurse is providing education to a patient with a hordeolum in the right eye. Which instruction is most important for this patient? Gently massage the affected area as prescribed avoid smoke and other fumes until the infection has subsided Refrain from using eye makeup until the infection has subsided Perform hand hygiene immediately before and after contact with the infected eye
Perform hand hygiene immediately before and after contact with the infected eye
The nurse is reviewing the history of a diabetic patient and finds that the patient has diabetic retinopathy. What treatment would the primary health care provider prescribe to ensure the patient's safety? Vitrectomy Keratoplasty Enucleation Photocoagulation
Photocoagulation
The primary health care provider (PHP) has prescribed a Snellen test for a 9-year-old child. What should the nurse do while preparing the child for the test?
Place the child at a distance of 20 feet from the chart
Hyperopia Nursing Interventions
Proper care of contact lens and yearly eye exams
While caring for a patient who has swimmer's ear, the nurse notices greenish, watery discharge, with a distinct odor, from the patient's ear. Which organism should the nurse suspect in such an observation? Candida albicans Aspergillus fumigatas Staphylococcus aureus Pseudomonas aeruginos
Pseudomonas aeruginos
While caring for a patient who has swimmer's ear, the nurse notices greenish, watery discharge, with a distinct odor, from the patient's ear. Which organism should the nurse suspect in such an observation? Candida albicans Aspergillus fumigatas Staphylococcus aureus Pseudomonas aeruginosa
Pseudomonas aeruginosa
Ability to see item clearly
Refraction
Abnormally shaped eye or cornea
Refractory Errors
A nurse is preparing a patient with detachment of the superior retina in the right eye for a pneumatic retinopexy. Which instruction is most important to ensure success of treatment?
Remain upright for several weeks after therapy Wear dark glasses when outside until normal vision returns Anticipate blurry vision in the affected eye for several weeks Wear patches over both eyes for 2 weeks after the procedure
A patient comes to the clinic complaining of new-onset flashes of light in the right eye along with floaters, and a dark area in the lower right visual field. The nurse anticipates which diagnosis? Cataract Retinal detachment Diabetic retinopathy Macular degeneration
Retinal detachment
A patient arrives at the clinic with uncontrolled type 2 diabetes mellitus. The nurse knows this patient is at an increased risk for which condition? Cataracts Glaucoma Retinopathy Macular degeneration
Retinopathy
performed to identify the amount of lacrimal secretions from the eye
Schirmer's test
What type of hearing loss involves normal sound conduction through the external and middle ear, but distortion in the inner ear, making discrimination difficult? Mixed hearing loss Functional hearing loss Conductive hearing loss Sensorineural hearing loss
Sensorineural hearing loss
A nurse is planning care for a patient who is legally blind. Which intervention for this patient would be most appropriate to complete activities of daily living (ADLs) and foster independence and self-confidence? Perform all ADLs for the patient quickly and efficiently Set aside extra time to assist the patient with ADLs as necessary Be available to help the patient with ADLs, should the patient request assistance Orient the patient to the exact location of the necessary tools for ADLs before leaving the room
Set aside extra time to assist the patient with ADLs as necessary
Magnification of inner eye structures and pressure
Slit-Lamp Examination
The nurse is caring for a patient with blurred vision. The patient complains of having a scratching sensation in the eye. The nurse notices warmth and redness around the eye and a small abscess at the base of the eyelashes. What does the nurse interpret from this? The patient has hyperopia. The patient has hordeolum. The patient has astigmatism. The patient has keratoconjunctivitis
The patient has hordeolum
What should the nurse infer from observing a patient who reports severe eye pain related to blepharospasms? The patient has keratitis. The patient has hordeolum. The patient has conjunctivitis. The patient has Sjögren syndrome.
The patient has keratitis.
double vision, blurred vision, pain, presence, of floaters or flashes of light, light sensitivity, halos, loss of peripheral vision, and itching/burning of eyes
Symptoms of Vision Loss
The nurse is collecting data on a child who is undergoing a Snellen test. What assessment findings should the nurse report? The child has excessive lacrimal secretions. The child reports having frequent dry eyes. The child has small, visible microaneurysms. The child cannot see the letters on the chart
The child cannot see the letters on the chart
The nurse is assisting a primary health care provider (PHP) while conducting an eye examination of a patient. The nurse finds that the PHP instructs the patient to view grids that are made using black lines on a white background. The PHP advises the patient to concentrate on the dot present on the grid. What is the rationale for these instructions? To assess for glaucoma To assess for corneal injury To assess for macular degeneration To assess for retinitis pigmentation
To assess for macular degeneration
A nurse caring for a patient with otitis externaL notes that the patient has been prescribed a topical corticosteroid and an antibiotic eardrop. The nurse knows the corticosteroid was prescribed for which reason?
To decrease edema and allow for penetration of the antibiotic eardrops
A puff of air on the eye
Tonometry
Hyperopia diagnostic test
Visual acuity test
Myopia diagnostic test
Visual acuity test
What are the most appropriate nursing care and patient teaching for the patient with external otitis? Applying cold compresses to the affected ear Washing hands before and after changing cotton plugs Advising patient to rinse ears out each morning in the shower Continuing antibiotic therapy until symptoms of the infection are relieved
Washing hands before and after changing cotton plugs
