Sensory- Eye + Ear Disorders

The employee health nurse is teaching a class on "Preventing Eye Injury." Which information should be discussed in the class? 1. Read instructions thoroughly before using tools and working with chemicals. 2. Wear some type of glasses when working around flying fragments. 3. Always wear a protective helmet with eye shield around dust particles. 4. Pay close attention to the surroundings so eye injuries will be prevented.

1. Instructions provide precautions and steps to take if eye injuries occur sec- ondary to the use of tools or chemicals.

The nurse is preparing information about cataracts for a community health fair. What should the nurse include about risk factors for the disorder? Select all that apply. 1) Obesity 2) Age over 60 3) Family history 4) Alcohol intake 5) Chronic health problems

1. Obesity may predispose an individual to development of cataracts. 2. Cataracts are more common after age 60 but can occur at any time. 3. Those with family members who had cataracts are more likely to develop them at some point in their life. 5. Chronic medical conditions such as diabetes, autoimmune disorders, hypertension, and other eye problems are considered to be at higher risk for cataract development.

2. A client is having a cataract removed and will use eyeglasses after the surgery. The nurse should develop a teaching plan that includes which of the following? Select all that apply. 1. Images will appear to be one-third larger. 2. Look through the center of the glasses. 3. The changes will be immediate. 4. Use handrails when climbing stairs. 5. Stay out of the sun for 2 weeks.

1, 2, 4. The use of glasses following cataract surgery does not totally restore binocular vision. Glasses will cause images to appear larger and peripheral vision will be distorted; the client should look through the center of the glasses and turn his or her head to view objects in the periphery. The client should also use caution when walking or climbing stairs until he or she has adjusted to the change in vision. Changes in vision following cataract surgery are not immediate and the nurse can instruct the client to be patient while adjusting to the changes. The client does not need to stay out of the sun, but should wear dark glasses to prevent discomfort from photophobia.

8. Which of the following is a potential complication following cataract surgery? Select all that apply. 1. Acute bacterial endophthalmitis. 2. Retrobulbar hemorrhage. 3. Rupture of the posterior capsule. 4. Suprachoroidal hemorrhage. 5. Vision loss.

1, 5. Acute bacterial endophthalmitis can occur in about 1 out of 1,000 cases. Organisms that are typically involved include Staphylococcus epi- dermidis, S. aureus, and Pseudomonas and Proteus species. Vision loss is one result of acute bacterial infection. In addition, vision loss can be the result of malposition of the intraocular lens implant or opacification of the posterior capsule. Retrobulbar hemorrhage is a complication that may occur right before surgery and is a result of retrobulbar infiltra- tion of anesthetic agents. Rupture of the posterior capsule and suprachoroidal hemorrhage are both complications that can result during surgery.

Which risk factors should the nurse discuss with the client concerning reasons for hearing loss? Select all that apply. 1. Perforation of the tympanic membrane. 2. Chronic exposure to loud noises. 3. Recurrent ear infections. 4. Use of nephrotoxic medications. 5. Multiple piercings in the auricle.

1,2,3 The tympanic membrane is the eardrum, and if it is punctured it may lead to hear- ing loss. Loud persistent noise, such as heavy machinery, engines, and artillery, over time may cause noise-induced hearing loss. Multiple ear infections scar the tympanic membrane, which can lead to hearing loss.

10. After returning home, a client who has had cataract surgery will need to continue to instill eye drops in the affected eye. The client is instructed to apply slight pressure against the nose at the inner canthus of the eye after instilling the eyedrops. The rationale that supports applying pressure is that it: 1. Prevents the medication from entering the tear duct. 2. Prevents the drug from running down the client's face. 3. Allows the sensitive cornea to adjust to the medication. 4. Facilitates distribution of the medication over the eye surface.

1. Applying pressure against the nose at the inner canthus of the closed eye after administering eyedrops prevents the medication from entering the lacrimal (tear) duct. If the medication enters the tear duct, it can enter the nose and pharynx, where it may be absorbed and cause toxic symptoms. Eyedrops should be placed in the eye's lower conjunctival sac. Applying pressure will not prevent the drug from running down the face as long as the drops are instilled in the eye. Pressure does not affect the cornea or facilitate distribution of the medication over the eye surface.

MED SURG SUCCESS The client is diagnosed with glaucoma. Which symptom should the nurse expect the client to report? 1. Loss of peripheral vision. 2. Floating spots in the vision. 3. A yellow haze around everything. 4. A curtain coming across vision.

1. In glaucoma, the client is often unaware he or she has the disease until the client experiences blurred vision, halos around lights, difficulty focusing, or loss of peripheral vision. Glaucoma is often called the "silent thief."

9. The nurse is instructing the client about postoperative care following cataract removal. What position should the nurse teach the client to use? 1. Remain in a semi-Fowler's position. 2. Position the feet higher than the body. 3. Lie on the operative side. 4. Place the head in a dependent position.

1. The nurse should instruct the client to remain in a semi-Fowler's position or on the non- operative side. Positioning the feet higher than the body does not affect the operative eye; placing the head in a dependent position could increase pres- sure within the eyes.

A patient is diagnosed with viral conjunctivitis. What should the nurse expect to be prescribed for this patient? Select all that apply. 1) Eye lubricants 2) Cold compresses 3) Topical steroid drops 4) Ocular decongestants 5) Topical antihistamine drops

1. The treatment for viral conjunctivitis includes eye lubricants. 2. The treatment for viral conjunctivitis includes cold compresses to the eye for pain relief and decrease in swelling/irritation. 4. The treatment for viral conjunctivitis includes ocular decongestants to help reduce swelling and inflammation.

The nurse is administering eyedrops to the client. Which guidelines should the nurse adhere to when instilling the drops into the eye? Select all that apply. 1. Do not touch the tip of the medication container to the eye. 2. Apply gently pressure on the outer canthus of the eye. 3. Apply sterile gloves prior to instilling eyedrops. 4. Hold the lower lid down and instill drops into the conjunctiva. 5. Gently pat the skin to absorb excess eyedrops on the cheek.

1. Touching the tip of the container to the eye may cause eye injury or an eye infection. 4. Medication should not be placed directly on the eye but in the lower part of the eyelid. 5. Eyedrops are meant to go in the eye,not on the skin, so the nurse shoulduse a clean tissue to remove excess medication.

MEDSURG TB1 The nurse is evaluating teaching provided to a patient with bacterial conjunctivitis. Which patient statement indicates that additional teaching is required? 1) I should place my towel in the bathroom 2) I should wash my hands frequently during the day 3) I should complete all of my prescribed meds 4) I should make a follow-up appointment as directed

1. Towels should be isolated from other family members to prevent possible transmission to another person.

The client has had an enucleation of the left eye. Which intervention should the nurse implement? 1. Discuss the need for special eyeglasses. 2. Refer the client for an ocular prosthesis. 3. Help the client obtain a seeing-eye dog. 4. Teach the client how to instill eyedrops.

2. An enucleation is the removal of the entire eye and part of the optic nerve. An ocular prosthesis will help maintain the shape of the eye socket after the enucleation.

The client diagnosed with glaucoma is prescribed a miotic cholinergic medication. Which data indicate the medication has been effective? 1. No redness or irritation of the eyes. 2. A decrease in intraocular pressure. 3. The pupil reacts briskly to light. 4. The client denies any type of floaters.

2. Both systemic and topical medications are used to decrease the intraocular pressure in the eye, which causes glaucoma.

A patient contemplating cataract surgery asks if there are any risk factors. How should the nurse respond? 1) Blindness 2) Detached retina 3) Corneal abrasion 4) Macular degeneration

2. Cataract removal increases the risk of retinal detachment.

11. To decrease intraocular pressure following cataract surgery, the nurse should instruct the client to avoid: ■ 1. Lying supine. ■ 2. Coughing. ■ 3. Deep breathing. ■ 4. Ambulation.

2. Coughing is contraindicated after cataract extraction because it increases intraocular pressure. Other activities that are contraindicated because they increase intraocular pressure include: turning to the operative side, sneezing, crying, and strain- ing. Lying supine, ambulating, and deep breathing do not affect intraocular pressure.

19. A client who has been treated for chronic open-angle glaucoma (COAG) for 5 years asks the nurse, "How does glaucoma damage my eyesight?" The nurse's reply should be based on the knowledge that COAG: 1. Results from chronic eye inflammation. 2. Causes increased intraocular pressure. 3. Leads to detachment of the retina. 4. Is caused by decreased blood flow to the retina.

2. In COAG, there is an obstruction to the outflow of aqueous humor, leading to increased intraocular pressure. The increased intraocu-lar pressure eventually causes destruction of the retina's nerve fibers. This nerve destruction causes painless vision loss. The exact cause of glaucoma is unknown. Glaucoma does not lead to retinal detachment.

6. The nurse is to instill drops of phenylephrine hydrochloride (Neo-Synephrine) into the client's eye prior to cataract surgery. Which of the following is the expected outcome? 1. Dilation of the pupil and blood vessels. 2. Dilation of the pupil and constriction of blood vessels. 3. Constriction of the pupil and constriction of blood vessels. 4. Constriction of the pupil and dilation of blood vessels.

2. Instilled in the eye, phenylephrine hydro- chloride (Neo-Synephrine) acts as a mydriatic, caus- ing the pupil to dilate. It also constricts small blood vessels in the eye.

A patient comes into the emergency department with manifestations of retinal detachment. What should the nurse do to minimize this patients eye movements? 1) Provide a sedative 2) Loosely cover both eyes 3) Elevate the head of the bed 45 degrees 4) Apply an eye patch over the affected eye

2. Movement of either eye can exacerbate internal eye injury. Because eyes move together, both eyes must be covered to minimize injury.

A patient is demonstrating signs of a detached retina. What is the reason this occurred? 1) Blood vessels in the eye spasm 2) Inner layers of the retina separate 3) Overgrowth of vessels damages vision 4) Drainage of vitreous humor is blocked

2. Retinal detachment occurs when there is a separation of the inner layers of the retina from the underlying retinal pigment epithelium (RPE; choroid).

18. A client with glaucoma is to receive 3 gtt of acetazolamide (Diamox) in the left eye. What should the nurse do? 1. Ask the client to close his right eye while administering the drug in the left eye. 2. Have the client look up while the nurse administers the eyedrops. 3. Have the client lift his eyebrows while the nurse positions the hand with the dropper on the client's forehead. 4. Wipe the eyes with a tissue following admin- istration of the drops.

2. The client should look up while the nurse instills the eyedrops. The client will need to keep both eyes open while the nurse administers the drug. If the client raises his eyebrows while the nurse's hand is positioned on the eyebrows, the movement of the forehead may cause the dropper to move and injure the eye. The client should gently blink his eyes after the eyedrops have been instilled. Using a tissue to wipe the eyes could remove some of the medication; excess fluid can be removed with a cot- ton ball.

The nurse who is at a local park sees a young man on the ground who has fallen and has a stick lodged in his eye. Which intervention should the nurse implement at the scene? 1. Carefully remove the stick from the eye. 2. Stabilize the stick as best as possible. 3. Flush the eye with water if available. 4. Place the young man in a high-Fowler's position.

2. The foreign object should be stabilized to prevent further movement which could cause more damage to the eye.

4. The client with a cataract tells the nurse that she is afraid of being awake during eye surgery. Which of the following responses by the nurse would be the most appropriate? 1. "Have you ever had any reactions to local anesthetics in the past?" 2. "What is it that disturbs you about the idea of being awake?" 3. "By using a local anesthetic, you won't have nausea and vomiting after the surgery." 4. "There's really nothing to fear about being awake. You'll be given a medication that will help you relax."

2. The nurse should give a client who seems fearful of surgery an opportunity to express her feel- ings. Only after identifying the client's concerns can the nurse intervene appropriately. Asking the client about previous reactions to local anesthetics maybe warranted, but it does not address the client's concerns in this instance. Telling the client that she will not have nausea or vomiting ignores the client's feelings of fear and does not provide any data about the client's feelings. More data would help the nurse plan care. Telling the client that there is nothingto be afraid of minimizes her feelings and does not address her concerns. Premature explanations and clichés do not provide needed assessment data and ignore the client's feelings.

MED SURG SUCCESS Which statement indicates to the nurse the client is experiencing some hearing loss? 1. "I clean my ears every day after I take a shower." "I keep turning up the sound on my television." "My ears hurt, especially when I yawn." "I get dizzy when I get up from the chair."

2.The need to turn up the volume on the television is an early sign of hearing impairment.

21. The expected outcome of using miotics to treat glaucoma is: ■ 1. Paralyzing ciliary muscles. ■ 2. Constricting intraocular vessels. ■ 3. Constricting the pupil. ■ 4. Relaxing ciliary muscles.

3. A miotic agent constricts the pupil and contracts ciliary musculature. These effects widen the filtration angle and permit increased outflow of aqueous humor. Miotics also cause vasodilation of the intraocular vessels, where intraocular fluids leave the eye, also increasing aqueous humor out- flow. Mydriatics cause cycloplegia, or paralysis of the ciliary muscle.

26. A client has been diagnosed with an acute episode of angle-closure glaucoma. The nurse plans the client's nursing care with the understanding that acute angle-closure glaucoma: 1. Frequently resolves without treatment. 2. Is typically treated with sustained bed rest. 3. Is a medical emergency that can rapidly lead to blindness. 4. Is most commonly treated with steroid therapy.

3. Acute angle-closure glaucoma is a medical emergency that rapidly leads to blindness if left untreated. Treatment typically involves miotic drugs and surgery, usually iridectomy or laser therapy. Both procedures create a hole in the periphery of the iris, which allows the aqueous humor to flow into the anterior chamber. Bed rest does not affect the progression of acute angle-closure glaucoma. Steroids are not a treatment for acute angle-closure glaucoma; in fact, they are associated with the development of glaucoma.

The client comes to the emergency department after splashing chemicals into the eyes. Which intervention should the nurse implement first? 1. Have the client move the eyes in all directions. 2. Administer a broad-spectrum antibiotic. 3. Irrigate the eyes with normal saline solution. 4. Determine when the client had a tetanus shot.

3. Before any further evaluation or treatment, the eyes must be thor- oughly flushed with sterile normal saline solution.

A patient with macular degeneration is being treated with verteporfin (Visudyne). What should the nurse emphasize in the patient teaching in order to reduce the risk of complications from this treatment? 1) Apply lotion to the skin for two weeks after the treatment 2) Increase the intake of water for three days after the treatment 3) Avoid indoor and outdoor light for five days after treatment 4) Wear sunglasses when going out of doors for one week after treatment

3. It is important to instruct the patient that he or she must avoid exposing skin/eyes to direct sunlight or bright indoor light for five days after treatment with verteporfin (Visudyne) because the medication is activated by light.

The 65-year-old client is diagnosed with macular degeneration. Which statement by the client indicates the client needs more discharge teaching? 1. "I should use magnification devices as much as possible." 2. "I will look at my Amsler grid at least twice a week." 3. "I need to use low-watt light bulbs in my house." 4. "I am going to contact a low-vision center to evaluate my home."

3. Macular degeneration is the most com- mon cause of visual loss in people older than age 60 years. Any intervention which helps increase vision should be included in the teaching, such as bright lighting, not decreased lighting.

The client is diagnosed with Ménière's disease. Which statement indicates the client understands the medical management for this disease? 1. "After intravenous antibiotic therapy, I will be cured." 2. "I will have to use a hearing aid for the rest of my life." 3. "I must adhere to a low-sodium diet, 2,000 mg/day." 4. "I should sleep with the head of my bed elevated."

3. Sodium regulates the balance of fluid within the body; therefore, a low-sodium diet is prescribed to help control the symptoms of Ménière's disease.

The client is postoperative retinal detachment surgery, and gas tamponade was used to flatten the retina. Which intervention should the nurse implement first? 1. Teach the signs of increased intraocular pressure. 2. Position the client as prescribed by the surgeon. 3. Assess the eye for signs/symptoms of complications. 4. Explain the importance of follow-up visits.

3. The nurse's priority must be assessment of complications, which include increased intraocular pressure, endophthalmitis, development of another retinal detach- ment, or loss of turgor in the eye.

23. A client uses timolol maleate (Timoptic) eye- drops. The expected outcome of this beta-adrenergic blocker is to control glaucoma by: 1. Constricting the pupils. 2. Dilating the canals of Schlemm. 3. Reducing aqueous humor formation. 4. Improving the ability of the ciliary muscle to contract.

3. Timolol maleate (Timoptic) is commonly administered to control glaucoma. The drug's action is not completely understood, but it is believed to reduce aqueous humor formation, thereby reducing intraocular pressure. Timolol does not constrict the pupils; miotics are used for pupillary constriction and contraction of the ciliary muscle. Timolol does not dilate the canal of Schlemm.

The nurse notes that a patient is diagnosed with primary open-angle glaucoma. What diagnostic test would have been used to diagnose this health problem? 1) MRI 2) CT scan 3) Tonometry 4) Ultrasound

3. Tonometry measures the pressures within the eyes and is usually conducted during a routine eye examination.

LIPPINCOTT 3. The client has had a cataract removed. The nurse's discharge instructions should include which of the following? ■ 1. Keep the head aligned straight. ■ 2. Utilize bright lights in the home. ■ 3. Use an eye shield at night. ■ 4. Change the eye patch as needed.

3. Using an eye shield at night prevents rub- bing the eye. The head should be turned to the side to scan the entire visual field to compensate for impaired peripheral vision. Eye medications may initially cause sensitivity to bright light. The sur- geon changes the eye patch on the second postop- erative day.

The 65-year-old male client who is complaining of blurred vision reports he thinks his glasses need to be cleaned all the time, and he denies any type of eye pain. Which eye disorder should the nurse suspect the client has? 1. Corneal dystrophy. 2. Conjunctivitis. 3. Diabetic retinopathy. 4. Cataracts.

4. A cataract is a lens opacity or cloudiness, resulting in the signs/symptoms discussed in the stem of the question.

7. A short time after cataract surgery, the client complains of nausea. The nurse should first: 1. Instruct the client to take a few deep breaths until the nausea subsides. 2. Explain that this is a common feeling that will pass quickly. 3. Tell the client to call the nurse promptly if vomiting occurs. 4. Medicate the client with an antiemetic, as ordered.

4. A prescribed antiemetic should be admin- istered as soon as the client complains of nausea fol- lowing a cataract extraction. Vomiting can increase intraocular pressure, which should be avoided after eye surgery because it can cause complications. Deep breathing is unlikely to relieve nausea. Postop- erative nausea may be common; however, it doesn't necessarily pass quickly and can lead to vomiting. Telling the client to call only if vomiting occurs ignores the client's need for comfort and interven- tion to prevent complications.

25. Which of the following clinical manifesta- tions should the nurse asessess when a client has acute angle-closure glaucoma? 1. Gradual loss of central vision. 2. Acute light sensitivity. 3. Loss of color vision. 4. Sudden eye pain.

4. Acute angle-closure glaucoma produces abrupt changes in the angle of the iris. Clinical man- ifestations include severe eye pain, colored halos around lights, and rapid vision loss. Gradual loss of central vision is associated with macular degenera- tion. The loss of color vision, or achromatopsia, isa rare symptom that occurs when a stroke damages the fusiform gyrus. It most often affects only half of the visual field.

20. The nurse should assess clients with chronic open-angle glaucoma (COAG) for: 1.Eyepain. 2. Excessive lacrimation. 3. Colored light flashes. 4. Decreasing peripheral vision.

4. Although COAG is usually asymptom-atic in the early stages, peripheral vision gradually decreases as the disorder progresses. Eye pain is not a feature of COAG but is common in clients with angle-closure glaucoma. Excessive lacrimation is not a symptom of COAG; it may indicate a blocked tear duct. Flashes of light is a common symptom of retinal detachment.

The nurse suspects that a patient is developing a cataract. What finding did the nurse use to make this clinical decision? 1) Itching of both eyes 2) Tearing of both eyes 3) Redness of the sclera 4) Double vision in one eye

4. Double vision in one eye is a manifestation of cataracts.

The nurse is caring for a patient recovering from cataract removal surgery. Which action should the nurse take to reduce intraocular pressure (IOP)? 1) Restrict fluids 2) Position on the operative side 3) Administer mydriatic eye drops 4) Elevate the head of the bed 45 degrees

4. Elevating the head of the bed 30 to 45 degrees promotes drainage and prevents any increase in IOP.

The client is scheduled for laser-assisted in situ keratomileusis (LASIK) surgery for severe myopia. Which instruction should the nurse discuss prior to the client's discharge from day surgery? 1. Wear bilateral eye patches for three (3) days. 2. Wear corrective lenses until the follow-up visit. 3. Do not read any material for at least one (1) week. 4. Teach the client how to instill corticosteroid ophthalmic drops.

4. LASIK surgery is an effective, safe, predictable surgery performed in day surgery; there is minimal postoperative care. Instilling topical corticosteroid drops helps decrease inflammation and edema of the eye.

A patient is diagnosed with bacterial conjunctivitis. What should the nurse expect to assess in this patient? Select all that apply. 1) Tearing 2) Red sclera 3) Puffy eyelids 4) Purulent eye discharge 5) Matting of the eyelashes

4. Purulent eye discharge is associated with bacterial conjunctivitis. 5. Matting of the eyelashes is associated with bacterial conjunctivitis.

12. After cataract removal surgery, the client is instructed to report sharp pain in the operative eye because this could indicate which of the following postoperative complications? ■ 1. Detached retina. ■ 2. Prolapse of the iris. ■ 3. Extracapsular erosion. ■ 4. Intraocular hemorrhage.

4. Sudden, sharp pain after eye surgery should suggest to the nurse that the client may be experiencing intraocular hemorrhage. The physician should be notified promptly. Detached retina and prolapse of the iris are usually painless. Extracapsu- lar erosion is not characterized by sharp pain.

The nurse is reviewing teaching provided to a patient with glaucoma. Which patient statement indicates that teaching has been effective? 1) I should consider surgery to cure this disorder 2) I should use the eye drops when my vision blurs 3) I should cut down on eating salty and high-fat food 4) I should call my doctor before taking any over-the-counter meds

4. The patient should be instructed to not take any medication, over-the-counter or prescription, without contacting the eye care practitioner first.

The client is scheduled for right-eye cataract removal surgery in five (5) days. Which preoperative instruction should be discussed with the client? 1. Administer dilating drops to both eyes for 72 hours prior to surgery. 2. Prior to surgery do not lift or push any objects heavier than 15 pounds. 3. Make arrangements for being in the hospital for at least three (3) days. 4. Avoid taking any type of medication which may cause bleeding, such as aspirin.

4. To reduce retrobulbar hemorrhage,any anticoagulation therapy is withheld, including aspirin, nonsteroidal anti- inflammatory drugs (NSAIDs), and warfarin (Coumadin).

The nurse is caring for a teenage client who was recently fitted for contacts who presents with conjunctivitis. Which risk factor may be associated with this​ adolescent? (Select all that​ apply.) A) improper hand hygiene B) participating in contact sports C) using old eye makeup D) wearing extended - wear contact lenses E) eating a balanced diet

A, C, D​ Rationale: The teenager is at risk of developing conjunctivitis from using old eye​ makeup, as bacteria easily grow in this medium. Performing proper hand hygiene when handling contacts is essential to the prevention of conjunctivitis caused by infection. There is no reason why the teenager who wears contact lenses needs to avoid contact sports. Eating a balanced diet is​ important, but not doing so is not a specific risk factor concerning the wearing of contact lenses. It is imperative that lenses be worn only for the prescribed time in order to avoid possible development of eye irritation or infection.

The nurse is teaching a college student with conjunctivitis ways to prevent the spread of the infection. Which student statement indicates that teaching has been​ effective? (Select all that​ apply.) A) ​"I will not share my towels with anyone at​ school." B) "I will save my eye medicine to use if the other eye gets​ infected." C.) "I will share my eye medication with a friend with the same​ infection." D.) "I will keep my contact lenses in place until the infection​ heals." E.) "I will wash my hands after removing eye​ discharge.

A, E​ Rationale: Ways to prevent the spread of conjunctivitis to the other eye or to other people include not sharing personal items such as towels with others and washing the hands after removing eye discharge. Keeping contact lenses in place until the infection heals could cause the infection to get worse. Medication should not be saved to be used later if the other eye becomes infected. Medication should not be shared with others.

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 be meclizine

A,B,E A. Enlarged adenoids B. Report of recent colds .E. Ear pain relieved be meclizine

A nurse is reinforcing discharge teaching with 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."

BRUNNER The nurse is assessing a child with conjunctivitis (pink eye). Which of the following would the nurse most likely assess? A. Crusting of eyelids and eyelashes B. Periorbital edema C. Severe eye pain D. Serous drainage from the affected eye

A. Crusting of eyelids and eyelashes Purulent exudate and crusting are characteristics of conjunctivitis. Therefore, the nurse would most likely assess crustng of eyelids and eyelashes. Conjunctivitis associated with foreign body can cause severe eye pain. Serous draingae and periorbital edema are not associated with conjunctivitis.

Which of the following instructions by the nurse is most appropriate for a client using contact lenses who is diagnosed with bacterial conjunctivitis? A. Discard all opened or used lens care products B. Disinfect contact lenses by soaking in a cleaning solution for 48 hours C. Put all cosmetics in a plastic bag for 1 week to kill any bacteria before resuing D. Disinfect all lens care products with the prescribed antibiotic drops for 1 week after infection

A. Discard all opened or used lens care products The client who wears contact lenses and develops an eye infection should discard all open or used lens care products and cosmetics to decrease the risk of reinfection from contaminated products.

A nurse is reinforcing teaching with a client who has a new diagnosis of dry macular degeneration. Which of the following instruction 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 waste .D. Wear an eye patch at night.

A. Increase intake of deep yellow and orange vegetables.

The nurse has notes that the physician has a diagnosis of presbycusis on the client's chart. The nurse plans care knowing the condition is: A. sensorineural hearing loss that occurs with aging B.A conductive hearing loss that occurs with aging. C.Tinnitus that occurs with aging D.Nystagmus that occurs with aging

A.Presbycusis is a type of hearing loss that occurs with aging. Presbycusis is a gradual sensorineural loss caused by nerve degeneration in the inner ear or auditory nerve.

A patient comes to the ophthalmology clinic for an eye examination. The patient tells the nurse that he often sees floaters in his vision. How should the nurse best interpret this subjective assessment finding? A) This is a normal aging process of the eye. B) Glasses will minimize this phenomenon. C) The patient may be exhibiting signs of glaucoma. D) This may be a result of weakened ciliary muscles.

Ans: A Feedback: As the body ages, the perfect gel-like characteristics of the vitreous humor are gradually lost, and various cells and fibers cast shadows that the patient perceives as floaters. This is a normal aging process.

14. A nurse is teaching a patient with glaucoma how to administer eye drops to achieve maximum absorption. The nurse should teach the patient to perform what action? A) Instill the medication in the conjunctival sac. B) Maintain a supine position for 10 minutes after administration. C) Keep the eyes closed for 1 to 2 minutes after administration. D) Apply the medication evenly to the sclera

Ans: A Feedback: Eye drops should be instilled into the conjunctival sac, where absorption can best take place, rather than distributed over the sclera. It is unnecessary to keep the eyes closed or to maintain a supine position after administration.

The nurse is admitting a 55-year-old male patient diagnosed with a retinal detachment in his left eye. While assessing this patient, what characteristic symptom would the nurse expect to find? A) Flashing lights in the visual field B) Sudden eye pain C) Loss of color vision D) Colored halos around lights

Ans: A Feedback: Flashing lights in the visual field is a common symptom of retinal detachment. Patients may also report spots or floaters or the sensation of a curtain being pulled across the eye. Retinal detachment is not associated with eye pain, loss of color vision, or colored halos around lights.

A patient with glaucoma has presented for a scheduled clinic visit and tells the nurse that she has begun taking an herbal remedy for her condition that was recommended by a work colleague. What instruction should the nurse provide to the patient? A) The patient should discuss this new remedy with her ophthalmologist promptly. B) The patient should monitor her IOP closely for the next several weeks. C) The patient should do further research on the herbal remedy. D) The patient should report any adverse effects to her pharmacist.

Ans: A Feedback: Patients should discuss any new treatments with an ophthalmologist; this should precede the patients own further research or reporting adverse effects to the pharmacist. Self-monitoring of IOP is not possible.

BRUNNERS 2. The nurse has taken shift report on her patients and has been told that one patient has an ocular condition that has primarily affected the rods in his eyes. Considering this information, what should the nurse do while caring for the patient? A) Ensure adequate lighting in the patients room. B) Provide a dimly lit room to aid vision by limiting contrast. C) Carefully point out color differences for the patient. D) Carefully point out fine details for the patient.

Ans: A Feedback: The nurse should provide adequate lighting in the patients room, as the rods are mainly responsible for night vision or vision in low light. If the patients rods are impaired, the patient will have difficulty seeing in dim light. The cones in the eyes provide best vision for bright light, color vision, and fine detail.

3. The nurse on the medicalsurgical unit is reviewing discharge instructions with a patient who has a history of glaucoma. The nurse should anticipate the use of what medications? A) Potassium-sparing diuretics B) Cholinergics C) Antibiotics D) Loop diuretics

Ans: B Feedback: Cholinergics are used in the treatment of glaucoma. The action of this medication is to increase aqueous fluid outflow by contracting the ciliary muscle and causing miosis and opening the trabecular meshwork. Diuretics and antibiotics are not used in the management of glaucoma.

The nurse is providing health education to a patient newly diagnosed with glaucoma. The nurse teaches the patient that this disease has a familial tendency. The nurse should encourage the patients immediate family members to undergo clinical examinations how often? A) At least monthly B) At least once every 2 years C) At least once every 5 years D) At least once every 10 years

Ans: B Feedback: Glaucoma has a family tendency and family members should be encouraged to undergo examinations at least once every 2 years to detect glaucoma early. Testing on a monthly basis is not necessary and excessive.

A patient has been diagnosed with glaucoma and the nurse is preparing health education regarding the patients medication regimen. The patient states that she is eager to beat this disease and looks forward to the time that she will no longer require medication. How should the nurse best respond? A) You have a great attitude. This will likely shorten the amount of time that you need medications. B) In fact, glaucoma usually requires lifelong treatment with medications. C) Most people are treated until their intraocular pressure goes below 50 mm Hg. D) You can likely expect a minimum of 6 months of treatment.

Ans: B Feedback: Glaucoma requires lifelong pharmacologic treatment. Normal intraocular pressure is between 10 and 21 mm Hg.

The nurse is providing discharge education to an adult patient who will begin a regimen of ocular medications for the treatment of glaucoma. How can the nurse best determine if the patient is able to self-administer these medications safely and effectively? A) Assess the patient for any previous inability to self-manage medications. B) Ask the patient to demonstrate the instillation of her medications. C) Determine whether the patient can accurately describe the appropriate method of administering her meds D) Assess the patients functional status.

Ans: B Feedback: The patient or the caregiver at home should be asked to demonstrate actual eye drop administration. This method of assessment is more accurate than asking the patient to describe the process or determining earlier inabilities to self-administer medications. The patients functional status will not necessarily determine the ability to administer medication safely.

A patient has just returned to the surgical floor after undergoing a retinal detachment repair. The postoperative orders specify that the patient should be kept in a prone position until otherwise ordered. What should the nurse do? A) Call the physician and ask for the order to be confirmed. B) Follow the order because this position will help keep the retinal repair intact. C) Instruct the patient to maintain this position to prevent bleeding. D) Reposition the patient after the first dressing change.

Ans: B For pneumatic retinopexy, postoperative positioning of the patient is critical because the injected bubble must float into a position overlying the area of detachment, providing consistent pressure to reattach the sensory retina. The patient must maintain a prone position that would allow the gas bubble to act as a tamponade for the retinal break. Patients and family members should be made aware of these special needs beforehand so that the patient can be made as comfortable as possible. It would be inappropriate to deviate from this order and there is no obvious need to confirm the order.

The nurse is administering eye drops to a patient with glaucoma. After instilling the patients first medication, how long should the nurse wait before instilling the patients second medication into the same eye? A) 30 seconds B) 1 minute C) 3 minutes D) 5 minutes

Ans: D Feedback: A 5-minute interval between successive eye drop administrations allows for adequate drug retention and absorption. Any time frame less than 5 minutes will not allow adequate absorption.

A patient is being discharged home from the ambulatory surgical center after cataract surgery. In reviewing the discharge instructions with the patient, the nurse instructs the patient to immediately call the office if the patient experiences what? A) Slight morning discharge from the eye B) Any appearance of redness of the eye C) A scratchy feeling in the eye D) A new floater in vision

Ans: D Feedback: Cataract surgery increases the risk of retinal detachment and the patient must be instructed to notify the surgeon of new floaters in vision, flashing lights, decrease in vision, pain, or increase in redness. Slight morning discharge, some redness, and a scratchy feeling may be expected for a few days after surgery.

35. A patient with a diagnosis of retinal detachment has undergone a vitreoretinal procedure on an outpatient basis. What subject should the nurse prioritize during discharge education? A) Risk factors for postoperative cytomegalovirus (CMV) B) Compensating for vision loss for the next several weeks C) Non-pharmacologic pain management strategies D) Signs and symptoms of increased intraocular pressure

Ans: D Feedback: Patients must be educated about the signs and symptoms of complications, particularly of increasing IOP and postoperative infection. CMV is not a typical complication and the patient should not expect vision loss. Vitreoretinal procedures are not associated with high levels of pain.

A patient with chronic open-angle glaucoma is being taught to self-administer pilocarpine. After the patient administers the pilocarpine, the patient states that her vision is blurred. Which nursing action is most appropriate? A) Holding the next dose and notifying the physician B) Treating the patient for an allergic reaction C) Suggesting that the patient put on her glasses D) Explaining that this is an expected adverse effect

Ans: D Feedback: Pilocarpine, a miotic drug used to treat glaucoma, achieves its effect by constricting the pupil. Blurred vision lasting 1 to 2 hours after instilling the eye drops is an expected adverse effect. The patient may also note difficulty adapting to the dark. Because blurred vision is an expected adverse effect, the drug does not need to be withheld, nor does the physician need to be notified. Likewise, the patient does not need to be treated for an allergic reaction. Wearing glasses will not alter this temporary adverse effect.

A patient is exploring treatment options after being diagnosed with age-related cataracts that affect her vision. What treatment is most likely to be used in this patients care? A) Antioxidant supplements, vitamin C and E, beta-carotene, and selenium B) Eyeglasses or magnifying lenses C) Corticosteroid eye drops D) Surgical intervention

Ans: D Feedback: Surgery is the treatment option of choice when the patients functional and visual status is compromised. No nonsurgical (medications, eye drops, eyeglasses) treatment cures cataracts or prevents age-related cataracts. Studies recently have found no benefit from antioxidant supplements, vitamins C and E, beta- carotene, or selenium. Corticosteroid eye drops are prescribed for use after cataract surgery; however, they increase the risk for cataracts if used long-term or in high doses. Eyeglasses and magnification may improve vision in the patient with early stages of cataracts, but have limitations for the patient with impaired functioning.

Several residents of a long-term care facility have developed signs and symptoms of viral conjunctivitis. What is the most appropriate action of the nurse who oversees care in the facility? A) Arrange for the administration of prophylactic antibiotics to unaffected residents. B) Instill normal saline into the eyes of affected residents two to three times daily. C) Swab the conjunctiva of unaffected residents for culture and sensitivity testing. D) Isolate affected residents from residents who have not developed conjunctivitis.

Ans: D Feedback: To prevent spread during outbreaks of conjunctivitis caused by adenovirus, health care facilities must set aside specified areas for treating patients diagnosed with or suspected of having conjunctivitis caused by adenovirus. Antibiotics and saline flushes are ineffective and normally no need to perform testing of individuals lacking symptoms.

The nurse is preparing to test the visual acuity of a client, using a Snellen chart. Which identies the accurate procedure for this visual acuity test? 1. The right eye is tested, followed by the left eye, and then both eyes are tested. 2. Both eyes are assessed together, followed by an assessment of the right eye and then the left eye. 3. The client is asked to stand at a distance of 40 feet (12 meters) from the chart and to read the largest line on the chart. 4. The client is asked to stand at a distance of 40 feet (12 meters) from the chart and to read the linehat can be read 200 feet (60 meters) away by an individual with unimpaired vision.

Answer: 1 Rationale: Visual acuity is assessed in one eye at a time, and then in both eyes together, with the client comfortably stand- ing or sitting. The right eye is tested with the left eye covered; then the left eye is tested with the right eye covered. Both eyes are then tested together. Visual acuity is measured with or without corrective lenses, and the client stands at a distance of 20 feet (6 meters) from the chart.

The nurse notes that the primary health care pro- vider has documented a diagnosis of presbycusis on a client's chart. Based on this information, what ac- tion would the nurse take? 1. Speak loudly but mumble or slur the words .2. Speak loudly and clearly while facing the client. 3. Speak at normal tone and pitch, slowly and clearly 4. Speak loudly and directly into the client's affected ear.

Answer: 3 Rationale: Presbycusis is a type of hearing loss that occurs with aging. Presbycusis is a gradual sensorineural loss caused by nerve degeneration in the inner ear or auditory nerve. When communicating with a client with this condition, the nurse would speak at a normal tone and pitch, slowly and clearly. It is inappropriate to speak loudly, to mumble or slur words, or to speak into the client's affected ear.

The nurse is developing a teaching plan for a client with glaucoma. Which instruction would the nurse include in the plan of care? 1.Avoid overuse of the eyes. 2.Decrease the amount of salt in the diet. 3.Eye medications will need to be administered for life. 4. Decrease fluid intake to control the intraocular pressure.

Answer: 3 Rationale: The administration of eye drops is a critical com- ponent of the treatment plan for the client with glaucoma. Clients with glaucoma need to be instructed that medications will need to be taken for the rest of their lives. Options 1, 2, and 4 are inaccurate instructions.

SAUNDERS 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 problem? 1.Total loss of vision 2.Pain in the affected eye 3.A yellow discoloration of the sclera 4.A sense of a curtain falling across the field of vision

Answer: 4 Rationale: A characteristic manifestation of retinal detach- ment described by the client is the feeling that a shadow or curtain is falling across the field of vision. No pain is associ- ated with detachment of the retina. Options 1 and 3 are not characteristics of this problem. A retinal detachment is an ophthalmic emergency, and even more so if visual acuity is still normal.

The nurse is performing an assessment on a client with a suspected diagnosis of cataract. Which clinical manifestation would the nurse expect to note in the early stages of cataract formation? 1. Diplopia 2. Eye pain 3. Floating spots 4. Blurred vision

Answer: 4 Rationale: A gradual, painless blurring of central vision is the chief clinical manifestation of a cataract. Early symptoms include slightly blurred vision and a decrease in color percep- tion. Options 1, 2, and 3 are not characteristics of a cataract.

Which action by the client indicates an understanding of how to prevent transmission of​ conjunctivitis? A) Washing hands B) Using a handkerchief C) Sharing towels at home D) Rubbing the eyes

A​ Rationale: Good handwashing is imperative for preventing transmission of conjunctivitis. Rubbing the eyes can get the pathogen on the hands and transmit the infection. The client should be instructed to use disposable tissues or cotton​ balls, not a reusable handkerchief. The client should be instructed to not share towels.

Which clinical manifestation would support a diagnosis of allergic​ conjunctivitis? A) itching B) photophobia C) yellow discharge D) sore throat

A​ Rationale: Allergic conjunctivitis causes itching to the eyes. Bacterial and viral conjunctivitis can cause sore throats and photophobia. Yellow discharge occurs with bacterial conjunctivitis.

Saunders The nurse is performing a voice test to assess hearing. Which of the following describes the accurate procedure for performing this test? A.Stand 4 feet away from the client to ensure that the client can hear at this distance. B.Whisper a statement and ask the client to repeat it. C.Whisper a statement with the examiners back facing the client. D.Whisper a statement while the client blocks both ears.

B The examiner stands 1-2 feet away from the client and asks the client to block one external ear canal. The nurse whispers a statement and asks the client to repeat it. Each ear is tested separately.

The nurse is preparing teaching for a client recovering from conjunctivitis. Which instruction should the nurse include when teaching about the care of the contact​ lenses? A) place clean lenses on a paper towel to dry B) wash hands before handling lenses C) keep contact lenses in place if signs of an irritation are present D) remove the lenses every morning

B ​Rationale: The nurse should teach the client to wash the hands before handling the lenses. The lenses should be removed before sleep. The lenses should be stored in the appropriate case. The lenses should not be worn if signs of an irritation are present.

The nurse is performing an assessment on a newly admitted client with cancer to a nursing care facility. Which observation leads the nurse to suspect the client has acute​ conjunctivitis? (Select all that​ apply.) A) dry eyes B) reddened eyes C) mucoid discharge D) itchy eyes E) photophobia

B, C, D, E Rationale: Manifestations of acute conjunctivitis include itchy​ eyes, photophobia, reddened​ eyes, and watery or mucoid discharge. Dry​ eyes, though often a complaint of an older​ adult, is not an observation made for the diagnosis of conjunctivitis.

A client with bacterial conjunctivitis is experiencing copious amounts of purulent eye drainage. Which treatment should the nurse expect to be prescribed for this​ client? (Select all that​ apply.) A) topical antihistamines B) eye irrigations C) antibiotic eye drops D) eyelid soaks E) warm clean cloths

B, C, D, E​ Rationale: Eyelid soaks before cleansing promote comfort and aid in the removal of crusts and exudate. Eye irrigations remove copious purulent secretions. Warm clean cloths assist with the removal of drainage. Antibiotic eye drops are prescribed for clients experiencing bacterial conjunctivitis. Topical antihistamines are used for allergic conjunctivitis.

The nurse is preparing instructions for a client diagnosed with viral conjunctivitis. Which should the nurse include in this​ teaching? (Select all that​ apply.) A) Soak the eyelids with a warm cloth. B) Wash hands after touching the eyes. C) Use a wet cloth to remove eye drainage. D) Apply cool compresses. E) Avoid bright lights.

B, C, D, E​ Rationale: Treatment of viral conjunctivitis includes using cool​ compresses, avoiding bright​ lights, using infection control techniques such as washing hands after touching the​ eyes, and removing eye discharge with a wet cloth. Soaking the eyelids with a warm cloth is part of the treatment for bacterial conjunctivitis.

A nurse is collecting data on a male older adult client who has a new diagnosis of glaucoma. Which of the following findings should the nurse recognize as risk factors associated with this disease? (Select all that apply.) A. Gender B. Genetic predisposition C. Eye trauma D. Age E. Diabetes mellitus

B,C,D,E

A client with Meniere's disease is experiencing severe vertigo. Which instruction would the nurse give to the client to assist in controlling the vertigo? A.Increase fluid intake to 3000 ml a day B.Avoid sudden head movements C.Lie still and watch the television D.Increase sodium in the diet

B. The nurse instructs the client to make slow head movements to prevent worsening of the vertigo. Dietary changes such as salt and fluid restrictions that reduce the amount of endolymphatic fluid sometimes are prescribed. Lying still and watching television will not control vertigo.

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 mnifestation of which of the following diseases? A. Cataracts B. Open-angle glaucoma C. Macular degeneration D. Angle-closure glaucoma

B. Open-angle glaucoma

Otosclerosis is a common cause of conductive hearing loss. Which such a partial hearing loss: A. Stapedectomy is the procedure of choice B.Hearing aids usually restore some hearing C.The client is usually unable to hear bass tones D. Air conduction is more effective than bone conduction

B.With a partial hearing loss that auditory ossicles have not yet become fixed; as long as vibrations occur, a hearing aid may be beneficial.

At the conclusion of a fluorescein​ stain, a client is diagnosed with conjunctivitis. Which test result should the nurse expect to be documented in the​ client's medical​ record? A) fluorescein stain orange B) Fluorescein stain yellow and blue C) Fluorescein stain green D) Fluorescein stain absence of color

C Rationale: A fluorescein stain uses a slit lamp to identify the presence of corneal ulcerations or abrasions. These injuries will appear green when stained. There will be an absence of color in conjunctivitis. The fluorescein stain does not cause areas of injury to turn​ orange, yellow, or blue.

A nurse is collecting data on 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 visiion D. White pupils E. Bilateral red relexes

C,D

During a hearing assessment, the nurse notes that the sound lateralizes to the clients left ear with the Weber test. The nurse analyzes this result as: A.A normal finding B.A conductive hearing loss in the right ear C.A sensorineural or conductive loss D.The presence of nystagmus

C. In the Weber tuning fork test the nurse places the vibrating tuning fork in the middle of the client's head, at the midline of the forehead, or above the upper lip over the teeth. Normally, the sound is heard in equally in both ears by bone conduction. If the client has a sensorineural hearing loss in one ear, the sound is heard in the other ear. If the client has a conductive hearing loss in one ear, the sound is heard in that ear.

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?

Complaints of a burst of black spots or floaters

When obtaining the health history from a male client with retinal detachment, the nurse expects the client to report: A. Light flashes and floaters in front of the eye. B. A recent driving accident while changing lanes. C. Headaches, nausea, and redness of the eyes. D. Frequent episodes of double vision.

Correct Answer: A. Light flashes and floaters in front of the eye.The sudden appearance of light flashes and floaters in front of the affected eye is characteristic of retinal detachment. Patients with a rhegmatogenous retinal detachment may present with a history of a large number of new-onset floaters. They may also have significant photopsia (flashes of light) in their vision.

The nurse is monitoring a male client for adverse reactions to atropine sulfate (Atropine Care) eyedrops. Systemic absorption of atropine sulfate through the conjunctiva can cause which adverse reaction? A. Tachycardia B. Increased salivation C. Hypotension D. Apnea

Correct Answer: A. Tachycardia Systemic absorption of atropine sulfate can cause tachycardia, palpitations, flushing, dry skin, ataxia, and confusion. To minimize systemic absorption, the client should apply digital pressure over the punctum at the inner canthus for 2 to 3 minutes after instilling the drops. Tachycardia is the most common side effect; titrate dose to effect when treating bradyarrhythmia in patients with coronary artery disease

NL Shortly after admission to an acute care facility, a male client with a seizure disorder develops status epilepticus. The physician orders diazepam (Valium) 10 mg I.V. stat. How soon can the nurse administer the second dose of diazepam, if needed and prescribed? A. In 30 to 45 seconds B. In 10 to 15 minutes C. In 30 to 45 minutes D. In 1 to 2 hours

Correct Answer: B. In 10 to 15 minutes When used to treat status epilepticus, diazepam may be given every 10 to 15 minutes, as needed, to a maximum dose of 30 mg. The nurse can repeat the regimen in 2 to 4 hours, if necessary, but the total dose shouldn't exceed 100 mg in 24 hours. It is crucial to monitor respiratory and cardiovascular status, blood

The nurse is assessing the motor function of an unconscious male client. The nurse would plan to use which of the following to test the client's peripheral response to pain? A. Sternal rub B. Nail bed pressure C. Pressure on the orbital rim D. Squeezing of the sternocleidomastoid muscle

Correct Answer: B. Nail bed pressure Motor testing in the unconscious client can be done only by testing response to painful stimuli. Nail bed pressure tests a basic peripheral response. Motor responses can be purposeful, such as the patient pulling on an airway adjunct, or reflexive, including withdrawal, flexion, or extension responses.

A female client admitted to the hospital with a neurological problem asks the nurse whether magnetic resonance imaging may be done. The nurse interprets that the client may be ineligible for this diagnostic procedure based on the client's history of: A. Hypertension B. Heart failure C. Prosthetic valve replacement D. Chronic obstructive pulmonary disorder

Correct Answer: C. Prosthetic valve replacement The client having a magnetic resonance imaging scan has all metallic objects removed because of the magnetic field generated by the device. A careful history is obtained to determine whether any metal objects are inside the client, such as orthopedic hardware, pacemakers, artificial heart valves, aneurysm clips, or intrauterine devices. These may heat up, become dislodged, or malfunction during this procedure. The client may be ineligible if a significant risk exists.

Aling Martha, a 73-year-old widow, tells to the nurse during the admission process that she was recently diagnosed with age-related hearing loss. Upon receiving such information, the nurse is correct if he suspects: A.Ménière's disease B.Otalgia C.Otitis media D. Presbycusis

D. The term presbycusis refers to sensorineural hearing impairment in elderly individuals.

A nurse is reinforcing postoperative teaching with 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."

A nurse is caring for a client who has suspected Meniere's disease. Which of the following is an expected finding? A. Purulent lesion in the external ear canal B. Feeling of pressure in the ear C. Bulging red bilateral TM D. Unilateral hearing loss

D. Unilateral hearing loss

The emergency department nurse is caring for an infant with suspected bacterial conjunctivitis. Which collaborative intervention should the nurse prepare to​ perform? A) administering NSAID B) obtaining a chest x ray C) establishing IV access for antibiotic therapy D) gathering a culture of the eye discharge

D​ Rationale: Culture and sensitivity testing is likely to be completed on the infant with suspected bacterial conjunctivitis in order to establish the culprit organism and treat with the best indicated antibiotic. There is no indication that a chest​ x-ray is needed. Nonsteroidal​ anti-inflammatory drugs are used for the discomfort of allergic conjunctivitis. Antibiotic therapy will be​ topical, not intravenous.

In a boarding home where most patients have slight to moderate visual or hearing impairment and some are periodically confused,which of the following would be the nurse's first priority in caring for sensory concerns? a. Maintaining safety and prevent sensory deterioration b. Insisting that every patient participate in as many self-care activities as possible c. Emphasizing and reinforcing individual patient strengths d. Encouraging reminiscence and life review in groups

The correct answer is a. Safety is a basic physiologic need that must be met before higher-level needs, such as love and belonging,self-esteem, and self-actualization, can be met.

You notice that Mr. Wong, who has cataracts, is sitting closer to the television than usual. The nurse would interpret the etiologicbasis of his sensory problem is an alteration in which of the following? a. Environmental stimuli b. Sensory reception c. Nerve impulse conduction d. Impulse translation

The correct response is b. Cataracts are interfering with the patient's ability to receive visual stimuli—altered sensory reception. The nature of incoming stimuli (a), the conduction of nerve impulses (c), and the translation of incoming impulses (d) in the brain arenot a problem here.

A nurse is performing an otoscopic examination of a client. Which of the following is an unexpected finding? A. Pearly, gray TM B. Malleus visible behind the TM C. Presence of soft cerumen in the external canal D. Fluid bubble seen behind the TM

d. Fluid bubble seen behind the TM