The Eye and Ear

The nurse is performing an assessment on a client with a suspected diagnosis of cataract. Which clinial manifestation should the nurse expect to note in the early stages of cataract? a. diplopia b. eye pain c. floating spots d. blurred vision

D

The nurse is performing an admission assessment on a client with a diagnosis of detached retina. Which sign or symptom is associated with this eye disorder? a. Total loss of vision b. Pain in the affected eye c. A yellow discoloration of the sclera d. A sense of a curtain falling across the field of vision

4

A woman was working in her garden. She accidentally sprayed insecticide into her right eye. She calls the emergency department, frantic and screaming for help. The nurse should instruct the woman to take which immediate action? a. Irrigate the eyes with water. b. Come to the emergency department. c. Call the health care provider (HCP). d. Irrigate the eyes with diluted hydrogen peroxide.

A

During the early postoperative period, a client who has undergone a cataract extraction complains of nausea and severe eye pain over the operative site. What should be the initial nursing action? a. Call the HCP b. Reassure the client that this is normal c. Turn the client onto his or her operative side d. Administer the prescribed pain medication and antiemetic

A

The nurse is preparing to test the visual acuity of a client, using a snellen chart. Which identifies the accurate procedure for this visual acuity test? a. the right eye is tested, followed by the left eye, and then both eyes b. Both eyes are assessed together, followed by an assessment of the right eye and then the left eye c. The client is asked to stand at a distance of 40 feet from the chart and to read the largest line on the chart d. the client is asked to stand at a distance of 40 ft from the chart and to read the line that can be read at 200ft away by an individual with unimpaired vision

A

The client sustains a contusion of the eyeball following a traumatic injury with a blunt object. Which intervention should be initiated immediately? a. apply ice to the affected eye b. irrigate the eye with cold water c. notify the HCP d. accompany the client to the emergency department

A Treatment begins at the time of injury. Apply ice immediately.

The nurse is preparing a teaching plan for a client who had a cataract extraction with intraocular implantation. Which home care measures should the nurse include in the plan? SELECT ALL THAT APPLY a. avoid activities that require bending over b. contact the surgeon if eye scratchiness occurs c. take acetaminophen for minor eye discomfort d. expect episodes of sudden severe pain in the eye e. place an eyeshield on the surgical eye at bedtime f. contact the surgeon if decreased visual acuity occurs

A, C, E, F

A client arrives at the ED with a penetrating eye injury from wood chips that occured while cutting wood. The nurse assesses the eye and notes a piece of wood protruding from the eye. What is the inital nursing action? a. apply an ice patch b. perform a visual acuity test c. irrigate the eye with sterile saline d. Remove the piece of wood using a sterile eye clamp

B

A client is diagnosed with a disorder involving the inner ear. Which is the most common client complaint associated with a disorder involving this part of the ear? a. pruritus b. tinnitus c. hearing loss d. burning in the ear

B

A client with Meniere's disease is experiencing severe vertigo. Which instruction should the nurse give to the client to assist in controlling vertigo? a. increase sodium in the diet b. avoid sudden head movements c. lie still and watch the television d. increase fluid intake to 3L a day

B

A clients vision is tested with a Snellen chart. The results of the tests are documented as 20/60. What action should the nurse implement based on this finding? a. Provide the client with materials on legal blindness b. instruct the client that they may need glasses when driving c. inform the client of where he or she can purchase a white cane with a red tip d. Inform the client that it is best to sit near the back of the room when attending lectures

B

Tonometry is performed on the client with a suspected diagnosis of glaucoma. The nurse reviews the test results as documented test results and notes an IOP of 23. What should be the nurse's initial action? a. apply normal saline drops b. note the time of day the test was done c. contact the HCP d. Instruct the patient to sleep with the head of the bed flat

B

A client arrives in the ED following an automobile crash. The client's forehead hit the steering wheel and a hyphema is diagnosed. The nurse should place the client in which position? a. flat b. a semi-fowlers position c. lateral on the affected side d. lateral on the unaffected side

B hyphema is the presence of blood in the anterior chamber. Client is treated with bed rest and semi-fowlers position.

The nurse is caring for a hearing impaired client. Which approach will facilitate communication? a. speak loudly b. speak frequently c. speak at a normal volume d. speak directly into the impaired ear

C

The nurse is developing a teaching plan for a client with glaucoma. Which instruction should the nurse include in the plan of care? a. Avoid overuse of the eyes b. Decrease the amount of salt in the diet c. Eye medications will need to be administered for life d. Decrease fluid intake to control the IOP

C

The nurse notes that the HCP has documented a diagnosis of presbycusis on a client's chart. Based on this information, what action should the nurse take? a. speak loudly, but mumble or slur words b. speak loudly, but mumble or slur the words c. Speak at normal tone and pitch, slowly and clearly d. speak loudly and directly into the clients affected ear

C

The nurse is caring for a client following enucleation and notes the presence of bright red drainage on the dressing. Which action should the nurse take at this time? a. document the finding b. continue to monitor for drainage c. Notify the HCP d. Mark the drainage on the dressing and monitor for any increase in bleeding.

C indicates hemorrhage

The nurse is caring for a client following craniotomy for removal of an acoustic neuroma. Assessment of which cranial nerve would identify a complication specifically associated with this injury? a. CN 1- olfactory b. CN 4- trochelar c. CN 3- oculomotor d. CN 7- facial

D

The nurse is performing an otoscopic examination on a client with mastoiditis. On examination of the tympanic membrane, which finding should the nurse expect to observe? a. a pink-colored tympanic membrane b. a pearly colored tympanic membrane c. A transparent and clear tympanic membrane d. A red, dull, thick, and immobile tympanic membrane

D