VISUAL/HEARING
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? 1. Call the health care provider (HCP). 2. Reassure the client that this is normal. 3. Turn the client onto his or her operative side. 4. Administer the prescribed pain medication and antiemetic.
1 Rationale: Severe pain or pain accompanied by nausea follow- ing a cataract extraction is an indicator of increased intraocular pressure and should be reported to the HCP immediately. Options 2, 3, and 4 are inappropriate actions. Test-Taking Strategy: Note the strategic word, initial, and the word severe. Eliminate option 2 because this is not a normal condition. The client should not be turned to the operative side; therefore, eliminate option 3. From the remaining options, focusing on the strategic word will direct you to the correct option.
The elderly client has undergone a right - eye cat aract removal with an intraocular implant. Which discharge instructions should the nurse teach the client ? 1. Have the client demonstrate placing the otic drops in the ear . 2. Teach the client to instill the eyedrops as prescribed . 3. Remind the client to keep the lights in the home low at all times . 4. Encourage the client to sleep on two pillows at night .
2. Postoperatively the client will be pre scribed eyedrops for several weeks ; the nurse should teach the client to admin ister as prescribed . TEST - TAKING HINT: The test taker must know basic instructions for postoperative clients .
The nurse is developing a teaching plan for a client with glaucoma. Which instruction should 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.
3 Rationale: The administration of eye drops is a critical component of the treatment plan for the client with glaucoma. The client needs to be instructed that medications will need to be taken for the rest of his or her life. Options 1, 2, and 4 are not accurate instructions. Test-Taking Strategy: Focus on the subject, client teaching for glaucoma. Recalling that medications are an integral component of the treatment plan will assist in directing you to the correct option.
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
ANS: 1, 2, 3, 5 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. 4) Alcohol intake is not identified as a risk factor for cataracts. 5) Chronic medical conditions such as diabetes, autoimmune disorders, hypertension, and other eye problems are considered to be at higher risk for cataract development.
The nurse is assessing a patient diagnosed with open-angle glaucoma. Which clinical manifestation should the nurse expect to find? 1) Gradual loss of peripheral vision 2) Intermittent stabbing eye pain 3) Progressive reduction of color brightness 4) Rapid change in visual acuity
ANS 1 In primary open-angle glaucoma, clinical manifestations include gradual loss of peripheral vision, usually in both eyes.
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
ANS 2 cataract removal increases the risk 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
ANS 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
ANS 4 Elevating the head of the bed 30 to 45 degrees promotes drainage and prevents any increase in IOP
A patient is scheduled for a cochlear implant. Which patient statement indicates that teaching about this surgery has been effective? 1) "This implant will not restore my hearing." 2) "I will be able to hear perfectly after this surgery." 3) "This surgery will drain fluid from my middle ear." 4) "This surgery will rebuild my damaged tympanic membrane."
ANS: 1 1) The cochlear implant does not restore normal hearing. 2) The cochlear implant does not restore normal hearing. 3) A myringotomy drains fluid from the middle ear. 4) A myringoplasty reconstructs the eardrum.
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 the vision
ANS: 1 In glaucoma , the client is often unaware of 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 . " TEST HINT: the findings of eye disorders are confusing. The test taker must know which reports will be made by the client diagnosed with a specific eye disorder.
Which referral is most important for the nurse to implement for the client diagnosed with per manent hearing loss? 1. Aural rehabilitation . 2. Speech therapist . 3. Social worker . 4. Vocational rehabilitation .
ANS: 1 The purpose of aural rehabilitation is to maximize the communication skills of clients with hearing impairments . It includes auditory training , speech reading , speech training , and the use of hearing aids and hearing guide dogs .
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 .
ANS: 1, 2, 3 1. The tympanic membrane is the ear drum , and if it is punctured , it may lead to hearing loss . 2. Loud , persistent noise , such as heavy machinery , engines , and artillery , over time may cause noise - induced hearing loss . 3. Multiple ear infections scar the tym panic membrane , which can lead to hearing loss . TEST - TAKING HINT : Many options can be eliminated as incorrect answers when the test taker knows medical terminology - nephro means kidney-related and normal anatomy of the body - auricle means "skin attached to the head ."
The 65 - year - old client is diagnosed with macular degeneration. Which statements by the client indi cate the client understands the discharge teaching ? Select all that apply . 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." 5. " I will take my ordered nutritional supplements daily . "
ANS: 1, 2, 4, 5 1. Magnifying devices used with activities such as threading a needle will help the client's vision ; therefore , this statement indicates the client understands the teaching . 2. An Amsler grid is a tool to assess macular degeneration , often providing the earliest sign of a worsening condition . If the lines of the grid become distorted or faded , the client should call the ophthalmologist . 4. Low - vision centers will send representatives to the client's home or work to make recommendations about improving lighting , thereby improving the client's vision and safety . 5. Taking nutritional supplements such as a combination of certain high - dose vitamins and minerals ( vitamin C and E, beta - carotene , zinc , and copper ) can protect against age - related macular degeneration or slow the progression. which statements TEST - TAKING HINT : This question is asking which statements indicate the client understands the teaching. It is an alternative format question. The test taker should select more than one option as correct and must select all appropriate options to receive credit for a correct answer.
Which situation makes the nurse suspect the client has glaucoma ? 1. An automobile accident because the client did not see the car in the next lane . 2. The cake tasted funny because the client could not read the recipe . 3. The client has been wearing mismatched clothes and socks . 4. The client ran a stoplight and hit a pedestrian walking in the crosswalk .
ANS: 1. Loss of peripheral vision as a result of glaucoma causes the client problems with seeing things on each side , resulting in a " blind spot . " This problem can lead to the client having car accidents when switching lanes .
The nurse is visiting the home of a patient recovering from laser trabeculoplasty. Which observation made by the nurse increases this patient's risk of developing a postoperative complication? 1) Takes a daily laxative 2) Picks up a 3-year-old grandchild 3) Washes hands before applying eye drops 4) Applies pressure to the lacrimal duct after applying eye drops
ANS: 2 1) Straining at a bowel movement is contraindicated and can increase the chance of postoperative bleeding within the eye. A laxative would avoid this potential complication. 2) Lifting heavy objects such as a grandchild increases intraocular pressure, which should be avoided after having this surgery. 3) Washing hands before applying eye drops reduces the risk of a postoperative infection. 4) Applying pressure to the lacrimal duct after applying eye drops reduces the risk of systemic absorption of the medication.
A patient has been experiencing a gradual loss of central vision. Which tool should the nurse use when assessing this patient? 1) Jaeger card 2) Amsler grid 3) Snellen chart 4) Ishihara chart
ANS: 2 1) The Jaeger card assesses near vision. 2) The Amsler grid is used to determine if a matrix of black lines appear straight or are wavy, which could indicate macular degeneration. 3) The Snellen chart is used to assess for visual acuity. 4) The Ishihara chart is used to assess color vision
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 . " 2. " I keep turning up the sound on my television . " 3. " My ears hurt , especially when I yawn . " 4. " I get dizzy when I get up from the chair . "
ANS: 2 The need to turn up the volume on the television is an early sign of hearing impairment TEST - TAKING HINT: If the test taker has no idea of the answer , option " 2 " is the only answer that has anything to do with sound .
A patient with a hearing loss is wearing headphones as a part of a diagnostic test. What test is being completed with this patient? 1) Tympanometry 2) Pure-tone threshold 3) MRI with gadolinium 4) Speech reception threshold
ANS: 2 1) Tympanometry is a test that measures the impedance of the middle ear to the acoustic energy. 2) Pure-tone threshold is an audiological test conducted with air and bone conduction assessment to quantify hearing loss. To complete this test, the patient wears headphones. 3) Standard MRI with gadolinium enhancement is usually performed with patients who present with an abnormal neurological examination and/or when a cerebellopontine- angle lesion is suspected. 4) Speech reception threshold is used to measure the intensity at which speech is recognized by a patient. This test is used to determine the softest level at which the patient is able to recognize speech.
Which behavior by the male client should make the nurse suspect the client has a hearing loss? Select all that apply. 1. The client reports hearing voices in his head. 2. The client becomes irritable very easily. 3. The client has difficulty making decisions. 4. The client's wife reports he ignores her. 5. The client does not dominate a conversation.
ANS: 2, 3, 4 1. Voices in the head may indicate schizophrenia, but it is not a symptom of hearing loss. 2. Fatigue may be the result of straining to hear, and a client may tire easily when listening to a conversation. Under these circumstances, the client may become irritable very easily. 3. Loss of self-confidence makes it increasingly difficult for a person who is hearing impaired to make a decision. 4. Often it is not the person with the hear- ing loss but a significant other who notices hearing loss; hearing loss is usually gradual. 5. Many clients who are hearing impaired tend to dominate the conversation because, as long as it is centered on the client, they can control it and are not as likely to be embarrassed by some mistake.
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
ANS: 2. Both systemic and topical medications are used to decrease the intraocular pressure in the eye , which causes glaucoma TEST - TAKING HINT : To determine the effectiveness of a medication , the nurse must know the findings of the disease process . If the test taker knew glaucoma was the result of an increase in intraocular pressure, then the medication is effective if ther was a decrease in intraocular pressure.
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
ANS: 3 1) An MRI would not detect glaucoma. 2) A CT scan would not detect glaucoma. 3) Tonometry measures the pressures within the eyes and is usually conducted during a routine eye examination. 4) An ultrasound would not detect glaucoma.
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
ANS: 3 1) This treatment does not affect the skin. 2) Increased fluid intake is not required after this 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. 4) The patient should avoid indoor and outdoor bright light for five days. Sunglasses would not be needed since bright light is avoided.
The nurse is preparing a tool about macular degeneration that will be posted during a health fair. Which modifiable risk factors should the nurse include in this tool? Select all that apply. 1) Race 2) Gender 3) Obesity 4) Smoking 5) High blood pressure
ANS: 3, 4, 5 1) Nonmodifiable risk factors for macular degeneration include race. 2) Nonmodifiable risk factors for macular degeneration include gender. 3) Modifiable risk factors for macular degeneration include obesity. 4) Modifiable risk factors for macular degeneration include smoking. 5) Modifiable risk factors for macular degeneration include high blood pressure.
The client diagnosed with cataracts had intraoc ular lens implants and is being discharged from the day surgery department . Which discharge instructions should the nurse discuss with the client ? 1. Do not push or pull objects heavier than 50 pounds . 2. Lie on the affected eye with two pillows at night . 3. Wear glasses or metal eye shields at all times. 4. Bend and stoop carefully for the rest of your life
ANS: 3. The eyes must be protected by wearing glasses or metal eye shields at all times following surgery . Very few answer options with " all " will be correct , but if the option involves ensuring safety , it may be the correct option .
The nurse notes that a patient known to the community clinic was unable to recognize the health-care provider. What health problem should the nurse suspect is occurring with this patient? 1) Cataracts 2) Glaucoma 3) Corneal abrasions 4) Macular degeneration
ANS: 4 1) Cataracts will not cause the patient to be unable to recognize faces. 2) Glaucoma will not cause the patient to be unable to recognize faces. 3) Corneal abrasions will not cause the patient to be unable to recognize faces. 4) Dry macular degeneration causes a gradual blurring of the central vision, and the patient may have difficulty recognizing faces.
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 foods." 4) "I should call my doctor before taking any over-the-counter medications."
ANS: 4 1) There is no surgery to cure glaucoma. 2) The eye drops should be used as prescribed and not only with blurred vision. 3) Dietary changes will not affect glaucoma. 4) The patient should be instructed to not take any medication, over-the-counter or prescription, without contacting the eye care practitioner first.
The student nurse asks the nurse, "Which type of hearing loss involves damage to the cochlea or vestibulocochlear nerve ?" Which statement is the best response of the RN ? 1. " It is called conductive hearing loss . " 2. " It is called a functional hearing loss . " 3. " It is called a mixed hearing loss . " 4. " It is called sensorineural hearing loss ."
ANS: 4 Sensorineural hearing loss is described in the stem of the question. It involves damage to the cochlea or vestibulocochlear nerve.
The client is scheduled for a right eye cataract removal surgery in 5 days. Which preoperative instruction should be discussed with the client ? 1. Administer dilating drops to both eyes for 72 hours before surgery . 2. Before surgery do not lift or push any objects heavier than 15 pounds . 3. Make arrangements for being in the hospital for at least 3 days . 4. Avoid taking any type of medication which may cause bleeding, such as aspirin .
ANS: 4. Anticoagulation therapy is withheld , including aspirin , NSAIDs , and warfa rin ( Coumadin ) to reduce retrobulbar hemorrhage . TEST - TAKING HINT : The test taker must notice the adjectives ; these descriptors are important when selecting a correct answer . The test taker should notice " preoperative" and " before surgery . "
The 65 - year - old male client is describing blurred vision and reports his glasses need to be cleaned all the time . The client denies any eye pain . Which eye disorder should the nurse suspect the client has ? 1. Corneal dystrophy . 2. Conjunctivitis . 3. Diabetic retinopathy . 4. Cataracts .
ANS: 4. A cataract is a lens opacity or cloudiness , resulting in the findings discussed in the stem of the question TEST - TAKING HINT : The test taker must know the findings of eye disorders , especially those commonly occurring in the elderly . Option " 2 " could be ruled out because -itis means inflammation , and none of the findings are inflammatory .