212 - Sensory Practice Questions

The nurse is reviewing postoperative instructions with a client undergoing stapedectomy. Which statement by the client indicates a need for further teaching?

"I will be able to hear as soon as my dressing is removed" Further teaching is necessary if the client states that he will be able to hear as soon as the dressing is removed. Hearing is initially worse after a stapedectomy. The client would be informed that improvement in hearing may not occur until 6 weeks after surgery. At first, the ear packing interferes with hearing, and swelling in the ear after surgery reduces hearing, but these conditions are temporary.

A client is returning home after cataract surgery with a patch over the affected eye. Which statement by the client's spouse indicates a need for further instruction on providing a safe home environment?

"I will rearrange the furniture for better flow before my spouse gets home." Changes in item location would not be made without input from the client with reduced vision.

The nurse is teaching a client who will soon be fitted for a hearing aid about proper care and use. Which statement by the client indicates that teaching was effective?

"Listening to the radio and television will help me get used to new sounds." Teaching was effective if the client states that listening to television and the radio and reading aloud will help the client to get used to new sounds.

The nurse is teaching a client with vertigo about safety precautions for fall prevention. Which statement by the client indicates a need for further instruction?

"Taking my medication will allow me to drive my car again" Medications for vertigo may cause drowsiness, so the client must not drive or operate machinery while taking these drugs.

The nurse is performing preoperative teaching for an older adult client who will be having a cataract removed. Which instructions does the nurse include? (Select all that apply)

- "Several different types of eye drops are requested after surgery, and they have to be taken several times a day for up to 4 weeks." - "You will receive a medication to help you relax. Then you will receive eye drops to dilate your pupils and paralyze the lens." - "Bring sunglasses with you on the day of your procedure." The client will have multiple eye drops to use after surgery and needs to be made aware of this before the procedure to understand the importance. Providing information on what to expect, such as telling the client about the medication that will be administered and the eye drops that will dilate and paralyze the lens, helps the client prepare for the day of surgery. The client will need to have sun protection after the procedure.

A bedridden client with reduced vision has been admitted. Which nursing interventions will ease the client's hospital stay? (Select all that apply)

- announce name & purpose when entering the client's room - explain food positions on the tray using a clock face as the example - orient the client to the location of the call light & keep it in that place - orient the client to the room surroundings & equipment Staff would always introduce themselves to clients, with or without visual issues. Using a standard clock face to explain food locations on the tray will assist the client with self-feeding. Providing room orientation to the client is important to improve his or her ability for self-care. Orienting the client to the room and equipment in the room will allow him or her to have increased comfort with surroundings.

The nurse is providing discharge instructions to a client with glaucoma. Which activities does the nurse instruct the client to avoid? (Select all that apply)

- blowing the nose frequently - lifting objects weighing more than 10 pounds (4.5 kg) - bending over to tie shoes Any action that would increase pressure in the eye needs to be avoided, such as bending over, excessive blowing of the nose, and lifting heavy objects that weigh more than 10 pounds (4.5 kg).

A nurse is teaching a client who has a new diagnosis of primary open-angle glaucoma (POAG). Which of the following information should the nurse include in the teaching? (Select all that apply)

- driving can be dangerous due to loss of peripheral vision - laser surgery can help reestablish the flow of aqueous humor Damage to the optic nerve that occurs secondary to increased intraocular pressure causes a decrease in peripheral vision and can cause complete vision loss if not treated. Laser surgery can reopen the trabecular meshwork and widen the Canal of Schlemm.

A nurse is providing teaching to a client who has a new diagnosis of migraine headaches about interventions to reduce pain at the onset of a migraine. Which of the following instructions should the nurse include in the teaching?

Darken the lights. The nurse should instruct the client to lie down in a dark room to reduce migraine pain.

The nurse is teaching the mother of a teenage client with conjunctivitis how to administer eye ointment. Which statement by the mother indicates a correct understanding of the nurse's instruction?

I will place the ointment in the lower lid. The mother's statement that she will place the ointment in the lower lid indicates that she understands the nurse's instruction correctly. After the lower lid is gently pulled down to form a small pocket, eye ointment would be placed in the lower lid. For instillation of eye ointment, the client would tilt the head backward and look up at the ceiling. After closing the eye, the client may gently wipe away any excess ointment with a tissue, but the eye would never be rubbed. Pressing on the inner canthus is a technique reserved for the instillation of glaucoma drops.

A nurse in a clinic is providing teaching to an adolescent client who has recurrent external otitis. Which of the following instructions should the nurse include in the teaching?

Instill a diluted alcohol solution into the ear after swimming. External otitis is an inflammation of the external auditory canal often due to the retention of water in the ear from swimming. After the inflammation is gone, the client can prevent recurrence of external otitis by instilling diluted alcohol drops to decrease bacteria and dry the external ear canal.

The nurse is providing postmortem care to a client who will donate a cornea. Which action is appropriate for the nurse to implement?

Instill antibiotic drops into the eyes. Antibiotic eye drops, such as Neosporin (polymyxin B, neomycin, bacitracin) or tobramycin, is appropriate to instill into the corneal donor's eyes to prevent infection.

A client with visual limitations has been admitted to the intensive care unit (ICU). Which action is most important to implement for this client?

Making all health care team members aware of the client's visual limitations It is most important to be sure all health care team members are aware of the client's visual limitations and need for assistance.

Which technique is correct when instilling ear drops?

Place the medication bottle of warm water before instillation The correct way to instill eardrops is to first place the bottle (with the top on tightly) in a bowl of warm water for 5 minutes. This warms the medication and makes instillation more comfortable for the client. The head would be gently moved back and forth five times after instillation to ensure proper distribution.

What is the proper technique for assessing an adult client's ear with an otoscope?

Pull the pinna up and back with the non dominant hand In the adult, pulling the pinna up and back with the nondominant hand allows the ear canal to straighten. The otoscope should be held upside down, like a large pen.

A client has purulent drainage in the inner canthus of the eye. Before examining the eye, what must the nurse do first?

Put on gloves The nurse must first put on gloves. Gloves must be worn in the presence of drainage and would be put on before examining the eye.

A client has recently had cataract surgery. The nurse will instruct the client to notify the health care provider immediately if which symptom occurs?

Reduction in vision A reduction in vision after cataract surgery indicates a problem, and the client would notify the provider immediately.

A client is in the immediate postoperative period after tympanoplasty. How does the nurse position the client?

With the affected ear facing up The nurse keeps the client flat, with the head turned to the side and the operative ear facing up, for at least 12 hours after surgery.

A client is having a stapedectomy. Which form of postoperative communication is most effective for the nurse to use?

Writing Writing is the most effective way to communicate with the client who has undergone a stapedectomy.

A nurse is providing discharge teaching to a client who is postoperative following scleral buckling to repair a detached retina. Which of the following instructions should the nurse include in the teaching?

You should avoid reading for 1 week. The client should avoid reading and any activity that can cause rapid movement of the eye because of the risk for detachment of the retina.

A client recently diagnosed with Ménière's disease is struggling with tinnitus. How does the nurse provide support to this client?

Refer the client to the American Tinnitus Association.

The nurse is teaching a client with impaired hearing about audiometric testing. Which statement by the nurse effectively communicates information about the procedure to the client?

"I will sit right in front of you in the soundproof booth and give you instructions on what types of sounds you will hear and how you'll need to respond." An effective statement by the nurse regarding audiometric testing involves informing the client that the nurse will be sitting in front of the hearing-impaired client while providing instructions. This allows the client to read lips.

The nurse is preparing a client for electronystagmography. Which statement by the client indicates that teaching was effective?

"I can't drink caffeine 24 to 48 hours before the test." The client must avoid caffeine-containing beverages for 24 to 48 hours before the test. Electronystagmography (ENG) is a test to assess for central and peripheral disease of the vestibular system in the ear by detecting and recording nystagmus (involuntary eye movements). This response is accurate because the eyes and ears depend on each other for balance.

A client has a bilateral corneal disorder and must instill anti-infective eye drops every hour for the first 24 hours. Which comment by the client indicates a need for further instruction by the nurse?

"I have two bottles of eye drops in case I run out." If both eyes are infected, separate bottles of drugs are needed for each eye. The client must be taught to clearly label the bottles "right eye" and "left eye" and to not switch the drugs from eye to eye.

The nurse is talking to a client about cerumen removal from the ear canal. Which statement by the client indicates a need for further teaching?

"I use a cotton swab to remove earwax." Use of a cotton swab can scrape the skin of the canal, push cerumen up against the eardrum, and even puncture the eardrum.

The nurse is teaching a client about ear protection. Which statement by the client indicates that teaching was effective?

"I wear foam ear inserts at works where it is noisy." Foam ear inserts or over-the-ear headsets protect against potential ear damage from loud noises.

Which clients are at high risk for developing hearing problems? (Select all that apply)

- Airline mechanic - Client with Down syndrome - Drummer in a rock band - Teenager listening to music using ear buds

The nurse is assessing a client with recent changes in hearing. After taking a medication history, which drugs does the nurse identify as possible causes of the client's hearing change? (Select all that apply)

- Erythromycin - Ibuprofen (Advil) - Furosemide (Lasix) The nurse identifies erythromycin, ibuprofen, and furosemide (Lasix) as medications known to increase the risk for hearing change related to ototoxicity and hearing problems.

Which client is most in need of immediate examination by an ophthalmologist?

A 40-year-old with glasses and a reddened sclera who reports brow pain, headache, and seeing colored halos around lights. This client is exhibiting signs and symptoms of increased intraocular pressure (IOP). This is a priority because the optic nerve can be damaged, which can cause possible blindness. Acute angle-closure glaucoma can occur in people 40 years of age and older.

An older adult client comes in for a routine visit. During the assessment he is irritable and says, "Speak up and quit mumbling!" How will the nurse respond?

Apologize and speak louder and clearer The nurse would repeat and speak more clearly first and then determine whether further assessment is needed.

Which test best determines hearing acuity?

Audiometry

A nurse is providing teaching to a client who has a new diagnosis of Meniere's disease. Which of the following instructions should the nurse include in the teaching?

Avoid sudden movements Meniere's disease is a disorder of the inner ear affecting balance and hearing, characterized by vertigo, hearing loss, and tinnitus. The nurse should instruct the client to avoid sudden movements that can increase manifestations.

A client with new-onset diminished vision is being discharged and is concerned about living independently. Which nursing technique best facilitates independent self-care for the client?

Building on the remaining vision Using large-print books, talking clocks, and telephones with large, raised block numbers are examples of building on the client's remaining vision, and best facilitates the client's independent self-care.

The nurse has just received change-of-shift report about these clients. Which client needs to be assessed first?

Client with labyrinthitis who has a temperature of 102.4° F (39.1° C) and a headache This may indicate that the client has developed meningitis requiring immediate intervention.

Which type of hearing loss is most likely to be reversible when treated appropriately?

Conductive hearing loss Conductive hearing loss is most likely to be reversible when treated appropriately. This type of hearing loss is often the result of an obstruction in the ear canal or a retracted or bulging tympanic membrane.

An older adult client reports ear pain. Otoscopic examination for otitis media by the nurse practitioner (NP) reveals a dull and retracted membrane. What does the NP do next?

Continues further assessment The NP needs to perform further assessments. A dull and retracted membrane is not the only indication of otitis media for the older adult client. This finding may be a normal age-related change.

The nurse is performing an otoscopic examination of a client's ear and notes greenish-white drainage. What does the nurse do next?

Disposes of the otoscope tip and washes the hands before examining the other ear To prevent cross-contamination, Contact Precautions must be used with any client who has drainage from the ear canal.

Which type of drug therapy does the nurse anticipate giving to a client with Ménière's disease to decrease endolymph volume?

Diuretics Mild diuretics are prescribed to decrease endolymph volume. Ménière's disease causes an excess of endolymphatic fluid that distorts the entire inner-canal system. This distortion decreases hearing by dilating the cochlear duct, causes vertigo because of damage to the vestibular system, and stimulates tinnitus.

An older adult client reports ear pain. To differentiate the cause, which clinical manifestation is more indicative of otitis media?

Dizziness Dizziness is more indicative of otitis media due to pressure as the middle ear pushes against the inner ear.

When preparing to examine an ear with drainage, what does the nurse do first?

Dons clean gloves The nurse needs to don clean gloves first to prevent infection, Contact Precautions need to be used when assessing drainage from a client's ear canal.

A nurse is teaching a client who has myopia about laser-assisted in situ keratomileusis (LASIK) surgery. The nurse should include in the teaching that which of the following is an adverse effect of LASIK surgery?

Dry eyes LASIK surgery is a procedure that can correct nearsightedness, farsightedness, and astigmatism by changing the shape of the cornea. Adverse effects of LASIK surgery include dryness of the eyes and blurred vision.

What is the action of miotic drugs that constrict the pupils in the client with glaucoma?

Enhance aqueous circulation to site of absorption Miotics are used to improve the flow of fluid (aqueous humor) and circulation and decrease intraocular pressure in clients with glaucoma.

A nurse is teaching a class of new parents about otitis media. Which of the following manifestations should the nurse include in the teaching?

Feeling of fullness in the ear A client who has otitis media can develop a feeling of fullness in the ear. Other manifestations can include ear pain, a cracking sound when yawning or swallowing, and mild dizziness.

A client with glaucoma is being assessed for new symptoms. Which symptom indicates a high priority need for reassessment of intraocular pressure?

Gradual vision changes Gradual vision changes are an indication of increased intraocular pressure and indicate a high priority for reassessment.

A client has recently been diagnosed with 20/200 vision bilaterally and tells the nurse he is "legally blind." How does the nurse best offer increased support?

Refers the family to local services for the blind Because the client is considered legally blind, referring the family to local services for the blind is the best way for the nurse to offer increased support.

The nurse is teaching a client about administering eye drops to treat open-angle glaucoma. Which statement by the client indicates a need for further instruction?

I must press on the inside of my eye to prevent washout Pressing on the inside of the eye after instillation of eye medication prevents systemic absorption of the drug. To avoid washout, the client must wait 10 to 15 minutes between eye drop medications.

A nurse is providing discharge teaching to a client who is postoperative following cataract surgery and has an intraocular lens implant. Which of the following statements by the client indicates an understanding of the instruction?

I will avoid bending over. The nurse should instruct the client to avoid activities that can increase intraocular pressure, such as lifting, bending, coughing, or performing the Valsalva maneuver. An increase in intraocular pressure can result in intraocular hemorrhage.

A client has sustained damage to the optic nerve after a traumatic injury. Which intervention does the nurse anticipate to accommodate for this injury?

Identifying food on the client's plate using the clock method Using the clock method helps the client with impaired vision or loss of vision locate food on his or her plate.

A nurse is assessing a client who has a new diagnosis of acute angle-closure glaucoma. The nurse should anticipate the client to report which of the following manifestations?

Severe eye pain Severe eye pain is a manifestation of acute angle-closure glaucoma. Other manifestations can include report of halos around lights, blurred vision, headache, brow pain, and nausea and vomiting.

An older adult client reports nausea during irrigation of the ear canal to remove impacted cerumen. What does the nurse do next?

Stop irrigation immediately If nausea, vomiting, or dizziness develops in the client, the nurse needs to next stop the irrigation immediately. The client's nausea may be a sign of vertigo.

A nurse is assessing a client who has a new diagnosis of mastoiditis. Which of the following manifestations should the nurse expect?

Swelling behind the affected ear Mastoiditis refers to an inflammation of the temporal bone behind the ear. Manifestations of mastoiditis include swelling and pain behind the ear.

The nurse is caring for a client who is admitted with mastoiditis. Which assessment data obtained by the nurse requires the most immediate action?

The client reports a headache and a stiff neck. The most immediate action is required when the client reports a headache and a stiff neck. These complaints may indicate meningitis, which is a serious illness requiring further assessment and immediate intervention.