460 exam 2 success eye and ear

15. The nurse is caring for a client diagnosed with acute otitis media. Which signs/symptoms support this medical diagnosis? 1. Unilateral pain in the ear. 2. Green, foul-smelling drainage. 3. Sensation of congestion in the ear. 4. Reports of hearing loss

15. *1. Otalgia (ear pain) is experienced by clients with otitis media.* 2. A green, foul-smelling drainage supports the diagnosis of external otitis, not of acute otitis media. 3. A sensation of congestion in the ear supports serous otitis media. 4. Hearing loss supports a diagnosis of chronic otitis media or serous otitis media.

1. Which recommendation should the nurse suggest to an elderly client who lives alone when discussing normal developmental changes of the olfactory organs? 1. Suggest installing multiple smoke alarms in the home. 2. Recommend using a night light in the hallway and bathroom. 3. Discuss keeping a high-humidity atmosphere in the bedroom. 4. Encourage the client to smell food prior to eating it

1. *1. The decreased sense of smell resulting from atrophy of olfactory organs is a safety hazard, and clients may not be able to smell gas leaks or fire, so the nurse should recommend a carbon monoxide detector and a smoke alarm. This safety equipment is critical for the elderly.* 2. Night lights do not address the client's sense of smell. 3. High humidity may help with breathing, but it does not help the sense of smell. 4. The client's sense of smell is decreased; therefore, smelling food before eating is not an appropriate intervention.

1. 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. 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." 2. Floating spots in the vision is a symptom of retinal detachment. 3. A yellow haze around everything is a complaint of clients experiencing digoxin toxicity. *4. The complaint of a curtain coming across vision is a symptom of retinal detachment.*

10. 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.

10. 1. Steroid medication is administered to decrease inflammation. *2. Both systemic and topical medications are used to decrease the intraocular pressure in the eye, which causes glaucoma.* 3. Glaucoma does not affect the pupillary reaction. 4. Floaters are a complaint of clients with retinal detachment.

11. The client is scheduled for laser-assisted in situkeratomileusis (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

11. 1. The client does not have to wear eye patches after this surgery. 2. The purpose of this surgery is to ensure the client does not have to wear any type of corrective lens. 3. The client can read immediately after this surgery. *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.*

11. The female client tells the clinic nurse she is going on a seven (7)-day cruise and is worried about getting motion sickness. Which information should the nurse discuss with the client? 1. Make an appointment for the client to see the health-care provider. 2. Recommend getting an over-the-counter scopolamine patch. 3. Discourage the client from taking the trip because she is worried. 4. Instruct the client to lie down and the motion sickness will go away.

11. 1. This is not a condition requiring an ap pointment with the health-care provider. *2. Anticholinergic medications, such as scopolamine patches, can be recommended by the nurse; this is not prescribing. Motion sickness is a disturbance of equilibrium caused by constant motion.* 3. Motion sickness can be controlled with medication and it may not even occur. Therefore, discussing canceling the trip is not providing the client with appropriate information. 4. This is providing the client with false in formation. Lying down may or may not help motion sickness. To be able to enjoy the cruise, the client needs medication.

12. 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

12. 1. Movement of the eye should be avoided until the client has received general anesthesia; therefore, this is not the first intervention. 2. Parenteral broad-spectrum antibiotics are initiated but not until the eyes are treated first. *3. Before any further evaluation or treatment, the eyes must be thoroughly flushed with sterile normal saline solution.* 4. Tetanus prophylaxis is recommended for full-thickness ocular wounds.

12. The nurse writes the diagnosis "risk for injury related to impaired balance" for the client diagnosed with vertigo. Which nursing intervention should be included in the plan of care? 1. Provide information about vertigo and its treatment. 2. Assess for level and type of diversional activity. 3. Assess for visual acuity and proprioceptive deficits. 4. Refer the client to a support group and counseling.

12. 1. This is appropriate for a diagnosis of "knowledge deficit." 2. This is appropriate for a diagnosis of "deficient diversional activity" related to environmental lack of activity. *3. Balance depends on visual, vestibular, and proprioceptive systems; therefore, the nurse should assess these systems for signs/symptoms.* 4. This is appropriate for a diagnosis of "ineffective coping."

13. The nurse is assessing the client's cranial nerves. Which assessment data indicate cranial nerve I is intact? 1. The client can identify cold and hot on the face. 2. The client does not have any tongue tremor. 3. The client has no ptosis of the eyelids. 4. The client is able to identify a peppermint smell.

13. 1. Being able to identify cold and hot on the face indicates an intact trigeminal nerve, cranial nerve V. 2. Not having any tongue tremor indicates an intact hypoglossal nerve, cranial nerve XI. 3. No ptosis of the eyelids indicates an intact oculomotor nerve (cranial nerve III), trochlear nerve (IV), and abducens nerve (VI). Tests also assess for ocular motion, conjugate movements, nystagmus, and papillary reflexes. *4. Cranial nerve I is the olfactory nerve, which involves the sense of smell. With the eyes closed, the client must identify familiar smells to indicate an intact cranial nerve I.*

13. 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.

13. 1. Cleaning the ears daily does not indicate the client has a hearing loss. *2. The need to turn up the volume on the television is an early sign of hearing impairment.* 3. Pain in the ears is not a clinical manifestation of hearing loss/impairment. 4. This statement may indicate a balance problem secondary to an ear disorder, but it does not indicate a hearing loss.

14. 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

14. *1. The tympanic membrane is the eardrum, 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 tympanic membrane, which can lead to hearing loss.* 4. Nephrotoxic means harmful to the kidneys; ototoxic is harmful to the ears. 5. Multiple pierced earrings do not lead to hearing loss. The auricle (skin attached to the head) is composed mainly of cartilage, except for the fat and subcutaneous tissue in the earlobe.

14. The elderly client is complaining of abdominal discomfort. Which scientific rationale should the nurse remember when addressing an elderly client's perception of pain? 1. Elderly clients react to pain the same way any other age group does. 2. The elderly client usually requires more pain medication. 3. Reaction to painful stimuli may be decreased with age. 4. The elderly client should use the Wong scale to assess pain.

14. 1. This is an inaccurate statement. 2. The elderly client usually requires less pain medication because of the effects of the normal aging process on the liver (metabolism) and renal system (excretion). *3. Decreased reaction to painful stimuli is a normal developmental change; there fore, complaints of pain may be more serious than the client's perception might indicate and thus such com plaints require careful evaluation.* 4. The Wong scale is used to assess pain for the pediatric client, not the adult client.

15. Which instruction should the nurse discuss with the client when completing a sensory assessment? 1. Instruct the client to lie flat without a pillow during the assessment. 2. Instruct the client to keep both eyes shut during the assessment. 3. During the assessment the client must be in a treatment room. 4. Keep the lights off during the client's sensory assessment.

15. 1. The client should be in the sitting position during a sensory assessment. *2. The eyes are closed so tactile, superficial pain, vibration, and position sense (proprioception) can be assessed without the client seeing what the nurse is doing.* 3. The sensory assessment can be conducted at the bedside; there is no reason to take the client to the treatment room. 4. There is no reason the lights should be off during the sensory assessment; the client should close his or her eyes.

16. The client diagnosed with chronic otitis media is scheduled for a mastoidectomy. Which discharge teaching should the nurse discuss with the client? 1. Instruct the client to blow the nose with the mouth closed. 2. Explain the client will never be able to hear from the ear. 3. Instill ophthalmic drops in both ears and then insert a cotton ball. 4. Do not allow water to enter the ear for six (6) weeks

16. 1. The client should blow the nose with the mouth open to prevent pressure in the Eustachian tube. 2. There may be temporary deafness as a result of postoperative edema, but the hearing will return as the edema subsides. 3. Ophthalmic drops are used in the eyes, not the ears. Otic drops are used for the ears. *4. Water should be prevented from entering the external auditory canal because it may irritate the surgical incision and is a medium for bacterial growth.*

16. Which signs/symptoms should the nurse expect to find when assessing the client with an acoustic neuroma? 1. Incapacitating vertigo and otorrhea. 2. Nystagmus and complaints of dizziness. 3. Nausea and vomiting. 4. Unilateral hearing loss and tinnitus.

16. 1. Vertigo and otorrhea are not the signs/ symptoms of an acoustic neuroma. 2. Neither nystagmus, an involuntary rhythmic movement of the eyes, nor dizziness is a sign of an acoustic neuroma. 3. Nausea and vomiting are not signs/ symptoms of an acoustic neuroma. *4. An acoustic neuroma is a slow growing, benign tumor of cranial nerve VII. It usually arises from the Schwann cells of the vestibular portion of the nerve and results in unilateral hearing loss and tinnitus, with or without vertigo.*

17. 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.

17. 1. Antibiotics will not cure this disease. Surgery is the only cure for Ménière's disease, which may result in permanent deafness as a result of the labyrinth being removed in the surgery. 2. Ménière's disease does not lead to deafness unless surgery is performed removing the labyrinth in attempts to eliminate the attacks of vertigo. *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.* 4. Sleeping with the head of the bed elevated will not affect Ménière's disease.

17. Which assessment technique should the nurse use to assess the client's optic nerve? 1. Have the client identify different smells. 2. Have the client discriminate between sugar and salt. 3. Have the client read the Snellen chart. 4. Have the client say "ah" to assess the rise of the uvula.

17. 1. This assesses cranial nerve I, the olfactory nerve. 2. This assesses cranial nerve IX, the glossopharyngeal nerve. *3. This assesses cranial nerve II, the optic nerve, along with visual field testing and ophthalmoscopic examination.* 4. This assesses cranial nerve X, the vagus nerve.

18. Which referral is most important for the nurse to implement for the client with permanent hearing loss? 1. Aural rehabilitation. 2. Speech therapist. 3. Social worker. 4. Vocational rehabilitation.

18. *1. The purpose of aural rehabilitation is to maximize the communication skills of the client who is hearing impaired. It includes auditory training, speech reading, speech training, and the use of hearing aids and hearing guide dogs.* 2. A speech therapist may be part of the aural rehabilitation team, but the most important referral is aural rehabilitation. 3. The client may or may not need financial assistance, but the most important referral is aural rehabilitation. 4. The client may or may not need assistance with employment because of hearing loss, but the most important referral is the aural rehabilitation.

18. The client is complaining of ringing in the ears. Which data are most appropriate for the nurse to document in the client's chart? 1. Complaints of vertigo. 2. Complaints of otorrhea. 3. Complaints of tinnitus. 4. Complaints of presbycusis

18. 1. Vertigo is an illusion of movement in which the client complains of dizziness. 2. Otorrhea is drainage of the ear. *3. Tinnitus is "ringing of the ears." It is a subjective perception of sound with internal origins.* 4. Presbycusis is progressive hearing loss associated with aging.

19. Which instruction should the nurse discuss with the female client with viral conjunctivitis? 1. Contact the HCP if pain occurs. 2. Do not share towels or linens. 3. Apply warm compresses to the eyes. 4. Apply makeup very lightly.

19. 1. The client should be aware eye pain (a sandy sensation and sensitivity to light) will occur with conjunctivitis. *2. Viral conjunctivitis is a highly contagious eye infection. It is easily spread from one person to another; therefore, the client should not share personal items.* 3. Cold compresses should be placed over the eyes for about 10 minutes four (4) to five (5) times a day to soothe the pain. 4. The client must not apply any makeup until the disease is over and should discard all old makeup to help prevent reinfection.

19. Which statement best describes the scientific rationale for the nurse holding the otoscope with the hand in a pencil-hold position when examining the client's ear? 1. It is usually the most comfortable position to hold the otoscope. 2. This allows the best visualization of the tympanic membrane. 3. This prevents inserting the otoscope too far into the external ear. 4. It ensures the nurse will not cause pain when examining the ear

19. 1. This is not the rationale for holding the otoscope in this manner. 2. Holding the otoscope in this manner does not help visualize the membrane any better than holding the otoscope in other ways. *3. Inserting the speculum of the otoscope into the external ear can cause ear trauma if not done correctly.* 4. If the ear is inflamed, it may be impossible to prevent hurting the client on

2. 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.

2. 1. Dilating drops are administered every 10 minutes for four (4) doses one (1) hour prior to surgery, not for three (3) days prior to surgery. 2. Lifting and pushing objects should be avoided after surgery, not prior to surgery. 3. All types of cataract removal surgery are usually done in day surgery. *4. To reduce retrobulbar hemorrhage, any anticoagulation therapy is withheld, including aspirin, nonsteroidal anti inflammatory drugs (NSAIDs), and warfarin (Coumadin).*

2. The elderly male client tells the nurse, "My wife says her cooking hasn't changed, but it is bland and tasteless." Which response by the nurse is most appropriate? 1. "Would you like me to talk to your wife about her cooking?" 2. "Taste buds change with age, which may be why the food seems bland." 3. "This happens because the medications sometimes cause a change in taste." 4. "Why don't you barbecue food on a grill if you don't like your wife's cooking?

2. 1. The nurse needs to discuss possible causes with the client and not talk to the wife. *2. The acuity of the taste buds decreases with age, which could cause regular foods to seem bland and tasteless.* 3. Some medications may cause a metallic taste in the mouth, but medication does not cause foods to taste bland. 4. Telling the client to cook if he doesn't like his wife's food is an argumentative and judgmental response.

20. The client is two (2) hours postoperative right ear mastoidectomy. Which assessment data should be reported to the health-care provider? 1. Complaints of aural fullness. 2. Hearing loss in the affected ear. 3. No vertigo. 4. Facial drooping.

20. 1. Aural fullness or pressure after surgery is caused by residual blood or fluid in the middle ear. This is an expected occurrence after surgery, and the nurse should administer the prescribed analgesic. 2. Hearing in the operated ear may be reduced for several weeks because of edema, accumulation of blood and tissue fluid in the middle ear, and dressings or packing, so this does not need to be reported to the health-care provider. 3. Vertigo (dizziness) is uncommon after this surgery, but if it occurs the nurse should administer an antiemetic or antivertigo medication and does not need to report it to the health-care provider. *4. The facial nerve, which runs through the middle ear and mastoid, is at risk for injury during mastoid surgery; therefore, a facial paresis should be reported to the health-care provider.*

20. The nurse is preparing to administer otic drops into an adult client's right ear. Which intervention should the nurse implement? 1. Grasp the earlobe and pull back and out when putting drops in the ear. 2. Insert the eardrops without touching the outside of the ear. 3. Instruct the client to close the mouth and blow prior to instilling drops. 4. Pull the auricle down and back prior to instilling drops

20. 1. This is not the correct way to administer eardrops. 2. The nurse must straighten the ear canal; therefore, the outside of the ear must be moved. 3. This will increase pressure in the ear and should not be done prior to administering eardrops. *4. This will straighten the ear canal so the eardrops will enter the ear canal and drain toward the tympanic membrane (eardrum).*

21. Which ototoxic medication should the nurse administer cautiously? 1. An oral calcium channel blocker. 2. An intravenous aminoglycoside antibiotic. 3. An intravenous glucocorticoid. 4. An oral loop diuretic

21. 1. Calcium channel blockers are not going to affect the client's hearing. *2. Aminoglycoside antibiotics are ototoxic. Over dosage of these medications can cause the client to go deaf, which is why peak and trough serum levels are drawn while the client is taking a medication of this type. These antibiotics are also very nephrotoxic.* 3. Steroids cause many adverse effects, but damage to the ear is not one of them. 4. Administering an intravenous push loop diuretic too fast can cause auditory nerve damage, but an oral loop diuretic does not.

21. 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.

21. 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 hearing 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.

22. The client with cataracts who has had intraocular lens implants 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.

22. 1. The client should not lift, push, or pull objects heavier than 15 pounds; 50 pounds is excessive. 2. The client should avoid lying on the side of the affected eye at night. *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.* 4. The client should avoid bending or stooping for an extended period—but not forever.

22. Which teaching instruction should the nurse discuss with students who are on the high school swim team when discussing how to prevent external otitis? 1. Do not wear tight-fitting swim caps. 2. Avoid using silicone ear plugs while swimming. 3. Use a drying agent in the ear after swimming. 4. Insert a bulb syringe into each ear to remove excess water

22. 1. Tight-fitting swim caps or wetsuit hoods should be worn because they prevent water from entering the ear canal. 2. Silicone ear plugs should be worn because they keep water from entering the ear canal without reducing hearing significantly. *3. A 2% acetic acid solution or 2% boric acid in ethyl alcohol is effective in drying the canal and restoring its normal acidic environment.* 4. A bulb syringe with a Teflon catheter can be used to remove impacted debris from the ear, but it is not used to remove excess water.

23. The client comes to the clinic and is diagnosed with otitis media. Which intervention should the clinic nurse include in the discharge teaching? 1. Instruct the client not to take any over-the-counter pain medication. 2. Encourage the client to apply cold packs to the affected ear. 3. Tell the client to call the HCP if an abrupt relief of ear pain occurs. 4. Wear a protective ear plug in the affected ear

23. 1. Mild analgesics such as aspirin or acetaminophen every four (4) hours as needed to relieve pain and fever are recommended; aspirin may help decrease inflammation of the ear. 2. Heat applied to the affected ear is recommended because heat dilates blood vessels, promoting the reabsorption of fluid and reducing edema. *3. Pain subsiding abruptly may indicate spontaneous perforation of the tympanic membrane within the middle ear and should be reported to the HCP.* 4. Ear plugs should not be used in clients with otitis media, but cotton balls could be used to keep otic antibiotics in the ear canal.

23. The nurse is assessing the client's sensory system. Which assessment data indicate an abnormal stereognosis test? 1. The client is unable to identify which way the toe is being moved. 2. The client cannot discriminate between sharp and dull objects. 3. The toes contract and draw together when the sole of the foot is stroked. 4. The client is unable to identify a key in the hand with both eyes closed.

23. 1. This is an abnormal finding for testing proprioception, or position sense. 2. This is an abnormal finding for assessing superficial pain perception. 3. This is a normal Babinski's reflex in an adult client. *4. Stereognosis is a test evaluating higher cortical sensory ability. The client is instructed to close both eyes and identify a variety of objects (e.g., keys, coins) placed in one hand by the examiner.*

24. The client is scheduled for ear surgery. Which statement indicates the client needs more preoperative teaching concerning the surgery? 1. "If I have to sneeze or blow my nose, I will do it with my mouth open." 2. "I may get dizzy after the surgery, so I must be careful when walking." 3. "I will probably have some hearing loss after surgery, but hearing will return." 4. "I can shampoo my hair the day after surgery as long as I am careful."

24. 1. Leaving the mouth open when coughing or sneezing will minimize the pressure changes in the middle ear. 2. Surgery on the ear may disrupt the client's equilibrium, increasing the risk for falling. 3. Hearing loss secondary to postoperative edema is common after surgery, but the hearing will return after the edema subsides. *4. Shampooing, showering, and immersing the head in water are avoided to prevent contamination of the ear canal; therefore, this comment indicates the client does not understand the preoperative teaching.*

24. Which statement by the daughter of an 80-year-old female client who lives alone warrants immediate intervention by the nurse? 1. "I put a night-light in my mother's bedroom." 2. "I got carbon monoxide detectors for my mother's house." 3. "I changed my mother's furniture around." 4. "I got my mother large-print books."

24. 1. With normal aging comes decreased peripheral vision, constricted visual field, and tactile alterations. A night-light addresses safety issues and warrants praise, not intervention. 2. Carbon monoxide detectors help ensure safety in the mother's home, so this comment doesn't warrant intervention. *3. Decreased peripheral vision, constricted visual fields, and tactile alterations are associated with normal aging. The client needs a familiar arrangement of furniture for safety. Moving the furniture may cause the client to trip or fall. The nurse should intervene in this situation.* 4. As a result of normal aging, vision may become impaired, and the provision of large-print books warrants praise.

25. The 72-year-old client tells the nurse food does not taste good anymore and he has lost a little weight. Which information should the nurse discuss with the client? 1. Suggest using extra seasoning when cooking. 2. Instruct the client to keep a seven (7)-day food diary. 3. Refer the client to a dietitian immediately. 4. Recommend eating three (3) meals a day.

25. *1. The acuity of taste buds decreases with age, which may cause a decreased appetite and subsequent weight loss. Extra seasoning may help the food taste better to the client.* 2. This may be an appropriate intervention if excessive weight is lost or if seasoning the food does not increase appetite, but it is not necessary at this time. 3. The client does not need a dietary consult for food not tasting good. The nurse can address the client's concern. 4. This recommendation does not address the client's comment about food not tasting good.

26. The male client diagnosed with type 2 diabetes mellitus tells the nurse he has begun to see yellow spots. Which interventions should the nurse implement? List in order of priority. 1. Notify the health-care provider. 2. Check the client's hemoglobin A1c. 3. Assess the client's vision using the Amsler grid. 4. Teach the client about controlling blood glucose levels. 5. Determine where the spots appear to be in the client's field of vision.

26. *In order of priority: 5, 3, 2, 1, 4.* 5. The nurse should question the client further to obtain information such as which eye is affected, how long the client has been seeing the spots, and whether this ever occurred before. 3. The Amsler grid is helpful in determining losses occurring in the visual fields. 2. The hemoglobin A1c laboratory tests results indicate glucose control over the past two (2) to three (3) months. Diabetic retinopathy is directly related to poor blood glucose control. 1. The health-care provider should be notified to plan for laser surgery on the eye. 4. The client should be instructed about controlling blood glucose levels, but this can wait until the immediate situation is resolved or at least until measures to address the potential loss of eyesight have been taken.

3. The charge nurse is admitting a 90-year-old client to a long-term care facility. Which intervention should the nurse implement? 1. Ensure the client's room temperature is cool. 2. Talk louder to make sure the client hears clearly. 3. Complete the admission as fast as possible. 4. Provide extra orientation to the surroundings

3. 1. Because of altered temperature regulation, the client usually needs a warmer room temperature, not a cooler room temperature. 2. The nurse should use a low-pitched, normal-volume, clear voice. Talking louder or shouting only makes it harder for the client to understand the nurse. 3. The elderly client requires adequate time to receive and respond to stimuli, to learn, and to react; therefore, the nurse should take time and not rush the admission. *4. Sensory isolation resulting from visual and hearing loss can cause confusion, anxiety, disorientation, and misinterpretation of the new environment; therefore, the nurse should provide extra orientation.*

3. 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. 1. This should be done, but it is not the first intervention the nurse should implement. 2. The client will have to be specifically positioned to make the gas bubble float into the best position; some clients must lie face down or on their side for days, but it is not the first intervention. *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.* 4. Follow-up visits are important, but this is not the first intervention the nurse should implement.

4. 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.

4. 1. Magnifying devices used with activities such as threading a needle will help the client's vision; therefore, this statement does not indicate the client needs more 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. *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.* 4. Low-vision centers will send representatives to the client's home or work to make rec ommendations about improving lighting, thereby improving the client's vision and safety.

4. Which assessment technique should the nurse implement when assessing the client's cranial nerves for vibration? 1. Move the big toe up and down and ask in which direction the vibration is felt. 2. Place a tuning fork on the big toe and ask if the vibrations are felt. 3. Tap the client's cheek with the finger and determine if vibrations are felt. 4. Touch the arm with two sharp objects and ask if one (1) vibration or two (2) is felt

4. 1. This assesses proprioception, or position sense; direction of the toe must be evaluated. *2. Vibration is assessed by using a low frequency tuning fork on a bony prominence and asking the client whether he or she feels the sensation and, if so, when the sensation ceases.* 3. Tapping the cheek assesses for tetany, not cranial nerve involvement. 4. A two-point discrimination test evaluates integration of sensation, but it does not assess for vibration.

5. 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

5. 1. A foreign object should never be removed at the scene of the accident because this may cause more damage. *2. The foreign object should be stabilized to prevent further movement which could cause more damage to the eye.* 3. Flushing with water may cause further movement of the foreign object and should be avoided. 4. The person should be kept flat and not in a sitting position because it may dislodge or cause movement of the foreign object.

5. Which intervention should the nurse include when conducting an in-service on caring for elderly clients addressing normal developmental sensory changes? 1. Ensure curtains are open when having the client read written material. 2. Provide a variety of written material when discussing a procedure. 3. Assist the client when getting out of the bed and sitting in the chair. 4. Request a telephone for the hearing impaired for all elderly clients

5. 1. Adequate lighting without a glare should be provided when having the client read written material; therefore, the curtains should be closed, not open. 2. The nurse should provide short, concise, and concrete material, not a variety of material. *3. Because fewer tactile cues are received from the bottom of the feet, the client may get confused as to body position and location. Safety is priority, and assisting the client getting out of bed and sitting in a chair is appropriate.* 4. This is making a judgment. Not all elderly clients are hard of hearing, and telephones for the hearing impaired require special training for the user

6. 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

6. *1. Instructions provide precautions and steps to take if eye injuries occur sec ondary to the use of tools or chemicals.* 2. The employee must wear safety glasses, not just any type of glasses and especially not regular prescription glasses. 3. A protective helmet is used to help prevent sports eye injuries, not work-related injuries. 4. Eye injuries will not be prevented by paying close attention to the surroundings. They are prevented by wearing protective glasses or eye shields.

6. 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

6. *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.* 2. This is indicative of cataracts because clients with cataracts have blurred vision and cannot read clearly. 3. This is indicative of cataracts because there is a color shift to yellow-brown and there is reduced light transmission. 4. This is indicative of macular degeneration, in which the central vision is affected. Content - Medical: Category of Health Alteration - Neurosensory: Integrated Nursing Process - Evaluation: Client Needs - Safe Effective Care Environment, Management of Care: Cognitive Level - Synthesis.

7. The client with a retinal detachment has just undergone a gas tamponade repair. Which discharge instruction should the nurse include in the teaching? 1. The client must lie flat with the face down. 2. The head of the bed must be elevated 45 degrees. 3. The client should wear sunglasses when outside. 4. The client should avoid reading for three (3) weeks

7. *1. If gas tamponade is used to flatten the retina, the client may have to be specially positioned to make the gas bubble float into the best position; clients must lie face down or on the side for days.* 2. The HOB should not be elevated after this surgery. 3. There is no need for the client to wear sunglasses; this surgery does not cause photophobia. 4. The client does not need to avoid reading.

7. 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

7. 1. Corneal dystrophy is an inherited eye disorder occurring at about age 20 and results in decreased vision and the development of blisters; it is usually associated with primary open-angle glaucoma. 2. Conjunctivitis is an inflammation of the conjunctiva, which results in a scratching or burning sensation, itching, and photophobia. 3. Diabetic retinopathy results from deteriora tion of the small blood vessels nourished by the retina; it leads to blindness. *4. A cataract is a lens opacity or cloudiness, resulting in the signs/symptoms discussed in the stem of the question.*

8. 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

8. *1. Touching the tip of the container to the eye may cause eye injury or an eye infection.* 2. Gentle pressure should be applied on the inner canthus, not outer canthus, near the bridge of the nose for one (1) or two (2) minutes after instilling eyedrops. 3. The nurse should wash hands prior to and after instilling medications; this is not a sterile procedure. *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 should use a clean tissue to remove excess medication.*

8. The nurse is conducting a Weber test on the client who is suspected of having conductive hearing loss in the left ear. Where should the nurse place the tuning fork when conducting this test? D A B C 1. A 2. B 3. C 4. D

8.* 1. The tuning fork should be struck to produce vibrations and then placed midline between the ears on top of the head.* 2. The right temple area is not an appropriate place to assess for conductive hearing loss. 3. The right occipital area is not the appropriate place to place the tuning fork; this is the area behind the ear where the Rinne test is performed. 4. The chin area is not the appropriate area to put the tuning fork.

9. 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 nurse? 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."

9. 1. Conductive hearing loss results from an external ear disorder, such as impacted cerumen, or a middle ear disorder, such as otitis media or otosclerosis. 2. Functional (psychogenic) hearing loss is nonorganic and unrelated to detectable structural changes in the hearing mechanisms. It is usually a manifestation of an emotional disturbance. 3. Mixed hearing loss involves both conductive loss and sensorineural loss. It results from dysfunction of air and bone conduction. *4. Sensorineural hearing loss is described in the stem of the question. It involves damage to the cochlea or vestibulocochlear nerve.*

9. 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. 10.

9. 1. Special eyeglasses are not needed for an enucleation. *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.* 3. The client had the left eye removed but is not blind because he or she still has the right eye. 4. The eyeball was totally removed and a pressure dressing was applied; therefore, there will be no need to instill eyedrops.