Chapter 53 Sensory Disorder
The nurse recognizes that the patient who is being evaluated for a visual impairment does not have glaucoma because the tonometry reveals an intraocular pressure of _____mmhg
18
The 60 year old patient who has had an enucleation ask when he can get his prosthesis fitted. The nurse responds that the prosthesis will be fitted by an optician in approximately ______ weeks
4
Why is otitis media found more frequently in children 6 to 36 months?
Eustachian tubes in children are shorter and straighter
Implementations that are appropriate in the care plan for a visually impaired person include
announcing your presence when you enter and leave the room
When the patient stares at the black dot on an Amsler grid, what should the nurse ask him to report?
any distortion of the grid
The nurse counsels the 16 year old boy that playing his music at high volume can result in impairment in hearing related to
damage of the fine hair cells in the organ of corti
When the patient in the emergency room complains of seeing flashing lights and a curtain down over his right eye, the nurse recognizes this as a symptom of which condition?
detached retina
Which complaint made by a 64 year old patient during a health interview would alert the nurse to the possibility of cataracts?
difficulty driving at night
The nurse will assess for _________ when the older adult home health patient complains that the entire right side of his head hurts and he cannot chew without pain.
external otitis
A nurse is performing an otoscopic examination of a client. Which of the following is an unexpected finding?
fluid bubble seen behind the TM
During the initial assessment of a very thin patient at the eye clinic, the nurse notes that the patient has very prominent eyes. The nurse should inquire about a history of
graves disease
The nurse takes into consideration that the Weber test indicated a conductive hearing loss in a patient because the patient reported hearing tone:
louder in his affected ear
A nurse is providing discharge instructions for a client following outpatient cataract surgery with insertion of a intraocular lens. Which of the following should the nurse include?
lying on the unaffected side can prevent complications
The nurse explains that the difference between open-angle and closed-angle glaucoma is that with closed-angled glaucoma
onset is acute
What is a common mistake that hinders communication when communicating with the hearing impaired?
over accentuating words
What must a patient do following a left vitrectomy?
position self in a face-down position for 4-5 days
What should a patient who has had a cataract repair avoid?
the lifting of heavy objects
What is the first indication of muscular degeneration?
the loss of central vision
The 62 year old home health patient who is recovering from eye surgery complains of a feeling of "grittiness" in the eye and is having blurred vision. The eyes are reddened and have stringy mucus. What do these complaints indicate?
sjogren syndrome
Why would the nurse encourage a group of teenagers to protect their eyes with dark sunglasses while using a UV lamp?
the lamp can cause cataracts
What is the process when the lens of the eye changes its curvature to focus on the retina?
accommodation
Upon performing an otoscope the nurse expects the light reflex to appear visible from:
auditory canal and the tympanic membrane
Which may contribute to otitis media? (Select all that apply.) a. Exposure to cigarette smoke b. Allergies c. Upper respiratory infections d. Swimming e. Trauma f. Prolonged exposure to loud noise
exposure to cigarette smoke allergies upper respiratory infections
The nurse considers in planing care for a patient with glaucoma that this disorder is caused by
increase in intraocular pressure
A patient tells the nurse he has hearing loss with occasional ringing in his ears. He states that the health care provider used another term. What term did the health care provider most likely use?
tinnitus
The nurse explains that the correct term to use for a patient with a vision disorder is
visually impaired
The newly diagnosed patient with macular degeneration flings her book at the television set and furiously says "I can't read this blasted book, and I can't see what is on the stupid TV!" The nurse recognizes this behavior as
anger stage of grieving
A patient who had an enucleation of the right eye has been admitted PACU. What should the nurse include in the plan of care?
apply a pressure dressing over the right eye socket
What should the nurse advise the 20 year old to do who has been put on cefaclor for a resistant otitis media?
avoid alcoholic beverages
The nurse clarifies that the difference between a photorefractive keratectomy (PRK) and a laser in-situ keratomileusis (LASIK) is that a LASIK:
removes some interal layers of the cornea
A nursing diagnosis for a visually impaired patient might include all of the following except
risk for delayed development
When the newly blind male home health patient asks the nurse how he might get assistance, who might the nurse suggest he contact?
American foundation for blind for a list of agencies
What does diabetes retinopathy result from?
Capillaries in retina hemorrhage
What should the nurse do when assisting a blind person to walk in an unfamiliar hospital environment? (Select all that apply) A. Discourage the use of the cane B. Advise the patient to walk quickly C. Describe the surroundings D. Encourage the patient to ask for verbal cues E. Place the patient hand on nurses shoulder or elbow
Describe the surroundings Encourage the patient to ask for verbal cues Place the patient hand on nurses shoulder or elbow
Four hours after stapedectomy, the patient complains that hearing has not improved at all. What knowledge would the nurse use to shape a response?
Hearing will not return until edema subsides
One of the housekeepers splashes a chemical in the eyes. What should be the first priority?
Irrigate with normal saline solution for 20 minutes
How should the nurse advise a patient who has severe vertigo from labyrinthitis?
Lie immobile and hold the hand in one position until the vertigo lessens
Which of the following are causes of cataracts? (Select all that apply) A. Long-term use of corticosteroids B. Hypotension C. Congenital from exposure to maternal rubella D. Diabetes mellitus E. Exposure to sand and dust F. Smoking
Long-term use of corticosteroids Congenital from exposure to maternal rubella Diabetes mellitus Smoking
The nurse notes that the PCP has documented a diagnosis of presbycusis on the history. Which explanation should the nurse give to the client to explain this condition?
a sensorineural hearing loss that occurs with aging
The patient tells the nurse that he is legally blind. How would this information impact the nurses plan of care for this patient?
The nurse would need to determine how this patient's visual impairment affects normal functioning.
How would the nurse explain the purpose of photocoagulation to a diabetic patient with diabetic retinopathy?
The procedure will destroy new blood vessels, seal leaking vessels help prevent renal edema
What would a nurse do when the patient arrives in the PACU after a left stapedectomy? (Select all that apply) A. Turn the patient to his right side B. Change the dressing as it becomes soiled C. Turn the patient every 2 hours D. Leave the bed flat E. Medicate immediately on the complaint of nausea
Turn the patient to his right side Leave the bed flat Medicate immediately on the complaint of nausea
What does the cataract treatment of phacoemulsification involve?
breaking the cataract with ultrasound
Select all the conditions that may cause conductive hearing loss. (Select all that apply.) a. Buildup of cerumen b. Foreign bodies c. Otosclerosis of external auditory canal d. Trauma e. Exposure to ototoxic drugs f. Otitis media with effusion
build up of cerumen foreign bodies otosclerosis of external auditory canal otitis media with effusion
When asked about his vision, the patient says that the last time he had it tested his vision was recorded as 20/50. This means that the patient
can read at 20 feet what a person with normal vision can read at 50 feet
What is the most interior part of the eye?
choroid
A nurse assessing the results of a Rinne test sees the notation of BC>AC. How should the nurse translate this result?
conductive hearing loss
What does a tympanoplasty correct?
conductive hearing loss
What do miotic eyedrops do for a patient with glaucoma?
constrict the pupil and open the canal of schlemm
Which is a sign of acute angle closure glaucoma (AACG)?
large fixed pupil
Which surgical implementation is most effective with retinal detachment?
scleral buckling
What should the nurse include in the plan of care following a tympanoplasty?
elevating head of the bed with operative side facing upward
The nurse explains that the portion of the eye that will make it possible for a person to see in a darkened environment is the
rods
The nurse explains to the patient who is to have a pneumatonometric study of the eye that his procedure requires that
his eye may be anesthetized
What is the first nursing intervention step for the immediate care of the patient with a penetrating wound of the eye?
lay the patient down flat
A nurse is collecting data from a client who has open-angle glaucoma. Which of the following findings should the nurse expect?
loss of peripheral vision
As the nurse you are aware that the retina requires 4 basic functions which include the following except
reflection
What should the nurse remind the hearing aid wearer to do when the nurse hears a whistling hearing aid?
reinsert the ear mold
When providing patient education about protecting vision, the nurse should tell the patient that
after 40 year of age, eye examinations should be performed every 2 years
A nurse is preparing a young adult client who has hearing impairment for surgery. Which of the following actions should the nurse take?
allow the client to keep her hearing aid in
The nurse instructs a family member how to guide a visually impaired person when ambulating by
allowing the visually impaired person to hold the helpers arm with the helper slightly ahead
The nurse is aware the extra ocular muscles control eye movement via the following cranial nerves which are
cranial nerves: ocular nerve III, trochlear nerve IV, abducens nerve VI
What factors must the nurse consider when assessing readiness to learn when teaching health promotion practices for the visually and hearing impaired (Select all that apply) A. Cultural beliefs B. Values C. Habits D. Income E. Occupation
cultural beliefs values habits