NCLEX, Med Surg Eyes & Ears

Which diagnostic test would verify the diagnosis of macular degeneration?

Amsler grid test

A client is diagnosed with glaucoma. Which data gathered by the nurse indicate a risk factor associated with glaucoma?

Cardiovascular disease

The nurse is providing client teaching regarding glaucoma. Which instructions are important to include in the teaching plan? Select all that apply.

Follow a low-sodium, minimal-caffeine diet with plenty of fiber. Be sure to report halos of light or increased eye pain to your primary health care provider.

A client who sustained an eye injury arrives at the emergency department. Which is the initial nursing action?

Obtain a history regarding the cause of the injury.

A client arrives in the emergency department with a chemical eye injury. The nurse immediately performs which action?

Irrigates the eye with copious amounts of sterile normal saline

A client sustains a chemical eye injury from a splash of battery acid. The nurse should prepare the client for which immediate measure?

Irrigating the eye with sterile normal saline

Surgery has been recommended for the client with otosclerosis. The client tells the nurse that she would prefer not to have surgery and asks the nurse about alternative methods to improve hearing. The nurse should make which appropriate response to the client?

"A hearing aid may improve your hearing."

A client with glaucoma asks the nurse if complete vision will return. The nurse should make which response to the client?

"Although some vision has been lost and cannot be restored, further loss may be prevented by adhering to the treatment plan."

A client arrives at the emergency department following an eye injury in which an acid used to clean the brick on the fireplace splashed into the eye. Which question should the nurse ask initially?

"Did you flush the eye following the injury?"

A client reports to the health care clinic for an eye examination, and a diagnosis of primary open-angle glaucoma is suspected. Which question will elicit information regarding the signs/symptoms associated with this disorder?

"Have you had difficulty with peripheral vision?"

The nurse is reinforcing preoperative instructions to a client scheduled for cataract surgery and prepares a written list of instructions for the client. Which statement by the client indicates a need for further teaching?

"I can drink any liquids that I want to on the morning of the surgery."

The nurse is reinforcing discharge instructions to a client who has had ocular surgery of the left eye. Which statement by the client indicates a need for further teaching?

"I need to call the doctor if I develop any fever."

The nurse is assisting a primary health care provider in performing a caloric test on a client. Following instillation of warm water into the ear, the nurse notes that nystagmus does not occur. The nurse should document the findings of this test as indicative of which result?

positive

The nurse is assisting in developing a plan of care for a client following the surgical removal of an acoustic neuroma. Which assessment will be included in the plan of care for this specific intervention?

Assessment of cranial nerve VII (facial)

A client has been admitted to the telemetry unit with a diagnosis of bradycardia. The nurse is reviewing the client's prescriptions with the registered nurse. The client has a history of open-angle glaucoma. Which prescription should the nurse suggest should be questioned?

Atropine intravenously

The nurse is caring for a client with glaucoma. Which medication prescribed for the client should the nurse question?

Atropine sulfate

The nurse reinforces home care instructions to a client after cataract removal and placement of an intraocular implant in the right eye. Which statement by the client indicates a need for further teaching?

"I need to remove the eye dressing as soon as I get home and place a warm pack on my eye."

The nurse is reinforcing instructions to a client regarding the use of a hearing aid. Which statement by the client indicates a need for further teaching?

"I should turn the hearing aid off after removing it from my ear."

The nurse is assigned to care for a client with a diagnosis of Ménière's disease. After reinforcing discharge instructions, which client statement indicates a need for further teaching?

"I will become totally deaf if I don't follow instructions."

The nurse is giving the client discharge instructions concerning glaucoma. Which client statement indicates a need for further teaching?

"I will only take the eye drops until my vision improves."

The nurse has reinforced instructions to a client following a right keratoplasty. Which statement by the client indicates a need for further teaching?

"In 1 week, I'll return to have the sutures removed."

The nurse is providing discharge instructions to a client following a keratoplasty. Which statement by the client indicates the need for further teaching?

"Sutures are removed in 2 weeks."

The nurse is assisting a client who has just been given a hearing aid to wear for the first time. When reinforcing client teaching, the nurse should include which instruction?

"The hearing aid should not be worn if an ear infection is present."

The nurse in the outpatient unit is preparing a client who is scheduled for a laser trabeculoplasty for the treatment of primary open-angle glaucoma. Which instructions should the nurse reinforce to the client?

"You may return to work 1 or 2 days following the procedure."

The nurse is assigned to administer the prescribed eye drops for a client preparing for cataract surgery. Which type of eye drops should the nurse expect to be prescribed?

A mydriatic medication

A nursing instructor asks a student about cochlear implants. The student understands that which clients are candidates for such a procedure? Select all that apply.

A client who has a profound hearing loss in both ears A client who has received no benefit from conventional hearing aids

The nurse is reviewing the medication list for an assigned client. Which medication is the only one on the client's prescription sheet that does not have an ototoxic effect?

Acetaminophen

A client was just admitted to the hospital to rule out a gastrointestinal bleed. The client has brought several bottles of medications prescribed by different specialists. During the admission assessment, the client states, "Lately, I have been hearing some roaring sounds in my ears, especially when I am alone." Which medication should the nurse determine to be the cause of the client's complaint?

Acetylsalicylic acid

The nurse is reviewing the plan of care developed by a nursing student for a client scheduled for keratoplasty. The nurse discusses the plan with the student if which incorrect intervention is listed in the plan?

Administering medications that will dilate the pupil

A client sustains a contusion of the eyeball after a traumatic injury with a blunt object. The nurse should take which immediate action?

Apply ice to the affected eye.

A client with Ménière's disease is experiencing severe vertigo. The nurse reinforces instructions to the client to do which to assist with controlling the vertigo?

Avoid sudden head movements.

A client is diagnosed with hyphema after experiencing a traumatic blow to the eye. The nurse explains to the client that which activity limitation needs to be implemented following this type of injury?

Bed rest with the head in semi-Fowler's position

A client has been diagnosed with macular degeneration. The nurse should expect to expect which signs and symptoms noted with macular degeneration? Select all that apply.

Blurred vision Inability to see the vividness of colors Objects that appear to be the wrong size

The nurse is caring for a client following enucleation. Which postsurgical observation requires immediate attention by the nurse?

Bright red drainage on the dressing

A client is brought to the emergency department by the ambulance team after collapse at home. Cardiopulmonary resuscitation is attempted but is unsuccessful. The wife of the client tells the nurse that the client is an organ donor and that their eyes are to be donated. Which action should the nurse take next?

Close the eyes, elevate the head of the bed, and place a small ice pack on the eyes.

The nurse caring for a client in the postoperative period following an enucleation notes bloody staining on the surgical eye dressing. Which is the appropriate nursing action?

Contact the registered nurse.

A client arrives at the emergency department for treatment of an injury to the eye after being hit by a baseball bat. On data collection, the nurse notes that the eye is bleeding. Which nursing action is appropriate?

Cover the eye with cold, sterile saline gauze.

The nurse administers meclizine hydrochloride to a client diagnosed with an attack of Ménière's disease. Which observations demonstrate to the nurse that the medication is effective? Select all that apply.

Decrease in nausea Decrease in vertigo

The nurse is gathering data from a client with a history of untreated cataracts. The nurse asks the client about the presence of which sign of a cataract?

Difficulty with driving at night and blurred vision

The nurse is assisting with developing a teaching plan for the client with glaucoma. Which instruction should the nurse suggest to include in the plan of care?

Eye medications may need to be administered for the rest of your life.

After an eye examination, a client has been diagnosed with acute angle-closure glaucoma. The nurse collecting data from the client asks the client about an accompanying history of which sign/symptom?

Eye pain

The nurse is reviewing the health care record of a client suspected of having mastoiditis. Which documented findings should the nurse expect to note if this disorder is present? Select all that apply.

Headache Elevated white blood cell count Swelling behind the ear on affected ear

The nurse has been assigned to a client with a hearing impairment. To enhance nurse-client communication, the nurse should plan to communicate with the client by speaking in which manner?

In a normal tone while facing the client

A client arrives at the emergency department after experiencing a traumatic blow to the eye and a hyphema is diagnosed. In which position should the nurse place the client?

In semi-Fowler's position

The nurse is reinforcing education to a client who has just obtained a hearing aid about its use and maintenance. The nurse tells the client that it is helpful to follow which practice?

Keep an extra battery readily available

Betaxolol hydrochloride eye drops have been prescribed for the client with glaucoma. Which nursing action is most appropriate related to monitoring for the side/adverse effects of this medication?

Monitoring blood pressure

The nurse is providing instructions to a client who will be self-administering eye drops. To minimize the systemic effects that eye drops can produce, the client is instructed to perform which action?

Occlude the nasolacrimal duct with a finger over the inner canthus for 30 to 60 seconds after instilling the drops.

The nurse in the recovery room area is preparing to care for a client following cataract extraction of the right eye. Which position does the nurse prepare to place the client?

On the left side with the head of the bed elevated

The nurse is preparing a plan of care for a client being admitted to the hospital with a diagnosis of retinal detachment. Which measure should the nurse include in the plan of care?

Place an eye patch over the affected eye.

During the early postoperative stage, the client who had a cataract extraction complains of nausea and severe eye pain over the operative site. Which action should the nurse implement?

Report the client's complaints.

The nurse is preparing to communicate with an older client who is hearing impaired. Which intervention should be implemented initially?

Stand in front of the client.

The nurse notes that the client's physical examination record states the client's eyes moved normally through the six cardinal fields of gaze. The nurse makes which interpretation?

The client has normal ocular movements.

A client has been newly diagnosed with glaucoma. As part of the discharge instructions, the nurse should plan to reinforce which information?

The need for lifelong medication therapy

In preparation for cataract surgery, the nurse is to administer cyclopentolate eye drops. The nurse administers the eye drops knowing that which is the purpose of this medication?

To dilate the pupil of the operative eye

The nurse is reviewing the results of an eye examination on a client. Which tests can detect glaucoma? Select all that apply.

Tonometry Visual field check

A client has had same-day surgery to insert a ventilating tube in the tympanic membrane. The nurse reinforces to the client to be sure to perform which action until the postoperative assessment by the primary health care provider?

Use a shower cap to protect the ears if taking a shower.

The nurse is providing discharge instructions for a client who has had a fenestration procedure for the treatment of otosclerosis. Which statement by the client indicates an understanding of the instructions?

"I will take stool softeners as prescribed by my doctor."

The instructor is quizzing the student nurse concerning care of a visually impaired client. Which statement indicates a need for further teaching?

"I will take the client's arm to lead while we are walking."

The nurse is giving home care instructions to a client with conjunctivitis. Which client statement indicates a need for further teaching?

"I will use a sterile gauze to rub any matter from my eyes."

The nurse is assisting the primary health care provider in performing a caloric test on a client. Following instillation of warm water into the ear, the client complains of vertigo. The nurse documents the findings of this test as indicative of which result?

Normal

The nurse is assigned to care for a client with a detached retina. Which finding should the nurse expect to be documented in the client's record?

A sense of a curtain falling across the field of vision

A client has a diagnosis of presbycusis. The nurse interprets that which behavior indicates that the client has successfully adapted to this disorder?

Agrees to use a prescribed hearing aid especially when home alone

The nurse is assisting the primary health care provider in performing a caloric test on a client. Following instillation of cool water into the ear, the nurse observes the presence of nystagmus. The nurse should document the findings of this test as indicative of which result?

Normal

A client who has undergone cataract removal without an intraocular lens implant is visibly upset because his vision is still blurry. Which action should the nurse perform to provide realistic reassurance to this client?

Explain that vision will improve with adjustment to aphakic lenses.

A clinic nurse is reviewing the record of a client recently diagnosed with a cataract. Which clinical manifestations associated with this disorder should the nurse expect to be documented in the client's record? Select all that apply.

Increasing nearsightedness Need for more light when reading Painless progressive loss of vision

A client is experiencing blockage of the eustachian tubes. The nurse teaches the client that which activities by the client may forcibly open the eustachian tube?

Performing the Valsalva maneuver

A client has been diagnosed with cataracts. Which signs and symptoms should the nurse expect to note? Select all that apply

Photophobia Blurred vision Decreased color perception

Which are age-related changes to the eyes? Select all that apply.

Presbyopia Arcus senilis Yellow-tinged sclera Decreased ability to see in dim light

After a routine eye examination, a client has been told there are refractive errors in both eyes. The nurse explains to the client that this problem is primarily treated with which intervention?

Prescription of corrective lenses

The nurse is attempting to inspect the lacrimal apparatus of a client's eye. Because of its anatomical location, the nurse should do which action?

Retract the upper eyelid and ask the client to look down.

A client is diagnosed with labyrinthitis. Which are signs and symptoms of labyrinthitis? Select all that apply.

Severe dizziness Nausea and vomiting Abnormal jerking movement of eyes

The nurse is attempting to communicate with a hearing-impaired client. Which strategy by the nurse would be least helpful when talking to this client?

Smiling continuously during conversation

The nursing student is developing information for use in a clinical conference about hearing disorders. In the presentation, the student plans to include the statement that the ear is housed in which bones of the skull?

Temporal

A client arrives in the emergency department following an eye injury from a chemical solution. Which is the initial nursing action?

Test the eye pH with litmus paper

An adult client with a history of ear infections reports a right earache accompanied by a sensation of fullness. The client also reports nausea and has a temperature of 100.6° F. The nurse questions the client about which aspect of the client's history?

Whether the client has had a recent upper respiratory infection (URI)

An adult client has increased fluid in the middle ear that is causing vertigo. The nurse checks this client for which associated signs and symptoms of this condition?

Nausea and vomiting

A client who frequently experiences hearing loss due to built-up cerumen in the ears asks the nurse about ways to deal with the problem including irrigating the ears. Which information is correct for the nurse to include in the teaching plan? Select all that apply.

Irrigate the ear canal with lukewarm tap water around 98° F. The ear irrigation should be stopped if the client becomes dizzy or nauseous. Instill drops of mineral oil and hydrogen peroxide for several days to soften dried cerumen before irrigation.

When reinforcing information to a client regarding how to appropriately care for a new hearing aid, the nurse should provide the client with which instruction?

To check the battery regularly to ensure that it is working before use

The nurse is reinforcing discharge instructions to a client who just underwent a myringotomy with placement of a polyethylene tube in the left ear. Which statement by the client indicates a need for further teaching? Select all that apply.

"I may wash my hair tomorrow." "I will irrigate the ear with gentle pressure." "I can expect to feel pressure inside the ear."

A miotic medication has been prescribed for the client with glaucoma. The client asks the nurse about the purpose of the medication. The nurse should tell the client which purpose?

"The medication causes the pupil to constrict and will lower the pressure in the eye."

The nurse is reinforcing home care instructions to a client following a fenestration procedure for the treatment of otosclerosis. Which instruction should the nurse give the client?

Increase fluids and take a stool softener daily.

Which nursing interventions are appropriate for a client recovering from surgery for retinal detachment? Select all that apply.

Monitor for hemorrhage. Administer eye medications. Maintain the eye patch or shield. Assist with activities of daily living. Educate regarding symptoms of retinal detachment.

The nurse is caring for a client after enucleation and notes the presence of bright red drainage on the dressing. The nurse should take which appropriate action?

Report the finding to the registered nurse (RN).

The nurse is preparing to administer eye drops. Which interventions should the nurse take to administer the drops? Select all that apply.

Wash hands. Put on gloves. Place the drop in the conjunctival sac. Pull the lower lid down against the cheekbone.

The nurse is reinforcing instructions to a client regarding the use of ice packs to treat an eye injury. The nurse instructs the client to do which action?

Wrap a plastic bag filled with ice with a pillowcase and place it on the eye.

The nurse is assigned to care for a client hospitalized with Ménière's disease. The nurse expects that which would most likely be prescribed for the client?

Low-sodium diet

The nurse is assisting the primary health care provider with performing a Rinne tuning fork test on a client. The nurse expects that the steps of the testing will be performed in which priority order? Arrange the actions in the order that they would be performed. All options must be used.

Place base of tuning fork on the mastoid bone. 2 Ask the client if he or she hears the sound and to indicate when the sound disappears. 3 Tap tuning fork to activate. 4 Move the tuning fork close to the ear canal 5 Have client indicate when the sound disappears. 6 Document whether bone or air conduction is better.

The nurse is reviewing the health care record of a client with a diagnosis of otosclerosis. Which signs and symptoms should the nurse note? Select all that apply.

Tinnitus Difficulty hearing voices of others Bone conduction better than air conduction

Pilocarpine hydrochloride is prescribed for the client with glaucoma. Which medication should the nurse plan to have available in the event of systemic toxicity?

Atropine sulfate

The nurse is caring for a client following craniotomy for removal of an acoustic neuroma. The nurse understands that assessment of which cranial nerve should identify a complication specifically associated with this surgery?

Cranial nerve VII, facial nerve

The nurse is reviewing the health record of a client diagnosed with a cataract. Which are signs and symptoms of cataract formation? Select all that apply

Decreased color perception Floaters in visual field Difficulty in night vision

The nurse is reinforcing discharge teaching to a client following right eye cataract surgery. The nurse determines that the client needs further teaching about ways to avoid strain on the operative eye when the client makes which statements? Select all that apply

"I can lie on my right side." "I will wear my eye shield only during the daytime."

The nurse provides discharge instructions to the client who was hospitalized for an acute attack of Ménière's disease. Which statement made by the client indicates a need for further teaching?

"It is not necessary to restrict salt in my diet."

A client is brought to the ambulatory care department by the spouse 1 day following a cataract extraction procedure. A diagnosis of hyphema is made, which occurred as a result of the surgical procedure. The nurse reinforces instructions to the client and spouse regarding the treatment for the complication and makes which statement?

"Maintain bed rest and patching of both eyes."

A client has bilateral aphakia. When reinforcing teaching instructions regarding the prescribed eyeglasses, the nurse determines the need for further teaching when the client makes which statement?

"My peripheral vision will not be distorted."

The nurse is caring for a client hospitalized with an acute attack from Ménière's disease. The client verbalizes concern because the client has experienced a hearing loss as a result of the attack. Which response should the nurse make to the client regarding the hearing loss?

"The attack leaves a hearing loss in the involved ear."

The nurse is observing an unlicensed assistive personnel (UAP) talk to a client who is hearing impaired. The nurse should intervene if which actions are performed by the UAP during communication with the client? Select all that apply.

The UAP speaks in a very loud voice The UAP speaks while cleaning the room. The UAP speaks directly into the impaired ear.