Saunders Ch 60: Eyes & Ears

751. Awoman was working in her garden. She acciden- tally sprayed insecticide into her right eye. She calls the emergency department, frantic and screaming for help. The nurse should instruct the woman to take which immediate action? 1. Irrigate th e eyes with water. 2. Come to the emergency department. 3. Call the health care provider (HCP). 4. Irrigate the eyes with diluted hydrogen peroxide.

1 Rationale: In this type of accident, the client is instructed to irrigate the eyes immediately with running water for at least 20 minutes, or until the emergency medical services personnel arrive. In the emergency department, the cleansing agent of choice is usually normal saline. Calling the HCP and going to the emergency department delays necessary intervention. Hydrogen peroxide is never placed in the eyes.

748. The client sustains a contusion of the eyeball follow- ing a traumatic injury with a blunt object. Which intervention should be initiated immediately? 1. Apply ice to the affected eye. 2. Irrigate the eye with cool water. 3. Notify the health care provider (HCP). 4. Accompany the client to the emergency department.

1 Rationale: Treatment for a contusion begins at the time of injury. Ice is applied immediately. The client then should be seen by an HCP and receive a thorough eye examination to rule out the presence of other eye injuries.

747. A client arrives in the emergency department following an automobile crash. The client's forehead hit the steering wheel and a hyphema is diagnosed. The nurse should place the client in which position? 1. Flat in bed 2. Asemi-Fowler'sposition 3. Lateral on the affected side 4. Lateral on the unaffected side

2 Rationale: Ahyphema is the presence of blood in the anterior chamber. Hyphema is produced when a force is sufficient to break the integrity of the blood vessels in the eye and can be caused by direct injury, such as a penetrating injury from a BB or pellet, or indirectly, such as from striking the forehead on a steering wheel during an accident. The client is treated by bed rest in a semi-Fowler's position to assist gravity in keep- ing the hyphema away from the optical center of the cornea.

749. Aclient arrives in the emergency department with a penetrating eye injury from wood chips that occurred while cutting wood. The nurse assesses the eye and notes a piece of wood protruding from the eye. What is the initial nursing action? 1.Applyaneyepatch. 2. Perform visual acuity tests. 3. Irrigate the eye with sterile saline. 4. Remove the piece of wood using a sterile eye clamp.

2 Rationale: If the eye injury is the result of a penetrating object, the object may be noted protruding from the eye. This object must never be removed except by the ophthalmologist because it may be holding ocular structures in place. Application of an eye patch or irrigation of the eye may disrupt the foreign body and cause further tearing of the cornea.

756. A client with Meniere's disease is experiencing severe vertigo. Which instruction should the nurse give to the client to assist in controlling the vertigo? 1. Increase sodium in the diet. 2. Avoid sudden head movements. 3. Lie still and watch the television. 4. Increase fluid intake to 3000 mL a day.

2 Rationale: The nurse instructs the client to make slow head movements to prevent worsening of the vertigo. Dietary changes such as salt and fluid restrictions that reduce the amount of endolymphatic fluid are sometimes prescribed. Lying still and watching television will not control vertigo.

750. The nurse is caring for a client following enucle- ation and notes the presence of bright red drainage on the dressing. Which action should the nurse take at th is time? 1. Document the finding. 2. Continue to monitor the drainage. 3. Notify the health care provider (HCP). 4. Mark the drainage on the dressing and monitor for any increase in bleeding.

3 Rationale: If the nurse notes the presence of bright red drain- age on the dressing, it must be reported to the HCP, because this indicates hemorrhage. Options 1, 2, and 4 are inappropri- ate at this time.

755. The nurse notes that the health care provider has documented a diagnosis of presbycusis on a client's chart. Based on this information, what action should the nurse take? 1. Speak loudly, but mumble or slur the words. 2. Speak loudly and clearly while facing the client. 3. Speak at normal tone and pitch, slowly and clearly. 4. Speak loudly and directly into the client's affected ear.

3 Rationale: Presbycusis is a type of hearing loss that occurs with aging. Presbycusis is a gradual sensorineural loss caused by nerve degeneration in the inner ear or auditory nerve. When communicating with a client with this condition, the nurse should speak at a normal tone and pitch, slowly and clearly. It is not appropriate to speak loudly, mumble or slur words, or speak into the client's affected ear.

759. The nurse is caring for a hearing-impaired client. Which approach will facilitate communication? 1. Speak loudly. 2. Speak frequently. 3. Speak at a normal volume. 4. Speak directly into the impaired ear.

3 Rationale: Speaking in a normal tone to the client with impaired hearing and not shouting are important. The nurse should talk directly to the client while facing the client and speak clearly. If the client does not seem to understand what is said, the nurse should express it differently. Moving closer to the client and toward the better ear may facilitate communication, but the nurse should avoid talking directly into the impaired ear.

742. The nurse is developing a teaching plan for a client with glaucoma. Which instruction should the nurse include in the plan of care? 1. Avoid overuse of the eyes. 2. Decrease the amount of salt in the diet. 3. Eye medications will need to be administered for life. 4. Decrease fluid intake to control the intraocular pressure

3 Rationale: The administration of eye drops is a critical compo- nent of the treatment plan for the client with glaucoma. The client needs to be instructed that medications will need to be taken for the rest of his or her life. Options 1, 2, and 4 are not accurate instructions.

746. The nurse is performing an assessment on a client with a suspected diagnosis of cataract. Which clin- ical manifestation should the nurse expect to note in the early stages of cataract formation? 1. Diplopia 2. Eye pain 3. Floating spots 4. Blurred vision

4 Rationale: A gradual, painless blurring of central vision is the chief clinical manifestation of a cataract. Early symptoms include slightly blurred vision and a decrease in color percep- tion. Options 1, 2, and 3 are not characteristics of a cataract.

754. The nurse is caring for a client following craniotomy for removal of an acoustic neuroma. Assessment of which cranial nerve would identify a complication specifically associated with this surgery? 1. Cranial nerve I, olfactory 2. Cranial nerve IV, trochlear 3. Cranial nerve III, oculomotor 4. Cranial nerve VII, facial nerve

4 Rationale: An acoustic neuroma (or vestibular schwannoma) is a unilateral benign tumor that occurs where the vestibulocochlear or acoustic nerve (cranial nerve VIII) enters the internal auditory canal. It is important that an early diagnosis be made because the tumor can compress the trigeminal and facial nerves and arteries within the internal auditory canal. Treat- ment for acoustic neuroma is surgical removal via a craniotomy. Assessment of the trigeminal and facial nerves is important. Extreme care is taken to preserve remaining hearing and preserve the function of the facial nerve. Acoustic neuromas rarely recur following surgical removal.

741. During the early postoperative period, the client who had a cataract extraction complains of nausea and severe eye pain over the operative site. The initial nursing action is to: A. Call the physician B. Reassure the client that this is normal. C. Turn the client on his or her operative side D. Administer the ordered main medication and antiemetic

A. Call the physician Rationale: Severe pain or pain accompanied by nausea follow- ing a cataract extraction is an indicator of increased intraocular pressure and should be reported to the HCP immediately. Options 2, 3, and 4 are inappropriate actions.

757. The nurse is preparing to test the visual acuity of a client, using a Snellen chart. Which identifies the accurate procedure for this visual acuity test? 1. The right eye is tested, followed by the left eye, and then both eyes are tested. 2. Both eyes are assessed together, followed by an assessment of the right eye and then the left eye. 3. The client is asked to stand at a distance of 40 feet (12 meters) from the chart and to read the larg- est line on the chart. 4. The client is asked to stand at a distance of 40 feet (12 meters) from the chart and to read the line that can be read 200 feet (60 meters) away by an individual with unimpaired vision.

1 Rationale:Visualacuityisassessedin1eyeatatime,andthen in both eyes together, with the client comfortably standing or sitting. The right eye is tested with the left eye covered; then the left eye is tested with the right eye covered. Both eyes are then tested together. Visual acuity is measured with or without cor- rective lenses and the client stands at a distance of 20 feet (6 meters) from the chart.

752. The nurse is preparing a teaching plan for a client who had a cataract extraction with intraocular implantation. Which home care measures should the nurse include in the plan? Select all that apply. 1. Avoid activities that require bending over. 2. Contact the surgeon if eye scratchiness occurs. 3. Take acetaminophen for minor eye discomfort. 4. Expect episodes of sudden severe pain in the eye. 5. Place an eye shield on the surgical eye at bedtime. 6. Contact the surgeon if a decrease in visual acuity occurs.

1, 3, 5, 6 Rationale: Following eye surgery, some scratchiness and mild eye discomfort may occur in the operative eye and usually is relieved by mild analgesics. If the eye pain becomes severe, the client should notify the surgeon because this may indicate hemorrhage, infection, or increased intraocular pressure (IOP). The nurse also would instruct the client to notify the sur- geon of increased purulent drainage, increased redness, or any decrease in visual acuity. The client is instructed to place an eye shield over the operative eye at bedtime to protect the eye from injury during sleep and to avoid activities that increase IOP, such as bending over.

745. A client is diagnosed with a disorder involving the inner ear. Which is the most common client com- plaint associated with a disorder involving this part of the ear? 1. Pruritus 2. Tinnitus 3. Hearing loss 4.Burningintheear

2 Rationale: Tinnitus is the most common complaint of clients with otological disorders, especially disorders involving the inner ear. Symptoms of tinnitus range from mild ringing in the ear, which can go unnoticed during the day, to a loud roar- ing in the ear, which can interfere with the client's thinking pro- cess and attention span. Options 1, 3, and 4 are not associated specifically with disorders of the inner ear.

753. Tonometry is performed on a client with a sus- pected diagnosis of glaucoma. The nurse looks at the documented test results and notes an intraocu- lar pressure (IOP) value of 23. What should be the nurse's initial action? 1. Apply normal saline drops. 2. Note the time of day the test was done. 3. Contact the health care provider (HCP). 4. Instruct the client to sleep with the head of the bed flat.

2 Rationale: Tonometry is a method of measuring intraocular fluid pressure. Pressures between 10 and 21 mm Hg are consid- ered within the normal range. However, IOP is slightly higher in the morning. Therefore, the initial action is to check the time the test was performed. Normal saline drops are not a specific treatment for glaucoma. It is not necessary to contact the HCP as an initial action. Flat positions may increase the pressure.

758. A client's vision is tested with a Snellen chart. The results of the tests are documented as 20/60. What action should the nurse implement based on this finding? 1. Provide the client with materials on legal blindness. 2. Instruct the client that he or she may need glasses when driving. 3. Inform the client of where he or she can purchase a white cane with a red tip. 4. Inform the client that it is best to sit near the back of the room when attending lectures.

2 Rationale: Vision that is 20/20 is normal—that is, the client is able to read from 20 feet (6 meters) what a person with normal vision can read from 20 feet (6 meters). A client with a visual acuity of 20/60 can only read at a distance of 20 feet (6 meters) what a person with normal vision can read at 60 feet (18 meters). With this vision, the client may need glasses while driving in order to read signs and to see far ahead. The client should be instructed to sit in the front of the room for lectures to aid in visualization. This is not considered to be legal blindness

744. The nurse is performing an otoscopic examination on a client with mastoiditis. On examination of the tympanic membrane, which finding should the nurse expect to observe? 1. A pink-colored tympanic membrane 2. A pearly colored tympanic membrane 3. A transparent and clear tympanic membrane 4. A red, dull, thick, and immobile tympanic membrane

4 Rationale: Otoscopic examination in a client with mastoiditis reveals a red, dull, thick, and immobile tympanic membrane, with or without perforation. Postauricular lymph nodes are

743. The nurse is performing an admission assessment on a client with a diagnosis of detached retina. Which sign or symptom is associated with this eye disorder? 1. Total loss of vision 2. Pain in the affected eye 3. A yellow discoloration of the sclera 4. A sense of a curtain falling across the field of vision

4 Rationale:Acharacteristicmanifestation ofretinaldetachment described by the client is the feeling that a shadow or curtain is falling across the field of vision. No pain is associated with detachment of the retina. Options 1 and 3 are not characteris- tics of this disorder. A retinal detachment is an ophthalmic emergency and even more so if visual acuity is still normal.