Saunders Ch 64

778. The client sustains a contusion of the eyeball following 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. Apply ice to the affected eye. 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. Test-Taking Strategy: Focus on the strategic word immediately. Recalling the principles related to initial treatment of injuries and noting the type of injury sustained will direct you to the correct option.

782. The nurse is preparing a teaching plan for a client who is undergoing 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. Place an eye shield on the surgical eye at bedtime. 4. Episodes of sudden severe pain in the eye are expected. 5. Contact the surgeon if a decrease in visual acuity occurs. 6. Take acetaminophen (Tylenol) for minor eye discomfort.

1. Avoid activities that require bending over. 3. Place an eye shield on the surgical eye at bedtime. 5. Contact the surgeon if a decrease in visual acuity occurs. 6. Take acetaminophen (Tylenol) for minor eye discomfort. 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. The nurse also would instruct the client to notify the surgeon 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 intraocular pressure, such as bending over. Test-Taking Strategy: Focus on the subject, postoperative care following eye surgery. Recalling that the eye needs to be protected and that increased intraocular pressure is a concern will assist in determining the home care measures to be included in the plan.

771. During the early postoperative period, a client who has undergone a cataract extraction complains of nausea and severe eye pain over the operative site. What should be the initial nursing action? 1. Call the health care provider (HCP). 2. Reassure the client that this is normal. 3. Turn the client onto his or her operative side. 4. Administer the prescribed pain medication and antiemetic.

1. Call the health care provider (HCP). Rationale: Severe pain or pain accompanied by nausea following 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. Test-Taking Strategy: Note the strategic word initial and the word severe. Eliminate option 2 because this is not a normal condition. The client should not be turned to the operative side; therefore, eliminate option 3. From the remaining options, focusing on the strategic word will direct you to the correct option.

781. A woman was working in her garden. She accidentally 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 the 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. Irrigate the eyes with water. 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 service 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. Test-Taking Strategy: Note the strategic word immediate. Focus on the type of injury and eliminate options 2 and 3 because they delay necessary intervention. Next, eliminate option 4 because hydrogen peroxide is never placed in the eyes.

787. The clinic 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 from the chart and is asked to read the largest line on the chart. 4. The client is asked to stand at a distance of 40 feet from the chart and to read the line that canbe read 200 feet away by an individual with unimpaired vision.

1. The right eye is tested, followed by the left eye, and then both eyes are tested. Rationale: Visual acuity is assessed in one eye at a time, and then 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 corrective lenses and the client stands at a distance of 20 feet from the chart. Test-Taking Strategy: Remember that normal visual acuity as measured by a Snellen chart is 20/20 vision. This should assist in eliminating options 3 and 4 because they are comparable or alike in that they indicate standing at a distance of 40 feet. From the remaining options, remember that it is best to test each eye separately and then test both eyes together. This method assesses visual acuity most accurately.

783. Tonometry is performed on a client with a suspected diagnosis of glaucoma. The nurse looks at the test results documented in the client's chart, knowing that which is the range for normal intraocular pressure? 1. 2 to 7 mm Hg 2. 10 to 21 mm Hg 3. 22 to 30 mm Hg 4. 31 to 35 mm Hg

2. 10 to 21 mm Hg Rationale: Tonometry is a method of measuring intraocular fluid pressure, using a calibrated instrument that indents or flattens the corneal apex. Pressures between 10 and 21 mm Hg are considered within the normal range. Test-Taking Strategy: Focus on the subject, normal intraocular pressure. Remember that normal intraocular pressure is between 10 and 21 mm Hg.

777. 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. A semi-Fowler's position 3. Lateral on the affected side 4. Lateral on the unaffected side

2. A semi-Fowler's position Rationale: A hyphema 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 keeping the hyphema away from the optical center of the cornea. Test-Taking Strategy: Focus on the subject, care of the client who has sustained a hyphema. Remember that placing the client flat will produce an increase in pressure at the injured site. Also, note that the correct option is the one that identifies a position different from the other options.

786. A client with Ménière'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. Avoid sudden head movements. 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. Test-Taking Strategy: Focus on the subject, preventing vertigo. Note the relationship between vertigo and avoiding sudden head movements in the correct option.

779. A client 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. Apply an eye patch. 2. Perform visual acuity tests. 3. Irrigate the eye with sterile saline. 4. Remove the piece of wood using a sterile eye clamp.

2. Perform visual acuity tests. 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. Test-Taking Strategy: Note the strategic word initial and note the word penetrating. This should indicate that a laceration has occurred and that interventions are directed at preventing further disruption of the integrity of the eye. The only option that will prevent further disruption is to assess visual acuity.

775. A client is diagnosed with a disorder involving the inner ear. Which is the most common client complaint associated with a disorder involving this part of the ear? 1. Pruritus 2. Tinnitus 3. Hearing loss 4. Burning in the ear

2. Tinnitus 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 roaring in the ear, which can interfere with the client's thinking process and attention span. Options 1, 3, and 4 are not associated specifically with disorders of the inner ear. Test-Taking Strategy: Note the strategic word most. Recalling the anatomy and the function of the inner ear will direct you to the correct option.

772. 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. Eye medications will need to be administered for life. Rationale: The administration of eye drops is a critical component 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. Test-Taking Strategy: Focus on the subject, client teaching for glaucoma. Recalling that medications are an integral component of the treatment plan will assist in directing you to the correct option.

780. The nurse is caring for a client following enucleation and notes the presence of bright red drainage on the dressing. Which nursing action is most appropriate? 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. Notify the health care provider (HCP). Rationale: If the nurse notes the presence of bright red drainage on the dressing, it must be reported to the HCP, because this indicates hemorrhage. Options 1, 2, and 4 are inappropriate. Test-Taking Strategy: Note the strategic words most appropriate and the words bright red. Remember that bright red drainage indicates active bleeding.

789. 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. Speak at a normal volume. 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. Test-Taking Strategy: Focus on the subject, an effective communication technique for the hearing impaired. Remember that it is important to speak in a normal tone.

774. 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. A red, dull, thick, and immobile tympanic membrane 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 tender and enlarged. Clients also have a low-grade fever, malaise, anorexia, swelling behind the ear, and pain with minimal movement of the head. Test-Taking Strategy: Focus on the subject, the assessment findings in mastoiditis. Think about the pathophysiology associated with mastoiditis and remember that mastoiditis reveals a red, dull, thick, and immobile tympanic membrane.

773. The nurse is performing an admission assessment on a client with a diagnosis of detached retina. Which sign/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. A sense of a curtain falling across the field of vision Rationale: A characteristic manifestation of retinal detachment 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 characteristics of this disorder. A retinal detachment is an ophthalmic emergency and even more so if visual acuity is still normal. Test-Taking Strategy: Focus on the subject, manifestations of retinal detachment. Thinking about the pathophysiology associated with this disorder will direct you to the correct option.

785. The nurse notes that the health care provider has documented a diagnosis of presbycusis on a client's chart. The nurse understands that which describes this condition? 1. Tinnitus that occurs with aging 2. Nystagmus that occurs with aging 3. A conductive hearing loss that occurs with aging 4. A sensorineural hearing loss that occurs with aging

4. A sensorineural hearing loss that occurs with aging 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. Options 1, 2, and 3 are incorrect. Test-Taking Strategy: Focusing on the subject, the description of presbycusis. Remember that presbycusis is a gradual sensorineural loss.

776. The nurse is performing an assessment on a client with a suspected diagnosis of cataract. What is the chief clinical manifestation that the nurse expects to note in the early stages of cataract formation? 1. Diplopia 2. Eye pain 3. Floating spots 4. Blurred vision

4. Blurred vision 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 perception. Options 1, 2, and 3 are not characteristics of a cataract. Test-Taking Strategy: Note the strategic word early. Remember the pathophysiology related to cataract development. As a cataract develops, the lens of the eye becomes opaque. This description will assist in directing you to the correct option.

784. 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. Cranial nerve VII, facial nerve 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. Treatment 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. Test-Taking Strategy: Focus on the subject, a complication following surgery. Think about the anatomical location of an acoustic neuroma and the nerves that the neuroma can compress to direct you to the correct option.

788. A client's vision is tested with a Snellen chart. The results of the tests are documented as 20/60. How should the nurse interpret this finding? 1. The client is legally blind. 2. The client's vision is normal. 3. The client can read at a distance of 60 feet what a client with normal vision can read at 20 feet. 4. The client can read only at a distance of 20 feet what a client with normal vision can read at 60 feet.

4. The client can read only at a distance of 20 feet what a client with normal vision can read at 60 feet. Rationale: Vision that is 20/20 is normal—that is, the client is able to read from 20 feet what a person with normal vision can read from 20 feet. A client with a visual acuity of 20/60 can only read at a distance of 20 feet what a person with normal vision can read at 60 feet. Test-Taking Strategy: Focus on the subject, interpreting a Snellen chart result. Note the test result, 20/60, to direct you to the correct option.