Saunders - Eyes and Ears

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 would prepare the client for which immediate measure?

Irrigating the eye with sterile normal saline

Which instruction is appropriate for the nurse to provide to a client who reports via telephone that he is certain an insect has flown into his ear because he can hear it "buzzing"?

Use a flashlight to coax the insect out of the ear.

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."

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 reinforcing discharge instructions with a client who is being discharged following a fenestration procedure for the treatment of otosclerosis. Which would be included on the list of instructions prepared for the client?

"You need to avoid air travel."

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 would the nurse make to the client regarding the hearing loss?

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

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 would the nurse reinforce to the client?

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

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 would 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 would 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 myringotomy is performed on a client in the ambulatory care center. The ambulatory care nurse calls the client 24 hours after the procedure to evaluate the status of the client. The client reports to the nurse that a small amount of brownish drainage has been coming from the ear. Which instruction would the nurse provide to the client?

"Continue to monitor the drainage because this is normal and may occur for 24 to 48 hours following the surgery."

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

"Did you flush the eye following the injury?"

A pilocarpine ocular system is prescribed for the client with glaucoma. The nurse reinforces instructions to the client regarding the medication. Which statement by the client indicates an understanding of the use of this medication?

"I should check my eye each morning to make sure that the medication system is in place."

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 reinforces instructions to a client with glaucoma regarding measures that will prevent an increase in intraocular pressure in the eyes. Which statement by the client indicates a need for further teaching?

"I can tie my shoelaces by bending over slowly."

A client with a diagnosis of otosclerosis is admitted to the ambulatory care unit for stapedectomy, and the nurse reinforces instructions to the client regarding home care following the procedure. Which statement by the client indicates a need for further teaching?

"I need to avoid air travel for at least 6 months."

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 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."

A client is being discharged from the ambulatory care unit following cataract removal, and the nurse provides instructions regarding home care. Which statement by the client indicates an understanding of the instructions?

"I will wear my eye shield at night and my glasses during the day."

The nurse is providing discharge instructions to a client who is postoperative cataract surgery on the left eye. Which statement indicates a need for further teaching?

"If I have severe eye pain, I will take the narcotic pain pill that my doctor will prescribe for me."

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."

An older client confides to the visiting nurse the fear of falling while going to the bathroom at night. Considering the visual changes affecting the older client, the nurse would make which recommendation?

"Keep a red light on in the bathroom at night."

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

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

Prescriptive glasses are prescribed for a client with bilateral aphakia, and the nurse reinforces instructions to the client regarding the use of the glasses. Which statement by the client indicates the need for further teaching?

"The prescriptive glasses will correct my visual field of sight."

A client with glaucoma has suffered significant eye damage before diagnosis and now has impaired vision. The nurse determines that the client needs further assistance in adapting to this situation if the client makes which statement?

"There is no difficulty driving at dusk."

The nurse is providing client and family instructions for a client who has been recently diagnosed with glaucoma. Which statement indicates that the client's family member needs further teaching regarding the eye drop application of pilocarpine hydrochloride? Select all that apply.

- "I should apply the eye drops directly over my family member's pupil." - "I have to contact the prescriber if my family member develops a small pupil." - "I need to wipe off the tip of the eye drop bottle with a tissue between administrations."

The nurse is reinforcing home-care instructions to a client and family regarding care after left cataract surgery with lens implant. Which statements made by the client indicate an understanding of the instructions? Select all that apply.

- "I will not sleep lying on my left side." - "I will sit at the table to eat breakfast." - "I will sit in my recliner with my feet elevated." - "I will not lift anything heavier than 10 pounds."

The nurse notes documentation that a client has conductive hearing loss. The nurse plans care knowing that this kind of hearing loss can be caused by which circumstances? Select all that apply.

- Acute otitis media with effusion - A physical obstruction to the transmission of sound waves

The nurse collects data from a client with a diagnosis of macular degeneration of the eye. The nurse would expect the client to report which symptoms? Select all that apply.

- Blurred central vision - Bending of straight lines - Inability to see color vividness

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.

- Floaters in visual field - Difficulty in night vision - Decreased color perception

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.

The nurse is reviewing the record of a client with mastoiditis. The nurse would expect to note which signs and symptoms? Select all that apply.

- Headache - Swelling directly behind the ear - Red and immobile tympanic membrane

A clinic nurse is reviewing the record of a client recently diagnosed with a cataract. Which clinical manifestations associated with this disorder would 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 has been diagnosed with cataracts. Which signs and symptoms would the nurse expect to note? Select all that apply.

- Photophobia - Blurred vision - Decreased color perception

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

Which actions would be performed when communicating with a client with presbycusis? Select all that apply.

- Speak slowly and distinctly. - Face client when speaking. - Use short sentences and phrases.

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

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

The nurse is preparing to reinforce a teaching plan for a client who is undergoing cataract extraction with intraocular implant. Which home care measures would the nurse include in the plan? Select all that apply.

- To avoid activities that require bending over - To take acetaminophen for minor eye discomfort - To place an eye shield on the surgical eye at bedtime - To contact the surgeon if a decrease in visual acuity occurs

The nurse is assigned to care for a client with a diagnosis of detached retina. Which findings would indicate that bleeding has occurred as a result of retinal detachment? Select all that apply.

- Vision may be cloudy - Complaints of a burst of black spots or floaters

The nurse is preparing to administer eye drops. Which interventions would 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.

Tonometry is performed on the client with a suspected diagnosis of glaucoma. The nurse reviews the test and determines that the intraocular pressure is normal if which result is noted?

15 mm Hg

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

A mydriatic medication

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

A sense of a curtain falling across the field of vision

The nurse notes that the primary health care provider (PHCP) has documented a diagnosis of presbycusis on the client's chart. Which explanation would the nurse give to the client to explain this condition?

A sensorineural hearing loss that occurs with aging

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 would the nurse determine to be the cause of the client's complaint?

Acetylsalicylic acid

The client is receiving an eye drop and an eye ointment to the right eye. Which action would the nurse take?

Administer the eye drop first, followed by the eye ointment.

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 who was hit in the eye with a baseball bat sustains a contusion of the eyeball. The emergency department nurse implements which immediate action?

Applies ice to the affected eye

The nurse is reinforcing instructions to a client with a diagnosis of hordeolum regarding the treatment plan. Which instruction would the nurse include in the teaching plan for the client?

Apply a warm compress for 15 minutes 4 times daily.

A client arrives in the emergency department with a foreign body in the eye. Which action would the nurse plan to perform first?

Apply an eye patch to both eyes.

A client arrives at the emergency department following a blow to the eye from a softball. Which intervention would be implemented by the nurse initially?

Apply ice to the affected eye.

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

Apply ice to the affected eye.

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

Atropine sulfate

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

Atropine sulfate

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.

The nurse reinforces instructions to a client who has been prescribed betaxolol eye drops for the treatment of glaucoma. The nurse instructs the client regarding the administration of the medication and about the importance of returning to the clinic for which assessment?

Blood pressure and apical pulse

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

Bright red drainage on the dressing

Latanoprost drops are prescribed for the client with glaucoma. The client returns to the health care clinic for evaluation. Which finding noted in the client indicates a side effect associated with the use of these eye drops?

Brown pigmentation of the iris

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

Cardiovascular disease

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 would the nurse take next?

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

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

Cranial nerve VII, facial nerve

The nurse would check for vision loss in a client with which condition?

Diabetes mellitus

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

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

The nurse determines that the client diagnosed with Ménière's disease understands the reinforced dietary instructions when the client states that which food will be avoided in the diet?

Hot dogs

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

In semi-Fowler's position

A client arrives at the emergency department with a foreign body in the left ear that has been determined to be an insect. Which initial intervention would the nurse anticipate to be prescribed?

Instillation of mineral oil or diluted alcohol

The nurse is caring for a client who has been taking acetazolamide for glaucoma. The nurse reviews the assessment data documented in the client's medical record and determines that an adverse effect of the medication may be occurring if which result is noted?

Jaundice

The nurse has reinforced instructions to a client regarding the method for instilling eye drops into the left eye. The nurse determines that the client needs further teaching if the client does which during a return demonstration?

Lies supine, pulls up on the upper lid, and puts the drop in the upper lid

The nurse is caring for a client with glaucoma who is receiving acetazolamide daily. Which sign/symptom indicates to the nurse that the client is experiencing an adverse effect related to the medication?

Low back pain and dysuria

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 communicating with a client who is hard of hearing in both ears. To facilitate communication with this client, the nurse would perform which?

Lower the voice pitch and face the client when speaking.

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 in the ambulatory care unit is caring for a client following cataract extraction. The client suddenly complains of nausea and severe eye pain in the surgical eye. The nurse would take which action?

Notify the registered nurse.

The nurse is caring for a client following enucleation. On data collection, the nurse notes staining and bleeding on the dressing. The nurse would take which action?

Notify the registered nurse.

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.

A client arrives in the emergency department after an automobile crash. The client's forehead hit the steering wheel, and a hyphema has been diagnosed. Which position would the nurse prepare to position the client?

On bed rest in a semi-Fowler's position

The nurse is assigned to care for a client following a cataract extraction. The nurse plans to place the client in which position?

On the nonoperative side

A client with retinal detachment is admitted to the outpatient nursing unit in preparation for a scleral buckling procedure. Which prescription would the nurse anticipate?

Placing an eye patch over the client's affected eye

The nurse is caring for a client who is hearing-impaired. Which approach would the nurse take to facilitate communication?

Speak in a normal tone.

The nurse is preparing to administer eardrops to an adult client. The nurse administers the eardrops by which technique?

Pulling the pinna up and back

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

Report the client's complaints.

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

Report the finding to the registered nurse (RN).

While at home, the nurse receives a telephone call from a neighbor who reports that while accidentally breaking a mirror, a piece of glass flew into her eye. Which is the appropriate initial nursing action after observing that the large glass shard is protruding from the neighbor's eye?

Secure a paper cup over the affected eye.

The nurse is assigned to care for a client diagnosed with cytomegalovirus retinitis and acquired immunodeficiency syndrome (AIDS) who is receiving foscarnet. The nurse would monitor the results of which laboratory study while the client is taking this medication?

Serum creatinine level

These are signs and symptoms of glaucoma. Which sign or symptom is found only in narrow-angle glaucoma?

Severe pain in and around eye

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

Stand in front of the client.

The nurse is inserting soft contact lenses into the eyes of a client. Which direction does the nurse tell the client to look?

Straight ahead

The nurse provides dietary instructions to a client with Ménière's disease. The nurse tells the client that which food or fluid item is acceptable to consume?

Sugar-free Jell-O

A client is being discharged from the ambulatory care unit following cataract removal. Which instruction from the discharge teaching plan would the nurse reinforce?

Take acetaminophen if any discomfort occurs.

The nurse is preparing to assist the primary health care provider to test the extraocular movements in a client and muscle weakness in the eyes. The nurse anticipates that which physical assessment technique will be done?

Testing the six cardinal positions of gaze

The nurse is reviewing the primary health care provider's prescriptions for a client admitted to the hospital with a diagnosis of an acute attack of Ménière's disease. Which prescription noted on the client's chart should the nurse question?

The administration of a vasoconstrictor

The nurse is caring for a client who will be undergoing surgical treatment for Ménière's disease. The nurse plans care based on which expected outcome?

The surgery relieves pressure from accumulation of inner ear fluid in the endolymphatic sac.

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

Which intervention would be implemented for the older client with presbycusis who has a hearing loss?

Use low-pitched tones.

The nurse assists with preparing the client for ear irrigation as prescribed by the primary health care provider (PHCP). Which action would the nurse plan to take?

Warm the irrigating solution to 98°F (36.6°C).