Sensory Exam - Practice Questions

A client has sustained damage to cranial nerve II (optic) after a traumatic injury. Which intervention does the nurse anticipate to accommodate for this injury? a) Artificial tears b) Identifying food on the client's plate using the clock method c) Daily eye assessment using the six cardinal positions of gaze d) Ensuring that the client wears sunglasses when the curtains are open or when the room light is on

b (cranial nerve 2 controls sight. using the clock method helps clients identify food on their plate) (a- artificial tears are used when tear production is decreased due to the aging process c- the six cardinal FOG is used to assess CN 3,4,6 d- sunglasses are used to protect the eye when they are dilated)

The nurse is teaching a client about open-angle glaucoma management. Which statement by the client indicates a need for further instruction? a) "I must wait 10 to 15 minutes between different eyedrop medications." b) "I must press on the inside of my eye to prevent washout." c) "It is important to not skip a dose." d) "These eyedrops will not cure my glaucoma."

b (pressing on the inside of the eye prevents systemic effect- the glaucoma medication works systemically)

The elderly client with a hearing deficit is likely to exhibit which characteristic? a) pt prefers to be alone b) pt is suspicious of others c) pt communicates best by writing d) pt is difficult to understand

b (pt can't communicate well with others, therefore is suspicious of them - believes others are mumbling)

The nurse should inform the client that after a stapedectomy, it is normal to experience what effect? a) severe nausea lasting 24 hrs b) further hearing loss that is temporary c) vertigo when standing upright d) rapid improvement with hearing

b (stapedectomy = removal of otosclerotic lesions & creation of a tissue implant w/ a prosthesis to maintain adequate conduction - hearing may be impaired temporarily post-op due to edema & packing)

Which technique is the correct way to instill eardrums? a) Maintain the head in the same position for 2 minutes after instillation. b) Place the medication bottle in a bowl of warm water before instillation. c) Rinse the ear canal with hydrogen peroxide before instillation. d) Check to see whether the eardrum is intact before instillation.

b (the medication should be placed in a bowl full of warm water for 5 minutes- makes it more comfortable for the client) (a- the head should be moved back and forth 5 times after instillation to ensure proper distribution c&d- it is not necessary to do these before instillation)

A client reports "something scratching on the inside of my eyelid." Before examining the eyelid, what does the nurse do first? a) Administer a Snellen test. b) Obtain an informed consent. c) Wash the hands. d) Put on sterile gloves.

c

Which proper technique does the nurse use for eyedrop instillation? a) Instilling the drops into the inner canthus b) Opening the eye by raising the upper eyelid c) Placing the eyedrop in the lower lid pocket d) Touching the bottle tip to the eyeball

c (a- instilling drops into the inner canthus would cause the drug to go into the punctum and be absorbed systemically b- the lower eyelid should be gently lowered d- touching the bottle tip to the eyeball will cause irritation and potentially irritate the eye)

A patient reports eye pain and states "I suddenly just felt something hit my eye." Which order by the ER physician might the nurse question? a) order for an x-ray b) order for a CT scan c) order for an MRI

c (MRI contraindicated b/c it may move any metal-containing projectile from the eye & cause more injury) *eye pain & suddenly feeling something hit the eye = indicative of penetrating injury*

Which type of drug therapy does the nurse anticipate giving to a client with Ménière's disease to decrease endolymph volume? a) Antihistamines b) Antipyretics c) Diuretics d) Nicotinic acid

c (Mild diuretics are prescribed to decrease endolymph volume) (a-help reduce the severity of or stop an acute attack b- help reduce fever and pain d- has been found to be helpful but does not reduce endolymph volume)

A client recently diagnosed with Ménière's disease is struggling with tinnitus. How does the nurse provide support to this client? a) Provide further assessment. b) Suggest a quiet environment. c) Suggest temporary removal of a hearing aid. d) Refer the client to the American Tinnitus Association.

d (The American Tinnitus Association assists clients in coping with tinnitus when other therapy is unsuccessful) (a- Reassessment of the client's diagnosis is not needed b-Background noise masks the tinnitus while quiet conditions exacerbate it c- ear-mold hearing aids can amplify sounds to drown out tinnitus during the day)

A client has a bilateral corneal disorder and must instill anti-infective eyedrops every hour for the first 24 hours. Which comment by the client indicates a need for further instruction by the nurse? a) "I have two bottles of eyedrops because I will require a lot of medication." b) "I won't be able to wear my contacts for a while." c) "I must apply the drops throughout the night." d) "I must wash my hands before and between eye applications and after putting the drops in."

a (if two bottles of eyedrops are used it is because the client should use one bottle per eye and should be taught to clearly label them "left" and "right")

A client is scheduled for extracapsular cataract removal. Which information is *most* important to be included in pre-op teaching? a) post-op activities & restrictions b) proper use of dark glasses c) S/S of a detached retina d) symptoms of eye hemorrhage

a (important to avoid increasing IOP which would cause the suture line to rupture)

The nurse is teaching a client who is scheduled for an ultrasonography of the eye. Which statement by the client indicates a need for further instruction? a) "I'll have to wear a bandage over my eye after the test." b) "I will be awake during this test." c) "I won't hear the high-frequency sound waves." d) "This test will help determine whether my retina is detached."

a (no follow up care is needed except for educating the client on not rubbing or touching the eye until the effects of the anesthetic drops wear off) *ultrasonography of the eye aids in the diagnosis of trauma, infraorbital tumor, proptosis, and choroidal, or retinal detachment*

When communicating with a client who has a hearing deficit, which action is *MOST* important for the nurse to take? a) speak using hands, face, & eyes b) speak normally c) place pt in good light so he/she can see nurse's mouth d) verify the pt understands the message by having the pt write what was said

a (nonverbal cues assist what is being said) *speak slowly & articulately w/ a normal tone *ask pts to verbally repeat statements

The nurse expects the older client with otosclerosis to exhibit which symptoms? a) hearing loss & a buzzing ear noise b) headache & vertigo c) pain & ringing in the ear d) progressive deafness & excessive cerumen

a (otosclerosis = cause of deafness, findings = gradual loss of hearing & tinnitus) b - meniere's disease c - otitis media

What is the primary purpose of performing a myringotomy on a client with acute otitis media? a) to relieve pressure on the eardrum b) create a pathway for administering meds c) avert the need for analgesia d) remove debris from the outer ear

a (relieves pressure & drains the middle ear

An older adult client comes in for a routine visit. During the assessment, he irritably exclaims, "Speak up and quit mumbling!" How does the nurse respond? a) Apologizes and speaks louder and clearer b) Asks whether the client has a hearing loss c) Offers the client a stethoscope to use d) Suggests that the client move to a soundproof examination room to improve his hearing

a (the nurse should speak more clearly and then determine if further assessment is needed) (b- the client is may become more irritable especially if they are in denial c- using a stethoscope will only be effective if a diagnosis of hearing loss is made d- soundproof rooms are used for hearing tests)

An older adult client reports ear pain. Otoscopic examination by the nurse practitioner (NP) reveals a dull and retracted membrane. What does the NP do next? a) Continues further assessment b) Irrigates the ear c) Prescribes antibiotics for probable otitis media d) Tests hearing acuity

a (this finding may be a normal related age change and requires further assessment) (b- irrigating the ear is not indicated for this client c- though a dull and retracted membrane is a symptom of otitis media, it also may be expected in the older adult so further assessment is needed d- auditory assessment is done after otoscopic examination)

The nurse is teaching a client about ear protection. Which statement by the client indicates that teaching was effective? a) "I always wear earplugs when I swim." b) "It is noisy where I work, so I listen to music with ear buds." c) "My ears ring after attending a rock concert, but it goes away." d) "The machinery is loud at work, but I get used to it."

a (this prevents infection) (b- to block out the noise of the environment, the music would have to be turned up loudly which could damage the ear c- ringing in the ears (tinnitus) may be a sign of injury d- "getting used to the noise" is a sign of damage)

A client with new-onset diminished vision is being discharged and is concerned about living independently. Which nursing technique best facilitates independent self-care for the client? a) Building on the remaining vision b) Keeping the floor free of clutter c) Suggesting a seeing-eye animal companion d) Teaching Braille

a (using large print books, talking clocks, and telephones with large raised numbers are all ways to build on the clients remaining vision and facilitate independence) (b- this is important but too specific c- eye seeing companions are used for clients who are legally blind d- braille is used for the client who is legally blind- this client will still be able to see using something like a magnifier)

The nurse is teaching a client about visual changes that occur with age. Which statement does the nurse include? a) "It may take your eyes longer to adjust in a darkened room." b) "Most visual changes occur before age 40." c) "When the sclera starts to turn yellow, this means you might have problems with your liver." d) "You probably will have to move reading materials closer to your eyes."

a (with increasing age, the iris has less ability to dilate which leads to difficulty adapting in dark environments) (b- presbyopia usually occurs in the 40's c- the sclera in an older client turns yellowish or blue and should not be a valid indicator for diagnosing jaundice d- older clients usually have to move reading materials further away from their eyes)

Which tasks are appropriate to delegate to an LPN/LVN who is functioning under the supervision of a team leader or RN? (SATA) a) Irrigating the ear canal to loosen impacted cerumen b) Administering amoxicillin to a child with otitis media c) Reminding the client not to blow the nose after tympanoplasty d) Counseling a client with Meniere's disease e) Suggesting communication techniques for the family of a hearing-impaired elder f) Assessing a client with labyrinthitis for headache and level of consciousness

a,b,c

You are interviewing an elderly client who reports that "lately there has been a roaring sound in my ears." What additional assessments should you include? (SATA) a) Obtain a medication history. b) Ask about exposure to loud noises. c) Observe the canal for earwax or foreign body. d) Assess for signs and symptoms of ear infection. e) Ask about frequency of ear hygiene.

a,b,c,d

Which clients are at high risk for developing hearing problems? (SATA) a) Airline mechanic b) Client with Down syndrome c) Drummer in a rock band d) Teenager listening to music using ear buds e) Telephone operator

a,b,c,d (a- airplane mechanic is exposed to loud noises b- individuals with Down Syndrome are at high risk due to genetic defect c- has exposure to loud noises d- listening to music with earbuds puts you at increased risk for hearing problems)

A bedridden client with reduced vision has been admitted. Which nursing interventions will ease the client's hospital stay? (SATA) a) Announce name and purpose when entering the client's room. b) Explain food positions on the tray using a clock face as the example. c) Orient the client to the location of the call light, and keep it in that place. d) Orient the client to the room surroundings and equipment. e) Speak in a loud, clear voice.

a,b,c,d (e- you do not have to speak in a loud voice because the client does not have hearing impairment)

Which clients would be best to assign to the most experienced nurse in an ambulatory care center that specializes in vision problems and eye surgery? (SATA) a) Client who requires postoperative instructions after cataract surgery b) Client who needs an eye pad and a metal shield applied c) Client who requests a home health referral for dressing changes and eyedrop instillation d) Client who needs teaching about self-administration of eyedrops e) Client who requires an assessment for recent and sudden loss of sight f) Client who requires preoperative teaching for laser trabeculoplasty

a,c,d,f

The nurse is providing discharge instructions to a client with glaucoma. Which activities does the nurse instruct the client to avoid? (SATA) a) Bending over to tie shoes b) Sitting with legs elevated c) Sleeping on more than two pillows d) Blowing the nose frequently e) Lifting objects weighing more than 10 pounds

a,d,e (anything that increases IOP is contraindicated for the client with glaucoma)

Place the following steps for ear irrigation in the correct order. a) Use an otoscope to ascertain that the eardrum is intact and that there is no evidence of infection. b) Place the tip of the syringe at an angle in the external canal. c) Watch for fluid return and signs of cerumen. d) If cerumen does not appear, wait 10 minutes and repeat the irrigation. e) Fill a syringe with warm irrigating solution. f) After completion of the irrigation, have the client turn the head to the side to facilitate drainage. g) Apply gentle but continuous pressure to the syringe plunger.

a,e,b,g,c,d,f

An elderly widow comes to the community clinic for her annual checkup. She is in reasonably good health, but she has a hearing loss of 40 dB. She confides, "I don't get out much. I used to be really active, but the older I get, the more trouble I have hearing. It can be really embarrassing." What is the priority nursing diagnosis? a) Risk for Situational Low Self-Esteem related to perceived inability to interact b) Impaired Social Interaction related to progressive hearing loss c) Deficient Knowledge related to pathophysiologic processes d) Ineffective Coping related to change in sensory abilities

b

Which of these symptoms are associated with acute (closed-angle) glaucoma? a) eye fatigue, photophobia, loss of peripheral vision b) blurred vision, headache, rainbows around lights c) tunnel vision, malaise, flashing lights d) nausea, orbital edema, blindness

b

You are interviewing an elderly woman and discover that she has been taking her glaucoma eyedrops by mouth for the past week. What should you do first? a) Call to obtain an order for tonometry so that her intraocular pressure can be checked. b) Try to determine how frequently and how much she has been ingesting. c) Ask her how she decided to take the drops orally instead of instilling them as eyedrops. d) Call the Poison Control Center and be prepared to describe untoward side effects

b

You are supervising a new nurse who has just finished assessing a client who came to the clinic for redness and discomfort to the right eye. You review her documentation, which includes "visual acuity N/A." What should you do next? a) Do nothing; the documentation is minimal but acceptable. b) Ask her to explain her rationale for the documentation. c) Reassess the client yourself to validate her findings. d) Suggest that she contact the clinical educator for documentation tips

b

A client with visual limitations has been admitted to the intensive care unit (ICU). Which action is most important to implement for this client? a) Allowing the client's seeing-eye dog in the unit b) Making all health care team members aware of the client's visual limitations c) Keeping the client bedridden for safety d) Addressing the client in a loud, clear voice

b (a- seeing eye dogs are not usually allowed in the ICU c- it is not necessary to keep the client bedridden d- the client should be assessed in a normal tone of voice since their hearing is not impaired)

The nurse is teaching the mother of a teenage client with conjunctivitis how to administer eye ointment. Which statement by the mother indicates a correct understanding of the nurse's instruction? a) "My child should look down at the floor during instillation." b) "I will place the ointment in the lower lid." c) "My child should rub the eye gently after instillation to increase absorption." d) "I will press gently on the inner canthus for 1 minute."

b (a- the client should tilt the head up and backwards c- the eye should never be rubbed, however the client can gently wipe away the excess d- pressing on the inner canthus is reserved for instillation of glaucoma medication)

the health care provider has ordered prochlorperazine postoperatively for a client who had a cataract extraction. What is the purpose of this drug? a) to prevent retinal detachment b) to prevent pressure on the suture line c) to help the client sleep better d) to increase the client's nutritional intake

b (antiemetic given to prevent nausea, therefor preventing an increase in IOP)

If blood is observed on a patient's ear dressing 1 hr after surgery, which nursing action is indicated? a) apply pressure to stop the bleeding b) notify the physician immediately c) chart the results d) change the dressing & notify the physician if bleeding persists

b (bleeding from outer ear is a post-op complication that should be reported asap)

What is the chief visual disturbance that occurs when a patch is placed over an affected eye? a) inability to focus on very near or far away objects b) difficulty judging the distance of objects c) impaired accommodation to darkness d) seeing floating spots in the affected eye

b (depth perception depends on *binocular* vision,

What is the action of miotics in the client with glaucoma? a) Decrease the inflammatory process b) Enhance aqueous outflow c) Increase the production of vitreous humor d) Vasoconstrict the blood vessels in the eye

b (miotics are used to increase aqueous flow (aqueous humor) and decrease IOP) (a- steroids are used to decrease inflammatory process c- vitreous humor is not replenished as aqueous humor is. It stays stagnant between the lens and the retina d- Miotics make the pupil smaller)

The client's parents ask the nurse if the cause of a retinal detachment is hereditary. What response by the nurse is best? a) Yes it is, do any of your other children have a detached retina b) The cause of retinal detachment is uncertain, there are many contributing factors c) No, the cause is RT trauma to the eye d) It's better to focus on how to prevent a detachment in the other eye due to the hereditary tendency

b (no certain cause, contributing factors = trauma, aging, diabetes, tumors - but hereditary factors increase the risk)

Which client is most in need of immediate examination by an ophthalmologist? a) A 58-year-old with glasses who reports an inability to see colors well and is feeling as though the glasses are always smudged b) A 40-year-old with glasses and a reddened sclera who reports brow pain, headache, and seeing colored halos around lights c) A 76-year-old with seborrhea of the eyebrows and eyelids who reports burning and itching of the eyes d) A 39-year-old with contacts who reports an inability to tolerate bright lights and has visible purulent drainage on eyelids and eyelashes

b (the client is exhibiting signs of increased IOP- this client needs to be assessed first due to the possibility of blindness) *client D will need to be assessed next but increased IOP is the priority*

A client has recently been diagnosed with 20/200 vision bilaterally. How does the nurse best offer increased support? a) Provides instructions in a loud, clear voice b) Refers the family to local services for the blind c) Tells the client to find a support group d) Writes instructions down in very large print

b (this client is considered legally blind) (a- the nurse should speak in a normal voice because being legally blind does not affect the clients hearing c- the client needs more specific guidelines for finding a support group d- the client will not be able to distinguish large print)

Which eye procedure requires informed consent from the client? a) Eyedrop instillation b) Fluorescein angiography c) Ophthalmoscopy d) Snellen test

b (this is an invasive test and requires informed consent)

The nurse is performing preoperative teaching for an older adult client who will be having a cataract removed. Which instructions does the nurse include? (SATA) a) "You will need to wear a patch on your eye for several weeks after the surgery." b) "Several different types of eyedrops are requested after surgery, and they have to be taken several times a day for up to 4 weeks." c) "You will receive a medication to help you relax. Then you will receive some different eyedrops to dilate your pupils and paralyze the lens." d) "Bring sunglasses with you on the day of your procedure." e) "You might experience a lot of bruising and swelling around the eye."

b,c,d (a- a patch is only required if there is a risk for injury e- cataract surgery does not cause bruising or swelling around the eye)

Which tasks are appropriate to delegate to an LPN/LVN who is functioning under the supervision of an RN? (SATA) a) Assessing the sexual implications for a client with oculogenital-type Chlamydia trachomatis infection b) Administering sulfacetamide sodium 10% to a child with conjunctivitis c) Reviewing hand-washing and hygiene practices with clients who have eye infections d) Showing clients how to gently cleanse eyelid margins to remove crusting e) Assessing nutritional factors for a client with age-related macular degeneration f) Reviewing the health history of a client to identify risk for ocular manifestations g) Performing a routine check of a client's visual acuity using the Snellen eye chart

b,c,d,g

Which systemic disorders may affect the eye and vision and require yearly eye examination by an ophthalmologist? (SATA) a) Anemia b) Diabetes mellitus c) Hepatitis d) Hypertension e) Multiple sclerosis (MS)

b,d,e (b) clients with DM are at an increased risk for diabetic retinopathy d) clients with HTN are at an increased risk for retinal damage e) the client with MS can have neurological effects that impact visual acuity)

In the care of a client who has sustained recent blindness, which tasks would be appropriate to delegate to a UAP? (SATA) a) Counseling the client to express grief or loss b) Assisting the client with ambulating in the hall c) Orienting the client to the surroundings d) Encouraging independence e) Obtaining supplies for hygienic care f) Storing personal items to reduce clutter g) Rearranging furniture to prevent falls

b,e

At a community health clinic, you are teaching a community group about the prevention of accidental eye injuries. What is the most important thing to stress? a) Workplace policies for handling chemicals should be followed. b) Children and parents should be cautious about aggressive play. c) Protective eyewear should be worn during sports or hazardous work. d) Emergency eyewash stations should be established in the workplace

c

Which action by a nurse is most likely to increase accurate communication with a client who has low vision? a) speaking slowly & loudly b) enhancing the talk using hand gestures c) being very specific with descriptions/directions d) marking the door of pt's room to indicate vision status

c

Which assessment is most important for the nurse to perform before instilling travoprost (prostaglandin agonist) into the client's eye? a) measure client's BP b) measure client's IOP c) check cornea for abrasions/open areas d) assess client's HR & rhythm for 1 full minute

c

You are working in an ambulatory care clinic. A client calls to report redness of the sclera, itching of the eyes, and increased lacrimation for several hours. What should you direct the caller to do first? a) "Please call your physician" (i.e., refuse to advise). b) "Apply a cool compress to your eyes." c) "If you are wearing contact lenses, remove them." d) "Take an over-the-counter antihistamine."

c

The nurse expects the client with a cataract to complain about which symptom? a) eye pain while doing close work b) double vision c) blurred vision d) halos around lights

c (S/S of cataracts = blurred vision, annoying glare, & pupil turning a milky gray color)

An older adult client reports nausea during removal of impacted cerumen from the ear canal. What does the nurse do next? a) Administer an antiemetic. b) Call the health care provider. c) Stop irrigation immediately. d) Use less water to irrigate.

c (The client's nausea may be a sign of vertigo. If nausea, vomiting, or dizziness develop in the client, irrigation should be stopped immediately) (a- antiemetics should not be immediately administered, further assessment should be done first b- the HCP should not be notified until further assessment is done d- using less water will not alleviate the nausea)

The nurse is caring for a client who is admitted with mastoiditis. Which assessment data obtained by the nurse requires the most immediate action? a) The eardrum is red, thick-appearing, and immobile. b) The lymph nodes are swollen and painful to touch. c) The client reports a headache and a stiff neck. d) The client's oral temperature is 100.1° F (37.8° C).

c (a headache and a stiff neck may indicate meningitis, which is a serious illness requiring further assessment and immediate intervention) (a,b,d- these are all expected findings)

The nurse is providing postmortem care to a client who has donated a cornea. Which action is appropriate for the nurse to implement? a) Apply a warm pack to the eyes. b) Elevate the lower extremities. c) Instill antibiotic drops into the eyes. d) Contact the recipient family.

c (antibiotics such as Neosporin [polymyxin B, neomycin, bacitracin] or tobramycin should be administered to prevent infection) (a- cool packs should be applied to the eyes b- the head of the bed should be elevated atleast 30 degrees to prevent blood pooling in the eyes d- the nurse is not the person to contact the recipient family- the donor organization does that)

A client is returning home after cataract surgery with a patch over the affected eye. Which statement by the client's spouse indicates a need for further instruction on providing a safe home environment? a) "I will get some books on tape for entertainment." b) "I will be sure to pick up all clutter and loose carpets from the floor." c) "I will rearrange the furniture for better flow before my spouse gets home." d) "I will place a nonslip mat in the bathtub."

c (changes should not be made without the input from the client whose vision is affected)

The nurse has just received change-of-shift report about these clients. Which client needs to be assessed first? a) Client with Ménière's disease who is reporting severe nausea and is requesting an antiemetic b) Client who has had removal of an acoustic neuroma and has complete hearing loss on the surgical side c) Client with labyrinthitis who has a temperature of 102.4° F (39.1° C) and a headache d) Client who has acute otitis media and is reporting drainage from the affected ear

c (elevated temperature and headache with labyrinthitis may indicate that the client has developed meningitis and requires further immediate assessment and intervention) (a- severe nausea is an expected finding with Ménière's disease b- Complete hearing loss on the surgical side is an expected postoperative finding after an acoustic neuroma d- Drainage from the affected ear can be an expected finding with otitis media)

While reading a client's optical chart, the nurse notices that the client has emmetropia. Which corrective equipment does the nurse expect to see this client wearing? a) Bilateral eye patches b) Contact lenses c) Nothing; this is normal d) Reading glasses

c (emmetropia is perfect refraction of light rays, it is normal (ideal) and does not require any corrective equipment)

You performed postoperative stapedectomy teaching several days ago for a client. Which comment by the client concerns you the most? a) "I'm going to take swimming lessons in a couple of months." b) "I have to take a long overseas flight in several weeks." c) "I can't wait to get back to my regular weightlifting class." d) "I have been coughing a lot with my mouth open."

c (heavy lifting should be strictly avoided for atleast 3 weeks following stapedectomy)

Which physical assessment findings should be reported to the physician? a) Pearly gray or pink tympanic membrane b) Dense whitish ring at the circumference of the tympanum c) Bulging red or blue tympanic membrane d) Cone of light at the innermost part of the tympanum

c (possible sign of otitis media or perforation) *other signs are considered normal anatomy*

The nurse is teaching a client with impaired hearing about audiometric testing. Which statement by the nurse effectively communicates information about the procedure to the client? a) "Here is a picture of how the test is done. See how your bad ear will be tested first? You will be alone in the soundproof booth, so you will need to watch for lights flashing on and off as your cues." b) "Here is a video of the procedure. Please watch and feel free to ask me any questions." c) "I will sit right in front of you in the soundproof booth and give you instructions on what types of sounds you will hear and how you'll need to respond." d) "You will be in a soundproof booth and the sounds will be piped in. When you first hear the loudest sound, put your hand down. When you stop hearing the sound, put your hand up to stop."

c (sitting in front of the client allows them to read your lips) (a- good ear tested first b- letting the client listen to a video is insensitive because tone and frequency differences, the client will not be able to read lips d- the client is asked to put their hand up at the first noise that they hear and lower their hand when the sound disappears)

Which description by a client reporting vertigo would concern you the most? a) Dizziness with hearing loss b) Episodic vertigo c) Vertigo without hearing loss d) "Merry-go-round" vertigo

c (the client reported with vertigo without hearing loss should be assessed for nonvestibular causes such as cardiovascular or metabolic)

A client has recently had cataract surgery. About which symptom does the nurse instruct the client to notify the health care provider? a) Increased tearing b) Itching of the eye c) Reduction in vision d) Swollen eyelid

c (the client should notify the HCP immediately) (a,b,d- these are all expected after cataract surgery)

What action should the nurse take when providing pre-op care for a client with a detached retina? a) apply ice packs to the affected eye b) irrigate the eye with warm NS c) maintain the client on bed rest d) instruct the client to lay on the unaffected side

c (want to minimize movement of the head/eyes)

A mother accidentally splashes ammonia into her child's eye. She contacts the pediatrician's office, which of the following instructions should the nurse give her *FIRST*? a) take child to ER immediately b) irrigate child's eyes with a boric acid solution c) flush child's eyes with lukewarm water d) place patches over both child's eyes

c (whenever a caustic or irritating liquid enters the eyes, immediately irrigate with water - the shorter the delay = less damage done)

The nurse providing education on eye protection suggests the special need for protective eyewear for which clients? (SATA) a) Cab driver b) College student c) Lifeguard d) Racquetball player e) Registered nurse

c,d (lifeguards need protection of UVA and UVB rays from sun exposure; racquetball players need eye protection from possible injury while playing)

A client reports a sudden excruciating pain in the left eye with the visual change of colored halos around lights and blurred vision. Which interventions should you anticipate and perform for this emergency condition? (SATA) a) Prepare the client for photodynamic therapy. b) Instill a mydriatic agent, such as phenylephrine. c) Instill a miotic agent, such as pilocarpine. d) Administer an oral hyperosmotic agent, such as isosorbide. e) Apply a cool compress to the forehead. f) Provide a darkened, quiet, and private space for the client.

c,d,e,f

The nurse is assessing a client with recent changes in hearing. After taking a medication history, which drugs does the nurse identify as possible causes of the client's hearing change? (SATA) a) Acetaminophen (Tylenol) b) Beta blockers c) Erythromycin d) Ibuprofen (Advil) e) Insulin f) Furosemide (Lasix)

c,d,f (Erythromycin, ibuprofen, and furosemide (Lasix) are medications known to increase the risk for ototoxicity and hearing problems) (a,b,e-Acetaminophen, beta blockers, and insulin are not known ototoxic drugs)

The nurse is reviewing postoperative instructions with a client undergoing stapedectomy. Which statement by the client indicates a need for further teaching? a) "I may have problems with vertigo after the surgery." b) "I should not drink from a straw for several weeks." c) "I will have to take antibiotics after the surgery." d) "I will be able to hear as soon as my dressing is removed."

d (hearing is initially worse after a stapedectomy. The client should be informed that improvement in hearing may not occur until 6 weeks after surgery) (a-Vertigo, nausea, and vomiting are common after surgery because of the nearness of the surgical site to inner ear structures. b-Clients should not drink through a straw for 2 to 3 weeks after surgery c-Antibiotics are used to reduce the risk for infection)

What is the proper technique for assessing an adult client's ear with an otoscope? a) Hold the otoscope right side up when inserting it into the ear canal. b) Maintain distance between the otoscope and the client's head. c) Place the otoscope in the nondominant hand. d) Pull the pinna up and back with the nondominant hand.

d (in the adult, pulling the pinna up and back allows the canal to straighten out) (a- the otoscope should be held upside down b- the distance between the otoscope and the clients head is very short c- the pinna should be pulled back with the non dominant hand and the otoscope held with the dominant hand)

The nurse is teaching a client with vertigo about safety precautions for fall prevention. Which statement by the client indicates a need for further instruction? a) "I may need to use a cane." b) "I should keep my grandkids' toys out of the hallway." c) "Moving more slowly may help the vertigo subside." d) "Taking my medication will allow me to drive my car again."

d (medications for vertigo may cause drowsiness, so the client should not drive or operate machinery while taking these drugs)

The nurse is talking to a client about ear hygiene safety. Which statement by the client indicates a need for further teaching? a) "After I shower, I dry my ears using my fingertip and a towel." b) "I irrigate my ears with tap water." c) "I never clean my ears with a cotton swab." d) "I use a bobby pin to remove earwax."

d (nothing smaller than the clients own fingertips should be inserted into the ear canal- this could scrape the canal, push cerumen up against the eardrum, and even puncture the eardrum)

A client says, "I have problems reading the signs when I am driving." Which test does the nurse use to assess this client's problem? a) Confrontation test b) Ishihara chart c) Rosenbaum Pocket Vision Screener or a Jaeger card d) Snellen chart

d (the Snellen chart assesses the clients distance vision which is the type of vision used while driving) (a- assesses the clients visual field b- assesses the clients color vision c- assesses the clients near vision)

A client is in the immediate postoperative period after tympanoplasty. How does the nurse position the client? a) On the affected side b) Supine, with eyes toward the ceiling c) With the head elevated 60 degrees d) With the affected ear facing up

d (the client should be kept flat with the affected ear facing up) (a- should be flat b- face should be turned so that the affected ear is turned up c- elevating the head of the bed places pressure on the surgical site)

When preparing to examine an ear with drainage, what does the nurse do first? a) Begins testing at 1000 Hz b) Reassures the client that the ear drainage is normal c) Tilts the client's head away slightly d) Dons clean gloves

d (the nurse should always use contact precautions for the client who has ear drainage to prevent infection) (a- testing at 1000 Hz is to assess for hearing loss b- ear drainage is not normal and must be assessed c- tilting the clients head is not the *first* thing to do)

The nurse is teaching a client who will soon be fitted for a hearing aid about proper care and use. Which statement by the client indicates that teaching was effective? a) "Background noises will be difficult for me to hear." b) "I should wear my hearing aid only to work at first." c) "I should just get a smaller hearing aid because I don't have much money." d) "Listening to the radio and television will help me get used to new sounds."

d (this can help the client get used to new sounds. Hearing aids amplify the sound of background noises so the client must learn how to filter them out) (a- will be able to hear them more b- to get used to it, the client should wear it only at home during part of the day c- the cost of smaller hearing aids is actually more than for larger ones)

An older adult client expresses concern about the ability to instill over-the-counter eyedrops, saying, "My vision is getting so bad, I can't even see my own eyes." What is the nurse's best response? a) "Don't worry about the eyedrops." b) "Getting old isn't fun, is it?" c) "Can your daughter help you do it?" d) "Let's find a way that will work for you."

d (this helps to promote client independence)

A client with glaucoma is being assessed for new symptoms. Which symptom indicates a high priority need for reassessment of intraocular pressure? a) Burning in the eye b) Inability to differentiate colors c) Increased sensitivity to light d) Gradual vision changes

d (this indicates an increase in IOP) (a- burning usually indicated irritation/infection b- a sign of cataracts c- may be a sign of corneal abrasion)

Which finding should be immediately reported to the physician? a) A change in color vision b) Crusty yellow drainage on the eyelashes c) Increased lacrimation d) A curtainlike shadow across the visual field

d (this is a symptom of retinal detachment which is an emergency situation)

In discharge teaching after cataract surgery, the client and family should be told to immediately report which symptom to the physician? a) A scratchy sensation in the operative eye b) Loss of depth perception with the patch in place c) Poor vision 6-8 hours after patch removal d) Pain not relieved by prescribed medications

d (this may signal hemorrhage)

A client is having a stapedectomy. Which form of postoperative communication is most effective for the nurse to use? a) Gesturing b) Sign language c) Speaking d) Writing

d (writing is the most effective way to communicate with the client who has undergone a stapedectomy) (a- gesturing can be vague and imprecise b- sign language requires training c- the client will not be able to hear for the first 6 weeks after surgery)

A client has a purulent drainage in the inner canthus of the eye. Before examining the eye, what must the nurse do first? a) Administer a Snellen test. b) Obtain an informed consent. c) Instill antibiotic drops. d) Put on gloves.

d (gloves should be put on when there may be contact with drainage and when examining the eye)

A client is admitted to the emergency department with metal shards in the right eye. Which test is contraindicated for this client? a) Magnetic resonance imaging (MRI) b) Ophthalmoscopy c) Radioisotope scanning d) Snellen chart

a

Which precaution is most important for the nurse to teach a 62 yo client newly diagnosed w/ early-stage *dry AMD*? a) quit smoking b) quit drinking alcoholic beverages c) eat more dark green, red, & yellow veggies d) wear dark glasses when outside or in brightly lit areas

a

You are working in a community health clinic and a client needs instructions for the care of a hordeolum (sty) on the right upper eyelid. What is the first treatment that the client should try? a) Apply warm compresses four times per day. b) Gently perform hygienic eyelid scrubs. c) Obtain a prescription for antibiotic drops. d) Contact the ophthalmologist

a

The Snellen chart is used for what purpose? a) to test visual acuity b) to measure eye pressure c) to determine the client's ability to read d) to test peripheral vision

a (20/20 --> numerator = distance at which test is conducted, denominator = the distance at which the smallest letters can be read by a person with 20/20 vision)

Which test best determines hearing acuity? a) Audioscopy b) Electronystagmography c) Otoscope d) Snellen test

a (Audioscopy involves the use of a handheld device to generate tones of varying intensity to test hearing) (b- sensitive for detecting central and peripheral disease of the vestibular system in the ear c- used to inspect the ear canal d- visual acuity test)

Which S/S is expected in a client with a detached retina? a) the client states he sees quick flashes of light b) client complains of severe pain in the affected eye c) client has decreased peripheral vision d) the nurse observes orbital edema

a (S/S of retina detachment = flashes of light, blurred/sooty vision, sensation of particles moving in the line of vision, & eventually vision loss)

The nurse is preparing a client for electronystagmography. Which statement by the client indicates that teaching was effective? a) "I can't drink caffeine 24 to 48 hours before the test." b) "I should drink more fluids 4 hours before the test." c) "I'll be placed in a soundproof booth for the test." d) "I'll be sedated for the test."

a (The client must fast for several hours before electronystagmography and avoid caffeine-containing beverages for 24 to 48 hours before the test) (b- fluids are carefully introduced after the test to prevent nausea and vomiting c- the client is placed in a soundproof booth for an audiometry test d- the client is not sedated for the test- they are asked to do simple math problems or say peoples names to ensure alertness)

An elderly client asked the nurse what caused his cataract. What is the nurse's best response? a) cataracts are most common in the elderly b) the usual cause of cataracts in the elderly is congenital c) any type of chronic system disease can cause cataracts d) all cataracts result from eye injuries

a (causes = aging,trauma, prolonged use of corticosteroids, phenothiazines, mitotic agents, & is RT some diseases)

The nurse is performing an otoscopic examination of a client's ear and sees a greenish-white drainage. What does the nurse do next? a) Disposes of the otoscope tip and washes the hands before examining the other ear b) Reports the finding to the health care provider immediately c) Sends a specimen for culture d) Suctions out the drainage

a (contact Precautions must be used with any client who has drainage from the ear canal. To prevent cross-contamination, the nurse should dispose of the otoscope tip and wash the hands before examining the opposite ear) (b- the findings should be reported to the HCP immediately after the exam is finished c- a specimen is only obtained if the nurse is examining the external meatus region d- suctioning the infected ear will cause trauma)

A client comes in stating, "I think I have a piece of glass in my eye." What action should the nurse take *first*? a) attempt to remove the glass with tweezers b) douse the affected eye with artificial tears c) assess visual losses in the affected eye d) cover the eye with a protective shield

d

Before giving a beta-adrenergic blocking glaucoma agent, you would make additional assessments and notify the physician if the client makes which statement? a) "My blood pressure runs a little high if I gain too much weight." b) "Occasionally I have palpitations, but they pass very quickly." c) "My joints feel stiff today, but that's just my arthritis." d) "My pulse rate is a little low today because I take digoxin."

d

Which assessment finding warrants further investigation by the nurse in the ophthalmology clinic? a) Snellen eye examination result is 20/50 for a client who normally wears corrective lenses, but does not have them at the time of the examination. b) When six cardinal positions of gaze of the left eye are assessed, the client exhibits nystagmus when looking to the left lower and upper fields. c) The pupil exhibits miosis when exposed to light from the ophthalmoscope during examination and mydriasis when the light is removed from the pupil. d) When assessing the cornea, the nurse notes cloudiness and the client reports pain when the ophthalmoscope light shines into the pupil.

d

Clients with a family history of which eye disorder may have problems with increased intraocular pressure (IOP), requiring additional assessment? a) Anisocoria b) Presbyopia c) Diabetic retinopathy d) Glaucoma

d ( a- anisocoria is characterized by unequal pupil size not a sign of IOP b- presbyopia is a condition RT aging with an progressive loss of the ability to focus on near objects c- diabetic retinopathy is microvascular damage caused by uncontrolled diabetes)

An older adult client reports ear pain. To differentiate the cause, which clinical manifestation is more indicative of otitis media? a) Dry, flaky cerumen b) Pain on movement of the triages c) Ringing in the ears d) Vertigo

d (a- this is normal with aging b- this is indicative of external otitis c- more indicative of Ménière's disease)

An older adult client with a new diagnosis of hearing loss is deeply concerned about not being able to hear at the neighborhood council meetings. Which nursing intervention best addresses the client's concern? a) Suggest that the client discuss with the chairperson about asking everyone speaking at the meeting to speak louder. b) Refer the client to the Center for the Visually Impaired for support. c) Arrange for a sign language specialist to attend the meetings to teach everyone how to communicate with the hearing-impaired member. d) Refer the client to the Hearing Loss Association of America.

d (The Hearing Loss Association of America can inform the client about support groups in the area, along with interventions to help improve hearing) (a-Speaking louder raises the frequency of the sound, making it more difficult to hear b- the client is hearing impaired not visually impaired c-The client and members of the neighborhood council must first express an interest in learning sign language before arrangements are made with a sign language specialist.)

When performing an eye or vision assessment, which comment by the client alerts the nurse that immediate care by an ophthalmologist is needed? a) "One eye is green and the other eye is blue." b) "My eyes are red and itchy." c) "My vision has been getting worse gradually." d) "Something hit my eye while I was cutting grass."

d (The client who is experiencing trauma, a foreign body in the eye, sudden ocular pain, or sudden redness should be seen immediately by an ophthalmologist) (a- heterochromia is an inherited condition and does not require immediate care b- this could be caused by irritation or allergies c- gradual vision loss could be caused by hypertension or diabetes but does not require immediate care)

With which client does the nurse avoid performing an otoscopic examination? a) 34 yo woman who's pregnant b) 90 yo woman who is visually impaired c) 75 yo man with dizziness & vertigo d) 70 yo man with advance Alzheimer's

d (avoid performing on confused pts)

What is most likely related to the cause of otitis media? a) client smokes 1 PPD b) client had pneumonia as a child c) client has been swimming in a chlorinated pool d) client had a cold two weeks ago

d (cause = bacteria entering the middle ear [immunity was decreased due to a cold])

Place the following steps for eyedrop administration in the correct order. a) Gently press on the lacrimal duct for 1 minute. b) Gently pull the tissue underneath the eye downward to expose the lower conjunctival sac. c) Have the client gently close the eye and move it around. d) Have the client look up while you instill the number of prescribed drops. e) Hold the dropper and stabilize your hand on the client's forehead. f) Have the client sit down and tilt his or her head slightly backward

f,b,e,d,c,a