26, 58, 59, 60, 42 Special Senses - Medical, Surgical and Diagnostic Procedures + Meds, Upper Respiratory Disorders (Med/Surg)
What is an advantage of taking beta-adrenergic eye drops
Does not cause night blindness or blurred vision
If the pt is due to receive both eye drops and ointment, which should be administered first?
EYE DROPS should be administered before OINTMENT
Which is a potential serious adverse effect associated with mannitol (Osmitrol)?
Fluid overload
After instillation of eyedrops, what should you do to prevent systemic absorption of the medication
Press down on the inner canthus for 3-5 MINS to prevent absorption into the mucous membranes
A major common side effect of Pilocarpine (cholinergic) is ____
Reduced visual acuity
moisturizers, ophthalmic
soothe eyes that are dry due to environmental irritants and allergens
14. Which nursing diagnosis is most appropriate for a patient having ear surgery? a. Disturbed body image b. Risk for injury c. Acute confusion d. Ineffective protection
B
A patient recently diagnosed with glaucoma is to begin drug therapy with carbonic anhydrase inhibitors. For which assessment(s) would the nurse need to contact the health care provider? (Select all that apply.)
Electrolyte levels Allergy to sulfonamides
The nurse is preparing a patient for an ophthalmic examination. Which action occurs when the nurse instills eyedrops to produce mydriasis?
Extreme dilation of the pupil
If another medication is due to be administered, separate administration of medications by at least ___ minutes
FIVE
This medication is given in the eyes for diagnostic purposes to identify any foreign bodies in they eyes, ulcerated areas of the cornea, etc
FLUORESCEIN **Also used in fitting hard contacts
What is the purpose of administering a cycloplegic agent? (Select all that apply.)
Facilitate examination of the eye Facilitate surgery on the eye Paralyze the ciliary muscle
Once the drops of FLUORESCEIN is administered in the eye, diseased tissues will turn ____
GREEN
How should Natacyn, and ANTIFUNGAL EYE DROP, be administered **GIVEN FOR CANDIDIASIS in the eye
Give at 1-2 hr intervals for 3-4 days in the conjunctival sac
For the patient with bilateral eye patches, how should you approach them
Grab their attention before you touch them YOU MAY SCARE THEM
___ ,an osmotic diuretic, is used for glaucoma to draw aqueous humor from the eye
MANNITOL
With both osmotic diuretics (MANNITOL) and carbonic anhydrase inhibitors (DIAMOX), what should be monitored for in regards to electrolytes
Monitor for electrolyte imbalances
This type of glaucoma results in reduced outflow of aqueous humor at Schelmm's canal
Open-angle glaucoma
___, an cholinergic agent, produces strong contractions of the iris to lower IOP by widening the angle
PILOCARPINE
If the pt has contact lens, educate them to do what before eye drop administration
Remove contact lens
decongestants, ophthalmic
constrict the small arterioles of the eye, decreasing redness and relieving conjectival congestion
otoplasty
corrective surgery for a deformed or excessively large or small pinna
blephoroplasty
cosmetic surgery that removes fatty tissue above and below the eyes that commonly form as a result of the aging process or excessive exposure to the sun
pressure-equalizing (PE) tube placement
insertion of tubes through the tympanic membrane, commonly used to treat chronic otitis media; also called tympanostomy tubes or ventilation tubes.
The nurse is caring for a patient immediately following a right-sided trabeculectomy. When positioning this patient, the nurse will encourage a _____ position.
left side lying
wax emulsifiers
loosen and help remove impacted cerumen.
audiometry
measurement of hearing acuity at various sound-wave frequecies
ophthalmodynamomometry
measurement of the blood pressure of the retinal vessels
electronystagmography (ENG)
method of assessing and recording eye movements by measuring the electrical activity of the extraocular muscles
phacoemulsificaition
method of treating cataracts by using ultrasonic waves to disintegrate a cloudy lens, which is then aspirated and removed
visual acuity (VA) test
part of an eye examination that determines the smallest letters that can be read on a standardized chart at a distance of 20 feet.
cochlear implant insertion
placement of an artificial hearing device that produces hearing sensations by electrically stimulation nerves inside the inner ear
otic analgesics
provide temporary relief from pain and inflammation associated with optic disorders
dacryocystography
radiographic imaging procedure of nasolacrimal (tear glands and ducts
tympanoplasty
reconstruction of the eardrum, commonly due to perforation;
slit-lamp examination (SLE)
stereoscopic magnified view of the anterior eye structures in detail, which includes the cornea, lens, iris, sclera, and vitreous humor
sclerostomy
surgical formation of an opening in the sclera
mastoid antrotomy
surgical opening of a cavity within the mastoid process
caloric stimulation test
test that uses different water temps to assess the vestibular portion of the nerve of the inner ear (acoustic nerve) to determine if the nerve damage is the cause of vertigo
ear antiemetics
treat and prevent nausea, vomiting, dizziness and vertigo by reducing the sensitivity of the inner ear to motion or inhibiting stimuli from reaching the parts of the brain that triggers nausea and vomiting.
tuning fork test / Rinne
tuning fork test that evaluates bone conduction (BC) versus air conduction (AC) of sound
tuning fork test / Weber
tuning fork test that evaluates bone conduction of sound in both ears at the same time.
21. A patient comes to the primary care clinic complaining of a head cold and ear pain with drainage. What should the nurse suspect this patient is experiencing? a. Otitis externa b. Hearing loss c. Acute otitis media d. Mastoiditis
ANS: C Acute otitis media is connected with colds and drainage from the ear. A hearing loss may be experienced as well, but the pain and drainage place the need to intervene for the infection first. DIF: Cognitive Level: Comprehension REF: p. 1264 OBJ: 1 TOP: Middle Ear KEY: Nursing Process Step: Assessment MSC:
6. A 75-year-old patient reports to a nurse that although she has cleaned her ears with cotton-tipped applicators for weeks, she still cannot hear her television unless the volume is loud, and she misses a great deal of conversations. What should the nurse anticipate when examining her ears? a. Otitis externa b. Purulent drainage c. Dry cerumen across the canal d. Pearly tympanic membrane
ANS: C Obstruction of the external canal with cerumen will result in a hearing loss. Cleaning the ears with something such as an applicator will pack the cerumen in the canal. DIF: Cognitive Level: Comprehension REF: p. 1251 OBJ: 6 TOP: External Auditory Canal KEY: Nursing Process Step: Assessment MSC:
5. A 94-year-old patient is receiving gentamicin sulfate (Garamycin) in a continuous intravenous (IV) infusion. The nurse adds to the nursing care plan the diagnosis "Risk for injury." What nursing action should be implemented? a. Pull side rails in place. b. Assist with ambulation. c. Measure intake and output. d. Provide for a possible seizure.
ANS: C Reduced urine output would cause the drug to stay in the system rather than being excreted, which could result in a drug saturation. Gentamicin is ototoxic and can cause hearing impairment. DIF: Cognitive Level: Application REF: p. 1253 OBJ: 7 TOP: Gentamicin KEY: Nursing Process Step: Assessment MSC:
1. A nurse reads in a patient's history that the patient has experienced otalgia. How should the nurse interpret this term? a. Difficulty hearing b. Buildup of cerumen c. Ear pain d. Ringing in the ears
C
12. What nursing action should be implemented when irrigating a patient's ear? a. Straighten the ear canal and irrigate with a large-tipped bulb syringe. b. Direct the solution to the middle of the canal to avoid damaging the ear. c. Use a body temperature solution and have the patient hold a basin under the ear while directing the solution toward the top of the canal. d. Repeat the irrigation with hotter water.
C
5. A 94-year-old patient is receiving gentamicin sulfate (Garamycin) in a continuous intravenous (IV) infusion. The nurse adds to the nursing care plan the diagnosis "Risk for injury." What nursing action should be implemented? a. Pull side rails in place. b. Assist with ambulation. c. Measure intake and output. d. Provide for a possible seizure.
C
6. A 75-year-old patient reports to a nurse that although she has cleaned her ears with cotton-tipped applicators for weeks, she still cannot hear her television unless the volume is loud, and she misses a great deal of conversations. What should the nurse anticipate when examining her ears? a. Otitis externa b. Purulent drainage c. Dry cerumen across the canal d. Pearly tympanic membrane
C
7. A patient reports that her hearing loss has become more severe over the past 3 months. The clinic nurse makes arrangements for an evaluation for a hearing aid. What health care provider should provide this service? a. Otologist b. Otolaryngologist c. Audiometrist d. Audiologist
D
8. When a patient has a suspected vestibular disorder, the physician orders an electronystagmography test. Which instruction should the nurse include when educating the patient about this test? a. Use tea or coffee on the morning of test. b. Electrodes will be placed on the scalp. c. Air will be blown into the external ear. d. The patient should have nothing to eat or drink (NPO) 3 hours before the test.
D
___ results from excessive production of aqueous humor or from diminished ocular fluid outflow
Intraocular Pressure (IOP)
What information will the nurse include when instructing a patient on the correct method of instilling eyedrops? (Select all that apply.)
With an infection, prevent cross-contamination and use a separate source of medication and droppers for each eye. Wash hands before and after administration. Place the lid on the surface area as instructed to avoid contamination. Never touch the tip of the dropper or opening of the ointment container.
These drugs relax smooth muscle o the ciliary body and iris TO EXAMINE THE INTERIOR OF THE EYE
Anticholinergic drugs **DO NOT GIVE TO INFANTS
eviceration
removal of the contents of the eye while leaving the sclera and cornea intact
enucleation
removal of the eyeball from the orbit
19. What information should a nurse stress when teaching a patient with Ménière disease about managing the disorder? a. Limiting fluid intake b. Avoiding the use of alcohol and tobacco c. Using antiemetic medications sparingly d. Staying active during the day
B
A factory worker had a chemical inadvertently splashed into his right eye. An eyewash was used at the work site. Which nursing assessment(s) would be important to include? (Select all that apply.)
Visual acuity Presence of pain, blurred or halo vision, or lack of vision Type of chemical Presence of contacts or use of eyeglasses
29. When planning care for a patient who cannot perceive or interpret sounds, a nurse takes into consideration that the patient may have a(n) _____ hearing loss.
central
ophthalmoscopy
visual examination of the interior of the eye using a handheld instrument called an ophthalmoscope, which has various adjustable lenses for magnification and light source to illuminate the interior of the eye.
radial keratotomy (RK)
incision of the cornea for treatment of nearsightedness or astigmatism
The nurse in a healthcare provider's office notes that a regular patient's voice is hoarse, a change from previous visits. The most appropriate question to ask the patient would be which of the following?
-"How long has your voice been hoarse?"
The nurse evaluates his teaching as effective when a patient with stage 1 laryngeal cancer states which of the following?
-"I'm glad this was diagnosed early, when it can be treated with radiation so I won't lose my voice."
Which of the following nursing interventions for the patient with posterior nasal packing is of highest priority?
-Maintain oxygen therapy.
A patient in the emergency department following facial trauma complains that his nose "just keeps dripping." The drainage appears like watery blood. The most appropriate nursing action would be to do which of the following?
-Obtain a specimen for glucose testing.
A patient with hypertension asks the nurse what he can do to relieve the symptoms of an acute URI. The nurse recommends that he do which of the following?
-Use an over-the-counter nasal spray for no more than three days to relieve congestion.
Expected findings in a patient with obstructive sleep apnea would include which of the following? Select all that apply.
-complaints of daytime sleepiness -elevated blood pressure -complaints of morning headache
In teaching a patient with bacterial sinusitis about home care, the nurse stresses the importance of which of the following?
-completing the antibiotic prescription as ordered
When providing tracheostomy care, the nurse does which of the following?
-secures clean ties before removing soiled ones
Place the following nursing interventions for the patient who has undergone total laryngectomy and radical neck dissection in order of priority.
1. Suction via tracheostomy as needed 2.Instruct to support head when moving 3. Provide small, frequent meals 4. Arrange consultation with speech therapist 5. Encourage to express feelings regarding loss of voice
22. A young woman being admitted to the clinic service states that all the members of her family have been hard of hearing. She says her hearing loss became more pronounced when she was pregnant. What term explains this type of hearing loss? a. Otosclerosis b. Ototoxicity c. Otalgia d. Otitis media
A
26. Which patient behaviors should alert a nurse to a possible hearing deficit? (Select all that apply.) a. Watches the speaker's mouth b. Gives inappropriate answers to questions c. Pulls at the ears d. Fails to respond when spoken to e. Turns the good ear to the speaker
A, B, D, E
28. A patient complains that his hearing aid is not working. What actions should a nurse implement to assess the device? (Select all that apply.) a. Check to see if the device is turned on. b. Clean the earpiece and remove cerumen clogged in the vent. c. Open the earpiece to see if the microphone wire is connected. d. Examine the interior of the earpiece for water. e. Validate that the battery is correctly placed.
A, B, E
27. Which common characteristics might a patient with conductive hearing loss display? (Select all that apply.) a. Hears adequately in noisy settings b. Hears sounds but has difficulty understanding speech c. Has improved hearing with hearing aids d. Has a history of diabetes mellitus e. Speaks in a normal volume
A, C, E
30. A nurse uses a diagram to show the physiologic sequence of hearing. After entering the external ear, the sound is then conducted through the (Arrange the options in sequence. Separate letters by a comma and space as follows: A, B, C, D.) A. tympanic membrane B. sensory receptors C. oval window D. acoustic nerve to the brain E. malleus, incus, and stapes
A, E, C, B, D
4. When making an initial assessment on a patient with a hearing deficit, the patient reports that he often feels off balance and is dizzy when he stands up. Which diagnosis might explain these symptoms? a. Sinus infection b. Rubella c. Otalgia d. Presbycusis
ANS: A A sinus infection can be an acute cause of hearing deficits and can create problems with balance. DIF: Cognitive Level: Comprehension REF: p. 1252 OBJ: 5 TOP: Hearing Assessment: Medical History KEY: Nursing Process Step: Assessment MSC:
18. A patient with glaucoma is taking a beta-adrenergic blocking agent, timolol (Timoptic). For which potential side effect should the nurse assess the patient? a. Wheezing b. Hypertension c. Sudden eye pain d. Blurred vision
ANS: A Beta-adrenergic blocking agents cause bronchospasm and tachycardia. DIF: Cognitive Level: Comprehension REF: p. 1243 OBJ: 3 TOP: Beta-Adrenergic Blocking Agents KEY: Nursing Process Step: Assessment MSC:
20. A nurse explains that laser-assisted in situ keratomileusis (Lasik) and photorefractive keratectomy (PRK) are methods to correct refractive errors surgically. What do these procedures reshape? a. Cornea b. Lens c. Iris d. Pupil
ANS: A Both surgical procedures are used to reshape the cornea. The clinician will need to determine which structure of the eye will need surgery to correct the vision. DIF: Cognitive Level: Knowledge REF: p. 1238 OBJ: 5 TOP: Surgical Treatment for Refractive Errors KEY: Nursing Process Step: Implementation MSC:
21. A patient reports to a home health care nurse of having cloudy vision and seeing spots and halos around lights. What should the nurse suspect based on these patient symptoms? a. Cataracts b. Glaucoma c. Detached retina d. Macular degeneration
ANS: A Cataracts are the cause of cloudy vision and seeing spots or halos. DIF: Cognitive Level: Comprehension REF: p. 1238 OBJ: 5 TOP: Internal Eye Disorders KEY: Nursing Process Step: Implementation MSC:
22. How does closed-angle glaucoma differ from open-angle glaucoma? a. The onset is acute. b. Trabeculectomy is the initial treatment. c. Treatment can be conservative. d. Intraocular pressure drops suddenly.
ANS: A Closed-angle glaucoma has an acute onset with eye pain and other systemic symptoms, such as nausea and vomiting. Reducing the intraocular pressure is an ocular emergency. DIF: Cognitive Level: Knowledge REF: p. 1240-1242 OBJ: 5 TOP: Open-Angle versus Closed-Angle Glaucoma KEY: Nursing Process Step: Implementation MSC:
12. What information should a nurse relay to a patient when providing education about protecting vision? a. After 40 years of age, eye examinations should be performed every 2 years. b. Crusted eyelids on awakening are caused by decreased tear production. c. Floaters are a sign of eye infection. d. Blurred vision without pain is temporary eye strain.
ANS: A Eye examinations every 2 years are recommended for persons older than 40 years of age. All the other options are indications that the person should consult a physician for an eye disorder. DIF: Cognitive Level: Comprehension REF: p. 1231 OBJ: 4 TOP: Protection of the Eye and Vision KEY: Nursing Process Step: Implementation MSC:
14. A newly diagnosed patient with macular degeneration flings her book at the television set and furiously says, "I can't read this blasted book, and I can't see what is on the stupid TV!" How should the nurse define this behavior? a. Anger stage of grieving b. Poor impulse control c. Ineffective management of a therapeutic regimen d. Psychotic reaction to loss
ANS: A Frequently, a grieving process accompanies the realization that deteriorating vision and ultimate blindness are inevitable with macular degeneration. DIF: Cognitive Level: Application REF: p. 1233 | p. 1246 OBJ: 6 TOP: Impact of Visual Impairment KEY: Nursing Process Step: Assessment MSC:
22. A young woman being admitted to the clinic service states that all the members of her family have been hard of hearing. She says her hearing loss became more pronounced when she was pregnant. What term explains this type of hearing loss? a. Otosclerosis b. Ototoxicity c. Otalgia d. Otitis media
ANS: A Otosclerosis is hereditary, develops in young women, and worsens with pregnancy. DIF: Cognitive Level: Comprehension REF: p. 1265 OBJ: 5 TOP: Otosclerosis KEY: Nursing Process Step: Assessment MSC:
6. When asked about his vision, a patient says that the last time he had it tested, his vision was recorded as 20/50. What does this mean? a. He can read at 20 feet what a person with normal vision can read at 50 feet. b. He can read at 50 feet what a person with normal vision can read at 20 feet. c. He needs to be 50 feet from objects to see them. d. He can see objects the best between 20 and 50 feet.
ANS: A The Snellen eye chart is read at 20 feet. The last line the patient can read with no more than two errors is recorded. This patient was able to read the 50-foot line at 20 feet, which means that he is reading at 20 feet what a person with normal vision can read at 50 feet. DIF: Cognitive Level: Comprehension REF: p. 1223 OBJ: 1 TOP: Physical Examination: Eyes KEY: Nursing Process Step: Assessment MSC:
11. Which instruction should a nurse include when providing patient teaching information for a patient who will be self-administering ear drops for an ear infection? a. Tip the affected ear up and keep it in that position for several minutes after instilling the medication. b. Keep the medication in the refrigerator to preserve it. Instill the medication with the affected ear tilted upward. c. Touch the dropper to the opening of the ear canal to ensure that the drops are correctly instilled. d. Warm the ear drops and then tilt the head downward.
ANS: A The head is kept in an upward position to ensure that the drops penetrate deep into the external ear. DIF: Cognitive Level: Application REF: p. 1256-1257 OBJ: 4 TOP: Ear Drops KEY: Nursing Process Step: Implementation MSC:
7. Which intraocular pressure reading obtained by tonometry indicates a patient being evaluated for a visual impairment does not have glaucoma? a. 18 mm Hg b. 28 mm Hg c. 45 mm Hg d. 52 mm Hg
ANS: A The normal intraocular pressure is between 12 and 21 mm Hg. If the patient had glaucoma, the intraocular pressure would be abnormally high. DIF: Cognitive Level: Comprehension REF: p. 1224 OBJ: 3 TOP: Tonometry KEY: Nursing Process Step: Assessment MSC:
9. A nurse assessing the results of a Rinne test sees the notation of BC > AC. How should the nurse translate this result? a. Conductive hearing loss b. Sensorineural hearing loss c. Normal hearing d. Cochlear defect
ANS: A When the bone conduction (BC) is greater than the air conduction (AC), the results of the Rinne test will read, BC > AC, which means the patient has a conductive hearing loss. The normal finding for the Rinne test is that AC is greater than BC (AC > BC). DIF: Cognitive Level: Analysis REF: p. 1255 OBJ: 2 TOP: Rinne Test KEY: Nursing Process Step: Assessment MSC:
28. What actions should a nurse implement when assessing a patient's accommodation? (Select all that apply.) a. Hold his or her finger approximately 20 inches in front of the patient's eyes. b. Observe for pupillary constriction. c. Assess for convergence. d. Note blinking. e. Move his or her finger slowly toward the patient's nose.
ANS: A, B, C, E Assessment for blinking is not part of the accommodation assessment. All of the other options are part of the accommodation assessment. The nurse holds his or her finger approximately 20 inches in front of the patient's eyes and slowly moves the finger toward the patient's nose, assessing for pupillary constriction and convergence. DIF: Cognitive Level: Application REF: p. 1223 OBJ: 2 TOP: Testing for Accommodation KEY: Nursing Process Step: Implementation MSC:
26. A nurse assesses an 80-year-old patient for age-related changes to the eye. What potential changes should the nurse anticipate? (Select all that apply.) a. Decreased tear production b. Eyeball sunk deep in orbit c. Hyperopia d. Eye lashes diminished e. Arcus senilis
ANS: A, B, C, E Eyelash diminution is not a consistent finding in older adults. All of the other options are common eye changes related to advancing age. DIF: Cognitive Level: Comprehension REF: p. 1222 OBJ: 1 TOP: Age-Related Changes in the Eye KEY: Nursing Process Step: Assessment MSC:
26. Which patient behaviors should alert a nurse to a possible hearing deficit? (Select all that apply.) a. Watches the speaker's mouth b. Gives inappropriate answers to questions c. Pulls at the ears d. Fails to respond when spoken to e. Turns the good ear to the speaker
ANS: A, B, D, E Pulling at the ear is not a signal for hearing loss; all of the other options are. DIF: Cognitive Level: Comprehension REF: p. 1261 OBJ: 1 TOP: Behavioral Cues to Hearing Deficit KEY: Nursing Process Step: Assessment MSC:
28. A patient complains that his hearing aid is not working. What actions should a nurse implement to assess the device? (Select all that apply.) a. Check to see if the device is turned on. b. Clean the earpiece and remove cerumen clogged in the vent. c. Open the earpiece to see if the microphone wire is connected. d. Examine the interior of the earpiece for water. e. Validate that the battery is correctly placed.
ANS: A, B, E Cleaning the earpiece to remove clogged cerumen and checking the device to see if it is turned on and if the battery is placed correctly are all good options. The earpiece should not be opened. If the hearing aid is still not working, it should be evaluated by the dealer. DIF: Cognitive Level: Application REF: p. 1258 OBJ: 4 TOP: Hearing Aids KEY: Nursing Process Step: Implementation MSC:
27. What makes up the refractive media of the eye? (Select all that apply.) a. Aqueous humor b. Retina c. Vitreous humor d. Cornea e. Lens
ANS: A, C, D, E The retina is not part of the refractive media. All of the other options are components of the refractive media. DIF: Cognitive Level: Knowledge REF: p. 1221 OBJ: 1 TOP: Refractive Media KEY: Nursing Process Step: Assessment MSC:
27. Which common characteristics might a patient with conductive hearing loss display? (Select all that apply.) a. Hears adequately in noisy settings b. Hears sounds but has difficulty understanding speech c. Has improved hearing with hearing aids d. Has a history of diabetes mellitus e. Speaks in a normal volume
ANS: A, C, E Persons with conductive hearing loss can hear in a noisy setting and can have improved hearing with the use of hearing aids. Persons with conductive hearing loss speak at a normal or soft volume because they can hear themselves. Muffled sounds and a history of diabetes would be associated with sensorineural hearing loss. DIF: Cognitive Level: Comprehension REF: p. 1260-1261 OBJ: 5 TOP: Common Characteristics in Persons with Conductive Hearing Loss KEY: Nursing Process Step: Assessment MSC:
23. What should a nurse include when educating a patient with Ménière disease? a. "When you feel dizzy, just stay in bed and take your medications." b. "Decrease your sodium intake and take your diuretic medication between attacks." c. "Vestibular rehabilitation might help, and you can still drink your morning coffee." d. "Your vertigo will get better if you take your medications. You won't need any relaxation techniques."
ANS: B A low-sodium diet and diuretic medications between attacks will prevent edema, which could cause an attack. DIF: Cognitive Level: Application REF: p. 1267 OBJ: 7 TOP: Inner Ear KEY: Nursing Process Step: Implementation MSC:
4. When being interviewed, a 50-year-old patient says that he cannot see the newspaper as well as he used to. What is the reason this patient vision has changed from near to far? a. The ciliary muscle changes the pupil size. b. The lens of the eye changes shape as the ciliary muscle contracts and relaxes. c. Nearsightedness has set in. d. Clouding of the vitreous humor has occurred.
ANS: B Accommodation or adjustment of the lens by contraction and expansion of the ciliary muscle allows an individual to see far or near. DIF: Cognitive Level: Comprehension REF: p. 1221 OBJ: 1 TOP: Lens Adjustment KEY: Nursing Process Step: Assessment MSC:
1. A 60-year-old patient who has had an enucleation asks when he can get his prosthesis fitted. In approximately how many weeks should this patient expect to be fitted? a. 2 b. 4 c. 8 d. 12
ANS: B After an enucleation, the patient is fitted with a prosthesis in 1 month. DIF: Cognitive Level: Knowledge REF: p. 1246 OBJ: 6 TOP: Enucleation KEY: Nursing Process Step: Implementation MSC:
23. What is the cause of glaucoma? a. Cloudiness in the lens b. Increase in intraocular pressure c. Failed eye surgery d. Retinal tears
ANS: B Glaucoma is caused by an increase in intraocular pressure. DIF: Cognitive Level: Knowledge REF: p. 1240 OBJ: 5 TOP: Glaucoma KEY: Nursing Process Step: Planning MSC:
16. Which nursing diagnosis is not appropriate for a visually impaired patient? a. Impaired sensory perception b. Risk for delayed development c. Self-care deficit d. Ineffective coping
ANS: B Patients with a visual impairment are not at risk for delayed development. They will have a nursing diagnosis of "Impaired sensory perception," "Ineffective coping," and "Self-care deficit." DIF: Cognitive Level: Comprehension REF: p. 1232-1233 OBJ: 6 TOP: Nursing Diagnosis, Goals, Outcomes KEY: Nursing Process Step: Planning MSC:
24. A 75-year-old patient reports having difficulty hearing in crowds but can hear just fine at home with his wife. What hearing disorder should the nurse suspect? a. Otitis media b. Presbycusis c. Ototoxicity d. Central deafness
ANS: B Presbycusis is a conductive hearing loss associated with normal aging and is caused by changes in the cochlea. DIF: Cognitive Level: Comprehension REF: p. 1269 OBJ: 5 TOP: Presbycusis KEY: Nursing Process Step: Implementation MSC:
24. A patient in the emergency department complains of severe pain in his eye and is seeing halos around lights and feeling nauseous. Which diagnosis should the nurse suspect? a. Open-angle glaucoma b. Angle-closure glaucoma c. Cataracts d. Retinal detachment
ANS: B Sudden onset of acute eye pain with nausea and vomiting and halos around lights are all symptoms of angle-closure glaucoma. The acute pain is caused by sudden blockage of the fluid channels in the eye. DIF: Cognitive Level: Comprehension REF: p. 1242 OBJ: 5 TOP: Glaucoma KEY: Nursing Process Step: Assessment MSC:
9. What is an appropriate nursing action to implement when performing eye irrigation? a. Ask the patient to tip up her head and run the irrigation fluid over her open eye. b. Direct the irrigating fluid from the inner canthus to the outer canthus. c. Not allow the patient to blink. d. Place the irrigating syringe directly onto the corner of the eye and allow the fluid to move across the eye.
ANS: B The direction of the flow should be from the inner canthus to the outer canthus. DIF: Cognitive Level: Application REF: p. 1226 OBJ: 3 TOP: Eye Irrigation KEY: Nursing Process Step: Implementation MSC:
10. What information should a nurse include when providing information to a patient using topical eye medications? a. Look upward and drop the medication into the inner canthus. b. Pull the lower eyelid down and drop the medication into the conjunctival sac. c. Hold both eyelids open and drop the medication onto the sclera. d. Tilt the head to the side and drop the medication into the outer canthus.
ANS: B The eye drops should be dropped into the lower eyelid, and the nurse should press the tear duct to slow absorption. DIF: Cognitive Level: Comprehension REF: p. 1229 OBJ: 3 TOP: Topical Medications KEY: Nursing Process Step: Implementation MSC:
3. Which portion of the eye makes it possible for a person to see in a darkened environment? a. Macula b. Rods c. Cones d. Optic nerve
ANS: B The eye uses rods to accommodate to dim light. Cones are the color receptors, the optic nerve transmits all sensory input from the eye to the brain, and the macula is an oval-shaped yellow spot near the center of the retina that mediates clear, detailed vision. DIF: Cognitive Level: Knowledge REF: p. 1220 OBJ: 1 TOP: Anatomy and Physiology of the Eye: Eyeball KEY: Nursing Process Step: Assessment MSC:
18. Which nursing diagnosis is most appropriate when considering the impact of a hearing deficit when planning care for a child who has been diagnosed with a hearing impairment? a. Risk for injury, related to hearing impairment b. Risk for social isolation, related to hearing impairment c. Knowledge deficit, related to hearing impairment d. Anxiety, related to hearing impairment
ANS: B The loss of hearing and the mild stigma associated with hearing impairment place the newly diagnosed child at risk for social isolation. DIF: Cognitive Level: Application REF: p. 1262 OBJ: 7 TOP: Impact of Hearing Impairment KEY: Nursing Process Step: N/A MSC:
17. Which nursing diagnosis should take priority in a nursing care plan for a patient with Ménière disease? a. Social isolation, related to anxiety b. Risk for injury, related to falls c. Risk for deficient fluid intake, related to weakness d. Nutrition: Less than body requirements, related to fatigue
ANS: B The nursing diagnosis that should take priority is that of preventing injury to the patient. A patient with Ménière disease is prone to falls because of dizziness. DIF: Cognitive Level: Application REF: p. 1266 OBJ: 7 TOP: Nursing Care Plan for Ménière Disease KEY: Nursing Process Step: Assessment MSC:
19. What information should a nurse stress when teaching a patient with Ménière disease about managing the disorder? a. Limiting fluid intake b. Avoiding the use of alcohol and tobacco c. Using antiemetic medications sparingly d. Staying active during the day
ANS: B The use of alcohol and tobacco products affects the amount of fluid in the middle ear, worsening the symptoms of Ménière disease. The patient with Ménière disease should drink adequate fluid, use antiemetic medications as needed, and conserve energy during the day. DIF: Cognitive Level: Application REF: p. 1266 OBJ: 7 TOP: Ménière Disease KEY: Nursing Process Step: Implementation MSC:
29. A patient who has had surgery this morning for cataracts is now going home. What should the nurse include when providing discharge instructions? (Select all that apply.) a. Sleep on the affected side. b. Use stool softeners. c. Avoid bending over. d. Avoid lifting anything heavier than 5 lb. e. Do not wear an eye shield at night.
ANS: B, C, D After cataract surgery, the patient should sleep on the unaffected side with the eye shield in place. He or she should avoid heavy lifting and use stool softeners to prevent straining. DIF: Cognitive Level: Application REF: p. 1240 OBJ: 3 TOP: Discharge Instructions for Cataract Surgery KEY: Nursing Process Step: Implementation MSC:
8. What does a pneumatonometric study of the eye require? a. Regional anesthesia b. A pneumotonometer to be placed into the eye c. A puff of air directed at the surface of the eye d. An applanation performed with a slit-lamp microscope
ANS: C A pneumotonometer directs a puff of air at the surface of the eye, measuring intraocular pressure by measuring the resistance to the air. The eye is anesthetized before the evaluation. DIF: Cognitive Level: Comprehension REF: p. 1224 OBJ: 2 TOP: Tonometry KEY: Nursing Process Step: Implementation MSC:
25. During an intake physical examination, a patient reports that he has been taking 10 aspirin tablets a day for his arthritis. What question should the nurse ask based on this information? a. "Can you hear high-pitched sounds?" b. "Have you noticed deafness in just one ear?" c. "Do you have ringing in your ears?" d. "Do you experience dizziness when you stand?"
ANS: C A ringing in the ears (tinnitus) is an indication of aspirin toxicity. The patient should be advised to stop taking aspirin. DIF: Cognitive Level: Application REF: p. 1252-1253 OBJ: 5 TOP: ASA Toxicity KEY: Nursing Process Step: Implementation MSC:
13. How should a nurse assist a visually impaired patient to ambulate? a. Hold the visually impaired person by his or her nondominant arm and walk side by side. b. Hold the nondominant hand, wrap the arm around his or her waist, and walk side by side. c. Allow the visually impaired person to hold the helper's arm, with the helper slightly ahead. d. Allow the visually impaired person to hold the shoulder of the helper and walk slightly behind the helper.
ANS: C Allowing the visually impaired person to walk slightly behind the helper and holding the helper's arm is the most effective way to guide someone who is visually impaired. DIF: Cognitive Level: Application REF: p. 1232-1233 OBJ: 6 TOP: Assisting the Visually Impaired with Ambulation KEY: Nursing Process Step: Implementation MSC:
1. A nurse reads in a patient's history that the patient has experienced otalgia. How should the nurse interpret this term? a. Difficulty hearing b. Buildup of cerumen c. Ear pain d. Ringing in the ears
ANS: C Otic- is the root word for ear, and -algia is the root term for pain of any type. DIF: Cognitive Level: Knowledge REF: p. 1252 OBJ: 5 TOP: Definitions KEY: Nursing Process Step: Assessment MSC:
19. A 52-year-old patient reports that he must hold his paper farther and farther away from his face to read it. What is the nurse's most informative response? a. "You are describing myopia. Glasses will help you read." b. "You may have astigmatism, but your eyes will finally adjust." c. "You have presbyopia. Nonprescription reading glasses will help you." d. "An eye infection may be the problem. Check with your physician for medication."
ANS: C Presbyopia is a normal age-related change. Changes in the ciliary muscles cause the condition. Corrective lenses such as bifocals are used to correct this visual change. DIF: Cognitive Level: Application REF: p. 1222 | p. 1237 OBJ: 5 TOP: Error of Refraction KEY: Nursing Process Step: Assessment MSC:
5. During the initial assessment of a very thin patient at the eye clinic, a nurse notes that the patient has very prominent eyes. What medical diagnosis might the nurse find in this patient's history? a. Diabetes b. Glomerulonephritis c. Graves disease d. Hypertension
ANS: C The appearance of the patient and the prominence of the eye (exophthalmos) would lead the nurse to inquire about a thyroid disorder such as Graves disease or hyperthyroidism. DIF: Cognitive Level: Comprehension REF: p. 1222 OBJ: 1 TOP: Medical History KEY: Nursing Process Step: Assessment MSC:
2. A patient who has been taking opioid medication for postoperative pain exhibits pinpoint pupils. Which anatomic portion of the eye has been affected by the medication? a. Sclera b. Retina c. Choroid d. Bulbar conjunctiva
ANS: C The choroid of the eye contains the pupil and iris. DIF: Cognitive Level: Comprehension REF: p. 1220 OBJ: 1 TOP: Anatomy and Physiology of the Eye: Eyeball KEY: Nursing Process Step: Assessment MSC:
12. What nursing action should be implemented when irrigating a patient's ear? a. Straighten the ear canal and irrigate with a large-tipped bulb syringe. b. Direct the solution to the middle of the canal to avoid damaging the ear. c. Use a body temperature solution and have the patient hold a basin under the ear while directing the solution toward the top of the canal. d. Repeat the irrigation with hotter water.
ANS: C The irrigation is done with warm water using a small-tipped syringe. The flow is directed upward. If the cerumen does not wash out, the procedure can be repeated but with the same water temperature. DIF: Cognitive Level: Application REF: p. 1257 OBJ: 3 TOP: Irrigation KEY: Nursing Process Step: Implementation MSC:
17. Which implementation is appropriate in the care plan for a visually impaired person? a. Leaving the bed in the highest position b. Keeping the door closed c. Announcing your presence when you enter and leave the room d. Leaving the radio on all the time to help the patient know the time of day
ANS: C The nurse should announce her or his presence in the room and address the patient before touching him or her. The bed should be in the lowest position, and the door should be open to avoid social isolation. DIF: Cognitive Level: Application REF: p. 1232 OBJ: 6 TOP: Implementation KEY: Nursing Process Step: Implementation MSC:
15. What significant instruction should a nurse include to a patient being discharged after ear surgery? a. Use stool softeners with caution. b. Assume your usual activities. c. Avoid blowing your nose. d. Shampoo your hair with baby shampoo.
ANS: C The patient should avoid blowing the nose to prevent back pressure in the eustachian tube. The patient should take stool softeners, limit activity until balance returns, and delay shampooing. DIF: Cognitive Level: Application REF: p. 1259-1260 OBJ: 7 TOP: Nursing Diagnosis and Outcome Criteria KEY: Nursing Process Step: Implementation MSC:
20. An 85-year-old patient has had age-related changes in the cochlea. What is the most appropriate nursing action for the nurse to implement? a. Speak slowly. b. Provide assistance with ambulation. c. Speak in a lower tone. d. Communicate with the patient in writing.
B
11. What does electroretinography measure? a. A fluorescein dye is injected intravenously (IV) into a vein in the arm, and the retina is observed as the dye circulates. b. Electrodes are placed on the scalp, each eye is stimulated, and retinal activity is assessed. c. A small plunger is used to apply pressure on the sclera while the retinal vessels are evaluated. d. A contact lens electrode is placed on the eye and exposed to flashes of light to evaluate the retinal response.
ANS: D A contact lens electrode is placed on the eye, and retinal activity is assessed as lights are flashed into the eye. The other three options describe fluorescein angiography, visual-evoked response, and tonometry. DIF: Cognitive Level: Knowledge REF: p. 1224-1225 OBJ: 2 TOP: Electroretinography KEY: Nursing Process Step: Implementation MSC:
16. A patient with diabetes says that he needs a hearing aid because he cannot hear well, and everything sounds garbled and distant. What type of hearing loss should the nurse suspect? a. Mixed hearing loss b. Conductive hearing loss c. Central hearing loss d. Sensorineural hearing loss
ANS: D A patient with long-term diabetes may have a sensorineural hearing loss that is not helped by hearing aids. DIF: Cognitive Level: Comprehension REF: p. 1261 OBJ: 5 TOP: Types of Hearing Loss KEY: Nursing Process Step: Assessment MSC:
7. A patient reports that her hearing loss has become more severe over the past 3 months. The clinic nurse makes arrangements for an evaluation for a hearing aid. What health care provider should provide this service? a. Otologist b. Otolaryngologist c. Audiometrist d. Audiologist
ANS: D Audiologists assess patients for hearing aids. The other specialists treat ear, nose, and throat (ENT) disorders. DIF: Cognitive Level: Knowledge REF: p. 1253 OBJ: 7 TOP: Audiometry KEY: Nursing Process Step: Implementation MSC:
8. When a patient has a suspected vestibular disorder, the physician orders an electronystagmography test. Which instruction should the nurse include when educating the patient about this test? a. Use tea or coffee on the morning of test. b. Electrodes will be placed on the scalp. c. Air will be blown into the external ear. d. The patient should have nothing to eat or drink (NPO) 3 hours before the test.
ANS: D Electronystagmography is used to detect vestibular lesions and requires a 3-hour period of NPO before the test. Coffee and tea should also be avoided before the test. DIF: Cognitive Level: Comprehension REF: p. 1255 OBJ: 3 TOP: Testing for Ear Disorders KEY: Nursing Process Step: Planning MSC:
25. Which surgical implementation is most effective with retinal detachment? a. Removing the lens b. Macular bonding c. Lasik surgery d. Scleral buckling
ANS: D Scleral buckling is used to hold the retinal repair in place. The band is left in place to keep together the layers of the eye tissue. DIF: Cognitive Level: Knowledge REF: p. 1245 OBJ: 5 TOP: Retinal Detachment KEY: Nursing Process Step: N/A MSC:
15. What is the correct term to use for a patient with a vision disorder? a. Blind b. Handicapped c. Partially blind d. Visually impaired
ANS: D The term visual impairment is a medically accepted term to use for patients with a vision loss. DIF: Cognitive Level: Knowledge REF: p. 1231 OBJ: 5 TOP: Nursing Care of the Visually Impaired Patient KEY: Nursing Process Step: N/A MSC:
2. A nurse is assisting with a caloric test and notes that the specific patient response that indicates a hearing disorder is a problem in the labyrinth. Which response did the nurse witness? a. Blinking b. Grimacing c. Headache d. Nystagmus
ANS: D When warm or cold water is introduced into the ear, the appearance of nystagmus is a positive indication that the hearing problem has its cause in the labyrinth. DIF: Cognitive Level: Comprehension REF: p. 1256 OBJ: 2 TOP: Caloric Test KEY: Nursing Process Step: Assessment MSC:
What drug class can be prescribed to treat herpes simplex of the eye
ANTIVIRAL **DO NOT EXCEED ADMINISTRATION OF 21 days will cause ocular toxicity
When is the best time to administer ointments
AT NIGHT
Which type of medication would be used to dilate the pupils before an eye examination?
Adrenergic agent
If MANNITOL, an osmotic diuretic for glaucoma, has been given IV. What should be assessed?
Assess the IV site because MANNITOL can cause tissue necrosis
Which discharge instruction will the nurse include for a patient sent home from the clinic who is taking an adrenergic ophthalmic solution for an acute inflammation?
Avoid driving or operating machinery until blurring subsides.
17. Which nursing diagnosis should take priority in a nursing care plan for a patient with Ménière disease? a. Social isolation, related to anxiety b. Risk for injury, related to falls c. Risk for deficient fluid intake, related to weakness d. Nutrition: Less than body requirements, related to fatigue
B
18. Which nursing diagnosis is most appropriate when considering the impact of a hearing deficit when planning care for a child who has been diagnosed with a hearing impairment? a. Risk for injury, related to hearing impairment b. Risk for social isolation, related to hearing impairment c. Knowledge deficit, related to hearing impairment d. Anxiety, related to hearing impairment
B
23. What should a nurse include when educating a patient with Ménière disease? a. "When you feel dizzy, just stay in bed and take your medications." b. "Decrease your sodium intake and take your diuretic medication between attacks." c. "Vestibular rehabilitation might help, and you can still drink your morning coffee." d. "Your vertigo will get better if you take your medications. You won't need any relaxation techniques."
B
24. A 75-year-old patient reports having difficulty hearing in crowds but can hear just fine at home with his wife. What hearing disorder should the nurse suspect? a. Otitis media b. Presbycusis c. Ototoxicity d. Central deafness
B
3. A 75-year-old patient has normal age-related changes in his ear. What change should not be considered a normal change in the aging patient? a. Dry and wrinkled skin on the auricle b. Otitis externa c. Dry cerumen d. Hair in the ear canal
B
For the asthmatic pt taking beta-adrenergic drops, what serious side effect should you monitor for
BRONCHOSPASM
Which statement(s) about aqueous humor is/are true? (Select all that apply.)
Bathes and feeds the lens, posterior surface of the cornea, and iris Drains out of the eye through drainage channels located near the junction of the cornea and sclera Flows out of the canal of Schlemm into the venous system of the eye
15. What significant instruction should a nurse include to a patient being discharged after ear surgery? a. Use stool softeners with caution. b. Assume your usual activities. c. Avoid blowing your nose. d. Shampoo your hair with baby shampoo.
C
21. A patient comes to the primary care clinic complaining of a head cold and ear pain with drainage. What should the nurse suspect this patient is experiencing? a. Otitis externa b. Hearing loss c. Acute otitis media d. Mastoiditis
C
25. During an intake physical examination, a patient reports that he has been taking 10 aspirin tablets a day for his arthritis. What question should the nurse ask based on this information? a. "Can you hear high-pitched sounds?" b. "Have you noticed deafness in just one ear?" c. "Do you have ringing in your ears?" d. "Do you experience dizziness when you stand?"
C
These drugs inhibits the enzyme carbonic anhydrase which then decreases the production of aqueous humor to control IOP
CARBONIC ANHDRASE INHIBITORS (Ex. Diamox)
These drugs prevent metabolism of acteycholine resulting in increased cholinergic activity and decreases IOP
CHOLINESTERASE DRUGS
What part of the eye releases aqueous humor
CILIARY BODY
____ closed glaucoma occurs when there is a sudden increase in IOP caused by a mechanical obstruction
CLOSED
___ is the outermost sheath of the eyeball that allows light into the eye
CORNEA
Paralysis of the ciliary muscle is known as ___
CYCLOPLEGIA
16. A patient with diabetes says that he needs a hearing aid because he cannot hear well, and everything sounds garbled and distant. What type of hearing loss should the nurse suspect? a. Mixed hearing loss b. Conductive hearing loss c. Central hearing loss d. Sensorineural hearing loss
D
___ is the white portion of the eye
SCLERA
Before the administration of Diamox, a carbonic anhydrase inhibitor, you must first ask the pt if they are allergic to ____
SULFUR
In regards to cholinesterase drugs, the nurse knows that a pt can build a ___ to these drugs
TOLERANCE
TrF Carbonic Anhydrase Inhibitors cannot be given to pregnant women
TRUE
Which are important teaching points for the nurse to review with a patient recently diagnosed with open-angle glaucoma? (Select all that apply.)
The disease will cause damage to the optic disc if left untreated. Loss of peripheral vision is a common trigger for diagnosis. Total blindness may result if the glaucoma is not treated.
What information will the nurse include when teaching the patient and family about postoperative care for a trabeculectomy? (Select all that apply.)
Use aseptic technique for all dressing changes and medication administration. Avoid heavy lifting. Redness in the eye, pain, and swelling are common occurrences after surgery. Avoid straining on defecation.
For the pt receiving PROSTAGLANDIN EYE DROPS, when should she place her contacts back in her eyes
Wait 15 mins after administration to put contacts back in
When initially teaching a patient the supraglottic swallow following a radical neck dissection, with which food or fluid should the nurse begin? a) Cola b) Applesauce c) French fries d) White grape juice
a) Cola When learning the supraglottic swallow, it may be helpful to start with carbonated beverages because the effervescence provides clues about the liquid's position. Thin, watery fluids should be avoided because they are difficult to swallow and increase the risk of aspiration. Nonpourable pureed foods, such as applesauce, would decrease the risk of aspiration, but carbonated beverages are the better choice with which to start.
The nurse is scheduled to administer seasonal influenza vaccinations to the residents of a long-term care facility. What would be a contraindication to the administration of the vaccine to a resident? a) Hypersensitivity to eggs b) Age greater than 80 years c) History of upper respiratory infections d) Chronic obstructive pulmonary disease (COPD)
a) Hypersensitivity to eggs Although current vaccines are highly purified, and reactions are extremely uncommon, a hypersensitivity to eggs precludes vaccination because the vaccine is produced in eggs. Advanced age and a history of respiratory illness are not contraindications for influenza vaccination.
The nurse notices clear nasal drainage in a patient newly admitted with facial trauma, including a nasal fracture. What should the nurse do first? a) Test the drainage for the presence of glucose. b) Suction the nose to maintain airway clearance. c) Document the findings and continue monitoring. d) Apply a drip pad and reassure the patient this is normal.
a) Test the drainage for the presence of glucose. Clear nasal drainage suggests leakage of cerebrospinal fluid (CSF). The drainage should be tested for the presence of glucose, which would indicate the presence of CSF. Suctioning should not be done. Documenting the findings and monitoring are important after notifying the health care provider. A drip pad may be applied, but the patient should not be reassured that this is normal.
The school nurse is providing information to high school students about influenza prevention. What should the nurse emphasize in teaching to prevent the transmission of the virus (select all that apply)? a) Cover the nose when coughing. b) Obtain an influenza vaccination. c) Stay at home when symptomatic. d) Drink non-caffeinated fluids daily. e) Obtain antibiotic therapy promptly.
a, b, & c Covering the nose and mouth when coughing is an effective way to prevent the spread of the virus. Obtaining an influenza vaccination helps prevent the flu. Staying at home helps prevent direct exposure of others to the virus. Drinking fluids helps liquefy secretions but does not prevent influenza. Antibiotic therapy is not used unless the patient develops a secondary bacterial infection.
When planning health care teaching to prevent or detect or detect early head and neck cancer, which people would be the priority to target (select all that apply)? a. 65-year-old man who has used chewing tobacco most of his life b. 45-year-old rancher who uses snuff to stay awake while driving his herds of cattle c. 78-year-old woman who has been drinking hard liquor since her husband died 15 years ago d. 21-year-old college student who drinks beer on weekends with his fraternity brothers e. 22-year-old woman who has been diagnosed with human papilloma virus (HPV) of the cervix
a, b, c, e
The best method for determining the risk of aspiration in a patient with a tracheostomy is to: a. consult a speech therapist for swallowing assessment b. have the patient drink plain water and assess for coughing. c. assess for change of sputum color 48 hours after patient drinks small amount of blue dye d. suction above the cuff after patient eats or drinks to determine presence of food in trachea.
a. consult a speech therapist for swallowing assessment
A patient is being discharged from the emergency department after being treated for epistaxis. In teaching the family first aid measures in the event the epistaxis would recur, what measures should the nurse suggest (select all that apply)? a) Tilt patient's head backwards. b) Apply ice compresses to the nose. c) Tilt head forward while lying down. d) Pinch the entire soft lower portion of the nose. e) Partially insert a small gauze pad into the bleeding nostril.
b & d First aid measures to control epistaxis include placing the patient in a sitting position, leaning forward. Pinching the soft lower portion of the nose or inserting a small gauze pad into the bleeding nostril should stop the bleeding within 15 minutes. Tilting the head back or forward does not stop the bleeding, but rather allows the blood to enter the nasopharynx, which could result in aspiration or nausea/vomiting from swallowing blood. Lying down also will not decrease the bleeding.
When caring for a patient who is 3 hours postoperative laryngectomy, what is the nurse's highest priority assessment? a) Patient comfort b) Airway patency c) Incisional drainage d) Blood pressure and heart rate
b) Airway patency Remember the ABCs with prioritization. Airway patency is always the highest priority and is essential for a patient undergoing surgery surrounding the upper respiratory system. Comfort, drainage, and vital signs follow the ABCs in priority.
A patient whose tracheostomy was inserted 30 minutes ago is recovering in the postanesthesia recovery unit when he coughs and expels the tracheostomy tube. How should the nurse respond? a) Suction the tracheostomy opening. b) Maintain the airway with a sterile hemostat. c) Use an Ambu bag and mask to ventilate the patient. d) Insert the tracheostomy tube obturator into the stoma.
b) Maintain the airway with a sterile hemostat. As long as the patient is not in acute respiratory distress after dislodging the tracheostomy tube, the nurse should use a sterile hemostat to maintain an open airway until a sterile tracheostomy tube can be reinserted into the tracheal opening. The tracheostomy is an open surgical wound that has not had time to mature into a stoma. If the patient is in respiratory distress, the nurse will use an Ambu bag and mask to ventilate the patient temporarily.
Which task can the registered nurse (RN) delegate to unlicensed assistive personnel (UAP) in the care of a stable patient who has a tracheostomy? a) Assessing the need for suctioning b) Suctioning the patient's oropharynx c) Assessing the patient's swallowing ability d) Maintaining appropriate cuff inflation pressure
b) Suctioning the patient's oropharynx Providing the individual has been trained in correct technique, UAP may suction the patient's oropharynx. Assessing the need for suctioning should be performed by an RN or licensed practical nurse, whereas swallowing assessment and the maintenance of cuff inflation pressure should be performed solely by the RN.
When using a prosthesis for transesophageal speech, the patient: a. places a vibrating device in the mouth b. blocks the stoma entrance with a finger c. swallows air using a Valsalva maneuver d. places a speaking valve next to the stoma
b. blocks the stoma entrance with a finger
A patient with a history of tonsillitis complains of difficulty breathing. Which patient assessment data warrants emergency interventions by the nurse? a) Bilateral erythema of especially large tonsils b) Temperature 102.2° F, diaphoresis, and chills c) Contraction of neck muscles during inspiration d) β-hemolytic streptococcus in the throat culture
c) Contraction of neck muscles during inspiration Contraction of neck muscles during inspiration indicates that the patient is using accessory muscles for breathing and is in serious respiratory distress. The reddened and enlarged tonsils indicate pharyngitis. The increased temperature, diaphoresis, and chills indicate an infection, which could be β-hemolytic streptococcus or fungal infection, but not an emergency situation for the patient.
The patient has been diagnosed with head and neck cancer. Along with the treatment for the cancer, what other treatment should the nurse expect? a) Nasal packing b) Epistaxis balloon c) Gastrostomy tube d) Peripheral skin care
c) Gastrostomy tube Because 50% of patients with head and neck cancer are malnourished before treatment begins, many patients need enteral feeding via a gastrostomy tube because the effects of treatment make it difficult to take in enough nutrients orally, whether surgery, chemotherapy, or radiation is used. Nasal packing could be used with epistaxis or with nasal or sinus problems. Peripheral skin care would not be expected because it is not related to head and neck cancer.
What is the priority nursing assessment in the care of a patient who has a tracheostomy? a) Electrolyte levels and daily weights b) Assessment of speech and swallowing c) Respiratory rate and oxygen saturation d) Pain assessment and assessment of mobility
c) Respiratory rate and oxygen saturation The priority assessment in the care of a patient with a tracheostomy focuses on airway and breathing. These assessments supersede the nurse's assessments that may also be necessary, such as nutritional status, speech, pain, and swallowing ability.
A patient is seen at the clinic with fever, muscle aches, sore throat with yellowish exudate, and headache. The nurse anticipates that the collaborative management will include (select all that apply): a. antiviral agents to treat influenza b. treatment with antibiotics starting ASAP c. a throat culture or rapid strep antigen test d. supportive care, including cool, bland liquids e. comprehensive history to determine possible etiology
c, d, & e
Which nursing action would be of highest priority when suctioning a patient with a tracheostomy? a. Auscultating lung sounds after suctioning is complete b. Providing a means of communication for the patient during the procedure c. Assessing the patient's oxygenation saturation before, during, and after suctioning d. Administering pain and/or anti anxiety medication 30 minutes before suctioning
c. Assessing the patient's oxygenation saturation before, during, and after suctioning
A patient had an open reduction repair of a bilateral nasal fracture. The nurse plans to implement an intervention that focuses on both nursing and medical goals for this patient. Which intervention should the nurse implement? a) Apply an external splint to the nose. b) Insert plastic nasal implant surgically. c) Humidify the air for mouth breathing. d) Maintain surgical packing in the nose.
d) Maintain surgical packing in the nose. A goal that is common to nursing and medical management of a patient after rhinoplasty is to prevent the formation of a septal hematoma and potential infections resulting from a septal hematoma. Therefore the nurse helps to keep the nasal packing in the nose. The packing applies direct pressure to oozing blood vessels to stop postoperative bleeding. A medical goal includes realigning the fracture with an external or internal splint. The nurse helps maintain the airway by humidifying inspired air because the nose is unable to do so following surgery because it is swollen and packed with gauze.
The patient seeks relief from the symptoms of an upper respiratory infection (URI) that has lasted for 5 days. Which patient assessment should the nurse use to help determine if the URI has developed into acute sinusitis? a) Coughing b) Fever, chills c) Dust allergy d) Maxillary pain
d) Maxillary pain The nurse should assess the patient for sinus pain or pressure as a clinical indicator of acute sinusitis. Coughing and fever are nonspecific clinical indicators of a URI. A history of an allergy that is likely to affect the upper respiratory tract is supportive of the sinusitis diagnosis but is not specific for sinusitis.
The patient has decided to use the voice rehabilitation that offers the best speech quality even though it must be cleaned regularly. The nurse knows that this is what kind of voice rehabilitation? a) Electromyograph b) Intraoral electrolarynx c) Neck type electrolarynx d) Transesophageal puncture
d) Transesophageal puncture The transesophageal puncture provides a fistula between the esophagus and trachea with a one-way valved prosthesis to prevent aspiration from the esophagus to the trachea. Air moves from the lungs, vibrates against the esophagus, and words are formed with the tongue and lips as the air moves out the mouth. The electromyography and both electrolarynx methods produce low-pitched mechanical sounds.
While in the recovery room, a patient with a total laryngectomy is suctioned and has bloody mucus with some clots. Which nursing interventions would apply? a. Notify the physician immediately. b. Place the patient in the prone position to facilitate drainage. c. Instill 3 mL mornal saline into the tracheostomy tube to loosen secretions. d. Continue your assessment of the patient, inclining O2 saturation, respiratory rate, and breath sounds.
d. Continue your assessment of the patient, inclining O2 saturation, respiratory rate, and breath sounds.
A patient was seen in the clinic for an episode of epitaxial, which was controlled by placement of anterior nasal packing. During discharge teaching, the nurse instructs the patient to: a. use aspirin for pain relief b. remove the packing later that day c. skip the next dose of antihypertensive medication d. avoid vigorous nose blowing and strenuous activity
d. avoid vigorous nose blowing and strenuous activity
A patient with allergic rhinitis reports severe nasal congestion; sneezing; and watery, itchy eyes and nose at various times of the year. To teach the patient to control these symptoms, the nurse advises the patient to: a. avoid all intranasal sprays and oral antihistamines b. limit the usage of nasal decongestant spray to 10 days c. use oral decongestants at bedtime to prevent symptoms during the night d. keep a diary of when the allergic reaction occurs and what precipitates it
d. keep a diary of when the allergic reaction occurs and what precipitates it
antiglaucoma agents
decrease aqueous humor production by constricting the pupil to open the angle between the iris and cornea
mydriatics
disrupt parasympathetic nerve supply to the eye or stimulate the sympathetic nervous system causing the pupil to dialate
florescence angiography
evaluation of blood vessels and their leakage in and beneath the retina after injection of florescence dye, which circulates while photographs of the vessels with in the eye are obtained.
tonometry
evaluation of intraocular pressure by measuring the resistance of the eyeball to indentation by an applied force
retinoscopy
evaluation of refractive errors of the eye by projecting a light into the eyes and determining the movement of reflected light rays
gonioscopy
examination of the angle of the anterior chamber of the eye to determine ocular motility and rotation and diagnose and manage glaucoma
ear irrigation
flushing of the ear canal with water or saline to dislodge foreign bodies or impacted cerumen (earwax)
cyclodialysis
formation of an opening between the anterior chamber and the suprachoroidal space for the draining of aqueous humor in glaucoma
10. A patient undergoing a Weber test says that the sound is louder in her left ear. What should this result indicate? a. Normal hearing b. Nerve damage from listening to loud music c. Blocked ear canal in the right ear d. Conductive hearing loss in the left ear
D
2. A nurse is assisting with a caloric test and notes that the specific patient response that indicates a hearing disorder is a problem in the labyrinth. Which response did the nurse witness? a. Blinking b. Grimacing c. Headache d. Nystagmus
D
You are due to give MANNITOL to a pt with glaucoma, but you see crystals in the medication. What is the next step?
DO NOT GIVE THE MEDICATION
What is the action of timolol maleate (Timoptic), a beta-adrenergic blocking agent?
Decreases the production of aqueous humor
___ surrounds the pupil and gives the eye its color
IRIS
What is the mechanism of action of osmotic agents when used to decrease IOP?
Increasing plasma osmolarity and drawing extracellular fluid into the blood
___ has the job the ensure that the image on the retina is in sharp focus
LENS
Which medication is used to produce miosis following a diagnostic procedure?
Pilocarpine (Pilocar)
20. An 85-year-old patient has had age-related changes in the cochlea. What is the most appropriate nursing action for the nurse to implement? a. Speak slowly. b. Provide assistance with ambulation. c. Speak in a lower tone. d. Communicate with the patient in writing.
ANS: B Assisting the patient when ambulating will diminish the risk of a fall. Changes in the cochlea will cause dizziness and ataxia. DIF: Cognitive Level: Application REF: p. 1252 OBJ: 5 TOP: Age-Related Changes KEY: Nursing Process Step: Assessment MSC:
11. Which instruction should a nurse include when providing patient teaching information for a patient who will be self-administering ear drops for an ear infection? a. Tip the affected ear up and keep it in that position for several minutes after instilling the medication. b. Keep the medication in the refrigerator to preserve it. Instill the medication with the affected ear tilted upward. c. Touch the dropper to the opening of the ear canal to ensure that the drops are correctly instilled. d. Warm the ear drops and then tilt the head downward.
A
4. When making an initial assessment on a patient with a hearing deficit, the patient reports that he often feels off balance and is dizzy when he stands up. Which diagnosis might explain these symptoms? a. Sinus infection b. Rubella c. Otalgia d. Presbycusis
A
This adrenergic drug causes pupil dilation to promote an increase in aqueous humor and also causes vasoconstriction
ALPHAGAN P (adrenergic drug)
To enhance the safety of eye medications, what has been established
The use of standard colors for drug labels and bottle caps
The nurse is educating a patient about a newly prescribed cholinergic agent. When relaying common adverse effects of this type of medication, the nurse will include information about (Select all that apply.)
conjunctival irritation. headache.
9. A nurse assessing the results of a Rinne test sees the notation of BC > AC. How should the nurse translate this result? a. Conductive hearing loss b. Sensorineural hearing loss c. Normal hearing d. Cochlear defect
A
30. A nurse uses a diagram to show the physiologic sequence of hearing. After entering the external ear, the sound is then conducted through the (Arrange the options in sequence. Separate letters by a comma and space as follows: A, B, C, D.) A. tympanic membrane B. sensory receptors C. oval window D. acoustic nerve to the brain E. malleus, incus, and stapes
ANS: A, E, C, B, D The sound impulse, after entering the external ear, is conducted through the tympanic membrane; into the malleus, incus, and stapes; through the oval window; into the sensory receptors in the inner ear; and then through the acoustic nerve to the brain. DIF: Cognitive Level: Comprehension REF: p. 1252 OBJ: 1 TOP: Physiology of Hearing KEY: Nursing Process Step: Implementation MSC:
29. When planning care for a patient who cannot perceive or interpret sounds, a nurse takes into consideration that the patient may have a(n) _____ hearing loss.
ANS: central The inability to perceive or interpret sounds is referred to as a central hearing loss. DIF: Cognitive Level: Comprehension REF: p. 1261 OBJ: 5 TOP: Central Hearing Loss KEY: Nursing Process Step: Planning MSC:
3. A 75-year-old patient has normal age-related changes in his ear. What change should not be considered a normal change in the aging patient? a. Dry and wrinkled skin on the auricle b. Otitis externa c. Dry cerumen d. Hair in the ear canal
ANS: B Otitis externa is an outer ear infection and therefore an exception. The other three options are normal age-related changes. DIF: Cognitive Level: Comprehension REF: p. 1251 OBJ: 5 TOP: Age-Related Changes KEY: Nursing Process Step: Assessment MSC:
14. Which nursing diagnosis is most appropriate for a patient having ear surgery? a. Disturbed body image b. Risk for injury c. Acute confusion d. Ineffective protection
ANS: B Patients who have had ear surgery are at risk for vertigo, fluid accumulation, or pressure in the operative ear. Because of the surgery and potential postoperative conditions, the patient may be at risk for a fall. DIF: Cognitive Level: Application REF: p. 1259-1260 OBJ: 7 TOP: Care Planning for Ear Surgery KEY: Nursing Process Step: Planning MSC:
13. A nursing report on a newly admitted patient who is profoundly deaf says that the patient is confused and difficult to assess because she does not appropriately respond to questions or sometimes fails to respond at all. What should be the first action of the oncoming nurse? a. Consider asking the physician to assess the patient for dementia. b. Assess the patient to determine whether her hearing aids are in. c. Report to the physician that the patient is exhibiting signs of the sundown syndrome. d. Assess the patient's medications to check for an overdose.
ANS: B Profoundly deaf persons can be mistakenly assessed as being confused or disoriented when not wearing their hearing aids. DIF: Cognitive Level: Application REF: p. 1258 OBJ: 5 TOP: Hearing Aids KEY: Nursing Process Step: Planning MSC:
10. A patient undergoing a Weber test says that the sound is louder in her left ear. What should this result indicate? a. Normal hearing b. Nerve damage from listening to loud music c. Blocked ear canal in the right ear d. Conductive hearing loss in the left ear
ANS: D With the Weber test, a conductive hearing loss is determined by the sound being heard loudest in the affected ear. DIF: Cognitive Level: Comprehension REF: p. 1256 OBJ: 2 TOP: Weber Test KEY: Nursing Process Step: Assessment MSC:
13. A nursing report on a newly admitted patient who is profoundly deaf says that the patient is confused and difficult to assess because she does not appropriately respond to questions or sometimes fails to respond at all. What should be the first action of the oncoming nurse? a. Consider asking the physician to assess the patient for dementia. b. Assess the patient to determine whether her hearing aids are in. c. Report to the physician that the patient is exhibiting signs of the sundown syndrome. d. Assess the patient's medications to check for an overdose.
B
Why should you use caution in giving Alphagan P to hypertensive, diabetic, and asthmatic pts?
Because serious side effects include tachycardia, hypertension, and fainting
The nurse is assisting with applanation tonometry on a patient at the ophthalmologist's office. The results indicate the patient's reading to be 15 mm Hg. The nurse interprets this result as _____ IOP.
normal
Serious side effects of MANNITOL
o Circulatory overload o Nausea o Thirst o Dehydration o Electrolyte imbalance o Headache
Symptoms of closed angle glaucoma
o Eye pain o Frontal headaches o Halos around white lights o Blurred vision