Chapter 14 for final

vertigo

feeling of motion (not the same as dizziness); implement safety precautions

pain management best practice

given routinely before pain starts or becomes extreme is more effective

understanding pain referral

great value in diagnosing illness

a nurse is an ophthalmology clinic is interviewing a client who was referred by his primary care provider for suspicion of cataracts. the nurse should expect the client to report

having a decreased ability to perceive colors

tinnitus

hearing abnormal noises in ear; caused by ototoxic meds

otitis externa

infection of inner ear

otitis media

infection of middle ear

keratitis

inflammation of the cornea caused by infection or trauma

pain tolerance

is caused by unrelieved pain and is the maximum intensity of pain that a person is willing to endure

sensation

is detected by the general and special senses

self report

is the most reliable indicator of the existence and intensity of pain

pain threshold

is the perception of pain and the level at which it is sensed

a nurse is assessing a client who was involved in a motor-vehicle crash. which of the following techniques should the nurse use to test corneal reflexes?

lightly touch the eyes with a wisp of cotton

amblyopia

loss of one eyes ability to see details; needs to be fixed before brain stops growing 5-10 years

a nurse is caring for a client who is postoperative. the nurse should base her pain management interventions primarily on which of the following methods of determining the intensity of the clients pain?

the clients self-report of pain severity

a nurse at an ophthalmology clinic is providing teaching to a client who has open angle glaucoma and a new prescription for timolol eye drops. which of the following instructions should the nurse provide?

the medication should be applied on a regular schedule for the rest of the clients life

a nurse is caring for a child who has otitis media. which of the following assessment findings should the nurse expect?

tugging on the affected ear lobe

rental detachemtn

typically painless; medical emergency; surgery

a nurse is caring for a client following cataract surgery. which of the following comments from the client should the nurse report to the clients provider?

"I need something for the pain in my eye. I can't stand it."

special sense include

taste, smell, sight, hearing, and balance

a home health nurse is teaching an older adult client who just had cataract surgery. which of the following instructions should the nurse include?

"keep your head up and straight"

glaucoma

chronic sensory disorder of the eyes; group of eye conditions that lead to damage to the optic nerve; second leading cause of blindness; diabetic retinopathy is number 1 cause

cataracts

chronic sensory disorder of the eyes; opacity or clouding of the lens

open-angle glaucoma

chronic; most common type; painless manifestations, blurb vision, tunnel vision; treated by timolol (beta blocker)

strabismus

crossed eyes

leading manifestation of otitis media in children includes

crying or irritability, with rubbing or pulling at ears

otosclerosis

abnormal sponge-like bone growth in middle ear

midbrain periaqueductal gray

endogenous analgesic center

a nurse is providing education for a client who has glaucoma. which of the following statements should the nurse include in the teaching?

"without treatment, glaucoma can cause blindness"

secondary glaucoma

Type of glaucoma that is a result of certain medications, eye diseases, and systemic diseases.

closed-angle glaucoma

acute; medical emergency b/c sudden blockage; manifestations include sever, sudden eye pain, headache, nausea

amount of sensory input needed to be aware of the sensation becomes greater as we

age

primary nursing diagnosis of sensory system is

altered sensory perception

a nurse is planning care for a client who is postoperative. which of the following statements about pain management should the nurse consider when implementing client care? (select all that apply)

each clients expression of pain may be different and individualized patient-controlled analgesia (PCA) offers a constant level of opioids within therapeutic range pain level and pain tolerance can be assessed using a scale from 0 to 10

a nurse is reviewing discharge instructions with a client following a right cataract extraction. which of the following instructions should the nurse include?

avoid lifting anything heavier than 4.5kg (10lb) for 1 week

a nurse is caring for a client who has bilateral eye patches in place following an injury. when the clients food tray arrives, which of the following interventions should the nurse take to promote independence in eating?

describe to the client the location of the food on the tray.

macular degeneration

deterioration of the macular area of the retina; blank black areas with vision; master grid is used to diagnose

a nurse is admitting a client who has a partial hearing loss. which of the following is the priority action by the nurse?

determine if the client uses hearing aids.

Meniere's disease

disorder of inner ear that results from endolymph swelling; unknown cause; manifestations include waves of acute episodes that last several months, vertigo, nausea, vomiting; treatment = meniett device

a nurse is administering timolol eye drops to a client who has glaucoma. which of the following actions should the nurse take?

drop prescribed amount of medication into the conjunctival sac.

two types

dry = no treatment; almost all ppl start with dry form wet = not as common

manifestation of congenital cataracts is

nystagmus (rapid, involuntary back-and-forth eye movement)

general sense include

pain, light touch, pressure, temperature, and proception

conjunctivitis

pink eye; manifestations: viral infections produce watery mucous-like exudate, bacterial produce yellow/green exudate, allergens produce redness/itching/excessive tearing

congenital glaucoma

present at birth

a nurse is talking with a client who is scheduled for surgery to repair retinal detachment. which of the following preoperative instructions should the nurse include?

restrict head movement

secondary nursing diagnosis of sensory system is

risk for injury

two types of hearing loss includes

sensorineural hearing ( involves damage to inner ear, auditory nerve or brain) conductive hearing loss (occurs when sound has problems transmitting through the outer and middle ear to the inner ear)

a nurse is caring for a child who has otitis media with effusion. the nurse should identify that which of the following manifestations indicates a tympanic membrane rupture?

sudden pain relief