Chapter 51 & 52 Vision and Hearing

The nurse is caring for a group of pts. Which pt is at risk for a middle ear congestion?

A pt who regularly has allergies

The nurse is caring for a group of pts. Which pt is at risk for a middle ear infection?

A pt who regularly has allergies

A pt is dx with Meniere Disease. Which therapeutic measures does the nurse expect the HCP to prescribe?

A salt-restricted diet and prescribed antihistamines and vasodilators

The nurse is assisting with a pt who is having a test to measure IOP. Which equipment should the nurse expect to be used?

A tonometer

The HCP is assessing the ability of the pts pupil to respond to near and far distance assessments. The nurse knows that this is an assessment for which visual response?

Accommodation

The nurse is collecting data from a pt with DM. The pts medical hx reveals multiple episodes of hyperglycemic requiring management. The pt tells the nurse, I just got new glasses, but I still do not see very well. Which condition does the nurse suspect?

Background retinopathy

A pt with acute ear pain and drainage comes into the community clinic. Which dx tests does the nurse expect to be performed prior to beginning tx for this pt? (Select all that apply)

CBC Rinne and Weber tests Culture of ear discharge

The nurse is reinforcing teaching provided to a pt with open angle glaucoma. What is most important for the nurse to include in the pt teaching?

Compliance with drug therapy is essential to prevent loss of vision

The nurse is teaching a pt about conjunctivitis. Which statement indicates a need for further teaching?

Conjunctivitis is not contagious, so my kid can go to school

During a physical exam of a pt, pupillary reflexes are checked. A light is shone into the right eye while it is observed. Pupillary reaction and pupil size are noted. Then a light is shone into the left eye is still observed. Which response occurs during the second step of the test?

Consensual response

While checking a pts pupils, the nurse notes that the left pupil constricts when a light is shone into the right eye. Which information does this finding suggest to the nurse?

Consensual response present

A pt with acute angle glaucoma and a fx femur that is scheduled for sx is prescribed the preoperative morphine 10 mg IM and atropine 0.4 mg IM. Which action does the nurse take?

Contact the physician

The nurse is assisting in the evaluation of the effectiveness of teaching for a pt who has severe visual impairment. Which statement by the pt indicates additional teaching is needed?

Cooking is still impossible, and I am just eating cold foods

The nurse is reinforced teaching with a pt about diagnostic tests that evaluate eye muscle balance. Which tests identified by the pt indicate teaching has been effective?

Cover test Corneal light reflex

The nurse in the ER is assisting with the care of a pt with penetrating wound to the eye. The pt keeps crying out and asking that the uninjured eye be uncovered. Which answer by the nurse provides understanding?

Covering the uninjured eye stops ocular movement in the injured eye

During a health hx. The nurse suspects that a pt is at risk for a vision problem. Which information within the family hx does the nurse use to make this decision? (select all that apply)

Diabetes Cataracts Blindness Glaucoma

The nurse is working at a summer camp for preadolescent children. One of the children comes to the nurse rubbing an eye and stating pain from getting sand in the eye. After the child is effectively tx'd, which teaching is the nurse promoted to provide to all the attendees?

Do not rub your eye if it has something in it

The nurse is caring for a pt who has diabetes and macular degeneration. Which question is most appropriate for the nurse to ask?

Do you have a family member who can administer your insulin injections?

The nurse is caring for a pt with a cataract. Which clinical manifestations can the nurse expect to find?

Double vision

The nurse in an HCP's office is assisting with the removal of impacted cerumen from the ear canal of an older adult pt. The pt presented with decreased hearing and a sensation of fullness. Which reason does the nurse identify as the most likely cause of the pts condition?

Dryness of secretions from shrinking ear canal glands

The nurse is collecting data from a pt with a detached retina. Which findings does the nurse expect in this pt? (Select all that apply)

Flashing lights Loss of peripheral vision Loss of acuity in the affected eye

The nurse is caring for a pt with retinal detachment. Which clinical manifestations can the nurse expect to find?

Floaters

The nurse is providing care for a pt with a sensorineural hearing loss. Which prescribed medications does the nurse question before administering medications to this pt? (Select all that apply)

Gentamicin Furosemide Indomethacin

The nurse is reinforcing teaching provided to a pt with primary open-angle glaucoma (POAG) about symptoms to report. Which pt statement regarding symptoms indicates a correct understanding of the teaching?

Headache and seeing halos around lights

THe nurse is teaching a pt with Meniere's Disease about preventing attacks. Which statement made by the pt indicates a need for further teaching?

I am going to have a cola for lunch today

The nurse is providing teaching to a pt with ear pain. Which statement made by the pt indicates an understanding of the teaching?

I can take some acetaminophen for the pain

The nurse places eyedrops for a pt with an injured eye and covers the eye with a patch as prescribed.Discharge instructions are given to the pt. Which pt statements indicate further instructions as needed? (Select all that apply)

I should exercise my patched eye 4 times a day I can watch TV without moving my eye too much I should apply pressure to the tear duct on the eye q5 minutes I should try to open my eyelid under the patch hourly while awake

The nurse is reinforcing teaching about eye hygiene. Which statement made by a client indicates an understanding of the teaching?

I should wear safety goggles when working with debris

The nurse is reinforcing teaching provided to a pt recovering from a stapedectomy. Which pt statement indicates teaching has been effective?

I will cough or sneeze with my mouth open

The nurse is caring for a pt with conductive hearing loss. Which factors can lead to this type of hearing loss? (Select all that apply)

Impacted cerumen Foreign bodies Trauma

The nurse is preparing a client for an electronystagmogram. Which information will the nurse give the pt?

Inform the pt of experiencing nasea

A pt presents with vertigo, tinnitus, and sensorineural hearing loss and is dx with labyrinthitis. Which pt teaching does the nurse reinforce with this pt?

Instruct to not turn the head quickly

The nurse is caring for a pt with Meniere's Disease. Which intervention will the nurse implement?

Keep the pt in a calm environment

The nurse is taking a health hx on a pt who is hard of hearing. Which illness reported in the hx can cause hearing loss?

Measles

A nurse is providing care for a school-age pt at a community clinic. The pt exhibits redness and crusting exudate and antibiotic drops were prescribed. Which action does the nurse take if the eye culture returns as positive for Neisseria Gonorrhea?

Notify the HCP and RN about a possible situation involving sexual abuse of a minor

The nurse is collecting information about a pts auditory system during a physical examination. Which process will the nurse perform first?

Observation

The nurse is caring for a pt with hearing loss. Which interventions will the nurse implement? (Select all that apply)

Obtain the pts attention before speaking Lower the voice pitch Allow extra time for the pt to answer

The nurse at the HCP's office is providing assistance with a pt who has purulent drainage from the ear. Which action by the HCP does the nurse expect?

Obtaining a swab of the drainage for culture

A pt with otitis media is experiencing severe ear pain. Which nonpharmacological measure does the nurse apply to help releieve this pts discomfort? (Select all that apply)

Offer a massage Apply heat to the area Offer liquid or soft diet

The nurse is caring for a pt with swimmers ear. Which clinical manifestations can the nurse expect to find? (Select all that apply)

Pain Drainage Swelling Itching

The nurse is preparing to administer eye medication as prescribed by the HCP after eye sx for cataract removal. The HCP prescribes one drop with punctual occlusion. Which action will the nurse perform when administering this medication?

Place the index finger on the corner of the eye and apply pressure against the nose bone

The nurse is assisting with the care of a pt being prepared for emergency interventions for a detached retina. If the nurse asks the pt about the ability to maintain a reclining position for 16 hours, which procedure is planned for this pt?

Pneumatic retinopexy

The nurse is assisting with the preparations of a pt for a cochlear implant due to profound deafness. Which teaching will the nurse reinforce for this pt?

Preparation instructions for sx

The nurse is caring for a pt with impacted cerumen. Which interventions will the nurse implement?

Prepare the pt for irrigation

The nurse determines that a pt is experiencing common age-related changes in vision and hearing. Which findings does the nurse identify in the pt? (select all that apply)

Presbycusis Yellowing of the lens Distorted depth perception Decreased lacrimal secretions

The nurse is collecting information from a pt who reports difficulty seeing the print in the newspaper. The pt is 50 years of age and does not have any condition that requires medical management. Which vision condition does the nurse suspect the pt is experiencing?

Presbyopia

The nurse is conduction hearing tests in a neighborhood clinic. The nurse is concerned about the number of young adult pts who exhibit signs of sensorineural hearing loss, for which reason does the nurse suspect this type of hearing loss in this population?

Prolonged exposure to loud music

The nurse is caring for a pt who is hard of hearing. Which pt action will the nurse expect to find when taking a health hx? (Select all that apply)

Pt turns head to the side during conversation Avoids places with several people Has difficulty hearing high-frequency consonants

The nurse performs visual assessment on a pt and documents the findings using the acronym PERRLA. Which assessment finding does PERRLA indicate?

Pupils equal, round, and reactive to light, and accommodation

Prior to measuring a pts hearing, the nurse obtains a tuning fork. Which hearing tests is the nurse preparing to conduct? (select all that apply)

Rinne test Weber test

The nurse is caring for an older adult pt. Which letter is commonly difficult to hear as a result of aging?

S

The nurse is teaching a pt with macular degeneration about nutrition. Which food choices by the pt indicate an understanding of the teaching?

Salad made with spinach and corn

The nurse is preparing to assist the HCP with the incision of a carbuncle in the ear canal of a pt. Which specific manifestations does the nurse associate with the pts dx?

Several hair follicles that have formed an abscess

The nurse is teaching a pt about eye examinations. Which statement made by the pt indicates a need for further teaching?

Since I haven't had eye problems, I only need an exam q5 years

The nurse is providing care for an older adult client. The nurse notices the pt appears to be having difficulty understanding her and asks that questions and comments be repeated. If the nurse suspects presbycusis, which action does the nurse take to promote better hearing for the pt?

Speaking to the pt in a lower tone of voice

The nurse is preparing a pt with DM for a fluorescein angiography. For which reason does the nurse understand the performance of this test?

TO find leakage or damamge to the blood vessels of the retina

The nurse is collecting information about the eyes from an older adult pt. Which finding is unexpected during the exam?

The best color discrimination is between blue, green, and purple

The caregiver pf a pt with macular degeneration voices being increasingly frustrated because of food spills on the pts clothes. Which explanation does the nurse give to help the caregiver understand what the pt is experiencing?

The central vision is gone and only peripheral vision remains

The nurse is explaining how the retina works to a pt who is experiencing visual changes. Which factor shared by the nurse is correct?

The fovea centralis is located directly behind the center of the lens and contains cones

A pt has an injury resulting in a major damage to the pinna of the right ear. The pt expresses fear about hearing loss in the damaged ear. Which statement by the nurse will alleviate the pts fear?

The impulses for hearing come from the middle and inner ear

A pt is scheduled to have cataract sx. Which structire of the pts eye does the nurse explain will be involved in the procedure?

The lens

The nurse is conducting hearing acuity evaluation on a pt using the Rinne test. The test involves the use of a tuning fork. Which test result will be validated with the documentation "AC greater than BC"?

The pt continues to hear the runing fork for twice as long when it is lifted from the mastoid bone

The nurse is giving instructions to a pt who is scheduled for an electronustagmomgram due to a dx of vertigo and ringing in the ears. Which finding regarding the pts medical hx will cause the nurse to notify the prescribing HCP for cancellation of the test?

The pt has a pacemaker

The nurse is visiting the home of a pt dx with visual impairment related to macular degeneration. Which observation indicates to the nurse the pt is adjusting to the condition?

The pt is moving about the apartment without problems

A pt is dx with otosclerosis and is scheduled for a stapedectomy. Which postoperative finding does the nurse report to the HCP or the RN immediately?

The pt received an antiemetic for nausea, but vomits after the medication

The nurse is teaching a pt about the use of an eye patch. Which pt action requires correction by the nurse?

The pt watches tv while applying patch

The nurse is attending while the HCP preforms an otoscopic examination of a pts ears. The nurse is aware that the exam is performed primarily for which purpose?

To examine the eardrum

The nurse is preparing to assess a pts auditory acuity. Which equipment will the nurse use for this exam?

Tuning fork

An adolescent pt is dx by the HCP with keratitis from a herpes simplex infection of the eye. Which pt teaching does the nurse reinforce as a method for pain management?

Wearing sunglasses indoors and outdoors to decrease effects of photophobia

The nurse is conducting an initial screening to determine a pts gross hearing acuity as part of a complete physical. Which test does the nurse include in the assessment?

Whisper voice

The national institute has performed research regarding the impact of nutrition on eye disease. Which factor does the nurse recognize as an incorrect conclusion from this research?

With intensive glycemic control, pts with DM do not experience retinopathy

The nurse is using a Snellen chart to assess a pts visual acuity. The pt asks the nurse what 20/70 vision means, Which statement by the nurse is most appropriate?

You are able to see at 20 feet what most people see at 70 feet away

The nurse is caring for a group of pts. Which pt is at highest risk for developing primary open-angle-glaucoma (POAG)?

a 40-year-old pt of African origin who has diabetes