Comprehensive NCLEX-PN: CH 59 Eye, Ear, Nose, and Throat

A client has completed a full course of abx for acute otitis media. The nurse conducting a follow-up examination to determine whether medication therapy was effective by questioning the client about relief from which is most common presenting symptom?

-Ear pain is the most common sx for clients to seek health care.

The nurse working in a pediatric clinic conducts that which finding in a child indicates a risk for visual impairment?

-Excessive rubbing of the eyes. Symptoms of decreased visual acuity are squinting to focus, excessive tearing of the eye, and rubbing of the eyes.

The nursing is caring for a client who is in the recovery area following cataract surgery. the nurse would ask the client about which manifestation that would indicate onset of retinal detachment as a postoperative complication? SATA

-Flashing lights -Part loss of visual field in the eye Clients w/ retinal detachment frequently report a flashing lights and loss of vision, commonly described as a veil or curtain being drawn across the eye.

What should be the initial intervention by the nurse for a client in the ED who suffered a chemical burn to the eyes?

-Irrigate the eyes w/ normal saline solution or water. The immediate priority for clients w/ chemical burns is flushing the effected eye with copious amounts of normal saline or water.

The nurse recommends a humidified atmosphere for a child with recurrent epistaxis. When questioned by the parent, the nurse explains that which of the following is a benefit of humidity for the child?

-Prevents drying of the mucous membranes. Humidifying the air can prevent dry mucous membranes and recurrence of epistaxis. Liquefying secretions is not a concern for a client with recurrent nose-bleeding. Humidification does not increase the oxygen percentage of ambient air, which its 21%. Humidifying the air does not increase the client's ventilation.

Which nursing diagnosis would be most appropriate for the nurse to use when caring for a child with pharyngitis?

-Risk for deficient fluid volume. A symptom of pharyngitis is sore throat and difficulty swallowing, which can lead to the refusal to drink. Thus, risk for deficient fluid volume is an appropriate diagnosis. The client many have anxiety because of pain associated with pharyngitis, but this will resolve with treatment of the infection. Risk for ineffective airway clearance would apply if the client cannot clear secretions from the respiratory tract, which is evident in this question. Impaired growth and development is not a concern with this brief health problem.

A client has undergone myringotomy. The nurse working in an ambulatory surgery center would reinforce to the client to avoid which activity while healing is occurring?

-Swimming. Myringotomy is a surgical procedure that perforates the tympanic membrane to allow drainage from the middle ear. Postop, the client should avoid getting water into the ear canal, which could potentially enter the middle ear.

A client reports ongoing problems with vertigo. The nurse should question the client about which accompanying manifestations to determine whether the client has developed Meniere's disease? SATA

-Tinnitus (roaring or ringing) -Hearing Loss -Sense of fullness in the ear. (Nystagmus occurs with acute attacks.)

After a client has undergone surgery for a right eye cataract removal, the nurse reinforces client teaching to avoid which actively when the client gets home? SATA

-Lying on the right side. -Mowing the lawn. The client should avoid lying on the operative side following eye surgery to minimize edema and intraocular pressure. Activities that involved pushing or straining, such as mowing the lawn, can increase intraocular pressure and should be avoided in the post period.

What is the most appropriate intervention by the nurse who is caring for an infant with acute otitis media and a fever of 102.7 F?

-Offer fluids frequently to prevent dehydration. A febrile infant is at risk for deficient fluid loss from larger than normal insensible fluid loss and decreased fluid intake. It is contradicted to sponge with cool water, which could lead to shivering and higher temperature. Intake of solid food is less important than preventing dehydration. A febrile infant will experience a higher fever if blankets are added.

The nurse would take which action when the client first comes into the ED with a blunt trauma to the eye?

-Place the client in semi-fowler's position. Prevention or reduction of intraocular pressure (that may accompany blunt trauma to the eye) can be accomplished by the use of semi-fowler's position and administration of carbonic anhydrase inhibitor, such as acetazolamide (Diamox). Semi-fowler's position also reduces edema formation at the site of injury when compared to lying flat. It is unnecessary to irrigate the eye because no foreign body is present. Constriction of the pupil with motifs is not indicated. Blunt trauma does not cause loss of intraocular contents.

A 68-y-o female client tells the ambulatory care nurse during a routine visit that she has recently noticed a decline in her ability to hear. The nurse documents this information on the client's health record, suspecting that this client most likely is exhibiting which disorder?

-Presbycusis. Most common form of sensorineural hearing loss in older adults.

A 4-year-old has been diagnosed with amblyopia. The nurse who is providing the parents with information abut this diagnosis should reinforce which items of information? SATA

-The child will need to wear a patch over his unaffected eye. -If not treated, the child may become permanently blind in the affected eye. Without treatment, including patching, corrective lenses, and muscular exercises, the damage will become permanent. The pathophysiology is misalignment of the eyes causing the brain to stop receiving the signal of the affected eye. Vision testing is done with Snellen chart not the Snellen E chart.

The nurse reinforces teaching to the parents of an infant with chronic otitis media. What should the nurse recommend to prevent further infections? SATA

-The parents should avoid exposing their infant to tobacco smoke. -The parent should not allow the baby to fall asleep with a pacifier. Exposure to secondhand smoke increases incidence of otitis media so this should be avoided to reduce the risk of future episodes of otitis media. Preventing the infant from falling asleep with a pacifier will also help because saliva from sucking cannot accumulate and enter the Eustachian tube. Medication such as nasal decongestant would have side effects and should be avoided unless specifically needed. Infants who feed in supine position have an increased risk of otitis media. Warm compresses will not prevent future infection.

The nurse is determining the effectiveness of preoperative teaching for a client who will undergo repair of a detached retina using a scleral buckling. The nurse identifies that the client understands the procedure after the client gives which description of the surgery?

-Using a piece of silicone to indent the sclera to increase contact between retinal layers. Scleral buckling involves using a piece of silicone, which is used to indent the sclera to increase contact between the retinal layers. It is used in conjunction with laser photocoagulation or cryothermy to achieve the best results. A gas is injected into the vitreous humor during pneumatic retinopexy as treatment for reached retina. Scleral buckling DOES NOT involve removing of torn segment of retina, which would result in permanent vision loss in that area o the eye. Scleral buckling does not include use of donor retinal tissue.

The nurse needs to administer an ophthalmic medication to a client. What action by the nurse is the correct way to administer this medication?

-Apply pressure to the inner canthus while administering the medication. The nurse should apply pressure to the inner canthus (nasolacrimal duct) during and for at least 30 seconds after instillation, according to agency procedure, to prevent systemic absorption of the medication. The medication should be dropped into the lower conjunctival sac. The eye should not be rubbed after instillation of the medication. The nurse should wait from 1 to 5 minutes between drops, depending on the medication and the manufacturer's recommendations.

To communicate effectively w/ a client who has hearing loss caused by presbycusis, the nurse should use which strategy to improve communication with the client? SATA

-Approach the client from the front. -Turn down background noise from the radio or TV before speaking.

A client who was diagnosed w/ chronic open-angle glaucoma has been started on med therapy with timolol maleate (Timoptic). The nurse monitors for which possible adverse systemic response to the drug?

-Bradycardia. Medications that end in -olol are beta-adrenergic blocking agents. When taken as ophthalmic preparations, they can produce systemic effects such as bradycardia, hypotension, and bronchospasm. Beta-adrenergic blockers may also be used to treat adrenergic sx associated with anxiety, but this does not relate to glaucoma.

The nurse has administered a dose of antibiotic intramuscularly to a 5-year-old client with tonsillitis. The child cries for an adhesive bandage over the injection site. What is the best action by the nurse?

-Apply an adhesive bandage. It is appropriate to comfort a child following a painful procedure and applying the bandage provides support and comfort. There is no reason to question the child. By fulfilling the child's request, the nurse allows the child to regain some control over the situation. The child may be looking for some comfort rather than concerned about bleeding.

The daughter of an older adult client diagnosed with dry macular degeneration asks the nurse to explain the disorder. In formulating a response, the nurse would include which characteristics of this condition?

-Atrophy and degeneration of outer pigmented layer of retina. Atrophic or dry macular degeneration results from atrophy and degeneration of the outer layer of the retina. In Exudative, or Wet macular degeneration, blood leaks into the subretinal space and scar tissue gradually forms. The resulting loss of vision occurs rapidly and is more profound. Exudative macular degeneration accounts for 90% of all cases of legal blindness. Separation of the retina from the choroid describes retinal detachment.

Which actions would be beneficial for the nurse to use as part of collaborative management of a client who has conjunctivitis? SATA

-Careful handwashing -Antibiotic therapy -Dark sunglasses Careful hygiene is effective in reducing the risk of transmitting the infection to others. Antibiotic therapy kills the bacteria that are responsible for the eye infection. Dark sunglasses are helpful in reducing photophobia. Warm compresses, not cold, should be used as part of the management of conjunctivitis. Warm compresses help relieve discomfort and reduce inflammation by increasing circulation to the area. Although there is eye discomfort, there is no need for strong analgesics such as opioids.

The nurse receives an order to do an otic irrigation to the left ear of assigned client. The nurse uses which technique to perform this procedure correctly?

-Help the client to lie on the left side after the irrigation is finished. The client should lay on the affected side following the irrigation to allow gravity to further assist in draining the ear canal. The irritant should be directed along the wall of the external canal, not the center (which could damage the tympanic membrane). Usually 50 to 70 mL of solution is used, according to the size of the syringe used for the procedure. A single cotton ball is placed loosely into the external meatus to absorb any remaining irrigant after the procedure.

A client has hearing loss characterized by distortion of sounds that are heard. The client asks the nurse about the benefits of obtaining a hearing aid. The nurse would include in a response that a hearing aid will have which effect for this client?

-It will intensify the already distorted sounds. When hearing loss is characterized by distortion of sounds, amplification of sounds is of little help because it only increases the intensity of distorted, and a hearing aid will not help the client distinguish words from background noises or make words louder and clearer.

The nurse prepares to reinforce client teaching for which medication commonly used to treat Meniere's disease?

-Meclizine (Antivert) Antivertigo and Antiemetic medications, such as meclinizine, are used to control symptoms associated with Meniere's disease.

The nurse would reinforce which instruction to a client after fluorescein angiography to diagnose an eye condition? SATA

-The dye causes temporary green discoloration to urine. -Avoid sunlight until pupil size returns to normal. The client should know that the dye causes temporary skin discoloration in the injected area and temporary green discoloration of urine that resolves when dye is fully excreted. The client should avoid sunlight or other bright light sources until pupil dilation returns to normal. Typical instructions after fluorescein angiography include increased fluid intake to aid in dye excretion. Although the client should rest after the procedure, it is not necessary to lie down with eyes closed for 12 hours. Headaches and blurred vision are not expected.