Eyes & Ears

A client had a retinal detachment and has undergone surgical correction. What discharge instruction is most important? a. "Avoid reading, writing, or close work such as sewing." b. "Dim the lights in your house for at least a week." c. "Keep the follow-up appointment with the ophthalmologist." d. "Remove your eye patch every hour for eyedrops."

ANS: A After surgery for retinal detachment, the client is advised to avoid reading, writing, and close work because they cause rapid eye movements. Dim lights are not indicated. Keeping a postoperative appointment is important for any surgical client. The eye patch is not removed for eyedrops.

An older adult in the family practice clinic reports a decrease in hearing over a week. What action by the nurse is most appropriate? a. Assess for cerumen buildup. b. Facilitate audiological testing. c. Perform tuning fork tests. d. Review the medication list.

ANS: A All options are possible actions for the client with hearing loss. The first action the nurse should take is to look for cerumen buildup, which can decrease hearing in the older adult. If this is normal, medications should be assessed for ototoxicity. Further auditory testing may be needed for this client.

A client has a corneal ulcer. What information provided by the client most indicates a potential barrier to home care? a. Chronic use of sleeping pills b. Impaired near vision c. Slightly shaking hands d. Use of contact lenses

ANS: A Antibiotic eyedrops are often needed every hour for the first 24 hours for corneal ulceration. The client who uses sleeping pills may not wake up each hour or may awaken unable to perform this task. This client might need someone else to instill the eyedrops hourly. Impaired near vision and shaking hands can both make administration of eyedrops more difficult but are not the most likely barriers. Contact lenses should be discarded.

A nurse is teaching a community group about preventing hearing loss. What instruction is best? a. Always wear a bicycle helmet. b. Avoid swimming in ponds or lakes. c. Don't go to fireworks displays. d. Use a soft cotton swab to clean ears.

ANS: A Avoiding head trauma is a practical way to help prevent hearing loss. Swimming can lead to hearing loss if the client has repeated infections. Fireworks displays are loud, but usually brief and only occasional. Nothing smaller than the client's fingertip should be placed in the ear canal.

A nurse is teaching a client about ear hygiene and health. What client statement indicates a need for further teaching? a. "A soft cotton swab is alright to clean my ears with." b. "I make sure my ears are dry after I go swimming." c. "I use good earplugs when I practice with the band." d. "Keeping my diabetes under control helps my ears."

ANS: A Clients should be taught not to put anything larger than their fingertip into their ears. Using a cotton swab, although soft, can cause damage to the ears and cerumen buildup. The other statements are accurate.

The nursing student studying the eye learns that which cranial nerves control its functions? (Select all that apply.) a. II b. III c. VI d. XII e. X

ANS: A, B, C The cranial nerves involved with eye function include II, III, IV, V, VI, and VII.

A client has been prescribed brinzolamide (Azopt). What assessment by the nurse requires consultation with the provider? a. Allergy to eggs b. Allergy to sulfonamides c. Use of contact lenses d. Use of beta blockers

ANS: B Brinzolamide is similar to sulfonamides, so an allergic reaction could occur. The other assessment findings are not related to brinzolamide.

A client has Ménière's disease with frequent attacks. About what drugs does the nurse plan to teach the client? (Select all that apply.) a. Broad-spectrum antibiotics b. Chlorpromazine hydrochloride (Thorazine) c. Diphenhydramine (Benadryl) d. Meclizine (Antivert) e. Nonsteroidal anti-inflammatory drugs (NSAIDs)

ANS: B, C, D Drugs such as chlorpromazine, diphenhydramine, and meclizine can all be used to treat Ménière's disease. Antibiotics and NSAIDs are not used.

A client is scheduled for a stapedectomy in 2 weeks. What teaching instructions are most appropriate? (Select all that apply.) a. Avoid alcohol use before surgery. b. Blow the nose gently if needed. c. Clean the telephone often. d. Sneeze with the mouth open. e. Wash the external ear daily.

ANS: B, C, D, E It is imperative that the client having a stapedectomy is free from ear infection. Teaching includes ways to prevent such infections, such as blowing the nose gently, cleaning objects that come into contact with the ear, sneezing with the mouth open, and washing the external ear daily. Avoiding alcohol will not help prevent ear infections.

A client is admitted to the nursing unit after having a tympanoplasty. What activities does the nurse delegate to the unlicensed assistive personnel (UAP)? (Select all that apply.) a. Administer prescribed antibiotics. b. Keep the head of the client's bed flat. c. Remind the client to lie on the operative side. d. Remove the iodoform gauze in 8 hours. e. Take and record postoperative vital signs.

ANS: B, E The UAP can keep the head of the client's bed flat and take/record vital signs. The nurse administers medications. The client should lie flat with the head turned so the operative side is up. The nurse or surgeon removes the gauze packing.

A client has been taught about retinitis pigmentosa (RP). What statement by the client indicates a need for further teaching? a. "Beta carotene, lutein, and zeaxanthin are good supplements." b. "I might qualify for a retinal transplant one day soon." c. "Since I'm going blind, sunglasses are not needed anymore." d. "Vitamin A has been shown to slow progression of RP."

ANS: C Sunglasses are needed to prevent the development of cataracts in addition to the RP. The other statements are accurate.

A nurse is teaching a community group about noise-induced hearing loss. Which client who does not use ear protection should the nurse refer to an audiologist as the priority? a. Client with an hour car commute on the freeway each day b. Client who rides a motorcycle to work 20 minutes each way c. Client who sat in the back row at a rock concert recently d. Client who is a tree-trimmer and uses a chainsaw 6 to 7 hours a day

ANS: D A chainsaw becomes dangerous to hearing after 2 hours of exposure without hearing protection. This client needs to be referred as the priority. Normal car traffic is safe for more than 8 hours. Motorcycle noise is safe for about 8 hours. The safe exposure time for a front-row rock concert seat is 3 minutes, but this client was in the back, and so had less exposure. In addition, a one-time exposure is less damaging than chronic exposure.

A client is in the preoperative holding area waiting for cataract surgery. The client says "Oh, yeah, I forgot to tell you that I take clopidogrel, or Plavix." What action by the nurse is most important? a. Ask the client when the last dose was. b. Check results of the prothrombin time (PT) and international normalized ratio (INR). c. Document the information in the chart. d. Notify the surgeon immediately.

ANS: D Clopidogrel is an antiplatelet aggregate and could increase bleeding. The surgeon should be notified immediately. The nurse should find out when the last dose of the drug was, but the priority is to notify the provider. This drug is not monitored with PT and INR. Documentation should occur but is not the priority.

A nurse is irrigating a client's ear when the client becomes nauseated. What action by the nurse is most appropriate for client comfort? a. Have the client tilt the head back. b. Re-position the client on the other side. c. Slow the rate of the irrigation. d. Stop the irrigation immediately.

ANS: D During ear irrigation, if the client becomes nauseated, stop the procedure. The other options are not helpful.

A client is going on a cruise but has had motion sickness in the past. What suggestion does the nurse make to this client? a. Avoid alcohol on the cruise ship. b. Change positions slowly on the ship. c. Change your travel plans. d. Try scopolamine (Transderm Scop).

ANS: D Scopolamine can successfully treat the vertigo and dizziness associated with motion sickness. Avoiding alcohol and changing positions slowly are not effective. Telling the client to change travel plans is not a caring suggestion.

A client had a myringotomy. The nurse provides which discharge teaching? a. Buy dry shampoo to use for a week. b. Drink liquids through a straw. c. Flying is not allowed for 1 month. d. Hot water showers will help the pain.

ANS: A The client cannot shower or get the head wet for 1 week after surgery, so using dry shampoo is a good suggestion. The other instructions are incorrect: straws are not allowed for 2 to 3 weeks, flying is not allowed for 2 to 3 weeks, and the client should not shower.

A client's chart indicates anisocoria. For what should the nurse assess? a. Difference in pupil size b. Draining infection c. Recent eye trauma d. Tumor of the eyelid

ANS: A Anisocoria is a noticeable difference in the size of a person's pupils. This is a normal finding in a small percentage of the population. Infection, trauma, and tumors are not related.

The nurse has given a community group a presentation on eye health. Which statement by a participant indicates a need for more instruction? a. "I always lose my sunglasses, so I don't wear them." b. "I have diabetes and get an annual eye exam." c. "I will not share my contact solution with others." d. "I will wear safety glasses when I mow the lawn."

ANS: A Clients should be taught to protect their eyes from ultraviolet (UV) exposure by consistently wearing sunglasses when outdoors, when tanning in tanning salons, or when working with UV light. The other statements are correct.

A client presents to the emergency department reporting a foreign body in the eye. For what diagnostic testing should the nurse prepare the client? a. Corneal staining b. Fluorescein angiography c. Ophthalmoscopy d. Tonometry

ANS: A Corneal staining is used when the possibility of eye trauma exists, including a foreign body. Fluorescein angiography is used to assess problems of retinal circulation. Ophthalmoscopy looks at both internal and external eye structures. Tonometry tests the intraocular pressure.

The nurse reads on a client's chart that the client has exophthalmos. What assessment finding is consistent with this diagnosis? a. Bulging eyes b. Drooping eyelids c. Sunken-in eyes d. Yellow sclera

ANS: A Exophthalmos is bulging eyes. Drooping eyelids is ptosis. Sunken-in eyes is enophthalmos. Yellow sclera indicates jaundice.

A client does not understand why vision loss due to glaucoma is irreversible. What explanation by the nurse is best? a. "Because eye pressure was too high, the tissue died." b. "Glaucoma always leads to permanent blindness." c. "The traumatic damage to your eye was too great." d. "The infection occurs so quickly it can't be treated."

ANS: A Glaucoma is caused when the intraocular pressure becomes too high and stays high long enough to cause tissue ischemia and death. At that point, vision loss is permanent. Glaucoma does not have to cause blindness. Trauma can cause glaucoma but is not the most common cause. Glaucoma is not an infection.

A client has labyrinthitis and is prescribed antibiotics. What instruction by the nurse is most important for this client? a. Immediately report headache or stiff neck. b. Keep all follow-up appointments. c. Take the antibiotics with a full glass of water. d. Take the antibiotic on an empty stomach.

ANS: A Meningitis is a complication of labyrinthitis. The client should be taught to take all antibiotics as prescribed and to report manifestations of meningitis such as fever, headache, or stiff neck. Keeping follow-up appointments is important for all clients. Without knowing what antibiotic was prescribed, the nurse cannot instruct the client on how to take it.

A client is scheduled to have a tumor of the middle ear removed. What teaching topic is most important for the nurse to cover? a. Expecting hearing loss in the affected ear b. Managing postoperative pain c. Maintaining NPO status prior to surgery d. Understanding which medications are allowed the day of surgery

ANS: A Removal of an inner ear tumor will likely destroy hearing in the affected ear. The other teaching topics are appropriate for any surgical client.

A client hospitalized for a wound infection has a blood urea nitrogen of 45 mg/dL and creatinine of 4.2 mg/dL. What action by the nurse is best? a. Assess the ordered antibiotics for ototoxicity. b. Explain how kidney damage causes hearing loss. c. Use ibuprofen (Motrin) for pain control. d. Teach that hearing loss is temporary.

ANS: A Some medications are known to be ototoxic. Diminished kidney function slows the excretion of drugs from the body, worsening the ototoxic effects. The nurse should assess the antibiotics the client is receiving for ototoxicity. The other options are not warranted.

A client had proxymetacaine (Ocu-Caine) instilled in one eye in the emergency department. What discharge instruction is most important? a. Do not touch or rub the eye until it is no longer numb. b. Monitor the eye for any bleeding for the next day. c. Rinse the eye with warm saline solution at home. d. Use all the eyedrops as prescribed until they are gone.

ANS: A This drug is an ophthalmic anesthetic. The client can injure the numb eye by touching or rubbing it. Bleeding is not associated with this drug. The client should not be told to rinse the eye. This medication was given in the emergency department and is not prescribed for home use.

What is the provider assessing? a. Color vision b. Depth perception c. Spatial perception d. Visual acuity

ANS: A This is an Ishihara chart, which is used for assessing color vision. Depth and spatial perception are not typically assessed in a routine vision assessment. Visual acuity is usually tested with a Snellen chart.

A client has a foreign body in the eye. What action by the nurse takes priority? a. Administering ordered antibiotics b. Assessing the client's visual acuity c. Obtaining consent for enucleation d. Removing the object immediately

ANS: A To prevent infection, antibiotics are provided. Visual acuity in the affected eye cannot be assessed. The client may or may not need enucleation. The object is only removed by the ophthalmologist.

Why is the optic disc considered to be a blind spot? a. This area does not contain photoreceptors. b. Light rays are unable to focus on this location. c. Blood vessels form a meshwork and interfere with vision. d. This area is heavily pigmented and light rays are absorbed.

ANS: A The optic nerve enters the eyeball at this point and contains no photoreceptors.

The nurse is caring for a client with Ménière's disease. The client asks the nurse how to prevent another acute episode from occurring again. Which is the nurse's best response? a. "Stop or reduce cigarette smoking." b. "Use aspirin for pain rather than acetaminophen (Tylenol)." c. "Reduce the amount of saturated fats in your diet." d. "Avoid crowds and people with upper respiratory infections."

ANS: A The vasoconstrictive effects of cigarette smoking promote acute episodes of Ménière's disease. Aspirin and other nonsteroidal anti-inflammatory drugs (NSAIDs) can be ototoxic and should be avoided. Avoiding saturated fats and upper respiratory infections will not help prevent a recurrence of Ménière's disease.

The nurse is caring for a newly deaf client who is learning to read lips. Which client statement indicates that additional teaching is needed? a. "After I practice lip reading for a while, I won't need to worry about using sign language any more." b. "I will have a harder time lip reading when I am not familiar with the topic of the conversation." c. "Focusing so much on lip reading will make me tired, so I will try to keep conversations short." d. "I may not be able to lip read very well when the other person has a beard or there isn't enough light in the room."

ANS: A Usually, experienced lip readers cannot understand more than half of what is being said by the other person, so the client should not abandon sign language as a means of communication. The client will find it easier to lip read for short conversations at first. Poor lighting and facial hair make lip reading difficult.

A nurse has delegated applying a warm compress to a client's eye. What actions by the unlicensed assistive personnel (UAP) warrant intervention by the nurse? (Select all that apply.) a. Heating the wet washcloth in the microwave b. Holding the cloth on the client using an Ace wrap c. Turning the cloth so it remains warm on the client d. Using a clean washcloth for the compress e. Washing the hands on entering the client's room

ANS: A, B The washcloth should be warmed under running warm water. Microwaving it can lead to burns. Gentle pressure is used to hold the compress in place. The other actions are correct.

A client had cataract surgery. What instructions should the nurse provide? (Select all that apply.) a. Call the doctor for increased pain. b. Do not bend over from the waist. c. Do not lift more than 10 pounds. d. Sexual intercourse is allowed. e. Use stool softeners to avoid constipation.

ANS: A, B, C, E The client should be taught to call the physician for increased pain as this might indicate infection or other complication. To avoid increasing intraocular pressure, clients are taught to not lift more than 10 pounds, to avoid bending at the waist, to avoid straining at stool, and to avoid sexual intercourse for a time after surgery.

The nursing student learns that age-related changes affect the eyes and vision. Which changes does this include? (Select all that apply.) a. Decreased eye muscle tone b. Development of arcus senilis c. Increase in far point of near vision d. Decrease in general color perception e. Increase in point of near vision

ANS: A, B, D, E Normal age-related changes include decreased eye muscle tone, development of arcus senilis, decreased color perception, and increased point of near vision. The far point of near vision typically decreases.

A client is scheduled for a tympanoplasty. What actions by the nurse are most appropriate? (Select all that apply.) a. Administer preoperative antibiotics. b. Assess for allergies to local anesthetics. c. Ensure that informed consent is on the chart. d. Give ordered antivertigo medications. e. Teach that hearing improves immediately.

ANS: A, C Preoperatively, the nurse administers antibiotics and ensures that informed consent is on the chart. Local anesthetics can be used, but general anesthesia is used more often. Antivertigo medications are not used. Hearing will be decreased immediately after the operation until the ear packing is removed.

A client has a hearing aid. What care instructions does the nurse provide the unlicensed assistive personnel (UAP) in the care of this client? (Select all that apply.) a. Be careful not to drop the hearing aid when handling. b. Soak the hearing aid in hot water for 20 minutes. c. Turn the hearing aid off when the client goes to bed. d. Use a toothpick to clean debris from the device. e. Wash the device with soap and a small amount of warm water.

ANS: A, C, D, E All these actions except soaking the hearing aid are proper instructions for the nurse to give to the UAP. While some water is used to clean the hearing aid, excessive wetting should be avoided.

A nursing student studying the auditory system learns about the structures of the inner ear. What structures does this include? (Select all that apply.) a. Cochlea b. Epitympanum c. Organ of Corti d. Semicircular canals e. Vestibule

ANS: A, C, D, E The cochlea, organ of Corti, semicircular canals, and vestibule are all part of the inner ear. The epitympanum is in the middle ear.

The student learning about vision should remember which facts related to the eyes? (Select all that apply.) a. Aqueous humor controls intraocular pressure. b. Cones work in low light conditions. c. Glaucoma occurs due to increased pressure in the eye. d. Muscles of the iris control light entering the eye. e. Rods work in low light conditions.

ANS: A, C, D, E The inflow and outflow of aqueous humor controls the intraocular pressure. Glaucoma results when the pressure is chronically high. Muscles of the iris relax and constrict to control the amount of light entering the eye. Rods work in low light conditions. Cones work in bright light conditions

The nurse working in the ophthalmology clinic sees clients with eyelid and eye problems. What information should the nurse understand about these disorders? (Select all that apply.) a. A chalazion is an inflammation of an eyelid sebaceous gland. b. An ectropion is the eyelid turning inward. c. An entropion is the eyelid turning outward. d. A hordeolum is an infection of the eyelid sweat gland. e. Keratoconjunctivitis sicca is caused by drugs or diseases.

ANS: A, D, E A chalazion is an inflammation of one of the sebaceous glands in the eyelid. A hordeolum is an infection of a sweat gland in the eyelid. Keratoconjunctivitis sicca can be caused by drugs or diseases. An ectropion is an outward turning and sagging eyelid, while an entropion is an inward turning of the eyelid.

A nurse is seeing clients in the ophthalmology clinic. Which client should the nurse see first? a. Client with intraocular pressure reading of 24 mm Hg b. Client who has had cataract surgery and has worsening vision c. Client whose red reflex is absent on ophthalmologic examination d. Client with a tearing, reddened eye with exudate

ANS: B After cataract surgery, worsening vision indicates an infection or other complication. The nurse should see this client first. The intraocular pressure is slightly elevated. An absent red reflex may indicate cataracts. The client who has the tearing eye may have an infection.

A client is brought to the emergency department after a car crash. The client has a large piece of glass in the left eye. What action by the nurse takes priority? a. Administer a tetanus booster shot. b. Ensure the client has a patent airway. c. Prepare to irrigate the client's eye. d. Turn the client on the unaffected side.

ANS: B Airway always comes first. After ensuring a patent airway and providing cervical spine precautions (do not turn the client to the side), the nurse provides other care that may include administering a tetanus shot. The client's eye may or may not be irrigated

An older client has decided to give up driving due to cataracts. What assessment information is most important to collect? a. Family history of visual problems b. Feelings related to loss of driving c. Knowledge about surgical options d. Presence of family support

ANS: B Loss of driving is often associated with loss of independence, as is decreasing vision. The nurse should assess how the client feels about this decision and what its impact will be. Family history and knowledge about surgical options are not related as the client has made a decision to decline surgery. Family support is also useful information, but it is most important to get the client's perspective on this change.

The student nurse is performing a Weber tuning fork test. What technique is most appropriate? a. Holding the vibrating tuning fork 10 to 12 inches from the client's ear b. Placing the vibrating fork in the middle of the client's head c. Starting by placing the vibrating fork on the mastoid process d. Tapping the vibrating tuning fork against the bridge of the nose

ANS: B The Weber tuning fork test includes placing the vibrating tuning fork in the middle of the client's head and asking in which ear the client hears the vibrations louder. The other techniques are incorrect.

The nurse is administering eyedrops to a client with an infection in the right eye. The drops go in both eyes, and two different bottles are used to administer the drops. The nurse accidentally uses the left eye bottle for the right eye. What action by the nurse is best? a. Inform the provider of the issue. b. Obtain a new bottle of eyedrops. c. Rinse the client's right eye thoroughly. d. Wipe the left eye bottle with alcohol.

ANS: B The nurse has contaminated the "clean" bottle by using it on the infected eye. The nurse needs to obtain a new bottle of solution to use on the left eye. The other actions are not appropriate.

Which technique will the nurse use to assess the blink reflex in a client who is blind? a. Asking the client to blink first with one eye and then the other b. Expelling a syringe of air toward the client's eyes c. Shining a bright light at the client's pupils one at a time d. Suddenly bringing a finger toward the client's face

ANS: B A blind client cannot respond to visually threatening movements with a blink reflex. Air blowing suddenly at the eye should elicit the blink reflex as a protective response

A client is scheduled for a fluorescein angiography. Place the nurse's activities in order, from highest to lowest priority. a. Start an intravenous access. b. Instill mydriatic eyedrops. c. Teach about color changes. d. Have the consent form signed. e. Have the client drink fluids. f. Inject fluorescein dye. g. Have the client wear dark glasses. G, E, F, D, C, B, A D, B, A, F, E, G, C B, A, C, D, F, E, G A, B, C, D, E, F, G

ANS: B D, B, A, F, E, G, C Prior to starting the invasive procedure, an informed consent form must be signed. The mydriatic drops are then instilled 1 hour prior to the procedure. An IV is then inserted and the fluorescein dye injected. A series of photographs are taken. After the procedure, the client is instructed to drink plenty of fluids to aid with the excretion of the dye through the urine. The client is taught to wear dark glasses to prevent pain caused by the bright light until the mydriatic action of the drops has worn off. The client is also taught about the color changes of the skin, sclera, and urine. She or he should be reassured that these changes are only temporary.

Which finding leads the nurse to conclude that hearing aids would be helpful for a client with hearing loss? a. The client smoked two packs of cigarettes a day for 30 years. b. The client had chronic middle ear infections during childhood. c. The client reports constant tinnitus that becomes worse at night. d. The client worked as a security guard at rock concerts for 10 years.

ANS: B Hearing aids are most effective for clients with conductive hearing loss, rather than sensorineural hearing loss caused by smoking or loud noises. Tinnitus is associated with sensorineural rather than conductive hearing loss. Chronic ear infections are a significant risk factor for conductive hearing loss.

The nurse is caring for a client with otitis media. The client reports that the pain was severe during the night but was gone when he woke up in the morning. Which finding will the nurse expect to find during the client's physical assessment? a. The tympanic membrane is bluish-gray in color. b. Purulent fluid is present in the ear canal. c. The pinna and tragus are reddened and swollen. d. Sounds are lateralized toward the affected ear.

ANS: B Spontaneous perforation of the tympanic membrane during acute otitis media relieves the pressure on middle ear structures and results in a sudden decrease or elimination of pain. Purulent drainage is often present in the ear canal as the fluid drains away from the tympanic membrane. Bluish-gray coloring to the tympanic membrane indicates blood behind the eardrum. A reddened pinna and tragus indicate otitis externa. Lateralization of sounds toward the affected ear would not be expected.

Which client is at greatest risk for developing vision problems? a. A postpartum woman b. A young man who has diabetes mellitus c. A middle-aged adult who takes aspirin daily d. An older man with chronic dry eye syndrome

ANS: B The hyperglycemia that characterizes diabetes mellitus causes numerous vascular problems in the eye and damages the nerves. Although good control of blood glucose levels delays visual problems, it does not eliminate it in the diabetic population. Daily aspirin therapy does not place a client at risk for vision problems. Dry eye places a client at risk for irritation. However, it does not necessarily interfere with the client's vision.

The nurse is evaluating the client's technique for instilling eyedrops. Which behavior indicates that the client needs more teaching? a. The client closes his eye after the drops are in. b. The client touches his eye with the tip of the dropper. c. The client allows the drops to spread across the eye surface. d. The client gets the drops into the conjunctival pocket.

ANS: B Touching the eye with the tip of the dropper contaminates the dropper and the medication. If the client has an infection in the eye that is touched, the dropper cannot even be used on the client's other eye. The other answers indicate correct technique.

MULTIPLE RESPONSE A nurse is assessing the eye changes in an older adult. Which acute changes suggest the need for physician consultation? (Select all that apply.) a. Increasing difficulty perceiving greens, blues, and violets b. Increasing redness in eyes c. Arcus senilis d. Acute pain in the eyes e. Sudden change in acuity f. Need for additional lighting for reading g. Need to hold newspaper farther away to read

ANS: B, D, E Increasing redness, acute pain, and sudden changes in acuity represent manifestations that might be indicative of a more serious complication and need a physician's evaluation. Delay could cause harm. The other signs are associated with the aging process and do not require immediate evaluation.

A hospitalized client has Ménière's disease. What menu selections demonstrate good knowledge of the recommended diet for this disorder? (Select all that apply.) a. Chinese stir fry with vegetables b. Broiled chicken breast c. Chocolate espresso cookies d. Deli turkey sandwich and chips e. Green herbal tea with meals

ANS: B, E The diet recommendations for Ménière's disease include low-sodium, caffeine-free foods and fluids distributed evenly throughout the day. Plenty of water is also needed. The broiled chicken breast and herbal tea are the best selections. The stir fry is high in sodium and possibly monosodium glutamate (MSG, also not recommended). The cookies have caffeine, and the sandwich and chips are high in sodium.

The client's chart indicates a sensorineural hearing loss. What assessment question does the nurse ask to determine the possible cause? a. "Do you feel like something is in your ear?" b. "Do you have frequent ear infections?" c. "Have you been exposed to loud noises?" d. "Have you been told your ear bones don't move?"

ANS: C Sensorineural hearing loss can occur from damage to the cochlea, the eighth cranial nerve, or the brain. Exposure to loud music is one etiology. The other questions relate to conductive hearing loss.

A client has external otitis. On what comfort measure does the nurse instruct the client? a. Applying ice four times a day b. Instilling vinegar-and-water drops c. Use of a heating pad to the ear d. Using a home humidifier

ANS: C A heating pad on low or a warm moist pack can provide comfort to the client with otitis externa. The other options are not warranted.

A client with Ménière's disease is in the hospital when the client has an attack of this disorder. What action by the nurse takes priority? a. Assess vital signs every 15 minutes. b. Dim or turn off lights in the client's room. c. Place the client in bed with the upper siderails up. d. Provide a cool, wet cloth for the client's face.

ANS: C Clients with Ménière's disease can have vertigo so severe that they can fall. The nurse should assist the client into bed and put the siderails up to keep the client from falling out of bed due to the intense whirling feeling. The other actions are not warranted for clients with Ménière's disease.

The nurse works with clients who have hearing problems. Which action by a client best indicates goals for an important diagnosis have been met? a. Babysitting the grandchildren several times a week b. Having an adaptive hearing device for the television c. Being active in community events and volunteer work d. Responding agreeably to suggestions for adaptive devices

ANS: C Clients with hearing problems can become frustrated and withdrawn. The client who is actively engaged in the community shows the best evidence of psychosocial adjustment to hearing loss. Babysitting the grandchildren is a positive sign but does not indicate involvement outside the home. Having an adaptive device is not the same as using it, and watching TV without evidence of other activities can also indicate social isolation. Responding agreeably does not indicate the client will actually follow through.

A client has severe tinnitus that cannot be treated adequately. What action by the nurse is best? a. Advise the client to take antianxiety medication. b. Educate the client on nerve cutting procedures. c. Refer the client to online or local support groups. d. Teach the client side effects of furosemide (Lasix).

ANS: C If the client's tinnitus cannot be treated, he or she will have to learn to cope with it. Referring the client to tinnitus support groups can be helpful. The other options are not warranted.

A client's intraocular pressure (IOP) is 28 mm Hg. What action by the nurse is best? a. Educate the client on corneal transplantation. b. Facilitate scheduling the eye surgery. c. Plan to teach about drugs for glaucoma. d. Refer the client to local Braille classes.

ANS: C This increased IOP indicates glaucoma. The nurse's main responsibility is teaching the client about drug therapy. Corneal transplantation is not used in glaucoma. Eye surgery is not indicated at this time. Braille classes are also not indicated at this time.

A nurse who is applying eyedrops to a client holds pressure against the corner of the eye nearest the nose after instilling the drops. The client asks what the nurse is doing. What response by the nurse is best? a. "Doing this allows time for absorption." b. "I am keeping the drops in the eye." c. "This prevents systemic absorption." d. "I am stopping you from rubbing your eye."

ANS: C This technique, called punctal occlusion, prevents eyedrops from being absorbed systemically. The other answers are inaccurate.

A client who is near blind is admitted to the hospital. What action by the nurse is most important? a. Allow the client to feel his or her way around. b. Let the client arrange objects on the bedside table. c. Orient the client to the room using a focal point. d. Speak loudly and slowing when talking to the client.

ANS: C Using a focal point, orient the client to the room by giving descriptions of items as they relate to the focal point. Letting the client arrange the bedside table is a good idea, but not as important as orienting the client to the room for safety. Allowing the client to just feel around may cause injury. Unless the client is also hearing impaired, use a normal tone of voice.

The nurse is assessing extraocular eye movements (EOMs) in an older adult client and finds that the client is unable to sustain an upward gaze for more than 2 seconds. What will the nurse do next? a. Repeat the test while holding the client's head in a fixed position. b. Perform a cover-uncover eye test. c. Document the finding and continue assessing. d. Assess for additional signs of impending brain attack.

ANS: C In the older adult, decreased muscle tone impairs the ability to maintain an upward gaze and to sustain convergence. Therefore, this finding is normal for an older adult client. The nurse would document the finding and continue to assess. This would not be a cause for concern, nor would it be a symptom of impending brain attack.

Which finding confirms normal accommodation during visual assessment? a. Both pupils constrict when a light is shined at one eye. b. The client blinks in response to a threatening movement. c. Both of the client's pupils constrict when focusing on an object being moved in toward the nose. d. The client is able to hold an upward gaze without moving the head for 15 seconds.

ANS: C Normal accommodation is seen when the client's eyes converge. The pupils constrict when the client focuses on an object being moved from about 18 cm from the client's nose in closer toward the nose.

The nurse is caring for a client with otitis media and notes purulent drainage in the ear canal during the physical assessment. Which is the nurse's priority intervention? a. Obtaining a specimen of the drainage for culture b. Irrigating the ear canal with sterile normal saline c. Gently examining the client's ear with an otoscope d. Placing a cotton ball in the ear canal to absorb the drainage

ANS: C The nurse should use an otoscope to determine if the client's tympanic membrane has ruptured. Until the tympanic membrane is examined and found to be intact, syringing is not performed. A specimen is only obtained if the infection has failed to respond to standard antibiotic therapy. A cotton ball should not be placed in the ear canal to absorb the drainage.

A client is seen in the ophthalmology clinic with bacterial conjunctivitis. Which statements by the client indicate a good understanding of home management of this condition? (Select all that apply.) a. "As long as I don't wipe my eyes, I can share my towel." b. "Eye irrigations should be done with warm saline or water." c. "I will throw away all my eye makeup when I get home." d. "I won't touch the tip of the eyedrop bottle to my eye." e. "When the infection is gone, I can use my contacts again."

ANS: C, D Bacterial conjunctivitis is very contagious, and re-infection or cross-contamination between the client's eyes is possible. The client should discard all eye makeup being used at the time the infection started. When instilling eyedrops, the client must be careful not to contaminate the bottle by touching the tip to the eye or face. The client should be instructed not to share towels. Eye irrigations are not needed. Contacts being used when the infection first manifests also need to be discarded.

A client is taking timolol (Timoptic) eyedrops. The nurse assesses the client's pulse at 48 beats/min. What action by the nurse is the priority? a. Ask the client about excessive salivation. b. Assess the client for shortness of breath. c. Give the drops using punctal occlusion. d. Hold the eyedrops and notify the provider.

ANS: D The nurse should hold the eyedrops and notify the provider because beta blockers can slow the heart rate. Excessive salivation can occur with cholinergic agonists. Shortness of breath is not related. If the drops are given, the nurse uses punctal occlusion to avoid systemic absorption.

A nursing student is instructed to remove a client's ear packing and instill eardrops. What action by the student requires intervention by the registered nurse? a. Assessing the eardrum with an otoscope b. Inserting a cotton ball in the ear after the drops c. Warming the eardrops in water for 5 minutes d. Washing the hands and removing the packing

ANS: D The student should wash his or her hands, don gloves, and then remove the packing. The other actions are correct.

An adult client asks why she needs to get her intraocular pressure tested every year. What will the nurse tell the client? a. "There are many changes that can occur because of aging." b. "If the pressure is too low, you will be blind." c. "If the pressure is too high, blood will not flow through the eye." d. "Loss of vision can occur if the pressure is too high or too low."

ANS: D Although all the responses are correct, explaining the outcome of abnormal pressure is to the point and at the client's level of understanding, especially if she is anxious about the test.

When a person enters a dimly lit room, which type of vision is most keen? a. Central color vision b. Central black and white vision c. Peripheral color vision d. Peripheral black and white vision

ANS: D Rods, the photoreceptors that function at low levels of environmental light, are positioned within the retina to provide peripheral vision.

The nurse teaches a client's wife how to administer eardrops to the client. Which statement by the client's wife indicates that additional teaching is needed? a. "I will make sure that the eardrops are at room temperature before putting them into his ears." b. "I will wash my hands before and after giving my husband the eardrops." c. "After I put the eardrops in, I will gently tug on the outer ear to make sure that they go into the ear canal." d. "I will have my husband lay on his back with his chin up when I give him the eardrops."

ANS: D The client should be positioned on his side for administration of eardrops. Hands should be washed before and after administration of eardrops. Cold eardrops may cause vertigo and nystagmus. The client or his wife may give a gentle tug on the outer ear to ensure that the drop has gone into the ear canal.

A client with Meniere's disease is experiencing severe vertigo. Which instructions should the nurse give to the client to assist in controlling the vertigo? 1. Increase sodium in the diet. 2. Increase oral fluid intake to 3000 ml/day. 3. Avoid sudden head movements. 4. Lie still and watch TV for quiet activity.

Answer 3 The nurse instructs the client to make head slow movements to avoid vertigo sensations and worsening of the condition. Diet changes such as salt and fluid restrictions that reduce the endolymphatic fluid are sometimes prescribed. Lying still and watching TV will not reduce vertigo.

A client is prescribed an eye drop and eye ointment for the right eye. How should the nurse BEST administer the medications? 1. Administer the eye drop first, followed by the eye ointment. 2. Administer the eye ointment first, followed by the eye drop. 3. Administer the eye drop, wait 15 minutes and administer the eye ointment. 4. Administer the eye ointment, wait 15 minutes and administer the eye drop.

Answer: 1 When an eye drop and an eye ointment are scheduled to be given at the same time, the eye drop is given first. The instillation of 2 medications is separated by 3 to 5 minutes.

A patient's vision is tested with the Snellen chart. The results of the test are documented as 20/60. What action should the nurse implement based on this finding? 1. Inform the client of where he/she can purchas a white can. 2. Provide the client with materials on legal blindness. 3. Inform the client that it is best to sit near the back of the room when going to lectures or meetings. 4. Instruct the client that he/she may need glasses while driving.

Answer: 4 Vision that is normal is 20/20-the client is able to read from 20 feet what a person with normal vision can read from 20 feet. A client with a vision acuity of 20/60 can only read at a distance of 20 feet, what a person with normal vision can read at 60 feet. With this vision, the client may need glasses while driving in order to read signs and see far ahead. The client should be instructed to sit in front of the room for lectures to aid in vision. 20/60 is not considered legal blindness.

The nurse is preparing to administer eye drops. Which interventions should the nurse take to administer the drops? Select all that apply. 1. Wash hands 2. Put gloves on 3. Place drop in the conjunctival sac 4. Pull the lower lid down against the cheekbone 5. Instruct the patient to squeeze the eyes shut after instilling the eye drop 6. Instruct the patient to tilt the head forward, open the eyes and look down

Rationale: 1,2,3,4 To administer eye medications, the nurse should wash hands, apply gloves. The patient is instructed to tilt the head backward, open the eyes and look up. The nurse pulls the lower lid down against the cheekbone and holds the bottle like a pencil with the tip downward. Holding the bottle the nurse gently rests the wrist of the hand on the patient's cheek and squeezes the bottle gently to allow the drop to fall into the conjunctival sac. The patient is instructed to close the eyes gently and not to squeeze the eyes shut to prevent loss of medication.