IGNAT SPECIAL SENSES

19. A client comes to the emergency department with periorbital ecchymosis of the right eye. Which is the nurse's priority action? a. Apply an ice pack to the affected eye. b. Patch the eye to prevent eye movement. c. Assess the client's vision in both eyes. d. Irrigate the affected eye with normal saline.

ANS: A Ice will cause capillary vasoconstriction, thereby decreasing swelling and capillary oozing. Treatment with ice begins at the time of injury. Whenever the eye or surrounding tissue is injured, visual acuity is assessed next. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Safe and Effective Care Environment (Management of Care—Establishing Priorities) MSC: Integrated Process: Nursing Process (Implementation)

1. The nurse is caring for a 132-lb client with an ear infection who is to receive amoxicillin, 40 mg/kg/day in divided doses every 8 hours. The nurse will administer ____ mg/dose of amoxicillin to the client.

ANS: 800 132 lb ´ (1 kg/2.2 lb) = 60 kg 60 kg ´ (40 mg/day) = 2400 mg/day)/3 = 800 mg/dose DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies—Dosage Calculation) MSC: Integrated Process: Nursing Process (Implementation)

1. A client is being taught how to safely irrigate ears to remove cerumen. What is the correct order of self-ear irrigation? (Separate letters by a comma and space as follows: a, b, c, d.) a. Fill the syringe with lukewarm water. b. Hold the head at a 30-degree angle. c. Insert the tip of the syringe carefully into the ear canal and aim toward the canal roof. d. Tilt the head at a 90-degree angle to remove excess fluid. e. Use one hand to hold the syringe and the other to push the plunger. f. Repeat the procedure on the opposite ear. g. Continue the procedure until at least a cup of fluid has flowed into and out of the ear. h. The ear should fill with fluid and the water will flow out with cerumen.

ANS: a, c, b, e, g, h, d, f Safe irrigation of the ear promotes cerumen removal without the use of penetrating objects. Warm water through the irrigating syringe will soften the cerumen, and the angle of the head will allow the cerumen to flow out of the ear. The order of the irrigation is important for safe removal of cerumen. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Health Promotion and Maintenance (Self-Care) MSC: Integrated Process: Teaching/Learning

1. A client has an eye prosthesis and needs to have it inserted into the eye socket. Place the following steps of how to insert an eye prosthesis in the correct order. (Select in order of priority.) a. Wash your hands. b. Explain the procedure to the client. c. Remove the prosthesis from its container and rinse it with tepid water. d. Cover the work area with a cloth or towel. e. Don gloves. f. Place the prosthesis between the thumb and forefinger of your dominant hand with the notched end of the prosthesis closest to the client's nose. g. Insert the prosthesis with the top edge slipping under the upper lid. h. Lift the client's upper lid using your nondominant hand. i. Retract the lower lid slightly until the bottom edge of the prosthesis slips behind it. j. Release your hand slowly. k. Gently release the upper eyelid.

ANS: b, a, d, e, c, h, f, g, k, i, j The proper procedure for inserting an eye prosthesis is to explain the procedure, wash hands, prepare your work area with a cloth or towel, apply gloves, remove the prosthesis from its container and rinse it, use your nondominant hand to open the client's upper eyelid, hold the prosthesis properly, insert the prosthesis with the top edge slipping under the lid, release the lid, retract the lower lid until the prosthesis slides into place behind the lower lid, and take your hand away slowly. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Safe and Effective Care Environment (Safety and Infection Control—Accident/Injury Prevention) MSC: Integrated Process: Nursing Process (Implementation)

2. A client is scheduled for a fluorescein angiography. Place the nurse's activities in order, from highest to lowest priority. (Separate letters by a comma and space as follows: a, b, c, d.) a. Start an intravenous access. b. Instill mydriatic eyedrops. c. Have the consent form signed. d. Have the client drink fluids. e. Inject fluorescein dye. f. Have the client wear dark glasses.

ANS: c, b, a, e, d, f Before the invasive procedure is started, an informed consent form must be signed. The mydriatic drops are then instilled 1 hour before the procedure. An IV is 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 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. DIF: Cognitive Level: Comprehension/Understanding REF: p. 1050 TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Diagnostic Tests) MSC: Integrated Process: Nursing Process (Implementation)

1. The nurse is instilling eardrops into a client's ear. Place the following in order according to best practice. (Separate letters by a comma and space as follows: a, b, c, d.) a. Ask the client to move the head gently back and forth five times. b. Wash your hands. c. Wear gloves to remove any packing from the ear. d. Perform an otoscopic examination to see if the eardrum is intact. e. Irrigate the ear if needed to remove cerumen. f. Tilt the client's head in the opposite direction of the affected ear and place the drops in the affected ear. g. Warm the bottle of eardrops in a bowl of warm water for 5 minutes. h. Wash your hands again. i. Insert a ball of cotton in the ear as packing.

ANS: c, b, d, e, g, f, a, i, h The correct sequence for performing this action is as follows: Remove any existing packing from the client's ear while wearing gloves, wash your hands, check the eardrum with an otoscope to ensure that it is intact, irrigate the ear if needed, warm the eardrops, tilt the client's head opposite the affected ear and instill the drops, ask the client to move his or her head back and forth five times, insert a cotton ball in the ear, and finally wash your hands again. DIF: Cognitive Level: Comprehension/Understanding REF: Chart 51-1, p. 1089 TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies—Medication Administration) MSC: Integrated Process: Nursing Process (Intervention) COMPLETION

1. The nurse is administering ophthalmic drops to a client with an eye infection. Put the following nursing interventions in order, from first to last. (Separate letters by a comma and space as follows: a, b, c, d.) a. Recheck the five Rs and the expiration date of the drug. b. Put on gloves. c. Have the client tilt the head backward. d. Wash your hands. e. Pull the lower eyelid downward and instill the medication into the conjunctival sac. f. Instruct the client to close the eyes gently without squeezing the eyelids together.

ANS: d, b, a, c, e, f Medication checking of the five Rs the first time is always the first step, followed by handwashing and gloving because of the risk for secretions. Rechecking the five Rs right before giving the medication, which is actually the third time that the five Rs are checked, is critical for maintaining safety. The nurse has the client tilt the head back, prepare the eye, give the drug, and have the client gently close the eye. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies—Medication Administration) MSC: Integrated Process: Nursing Process (Implementation)

17. In the emergency department, the nurse is caring for a client diagnosed with a hyphema. Which statement by the client indicates a need for further teaching? a. "When I get home, I can lie flat in bed and turn from side to side." b. "For a few days, I cannot even read a book or watch television." c. "I will need to protect the eye with a patch and shield." d. "I need to stay on bedrest and will try not to make any sudden movement."

ANS: A A hyphema is a hemorrhage in the anterior chamber of the eye due to blunt force such as a motor vehicle accident. For management of this condition, the client must be on bedrest but must remain in a semi-Fowler's position to prevent accumulation of blood around the optical center of the cornea. The client cannot lie flat in bed and rotate from side to side. The client cannot read a book or watch television and must protect the eye if paralytic eyedrops were used. The client needs to be as still as possible to prevent further bleeding. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Safe and Effective Care Environment (Safety and Infection Control—Home Safety) MSC: Integrated Process: Teaching/Learning

10. During assessment, the nurse notes that a client's right pupil is 2 mm larger than the left pupil. Which is the nurse's first action? a. Ask the client how long this condition has been present. b. Attempt to elicit a red reflex in both eyes. c. Document the finding as the only action. d. Identify the medications that the client is taking.

ANS: A Although both pupils are normally the same size and a difference in size can indicate various pathologies, approximately 5% of people have a noticeable difference in the size of their pupils. The nurse should first determine whether this condition represents a change or has been present for a long time. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Health Promotion and Maintenance (Health Screening) MSC: Integrated Process: Nursing Process (Assessment)

5. A client with a ruptured tympanic membrane asks the nurse whether hearing will be affected permanently. Which is the nurse's best response? a. "Possibly. The eardrum usually heals in 1 to 2 weeks. Any persistent hearing problem should be evaluated." b. "No. Antibiotics will help resolve the infection and cure your hearing impairment." c. "Yes. It will be important for you to be fitted with a hearing aid as soon as possible." d. "Yes. Any time the eardrum is ruptured it will form a scar, which will cause some degree of permanent hearing loss."

ANS: A An uncomplicated rupture of the tympanic membrane usually heals spontaneously within 1 to 2 weeks and does not result in a permanent hearing impairment. Antibiotics may not be effective in restoring hearing fully. Hearing aids may be prescribed for the client only if hearing loss is determined to be permanent. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Alterations in Body Systems) MSC: Integrated Process: Teaching/Learning

5. The nurse is caring for a client who will undergo electronystagmography testing the following day. Which instruction does the nurse provide for the client? a. "You should drink only caffeine-free beverages the day of and the day before the test." b. "Do not chew gum or clean your ears for 24 hours after the test is completed." c. "You may feel flushed as the contrast dye is injected through your IV for the test." d. "You will be sedated for the test, so you need someone to drive you home."

ANS: A Caffeinated drinks may interfere with the test results, so the client should be sure to drink only decaffeinated beverages during the 24 to 48 hours before the test. Clients may chew gum or clean their ears after the test, if desired. Neither IV contrast nor sedation is used for the test. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiologic Integrity (Reduction of Risk Potential—Diagnostic Tests) MSC: Integrated Process: Teaching/Learning

12. Several clients come to the emergency department following an accident. Which client does the nurse assess first? a. Client with clear watery drainage from the ear canals b. Client who reports tinnitus and pain in the right ear c. Client with a deep, 1-inch laceration to the pinna d. Client who has had severe difficulty hearing since the accident

ANS: A Clear watery drainage from the ears following trauma suggests a basal skull fracture and should be assessed immediately. Tinnitus and pain, lacerations, and hearing loss all may be assessed by the nurse in a timely manner, after the possible skull fracture. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—System-Specific Assessments) MSC: Integrated Process: Nursing Process (Assessment)

11. The nurse is assessing a client who wishes to be considered as a potential donor for corneal transplantation. Which medical diagnosis at the time of death excludes the client from consideration? a. Small cell lung cancer b. Chronic heart failure c. Profound nearsightedness d. History of detached retina

ANS: A Clients of any age may donate corneas as long as the corneas are clear and the client is free from infectious disease or cancer at the time of death. The other problems would not keep a client from donating corneas. DIF: Cognitive Level: Comprehension/Understanding REF: p. 1059 TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications from Surgical Procedures and Health Alterations) MSC: Integrated Process: Nursing Process (Assessment)

16. Which recommendation does the nurse provide for the client with Ménière's disease who has periodic spells of vertigo? a. "Avoid wearing high-heeled shoes." b. "Put brightly colored rugs on the floor for visibility." c. "Step on a sturdy chair to get items from high shelves." d. "Wait to drive a car until after you have taken your Benadryl."

ANS: A Clients with vertigo should wear low-heeled shoes with nonskid soles and tied laces to prevent injury. Brightly colored rugs would not help with safety concerns, especially if the rugs were throw rugs. Clients should use a stepstool with arms to reach items from high shelves, not just a sturdy chair. Diphenhydramine hydrochloride (Benadryl) may cause drowsiness, and clients should not drive after taking it. DIF: Cognitive Level: Comprehension/Understanding REF: p. 1095 TOP: Client Needs Category: Safe and Effective Care Environment (Safety and Infection Control—Home Safety) MSC: Integrated Process: Teaching/Learning

5. A client has paralysis of the right medial rectus muscle of the right eye. Which assessment finding assists the nurse in validating this diagnosis? a. Client is unable to turn the eye in toward the nose. b. Client is unable to lift the upper eyelid. c. Client cannot look downward. d. Client cannot look upward.

ANS: A Contraction of the medial rectus muscle turns the eye toward the nose. The superior oblique muscle pulls the eye downward, and the inferior oblique muscle pulls the eye upward. The ocular muscles do not lift the upper eyelid. DIF: Cognitive Level: Comprehension/Understanding REF: Table 48.1, p.1042 TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology) MSC: Integrated Process: Nursing Process (Assessment)

2. Which is the most important information for the nurse to teach a client who is receiving cycloplegic drug therapy? a. "Do not drive or operate machinery until the drug wears off." b. "Use at least a 30 SPF sunscreen agent when going outdoors." c. "Remain on bedrest for 24 hours in a prone position." d. "Turn up the lights because acuity will be decreased in low-light environments."

ANS: A Cycloplegic agents prevent accommodation of the iris, resulting in a widely dilated pupil. The pupil cannot accommodate to bright light, causing eye discomfort and pain. Turning up the lights will not assist the client to see more clearly. Bedrest and sunscreen are not measures needed for this drug. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Health Promotion and Maintenance (Self-Care) MSC: Integrated Process: Teaching/Learning

2. The nurse is performing an ear assessment on an older adult. Which assessment finding does the nurse document in the client's chart as an expected age-related change? a. Coarse hair is seen in the auditory canal. b. Tympanic membrane is intact and bulging. c. Impacted cerumen is present in the auditory canal. d. Small, painless nodules are noted on the helix of the pinna.

ANS: A Growth of coarse hair in the auditory canal occurs in some older men and women. It does not interfere with hearing and is considered a normal variation related to aging; it would be considered abnormal in a younger adult. Bulging tympanic membranes, impacted cerumen, and pinna nodules are not expected findings in the older adult. DIF: Cognitive Level: Comprehension/Understanding REF: Chart 50-1, p. 1082 TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—System-Specific Assessments) MSC: Integrated Process: Nursing Process (Assessment)

13. A client is being discharged after a tympanoplasty. Which instruction about cephalexin (Keflex) does the nurse provide to this client? a. "Be sure to finish all the Keflex pills, even if you feel fine." b. "The Keflex may turn your urine an orange color while you are taking it." c. "Take the Keflex on an empty stomach and stay upright for 30 minutes afterward." d. "Use sunscreen and avoid exposure to sunlight while you are taking Keflex."

ANS: A Keflex is an antibiotic. Clients should be sure to take the entire course of therapy to prevent the development of infection with resistant microorganisms. Keflex will not turn the urine orange and may be taken on an empty stomach. Keflex will not cause sun sensitivity. The client does not need to stay in an upright position after taking Keflex. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies—Medication Administration) MSC: Integrated Process: Teaching/Learning

20. The nurse is caring for an older client whose ear canals are impacted with hard cerumen. Which action by the nurse is best to remove the cerumen? a. Instruct the client to put a few drops of mineral oil into each ear every evening and to schedule the irrigation for 3 days later. b. Aim the irrigation fluid directly at the center of the cerumen to facilitate dissolving the impaction. c. Administer 10 mg of prochlorperazine (Compazine) to prevent nausea during irrigation of the ears. d. Irrigate the ears with 35 to 40 mL of sterile normal saline and repeat as needed until the cerumen is cleared.

ANS: A Softening hard cerumen with mineral oil for 3 days before irrigation will facilitate removal from the ear canal. Irrigation fluid should be aimed at the side of the impacted cerumen to facilitate removal. Administration of prochlorperazine before irrigation is not recommended. Normal saline need not be sterile for ear irrigation. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Basic Care and Comfort—Personal Hygiene) MSC: Integrated Process: Nursing Process (Implementation) MULTIPLE RESPONSE

14. A client is scheduled for a caloric test to evaluate the vestibular portion of the inner ear. Which statement by the client leads the nurse to conclude that more teaching is necessary? a. "I can eat a hearty breakfast before the procedure." b. "I will have to stay in bed after the procedure to prevent nausea." c. "Warm water will be infused into my affected ear." d. "I may experience dizziness after the water is inserted."

ANS: A The client usually is asked to fast for several hours before the caloric test. A hearty breakfast is not a good idea because nausea and vomiting is a common reaction following the test. Fasting will lower the risk of aspiration. The other responses demonstrate adequate knowledge of this procedure and its follow-up care. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiologic Integrity (Reduction of Risk Potential—Diagnostic Tests) MSC: Integrated Process: Nursing Process (Evaluation) MULTIPLE RESPONSE

1. 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 other responses are incorrect. DIF: Cognitive Level: Knowledge/Remembering REF: p. 1040 TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology) MSC: Integrated Process: Nursing Process (Assessment)

10. The nurse notes reddened areas behind both ears. What does the nurse ask the client? a. "Do you wear eyeglasses?" b. "Do you have any allergies?" c. "Do you use dandruff shampoo?" d. "Have you been around anyone with lice?

ANS: A The presence of reddened areas behind both ears strongly suggests constant pressure, such as that incurred from wearing eyeglasses or sunglasses. Dandruff shampoo, allergies, and lice would not cause reddened areas only behind the ears. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—System-Specific Assessments) MSC: Integrated Process: Nursing Process (Assessment)

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

ANS: A The vasoconstrictive effects of cigarette smoking promote acute episodes of Ménière's disease. Aspirin and other NSAIDs can be ototoxic and should be avoided. Avoiding saturated fats and people with upper respiratory infection will not help prevent a recurrence of Ménière's disease. A hydrops diet may stabilize body fluid levels to prevent excess endolymph accumulation. DIF: Cognitive Level: Comprehension/Understanding REF: p. 1096 TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Illness Management) MSC: Integrated Process: Teaching/Learning

4. The nurse performs an assessment of a client's extraocular movement and notes no difficulty. Which additional assessment data assist in confirming this finding? a. No episodes of double vision b. Synchronized blinking movements c. No reports of headaches and dizziness d. Both pupils constricting equally in response to light

ANS: A The voluntary muscles of the orbit rotate the eye and coordinate eye movements to ensure that the retina of each eye receives an image at the same time, so that only a single image is perceived. If the client has reported double vision, this would indicate a problem with this coordination. The other answers are not related to extraocular eye movements. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Health Promotion and Maintenance (Health Screening) MSC: Integrated Process: Nursing Process (Assessment)

15. The nurse is providing discharge teaching for a client with posterior uveitis. Which is the most important precaution for the nurse to teach the client? a. Correct technique for eyedrop instillation b. Clinical manifestations of retinal hemorrhage c. Correct technique for insertion of contact lenses d. Proper timing of opioid analgesics

ANS: A Treatment of posterior uveitis is symptomatic, with eyedrops used to dilate the pupil and decrease the inflammatory response. The client may have to instill eyedrops as frequently as every hour. This condition consists of inflammation of the retina—not a hemorrhage. Opioids are not prescribed to lessen the pain, but cool or warm compresses may be used for ocular pain. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Health Promotion and Maintenance (Self-Care) MSC: Integrated Process: Teaching/Learning

12. 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 anymore." 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 when light in the room is inadequate."

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. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Psychosocial Integrity (Sensory/Perceptual Alterations) MSC: Integrated Process: Nursing Process (Evaluation)

2. Which client statement indicates that the client understands teaching about stapedectomy surgery? (Select all that apply.) a. "My hearing will get worse before it gets better." b. "I will have to miss 6 weeks of swim team practice." c. "I will see the doctor 1 week after surgery to have my stitches removed." d. "Foods may taste funny for a short time after surgery." e. "I may get dizzy and feel like the room is spinning after surgery." f. "I can blow my nose to relieve the feeling of fullness in my ear after surgery."

ANS: A, B, D, E Postoperative swelling and packing in the ear will result in reduced hearing ability for the first few weeks after surgery. When the swelling subsides and the packing is removed, hearing will improve. The client should not get water in the ear for the first 6 weeks after surgery. Damage to or swelling of the facial nerve may result in postoperative loss of taste sensation. Vertigo is common after stapedectomy because of close proximity to inner ear structures. Blowing the nose should be avoided to prevent increased pressure within the ear. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications from Surgical Procedures and Health Alterations) MSC: Integrated Process: Nursing Process (Evaluation)

1. Which of the nurse's assessment findings will require collaboration with the client's primary health care provider? (Select all that apply.) a. Purulent drainage from the ear canal b. Hearing loss with nausea and vertigo c. Ringing in the ears after attending a loud rock concert d. Presence of cerumen blocking 50% of the ear canal e. Increasing hearing loss since starting furosemide (Lasix) f. Temperature of 101.7° F following a stapedectomy 3 days ago

ANS: A, B, E, F Purulent drainage in the ear canal indicates a middle ear infection with a ruptured tympanic membrane. Hearing loss with vertigo and nausea indicates labyrinthitis. Furosemide is ototoxic. Fever following stapedectomy is most likely caused by infection inside the ear. Ringing in the ears following exposure to loud noise is a common symptom, which should resolve spontaneously. Nonimpacted cerumen may be left alone if it is not impairing the client's hearing. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Alterations in Body Systems) MSC: Integrated Process: Nursing Process (Assessment)

2. Which statements by a client alert the nurse that the client may have some psychosocial issues with impaired hearing? (Select all that apply.) a. "I get so angry when I cannot hear what my daughter says." b. "When I use my hearing aids, I hear the choir so clearly." c. "I don't mind sitting in my chair all day long and not playing bingo." d. "My family never seems to visit anymore because their voices all seem so distant." e. "No one asks my opinion because I cannot hear their question." f. "My grandchildren do not think that I am funny anymore because I cannot hear their jokes."

ANS: A, C, D, E, F The client may become angry, frustrated, and depressed by an inability to hear and may respond appropriately. The inability to hear often isolates the client from the world, as depicted by sitting in a chair all day long, the perception of the family being distant, and no one asking for an opinion or joking around. The nurse must be sensitive to the depression resulting from the sensory isolation of hearing loss. If hearing aids are working so that the client can clearly hear a choir, psychosocial issues may be less of a problem. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Psychosocial Integrity (Grief and Loss) MSC: Integrated Process: Nursing Process (Assessment) OTHER

2. The nurse is teaching a postoperative client who had a keratoplasty. Which responses by the client require further teaching about safety in the home? (Select all that apply.) a. "We use throw rugs in the bathroom." b. "Our neighbors will be bringing food for a week." c. "We may have two extension cords in the living room." d. "Most of the furniture is placed against the wall, except for one rocking chair." e. "Every room has at least one window." f. "The hallway has low lighting."

ANS: A, C, D, F Throw rugs pose a danger of slipping or tripping. The client cannot see if the rug is flat or elevated. Extension cords should be placed under or behind the furniture to decrease the possibility of tripping. Furniture should be out of the normal walking pathway. Low lighting in the hallway may pose a problem when the client has a patch and shield over the operated eye. Lighting from a window should not be a problem. When neighbors bring food, the chance of burns occurring while cooking with limited vision is reduced. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Health Promotion and Maintenance (Self-Care) MSC: Integrated Process: Nursing Process (Evaluation)

11. The nurse is assessing several clients with hearing loss. Which client does the nurse recommend should investigate hearing aids? a. Client who has smoked two packs of cigarettes a day for 30 years b. Client who had chronic middle ear infections during childhood c. Client with constant tinnitus that becomes worse at night d. Client who 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. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Health Promotion and Maintenance (Health and Wellness) MSC: Integrated Process: Nursing Process (Assessment)

1. The nurse is caring for an older client who presents with dizziness and difficulty hearing. Which of the nurse's assessment findings will require collaboration with the client's primary health care provider? (Select all that apply.) a. Tympanic membrane is retracted, with multiple air bubbles. b. The client reports inability to hear high-frequency voices and sounds. c. Clear watery drainage is present in the ear canal and is positive for glucose. d. Tympanic membrane is shiny and translucent, with light reflex noted. e. Hearing test indicates positive Rinne test, with AC > BC noted bilaterally. f. The client reports dizziness after taking naproxen (Aleve) for arthritis pain.

ANS: A, C, F Aleve can cause ototoxicity, which can present as dizziness. Retraction of the tympanic membrane with air bubbles indicates an ear infection, which may be treated with antibiotics. Clear, watery, glucose-positive drainage from the ear canal suggests a basal skull fracture. An inability to hear high-frequency voices and sounds are commonly found in older adults as normal age-related changes. A shiny, translucent, tympanic membrane with a light reflex is a normal assessment finding, as is a positive Rinne test with AC > BC noted bilaterally. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Alterations in Body Systems) MSC: Integrated Process: Nursing Process (Assessment)

11. The nurse is assessing the blink reflex in a client who is blind. Which is the best technique to use? a. Ask the client to blink first with one eye and then with the other. b. Expel a syringe of air toward the client's eyes. c. Shine a bright light at the client's pupils one at a time. d. Suddenly bring a finger toward the client's face.

ANS: B A blind client cannot respond with a blink reflex to visually threatening movements such as bright light or bringing a finger toward the client. Air blowing suddenly at the eye should elicit the blink reflex as a protective response. Asking the client to blink first with one eye and then with the other will not elicit the blink reflex. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—System-Specific Assessments) MSC: Integrated Process: Nursing Process (Assessment)

6. A client is recovering from cataract surgery and needs medication to prevent a potential eye infection. Which drug does the nurse question administering to the client? a. Tobramycin (Tobrex) b. Apraclonidine (Iopidine) c. Gentamicin (Genoptic) d. Ciprofloxacin (Ciloxan)

ANS: B Apraclonidine is an adrenergic agonist that binds to eye receptors to reduce the amount of aqueous humor in the eye, resulting in decreased intraocular pressure. This medication usually is administered to clients with glaucoma. Tobramycin, gentamicin, and ciprofloxacin are anti-infectives. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies—Expected Actions/Outcomes) MSC: Integrated Process: Nursing Process (Implementation)

4. Which statement indicates that the client understands teaching about the use of aspirin post-cataract surgery? a. "It may increase intraocular pressure after cataract surgery." b. "It changes the ability of the blood to clot and increases the risk of bleeding." c. "It reduces inflammation and might mask any symptoms of infection." d. "It can cause nausea and vomiting and may increase intraocular pressure."

ANS: B Aspirin disrupts platelet aggregation and increases the risk for bleeding after surgery. Aspirin may decrease inflammation but would not mask symptoms of infection. Aspirin does not cause increased intraocular pressure, nor does it typically cause nausea and vomiting. Aspirin should not mask signs of infection. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies—Adverse Effects/Contraindications/Side Effects/Interactions) MSC: Integrated Process: Nursing Process (Evaluation)

21. The nurse is assessing a client's eyes. Which is the first step for the nurse in this procedure? a. Explain the procedure. b. Wash the hands. c. Assess for infections. d. Use the Snellen chart.

ANS: B Before examining a client's eyes, the examiner should wash his or her hands. This is done to prevent contamination of the eye and structures. The nurse could then proceed to explain any procedure, assess infection, or assess visual acuity using the Snellen chart. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Safe and Effective Care Environment (Safety and Infection Control—Standard Precautions/Transmission-Based Precautions/Surgical Asepsis) MSC: Integrated Process: Nursing Process (Implementation)

7. When performing a client's physical assessment, the nurse notes that the client has conductive hearing loss. Which finding does the nurse expect to see in the client's medical history? a. History of diabetes with peripheral neuropathy b. Frequent episodes of otitis media during childhood c. History of frequent impactions of cerumen in the ear canals d. History of osteomyelitis treated with IV gentamicin (Garamycin)

ANS: B Chronic middle ear infections can thicken the tympanic membrane, leading to conductive hearing loss. Gentamicin and diabetes mellitus damage the eighth cranial nerve and cause sensorineural hearing loss. Cerumen impaction results in temporary conduction hearing loss. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Alterations in Body Systems) MSC: Integrated Process: Nursing Process (Assessment)

2. The nurse is caring for a client with a furuncle on the pinna at the opening of the ear canal. The nurse is reviewing home care instructions with the client. Which statement by the client indicates that additional teaching is needed? a. "I will put the bacitracin ointment on the sore three times a day." b. "I will gently squeeze the sore to drain the liquid out once a day." c. "I will take Tylenol (acetaminophen) if my ear starts to hurt a lot." d. "I will put a warm compress on the sore for 15 minutes three times a day."

ANS: B Compressing or squeezing the furuncle can traumatize tissues and can force infective material deeper into the tissue layers, spreading the infection. Tylenol may be taken to reduce pain, and a warm compress will facilitate drainage and healing of the furuncle. Bacitracin ointment is an anti-infective and will help clear the infection. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Illness Management) MSC: Integrated Process: Nursing Process (Evaluation)

18. A teenager is admitted to the emergency department with a possible fracture of the left orbit after getting hit in the face with a baseball. All tests are negative and the client is being discharged. Which is important for the nurse to teach the client? a. "Keep an eye patch on the eye for 48 hours." b. "Always wear protective equipment to prevent eye damage." c. "Take aspirin if a headache should occur." d. "Do not do any heavy lifting for a week."

ANS: B If all tests are negative, restrictions on heavy lifting are not needed. An eye patch does not have to be worn. Acetaminophen (Tylenol) would be a better choice for a headache because aspirin promotes bleeding. The client and the family should be taught about protective equipment while playing sports (helmet and goggles). DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Health Promotion and Maintenance (Principles of Teaching/Learning) MSC: Integrated Process: Teaching/Learning

20. The nurse is teaching a client how to apply eye medication. Which is the correct technique for applying ointment into the eye? a. From the middle out b. From the inner canthus to the outer canthus c. From the outer canthus to the inner canthus d. Against the inner aspect of the eyelid

ANS: B Ointment should be applied by pulling down the lower lid and forming a pocket. Application should proceed from the inner canthus toward the outer canthus, with the client tilting the head backward and looking up at the ceiling. DIF: Cognitive Level: Knowledge/Remembering REF: Chart 49-1, p. 1053 TOP: Client Needs Category: Safe and Effective Care Environment (Safety and Infection Control—Standard Precautions/Transmission-Based Precautions/Surgical Asepsis) MSC: Integrated Process: Nursing Process (Implementation)

12. The nurse assesses several clients. Which one is most likely to have secondary open-angle glaucoma? a. Client with gradual onset of blurred vision b. Client who has recently had eye surgery c. Client who sees halos around lights d. Client with reactive pupils and clear sclera

ANS: B Secondary open-angle glaucoma results from another condition that interferes with drainage of the aqueous humor such as recent eye surgery. Cataracts usually start with a slow onset of blurred vision but do not lead to secondary open-angle glaucoma. A late manifestation of primary open-angle glaucoma is seeing halos around lights; this is not considered secondary open-angle glaucoma. The client with reactive pupils and clear sclera has normal assessment findings, not related to secondary open-angle glaucoma. DIF: Cognitive Level: Comprehension/Understanding REF: Table 49-3, p. 1063 TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology) MSC: Integrated Process: Nursing Process (Evaluation)

3. The nurse is caring for a client with otitis media. The client reports that the pain was severe during the night but was gone upon awakening in the morning. Which finding does the nurse expect to observe during the client's physical assessment? a. The tympanic membrane is bluish-gray. b. Purulent fluid is present in the ear canal. c. The pinna and the 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 in 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 of 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. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology) MSC: Integrated Process: Nursing Process (Assessment)

20. A client is told that he has 20/10 vision when tested on the Snellen chart. How does the nurse explain this finding to the client? a. "You can read at 10 feet what others can read at 20 feet." b. "You can read at 20 feet what others can read at 10 feet." c. "This demonstrates normal vision." d. "You are considered legally blind."

ANS: B The "20" is the point at which the client can see from the chart, and the "10" is the point at which a healthy eye can see from the chart. Normal vision is 20/20. DIF: Cognitive Level: Comprehension/Understanding REF: p. 1046 TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Diagnostic Tests) MSC: Integrated Process: Nursing Process (Assessment)

3. Which teaching is essential for a client who is going to have intraocular pressure measurement with a slit lamp? a. "The test causes temporary blindness." b. "The test is quick and a local anesthetic is used." c. "The test does cause a little pain, but it is over quickly." d. "The test causes some tearing, but no pain."

ANS: B The IOP test done with a slit lamp must have direct eye contact, which could cause discomfort, so a local anesthetic is used. The test is quick but does not cause temporary blindness. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Health Promotion and Maintenance (Health Screening) MSC: Integrated Process: Teaching/Learning

1. The nurse notes that a client's tympanic membrane moves in response to air injected into the external canal. What is the nurse's best action? a. Notify the health care provider. b. Document the finding. c. Prepare to wash the external ear canal. d. Immediately remove the otoscope.

ANS: B The healthy ear should have a tympanic membrane that is mobile when air is injected into the external canal. This normal finding should be documented in the client's chart. Because the mobile tympanic membrane is an expected finding, the nurse does not need to remove the otoscope immediately from the client's ear canal. No cerumen is impacting the ear canal, so irrigation is not appropriate. The physician does not need to be notified about a normal finding. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—System-Specific Assessments) MSC: Integrated Process: Nursing Process (Assessment)

8. The nurse is performing vision screenings. Which client is at greatest risk for developing vision problems? a. Postpartum woman with no complications b. Young client who has diabetes mellitus c. Middle-aged adult who takes aspirin daily d. Older client 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 these problems in the diabetic population. Daily aspirin therapy does not place a client at risk for vision problems. Dry eyes are a common finding with older clients because tear production is decreased, but this does not necessarily interfere with the client's vision. Postpartum women should not be at risk for vision problems. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Health Promotion and Maintenance (Health Screening) MSC: Integrated Process: Nursing Process (Assessment)

18. The nurse is caring for a client who has just been diagnosed with profound hearing loss. The client tells the nurse, "The doctors must have made a mistake. There's no way I can be deaf!" Which is the nurse's best response? a. "Why do you think that the doctors made a mistake?" b. "I can tell that you are anxious and scared about your hearing." c. "Lots of people lead productive lives after losing their hearing." d. "The doctors did extensive tests to make sure that the diagnosis was correct."

ANS: B The nurse should acknowledge the client's feelings rather than trying to convince the client of the physicians' correct diagnosis. Reflective techniques can help the client clarify feelings and share concerns with the nurse. The nurse should not belittle the client's concerns with generalizations. "Why" questions can seem probing and often put the client on the defensive. Merely reassuring the client that all pertinent tests were conducted will not help the client resolve feelings about deafness. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Psychosocial Integrity (Therapeutic Communication) MSC: Integrated Process: Communication and Documentation

17. Which is the best approach for the nurse to use to obtain a history from a client with sudden hearing loss? a. Question the client's family. b. Write out the questions for the client to answer. c. Obtain the information from the client's old chart. d. Check with the client's primary health care provider.

ANS: B The nurse should communicate with the client directly, using written questions if the client cannot hear. The nurse can use old charts or information from the client's family or primary health care provider only if the client is unable to answer the questions. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—System-Specific Assessments) MSC: Integrated Process: Communication and Documentation

13. The nurse is assessing a client for the possibility of a lens opacity. Which assessment finding confirms this problem? a. Increased intraocular pressure b. Absence of a red reflex c. Decreased central vision d. Positive corneal staining

ANS: B The red reflex is elicited with an ophthalmoscope and represents reflection of the ophthalmoscopic light through the lens onto the vascular retina. The absence of a red reflex strongly indicates a lens opacity that does not allow light to penetrate through to the retina. The other answers are not related to a lens opacity. Increased intraocular pressure is measured by tonometry and could indicate glaucoma. Decreased central vision is measured by a Snellen chart and a Jaeger card and indicates decreased visual acuity. Positive corneal staining with topical dye could indicate corneal abrasion. DIF: Cognitive Level: Comprehension/Understanding REF: p. 1049 TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology) MSC: Integrated Process: Nursing Process (Assessment)

15. The nurse is evaluating a client's technique for instilling eyedrops. Which behavior indicates that the client needs more teaching? a. Closing they eye after the drops are in b. Touching the eye with the tip of the dropper c. Allowing the drops to spread across the eye surface d. Getting 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. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies—Medication Administration) MSC: Integrated Process: Nursing Process (Evaluation)

6. The nurse is caring for a client who may have an ear infection. Which intervention is used to prevent spread of the infection to other clients? a. A new sterile otoscope speculum is used to examine each of the client's ears. b. The nurse washes his hands after removing hearing aids from the client's ears. c. Hearing aids are cleaned with alcohol before they are re-inserted into the client's ears. d. The tuning fork is cleaned with hydrogen peroxide before and after use with the client.

ANS: B Washing hands after removal of a hearing aid should prevent any spread of infection between clients. Hearing aids may harbor infectious microorganisms, especially in clients who may have an ear infection. The other answers pertain to the possible spread of infection from one ear to the other—not to other clients. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Safe and Effective Care Environment (Safety and Infection Control—Standard Precautions/Transmission-Based Precautions/Surgical Asepsis) MSC: Integrated Process: Nursing Process (Implementation)

10. The nurse assesses a client post-cataract surgery and finds white, dry, crusty drainage on the client's eyelid and lashes. What does the nurse do next? a. Obtain a specimen of the drainage for culture. b. Clean away the drainage and apply the prescribed drops. c. Contact the physician for an antibiotic order. d. Arrange for the client to be seen by the ophthalmologist today.

ANS: B White, dry, crusty drainage on the eyelid and lashes is expected after cataract surgery. Because the drainage is white and no other symptoms of infection are noted, a culture does not need to be done and an antibiotic will not be needed. Urgency is not an issue because this is an expected effect from the trauma of surgery. The physician does not need to be called. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications from Surgical Procedures and Health Alterations) MSC: Integrated Process: Nursing Process (Implementation)

1. The nurse is assessing the eye changes in an older adult. Which changes lead the nurse to consult with the health care provider? (Select all that apply.) a. Increasing difficulty perceiving greens, blues, and violets b. Increasing redness in the eyes c. Acute pain in the eyes d. Sudden change in acuity e. Need for additional lighting for reading f. Need to hold newspaper farther away to read

ANS: B, C, D Increasing redness, acute pain, and sudden changes in acuity represent manifestations that might be indicative of a more serious complication and need the provider's evaluation. Delay could cause harm. The other signs are associated with the aging process and do not require immediate evaluation. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Health Promotion and Maintenance (Health Screening) MSC: Integrated Process: Nursing Process (Implementation) OTHER

3. A blind client is admitted to the hospital unit. Orientation to the unit includes which information? (Select all that apply.) a. Introduce the staff to the client. b. Describe the room to the client using one reference point. c. Walk the client to the bathroom and describe it. d. Tell the client to use the call light if he or she wants to go to the bathroom. e. Explain the routine of the unit and how to operate the bed controls. f. Assist in putting the client's belongings away.

ANS: B, C, E, F The client needs to know where everything is located to be independent and safe from falls. Clients need to be shown where things are and how to do things such as turn on the call light and raise the head of the bed. The client should be introduced to the staff, not the reverse, and should first be shown how to use the call light. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Safe and Effective Care Environment (Safety and Infection Control—Accident/Injury Prevention) MSC: Integrated Process: Nursing Process (Implementation) OTHER

14. A client is scheduled for electroretinography. Which statement indicates that the client understands the teaching about this procedure? a. "I will wear dark glasses in sunlight to prevent eye pain." b. "I am going to drink at least 3 liters of water to flush the dye out of my system." c. "I will avoid rubbing my eyes until the anesthetic drops have worn off." d. "I will not drive for the first 24 hours after the procedure."

ANS: C A local anesthetic agent is used for this procedure because an electrode is placed on the cornea. The client could inadvertently scratch or harm the eye by touching or rubbing it while the anesthetic effect is present. No eye pain should be noted with this procedure, no dye is used, and restricting driving for 24 hours is not necessary. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Diagnostic Tests) MSC: Integrated Process: Teaching/Learning

23. A client just underwent a keratoplasty. Which activity does the nurse suggest that the client begin possibly 1 week after surgery? a. Continue with salsa dance lessons. b. Jog only one-half mile versus the usual 2 miles. c. Return to employment as a receptionist. d. Help the family move furniture from room to room.

ANS: C Activities that raise the intraocular pressure (e.g., jogging, dancing, any movement that can cause jerky head motion) should be discouraged for at least 3 weeks after surgery. No heavy lifting should be done for 6 to 8 weeks. A sedentary job such as a receptionist can be tolerated a week after surgery. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Health Promotion and Maintenance (Self-Care) MSC: Integrated Process: Teaching/Learning MULTIPLE RESPONSE

13. Which statement made by a client after corneal transplantation indicates a need for further teaching? a. "I will wear an eye shield at night for at least 1 month." b. "I will avoid bending at the waist and straining when moving my bowels." c. "I won't worry if I have increased tearing, because it is normal." d. "I'll notify the ophthalmologist if any signs of rejection occur."

ANS: C Aqueous humor can leak from the incision site if wound closure is incomplete. Any fluid coming from the eye in the early postoperative period needs to be checked by the provider. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications from Surgical Procedures and Health Alterations) MSC: Integrated Process: Nursing Process (Evaluation)

11. Which statement indicates that a client needs additional teaching about ear hygiene? a. "I will wash my hands before I put in my earplugs at work." b. "I will clean my ears with plain warm water and a washcloth every day." c. "I will use a cotton swab to get the extra water out of my ears after I swim." d. "I can rinse my ears with half-strength hydrogen peroxide if ear wax builds up."

ANS: C Cotton swabs should not be inserted into the ear canal because injury to the tympanic membrane can result. The cotton swab can push cerumen deeper into the ear canal, possibly resulting in impaction. Hands should always be washed before earplug insertion to prevent ear infection. Ears should be cleaned with plain warm water and a washcloth to prevent irritation of the ear canal. The ears may be safely rinsed with half-strength hydrogen peroxide to remove excess ear wax within the ear canal. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Health Promotion and Maintenance (Self-Care) MSC: Integrated Process: Nursing Process (Evaluation)

9. Which is the best assessment question for the nurse to ask a client with tinnitus? a. "How exactly do you clean your ears?" b. "Have you had your hearing checked lately?" c. "Do you have ringing in both ears or in only one ear?" d. "Does the ringing make it hard for you to sleep at night?"

ANS: C Determining whether the tinnitus is in one or both ears provides valuable information about the cause of the problem. Tinnitus is not related to how the client cleans his or her ears. Asking about the last hearing check will not help determine the cause of the tinnitus. Asking about nighttime tinnitus is helpful but is less important than asking if the problem is present in one or both ears. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Alterations in Body Systems) MSC: Integrated Process: Nursing Process (Assessment)

7. The nurse is caring for a client who is hard of hearing. Which intervention best helps the client with communication? a. Speaking loudly and adding extra inflections to the tone of voice b. Bending over the client so that he or she can see the nurse's lips more easily c. Closing the door to the room and making sure that lighting is adequate d. Asking the client's spouse to answer questions that are not heard by the client

ANS: C Environmental noise decreases the hearing-impaired client's ability to hear conversation. The room should be adequately lit so the client can read supplemental written notes. Bending down to the client may be seen as condescending or offensive. Speaking loudly, with extra inflections, can actually make it harder for the client to understand the nurse. The nurse should not bend over the client and should instead sit to meet the client's eye level. The client's spouse should be used only as a last resort if no other means of communication are possible. DIF: Cognitive Level: Comprehension/Understanding REF: p. 1080 TOP: Client Needs Category: Psychosocial Integrity (Therapeutic Communication) MSC: Integrated Process: Communication and Documentation

16. The nurse is educating a client about the instillation of eyedrops. Which client statement indicates the need for additional teaching? a. "Squeezing my eye tightly after I put the drops in may force the drops out of my eye too quickly." b. "If the drops are kept in the refrigerator, I will be able to tell when they are in my eye because they will feel cold." c. "My sister has the same prescription, so we can use the same bottle of eyedrops." d. "I will wash my hands before I use these eyedrops."

ANS: C Eyedrops or eye ointment should never be shared because of the risk of spreading infection. The other answers indicate correct technique. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies—Medication Administration) MSC: Integrated Process: Nursing Process (Evaluation)

3. Which client is at highest risk for hearing loss? a. Client with heart failure receiving digoxin (Lanoxin), 0.125 mg orally daily b. Client with asthma receiving high-dose methylprednisolone (Solu-Medrol) therapy c. Client with osteomyelitis receiving IV gentamicin (Garamycin) d. Client with hyperkalemia being treated with intravenous glucose and insulin

ANS: C Gentamicin is an aminoglycoside that can cause ototoxicity. Assessment of hearing should be done before and during therapy. Digoxin, methylprednisolone, and insulin do not put the client at risk for hearing loss. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies—Adverse Effects/Contraindications/Interactions/Side Effects) MSC: Integrated Process: Nursing Process (Assessment)

6. 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 longer than 2 seconds. What does 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 not repeat the test or hold the client's head in a fixed position. 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. The cover-uncover test is used for determining the degree of peripheral vision. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Alterations in Body Systems) MSC: Integrated Process: Nursing Process (Assessment)

22. A client is having intraocular pressure measured for both eyes. Which response by the client best indicates that the client understands why this is necessary every year? a. "Elevated eye pressure can cause high blood pressure." b. "If eye pressure is too high, your eyes will dry out." c. "Elevated eye pressure can press on blood vessels in the eye." d. "Increased eye pressure causes the tear ducts to become blocked."

ANS: C Intraocular pressure is the pressure generated by the fluids inside the globe of the eye. As intraocular pressure increases to above normal, it compresses the blood vessels and the optic nerves. As the blood vessels are compressed, oxygenation to the internal eye structures, including the nerves and photoreceptors, is diminished. The nerves and photoreceptors require a constant supply of oxygen and will die if blood flow is inadequate, leading to blindness. The other statements are inaccurate. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Diagnostic Tests) MSC: Integrated Process: Teaching/Learning

14. A client tells the nurse, "Bumps have developed in my ear canals from my hearing aid." Which is the nurse's best recommendation for the client? a. "Clean your hearing aid with rubbing alcohol every evening and let it dry overnight." b. "Apply a small amount of benzoyl peroxide cream to the inside of your ear canals before you insert your hearing aid." c. "Clean your hearing aid with mild soap and water and make sure that it is completely dry before inserting it in your ears." d. "Clean your ears with half-strength hydrogen peroxide twice a day before you put in your hearing aid and after you take it out."

ANS: C Keeping the hearing aid clean and making sure that it is dry before insertion into the ear will minimize plugging of the sebaceous glands, resulting in "bumps." Rubbing alcohol should never be used to clean the hearing aid. Benzoyl peroxide should not be applied to the inside of the ear canals, although carbamide peroxide (Debrox) may be used to facilitate excessive ear wax removal. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Health Promotion and Maintenance (Self-Care) MSC: Integrated Process: Teaching/Learning

19. The client requires a hearing aid but tells the nurse that he cannot afford to pay for it right now. What is the nurse's best response? a. "Your insurance company should pay some of the cost." b. "The hospital can set up a payment plan for the new hearing aid." c. "I'll ask the social worker about organizations that help pay for hearing aids." d. "You can check around to see who has the lowest price."

ANS: C Local organizations may be able to help the client pay for the hearing aid. The social worker should be contacted as soon as possible. The client should not shop around for the best price for a hearing aid because discount providers may not be able to offer required diagnostic tests or follow-up care. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Psychosocial Integrity (Support Systems) MSC: Integrated Process: Communication and Documentation

14. Which clinical manifestation alerts the nurse to the possibility of a vitreous humor hemorrhage? a. Presence of a red reflex b. Reddened whites of the eye c. Red haze or floaters in the line of vision d. Swelling of the upper and lower eyelids

ANS: C Mild seepage of blood into the vitreous humor causes the client's vision to have an overall red haze or floaters. With a vitreous humor hemorrhage, the red reflex is reduced. Reddened whites of the eye and swelling of the eyelids would indicate irritation and infection of the eye. DIF: Cognitive Level: Comprehension/Understanding REF: p. 1067 TOP: Client Needs Category: Health Promotion and Maintenance (Health Screening) MSC: Integrated Process: Nursing Process (Assessment)

1. A client is using an ophthalmic beta-blocking agent for the treatment of glaucoma. Which instruction does the nurse give to the client to prevent orthostatic hypotension? a. "Change positions quickly after administering the drops." b. "Take your pulse at least four times daily." c. "Apply pressure to the inside corner of your eye when administering the drops." d. "Lay down for 10 minutes after administering the drops."

ANS: C Nasal punctal occlusion during eyedrop instillation keeps the drug in contact with the eye structures longer and decreases systemic absorption and side effects. Systemic distribution of the drug is what may cause orthostatic hypotension. The other answers will not help prevent orthostatic hypotension. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies—Adverse Effects/Contraindications/Side Effects/Interactions) MSC: Integrated Process: Nursing Process (Implementation)

12. The nurse is performing an eye assessment on a client. 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 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 that is being moved from about 18 cm from the client's nose in closer toward the nose. Consensual response occurs when both pupils constrict after a light is shined at one eye. The blink reflex occurs in response to a sudden movement. Extraocular muscle function is tested when the client is asked to hold an upward gaze while keeping the head still. DIF: Cognitive Level: Comprehension/Understanding REF: p. 1046 TOP: Client Needs Category: Health Promotion and Maintenance (Health Screening) MSC: Integrated Process: Nursing Process (Assessment)

17. A client with presbyopia asks her nurse about corrective lenses. Which is the nurse's best response? a. "This type of problem cannot be helped with corrective lenses." b. "Corrective lenses are needed for both near and distance vision." c. "Corrective lenses can be used for reading and close work." d. "Corrective lenses are needed for distance only."

ANS: C Presbyopia is caused by stiffening of the lens as a result of water loss as the lens ages. Consequently, the lens does not refract as well and light waves converge behind the retina—a condition similar to farsightedness (hyperopia). The condition makes near vision blurry. Corrective lenses for presbyopia increase light wave refraction and are used for reading or close work. Therefore the other answers are incorrect. Presbyopia can be helped with corrective lenses but only for near vision, not for distance vision. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Alterations in Body Systems) MSC: Integrated Process: Nursing Process (Implementation)

4. The nurse is caring for an older adult client with sensorineural hearing loss. Which assessment finding does the nurse correlate with the client's health history? a. History of frequent ear infections b. Swims frequently c. Worked in a sawmill for the last 20 years d. Had a tumor removed from his left eardrum last year

ANS: C Sensorineural hearing loss is caused by damage to the cochlear hair cells. This damage may be caused by exposure to loud noises, including noise from machinery in factories or sawmills. Tumor removal from the eardrum, swimming, and ear infections do not increase the risk for sensorineural hearing loss because conduction of sound through the nerves is not affected. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—System-Specific Assessments) MSC: Integrated Process: Nursing Process (Assessment)

13. A client asks the nurse why there is "waxy yellow stuff" on the cotton swab when he cleans his ears. Which is the nurse's best response? a. "The yellow ear wax helps transmit sound to your middle ear." b. "The yellow ear wax indicates that you have an infection in your ears." c. "The yellow ear wax helps protect and lubricate the inside of your ear canal." d. "The yellow ear wax builds up when you don't clean your ears often enough."

ANS: C The ear canal is lined with ear wax (cerumen), which offers protection and lubrication. Ear wax does not help with sound transmission and does not indicate ear infection or buildup because of infrequent cleaning. DIF: Cognitive Level: Comprehension/Understanding REF: p. 1078 TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology) MSC: Integrated Process: Teaching/Learning

4. 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. Obtain a specimen of the drainage for culture. b. Irrigate the ear canal with sterile normal saline. c. Gently examine the client's ear with an otoscope. d. Place a cotton ball in the ear canal to absorb the drainage.

ANS: C The nurse should use an otoscope to determine whether the client's tympanic membrane has ruptured. Until the tympanic membrane is examined and is found to be intact, syringing is not performed. A specimen is obtained only 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. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Illness Management) MSC: Integrated Process: Nursing Process (Assessment)

9. A client is being started on scopolamine (Transderm Scop) for vertigo. What does the nurse tell the client regarding this medication? a. "You may drive your car while taking this medication." b. "Concentration on your college courses will not be affected." c. "It is recommended that you limit activities requiring a detailed focus." d. "You should be able to continue your job as a crane operator."

ANS: C With scopolamine (Transderm Scop), drowsiness can be a problematic side effect. Clients are encouraged not to operate machinery or drive while taking this medication. Therefore driving a car or operating a crane could be dangerous. College coursework may be challenging because of tiredness experienced by the client. DIF: Cognitive Level: Comprehension/Understanding REF: p. 1095 TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies—Adverse Effects/Contraindications/Side Effects/Interactions) MSC: Integrated Process: Teaching/Learning

3. A client has mastoiditis. The nurse assesses most carefully for which manifestations? (Select all that apply.) a. Red and bulging eardrum b. A crackling sound upon yawning c. Enlarged lymph nodes behind the ear d. Low-grade fever and malaise e. Diminished hearing f. Loss of appetite

ANS: C, D, E, F Common signs and symptoms of mastoiditis include enlarged lymph nodes behind the ear, low-grade fever, malaise, loss of hearing, and loss of appetite. When the eardrum is red and bulging and a crackling sound is heard upon yawning, the client is usually diagnosed with otitis media. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—System-Specific Assessments) MSC: Integrated Process: Nursing Process (Assessment) OTHER

1. A client with acute-angle glaucoma has several medications ordered. Which medications does the nurse question? (Select all that apply.) a. Acetazolamide (Diamox) b. Pilocarpine (Pilocar) c. Atropine (Isopto Atropine) d. Latanoprost (Xalatan) e. Timolol (Timoptic) f. Epinephrine

ANS: C, F Atropine and epinephrine are mydriatics, which decrease the outflow of aqueous humor, resulting in increased intraocular pressure (IOP). Diamox is a carbonic anhydrase inhibitor that decreases the formation of aqueous humor. Pilocar is a miotic that enhances outflow of aqueous humor. Xalatan is a prostaglandin agonist that improves outflow, and Timoptic is a beta blocker that decreases the formation of aqueous humor. All these help decrease IOP. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies—Expected Actions/Outcomes) MSC: Integrated Process: Nursing Process (Implementation)

9. A client relates that the vision in the left eye is greatly decreased from the day before. What does the nurse do first? a. Assess current medications. b. Patch the left eye. c. Notify the ophthalmologist. d. Perform an in-depth interview.

ANS: D A client with a sudden or persistent loss of vision needs to undergo a complete history and assessment first to identify the possible cause. Information such as current medications must be available before the ophthalmologist is called. The nurse cannot patch the left eye without completing an interview first. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Diagnostic Tests) MSC: Integrated Process: Nursing Process (Assessment)

22. The nurse is triaging clients in the emergency department. Which clients require immediate attention by an ophthalmologist? a. Older client with an intraocular pressure (IOP) of 15 b. Confused client in need of an ophthalmoscopic examination c. Young client with dry drainage from one eye d. Middle-aged client with recent onset of eye pain

ANS: D A client with abrupt onset of eye pain should be the priority because of possible underlying pathology causing the symptom. An IOP of 15 is within the normal range (10 to 21); therefore the client does not need to be seen by an eye doctor. If a client is confused, the ophthalmoscopic examination must be rescheduled because it would not be safe to perform the examination at this time. Drainage from an eye indicates possible infection, but this would not be the first client to be seen. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Safe and Effective Care Environment (Management of Care—Establishing Priorities) MSC: Integrated Process: Nursing Process (Implementation) MULTIPLE RESPONSE

19. An anxious adult client asks why she needs to have intraocular pressure tested every year. What is the best response from the nurse? a. "Many changes 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 responses are somewhat correct, explaining the outcome of abnormal pressure is to the point and is done at the client's level of understanding, especially if she is anxious about the test. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Diagnostic Tests) MSC: Integrated Process: Teaching/Learning

3. An older adult client who has a mature cataract in the right eye states, "Now I have lost the sight in my right eye because I waited too long for treatment." How does the nurse best respond to the client? a. "Yes, this type of blindness could have been prevented by earlier treatment." b. "It is fortunate you came for treatment in time to save the sight of your other eye." c. "Nothing you could have done would have made any difference." d. "Surgery can still save the sight in your eye with removal of the cataract."

ANS: D Although sight is increasingly impaired as a cataract matures, no other damage is done to the eye by waiting. Removal of the cataract will result in improved vision, regardless of how long the cataract has been present. No indication suggests that the client will develop a cataract in the other eye. The other statements are inaccurate. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Psychosocial Integrity (Grief and Loss) MSC: Integrated Process: Nursing Process (Caring)

9. A client has been educated about activities that can increase intraocular pressure. Which statement indicates that the client requires further teaching? a. "I will avoid wearing tight shirt collars and ties." b. "I will take stool softeners daily to prevent straining." c. "I will try not to sneeze, cough, or blow my nose." d. "I will not put my arms above my head."

ANS: D Arm position does not influence intraocular pressure. All other activities listed decrease the incidence of increased intraocular pressure. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications from Surgical Procedures and Health Alterations) MSC: Integrated Process: Nursing Process (Evaluation)

5. Which assessment alerts the nurse to the possible presence of a cataract in a client? a. Loss of central vision b. Loss of peripheral vision c. Dull aching in the eye and brow areas d. Blurred vision and reduced color perception

ANS: D As the lens becomes opaque and less able to refract light appropriately, the client experiences blurred vision and a reduced ability to distinguish among different colors. The development of a cataract does not typically cause loss of peripheral or central vision, nor does it result in aching in the brow area. DIF: Cognitive Level: Comprehension/Understanding REF: p. 1060 TOP: Client Needs Category: Health Promotion and Maintenance (Health Screening) MSC: Integrated Process: Nursing Process (Assessment)

21. A client has conjunctivitis in both eyes and is being treated with topical antibiotics. Which statement by the client indicates a need for further teaching? a. "I'll avoid sharing washcloths or towels with other family members." b. "I will wash my hands after applying the eye ointment to each eye." c. "I will call the ophthalmologist if the drainage continues after the antibiotics are started." d. "I'll use the same tube of topical ointment for each infected eye."

ANS: D Bacterial conjunctivitis is highly contagious; therefore the client must avoid sharing anything with others that has the potential to come in contact with the infected eye, such as washcloths or towels. The client needs to protect from reinfection by washing hands frequently during application of the antibiotic ointment and must let the eye doctor know if drainage continues after treatment is begun. Separate tubes of eye ointment should be used, with one specifically labeled for each eye. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Health Promotion and Maintenance (Self-Care) MSC: Integrated Process: Nursing Process (Evaluation)

10. The nurse is providing discharge instructions for a client who will be going home following tympanoplasty surgery. Which statement by the client indicates that additional teaching is needed? a. "I will wear earplugs whenever I am in noisy areas." b. "I will occlude only one nostril when I blow my nose." c. "I will wait 3 weeks before I resume my aerobics workouts." d. "I will use a cotton swab to clean drainage from inside my ear."

ANS: D Cotton swabs should not be used to clean drainage from the ear canal, especially after ear surgery. The client should be careful to avoid pressure extremes that could damage the tympanic membrane, including jumping or blowing the nose forcefully. Occluding only one nostril when blowing the nose reduces pressure within the ear and minimizes the chance of injury to the ear. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Illness Management) MSC: Integrated Process: Nursing Process (Evaluation)

1. The nurse is caring for a client with external otitis. Which assessment finding indicates to the nurse that the client's infection has worsened? a. The client now reports tinnitus and vertigo at night. b. The client now has a positive Rinne test, with AC > BC. c. The tympanic membrane is pearly gray with white patches. d. The auricular lymph nodes have increased in size over the last 24 hours.

ANS: D Enlargement of the auricular lymph nodes indicates that the client's external otitis is becoming more widespread and that current therapy is insufficient. Tinnitus, vertigo, and a positive Rinne test all indicate middle to inner ear problems not related to external otitis media. The tympanic membrane is normally pearly gray in color. White patches on the tympanic membrane are called tympanosclerosis and generally have no clinical importance. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology) MSC: Integrated Process: Nursing Process (Assessment)

8. The nurse is teaching a client about home care after cataract surgery. Which statement indicates that the client requires further teaching? a. "I am glad that I don't need an eye patch after the surgery." b. "I will try a cool compress to decrease the swelling around the operated eye." c. "Dark sunglasses will be necessary when I am in the sun." d. "Pain, nausea, and vomiting are normal after this surgery."

ANS: D Eye pain accompanied by nausea and vomiting is an indication of increased intraocular pressure and/or hemorrhage. This is an emergent situation and the surgeon must be contacted by the client. The other responses are correct. The client will not need an eye patch, cool compresses will decrease the slight swelling, and dark glasses are necessary outdoors until the pupil responds to sunlight. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications from Surgical Procedures and Health Alterations) MSC: Integrated Process: Nursing Process (Evaluation)

2. During assessment of an older adult, which finding does the nurse immediately report to the health care provider? a. Yellowing or bluing of the sclera b. Lack of discrimination between green and violet c. An opaque, bluish-white ring within the outer edge of the cornea d. Pupil constriction in response to light occurring in 2 seconds

ANS: D In an older client, it is normal for the sclera to turn yellow or blue with aging. It is also common for the older adult to have problems discriminating between the colors of green, blue, and violet. Arcus senilis, an opaque, bluish-white ring on the edge of the cornea, is a common occurrence in the older adult. This does not cause vision loss. Pupil constriction as a reaction to light should occur in less than 1 second. If pupil constriction takes longer, then the reaction is considered sluggish and should be reported to the provider. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Alterations in Body Systems) MSC: Integrated Process: Nursing Process (Assessment)

16. A client with macular degeneration would like to watch television. Where does the nurse place the television for best visualization of the screen? a. As close to the client's face as possible b. As far away as possible, with low lights c. Directly in front of the client d. On either side of the client

ANS: D Macular degeneration decreases central vision but usually does not affect peripheral vision. Clients looking straight ahead can see people and objects off to the side. Therefore the television should be placed on either side of the client. The other options would not help the client with macular degeneration to see the screen. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Health Promotion and Maintenance (Self-Care) MSC: Integrated Process: Teaching/Learning

8. Which statement indicates that a client needs additional teaching about protecting the ears and preventing hearing loss? a. "I will start a smoking cessation program and will take a multivitamin every day." b. "I will wear earplugs whenever I cut the grass or use my snow blower." c. "I will blow my nose gently, one nostril at a time, whenever I get a cold or the flu." d. "I will take Motrin (ibuprofen) instead of Tylenol (acetaminophen) for pain."

ANS: D Motrin (ibuprofen) can be ototoxic. Its use should be avoided to help prevent additional hearing loss. Blowing the nose gently can help prevent damage to the tympanic membrane. Smoking reduces oxygen supply to the cochlea, possibly increasing damage to the sensory cells, and should be avoided. Clients should use earplugs whenever they are exposed to loud noises to help prevent cochlear hair cell damage. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Health Promotion and Maintenance (Health and Wellness) MSC: Integrated Process: Nursing Process (Evaluation)

18. A client has just returned from having surgery, and sulfahexafluoride gas was used intraocularly. How does the nurse position the client? a. Completely supine, with sandbags beside the head b. On the nonoperative side in the Trendelenburg position c. On the operative side in the Trendelenburg position d. On the abdomen, with the affected eye up

ANS: D Sulfahexafluoride gas has a lower specific gravity than the vitreous humor. It will float to the highest position. The client should be positioned so that the gas will float up and against the newly reattached retina. The other positions are incorrect after this procedure. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications from Surgical Procedures and Health Alterations) MSC: Integrated Process: Nursing Process (Implementation)

15. 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 using them." b. "I will wash my hands before and after giving my husband the eardrops." c. "After I put the drops 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. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Safe and Effective Care Environment (Safety and Infection Control—Home Safety) MSC: Integrated Process: Teaching/Learning

7. Which statement indicates that a client understands why his cataract surgery is being done first on the eye with the poorest vision? a. "Insurance reimbursement dictates the timing of surgeries." b. "The eye with poorer vision is at greater risk for permanent damage." c. "The pressure in the poorer eye could increase, causing permanent damage." d. "If a complication arises in that eye, I will still have some vision in the better eye."

ANS: D The eye with the better sight is left alone until the outcome of the first surgery is known to reduce the chance that the client will lose sight in both eyes if complications arise from the surgery. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications from Surgical Procedures and Health Alterations) MSC: Integrated Process: Nursing Process (Evaluation)

8. The nurse is caring for a client with Ménière's disease. What does the nurse recommend to the client to reduce the symptoms of vertigo? a. "Take salt and potassium supplements daily." b. "Drink at least eight glasses of water every day." c. "Blow your nose hard when dizziness first begins." d. "When dizziness begins, lie down and keep your head still."

ANS: D Vertigo is a sense of whirling or turning in space, disturbing the sense of balance and inducing nausea and/or vomiting. Restricting head motions can help reduce the disturbances induced by vertigo. Excessive endolymph fluid can cause symptoms of Ménière's disease, so the nurse should not encourage extra fluid intake. Sodium will encourage water retention, which can exacerbate symptoms. The client should not blow his or her nose forcefully because this can cause damage to the ear. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Illness Management) MSC: Integrated Process: Teaching/Learning

7. The nurse is assessing an older adult client whose irises no longer fully dilate. What is the best intervention for the nurse to suggest? a. "Wear dark glasses whenever you are outside." b. "Use eyedrops on a regular basis to prevent dryness." c. "Avoid rubbing your eyes to prevent corneal abrasions." d. "Turn up room lights when reading or doing close work."

ANS: D With increasing age, the iris has less ability to dilate and clients have difficulty adapting to a darker environment. Older adult clients may need additional light for reading. Wearing dark glasses will not assist the client, and no indication suggests that the client's eyes are dry. Rubbing the eyes should not cause corneal abrasions. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Alterations in Body Systems) MSC: Integrated Process: Teaching/Learning