Saunders NCLEX RN - Eyes/Ears

he nurse is caring for a client in the postoperative period following enucleation. The nurse notes bloody staining on the surgical eye dressing. Which nursing action is most appropriate? 1. Document the finding. 2. Reinforce the dressing. 3. Mark the site and continue to monitor. 4. Contact the health care provider (HCP).

4. Contact the health care provider (HCP).

The nurse provides dietary instructions to a client with Ménière's disease. The nurse should tell the client that which food or fluid item is acceptable to consume? 1. Tea 2. Coffee 3. Cold-cut meats 4. Sugar-free Jell-O

4. Sugar-free Jell-O

The nurse is providing discharge instructions to the client being discharged after a fenestration procedure for the treatment of otosclerosis. Which statement made by the client indicates a need for further instruction? 1. "I should use a straw to drink liquids for the next 2 to 3 weeks." 2. "I need to avoid washing my hair and showering for at least 1 week." 3. "I should avoid movements requiring bending over for at least 3 weeks." 4. "I should take stool softeners to avoid straining when having a bowel movement."

1. "I should use a straw to drink liquids for the next 2 to 3 weeks."

The nurse is caring for a client who was recently diagnosed with primary open-angle glaucoma (POAG). Which assessment finding is specific to this type of glaucoma? 1. Client report of blurred vision 2. Client report of "tunnel vision" 3. Client report of ocular erythema 4. Client report of halos around lights

2. Client report of "tunnel vision"

The nurse in the health care clinic is providing instructions to a client regarding the use of a hearing aid. Which statement is most appropriate for the nurse to include? 1. "The hearing aid should not be worn if an ear infection is present." 2. "The ear mold for the hearing aid should be washed with mild soap and water once a month." 3. "The hearing aid should be removed from the ear at the end of the day and then turned off after removal." 4. "The hearing aid contains a lifelong battery, so you will not need to be concerned about changing batteries."

1. "The hearing aid should not be worn if an ear infection is present."

A caloric test is prescribed for a client suspected of having disease of the labyrinth. The nurse should obtain which essential item in preparation for this test? 1. An otoscope 2. A tongue blade 3. An emesis basin 4. An ophthalmoscope

1. An otoscope

The nurse is preparing a teaching plan for a client who had a cataract extraction with intraocular implantation. Which home care measures should the nurse include in the plan? Select all that apply. 1. Avoid activities that require bending over. 2. Contact the surgeon if eye scratchiness occurs. 3. Take acetaminophen for minor eye discomfort. 4. Expect episodes of sudden severe pain in the eye. 5. Place an eye shield on the surgical eye at bedtime. 6. Contact the surgeon if a decrease in visual acuity occurs.

1. Avoid activities that require bending over. 3. Take acetaminophen for minor eye discomfort. 5. Place an eye shield on the surgical eye at bedtime. 6. Contact the surgeon if a decrease in visual acuity occurs.

The nurse is providing discharge instructions to a client who had a fenestration procedure for the treatment of otosclerosis. The nurse should instruct the client to take which measure? 1. Avoid air travel. 2. Shower daily to prevent infection. 3. Resume all normal activities in 1 week. 4. Drink liquids through a straw for the next 2 to 3 weeks.

1. Avoid air travel.

A client is diagnosed with glaucoma. Which piece of nursing assessment data identifies a risk factor associated with this eye disorder? 1. Cardiovascular disease 2. Frequent urinary tract infections 3. A history of migraine headaches 4. Frequent upper respiratory infections

1. Cardiovascular disease

The nurse is caring for a client diagnosed with Ménière's disease. The nurse plans care, understanding that this disorder is characterized by which manifestation? 1. Dizziness 2. Photophobia 3. Hemianopsia 4. Blurred vision

1. Dizziness

The nurse creates a plan of care for a client with a diagnosis of Ménière's disease who is being admitted to the hospital. The priority nursing intervention in the plan of care should focus on which item? 1. Measures that will ensure safety 2. Determining any knowledge deficits 3. Assessing for any psychosocial needs 4. Asking the client about knowledge of the treatment plan

1. Measures that will ensure safety

The nurse is developing a plan of care for a client with a diagnosis of severe vertigo from Ménière's disease who is being admitted to the hospital. What is the priority nursing intervention in the plan of care? 1. Safety measures 2. Self-care measures 3. Food items to avoid 4. Knowledge about medication therapy

1. Safety measures

A client with a history of ear problems is going on vacation by aircraft. The nurse advises the client to include which activities to prevent barotrauma during ascent and descent of the airplane? Select all that apply. 1. Yawning 2. Humming 3. Swallowing 4. Chewing gum 5. Sucking on hard candy

1. Yawning 3. Swallowing 4. Chewing gum 5. Sucking on hard candy

The student nurse is working with a registered nurse (RN) in the clinic. The RN is educating the student nurse on dysfunction in the area of the semicircular canals of the ear. Which statement by the student nurse indicates that the teaching has been effective? 1. "Tinnitus is common." 2. "Disturbance in balance occurs." 3. "Conduction hearing loss often happens." 4. "Sensorineural hearing loss is not unusual."

2. "Disturbance in balance occurs."

A client is experiencing blockage of the eustachian tubes. The nurse educates the client on how the client may forcibly open the eustachian tube. Which statement by the client indicates that the teaching has been effective? 1. "I should tap the side of the head lightly." 2. "I should perform the Valsalva maneuver." 3. "I should use cotton-tipped applicators in the ears." 4. "I should chew food using exaggerated mouth movements."

2. "I should perform the Valsalva maneuver."

A client being prepared for a myringotomy asks the nurse about the procedure. The nurse should respond by making which statement? 1. "This procedure involves removing a bone from the ear." 2. "This procedure will reduce the pressure you feel in your ear and allow fluid to drain." 3. "This procedure involves removing the eardrum and inserting a mechanical bone in the ear." 4. "This procedure involves removal of middle ear and inserting a ring around the ear bones that will vibrate on sound to promote better hearing."

2. "This procedure will reduce the pressure you feel in your ear and allow fluid to drain."

The nurse is planning care for a client with acute otitis media. To reduce pressure and allow fluid to drain, the nurse anticipates that which measure would most likely be recommended to the client? 1. Strict bed rest 2. A myringotomy 3. A mastoidectomy 4. Diphenhydramine

2. A myringotomy

The nurse has given a client who is at risk for motion sickness suggestions about medications that can prevent an occurrence. The nurse determines that the client has correctly learned the information if the client states that the medication is taken at what time before the triggering event? 1. At least 2 days before 2. At least 1 hour before 3. At least the day before 4. At least a half-day before

2. At least 1 hour before

A client arrives at the emergency department with a foreign body in the left ear and tells the nurse that an insect flew into the ear. Which intervention should the nurse implement initially? 1. Irrigation of the ear 2. Instillation of mineral oil 3. Instillation of antibiotic eardrops 4. Instillation of corticosteroid ointment

2. Instillation of mineral oil

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

2. Instruct the client that he or she may need glasses when driving.

A client arrives at the emergency department stating that a mosquito flew into his ear and that he is hearing a constant buzzing noise. Which intervention should the nurse take first? 1. Initiate a consult for an ear specialist. 2. Look into the ear canal using a flashlight. 3. Irrigate the ear and try to drown the mosquito. 4. Use an ear forcep and try to pull the mosquito out.

2. Look into the ear canal using a flashlight.

The nurse is reviewing the health care provider's prescriptions for a client with Ménière's disease. Which diet would most likely be prescribed for the client? 1. Low-fat diet 2. Low-sodium diet 3. Low-cholesterol diet 4. Low-carbohydrate diet

2. Low-sodium diet

Tonometry is performed on a client with a suspected diagnosis of glaucoma. The nurse looks at the documented test results and notes an intraocular pressure (IOP) value of 23. What should be the nurse's initial action? 1. Apply normal saline drops. 2. Note the time of day the test was done. 3. Contact the health care provider (HCP). 4. Instruct the client to sleep with the head of the bed flat.

2. Note the time of day the test was done.

The nurse is preparing to provide care for a client who will need an ear irrigation to remove impacted cerumen. Which interventions should the nurse take when performing the irrigation? Select all that apply. 1. Apply some force when instilling the irrigation solution. 2. Position the client with the affected side down after the irrigation. 3. Warm the irrigating solution to a temperature that is close to body temperature. 4. Position the client to turn the head so that the ear to be irrigated is facing upward. 5. Direct a slow, steady stream of irrigation solution toward the upper wall of the ear canal.

2. Position the client with the affected side down after the irrigation. 3. Warm the irrigating solution to a temperature that is close to body temperature. 5. Direct a slow, steady stream of irrigation solution toward the upper wall of the ear canal.

The nurse is observing an unlicensed assistive personnel (UAP) communicating with a client who is deaf. The nurse should intervene if which behavior is observed? 1. The UAP is speaking directly to the client. 2. The UAP overenunciates words when speaking. 3. The UAP faces the client when speaking to the client. 4. The UAP touches the client's arm to gain his or her attention.

2. The UAP overenunciates words when speaking.

The nurse is performing an assessment on a client with a diagnosis of Ménière's disease. The nurse anticipates that the client is most likely to report which symptom during an acute attack? 1. Fatigue 2. Tinnitus 3. Headache 4. Insomnia

2. Tinnitus

The nurse is educating a client on how to eliminate whistling from a hearing aid. The nurse recognizes that further teaching is needed when the client makes which statement? 1. "I will cleanse my ear mold." 2. "I will try reinserting the hearing aid." 3. "I will raise the volume of my hearing aid." 4. "I will make sure that my hair is not caught between the ear mold and canal."

3. "I will raise the volume of my hearing aid."

The nurse educator is conducting an in-service education session for the nurses employed in the eye and ear surgical unit of a large trauma center. In discussing the topic of cochlear implants, the educator notes that this surgical procedure is contraindicated in which client? 1. A client with bilateral profound hearing loss 2. A client who communicates primarily by speech 3. A client who became deaf before learning to speak 4. A client who received no benefit from conventional hearing aids

3. A client who became deaf before learning to speak

The nurse instructs a client in the use of a hearing aid. The nurse should include which instruction? 1. Hearing aids do not require any care. 2. Leave the hearing aid in place while showering. 3. Check the battery to ensure that it is working before use. 4. A water-soluble lubricant is used on the hearing aid before insertion.

3. Check the battery to ensure that it is working before use.

A client makes an appointment with an ear specialist because of the frequent recurrence of middle ear infections. In performing an intake assessment of the client, the nurse should ask about which risk factor related to infection of the ears? 1. Occupational noise 2. Exposure to loud noise 3. Congenital abnormalities 4. Use of drilling and other power tools

3. Congenital abnormalities

The nurse is planning a presentation on noise prevention and ear protection for a display booth at a local health fair. The nurse plans to incorporate which important concept regarding hearing loss in the presentation? 1. Sitting near loud music is not harmful. 2. Prolonged ringing in the ears after loud noises is normal. 3. Cup the hands over the ears if loud noise is expected suddenly. 4. Ear plugs or other protectors are necessary only with the use of power tools.

3. Cup the hands over the ears if loud noise is expected suddenly.

The nurse is developing a teaching plan for a client with glaucoma. Which instruction should the nurse include in the plan of care? 1. Avoid overuse of the eyes. 2. Decrease the amount of salt in the diet. 3. Eye medications will need to be administered for life. 4. Decrease fluid intake to control the intraocular pressure.

3. Eye medications will need to be administered for life.

The nurse is assigned to care for a client after a mastoidectomy. Which nursing intervention would be a priority in the care of this client? 1. Maintain a supine position. 2. Change the ear dressing daily. 3. Monitor for signs of facial nerve injury. 4. Position the client on the affected side to promote drainage.

3. Monitor for signs of facial nerve injury.

The home care nurse is visiting a client who was recently diagnosed with a hearing impairment. The nurse should prepare to instruct the client's spouse in which measure that will facilitate communication? 1. Speak loudly to the client to facilitate hearing. 2. Speak directly into the impaired ear to facilitate hearing. 3. Speak in a normal tone and face the client when speaking. 4. Speak frequently to the client to provide sensory stimulation.

3. Speak in a normal tone and face the client when speaking.

Which statement made by the client who had ear surgery to treat otosclerosis would indicate that the client understands postoperative home care instructions? 1. "It is okay to take a shower and wash my hair." 2. "I can resume my tennis lessons starting next week." 3. "I should drink liquids through a straw for the next 2 to 3 weeks." 4. "I will take stool softeners as prescribed by my health care provider."

4. "I will take stool softeners as prescribed by my health care provider."

The nursing student is caring for a client with a diagnosis of presbycusis. The nursing instructor determines that the student understands presbycusis when which statement is made? 1. "It's a loss of vision associated with aging." 2. "A loss of balance occurs with presbycusis." 3. "Presbycusis is a conductive hearing loss that occurs with aging." 4. "It's a sensorineural hearing loss that occurs with the aging process."

4. "It's a sensorineural hearing loss that occurs with the aging process."

The clinic nurse is performing an otoscopic examination on an adolescent who was hit in the ear with a basketball during a neighborhood game. A perforated eardrum is suspected. Which finding should the nurse expect to observe if the eardrum is perforated? 1. A red and bulging eardrum 2. Dense white patches on the eardrum 3. A colony of black dots on the eardrum 4. A round or oval darkened area on the eardrum

4. A round or oval darkened area on the eardrum

The nurse is performing an admission assessment on a client with a diagnosis of detached retina. Which sign or symptom is associated with this eye disorder? 1. Total loss of vision 2. Pain in the affected eye 3. A yellow discoloration of the sclera 4. A sense of a curtain falling across the field of vision

4. A sense of a curtain falling across the field of vision

The nurse has admitted to the hospital a client with a diagnosis of an acute attack of Ménière's disease. The nurse reviews the health care provider's prescriptions for the client. Which prescription should the nurse question? 1. Diazepam 2. Nicotinic acid 3. Diphenhydramine 4. Ambulation four times daily

4. Ambulation four times daily

The nurse is performing an assessment on a client with a suspected diagnosis of cataract. Which clinical manifestation should the nurse expect to note in the early stages of cataract formation? 1. Diplopia 2. Eye pain 3. Floating spots 4. Blurred vision

4. Blurred vision

A client with retinal detachment is admitted to the nursing unit in preparation for a repair procedure. Which prescription should the nurse anticipate? 1. Allowing bathroom privileges only 2. Elevating the head of the bed to 45 degrees 3. Wearing dark glasses to read or watch television 4. Placing an eye patch over the client's affected eye

4. Placing an eye patch over the client's affected eye