Sensory

741. During the early postoperative period, a client who has undergone a cataract extraction complains of nausea and severe eye pain over the operative site. What should be the initial nursing action? 1. Call the health care provider (HCP). 2. Reassure the client that this is normal. 3. Turn the client onto his or her operative side. 4. Administer the prescribed pain medication and antiemetic.

1 Rationale: Severe pain or pain accompanied by nausea follow- ing a cataract extraction is an indicator of increased intraocular pressure and should be reported to the HCP immediately. Options 2, 3, and 4 are inappropriate actions.Test-Taking Strategy: Note the strategic word, initial, and the word severe. Eliminate option 2 because this is not a normal condition. The client should not be turned to the operative side; therefore, eliminate option 3. From the remaining options, focusing on the strategic word will direct you to the correct option.

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

1 Rationale: When an eye drop and an eye ointment are scheduled to be administered at the same time, the eye drop is administered first. The instillation of two medications is separated by 3 to 5 minutes.Test-Taking Strategy: Note the strategic word, best. Focus on the subject, the guidelines for administering eye medications. Eliminate options 3 and 4 first because of the words 15 minutes. Next, thinking about the consistency and absorption of a drop versus ointment will direct you to the correct option.

18. The nurse is reviewing data in a patient's medical record. Which information increases the patient's risk for developing Ménière's disease? 1) Follows a gluten-free diet 2) Allergic to house dust and pet dander 3) Works as a computer science technician 4) Treated for a pinched nerve in the lower back

1) A gluten-free diet is not a risk factor for Ménière's disease. 2) Risk factors for Ménière's disease include allergies. 3) Vocation is not identified as a risk factor for Ménière's disease. 4) Lower spinal cord disorders are not identified as risk factors for Ménière's disease.

20. A patient comes into the emergency department with manifestations of retinal detachment. What should the nurse do to minimize this patient's eye movements? 1) Provide a sedative 2) Loosely cover both eyes 3) Elevate the head of the bed 45 degrees 4) Apply an eye patch over the affected eye

1) A sedative might help with anxiety; however, it will not minimize eye movements. 2) Movement of either eye can exacerbate internal eye injury. Because eyes move together, both eyes must be covered to minimize injury. 3) Elevating the head of the bed helps decrease intraocular pressure; however, this is not a problem with retinal detachment. 4) A single eye patch is not recommended. Both eyes should be covered.

12. The nurse notes that a patient is diagnosed with primary open-angle glaucoma. What diagnostic test would have been used to diagnose this health problem? 1) MRI 2) CT scan 3) Tonometry 4) Ultrasound

1) An MRI would not detect glaucoma. 2) A CT scan would not detect glaucoma. 3) Tonometry measures the pressures within the eyes and is usually conducted during a routine eye examination. 4) An ultrasound would not detect glaucoma.

9. A patient contemplating cataract surgery asks if there are any risk factors. How should the nurse respond? 1) Blindness 2) Detached retina 3) Corneal abrasion 4) Macular degeneration

1) Cataract removal does not increase the risk of blindness. 2) Cataract removal increases the risk of retinal detachment. 3) Cataract removal is not associated with a corneal abrasion. 4) Cataract removal does not increase the risk of macular degeneration.

15. The nurse notes that a patient known to the community clinic was unable to recognize the health-care provider. What health problem should the nurse suspect is occurring with this patient? 1) Cataracts 2) Glaucoma 3) Corneal abrasions 4) Macular degeneration

1) Cataracts will not cause the patient to be unable to recognize faces. 2) Glaucoma will not cause the patient to be unable to recognize faces. 3) Corneal abrasions will not cause the patient to be unable to recognize faces. 4) Dry macular degeneration causes a gradual blurring of the central vision, and the patient may have difficulty recognizing faces.

20. A patient with Ménière's disease is experiencing severe nausea and vomiting. Which medication should the nurse expect to be prescribed for this patient? 1) Diazepam (Valium) 2) Meclizine (Antivert) 3) Promethazine (Phenergan) 4) Dimenhydrinate (Dramamine)

1) Diazepam (Valium) depresses all levels of the central nervous system and thereby decreases symptoms. 2) Meclizine (Antivert) decreases excitability of the inner ear labyrinth and blocks conduction of the inner ear vestibular cerebellar pathways. 3) Promethazine (Phenergan) blocks histamine at the site to decrease symptoms of nausea and vomiting. 4) Dimenhydrinate (Dramamine) decreases the exaggerated sense of motion.

23. The nurse is preparing teaching materials for a group of senior citizens. What information should the nurse include as risk factors for hearing loss? Select all that apply. 1) Diet 2) Heredity 3) Medications 4) Recreational noise 5) Occupational noise

1) Diet is not identified as placing a person at higher risk for developing hearing loss. 2) Heredity is identified as placing a person at higher risk for developing hearing loss. 3) Medications are identified as placing a person at higher risk for developing hearing loss. 4) Recreational noise is identified as placing a person at higher risk for developing hearing loss. 5) Occupational noise is identified as placing a person at higher risk for developing hearing loss.

18. It is documented in the medical record that a patient has a rhegmatogenous detached retina. How should this diagnosis be explained to the patient? 1) Eye trauma causes the retinal to detach from the retinal pigment epithelium (RPE). 2) Eye inflammation causes vitreous fluid leaks into the area under the retina. 3) Vitreous fluid moves under the retina and separates the retina from the pigmented cell layer. 4) Scar tissue on the retina causes the retina to separate from the retinal pigment epithelium (RPE).

1) Exudative retinal detachment can occur with eye trauma. 2) Exudative retinal detachment can occur with eye inflammation. 3) Rhegmatogenous is the most common form of retinal detachment and occurs when a tear or break in the retina allows vitreous fluid to move under the retina and separate it from the pigmented cell layer that nourishes the retina. 4) Tractional is the least common type of detachment and occurs when scar tissue on the retina's surface contracts and causes the retina to separate from the RPE.

22. The nurse suspects that patient is experiencing undiagnosed Ménière's disease. Which assessment finding supports the nurse's clinical decision? 1) Facial pain 2) Nasal drainage 3) Positive Romberg test 4) Decreased deep tendon reflexes

1) Facial pain is not associated with Ménière's disease. 2) Nasal drainage is not a primary symptom of Ménière's disease. 3) In Ménière's disease, patients may exhibit a positive Romberg test on examination (meaning they have a disturbance in balance) and may also have nystagmus. 4) Changes in deep tendon reflexes do not occur in Ménière's disease.

10. The nurse is caring for a patient recovering from cataract removal surgery. Which action should the nurse take to reduce intraocular pressure (IOP)? 1) Restrict fluids 2) Position on the operative side 3) Administer mydriatic eye drops 4) Elevate the head of the bed 45 degrees

1) Fluids do not need to be restricted after cataract surgery. This does not decrease intraocular pressure. 2) Positioning on the operative side would increase IOP. 3) Mydriatic eye drops dilate the pupil and would be provided preoperatively. These drops do not affect IOP. 4) Elevating the head of the bed 30 to 45 degrees promotes drainage and prevents any increase in IOP.

4. The nurse is planning care for a patient recovering from a tympanoplasty. Which action should the nurse include to ensure the ear packing stays intact? 1) Increase fluid intake 2) Administer tobramycin 3) Maintain nothing by mouth status 4) Position flat with the operative side up

1) Increasing the fluid intake may decrease the thickening of the earwax. 2) Tobramycin is an identified ototoxic medication and should be questioned. 3) There is no need to keep the patient NPO. 4) The patient should be positioned flat, turned on the side with the operative side facing up after tympanoplasty. This decreases the chance of packing being displaced.

1. During a home visit the nurse suspects that someone in the family has hearing loss. What did the nurse observe to come to this conclusion? 1) Television volume on loud 2) Patient sitting in the kitchen 3) Music playing in the background 4) Family member cooking at the stove

1) Manifestations of increasing difficulty in hearing include turning up the volume on electronics such as televisions and radios. 2) The patient sitting in the kitchen does not indicate a hearing loss. 3) More information is needed about music playing in the background because the volume of the music is not addressed. 4) A family member's actions do not indicate a hearing loss.

19. A patient with Ménière's disease is admitted for intravenous fluid administration. What additional manifestation is seen in this disease process? 1) Muscle cramps 2) Drop in blood pressure 3) Capillary glucose 90 mg/dL 4) Uncontrollable eye movements

1) Muscle cramps are not associated with Ménière's disease. 2) Hypotension is not a manifestation of Ménière's disease. 3) Blood glucose level is not typically assessed in Ménière's disease. 4) Uncontrollable eye movements are manifestations of Ménière's disease.

28. The nurse is preparing a tool about macular degeneration that will be posted during a health fair. Which modifiable risk factors should the nurse include in this tool? Select all that apply. 1) Race 2) Gender 3) Obesity 4) Smoking 5) High blood pressure

1) Nonmodifiable risk factors for macular degeneration include race. 2) Nonmodifiable risk factors for macular degeneration include gender. 3) Modifiable risk factors for macular degeneration include obesity. 4) Modifiable risk factors for macular degeneration include smoking. 5) Modifiable risk factors for macular degeneration include high blood pressure.

27. The nurse is preparing information about cataracts for a community health fair. What should the nurse include about risk factors for the disorder? Select all that apply. 1) Obesity 2) Age over 60 3) Family history 4) Alcohol intake 5) Chronic health problems

1) Obesity may predispose an individual to development of cataracts. 2) Cataracts are more common after age 60 but can occur at any time. 3) Those with family members who had cataracts are more likely to develop them at some point in their life. 4) Alcohol intake is not identified as a risk factor for cataracts. 5) Chronic medical conditions such as diabetes, autoimmune disorders, hypertension, and other eye problems are considered to be at higher risk for cataract development.

19. A patient is demonstrating signs of a detached retina. What is the reason this occurred? 1) Blood vessels in the eye spasm 2) Inner layers of the retina separate 3) Overgrowth of vessels damages vision 4) Drainage of vitreous humor is blocked

1) Retinal detachment is not caused by vessel spasms. 2) Retinal detachment occurs when there is a separation of the inner layers of the retina from the underlying retinal pigment epithelium (RPE; choroid). 3) Retinal detachment is not caused by overgrowth of vessels. 4) Retinal detachment is not caused by blocking the drainage of vitreous humor.

11. During a vision test, the nurse notes that a patient has decreased peripheral vision of both eyes. Which health problem should the nurse suspect that this patient is experiencing? 1) Secondary glaucoma 2) Acute angle glaucoma 3) Normal-tension glaucoma 4) Primary open-angle glaucoma

1) Secondary glaucoma usually results from an eye injury, inflammation, tumor, or advanced cases of cataracts, or diabetes. Medications such as steroids, when used chronically, are also noted to cause this type of glaucoma. 2) Acute angle glaucoma is characterized by severe eye pain, nausea and vomiting, sudden onset of visual disturbance (often in low light), blurred vision, halo vision, and reddening of the eye. 3) Normal-tension glaucoma (also referred to as low-tension glaucoma) is a condition where optic nerve damage and vision loss occur despite having a normal IOP between 10 and 21 mm Hg. 4) In primary open-angle glaucoma, clinical manifestations include gradual loss of peripheral vision, usually in both eyes.

13. The nurse is visiting the home of a patient recovering from laser trabeculoplasty. Which observation made by the nurse increases this patient's risk of developing a postoperative complication? 1) Takes a daily laxative 2) Picks up a 3-year-old grandchild 3) Washes hands before applying eye drops 4) Applies pressure to the lacrimal duct after applying eye drops

1) Straining at a bowel movement is contraindicated and can increase the chance of postoperative bleeding within the eye. A laxative would avoid this potential complication. 2) Lifting heavy objects such as a grandchild increases intraocular pressure, which should be avoided after having this surgery. 3) Washing hands before applying eye drops reduces the risk of a postoperative infection. 4) Applying pressure to the lacrimal duct after applying eye drops reduces the risk of systemic absorption of the medication.

3. A patient is scheduled for a cochlear implant. Which patient statement indicates that teaching about this surgery has been effective? 1) "This implant will not restore my hearing." 2) "I will be able to hear perfectly after this surgery." 3) "This surgery will drain fluid from my middle ear." 4) "This surgery will rebuild my damaged tympanic membrane."

1) The cochlear implant does not restore normal hearing. 2) The cochlear implant does not restore normal hearing. 3) A myringotomy drains fluid from the middle ear. 4) A myringoplasty reconstructs the eardrum.

14. The nurse is reviewing teaching provided to a patient with glaucoma. Which patient statement indicates that teaching has been effective? 1) "I should consider surgery to cure this disorder." 2) "I should use the eye drops when my vision blurs." 3) "I should cut down on eating salty and high-fat foods." 4) "I should call my doctor before taking any over-the-counter medications."

1) There is no surgery to cure glaucoma. 2) The eye drops should be used as prescribed and not only with blurred vision. 3) Dietary changes will not affect glaucoma. 4) The patient should be instructed to not take any medication, over-the-counter or prescription, without contacting the eye care practitioner first.

17. A patient with macular degeneration is being treated with verteporfin (Visudyne). What should the nurse emphasize in the patient teaching in order to reduce the risk of complications from this treatment? 1) Apply lotion to the skin for two weeks after the treatment 2) Increase the intake of water for three days after the treatment 3) Avoid indoor and outdoor light for five days after treatment 4) Wear sunglasses when going out of doors for one week after treatment

1) This treatment does not affect the skin. 2) Increased fluid intake is not required after this treatment. 3) It is important to instruct the patient that he or she must avoid exposing skin/eyes to direct sunlight or bright indoor light for five days after treatment with verteporfin (Visudyne) because the medication is activated by light. 4) The patient should avoid indoor and outdoor bright light for five days. Sunglasses would not be needed since bright light is avoided.

21. A patient with severe Ménière's disease is considering a labyrinthectomy. What should the nurse emphasize as a complication of this procedure? 1) Long-term tinnitus 2) Chronic otitis media 3) Rupture of the tympanic membrane 4) Complete hearing loss of the affected ear

1) Tinnitus is not a complication after a labyrinthectomy. 2) Chronic otitis media is not a complication after a labyrinthectomy. 3) Tympanic membrane rupture is not a complication after a labyrinthectomy. 4) A more radical surgery reserved for very severe cases includes removal of part of the inner ear called a labyrinthectomy. Although this surgery also improves the vertigo symptoms, complete hearing loss in the ear on the affected side is a result of the procedure.

2. A patient with a hearing loss is wearing headphones as a part of a diagnostic test. What test is being completed with this patient? 1) Tympanometry 2) Pure-tone threshold 3) MRI with gadolinium 4) Speech reception threshold

1) Tympanometry is a test that measures the impedance of the middle ear to the acoustic energy. 2) Pure-tone threshold is an audiological test conducted with air and bone conduction assessment to quantify hearing loss. To complete this test, the patient wears headphones. 3) Standard MRI with gadolinium enhancement is usually performed with patients who present with an abnormal neurological examination and/or when a cerebellopontine- angle lesion is suspected. 4) Speech reception threshold is used to measure the intensity at which speech is recognized by a patient. This test is used to determine the softest level at which the patient is able to recognize speech.

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

1, 2, 3, 4 Rationale: To administer eye medications, the nurse should wash hands and put gloves on. The client is instructed to tilt the head backward, open the eyes, and look up. The nurse pulls the lower lid down against the cheekbone and holds the bottle like a pencil with the tip downward. Holding the bottle, the nurse gently rests the wrist of the hand on the client's cheek and squeezes the bottle gently to allow the drop to fall into the conjunctival sac. The client is instructed to close the eyes gently and not to squeeze the eyes shut to prevent the loss of medication. Test-Taking Strategy: Focus on the subject, the procedure for administering eye drops. Use guidelines related to standard precautions and visualize this procedure. This will assist in determining the correct interventions.

17. The client is diagnosed with Ménière'sdisease. Which statement indicates the client understands the medical management for this disease? 1. "After intravenous antibiotic therapy, I will be cured." 2. "I will have to use a hearing aid for the rest of my life." 3. "I must adhere to a low-sodium diet, 2,000 mg/day." 4. "I should sleep with the head of my bed elevated."

1. Antibiotics will not cure this disease. Surgery is the only cure for Ménière's disease, which may result in permanent deafness as a result of the labyrinth being removed in the surgery. 2. Ménière's disease does not lead to deafness unless surgery is performed removing the labyrinth in attempts to eliminate the attacks of vertigo. 3. Sodium regulates the balance of fluid within the body; therefore, a low-sodium diet is prescribed to help control the symptoms of Ménière's disease. 4. Sleeping with the head of the bed elevated will not affect Ménière's disease. TEST-TAKING HINT: Sleeping with the HOB elevated is not a medical treatment; there- fore, option "4" can be eliminated as a possible answer. The test taker must read the stem carefully.

20. The client is two (2) hours postoperative right- ear mastoidectomy. Which assessment data should be reported to the health-care provider? 1. Complaints of aural fullness. 2. Hearing loss in the affected ear. 3. No vertigo. 4. Facial drooping.

1. Aural fullness or pressure after surgery is caused by residual blood or fluid in the middle ear. This is an expected occurrence after surgery, and the nurse should administer the prescribed analgesic. 2. Hearing in the operated ear may be reduced for several weeks because of edema, accumulation of blood and tissue fluid in the middle ear, and dressings or packing, so this does not need to be reported to the health-care provider. 3. Vertigo (dizziness) is uncommon after this surgery, but if it occurs the nurse should administer an antiemetic or antivertigo medication and does not need to report it to the health-care provider. 4. The facial nerve, which runs through the middle ear and mastoid, is at risk for in- jury during mastoid surgery; therefore, a facial paresis should be reported to the health-care provider.

13. The nurse is assessing the client's cranial nerves. Which assessment data indicate cranial nerve I is intact? 1. The client can identify cold and hot on the face. 2. The client does not have any tongue tremor. 3. The client has no ptosis of the eyelids. 4. The client is able to identify a peppermint smell.

1. Being able to identify cold and hot on the face indicates an intact trigeminal nerve, cranial nerve V. 2. Not having any tongue tremor indicates an intact hypoglossal nerve, cranial nerve XI. 3. No ptosis of the eyelids indicates an intact oculomotor nerve (cranial nerve III), trochlear nerve (IV), and abducens nerve (VI). Tests also assess for ocular motion, conjugate movements, nystagmus, and papillary reflexes. 4. Cranial nerve I is the olfactory nerve, which involves the sense of smell. With the eyes closed, the client must identify familiar smells to indicate an intact cranial nerve I.

21. Which ototoxic medication should the nurse recognize as potentially life altering or threatening to the client? 1. An oral calcium channel blocker. 2. An intravenous aminoglycoside antibiotic. 3. An intravenous glucocorticoid. 4. An oral loop diuretic.

1. Calcium channel blockers are not going to affect the client's hearing. 2. Aminoglycoside antibiotics are ototoxic. Overdosage of these medications can cause the client to go deaf, which is why peak and trough serum levels are drawn while the client is taking a medication of this type. These antibiotics are also very nephrotoxic. 3. Steroids cause many adverse effects, but damage to the ear is not one of them. 4. Administering an intravenous push loop diuretic too fast can cause auditory nerve damage, but an oral loop diuretic does not.

13. Which statement indicates to the nurse the client is experiencing some hearing loss? 1. "I clean my ears every day after I take a shower." 2. "I keep turning up the sound on my television." 3. "My ears hurt, especially when I yawn." 4. "I get dizzy when I get up from the chair."

1. Cleaning the ears daily does not indicate the client has a hearing loss. 2. The need to turn up the volume on the television is an early sign of hearing impairment. 3. Pain in the ears is not a clinical manifestation of hearing loss/impairment. 4. This statement may indicate a balance problem secondary to an ear disorder, but it does not indicate a hearing loss. TEST-TAKING HINT: If the test taker has no idea of the answer, option "2" is the only answer which has anything to do with sound.

9. The student nurse asks the nurse, "Which type of hearing loss involves damage to the cochlea or vestibulocochlear nerve?" Which statement is the best response of the nurse? 1. "It is called conductive hearing loss." 2. "It is called a functional hearing loss." 3. "It is called a mixed hearing loss." 4. "It is called sensorineural hearing loss."

1. Conductive hearing loss results from an external ear disorder, such as impacted cerumen, or a middle ear disorder, such as otitis media or otosclerosis. 2. Functional (psychogenic) hearing loss is non- organic and unrelated to detectable structural changes in the hearing mechanisms. It is usually a manifestation of an emotional disturbance. 3. Mixed hearing loss involves both conductive loss and sensorineural loss. It results from dysfunction of air and bone conduction. 4. Sensorineural hearing loss is described in the stem of the question. It involves damage to the cochlea or vestibulocochlear nerve.

7. The 65-year-old male client who is complaining of blurred vision reports he thinks his glasses need to be cleaned all the time, and he denies any type of eye pain. Which eye disorder should the nurse suspect the client has? 1. Corneal dystrophy. 2. Conjunctivitis. 3. Diabetic retinopathy. 4. Cataracts.

1. Corneal dystrophy is an inherited eye disorder occurring at about age 20 and results in de- creased vision and the development of blisters; it is usually associated with primary open-angle glaucoma. 2. Conjunctivitis is an inflammation of the conjunctiva, which results in a scratching or burning sensation, itching, and photophobia. 3. Diabetic retinopathy results from deterioration of the small blood vessels nourished by the retina; it leads to blindness. 4. A cataract is a lens opacity or cloudiness, resulting in the signs/symptoms discussed in the stem of the question. TEST-TAKING HINT: The test taker mustknow the signs/symptoms of eye disorders, especially those commonly occurring in the elderly. Option "2" could be ruled out because -itis means inflammation and none of the signs/symptoms is inflammatory.

2. The client is scheduled for right-eye cataract removal surgery in five (5) days. Which preoperative instruction should be discussed with the client? 1. Administer dilating drops to both eyes for 72 hours prior to surgery. 2. Prior to surgery do not lift or push any objects heavier than 15 pounds. 3. Make arrangements for being in the hospital for at least three (3) days. 4. Avoid taking any type of medication which may cause bleeding, such as aspirin.

1. Dilating drops are administered every10 minutes for four (4) doses one (1) hour prior to surgery, not for three (3) days prior to surgery. 2. Lifting and pushing objects should be avoided after surgery, not prior to surgery. 3. All types of cataract removal surgery are usually done in day surgery. 4. To reduce retrobulbar hemorrhage, any anticoagulation therapy is withheld, including aspirin, nonsteroidal anti- inflammatory drugs (NSAIDs), and warfarin (Coumadin). TEST-TAKING HINT: The test taker must notice the adjectives; these descriptors are important when selecting a correct answer. The test taker should notice "preoperative" and "prior to surgery."

29. The nurse is caring for a client diagnosed with a cerebrovascular accident (CVA). Which assessment information should the nurse determine first when placing the client in the assigned room? 1. Determine if the client has loss of vision in the same half of each visual field. 2. Find out if the client prefers the bed by the window or by the bathroom. 3. Request dietary to place the meat at 1200 on each plate and vegetables at 0900 and 1500. 4. Request a physical therapy consult to assess the client's mobility issues.

1. Homonymous hemianopsia (blindness in the same half of each visual field) is a common problem after a stroke. Clients disregard objects in that part of the visual field. The nurse would want to place the client in a room with the bed positioned so that the client will know when some- one is entering the room. 2. Client preference can be taken into consideration but is not a priority. 3. Requesting dietary to place foods in a certain order will assist the client with visual disturbances to know where to find the food on the plate but is not first. 4. Physical therapy may need to assess the client, but it is not first. TEST-TAKING HINT: The signs/symptoms of CVA vary and some of the clinical manifestations may not be immediately observable. The brain impacts the entire body. The test taker must know which symptoms impact the client's daily life.

7. The client with a retinal detachment has just undergone a gas tamponade repair. Which discharge instruction should the nurse include in the teaching? 1. The client must lie flat with the face down. 2. The head of the bed must be elevated 45 degrees. 3. The client should wear sunglasses when outside. 4. The client should avoid reading for three (3) weeks.

1. If gas tamponade is used to flatten the retina, the client may have to be specially positioned to make the gas bubble float into the best position; clients must lie face down or on the side for days. 2. The HOB should not be elevated after this surgery. 3. There is no need for the client to wear sunglasses; this surgery does not cause photophobia. 4. The client does not need to avoid reading.

1. The client is diagnosed with glaucoma. Which symptom should the nurse expect the client to report? 1. Loss of peripheral vision. 2. Floating spots in the vision. 3. A yellow haze around everything. 4. A curtain coming across vision.

1. In glaucoma, the client is often unaware he or she has the disease until the client experiences blurred vision, halos around lights, difficulty focusing, or loss of peripheral vision. Glaucoma is often called the "silent thief." 2. Floating spots in the vision is a symptom of retinal detachment. 3. A yellow haze around everything is a com- plaint of clients experiencing digoxin toxicity. 4. The complaint of a curtain coming across vi- sion is a symptom of retinal detachment. TEST-TAKING HINT: The signs/symptoms of eye disorders are confusing. The test taker must know which complaints will be made by the client with a specific eye disorder.

24. The client is scheduled for ear surgery. Which statement indicates the client needs more preoperative teaching concerning the surgery? 1. "If I have to sneeze or blow my nose, I will do it with my mouth open." 2. "I may get dizzy after the surgery, so I must be careful when walking." 3. "I will probably have some hearing loss after surgery, but hearing will return." 4. "I can shampoo my hair the day after surgery as long as I am careful."

1. Leaving the mouth open when coughing or sneezing will minimize pressure changes in the ear. 2. Surgery on the ear may disrupt the client's equilibrium, increasing the risk for falling. 3. Hearing loss secondary to postoperative edema is common after surgery, but the hearing will return after the edema subsides. 4. Shampooing, showering, and immersing the head in water are avoided to prevent contamination of the ear canal; therefore, this comment indicates the client does not understand the preoperative teaching. TEST-TAKING HINT: This is an "except" question. The stem states "needs more teaching"; therefore, three (3) of the options reflect an appropriate understanding of the teaching and only one (1) indicates a misunderstand- ing of the teaching.

12. The client comes to the emergency department after splashing chemicals into the eyes. Which intervention should the nurse implement first? 1. Have the client move the eyes in all directions. 2. Administer a broad-spectrum antibiotic. 3. Irrigate the eyes with normal saline solution. 4. Determine when the client had a tetanus shot.

1. Movement of the eye should be avoided until the client has received general anesthesia; therefore, this is not the first intervention. 2. Parenteral broad-spectrum antibiotics are initiated but not until the eyes are treated first. 3. Before any further evaluation or treatment, the eyes must be thoroughly flushed with sterile normal saline solution. 4. Tetanus prophylaxis is recommended for full-thickness ocular wounds. TEST-TAKING HINT: If the test taker is not sure of the answer, the test taker should select the answer directly addressing the client's condition. Options "1" and "3" directly affect the eyes, but when choosing between these two options, the test taker should ask, "How will moving the eyes help treat the eyes?" and then eliminate option "1."

30. The elderly client has undergone a right-eye cataract removal with an intraocular implant. Which discharge instructions should the nurse teach the client? 1. Have the client demonstrate placing the otic drops in the ear. 2. Teach the client to instill the eyedrops as prescribed. 3. Remind the client to keep the lights in the home low at all times. 4. Encourage the client to sleep on two pillows at night.

1. Otic drops go in the ear, not the eye. 2. Postoperatively the client will be prescribed eyedrops for several weeks; the nurse should teach the client to administer as prescribed. 3. The light should be brighter for safety. 4. The client does not need to sleep with the HOB elevated. TEST-TAKING HINT: The test taker must know basic instructions for postoperative clients.

10. The client diagnosed with glaucoma is prescribed a miotic cholinergic medication. Which data indicate the medication has been effective? 1. No redness or irritation of the eyes. 2. A decrease in intraocular pressure. 3. The pupil reacts briskly to light. 4. The client denies any type of floaters.

1. Steroid medication is administered to decrease inflammation. 2. Both systemic and topical medications are used to decrease the intraocular pressure in the eye, which causes glaucoma. 3. Glaucoma does not affect the pupillary reaction. 4. Floaters are a complaint of clients with retinal detachment. TEST-TAKING HINT: To determine the ef- fectiveness of a medication, the nurse must know the signs/symptoms of the disease pro- cess. If the test taker knew glaucoma was the result of an increase in intraocular pressure, then the medication is effective if there was a decrease in intraocular pressure.

56. Which assessment data indicate to the nurse the client has a conductive hearing loss? 1. The Rinne test results in air-conducted sound being louder than bone-conducted. 2. The client is unable to hear accurately when conducting the whisper test. 3. The Weber test results in the sound being heard better in the affected ear. 4. The tympanogram results in the ticking watch heard better in the unaffected ear.

1. The Rinne test result indicate a normal hearing; in conductive hearing loss, bone-conductive sound is heard as long as or longer than air-conducted sound. 2. The whisper test is used to make a general estimation of hearing, but it is not used to specifically diagnose for conductive hearing loss. 3. The Weber test uses bone conduction to test lateralization of sound by placing a tuning fork in the middle of the skull or forehead. A normal test results in the client hearing the sound equally in both ears. 4. The tympanogram (impedance audiometry) measures middle-ear muscle reflex to sound stimulation and compliance of the tympanic membrane by changing air pressure in a sealed ear canal. It does not specifically sup- port the diagnosis of conductive hearing loss.

25. The 72-year-old client tells the nurse food does not taste good anymore and he has lost a little weight. Which information should the nurse discuss with the client? 1. Suggest using extra seasoning when cooking. 2. Instruct the client to keep a seven (7)-day food diary. 3. Refer the client to a dietitian immediately. 4. Recommend eating three (3) meals a day.

1. The acuity of taste buds decreases with age, which may cause a decreased appetite and subsequent weight loss. Spices or other seasonings may help the food taste better to the client. 2. This may be an appropriate intervention if excessive weight is lost or if seasoning the food does not increase appetite, but it is not necessary at this time. 3. The client does not need a dietary consult for food not "tasting good." The nurse can address the client's concern. 4. This recommendation does not address the client's comment about food not tasting good.

11. The client is scheduled for laser-assisted in situ keratomileusis (LASIK) surgery for severe myopia. Which instruction should the nurse discuss prior to the client's discharge from day surgery? 1. Wear bilateral eye patches for three (3) days. 2. Wear corrective lenses until the follow-up visit. 3. Do not read any material for at least one (1) week. 4. Teach the client how to instill corticosteroid ophthalmic drops.

1. The client does not have to wear eye patches after this surgery. 2. The purpose of this surgery is to ensure the client does not have to wear any type of corrective lens. 3. The client can read immediately after this surgery. 4. LASIK surgery is an effective, safe, predictable surgery performed in day surgery; there is minimal postoperative care. Instilling topical corticosteroid drops helps decrease inflammation and edema of the eye. TEST-TAKING HINT: Option "3" has the absolute word "any," so the test taker could eliminate it. LASIK is a corrective surgery, and if the problem is corrected, then corrective lenses should not be necessary.

25. The nurse is observing the client administer the prescribed eyedrops. Which intervention should the nurse implement? 1. Praise the client for instilling the eyedrops as recommended. 2. Remind the client to instill the eyedrops from 0.4 to 0.8 inch above the eye. 3. Ask the client if the eyedrops have been warmed to room temperature. 4. Teach the client to instill the eyedrops in the upper conjunctival sac.

1. The client is holding the dropper too high. Eyedrops are instilled from one (1) to two (2) cm (0.4 to 0.8 inch) above the eye. 2. Eyedrops are instilled from one (1) to two (2) cm (0.4 to 0.8 inch) above the eye. The client should not hold the dropper too high. 3. Eyedrops can be instilled at room temperature or chilled. If a client has trouble recognizing if the drops have been instilled, the nurse can recommend refrigerating the drops so the client can feel when the eyedrops have been administered. 4. Eyedrops are administered in the lower conjunctival sac. TEST-TAKING HINT: The test taker must remember basics of medication administration.

22. The client with cataracts who has had intraocular lens implants is being discharged from the day surgery department. Which discharge instructions should the nurse discuss with the client? 1. Do not push or pull objects heavier than 50 pounds. 2. Lie on the affected eye with two pillows at night. 3. Wear glasses or metal eye shields at all times. 4. Bend and stoop carefully for the rest of your life.

1. The client should not lift, push, or pull objects heavier than 15 pounds; 50 pounds is excessive. 2. The client should avoid lying on the side of the affected eye at night. 3. The eyes must be protected by wearing glasses or metal eye shields at all times following surgery. Very few answer options with "all" will be correct, but if the option involves ensuring safety, it may be the correct option. 4. The client should avoid bending or stooping for an extended period—but not forever.

1. Which recommendation should the nurse suggest to an elderly client who lives alone when discussing normal developmental changes of the olfactory organs? 1. Suggest installing multiple smoke alarms in the home. 2. Recommend using a night-light in the hallway and bathroom. 3. Discuss keeping a high-humidity atmosphere in the bedroom. 4. Encourage the client to smell food prior to eating it.

1. The decreased sense of smell resulting from atrophy of olfactory organs is a safety hazard, and clients may not be able to smell gas leaks or fire, so the nurse should recommend a carbon monoxide detector and a smoke alarm. This safety equipment is critical for the elderly. 2. Night-lights do not address the client's sense of smell. 3. High humidity may help with breathing, but it does not help the sense of smell. 4. The client's sense of smell is decreased; there- fore, smelling food before eating is not an appropriate intervention.

2. The elderly male client tells the nurse, "My wife says her cooking hasn't changed, but it is bland and tasteless." Which response by the nurse is most appropriate? 1. "Would you like me to talk to your wife about her cooking?" 2. "Taste buds change with age, which may be why the food seems bland." 3. "This happens because the medications sometimes cause a change in taste." 4. "Why don't you barbecue food on a grill if you don't like your wife's cooking?"

1. The nurse needs to discuss possible causes with the client and not talk to the wife. 2. The acuity of the taste buds decreases with age, which could cause regular foods to seem bland and tasteless. 3. Some medications may cause a metallic taste in the mouth, but medication does not cause foods to taste bland. 4. Telling the client to cook if he doesn't like his wife's food is an argumentative and judgmental response.

26. The nurse is administering eardrops to a six (6)-year-old client. Which indicates the nurse is aware of the correct method for instilling eardrops to a child? 1. Pull the pinna upward only to instill the eardrops. 2. Pull the pinna to a neutral position to instill the eardrops. 3. Pull the pinna upward and backward prior to instilling the drops. 4. Pull the pinna downward and forward to instill the drops.

1. The pinna should be pulled upward and backward for all clients three (3) years of age and older. Prior to three (3) years of age the pinna is directed upward only. 2. The pinna should be pulled upward and backward for all clients three (3) years of age and older. Prior to three (3) years of age the pinna is directed upward only. 3. The pinna should be pulled upward and backward for all clients three (3) years of age and older. Prior to three (3) years of age the pinna is directed upward only. 4. The pinna should be pulled upward and backward for all clients three (3) years of age and older. Prior to three (3) years of age the pinna is directed upward only. TEST-TAKING HINT: The test taker must remember basics of medication administration.

18. Which referral is most important for the nurse to implement for the client with permanent hearing loss?1. Aural rehabilitation. 2. Speech therapist. 3. Social worker. 4. Vocational rehabilitation.

1. The purpose of aural rehabilitation is to maximize the communication skills of the client who is hearing impaired. It includes auditory training, speech reading, speech training, and the use of hearing aids and hearing guide dogs. 2. A speech therapist may be part of the aural rehabilitation team, but the most important referral is aural rehabilitation. 3. The client may or may not need financial assistance, but the most important referral is aural rehabilitation. 4. The client may or may not need assistance with employment because of hearing loss, but the most important referral is the aural rehabilitation.

14. Which risk factors should the nurse discuss with the client concerning reasons for hearing loss? Select all that apply. 1. Perforation of the tympanic membrane. 2. Chronic exposure to loud noises. 3. Recurrent ear infections. 4. Use of nephrotoxic medications. 5. Multiple piercings in the auricle.

1. The tympanic membrane is the eardrum, and if it is punctured it may lead to hear- ing loss. 2. Loud persistent noise, such as heavy machinery, engines, and artillery, over time may cause noise-induced hearing loss. 3. Multiple ear infections scar the tympanic membrane, which can lead to hearing loss. 4. Nephrotoxic means harmful to the kidneys; ototoxic is harmful to the ears. 5. Multiple pierced earrings do not lead to hearing loss. The auricle (skin attached to the head) is composed mainly of cartilage, except for the fat and subcutaneous tissue in the earlobe. TEST-TAKING HINT: This alternate-type question requires the test taker to select multiple correct answers. Many options can be eliminated as incorrect answers when the test taker knows medical terminology— nephro- means kidney-related—and normal anatomy of the body—auricle means "skin attached to the head."

17. Which assessment technique should the nurse use to assess the client's optic nerve? 1. Have the client identify different smells. 2. Have the client discriminate between sugar and salt. 3. Have the client read the Snellen chart. 4. Have the client say "ah" to assess the rise of the uvula.

1. This assesses cranial nerve I, the olfactory nerve. 2. This assesses cranial nerve IX, the glossopharyngeal nerve. 3. This assesses cranial nerve II, the optic nerve, along with visual field testing and ophthalmoscopic examination. 4. This assesses cranial nerve X, the vagus nerve.

4. Which assessment technique should the nurse implement when assessing the client's cranial nerves for vibration? 1. Move the big toe up and down and ask in which direction the vibration is felt. 2. Place a tuning fork on the big toe and ask if the vibrations are felt. 3. Tap the client's cheek with the finger and determine if vibrations are felt. 4. Touch the arm with two sharp objects and ask if one (1) vibration or two (2) is felt.

1. This assesses proprioception, or position sense; direction of the toe must be evaluated. 2. Vibration is assessed by using a low- frequency tuning fork on a bony prominence and asking the client whether he or she feels the sensation and, if so, when the sensation ceases. 3. Tapping the cheek assesses for tetany, not cranial nerve involvement. 4. A two-point discrimination test evaluates integration of sensation, but it does not assess for vibration.

20. The nurse is preparing to administer oticdrops into an adult client's right ear. Which intervention should the nurse implement? 1. Grasp the earlobe and pull back and out when putting drops in the ear. 2. Insert the eardrops without touching the outside of the ear. 3. Instruct the client to close the mouth and blow prior to instilling drops. 4. Pull the auricle down and back prior to instilling drops.

1. This is not the correct way to administer eardrops. 2. The nurse must straighten the ear canal; therefore, the outside of the ear must be moved. 3. This will increase pressure in the ear and should not be done prior to administering eardrops. 4. This will straighten the ear canal so the eardrops will enter the ear canal and drain toward the tympanic membrane (eardrum). TEST-TAKING HINT: The test taker should notice options "1" and "4" are opposite, which should clue the test taker into either eliminating both or deciding one (1) of these two (2) is the correct answer. Either way, the test taker now has a 50/50 chance of selecting the correct answer.

3. The client is postoperative retinal detachment surgery, and gas tamponade was used to flatten the retina. Which intervention should the nurse implement first? 1. Teach the signs of increased intraocular pressure. 2. Position the client as prescribed by the surgeon. 3. Assess the eye for signs/symptoms of complications. 4. Explain the importance of follow-up visits.

1. This should be done, but it is not the first intervention the nurse should implement. 2. The client will have to be specifically positioned to make the gas bubble float into the best position; some clients must lie face down or on their side for days, but it is not the first intervention. 3. The nurse's priority must be assessment of complications, which include increased intraocular pressure, endophthalmitis, development of another retinal detachment, or loss of turgor in the eye. 4. Follow-up visits are important, but this is not the first intervention the nurse should implement. TEST-TAKING HINT: When the question asks which intervention should be implemented first, all four (4) answer options are possible interventions but only one (1) should be implemented first. Remember to apply the nursing process to help select the correct answer. Assessment is the first part of the nursing process.

18. The client is complaining of ringing in the ears. Which data are most appropriate for the nurse to document in the client's chart? 1. Complaints of vertigo. 2. Complaints of otorrhea. 3. Complaints of tinnitus. 4. Complaints of presbycusis.

1. Vertigo is an illusion of movement in which the client complains of dizziness. 2. Otorrhea is drainage of the ear. 3. Tinnitus is "ringing of the ears." It is a subjective perception of sound with internal origins. 4. Presbycusis is progressive hearing loss associated with aging. TEST-TAKING HINT: The test taker who is familiar with medical terminology can rule out options based on the understanding of medical terms.

21. Which behavior by the male client should make the nurse suspect the client has a hearing loss? Select all that apply. 1. The client reports hearing voices in his head. 2. The client becomes irritable very easily. 3. The client has difficulty making decisions. 4. The client's wife reports he ignores her. 5. The client does not dominate a conversation.

1. Voices in the head may indicate schizophrenia, but it is not a symptom of hearing loss. 2. Fatigue may be the result of straining to hear, and a client may tire easily when listening to a conversation. Under these circumstances, the client may become irritable very easily. 3. Loss of self-confidence makes it increasingly difficult for a person who is hearing impaired to make a decision. 4. Often it is not the person with the hear- ing loss but a significant other who notices hearing loss; hearing loss is usually gradual. 5. Many clients who are hearing impaired tend to dominate the conversation because, as long as it is centered on the client, they can control it and are not as likely to be embarrassed by some mistake.

24. Which statement by the daughter of an 80-year-old female client who lives alone warrants immediate intervention by the nurse? 1. "I put a night-light in my mother's bedroom." 2. "I got carbon monoxide detectors for my mother's house." 3. "I changed my mother's furniture around." 4. "I got my mother large-print books."

1. With normal aging comes decreased peripheral vision, constricted visual field, and tactile alterations. A night-light addresses safety issues and warrants praise, not intervention. 2. Carbon monoxide detectors help ensure safety in the mother's home, so this comment doesn't warrant intervention. 3. Decreased peripheral vision, constricted visual fields, and tactile alterations are associated with normal aging. The client needs a familiar arrangement of furniture for safety. Moving the furniture may cause the client to trip or fall. The nurse should intervene in this situation. 4. As a result of normal aging, vision may become impaired, and the provision of large-print books warrants praise.

756. A client with Meniere's disease is experiencing severe vertigo. Which instruction should the nurse give to the client to assist in controlling the vertigo? 1. Increase sodium in the diet. 2. Avoid sudden head movements. 3. Lie still and watch the television. 4. Increase fluid intake to 3000 mL a day.

2 Rationale: The nurse instructs the client to make slow head movements to prevent worsening of the vertigo. Dietary changes such as salt and fluid restrictions that reduce the amount of endolymphatic fluid are sometimes prescribed. Lying still and watching television will not control vertigo. Test-Taking Strategy: Focus on the subject, preventing vertigo. Note the relationship between vertigo and avoiding sudden head movements in the correct option.

745. A client is diagnosed with a disorder involving the inner ear. Which is the most common client com- plaint associated with a disorder involving this part of the ear? 1. Pruritus 2. Tinnitus 3. Hearing loss 4. Burning in the ear

2 Rationale: Tinnitus is the most common complaint of clients with otological disorders, especially disorders involving the inner ear. Symptoms of tinnitus range from mild ringing in the ear, which can go unnoticed during the day, to a loud roar- ing in the ear, which can interfere with the client's thinking pro- cess and attention span. Options 1, 3, and 4 are not associated specifically with disorders of the inner ear.Test-Taking Strategy: Note the strategic word, most. Recalling the anatomy and the function of the inner ear will direct you to the correct option.

768. In preparation for cataract surgery, the nurse is to administer cyclopentolate eye drops at 0900 for surgery that is scheduled for 0915. What initial action should the nurse take in relation to the char- acteristics of the medication action? 1. Provide lubrication to the operative eye prior to giving the eye drops. 2. Call the surgeon, as this medication will further constrict the operative pupil. 3. Consult the surgeon, as there is not sufficient time for the dilative effects to occur. 4. Give the medication as prescribed; the surgeon needs optimal constriction of the pupil.

3 Rationale: Cyclopentolate is a rapidly acting mydriatic and cycloplegic medication. Cyclopentolate is effective in 25 to 75 minutes, and accommodation returns in 6 to 24 hours. Cyclopentolate is used for preoperative mydriasis, not pupil constriction. The nurse should consult with the surgeon about the time of administration of the eye drops since 15 minutes is not adequate time for dilation to occur.Test-Taking Strategy: Note the strategic word, initial. Options 2 and 4 are comparable or alike and are eliminated first (mio- sis refers to a constricted pupil). Note that the question identifies a client being prepared for eye surgery. The pupil would need to be dilated for the surgical procedure.

766. A miotic medication has been prescribed for the client with glaucoma and the client asks the nurse about the purpose of the medication. Which response should the nurse provide to the client? 1. "The medication will help dilate the eye to prevent pressure from occurring." 2. "The medication will relax the muscles of the eyes and prevent blurred vision." 3. "The medication causes the pupil to constrict and will lower the pressure in the eye." 4. "The medication will help block the responses that are sent to the muscles in the eye."

3 Rationale: Miotics cause pupillary constriction and are used to treat glaucoma. They lower the intraocular pressure, thereby increasing blood flow to the retina and decreasing retinal dam- age and loss of vision. Miotics cause a contraction of the ciliary muscle and a widening of the trabecular meshwork. Options 1, 2, and 4 are incorrect.

742. 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 Rationale: The administration of eye drops is a critical component of the treatment plan for the client with glaucoma. The client needs to be instructed that medications will need to be taken for the rest of his or her life. Options 1, 2, and 4 are not accurate instructions.Test-Taking Strategy: Focus on the subject, client teaching for glaucoma. Recalling that medications are an integral component of the treatment plan will assist in directing you to the correct option.

8. The nurse suspects that a patient is developing a cataract. What finding did the nurse use to make this clinical decision? 1) Itching of both eyes 2) Tearing of both eyes 3) Redness of the sclera 4) Double vision in one eye

1) Itching eyes is not a manifestation of cataracts. 2) Eye tearing is not a manifestation of cataracts. 3) Reddened sclera is not a manifestation of cataracts. 4) Double vision in one eye is a manifestation of cataracts.

16. A patient has been experiencing a gradual loss of central vision. Which tool should the nurse use when assessing this patient? 1) Jaeger card 2) Amsler grid 3) Snellen chart 4) Ishihara chart

1) The Jaeger card assesses near vision. 2) The Amsler grid is used to determine if a matrix of black lines appear straight or are wavy, which could indicate macular degeneration. 3) The Snellen chart is used to assess for visual acuity. 4) The Ishihara chart is used to assess color vision

752. 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, 3, 5, 6 Rationale: Following eye surgery, some scratchiness and mild eye discomfort may occur in the operative eye and usually is relieved by mild analgesics. If the eye pain becomes severe, the client should notify the surgeon because this may indicate hemorrhage, infection, or increased intraocular pressure (IOP). The nurse also would instruct the client to notify the surgeon of increased purulent drainage, increased redness, or any decrease in visual acuity. The client is instructed to place an eye shield over the operative eye at bedtime to protect the eye from injury during sleep and to avoid activities that increase IOP, such as bending over.Test-Taking Strategy: Focus on the subject, postoperative care following eye surgery. Recalling that the eye needs to be protected and that increased IOP is a concern will assist in deter- mining the home care measures to be included in the plan. Review: Cataract extraction with intraocular implant

5. The nurse who is at a local park sees a young man on the ground who has fallen and has a stick lodged in his eye. Which intervention should the nurse implement at the scene? 1. Carefully remove the stick from the eye. 2. Stabilize the stick as best as possible. 3. Flush the eye with water if available. 4. Place the young man in a high-Fowler's position.

1. A foreign object should never be removed at the scene of the accident because this may cause more damage. 2. The foreign object should be stabilized to prevent further movement, which could cause more damage to the eye. 3. Flushing with water may cause further movement of the foreign object and should be avoided. 4. The person should be kept flat and not in a sit- ting position because it may dislodge or cause movement of the foreign object. TEST-TAKING HINT: In an emergency situation, the first responder should first "do no harm." The test taker should examine each option and decide what will happen if this option is performed—will it help, harm, or stabilize the client? If the test taker determines one (1) action may not help, then stabilization becomes the priority.

6. Which situation makes the nurse suspect the client has glaucoma? 1. An automobile accident because the client did not see the car in the next lane. 2. The cake tasted funny because the client could not read the recipe. 3. The client has been wearing mismatched clothes and socks. 4. The client ran a stoplight and hit a pedestrian walking in the crosswalk.

1. Loss of peripheral vision as a result of glaucoma causes the client problems with seeing things on each side, resulting in a "blind spot." This problem can lead to the client having car accidents when switching lanes. 2. This is indicative of cataracts because clients with cataracts have blurred vision and cannot read clearly. 3. This is indicative of cataracts because there is a color shift to yellow-brown and there is reduced light transmission. 4. This is indicative of macular degeneration, in which the central vision is affected.

4. The 65-year-old client is diagnosed with macular degeneration. Which statement by the client indicates the client needs more discharge teaching? 1. "I should use magnification devices as much as possible." 2. "I will look at my Amsler grid at least twice a week." 3. "I need to use low-watt light bulbs in my house." 4. "I am going to contact a low-vision center to evaluate my home."

1. Magnifying devices used with activities such as threading a needle will help the client's vision; therefore, this statement does not indicate the client needs more teaching. 2. An Amsler grid is a tool to assess macular degeneration, often providing the earliest sign of a worsening condition. If the lines of the grid become distorted or faded, the client should call the ophthalmologist. 3. Macular degeneration is the most common cause of visual loss in people older than age 60 years. Any intervention which helps increase vision should be included in the teaching, such as bright lighting, not decreased lighting. 4. Low-vision centers will send representatives to the client's home or work to make recommendations about improving lighting, thereby improving the client's vision and safety. TEST-TAKING HINT: This question is asking which statement indicates more teachingis needed. Therefore, three (3) options will indicate the client understands appropriate discharge teaching and only one (1) will indicate the client does not understand the teaching.

8. The nurse is administering eyedrops to the client. Which guidelines should the nurse adhere to when instilling the drops into the eye? Select all that apply. 1. Do not touch the tip of the medication container to the eye. 2. Apply gentle pressure on the outer canthus of the eye. 3. Apply sterile gloves prior to instilling eyedrops. 4. Hold the lower lid down and instill drops into the conjunctiva. 5. Gently pat the skin to absorb excess eyedrops on the cheek.

1. Touching the tip of the container to the eye may cause eye injury or an eye infection. 2. Gentle pressure should be applied on the inner canthus, not outer canthus, near the bridge of the nose for one (1) or two (2) minutes after instilling eyedrops. 3. The nurse should wash hands prior to and after instilling medications; this is not a sterile procedure. 4. Medication should not be placed directly on the eye but in the lower part of the eyelid. 5. Eyedrops are meant to go in the eye, not on the skin, so the nurse should use a clean tissue to remove excess medication.

753. 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 Rationale: Tonometry is a method of measuring intraocular fluid pressure. Pressures between 10 and 21 mm Hg are considered within the normal range. However, IOP is slightly higher in the morning. Therefore, the initial action is to check the time the test was performed. Normal saline drops are not a specific treatment for glaucoma. It is not necessary to contact the HCP as an initial action. Flat positions may increase the pressure. Test-Taking Strategy: Focus on the subject, normal IOP, and note the strategic word, initial. Remember that normal IOP is between 10 and 21 mm Hg and the pressure may be higher in the morning.

760. Betaxolol hydrochloride eye drops have been prescribed for a client with glaucoma. Which nursing action is most appropriate related to monitoring for side and adverse effects of this medication? 1. Assessing for edema 2. Monitoring temperature 3. Monitoring blood pressure 4. Assessing blood glucose level

3 Rationale: Hypotension, dizziness, nausea, diaphoresis, head- ache, fatigue, constipation, and diarrhea are side and adverse effects of the medication. Nursing interventions include monitoring the blood pressure for hypotension and assessing the pulse for strength, weakness, irregular rate, and bradycardia. Options 1, 2, and 4 are not specifically associated with this medication.Test-Taking Strategy: Note the strategic words, most appropriate. Use the ABCs—airway-breathing-circulation—to direct you to the correct option.

743. 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 Rationale: A characteristic manifestation of retinal detachment described by the client is the feeling that a shadow or curtain is falling across the field of vision. No pain is associated with detachment of the retina. Options 1 and 3 are not characteristics of this disorder. A retinal detachment is an ophthalmic emergency and even more so if visual acuity is still normal. Test-Taking Strategy: Focus on the subject, manifestations of retinal detachment. Thinking about the pathophysiology associated with this disorder will direct you to the correct option.

746. 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 Rationale: A gradual, painless blurring of central vision is the chief clinical manifestation of a cataract. Early symptoms include slightly blurred vision and a decrease in color perception. Options 1, 2, and 3 are not characteristics of a cataract. Test-Taking Strategy: Note the strategic word, early. Remember the pathophysiology related to cataract development. As a cataract develops, the lens of the eye becomes opaque. This description will assist in directing you to the correct option.

26. The male client diagnosed with type 2 diabetes mellitus tells the nurse he has begun to see yellow spots. Which interventions should the nurse implement? List in order of priority. 1. Notify the health-care provider. 2. Check the client's hemoglobin A1c. 3. Assess the client's vision using the Amsler grid. 4. Teach the client about controlling blood glucose levels. 5. Determine where the spots appear to be in the client's field of vision.

In order of priority: 5, 3, 2, 1, 4.5. 5. The nurse should question the client further to obtain information such as which eye is affected, how long the client has been seeing the spots, and whether this ever occurred before. 3. The Amsler grid is helpful in determining losses occurring in the visual fields. 2. The hemoglobin A1c laboratory tests results indicate glucose control over the past two (2) to three (3) months. Diabetic retinopathy is directly related to poor blood glucose control. 1. The health-care provider should be notified to plan for laser surgery on the eye. 4. The client should be instructed about controlling blood glucose levels, but this can wait until the immediate situation is resolved or at least until measures to address the potential loss of eyesight have been taken.

767. A client was just admitted to the hospital to rule out a gastrointestinal (GI) bleed. The client has brought several bottles of medications prescribed by different specialists. During the admission assessment, the client states, "Lately, I have been hearing some roaring sounds in my ears, especially when I am alone." Which medication would the nurse identify as the cause of the client's complaint? 1. Doxycycline 2. Atropine sulfate 3. Acetylsalicylic acid 4. Diltiazem hydrochloride

3 Rationale: Aspirin is contraindicated for GI bleeding and is potentially ototoxic. The client should be advised to notify the prescribing health care provider so the medication can be discontinued and/or a substitute that is less toxic to the ear can be taken instead. Options 1, 2, and 4 do not have effects that are potentially associated with hearing difficulties.Test-Taking Strategy: Focus on the subject, the medication that may be causing the client's complaint. Review the classifications and/or therapeutic effects as well as the side and adverse effects of each medication in the options. Of the medications identified, only aspirin can cause ototoxicity. In addition, it is contraindicated for GI bleed.

759. The nurse is caring for a hearing-impaired client. Which approach will facilitate communication? 1. Speak loudly. 2. Speak frequently. 3. Speak at a normal volume. 4. Speak directly into the impaired ear.

3 Rationale: Speaking in a normal tone to the client with impaired hearing and not shouting are important. The nurse should talk directly to the client while facing the client and speak clearly. If the client does not seem to understand what is said, the nurse should express it differently. Moving closer to the client and toward the better ear may facilitate communication, but the nurse should avoid talking directly into the impaired ear. Test-Taking Strategy: Focus on the subject, an effective communication technique for the hearing impaired. Remember that it is important to speak in a normal tone.