sensory untk

A nurse is attempting to communicate with a hearing-impaired client. Which of the following strategies by the nurse would be least helpful when talking to this client?

Smiling continuously during conversation

A nurse in a health care clinic is assisting to test the client for accommodation. Initially, the nurse should ask the client to:

Focus on a distant object.

A nurse has reinforced instructions to a client following a right keratoplasty. Which statement by the client indicates a need for further instruction?

"In 1 week I'll return to have the sutures removed."

The nurse should assess for vision loss in a client with which of the following conditions?

Diabetes mellitus

Prescriptive eyeglasses are prescribed for a client with bilateral aphakia. When reinforcing teaching instructions regarding the glasses, the nurse determines the need for further instructions when the client states:

My peripheral vision will not be distorted."

A myringotomy is performed on a client in the ambulatory care center. The ambulatory care nurse calls the client 24 hours after the procedure to evaluate the status of the client. The client reports to the nurse that a small amount of brownish drainage has been coming from the ear. Which instruction should the nurse provide to the client?

"Continue to monitor the drainage, because this is normal and may occur for 24 to 48 hours following the surgery."

A client arrives at the emergency department following an eye injury in which an acid used to clean the brick on the fireplace splashed into the eye. The initial question by the nurse is which of the following?

"Did you flush the eye following the injury?"

A client reports to the health care clinic for an eye examination, and a diagnosis of primary open-angle glaucoma is suspected. Which data collection question will elicit information regarding the initial clinical manifestations associated with this disorder?

"Have you had difficulty with peripheral vision?"

A clinic nurse has provided home care instructions to a client with a diagnosis of glaucoma. Which statement by the client indicates an understanding of the treatment plan for glaucoma?

"I need to take my eye drops for the rest of my life."

A nurse is reinforcing home-care instructions to a client and family regarding care after cataract removal from the right eye. Which of the following statements, if made by the client, would indicate an understanding of the instructions?

"I will not sleep on my right side."

A client is brought to the ambulatory care department by the spouse one day following a cataract extraction procedure. A diagnosis of hyphema is made, which occurred as a result of the surgical procedure. The nurse provides instructions to the client and spouse regarding the treatment for the complication and makes which statement to them?

"Maintain bedrest and patching of both eyes."

A nurse is caring for a client hospitalized with an acute attack from Ménière's disease. The client verbalizes concern because the client has experienced a hearing loss as a result of the attack. Which response would the nurse make to the client regarding the hearing loss?

"The attack leaves a hearing loss in the involved ear."

A nurse is assisting a client who has just been given a hearing aid to wear for the first time. The nurse provides teaching about the device, including that:

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

A miotic medication has been prescribed for the client with glaucoma. The client asks the nurse about the purpose of the medication. The nurse tells the client that:

"The medication causes the pupil to constrict and will lower the pressure in the eye."

Prescriptive glasses are prescribed for a client with bilateral aphakia, and the nurse provides instructions to the client regarding the use of the glasses. Which statement by the client indicates the need for further instructions?

"The prescriptive glasses will correct my visual field of sight."

A nurse is reinforcing discharge instructions with a client who is being discharged following a fenestration procedure for the treatment of otosclerosis. Which of the following should be included in the list of instructions prepared for the client?

"You need to avoid air travel."

A clinic nurse notes that following several eye examinations the health care provider has documented a diagnosis of legal blindness in the client's chart. Which of the following would the nurse expect to note documented as the result of the Snellen chart test?

20/200 vision

A nursing student is caring for a client in the health care clinic who has been diagnosed with glaucoma. The nursing instructor asks the student to describe the type of medication that will likely be prescribed for the client to treat the eye disorder. Which statement by the student indicates an accurate understanding of the treatment for glaucoma?

A miotic agent will lower the pressure in the eye and increase the blood flow to the retina."

A nurse is assigned to administer the prescribed eye drops for a client preparing for cataract surgery. Which type of eye drops will the nurse expect to be prescribed?

A mydriatic medication

A perforated eardrum is suspected in a client who was hit in the ear with a basketball. Which documented observation concerning an otoscopic examination supports this suspicion?

A round or oval darkened area on the eardrum

A nurse is assigned to care for a client with a detached retina. Which finding would the nurse expect to be documented in the client's record?

A sense of a curtain falling across the field of vision

A nurse notes that the health care provider has documented a diagnosis of presbycusis on the client's chart. The nurse understands that this condition is accurately described as:

A sensorineural hearing loss that occurs with aging

A nurse is reviewing the medication list for an assigned client. The nurse becomes concerned because which of the following medications is the only one on the client's prescription sheet that does not have an ototoxic effect?

Acetaminophen (Tylenol)

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 determine could be the cause of the client's complaint?

Acetylsalicylic acid (aspirin)

A nurse is reviewing the preoperative prescriptions of a client scheduled for a keratoplasty. Which of the following prescriptions, if noted in the client's chart, would the nurse question?

Administer medication to dilate the affected pupil.

A nurse is reviewing the plan of care developed by a nursing student for a client scheduled for keratoplasty. The nurse discusses the plan with the student if which incorrect intervention is listed in the plan?

Administering medications that will dilate the pupil

A client has a diagnosis of presbycusis. The nurse interprets that which behavior indicates that the client has successfully adapted to this disorder?

Agrees to use a prescribed hearing aid, especially when home alone

A client with glaucoma asks the nurse if complete vision will return. The nurse makes which response to the client?

Although some vision has been lost and cannot be restored, further loss may be prevented by adhering to the treatment plan."

A caloric test is prescribed for a client suspected of having a disease of the labyrinth. The nurse obtains what essential item in preparation for this test?

An otoscope

A nurse is listening to a health care provider explain the results of an eye examination to a client. The health care provider states that the client has glaucoma resulting from a congenitally narrow anterior chamber angle, which has suddenly become blocked by the base of the iris. The nurse interprets that the health care provider is describing which of the following types of glaucoma?

Angle-closure glaucoma

A client sustains a contusion of the eyeball after a traumatic injury with a blunt object. The nurse takes which action immediately?

Applies ice to the affected eye

A client who was hit in the eye with a baseball bat sustains a contusion of the eyeball. The emergency department nurse implements which immediate action?

Applies ice to the affected eye

The nurse is caring for a client with glaucoma. Which of the following medications, if prescribed for the client, would the nurse question?

Atropine sulfate (Isopto Atropine)

A nurse is providing client teaching regarding glaucoma. Which of the following are important to include in the teaching plan? Select all that apply.

Be sure to report halos of light or increased eye pain to your health care provider. Follow a low-sodium, minimal-caffeine diet with plenty of fiber.

A client is diagnosed with hyphema after experiencing a traumatic blow to the eye. The nurse explains to the client that which activity limitations need to be implemented following this type of injury?

Bedrest with the head in semi-Fowler's position

A client is experiencing double vision, or diplopia. The nurse interprets that this client is experiencing a loss of which of the following normal functions of the eye

Binocular vision

A nurse collects data from a client with a diagnosis of macular degeneration of the eye. The nurse should expect the client to report which of the following symptoms?

Blurred central vision

A nurse is reviewing the health record of a client diagnosed with a cataract. The chief clinical manifestation that the nurse would expect to note in the early stages of cataract formation is:

Blurred vision

A nurse has given discharge instructions to the client who has had ocular surgery of the right eye. The nurse determines that the client needs further instruction if the client states to:

Call the health care provider if a temperature of 99° F is present.

A client is diagnosed with glaucoma. Which data gathered by the nurse indicate a risk factor associated with glaucoma?

Cardiovascular disease

A nurse is developing a poster to use in teaching clients about the prevention of hearing loss. The nurse would diagram which of the following structures as part of the inner ear?

Cochlea

A nurse is assigned to care for a client with a diagnosis of detached retina. Which finding would indicate that bleeding has occurred as a result of retinal detachment?

Complaints of a burst of black spots or floaters

A nurse caring for a client in the postoperative period following an enucleation, notes bloody staining on the surgical eye dressing. Which of the following is the appropriate initial action?

Contact the health care provider.

A client arrives at the emergency department for treatment of an injury to the eye after being hit by a baseball bat. On data collection, the nurse notes that the eye is bleeding. Which of the following nursing actions is appropriate?

Cover the eye with cold, sterile saline gauze.

A nurse is caring for a client following craniotomy for removal of an acoustic neuroma. The nurse understands that assessment of which of the following cranial nerves would identify a complication specifically associated with this surgery?

Cranial nerve VII, facial nerve

A nurse is assisting in performing a confrontation test on a client seen in the clinic. The nurse understands that this test is performed to check the client's ability to:

Demonstrate effective peripheral vision.

A client who had previously undergone cataract surgery tells the nurse that she has begun seeing flashing lights and floaters in the eye. Based on the client's history, the nurse interprets that the client is at risk of:

Detached retina

A nurse is gathering data from a client with a history of untreated cataracts. The nurse asks the client about the presence of which of the following signs of a cataract

Difficulty with driving at night and blurred vision

In preparation for cataract surgery, the nurse is to administer cyclopentolate (Cyclogyl) eyedrops. The nurse administers the eyedrops, knowing that the purpose of this medication is to:

Dilate the pupil of the operative eye

A nurse is preparing the client for eye testing and the examiner is planning to test the eyes using the confrontational method. The nurse tells the client that this test is performed to:

Examine visual fields or peripheral vision.

A client who has undergone cataract removal without an intraocular lens implant is visibly upset because his vision is still blurry. The nurse should do which of the following to provide realistic reassurance to this client?

Explain that vision will improve with adjustment to aphakic lenses

After an eye examination, a client has been diagnosed with acute angle-closure glaucoma. The nurse collecting data from the client asks the client about an accompanying history of which of the following?

Eye pain

A client presents to the urgent care center with a chemical burn of the right eye. The first priority of the nurse is to prepare the client for:

Flushing the right eye with copious amounts of sterile solution

An adult client with a history of ear infections reports a right earache accompanied by a sensation of fullness. The client also reports nausea and has a temperature of 100.6° F. The nurse initially questions the client about whether:

He has had a recent upper respiratory infection (URI)

A nurse is assisting the health care provider with performing a Weber tuning fork test on a client. The nurse understands that this test checks for:

Hearing loss

The nurse determines that the client diagnosed with Ménière's disease understands the discussed dietary instructions when the client states that which food will be avoided in the diet?

Hot dogs

A nurse is providing preoperative instructions to a client scheduled for cataract surgery and prepares a written list of instructions for the client. Which statement by the client indicates a need for further instruction?

I can drink any liquids that I want to on the morning of the surgery."

A nurse provides home care instructions to a client after cataract removal and placement of an intraocular implant in the right eye. Which statement by the client indicates a need for further instruction?

I need to remove the eye dressing as soon as I get home and place a warm pack on my eye."

A nurse is reinforcing home care instructions to a client who has a hordeolum (stye) of the right eye. Which statement by the client indicates an understanding of the instructions?

I should apply antibiotic ointment as prescribed."

A client reporting recent right eye discomfort is diagnosed with chalazion of the right eye. The nurse reinforces instructions to the client regarding care to the eye. Which statement by the client indicates an understanding of the measures?

I should apply warm packs to my eye."

A pilocarpine ocular system is prescribed for the client with glaucoma. The nurse provides instructions to the client regarding the medication. Which statement by the client indicates an understanding of the use of this medication?

I should check my eye each morning to make sure that the medication system is in place."

A nurse is providing instructions to a client regarding the use of a hearing aid. Which statement by the client indicates a need for further instructions?

I should turn the hearing aid off after removing it from my ear."

A nurse has been assigned to a client with a hearing impairment. To enhance nurse-client communication, the nurse should plan to communicate with the client by speaking:

In a normal tone while facing the client

A client diagnosed with primary open-angle glaucoma has been prescribed pilocarpine ophthalmic drops. When the client asks the nurse how this medication lowers intraocular pressure, the nurse tells the client that the medication:

Increases the outflow of aqueous humor

A nurse is assigned to care for a client with a diagnosis of Ménière's disease. The nurse plans care, knowing that this condition is a disorder of the:

Inner ear

A client arrives in the emergency department with an eye injury caused by metal fragments that hit the eye while drilling into metal. The nurse checks the eye and notes small pieces of metal floating on the eyeball. Which action should the nurse plan to assist with first

Irrigate the eye with sterile saline.

A client arrives in the emergency department with a chemical eye injury. The nurse immediately:

Irrigates the eye with copious amounts of sterile normal saline

A client sustains a chemical eye injury from a splash of battery acid. The nurse prepares the client for which immediate measure?

Irrigating the eye with sterile normal saline

A nurse is assigned to care for a client hospitalized with Ménière's disease. The nurse expects that which of the following would most likely be prescribed for the client?

Low-sodium diet

A nurse is communicating with a client who is hard of hearing in both ears. To facilitate communication with this client, the nurse should:

Lower the voice pitch and face the client when speaking.

A nurse is preparing to provide instructions to a client with glaucoma regarding the prescribed treatment measures for the disorder. The nurse prepares the instructions based on the primary objective of:

Maintaining intraocular pressure at a reduced level

Which nursing interventions are appropriate for a client recovering from surgery for retinal detachment? Select all that apply.

Monitor for hemorrhage. Administer eye medications. Maintain the eye patch or shield. Assist with activities of daily living. Educate regarding symptoms of retinal detachment

A nurse is caring for a client with acute otitis media. The nurse plans care, knowing that the treatment for this problem is likely to include:

Myringotomy

A nurse is assisting the health care provider in performing a caloric test on a client. Following instillation of warm water into the ear, the client complains of vertigo. The nurse documents the findings of this test as:

Normal

Immediately following cataract repair, the client's affected conjunctiva and eyelids are edematous. The nurse tells the client that this is:

Normal and should subside within 3 days

A nurse is reviewing the results of an eye examination on a client and notes that results from the tonometry test indicate an intraocular pressure of 20 mm Hg. The nurse interprets these findings as:

Normal intraocular pressure

A nurse in the ambulatory care unit is caring for a client following cataract extraction. The client suddenly complains of nausea and severe eye pain in the surgical eye. The nurse should take which of the following actions immediately?

Notify the registered nurse.

A nurse is caring for a client following enucleation. On data collection the nurse notes staining and bleeding on the dressing. The nurse should take which appropriate action?

Notify the registered nurse.

A client who sustained an eye injury arrives at the emergency department. The initial nursing action is to

Obtain a history regarding the cause of the injury.

The nurse is providing instructions to a client who will be self-administering eyedrops. To minimize the systemic effects that eyedrops can produce, the client is instructed to:

Occlude the nasolacrimal duct with a finger over the inner canthus for 30 to 60 seconds after instilling the drops

The nurse notes that the client's physical examination record states the client's eyes moved normally through the six cardinal fields of gaze. The nurse interprets that this means that the client has normal:

Ocular movements

A client arrives in the emergency department after an automobile crash. The client's forehead hit the steering wheel and a hyphema has been diagnosed. The nurse would prepare to position the client:

On bedrest in a semi-Fowler's position

A nurse in the recovery room area is preparing to care for a client following cataract extraction of the right eye. The nurse prepares to position the client:

On the left side with the head of the bed elevated

A nurse is assigned to care for a client following a cataract extraction. The nurse plans to position the client:

On the nonoperative side

A client susceptible to motion sickness asks the nurse about the use of medication to prevent an occurrence. The nurse plans to incorporate into the discussion that the medication works effectively if it is taken at least:

One hour before a triggering event

A clinic nurse is reviewing the record of a client recently diagnosed with a cataract. Which clinical manifestation associated with this disorder should the nurse expect to be documented in the client's record?

Painless progressive loss of vision

A client is experiencing blockage of the eustachian tubes. The nurse teaches the client that which of the following activities by the client may forcibly open the eustachian tube?

Performing the Valsalva maneuver

A client has been diagnosed with glaucoma. The nurse who is teaching the client principles of self-care would encourage the client to limit or refrain from which of the following usual activities on a repeated basis?

Picking objects up off the floor

A nurse is preparing a plan of care for a client being admitted to the hospital with a diagnosis of retinal detachment. Which of the following will the nurse include in the plan of care?

Place an eye patch over the affected eye.

A client with retinal detachment is admitted to the outpatient nursing unit in preparation for a scleral buckling procedure. Which of the following would the nurse anticipate to be prescribed?

Placing an eye patch over the client's affected eye

A nurse notes that a client with glaucoma has vision that is lost due to obstruction to aqueous humor flow by the trabecular meshwork. The nurse interprets that this client is suffering from:

Primary open-angle glaucoma

A nurse is caring for a client who will be undergoing surgical treatment for Ménière's disease. The nurse plans care, understanding that surgical treatment for this disorder is performed to:

Provide relief from accumulation of inner ear fluid in the endolymphatic sac

A nurse is preparing to instill an otic solution into the adult client's right ear. The nurse would include which action while performing this procedure? Select all that apply.

Pulling the auricle of the right ear upward Pulling the auricle of the right ear forward Warming the solution to room temperature Placing the client in a left side-lying position

A nurse is reviewing the record of a client with mastoiditis. The nurse would expect to note which documented characteristic regarding the results of the otoscopic examination?

Red, dull, thick, and immobile tympanic membrane

A nurse is caring for a client after enucleation and notes the presence of bright red drainage on the dressing. The nurse takes which appropriate action?

Reports the finding to the registered nurse (RN)

A nurse is reviewing the health care record of a client with a diagnosis of otosclerosis. The nurse would expect to note documentation of which early symptom of this disorder?

Ringing in the ears

A nurse is assisting in preparing a teaching plan for a client with Ménière's disease. The nurse places highest priority on teaching the client information related to:

Safety

The nurse is preparing to communicate with an older client who is hearing impaired. Which intervention should be implemented initially?

Stand in front of the client.

A nurse is explaining how sound is conducted from the middle ear to the inner ear in teaching a client who is experiencing hearing loss. The nurse plans to use a diagram that illustrates how which of the following bones connects to the cochlea at the oval window?

Stapes

A male client with a history of ear problems telephones the ambulatory care nurse to cancel an appointment because he will be away on business. The client mentions that he will be flying during this trip. The nurse advises the client to engage in which of the following to prevent barotrauma during takeoff and landing? Select all that apply.

Sucking on a piece of hard candy Swallowing a few times Yawning occasionally Chewing gum

A nurse provides dietary instructions to a client with Ménière's disease. The nurse tells the client that which food or fluid item is acceptable to consume?

Sugar-free Jell-O

A client is being discharged from the ambulatory care unit following cataract removal. Which instruction from the discharge teaching plan should the nurse reinforce?

Take acetaminophen (Tylenol) if any discomfort occurs.

The nurse interprets that a client diagnosed with glaucoma needs information about the expected effects of this condition when she states that:

Taking my daily walk right around dusk each evening has proven to be so enjoyable."

A nursing student is developing information for use in a clinical conference about hearing disorders. In the presentation, the student plans to include the statement that the ear is housed in which of the following bones of the skull?

Temporal

A client arrives in the emergency department following an eye injury from a chemical solution. Which of the following is the initial nursing action?

Test the eye pH with litmus paper.

A nursing student is preparing to assist with an ear irrigation on an assigned client who has a buildup of cerumen in the left ear. The nursing instructor asks the student about the procedure for the irrigation. The instructor determines that the student understands this procedure if the student tells the instructor that:

The irrigating solution is warmed to 100° F.

A client has been newly diagnosed with glaucoma. As part of the discharge instructions, the nurse should plan to include which of the following?

The need for lifelong medication therapy

A nurse is observing a nursing assistant talking to a client who is hearing impaired. The nurse would intervene if which is performed by the nursing assistant during communication with the client?

The nursing assistant is speaking directly into the impaired ear

A client has been diagnosed with open-angle glaucoma and asks the nurse to repeat the health care provider's explanation of the disorder. The nurse would tell the client that:

The pressure increases within the eye from excess fluid or blocking of drainage.

A client is taking large doses of acetylsalicylic acid (aspirin) for rheumatoid arthritis. The nurse tells the client to report which of the following signs and symptoms of ototoxicity?

Tinnitus, hearing loss, dizziness, ataxia

When reinforcing information to a client regarding how to appropriately care for a new hearing aid, the nurse would tell the client:

To check the battery regularly to ensure that it is working before use

A client has had same-day surgery to insert a ventilating tube in the tympanic membrane. The nurse reinforces to the client to be sure to do which of the following until the postoperative assessment by the surgeon?

Use a shower cap to protect the ears if taking a shower.

Which intervention should be implemented for the older client with presbycusis who has a hearing loss?

Use low-pitched tones

The nurse prepares the client for ear irrigation as prescribed by the health care provider. In performing the procedure, the nurse:

Warms the irrigating solution to 98°

A nurse is reinforcing discharge instructions to a client going home after same-day eye surgery. During the postoperative period, the nurse stresses that the client may safely:

Watch television.

A nursing instructor asks a student about cochlear implants. The student understands that which clients are candidates for such a procedure? Select all that apply.

Who have a profound hearing loss in both ears Who received no benefit from conventional hearing aids

A client with glaucoma and an acute exacerbation of chronic obstructive pulmonary disease (COPD) has a new prescription to receive carteolol HCl (Ocupress) eye drops. Which action by the nurse is most appropriate?

Withhold the dose and notify the registered nurse.

A nurse is providing instructions to a client regarding the use of ice packs to treat an eye injury. The nurse instructs the client to:

Wrap a plastic bag filled with ice with a pillowcase and place it on the eye.

A nurse in the outpatient unit is preparing a client who is scheduled for a laser trabeculoplasty for the treatment of primary open-angle glaucoma. Which of the following instructions should the nurse provide to the client?

You may return to work 1 or 2 days following the procedure."

A nurse has provided discharge instructions to a client following right eye cataract surgery about ways to avoid strain on the operative eye. The nurse determines that the client needs further instruction if the client makes which of the following statements?

"I can lie on my right side."

A nurse is reinforcing discharge teaching to a client following right eye cataract surgery. The nurse determines that the client needs further instruction about ways to avoid strain on the operative eye when he makes which of the following statements?

"I can lie on my right side."

A client with a diagnosis of otosclerosis is admitted to the ambulatory care unit for stapedectomy, and the nurse provides instructions to the client regarding home care following the procedure. Which statement by the client indicates a need for further instructions?

"I need to avoid air travel for at least 6 months."

A nurse is reinforcing discharge instructions to a client who has had ocular surgery of the left eye. Which statement by the client indicates a need for further instructions?

"I need to call the doctor if I develop any fever."

A nurse is reinforcing instructions to a client following a cataract extraction on the right eye. Which statement by the client indicates a need for further teaching?

"I need to wear an eye shield all the time."

A nurse is providing client and family instructions for a client who has been recently diagnosed with glaucoma. Which statement indicates that the client's family member needs additional instruction regarding the eye drop application of pilocarpine hydrochloride (Isopto Carpine)? Select all that apply.

"I should apply the eye drops directly over my family member's pupil." I need to wipe off the tip of the eye drop bottle with a tissue between administrations." "I have to contact the prescriber if my family member develops a small pupil."

A clinic nurse is providing instructions to a client regarding the use of a hearing aid. Which statement by the client indicates a need for further instructions?

"I should turn the hearing aid off after removing it from my ear."

A nurse is providing discharge instructions for a client who has had a fenestration procedure for the treatment of otosclerosis. Which of the following, if stated by the client, would indicate an understanding of the instructions?

"I will take stool softeners as prescribed by my doctor."

A nurse provides discharge instructions to the client who was hospitalized for an acute attack of Ménière's disease. Which statement, if made by the client, indicates a need for further instructions?

"It is not necessary to restrict salt in my diet."

A nurse is providing discharge instructions to a client following a keratoplasty. Which statement by the client indicates the need for further instruction?

"Sutures are removed in 2 weeks."

Tonometry is performed on the client with a suspected diagnosis of glaucoma. The nurse reviews the test results as documented in the client's chart and understands that normal intraocular pressure is approximately:

10 to 21 mm Hg

The client is receiving an eyedrop and an eye ointment to the right eye. The nurse should:

Administer the eyedrop first, followed by the eye ointment

A client arrives at the emergency department following a blow to the eye from a softball. Which intervention should be implemented by the nurse initially?

Apply ice to the affected eye.

A nurse is assisting in developing a plan of care for a client following the surgical removal of an acoustic neuroma. Which assessment will be included in the plan of care for this specific intervention?

Assessment of cranial nerve VII (facial)

Pilocarpine hydrochloride (Isopto Carpine) is prescribed for the client with glaucoma. Which medication does the nurse plan to have available in the event of systemic toxicity?

Atropine sulfate

A nurse is caring for a client following enucleation. Which post-surgical observation requires immediate attention by the nurse?

Bright red drainage on the dressin

Latanoprost (Xalatan) drops are prescribed for the client with glaucoma. The client returns to the health care clinic for evaluation. Which of the following findings, if noted in the client, indicates a side effect associated with the use of these eye drops?

Brown pigmentation of the iris

A nurse notes that the client's eyes are reddened, and the client states that an eye infection has been diagnosed. The nurse interprets that the client is most likely referring to infection of which of the following structures that provides a protective covering for the eye?

Conjunctiva

A nurse is collecting data from a client who has a history of untreated cataracts. The nurse checks the client for which associated manifestation

Difficulty with driving a car at night

A nursing student is caring for a client scheduled for cataract surgery. The student reviews the preoperative prescriptions with the nursing instructor and notes that cyclopentolate (Cyclogyl) eye drops are prescribed to be administered preoperatively. The nursing instructor asks the student about the action of the eye drops. The student appropriately responds by telling the instructor that the action of these eye drops is to:

Dilate the pupil of the operative eye.

A client arrives at the emergency department after experiencing a traumatic blow to the eye and a hyphema is diagnosed. The nurse immediately positions the client:

In semi-Fowler's position

A client arrives at the emergency department with a foreign body in the left ear that has been determined to be an insect. Which intervention would the nurse anticipate to be prescribed initially?

Instillation of mineral oil or diluted alcohol

A client arrives in the emergency department with an eye injury resulting from metal fragments that hit the eye while the client was drilling into metal. The nurse assesses the eye and notes small pieces of metal floating on the eyeball. Which action should the nurse take first?

Irrigate the eye with sterile saline.

A nurse is reinforcing education to a client who has just obtained a hearing aid about its use and maintenance. The nurse tells the client that it is helpful to

Keep an extra battery readily available.

A client has sought treatment in the ambulatory care clinic after an insect has become trapped in the external ear canal. The nurse prepares to assist the health care provider to instill which acceptable solutions into the ear to remove the insect? Select all that apply.

Lidocaine Mineral oil Ether solution

Betaxolol hydrochloride (Betoptic SR) eye drops have been prescribed for the client with glaucoma. Which nursing action is most appropriate related to monitoring for the side effects of this medication?

Monitoring blood pressure

An adult client has increased fluid in the middle ear, which is causing vertigo. The nurse assesses this client for which associated signs and symptoms of this condition?

Nausea and vomiting

A nurse has reinforced instructions to a client who is scheduled for a cataract extraction. Which statement by the client indicates a need for further instruction?

No eating or drinking for at least 18 hours before the surgery."

A nurse is assisting the health care provider in performing a caloric test on a client. Following instillation of cool water into the ear, the nurse notes the presence of nystagmus. The nurse should document the findings of this test as:

Normal

The client has undergone funduscopic examination of the eye. The documented results indicate that the blood vessels are without tortuosity, narrowing, pulsation, or nicking. The nurse interprets that this report indicates which of the following?

Normal retinal examination

A nurse is assisting a health care provider in performing a caloric test on a client. Following instillation of warm water into the ear, the nurse notes that nystagmus does not occur. The nurse would document the findings of this test as:

Positive

After a routine eye examination, a client has been told there are refractive errors in both eyes. The nurse explains to the client that this problem is primarily treated by

Prescription of corrective lense

A nurse is preparing to administer eardrops to an adult client. The nurse administers the eardrops by:

Pulling the pinna up and back

During the early postoperative stage, the cataract extraction client complains of nausea and severe eye pain over the operative site. Which action by the nurse is appropriate

Report the client's complaints.

A nurse is attempting to inspect the lacrimal apparatus of a client's eye. Because of its anatomical location, the nurse should do which of the following?

Retract the upper eyelid and ask the client to look down.

While at home, a nurse receives a telephone call from a neighbor, who reports that while accidentally breaking a mirror, a piece of glass flew into her eye. What is the appropriate initial nursing action after observing that the large glass shard is protruding from the neighbor's eye?

Secure a cup over the affected eye.

A nurse is caring for a client who is hearing-impaired and takes which approach to facilitate communication?

Speaks in a normal tone

A nurse is inserting soft contact lenses into the eyes of a client. The nurse tells the client to look:

Straight ahead

A nurse is reviewing the health care record of a client suspected of having mastoiditis. Which finding does the nurse expect to note if this disorder is present?

Swelling behind the ear

A client with glaucoma has suffered significant eye damage prior to diagnosis and now has impaired vision. The nurse determines that the client needs further assistance in adapting to this situation if the client states that:

There is no difficulty driving at dusk.

A nurse is providing home care instructions to a client following a fenestration procedure for the treatment of otosclerosis. The nurse tells the client:

To increase fluids and take a stool softener daily

A nurse assigned to care for a hearing-impaired client should use which approach to communication in order to enhance communication and preserve the client's self-esteem? Select all that apply.

Turning down the volume on the radio or TV when talking Standing directly in front of the client while speaking Speaking slowly and clearly

Which instruction is appropriate for the nurse to initially provide to a client who reports via telephone that he is certain an insect has flown into his ear because he can hear it "buzzing"?

Use a flashlight to coax the insect out of the ear.

A nurse is speaking with a client with a hearing impairment. The nurse refrains from doing which of the following, which is least helpful when communicating with this client?

Using many exaggerated hand gestures while talking

Surgery has been recommended for the client with otosclerosis. The client tells the nurse that surgery is not desired and asks the nurse about alternative methods to improve hearing. The nurse makes which appropriate response to the client?

"A hearing aid may improve your hearing."

A nurse provides a list of instructions to a client with glaucoma regarding measures that will prevent an increase in intraocular pressure in the eyes. Which statement by the client indicates a need for further instructions?

"I can tie my shoelaces by bending over slowly."

A client is being discharged from the ambulatory care unit following cataract removal, and the nurse provides instructions regarding home care. Which of the following, if stated by the client, indicates an understanding of the instructions?

"I will wear my eye shield at night and my glasses during the day."

A nurse is providing instructions to a client with a diagnosis of hordeolum regarding the treatment plan. Which of the following will the nurse include in the instructions to the client?

Apply a warm compress for 15 minutes four times daily

A client with Ménière's disease is experiencing severe vertigo. The nurse instructs the client to do which of the following to assist in controlling the vertigo?

Avoid sudden head movements

A nurse is assisting in developing a teaching plan for the client with glaucoma. Which instruction should the nurse suggest to include in the plan of care?

Eye medications will need to be administered for the rest of your life.

A nurse is assisting to perform a Romberg test on a client being seen in the clinic. The nurse performs this test to determine

The ability of the vestibular apparatus in the inner ear

A nurse is reviewing the health care provider's prescriptions for a client admitted to the hospital with a diagnosis of an acute attack of Ménière's disease. Which prescription, if noted on the client's chart, should the nurse question?

The administration of a vasoconstrictor

A client's vision is tested with a Snellen chart. The results of the test are documented as 20/60. The nurse interprets this as:

The client can read at a distance of 20 feet what a client with normal vision can read at 60 feet.

A client is diagnosed with a disorder involving the inner ear. The nurse caring for the client understands that which of the following is the most common client complaint associated with a disorder involving the inner ear

Tinnitus

The nurse is preparing to administer eye drops. Select the interventions that the nurse takes to administer the drops. Select all that apply.

Wash hands. Put on gloves. Place the drop in the conjunctival sac. Pull the lower lid down against the cheek bone.

The nurse is preparing a teaching plan for a client who is undergoing cataract extraction with intraocular implant. Which home care measures will the nurse include in the plan? Select all that apply.

To avoid activities that require bending over To place an eye shield on the surgical eye at bedtime To contact the surgeon if a decrease in visual acuity occurs To take acetaminophen (Tylenol) for minor eye discomfort

When the nurse documents the results of a Snellen vision test as 20/80 vision, the client asks the nurse to describe what these numbers mean. Which statement is the appropriate response?

You can read at a distance of 20 feet what a client with normal vision can read at 80 feet."

Which statement by the nurse indicates an understanding of the diagnosis of presbycusis?

It is a sensorineural type of hearing loss that occurs with aging."

A nurse is assisting in developing a plan of care for the client scheduled for cataract surgery. The nurse makes suggestions regarding the plan, knowing that which problem is specifically associated with this type of surgery?

Sensory perceptual alteration