Chapter 14 sensory deficits

the pediatric nurse is administering nasal medication to the 13 - month-old child. Which intervention should the nurse implement? 1) place the child in a prone position with the head to the side 2) gently place the child's chin on the chest using the nondominant hand. 3) turn the child's head slightly form side to side and back to midline 4) allow the child to sit up immediately after the med is instilled

3) turn the child's head slightly form side to side and back to midline Turning the head slightly from side to side and back to the midline position will help dispense the medication to the maxillary and frontal sinuses

to which client should the nurse question administering betaxolol ophthalmic drops? 1) the client diagnosed with OAG 2) the client diagnosed with end stage liver failure 3) the client diagnosed with allergies to sulfa 4) the client diagnosed with COPD

4) the client diagnosed with COPD contraindications to using beta blocker ophthalmic drops include clients who may be receiving beta-blocker therapy. which includes clients diagnosed with COPD, asthma, heart block, and heart failure

the nurse is preparing to admin ophthalmic med to the client. to which area should the nurse admin the med? 1) A 2) B 3) C 4) D

the medication should be administered into the lower conjunctival sac, then the client should close the eye for 1 to 2 minutes, which will help ensure the med stays in the eye

the nurse is administering ophthalmic med to the client. to which area should the nurse instruct the client to apply pressure for 1 to 2 min after instilling the med? 1) A 2) B 3) C 4) D

1) A Gentile pressure should be applied to the inner canthus (lacrimal sac) for 1 or 2 minutes to increase the local effect and decrease systemic absorption

the client who has undergone eye surgery is reporting being nauseated. which intervention should the post-anesthesia care unit recovery room nurse implement? 1) admin an IV antiemetic med 2) determine if the client had anything to eat preoperatively 3) place a cold washcloth under the chin along the client's throat 4) put the client on the left side and insert a rectal antiemetic med

1) admin an IV antiemetic med The nurse must take action as soon as possible to prevent vomiting because vomiting will increase intraocular pressure

the client diagnosed with glaucoma is prescribed oral acetazolamide. which info should the client discuss with the client? 1) admin the med in the morning 2) instill med in the lower conjunctival sac 3) wash hands prior to administering med 4) hold the eyes shut for 2 min after taking the med

1) admin the med in the morning The oral medication acetazolamide (Diamox), a carbonic anhydrase inhibitor, has a diuretic effect; therefore, it should be taken in the morning to prevent sleep deprivation because of the need to get up to urinate during the night

the client diagnosed with bilateral conjunctivitis is prescribed antibiotic ophthalmic ointment. which interventions should the nurse implement when discussing the med with the client? select all that apply 1) apply a thin line of ointment evenly along the inner edge of lower lid margin 2) press the nasolacrimal duct after applying the antibiotic ointment 3) don non sterile gloves prior to administering the med 4) apply antibiotic ointment from the outer canthus to the inner canthus 5 ) instruct the client to sit with the head slightly tilted back or lie supine

1) apply a thin line of ointment evenly along the inner edge of lower lid margin 2) press the nasolacrimal duct after applying the antibiotic ointment 5 ) instruct the client to sit with the head slightly tilted back or lie supine

the client diagnosed with glaucoma is prescribed epinephrine ophthalmic drops. which statement indicates client understands the client teaching? 1) i will call my HCP if i start experiencing eye pain 2) this medication does not interfere with ant OTC med 3) i will probably experience anxiety, nervousness, and muscle tremors 4) after putting the med in my eyes i must lie down for 1 hour

1) i will call my HCP if i start experiencing eye pain eye pain may indicate an attack of angle-closure glaucoma and must be reported to the HCP immediately

the nurse is teaching the parents how to instill antibiotic otic drops to the 6-year-old child diagnosed with otitis media. which instruction should the nurse discuss with the parents? select all that apply 1) insert the otic med in the affected ear after pulling the earlobe upward and back 2) after instilling med, gently massage the area immediately anterior to the ear 3) gently pull the pinna downward and straight back when inserting the ear drops 4) allow the child to lie quietly on the side after instilling the ear drops into the affected ear 5) insert the dropper with prescribed med deep into the ear canal and instill drops.

1) insert the otic med in the affected ear after pulling the earlobe upward and back 2) after instilling med, gently massage the area immediately anterior to the ear 4) allow the child to lie quietly on the side after instilling the ear drops into the affected ear

the parent of a 23-month-old child diagnosed with acute otitis media calls the clinic and tells the nurse their child is crying and pulling at her ears. Which action should the nurse implement? 1) instruct the parent to give acetaminophen elixir as prescribed on the bottle 2) determine when the parent gave the last dose of prescribed antibiotic 3) tell the parent to administer two chewable baby aspirins every 6 hours 4) encourage the parent to hold the child and rock her until she falls asleep

1) instruct the parent to give acetaminophen elixir as prescribed on the bottle acetaminophen is the drug of choice to help relieve discomfort in children

the client diagnosed with Meniere's disease, also known as endolymphatic hydrops, is prescribed meclizine. which statement best describes the scientific rationale for this med? 1) it will help decrease the whirling sensation experienced with Meniere's disease 2) it will help prevent an acute episode of nausea and vomiting 3) it will help maintain a lower labyrinthine pressure in the ears 4) it will help the ear canal vasoconstrict, reducing the pressure in the ears.

1) it will help decrease the whirling sensation experienced with Meniere's disease Meclizine (Antivert), an antivertigo medication, helps prevent dizzines and the whirling sensation characteristic of Meniere's disease

the client diagnosed with glaucoma is using an ophthalmic ocular system when applying pilocarpine. Which intervention should the nurse discuss with the client? select all that apply 1) place the ophthalmic ocular system in the inferior cul-de-sac between sclera and eyelid. 2) apply the ophthalmic ocular system at bedtime 3) replace the system daily the first thing in the morning 4) notify the HCP if increased lacrimation or HA occurs 5) store the ophthalmic ocular system in the refrigerator

1) place the ophthalmic ocular system in the inferior cul-de-sac between sclera and eyelid. 2) apply the ophthalmic ocular system at bedtime 5) store the ophthalmic ocular system in the refrigerator

the 3 year old child diagnosed with an eye infection has both an ophthalmic ointment and ophthalmic drops prescribed. which action by the primary nurse warrants intervention by the charge nurse? 1) the primary nurse applies the ophthalmic ointment first 2) the primary nurse instills the ophthalmic drops in the lower lid 3) the primary nurse does not allow the dropper to touch the eye 4) the primary nurse instills the ophthalmic drops first

1) the primary nurse applies the ophthalmic ointment first The nurse should apply the drops first because if the drop are placed after the ointment, the ophthalmic drops will not be absorbed. This action would warrant intervention by the charge nurse

the nurse is discussing how to instill artificial tears into the clients eyes. which info should the nurse discuss with the client? select all that apply 1) do not allow the artificial tear dropper to touch the eye 2) keep the eyes closed 1 to 2 min after instilling drops 3) apply pressure to the inner canthus after instilling eye drops 4) wash the hands prior to instilling the artificial tears into the eyes 5) lie in the prone position when instilling the eye drops

1, 2, 4 1) do not allow the artificial tear dropper to touch the eye 2) keep the eyes closed 1 to 2 min after instilling drops 4) wash the hands prior to instilling the artificial tears into the eyes

the mother of a 13 y/o child is diagnosed with external otitis tells the nurse her child spends a lot of time swimming. which information is most important for the nurse to discuss with the mother? 1) insert silicone ear plugs prior to entering the water 2) administer a drying agent in the ear canal after swimming 3) wear a tight-fitting swim cap, esp in cold water 4) tilt the head to allow water to drain from the ear.

2) administer a drying agent in the ear canal after swimming a 2 % acetic acid solution or 2% boric acid in ethyl alcohol is effective in drying the canal and restoring its normal acidic environment. This is the most important information for the nurse to each bc, although suggesting ways to prevent water from entering is helpful, the client must dry the canal to prevent further episodes of external otitis

The client diagnosed with Meniere's disease is admitted with an acute attack and prescribed IV diazepam. Which interventions should the nurse implement when administering the med 1) dilute the diazepam to a 10-mL bolus with normal saline 2) administer the diazepam undiluted via a saline lock 3) infuse the diazepam via an IV piggyback over 1 hour 4) question the order bc diazepam cannot be given IV push

2) administer the diazepam undiluted via a saline lock Diazepam (Valium), a sedative-hypnotic, cannot be dilated because it is oil based and will not dissolve with normal saline. Diazepam should be administered via a saline lock or at the port closest to the client if administered through an existing IV line

the client reports having dry and irritated eyes to the clinic nurse. which intervention should the nurse implement first? 1) recommend the client use artificial tears in both eyes 2) assess the eyes for any redness or discharge 3) check the client's eye using the opthalmoscope 4) evaluate the clients cardinal fields of vision

2) assess the eyes for any redness or discharge the nurse should first assess the eyes for redness or inflammation to determine if there is any type of infection, which would need an HCP's prescription for antibiotics

the client diagnosed with multiple mouth ulcers is prescribed nystatin to swish and swallow. Which intervention should the nurse implement when administering this med? 1) instruct the client to swish the med in the mouth and spit it out 2) encourage the client to swish the med in the mouth for at least 2 min 3) tell the client to swish the mouth with normal saline after swallowing the medication 4) tell the client to apply the nystatin med to the mouth ulcers with a sterile cotton swab

2) encourage the client to swish the med in the mouth for at least 2 min The client should swish the medication in the mouth for at least 2 minutes and then swallow the medication

which statement indicates that the parent understands the procedure for administering otic drops to the clild who is diagnosed with otitis media? 1) i should clean my child's ear canal very gently with cotton swabs 2) i will warm the drops to room temp before instilling them 3) i can place a heating pad over my child's ear after putting in the drops 4) i need to place the dropper gently into my child's ear canal

2) i will warm the drops to room temp before instilling them cold otic drops cause pain when they come in contact with the tympanic membrane; therefore, otic solutions should be allowed to warm to room temp before being administered

which statement best describes the scientific rationale for administering a mydriatic ophthalmic med to a client diagnosed with glaucoma? 1) it constricts the pupil, which cause the pupil to dilate in low light 2) it dilates the pupil to reduce the production of aqueous humor 3) it decreases production of aqueous humor but does not affect the eye 4) it is used as adjunctive therapy primarily to reduce intraocular pressure.

2) it dilates the pupil to reduce the production of aqueous humor mydriatic meds dilate the pupil, reduce the production of AH, and increase the absorption effectiveness of aqueous humor, thus reducing intraocular pressure in OAG

the 3 y/o female child is diagnosed with acute otitis media. which statement by the parents indicates to the nurse that the parent needs more teaching? 1) i will be sure and take my daughter to her follow-up appointment with her doctor 2) my son started pulling at his ears so i gave him some of my daughter's antibiotics 3) i will give my daughter all of the medication, even if she starts feeling better 4) if my daughter does not get better in 48 hours, i will call her HCP

2) my son started pulling at his ears so i gave him some of my daughter's antibiotics Antibiotics are prescribed for a specific condition for a specific client. The parent should not give antibiotics prescribed for their daughter to their son. The parent does not understand the medication teaching

the client with nasal congestion is prescribed nasal solution. Which info should be included in the medication teaching? 1) direct the solution toward the base of the nasal cavity 2) tell the client to blow the nose prior to instilling solution 3) replace remaining nasal solution in the dropper back into the bottle 4) have the client squeeze the nostrils shut after instilling solution

2) tell the client to blow the nose prior to instilling solution The client should blow his or her nose to clear the nasal passages prior to instilling the nasal solution

which client should the HCP recommend an OTC ceruminolytic? 1) the client with swimmers ear 2) the client with impacted earwax 3) the client with external otitis 4) the client with bilateral cataracts

2) the client with impacted earwax A ceruminolytic medication helps to loosen and remove impacted cerumen (earwax) from the ear canal

the primary nurse is administering antibiotic otic drops to a 2 y/o child. which action by the primary nurse warrants intervention by the charge nurse? 1) the primary nurse asks the parent if the child has any known allergies 2) the primary nurse dons nonsterile gloves before inserting the otic drops 3) the primary nurse washes his or her hands prior to administering meds 4) the primary nurse gets assistance to restrain the child when giving otic drops

2) the primary nurse dons nonsterile gloves before inserting the otic drops this procedure does not warrant wearing nonsterile gloves bc the nurse will not come into contact with any blood or body fluids. The nurse should was their hands and admin the med. This action warrants intervention by the charge nurse

the 4 y/o child diagnosed with otitis media with effusion is not prescribed systemic antibiotics. the parent asks the nurse, "why didn't the doctor order antibiotics for my child?" which statement is the nurses best response? 1) your child is too young to receive antibiotics 2) you should discuss this with your child's HCP 3) because you child did not have a fever the doctor did not order antibiotics 4) most HCPs prescribe ear drops instead of antibiotics

3) because you child did not have a fever the doctor did not order antibiotics otitis media with effusion differs from acute otitis media in that there are no signs of acute infection, if there are no signs of infection, such as fever or pain, the nurse should explain that with the emergence of antimicrobial-resistant organisms, recent recommendations discourage antibiotic use for otitis media with effusion because 50% of effusions will resolve on their own

the client diagnosed with seasonal allergies is reporting ocular itching. the HCP orders cetirizine ophthalmic solution. which info should the nurse include when teaching about this med? 1) contact lenses should not be worn until the med course of treatment is complete 2) this med does no affect wearing of contact lenses 3) contact lenses may be reinserted 10 min after medication administration 4) wearing contact lenses during med admin improves visual acuity

3) contact lenses may be reinserted 10 min after medication Contact lenses should be removed prior to administration of cetirizine ophthalmic solution (Zerviate), an antihistamine. The contacts may be reinserted 10 minutes after medication administration

The client calls the clinic and tells the nurse that a live insect is in the client's right ear. which intervention should the clinic nurse implement? 1) encourage the client to get someone to remove the insect 2) instruct the client to put water into the ear canal 3) have the client put mineral oil into the ear canal 4) tell the client to put a medicated cotton ball in the ear

3) have the client put mineral oil into the ear canal Mineral oil or topical lidocaine drops are used to immobilize or kill insects prior to their removal from the ear

the client diagnosed with glaucoma is prescribed betaxolol ophthalmic drops. which info should the nurse discuss with the client? 1) instruct the client tot call HCP if dizziness occurs when getting up to fast 2) discuss that the drops will cause the vision to get worse initially 3) teach the client how to prevent orthostatic hypotension 4) explain the importance of apply pressure at the outer canthus

3) teach the client how to prevent orthostatic hypotension Betaxolol (Betoptic) is a beta blocker that if absorbed systemically may cause bradycardia and hypotension. The nurse should discuss ways to prevent orthostatic hypotension

the client diagnosed with OAG is prescribed pilocarpine ophthalmic drops. the client is demonstrating instilling the medication. Which action by the client warrants intervention? 1) the client washes his or her hands prior to instilling the med 2) the client squeezes the bridge of the nose after administering the med 3) the client keeps the eyes open immediately after administering the med 4) the client does not touch the dropper to the eye when instilling the med

3) the client keeps the eyes open immediately after administering the med the client should keep the eyes closed for 1-2 min after instilling the drops to enhance the effectiveness of the med.

the nurse is administering otic drops to a 5 y/o child diagnosed with acute otitis media. Which interventions should the nurse implement? rank in order of performance 1) brace the administering hand against the child's head above the ear. 2) insert the required number of drops and gently massage the tragus 3) explain the procedure to the child in developmentally appropriate terms 4) gently pull the top of the child's ear up and back 5) keep the child on the unaffected side for several minutes

3, 1, 4, 2, 5 3) explain the procedure to the child in developmentally appropriate terms 1) brace the administering hand against the child's head above the ear. 4) gently pull the top of the child's ear up and back 2) insert the required number of drops and gently massage the tragus 5) keep the child on the unaffected side for several minutes

which interventions should be included when the nurse is teaching the adult client diagnosed with external otitis how to instill the otic drops? rank in the order of performance 1) loosely place a small piece of cotton in the auditory meatus 2) demonstrate pulling the pinna of the ear up and back when inserting the drops 3) warm the med by holding the container in the hand for 5 min 4) tilt the head toward the unaffected side when in the sitting position 5) admin the prescribed number of drops into the ear canal

3, 4, 2, 5, 1 3) warm the med by holding the container in the hand for 5 min 4) tilt the head toward the unaffected side when in the sitting position 2) demonstrate pulling the pinna of the ear up and back when inserting the drops 5) admin the prescribed number of drops into the ear canal 1) loosely place a small piece of cotton in the auditory meatus

the client diagnosed with a fungal infection of the eye is prescribed natamycin ophthalmic drops. which med teaching should the nurse discuss with the client? select all that apply 1) instruct the client to patch both eyes after instilling the med 2) tell the client cool packs to the eye after instilling the med 3) explain that the med may cause temporary blurred vision 4) discuss the need to instill drops once a day prior to going to sleep 5) teach the client to shake the med well before using

3, 5 3) explain that the med may cause temporary blurred vision 5) teach the client to shake the med well before using

the nurse is discussing how to instill nasal drops. Which instruction should the nurse discuss with the client? rank in order of performance 1) discard any remaining solution that is in the dropper 2) remain in position for 5 minutes 3) open and breathe through the mouth 4) instill the solution laterally toward the nasal septum 5) hold the tip of the dropper just above the nostril without touching the nose

3, 5, 4, 2, 1 3) open and breathe through the mouth 5) hold the tip of the dropper just above the nostril without touching the nose 4) instill the solution laterally toward the nasal septum 2) remain in position for 5 minutes 1) discard any remaining solution that is in the dropper

the client is diagnosed with acute bacterial conjunctivitis. the HCP prescribed erythromycin ophthalmic ointment. which info should the nurse discuss with the client? 1) apply a thick line of ointment in the upper lid margin of the eye 2) look downward when applying the ointment 3) clean the eye with antibiotic solution prior to applying ointment 4) apply the ophthalmic ointment from the inner to the otter canthus

4) apply the ophthalmic ointment from the inner to the otter canthus When applying ointment, a thin line of ointment should be applied evenly along the inner edge of the lower lid margin, from the inner canthus to the outer canthus

the client called the ED and told the nurse that bleach had splashed in both eyes. Which action should the nurse tell the client to perform first? 1) come to the ED immediately 2) determine if the client has normal saline flush 3) apply antibiotic ointment and patch the eyes bilaterally 4) cleanse the eye continuously with tap water

4) cleanse the eye continuously with tap water the nurse should instruct the client to rinse the eye with tap water for at least 5 minutes in each eye and then come to the ED. The bleach must be thoroughly removed form the eyes as soon as possible

the client diagnosed with otitis media is prescribed clarithromycin 500 mg PO every 12 hours for 10 days. which medication teaching should the nurse discuss with the client? 1) discuss the need to take the med with food 2) tell the client to wear sunglasses when going outdoors 3) instruct the client to get cultures after completing meds 4) encourage the client to eat yogurt or buttermilk daily

4) encourage the client to eat yogurt or buttermilk daily Yogurt and buttermilk will help to maintain the intestinal flora, which may be destroyed when receiving clarithromycin (Biaxin) antibiotic therapy. The destruction of intestinal flora will lead to a superinfection, resulting in diarrhea

the client is undergoing eye surgery and the nurse is administering a cycloplegic ophthalmic med. which intervention should the nurse implement 1) don sterile gloves prior to administering the med 2) tape the client's eyelids shut with nonadhesive tape 3) place an eye catheter at the outer canthus to insert med 4) explain that the eyes will be paralyzed for 24 to 48 hours

4) explain that the eyes will be paralyzed for 24 to 48 hours cyclopegic medication paralyzes the eye for 1 to 2 days and the client should be aware of this info bc most ophthalmic surgery is performed as day surgery. Because the client will be at home, he or she needs to be knowledgeable about the medications

the client just diagnosed with glaucoma is prescribed pilocarpine eye drops. Which statement indicates the client needs more teaching concerning the medication? 1) i will use nightlights in the halls and in the bathroom 2) i will get my wife or son to drive me around at night 3) i will avoid doing tasks that require sharp vision 4) i will take the eye drops every time I have eye pain

4) i will take the eye drops every time I have eye pain This medication should be taken routinely every day to reduce intraocular pressure. Glaucoma is painless, so if the client experiences pain, the client should call the HCP immediately. This statement indicates the client need more teaching

the 2 y/o child is diagnosed with acute otitis media. Which intervention will help increase the parents compliance with the medical regimen? 1) instruct the parent verbally on how to use a calibrated measuring device 2) give the parent a sample of the antibiotic therapy to take home 3) make an appointment for a follow-up visit in 1 week 4) provide written and oral instructions about antibiotic therapy

4) provide written and oral instructions about antibiotic therapy many times in the HCP's office the parents may be nervous. The child is in the room, and there are many distraction; therefor, verbal instruction alone may not be thoroughly understood. Written info may increase compliance with the medication regimen.

the parent of a 5 y/o child who has had five ear infections in the past 6 months asks the nurse, "what can be done bc my child keeps having ear infections?" which response by the nurse is most appropriate? 1) there are many different types of antibiotics, and one will work 2) you are concerned your child keeps having ear infections? 3) does you child dunk his head under water during bath time 4) your child may need tubes inserted into both ears

4) your child may need tubes inserted into both ears this is the most appropriate response. a myringotomy with insertion of tympanostomy tubes is performed on children with persistent ear infections despite antibiotic therapy or otitis media with effusion for more than 3 months with associated hearing loss.