Eyes and ears
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 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 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 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."
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
A nurse is caring for a client following enucleation. Which post-surgical observation requires immediate attention by the nurse?
Bright red drainage on the dressing
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 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 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 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.
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
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 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
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
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
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
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.
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 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 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 lenses
A nurse is preparing to administer eardrops to an adult client. The nurse administers the eardrops by:
Pulling the pinna up and back
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
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 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
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 is caring for a client who is hearing-impaired and takes which approach to facilitate communication?
Speaks in a normal tone
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 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. All the nxt 4
Sucking on 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'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 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 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
Which intervention should be implemented for the older client with presbycusis who has a hearing loss?
Use low-pitched tones
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.
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
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 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 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 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 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 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 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 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."
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."
A nurse is providing client teaching regarding glaucoma. Which of the following are important to include in the teaching plan? Select all that apply. 1&2
1. Be sure to report halos of light or increased eye pain to your health care provider. 2. Follow a low-sodium, minimal-caffeine diet with plenty of fiber.
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. all 4
1. Pulling the auricle of the right ear upward 2. Pulling the auricle of the right ear forward 3. Warming the solution to room temperature 4. Placing the client in a left side-lying position
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 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 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 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 client arrives in the emergency department with a chemical eye injury. The nurse immediately:
Irrigates the eye with copious amounts of sterile normal saline
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.
The nurse is preparing to administer eye drops. Select the interventions that the nurse takes to administer the drops. Select all that apply. all 4
Wash hands. Put on gloves. Place the drop in conjunctival sac. Pull the lower lid down against the cheek bone.
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 conjunctival sac. Pull the lower lid down against the cheek bone.
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 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 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 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
Which nursing interventions are appropriate for a client recovering from surgery for retinal detachment? Select all that apply. All the next 5
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 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 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
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 is diagnosed with glaucoma. Which data gathered by the nurse indicate a risk factor associated with glaucoma?
Cardiovascular disease
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 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 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. All of the following (3)
Lidocaine Mineral oil Ether solution
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 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
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)
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 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
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° F
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
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 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.
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 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 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.
