Med Surg Ch. 41-43 Exam
A client comes to the walk-in clinic reporting feeling a "bug in my ear." What action should be taken when there is an insect in the ear? A. Instillation of mineral oil B. Instillation of carbamide peroxide C. Instillation of hot water D. Use of a small forceps
A
A client is diagnosed with blepharitis. What symptoms should a nurse monitor in this client? A. Patchy flakes clinging to the eyelashes B. A red pustule in the internal tissue of the eyelid C. Redness surrounding the conjunctival sac D. A halo around the pupil
A
A client is having problems with dizziness and complains of the "room spinning." The physician performs the caloric stimulation test. The nurse knows that a diminished response in one eye during the caloric stimulation test is indicative of what? A. Inner ear disorder B. Middle ear disorder C. Outer ear disorder D. Age-related macular degeneration
A
A client presents to the emergency room with symptoms of blurred vision. Which type of question would be best to ask first? A. "Have you ever had these symptoms before?" B. "Did these symptoms come on abruptly?" C. "Do you have a family history of vision problems?" D. "Do you have any other diseases?"
A
A nurse is assessing a pediatric client in a public health clinic. The parent states that the client has been sneezing and rubbing the eyes. The nurses observes the client's eyes and documents objective symptoms of watery and red eyes. When reporting the assessment findings to the health care provider, which description is appropriate? A. Signs and symptoms of conjunctivitis B. Signs and symptoms of ptosis C. Signs and symptoms of nystagmus D. Signs and symptoms of proptosis
A
A nurse is caring for a 24-year-old female client diagnosed with otosclerosis. Which teaching by the nurse is most accurate? A. Symptoms may be accelerated by pregnancy. B. Medications can interfere with birth control pills. C. Menstrual periods may be longer and more severe. D. Females otosclerosis is linked with infertility.
A
A nurse is caring for a client newly diagnosed with glaucoma. Which would be a priority in the nurse's teaching about maintaining normal pressure range in the eye? A. Increase fiber in the diet. B. Avoid reading. C. Eat small meals. D. Treat allergy symptoms promptly.
A
A nurse is caring for a client who has exhibited repeated return of hordeolum (sty). Which assessment finding is most important in determining care for this client? A. Dabbing the eyes multiple times with a washcloth B. Presence of low blood sugar C. Use of disposable wash cloths D. Use of antibacterial facial wash
A
A nursing instructor is teaching pre-nursing students in a pathophysiology class. What would the instructor teach the students about Ménière disease? A. It is referred to as endolymphatic hydrops. B. It originates in the middle ear. C. It is referred to as lymphatic hydrops. D. It originates in the outer ear.
A
An eighth-grade client visits the school nurse and reports having been to an eye doctor who identified an astigmatism and described it as a condition in which the eyeball is not shaped correctly. The client asks the nurse why both eyes look alike in the mirror if this is the case. What is the nurse's best response? A. "Astigmatism means that the very front part of the eye is shaped differently than the very front part in most eyes." B. "Astigmatism means that the overall shape of the eye resembles an olive more than most eyes." C. "Astigmatism means that the inside of the eye is shaped differently than the inside of most eyes." D. "Astigmatism means that the overall shape of your eye is shorter than most eyes."
A
An older adult client is scheduled for cataract surgery and asks the nurse, "Will I need to wear thick lenses after surgery?" Which is an appropriate response from the nurse? A. "An implanted lens has replaced the need for corrective glasses." B. "Contact lenses are preferred by most clients after this surgery." C. "They can make corrective lenses much thinner now." D. "No lens is necessary with cataract surgery."
A
The client with chronic open-angle glaucoma is receiving timolol eye drops. Which evaluation finding would indicate to the nurse the treatment is working? A. Intraocular pressure 15 mm Hg B. Reduced peripheral vision C. Halos around lights D. Decrease in nausea and vomiting
A
The nurse is assessing a client's eyes as part of the inspection part of the assessment process. For which reason does the nurse identify a normal variation in the angle of the lateral and medial canthus? A. Ethnic differences B. Chromosomal differences C. Structural changes D. Cosmetic alterations
A
The nurse is caring for a client experiencing hearing loss. The nurse uses the otoscope to assess the ear canal and tympanic membrane and notes a significant accumulation of cerumen. Which documentation of hearing loss type would be accurate? a. Conductive b. Mixed c. Central d. Sensorineural
A
The nurse is caring for a client who just returned from a trip requiring an airline flight. The client reported ear pain upon descent. The nurse is correct in stating which site as being the pressure equalizer in the ear? A. Eustachian tube B. Auricle C. Tympanic membrane D. Labyrinth
A
The nurse is caring for a client who underwent surgery for a retinal detachment. The surgery included the injection of an air bubble to promote contact between the retina and choroids. What position should the nurse keep the client in? A. With the face parallel to the floor B. With the client's head slightly elevated C. With the client lying in a high Fowler's position D. With the client in an upright position
A
The nurse is conducting hearing tests at the local junior high school. Which of the following indicates normal hearing in a child? A. A client who first perceives sound at 20 dB B. A client who first perceives sound at 40 dB C. A client for whom the painful sound occurs at 80 dB D. A client for whom the painful sound occurs at 100 dB
A
The nurse is evaluating the client taking the color vision test. Which response would the nurse anticipate when caring for a client with normal color vision? A. The nurse would anticipate the client identifying numbers and shapes. B. The nurse would anticipate a cross-eyed appearance. C. The nurse would anticipate responding to the color names in the pictures. D. The nurse would anticipate no differentiation in between colors.
A
The nurse is instructing a client's family members on the most incapacitating symptom of Ménière disease. Which nursing instruction associated with the symptom is most helpful? A. Assist the client when ambulating. B. Keep a bucket beside the bed. C. Ensure low lighting in the room. D. Sit in front of the client when speaking.
A
The nurse is obtaining a history from a client complaining of ear pain and dizziness. Which assessment finding is the best evidence that the client has a perforated eardrum? A. Fluid draining in the external canal B. Pain has resolved C. Elevated white blood cell count D. Inflammation and a reddened eardrum
A
The nurse is obtaining a visual history from a client who has noted an increase in glare and changes in color perception. Which assessment would the nurse anticipate to confirm a definitive diagnosis? A. Identification of opacities on the lens B. Identification of white circle around the cornea C. Identification of yellowish aging spot on the retina D. Identification of redness of the sclera
A
The nursing student is taking an anatomy and physiology class. What anatomical structure equalizes air pressure in the middle ear? A. Eustachian tube B. The malleus C. The pinna D. The meatus
A
While cleaning gutters, a client reports getting debris in the eyes. On inspection, the nurse notes no obvious foreign object. Which diagnostic evaluation technique would be most beneficial for this client? A. Administer fluorescein dye. B. Obtain an x-ray for orbital fractures. C. Assess intraocular movements. D. Assess with tonometer.
A
A nurse anticipates that an 8-year-old client has otitis externa from symptoms stated on the history. Which symptom(s), from the history and physical examination, would confirm the diagnosis? Select all that apply. A. Discomfort in the ear B. Redness of the ear canal C. Pus noted in the ear canal D. Conductive hearing loss E. Tympanic membrane may appear normal
A, B, C, D, E
An older adult client is admitted with the diagnosis of retinal detachment and is scheduled for laser surgery and scleral buckling procedure. The nurse anticipates which symptom(s) to be exhibited in this client? Select all that apply. A. Flashing lights B. Cobwebs in vision field C. Complete loss of vision in both eyes D. Loss of central vision E. Eye pain F. Arcus senilis
A,B
The nurse, employed in an ear, nose, and throat (ENT) physician's office, is obtaining a client history. The nurse documents the client's statements. Which symptom(s) may indicate a diagnosis of otosclerosis? Select all that apply. A. "It seems that I increasingly could not hear my kids talk to me." B. "I woke up on Monday and had ear pain with a marked decrease in hearing." C. "I now notice a ringing in my ears especially when I lay down to sleep at night." D. "I can hear better when someone speaks in low tones." E. "I can hear best when you put the tuning fork behind my ear."
A,C,E
The nurse is obtaining subjective data from a client with difficulty hearing. What should the nurse do to facilitate communication with the client? Select all that apply. A. Speak clearly at a normal pace. B. Avoid gesturing. C. Ensure there is adequate natural or artificial light. D. Exaggerate pronunciations. E. Promote a clear image of the nurse's mouth. F. Face the client when speaking.
A,C,E,F
When caring for a client with a foreign object removed from the eye, the nurse is most correct to assess the eye protective functions of which structure(s)? Select all that apply. a. Eyelids and lashes b. Aqueous humor c. Superior and inferior oblique muscles d. Conjunctiva e. Sclera f. Tears
A,F
The client is consulting with a physician regarding a potential diagnosis of Ménière disease. The nurse is assisting in positional testing and documentation. Which diagnostic test would the nurse anticipate to obtain a more precise evaluation of vestibular function? A. Audiometry B. Electronystagmography C. Caloric stimulation test D. Romberg test
B
The nurse is assessing a client's hearing using the Rinne test. When providing instruction to elicit client feedback, which instruction is essential? A. Raise your hand when you hear the vibration. B. Raise your hand when you no longer hear sound. C. Raise your hand when the vibration exceeds the sound. D. Raise your hand when the sound exceeds the vibration.
B
A nurse is caring for a client diagnosed with keratitis. What advice should the nurse give this client? A. Use warm soaks frequently. B. Begin using dark glasses. C. Wash the face and hair frequently. D. Massage the surrounding area.
B
A nurse is caring for a client who has just been diagnosed with glaucoma. What teaching should the nurse include with this client? A. How long it will be necessary to wear dark glasses B. The importance of regular bowel habits C. What vegetables to eat D. When it will be possible to read again
B
A nursing student is presenting a report on Ménière disease to other members of the class. What symptom would the student list? A. Pinkish-orange eardrum B. Nystagmus of the eyes C. Enlarged lymph nodes behind the ear D. Swelling and redness in the auditory canal
B
Following an ophthalmologic exam, an anxious client asks the nurse, "How serious is a refraction error?" Which is the best response from the nurse? A. "It is nothing serious." B. "It means corrective lenses are required." C. "Simple surgery can fix this problem." D. "This is normal for anyone your age."
B
The nurse is assisting the client in planning care during exacerbations of Ménière disease. Which diet would the nurse identify as appropriate at this time? A. A high-protein diet B. A low-sodium diet C. A low-fat diet D. A calorie-controlled diet
B
The nurse is assisting the eye surgeon in completing an examination of a client's eye. Which piece of equipment would the nurse provide to the surgeon to examine the optic disc under magnification? A. Retinoscope B. Ophthalmoscope C. Tonometer D. Amsler grid
B
The nurse is caring for a client with recurrent ear infections. The nurse assesses the client for further infectious processes traveling deeper into the tissue and becoming more lethal. Which infection, originated in the ear, is of most concern? A. Mastoiditis B. Meningitis C. Sinusitis D. Labyrinthitis
B
The nurse is caring for a client with symptoms of ototoxicity from aminoglycoside administration. On which structure does the medication produce the ototoxic effect? A. The auditory canal B. The eighth cranial nerve C. The tympanic membrane D. The cochlear nerve
B
The nurse is collecting the history of a client diagnosed with a cataract and is performing a focused assessment. Which finding should the nurse anticipate? A. A burning sensation and the sensation of an object in the eye B. Blurred or cloudy vision C. Inability to produce sufficient tears D. A swollen lacrimal caruncle
B
The nurse is establishing a visual test using the Snellen chart for a client experiencing visual changes. At which distance should the nurse instruct the client to stand? A. A 10-feet distance B. A 20-feet distance C. A 30-feet distance D. A 40-feet distance
B
The nurse is evaluating the independent care of a client recovering from a stapedectomy. Which action made by the client indicates a need for further teaching? A. The client turns head slowly when family approaches. B. The client uses clean technique to clean the wound. C. The client takes antibiotics on schedule D. The client asks for assistance upon ambulation.
B
The nurse is obtaining a history from a client who indicates hearing loss due to drug toxicity. Which type of hearing loss is noted? A. Conductive B. Sensorineural C. Mixed D. Central
B
The nurse is performing a Weber test on a client. During this test, where should the nurse place the tuning fork? A. On the mastoid process behind the ear B. In the midline of the client's skull or in the center of the forehead C. Near the external meatus of each ear D. Under the bridge of the nose
B
The nurse is supervising a family member who is instilling ear drops into the client's ear. Which of the following statements, made by the family member, would prompt further nursing instruction? A. "Turn your head to the side so I can put these drops in." B. "These drops are cold from being on the windowsill." C. "Let me put this cotton ball in your ear because I put the drop in." D. "I squeeze the dropper to put a drop of medicine in the ear."
B
The nurse is teaching a class on diseases of the ear. What would the nurse teach the class is the most characteristic symptom of otosclerosis? A. The client being distressed in the mornings B. A progressive, bilateral loss of hearing C. A red and swollen ear drum D. The client describing a recent upper respiratory infection
B
The nurse is teaching a parent how to instill drops in a 12-year-old child's eyes. Which action would the nurse instruct the parent to perform first? A. Close the eye gently. B. Tilt the head slightly backward. C. Instill the prescribed number of drops into the conjunctival pocket. D. Do not allow the tip of the container to touch the eye.
B
The nurse on a cruise ship is assessing clients for motion sickness. Which is a common misconception regarding motion sickness? A. Repeated motion is the cause. B. Once symptoms occur, they will always be present. C. Medications help the symptoms. D. Pallor and diaphoresis is a first symptom.
B
The occupational nurse is advising a client on options to enhance workplace communication because the client has progressive hearing loss. The client works as a customer service representative. In discussing the options with the client, which type would be the last option offered by the nurse? A. Battery-operated hearing aid B. American sign language C. Headsets with amplifiers D. Text-based telecommunications
B
There are several types of hearing loss. Which type of hearing loss benefits from the use of a hearing aid? A. Sensorineural B. Conductive C. Genetic D. Acquired
B
Which nursing goal is a priority when caring for a client newly diagnosed with vertigo? A. Client will maintain therapeutic medication schedule. B. Client will remain safe while ambulating in the home. C. Client will have a caretaker in the home. D. Client will close eyes as needed to reduce symptoms.
B
Which nursing suggestion would be most helpful to the client with recurrent otitis externa? A. Use a cotton applicator to ensure that the ear canal is dry. B. Place ear plugs into the ears before swimming C. Flush the ear with hydrogen peroxide D. Avoid lying on the side of the affected ear
B
A client asks the nurse why miotic eye solutions were prescribed in the treatment of the client's glaucoma. Which is the best nursing rationale for the use of this medication? A. Constricts intraocular vessels B. Paralyzes ciliary muscles C. Constricts pupil D. Dilates the pupil
C
A client comes to the occupational health nurse complaining of eye irritation. The client works in a dusty, outdoor environment. Why should the nurse advise periodic blinking to this client? A. To control the amount of sunlight that enters the eye B. To minimize the impact of the wind on the eye and to trap foreign debris C. To clear the dust and particles from the surface of the eyes D. To prevent the collection of tears over the surface of the eye
C
A client has been referred to an ophthalmologist for suspected macular degeneration. The nurse knows to prepare what test for the physician to give the client? A. Ishihara polychromatic plates B. Visual field C. Amsler grid D. Slit lamp
C
A client with chronic open-angle glaucoma is now presenting with eye pain and intraocular pressure of 50 mm Hg. An immediate iridotomy is scheduled. Which explanation by the nurse describes the desired effects of this procedure? A. Reverse optic nerve damage B. Restore vision C. Improve outflow drainage D. To relieve pain
C
A middle-aged client reports increasing difficulty reading newspaper print. Which of the following nursing explanations best describes this type of refractive error? A. Client is nearsighted. B. Lens has become cloudy and thick. C. Loss of elasticity of the lens. D. Floaters in the eye increase with age.
C
A nurse is caring for a client immediately following cataract removal. Which symptom would be most alarming to the nurse? A. Irritation in the operative eye B. Dilation of the pupil C. Dry, tickling cough D. Fever
C
A nurse is caring for a client who has undergone enucleation. What complication of enucleation should be addressed by the nurse? A. Hypotension B. Nausea and vomiting C. Hemorrhage D. Pneumonia
C
A nurse is doing preoperative and postoperative teaching with a client who is undergoing cataract surgery. What is an important teaching point the nurse should emphasize to the client? A. Prepare for possible feelings of depression. B. Expect increased urine output. C. Eat soft, easily chewed food until healing is complete. D. Anticipate development of a periorbital hematoma.
C
Audiometry is testing that measures hearing acuity precisely. Who does the nurse know can perform audiometric testing? A. School nurse B. Hearing aide salesperson C. Audiologist D. Office nurse
C
The nurse is assessing a client for objective symptoms of hearing difficulties. Which sign leads the nurse to take alternate measures to ensure client understanding of teaching? A. The client interrupts by asking the nurse to repeat instruction. B. The client is quiet and responds appropriately. C. The client leans forward and turns the head. D. The client quietly reads the instructional literature.
C
The nurse is assisting in providing coordination of services between the physician's office and vision specialist's office for a client who is being referred for potential retinal surgery. Which eye care specialist will the nurse make the referral to? A. Optician B. Optometrist C. Ophthalmologist D. Ophthalmic technician
C
The nurse is assisting with the administration of a caloric stimulation test. Which client response would the nurse document as an expected response? A. Dizziness B. Headache C. Nystagmus D. Double vision
C
The nurse is caring for a client being treated for Ménière disease. Which medication is monitored closely due to its addictive properties? A. Meclizine B. Hydrochlorothiazide C. Diazepam D. Promethazine
C
The nurse is caring for a client ordered for multiple eye screening. Following which procedure will the nurse instruct the client on a yellow coloring to the skin and urine as being normal? A. Ultrasonography B. Retinal Imaging C. Retinal Angiography D. Retinoscopy
C
The nurse is caring for a client with increased fluid accumulation in the eye. When assessing the client, which structure within the eye is noted to drain fluid from the anterior chamber? A. Fovea centralis B. Canthus C. Canal of Schlemm D. Choroid
C
The nurse is instructing a nursing student when a new client comes to the eye clinic. The client reports suspecting a corneal abrasion. The nurse should explain what to the student nurse? A. "To detect corneal abrasions, an ophthalmoscope is used." B. "To detect corneal abrasions, ultrasonography is used." C. "To detect corneal abrasions, a slit lamp is used." D. "To detect corneal abrasions, retinal angiography is used."
C
The nurse is instructing the client with dried cerumen blocking the ear canal on potential methods to reduce symptoms. Which at-home methods of cerumen removal are discouraged? A. Instilling 1 to 2 drops of half-strength peroxide in the ear B. Using warm glycerin or mineral oil to soften the cerumen C. Removing the cerumen by means of a cotton tip applicator D. Irrigating the ear with warm water and a rubber-bulb syringe
C
The nurse is obtaining a history on a client stating the inability to read the newspaper and seeing detail when looking at an image. Which assessment test would add additional data for a diagnosis? A. Assess if the pupils are equal and reactive to light. B. Assess vision on the Snellen chart. C. Assess peripheral vision. D. Assess color vision.
C
What aspect should the nurse closely monitor for in clients who have been administered salicylates, loop diuretics, quinidine, quinine, or aminoglycosides? A. Signs of hypotension B. Reduced urinary output C. Tinnitus and sensorineural hearing loss D. Impaired facial movement
C
What kind of otitis media is a pathogen-free fluid behind the tympanic membrane, resulting from irritation associated with respiratory allergies and enlarged adenoids? A. Purulent otitis media B. Infectious otitis media C. Serous otitis media D. Sterile otitis media
C
Which technique would be most beneficial for ambulation of a client who is visually impaired? A. Speak before touching the client. B. Provide a detailed description of the room and walkway. C. Allow client to follow the nurse's lead. D. Provide the client with a guide dog.
C
The nurse is caring for a client with open-angle glaucoma. What does the nurse know that this disease causes? Select all that apply. A. Atrophy of nerve fibers in the central area of the retina B. Edema of the lens C. Degeneration of the optic nerve D. Edema of the cornea E. Atrophy of nerve fibers in the peripheral areas of the retina
C,D,E
A client states having difficulty noting details on faces or television. Which of the following structures of the eye allows for detailed vision? A. The pupil B. The iris C. The cornea D. The macula lutea
D
A nurse is assessing a client for a fracture to the bony orbit. What would the nurse document if the assessment for fracture was positive? A. There is excessive tearing. B. The client's vision is blurred. C. A rust ring is seen around the pupil. D. The client has diplopia.
D
A nurse is caring for a client scheduled for general anesthesia. Which assessment finding would contraindicate the use of atropine in this client? A. Detached retina B. Cerebrovascular accident C. Cataracts D. Glaucoma
D
A nurse is caring for an older adult client with macular degeneration who has received injections of angiogenesis inhibitors. Which assessment finding would indicate the condition is worsening? A. Blurred vision B. Burning sensation of the eyes C. Loss of peripheral field vision D. Central vision impairment
D
At morning report, the nurse learns the assigned client is blind. Which question should the nurse ask the client upon initial assessment? A. "Have you always been blind?" B. "What caused your vision problem?" C. "Are you dependent with your care?" D. "Can you perceive light and motion?"
D
Following cataract removal, the client receives discharge instructions from the nurse. Which of the following instructions is most important? A. Apply a protective patch to the affected eye at bedtime. B. For the first 48 hours, avoid any activity that could cause particles to lodge in the eye. C. Avoid washing face and eyes for the first 24 hours. D. Avoid heavy lifting for 1 week.
D
The nurse is caring for a client in the triage section of a walk-in clinic. Which triad of common symptoms suggests a diagnosis of Ménière disease? A. Blurred vision, vertigo, nausea B. Syncope, vertigo, ear pain C. Disorientation, vertigo, nausea D. Hearing loss, vertigo, tinnitus
D
The nurse is caring for a client who is post-stapedectomy. What would the nurse include in the nursing care? A. Place the client on the operative side. B. Keep the affected ear packed with cotton. C. Encourage the client to exercise within 24 hours. D. Assess the facial nerve.
D
The nurse is caring for geriatric clients who state that they are prescribed reading glasses. Some individuals state needing assistance with seeing writing far away, and others need assistance with closer vision. What does the nurse understand to be related to visual changes caused by aging? A. Changes in refraction B. Changes in the visual field C. Changes in central vision D. Changes in accommodation
D
The nurse is completing a corneal light reflex test on a client, using a penlight. Which result would indicate a normal test result? A. The pupils have reaction to light. B. The eyes follow the light in all four directions. C. The client can see the light using peripheral vision. D. The light reflection is in the same spot on each eye.
D
The nurse is instructing a client on the benefits of a cochlear implant. The client asks, "How am I able to interpret sound?" The nurse credits which of the following as significant in the production of hearing? A. External microphone B. Internal processor C. Amplifier D. Auditory nerve
D
The nurse is teaching a family member how to instill ear drops to the client to remove impacted cerumen. What is important to teach this family member? A. Insert the irrigating syringe deeply. B. Direct the flow of the ear drops toward the eardrum. C. Refrigerate before instillation. D. Place the container in warm water before instillation.
D
What is located in the cochlea of the inner ear? A. Semicircular canals B. Labyrinth C. Vestibulocochlear nerve D. Organ of Corti
D
Which symptom reported by a client would the nurse relate to a tentative diagnosis of objective vertigo? A. Frequency of a headache B. Pain in the outer ear C. Hearing ability fluctuations D. A sensation of things moving
D