NCLEX EAR/EYE (VISUAL/AUDITORY)
The nurse is developing a teaching plan for a client with glaucoma. Which instruction should the nurse include in the plan of care?
Eye medications will need to be administered for life.
A client arrives at the emergency department with a foreign body in the left ear and tells the nurse that an insect flew into the ear. Which intervention should the nurse implement initially?
Instillation of mineral oil
A client's vision is tested with a Snellen chart. The results of the tests are documented as 20/60. What action should the nurse implement based on this finding?
Instruct the client that he or she may need glasses when driving.
A client arrives at the emergency department stating that a mosquito flew into his ear and that he is hearing a constant buzzing noise. Which intervention should the nurse take first?
Look into the ear canal using a flashlight.
The nurse is reviewing the primary health care provider's prescriptions for a client with Ménière's disease. Which diet would most likely be prescribed for the client?
Low-sodium diet
The nurse creates a plan of care for a client with a diagnosis of Ménière's disease who is being admitted to the hospital. The priority nursing intervention in the plan of care should focus on which item?
Measures that will ensure safety
The nurse is assigned to care for a client after a mastoidectomy. Which nursing intervention would be a priority in the care of this client?
Monitor for signs of facial nerve injury.
Tonometry is performed on a client with a suspected diagnosis of glaucoma. The nurse looks at the documented test results and notes an intraocular pressure (IOP) value of 23. What should be the nurse's initial action?
Note the time of day the test was done.
The student nurse is working with a registered nurse (RN) in the clinic. The RN is educating the student nurse on dysfunction in the area of the semicircular canals of the ear. Which statement by the student nurse indicates that the teaching has been effective?
"Disturbance in balance occurs."
The nurse is preparing a teaching plan for a client who had a cataract extraction with intraocular implantation. Which home care measures should the nurse include in the plan? Select all that apply
Place an eye shield on the surgical eye at bedtime. Contact the surgeon if a decrease in visual acuity occurs Take acetaminophen for minor eye discomfort. Avoid activities that require bending over.
A client with retinal detachment is admitted to the nursing unit in preparation for a repair procedure. Which prescription should the nurse anticipate?
Placing an eye patch over the client's affected eye
The nurse is developing a plan of care for a client with a diagnosis of severe vertigo from Ménière's disease who is being admitted to the hospital. What is the priority nursing intervention in the plan of care?
Safety measures
The nurse is caring for a hearing-impaired client. Which approach will facilitate communication?
Speak at a normal volume.
The nurse notes that the primary health care provider has documented a diagnosis of presbycusis on a client's chart. Based on this information, what action should the nurse take?
Speak at normal tone and pitch, slowly and clearly.
The home care nurse is visiting a client who was recently diagnosed with a hearing impairment. The nurse should prepare to instruct the client's spouse in which measure that will facilitate communication?
Speak in a normal tone and face the client when speaking.
The nurse is providing diet instructions to a client with Ménière's disease who is being discharged from the hospital after admission for an acute attack. Which statement, if made by the client, indicates an understanding of the dietary measures to take to help prevent further attacks?
"I need to be sure to consume foods that are low in sodium."
A client is experiencing blockage of the eustachian tubes. The nurse educates the client on how the client may forcibly open the eustachian tube. Which statement by the client indicates that the teaching has been effective?
"I should perform the Valsalva maneuver."
The nurse is providing discharge instructions to the client being discharged after a fenestration procedure for the treatment of otosclerosis. Which statement made by the client indicates a need for further instruction?
"I should use a straw to drink liquids for the next 2 to 3 weeks."
The nurse is educating a client on how to eliminate whistling from a hearing aid. The nurse recognizes that further teaching is needed when the client makes which statement?
"I will raise the volume of my hearing aid."
Which statement made by the client who had ear surgery to treat otosclerosis would indicate that the client understands postoperative home care instructions?
"I will take stool softeners as prescribed by my primary health care provider."
The nursing student is caring for a client with a diagnosis of presbycusis. The nursing instructor determines that the student understands presbycusis when which statement is made?
"It's a sensorineural hearing loss that occurs with the aging process."
The nurse in the health care clinic is providing instructions to a client regarding the use of a hearing aid. Which statement is most appropriate for the nurse to include?
"The hearing aid should not be worn if an ear infection is present."
A client being prepared for a myringotomy asks the nurse about the procedure. The nurse should respond by making which statement?
"This procedure will reduce the pressure you feel in your ear and allow fluid to drain."
The nurse provides dietary instructions to a client with Ménière's disease. The nurse should tell the client that which food or fluid item is acceptable to consume?
Sugar-free Jell-O
A client with a history of ear problems is going on vacation by aircraft. The nurse advises the client to include which activities to prevent barotrauma during ascent and descent of the airplane? Select all that apply.
Swallowing Chewing gum Sucking on hard candy Yawning
The nurse is preparing to provide care for a client who will need an ear irrigation to remove impacted cerumen. Which interventions should the nurse take when performing the irrigation? Select all that apply.
-Position the client with the affected side down after the irrigation. -Warm the irrigating solution to a temperature that is close to body temperature. -Direct a slow, steady stream of irrigation solution toward the upper wall of the ear canal.
The nurse is observing an assistive personnel (AP) communicating with a client who is deaf. The nurse should intervene if which behavior is observed?
The AP overenunciates words when speaking.
A client is diagnosed with a disorder involving the inner ear. Which is the most common client complaint associated with a disorder involving this part of the ear?
Tinnitus
A client is diagnosed with a problem involving the inner ear. Which is the most common client complaint associated with a problem involving this part of the ear?
Tinnitus
The nurse is performing an assessment on a client with a diagnosis of Ménière's disease. The nurse anticipates that the client is most likely to report which symptom during an acute attack?
Tinnitus
The nurse educator is conducting an in-service education session for the nurses employed in the eye and ear surgical unit of a large trauma center. In discussing the topic of cochlear implants, the educator notes that this surgical procedure is contraindicated in which client?
A client who became deaf before learning to speak
The nurse is planning care for a client with acute otitis media. To reduce pressure and allow fluid to drain, the nurse anticipates that which measure would most likely be recommended to the client?
A myringotomy
The nurse is performing an otoscopic examination on a client with mastoiditis. On examination of the tympanic membrane, which finding should the nurse expect to observe?
A red, dull, thick, and immobile tympanic membrane
The clinic nurse is performing an otoscopic examination on an adolescent who was hit in the ear with a basketball during a neighborhood game. A perforated eardrum is suspected. Which finding should the nurse expect to observe if the eardrum is perforated?
A round or oval darkened area on the eardrum
The nurse is performing an admission assessment on a client with a diagnosis of detached retina. Which sign or symptom is associated with this eye disorder?
A sense of a curtain falling across the field of vision
The nurse is performing an admission assessment on a client with a diagnosis of detached retina. Which sign or symptom is associated with this eye problem?
A sense of a curtain falling across the field of vision
The nurse has admitted to the hospital a client with a diagnosis of an acute attack of Ménière's disease. The nurse reviews the primary health care provider's prescriptions for the client. Which prescription should the nurse question?
Ambulation four times daily
A caloric test is prescribed for a client suspected of having disease of the labyrinth. The nurse should obtain which essential item in preparation for this test?
An otoscope
The nurse has given a client who is at risk for motion sickness suggestions about medications that can prevent an occurrence. The nurse determines that the client has correctly learned the information if the client states that the medication is taken at what time before the triggering event?
At least 1 hour before
The nurse is preparing a teaching plan for a client who had a cataract extraction with intraocular implantation. Which home care measures should the nurse include in the plan? Select all that apply.
Avoid activities that require bending over. Take acetaminophen for minor eye discomfort. Place an eye shield on the surgical eye at bedtime. Contact the surgeon if a decrease in visual acuity occurs.
The nurse is providing discharge instructions to a client who had a fenestration procedure for the treatment of otosclerosis. The nurse should instruct the client to take which measure?
Avoid air travel.
A client with Meniere's disease is experiencing severe vertigo. Which instruction should the nurse give to the client to assist in controlling the vertigo?
Avoid sudden head movements.
A client with Ménière's disease is experiencing severe vertigo. Which instruction should the nurse give to the client to assist in controlling the vertigo?
Avoid sudden head movements.
The nurse is performing an assessment on a client with a suspected diagnosis of cataract. Which clinical manifestation should the nurse expect to note in the early stages of cataract formation?
Blurred vision
A client is diagnosed with glaucoma. Which piece of nursing assessment data identifies a risk factor associated with this eye disorder?
Cardiovascular disease
The nurse instructs a client in the use of a hearing aid. The nurse should include which instruction?
Check the battery to ensure that it is working before use.
The nurse is caring for a client who was recently diagnosed with primary open-angle glaucoma (POAG). Which assessment finding is specific to this type of glaucoma?
Client report of "tunnel vision"
A client makes an appointment with an ear specialist because of the frequent recurrence of middle ear infections. In performing an intake assessment of the client, the nurse should ask about which risk factor related to infection of the ears?
Congenital abnormalities
The nurse is caring for a client in the postoperative period following enucleation. The nurse notes bloody staining on the surgical eye dressing. Which nursing action is most appropriate?
Contact the primary health care provider (PHCP).
The nurse is caring for a client following craniotomy for removal of an acoustic neuroma. Assessment of which cranial nerve would identify a complication specifically associated with this surgery?
Cranial nerve VII, facial nerve
The nurse is planning a presentation on noise prevention and ear protection for a display booth at a local health fair. The nurse plans to incorporate which important concept regarding hearing loss in the presentation?
Cup the hands over the ears if loud noise is expected suddenly.
The nurse is caring for a client diagnosed with Ménière's disease. The nurse plans care, understanding that this disorder is characterized by which manifestation?
Dizziness
