Practice Q & A- Eyes & Ears Exam 1 Med Surg

485 A client with glaucoma asks a nurse about future treatment and precautions. What information should the nurse's explanation include? 1 Avoidance of cholinergics 2 Surgical replacement of lens 3 Continuation of therapy for life 4 Prevention of high blood pressure

485 3 Therapy must be continued for life to prevent damage to the optic nerve from increased intraocular pressure. 1 These are used in the treatment of glaucoma; anticholinergics are contraindicated. 2 This is the treatment for cataracts. 4 There is an increase in intraocular pressure with glaucoma; the blood pressure may be unaffected. Client Need: Physiological Adaptation; Cognitive Level: Application; Integrated Process: Teaching/Learning; Nursing Process: Planning/Implementation; Reference: Ch 11, Glaucoma, Nursing Care

488 Which clinical indicator is the nurse most likely to identify when exploring the history of a client with open-angle glaucoma? 1 Constant blurring 2 Abrupt attacks of acute pain 3 Sudden, complete loss of vision 4 Impairment of peripheral vision

488 4 Open-angle glaucoma has an insidious onset, with increased intraocular pressure causing pressure on the retina and blood vessels in the eye. Peripheral vision is decreased as the visual field progressively diminishes. 1 This may occur with untreated acute angle-closure glaucoma. 2 Pain occurs in acute angle-closure, not open-angle, glaucoma. 3 Occlusions of the central retinal artery or retinal detachment will cause a sudden loss of vision. Client Need: Physiological Adaptation; Cognitive Level: Application; Nursing Process: Assessment/Analysis; Reference: Ch 11, Glaucoma, Data Base

489 A client's relative asks the nurse what a cataract is. What explanation should the nurse provide? 1 An opacity of the lens 2 A thin film over the cornea 3 A crystallinization of the pupil 4 An increase in the density of the conjunctiva

489 1 A cataract is a clouding of the crystalline lens or its capsule. 2, 3, 4 This is not the pathophysiology related to cataracts. Client Need: Physiological Adaptation; Cognitive Level: Knowledge; Integrated Process: Teaching/Learning; Nursing Process: Planning/Implementation; Reference: Ch 11, Cataract, Data Base

490 What should the nurse do for a client who just had cataract surgery? 1 Instruct the client to avoid driving for several weeks. 2 Teach the client coughing and deep-breathing techniques. 3 Advise the client to refrain from vigorous brushing of the teeth and hair. 4 Encourage the client to perform eye exercises to strengthen the ocular musculature.

490 3 Activities such as rigorous brushing of hair and teeth cause increased intraocular pressure and may lead to hemorrhage in the anterior chamber. 1 This is unnecessary; clients are usually permitted to drive before this time. 2 Coughing and deep breathing can increase intraocular pressure and should be avoided. 4 Weakening of the eye musculature is not related to cataracts. Client Need: Reduction of Risk Potential; Cognitive Level: Application; Integrated Process: Teaching/Learning; Nursing Process: Planning/Implementation; Reference: Ch 11, Cataract, Nursing Care

491 A nurse is caring for a client who is scheduled for surgery for a detached retina. Which goal of surgery identified by the client indicates that the preoperative teaching was effective? 1 Promote growth of new retinal cells 2 Adhere the sclera to the choroid layer 3 Graft a healthy piece of retina in place 4 Create a scar that aids in healing retinal holes

491 4 Scar formation seals the hole and promotes attachment of the two retinal surfaces. 1 The retina is part of the nervous system; it does not regenerate or grow new cells. 2 The sclera is not involved; the retina adjoins and is nourished by the choroid. 3 This is not the treatment used; treatment includes the formation of a scar by the use of lasers or surgical "buckling." Client Need: Physiological Adaptation; Cognitive Level: Application; Integrated Process: Teaching/Learning; Nursing Process: Evaluation/Outcomes; Reference: Ch 11, Detached Retina, Data Base

493 A client is scheduled for a labyrinthectomy to treat Ménière syndrome. What expected outcome of the procedure should be included in preoperative teaching? 1 Absence of pain 2 Decreased cerumen 3 Loss of sense of smell 4 Permanent irreversible deafness

493 4 The labyrinth is the inner ear and consists of the vestibule, cochlea, semicircular canals, utricle, saccule, cochlear duct, and membranous semicircular canals. A labyrinthectomy is performed to alleviate the symptom of vertigo but results in deafness, because the organ of Corti and cochlear nerve are located in the inner ear. 1 There is no pain associated with Ménière syndrome. 2 Ménière syndrome is not related to cerumen production. 3 The loss of the sense of smell (anosmia) is not affected by surgery to the ear. Client Need: Reduction of Risk Potential; Cognitive Level: Application; Integrated Process: Teaching/Learning; Nursing Process: Planning/Implementation; Reference: Ch 11, Ménière Disease, Data Base

494 A nurse is developing a teaching plan for a client with otosclerosis. What information should the nurse include in the teaching plan? 1 Stapedectomy is the procedure of choice. 2 Hearing aids usually restore some hearing. 3 The client is usually unable to hear bass tones. 4 Air conduction is more effective than bone conduction.

494 2 With a partial hearing loss the auditory ossicles have not yet become fixed; as long as vibrations occur, a hearing aid may be beneficial. 1 This procedure usually is not performed unless there was total hearing loss or if what was heard was useless. 3 Although the bass tones are particularly affected, all tones are affected. 4 With conduction hearing loss, bone conduction is more effective than air conduction. Client Need: Physiological Adaptation; Cognitive Level: Application; Integrated Process: Teaching/Learning; Nursing Process: Planning/Implementation; Reference: Ch 11, Otosclerosis, Data Base

7 A nurse is caring for an older adult with a hearing loss secondary to aging. What can the nurse expect to identify when assessing this client? Select all that apply.

7 Answer: 1, 3. 1 Cerumen (ear wax) becomes drier and harder as a person ages. 2 There is no greater incidence of tympanic tears caused by the aging process. 3 Generally, female voices have a higher pitch than male voices; older adults with presbycusis (hearing loss caused by the aging process) have more difficulty hearing higher-pitched sounds. 4 The hair in the auditory canal increases, not decreases. 5 The epithelium of the lining of the ear becomes thinner and drier. Client Need: Health Promotion and Maintenance; Cognitive Level: Analysis; Nursing Process: Assessment/Analysis; Reference: Ch 5, General Nursing Care of Middle-Older and Old-Older Adults

487 Which desired effect of therapy should the nurse explain to the client who has primary angle-closure glaucoma? 1 Dilating the pupil 2 Resting the eye muscles 3 Preventing secondary infection 4 Controlling intraocular pressure

87 4 Glaucoma is a disease in which there is increased intraocular pressure resulting from narrowing of the aqueous outflow channel (canal of Schlemm). This can lead to blindness, caused by compression of the nutritive blood vessels supplying the rods and cones. 1 Pupil dilation increases intraocular pressure because it narrows the canal of Schlemm. 2 Intraocular pressure is not affected by activity of the eye. 3 Although secondary infections are not desirable, the priority is to maintain vision by controlling the pressure. Client Need: Physiological Adaptation; Cognitive Level: Application; Integrated Process: Teaching/Learning; Nursing Process: Planning/Implementation; Reference: Ch 11, Glaucoma, Data Base

Practice Q & A- Eyes & Ears Medsurg Exam 5

Practice Q & A- Eyes & Ears Medsurg exam 5