PVN141 Neurosensory Nursing Care
The nurse is aware that the patient has 20/40 vision. This means that the patient can see at 20 ft what the normal eye can see at _____ ft?
40 Rationale: The Snellen Eye Chart tests visual acuity. A vision evaluation of 20/40 means that the patient can see at 20 ft what the person with normal vision can see at 40 ft
Select all the conditions that may cause conductive hearing loss. (Select all that apply)
A. Build-up of cerumen B. Foreign Bodies C. Otosclerosis of external auditory canal F. Otitis media with effusion Rationale: Common causes of conductive hearing loss are build-up of cerumen and otitis media with effusion (escape of effusion). Other conditions that may result in conductive hearing loss are foreign bodies, otosclerosis, and stenosis of the external auditory canal. Sensorineural hearing loss is usually due to trauma, infectious processes, or exposure to ototoxic drugs
Why is otitis media found more frequently in children 6 to 36 months?
Eustachian tubes in children are shorter and straighter Rationale: Children's shorter and straighter eustachian tubes provide easier access of the organisms from the nasopharynx to travel to the middle ear.
One of the housekeepers splashes a chemical in the eyes. What should be the first priority?
Irrigate with normal saline solution for 20 minutes. Rationale: Burns are medically treated with a prolonged, 15 to 20 minute or longer normal saline flush immediately after burn exposure.
What is the process when the lens of the eye changes its curvature to focus on the retina?
Accommodation Rationale: The ability of the lens to alter its curvature as it focuses on the retina is accommodation
When the newly blind male home health patient asks the nurse how he might get assistance, who might the nurse suggest he contact?
American Foundation for the Blind for a list of agencies Rationale: The American foundation for the Blind has lists of agencies to assist and educated the visually impaired patient.
What does the cataract treatment of phacoemulsification involve?
Breaking the cataract with ultrasound Rationale: Phacoemulsification uses ultrasound to break up the cataract
What does diabetic retinopathy result from?
Capillaries in the retina hemorrhage Rationale: Retinopathy is caused when the capillaries in the retina have aneurysms or hemorrhage.
What is the most interior part of the eye?
Choroid Rationale: The cornea is the outermost, followed by the aqueous humor, iris, lens, retina, and the choroid
What does a tympanoplasty correct?
Conductive hearing loss Rationale: Tympanoplasty can correct a conductive hearing loss
What do miotic eye drops do for a patient with glaucoma?
Constrict the pupil and open the canal of Schlemm Rationale: Miotic eye drops allow the pupil to constrict and open the canal of Schlemm to drain the excess fluid.
The nurse counsels the 16-year-old boy that playing his music at high volume can result in impairment in hearing related to:
Damage of the fine hair cells in the organ of Corti Rationale: Long-term exposure to loud noises can damage the fine hair cells in the organ of Corti, which causes a conductive hearing loss
When the patient in the emergency room complains of seeing flashing lights and a curtain down over his right eye, the nurse recognizes this as a symptom of which condition?
Detached retina Rationale: The standard complaint of a detached retina is the report of seeing flashing lights and having a curtain being drawn over the eyes.
Which complaint made by a 64-year-old patient during a health interview would alert the nurse to the possibility of cataracts?
Difficulty driving at night Rationale: Blurring of vision and difficulty driving at night is often the first subjective symptom reported by a patient who has cataracts.
What should the nurse include in the plan of care following a tympanoplasty?
Elevating head of bed with operative side facing upward Rationale: Postoperative management for patients who have had a tympanoplasty consists of bed rest until the next morning. The head of the bed is elevated 40 degrees, and the operative side faces upward.
The home health patient complains of tearing and a feeling of dryness in the right eye. The nurse assesses that the eyelid is turned inward and the sclera is red. The nurse documents the presence of a(n) _____.
Entropion Rationale: An entropion is the abnormal turning in of the eyelid, causing irritation and tearing of the eye
The total removal of an eye is a(n) _____.
Enucleation Rationale: The surgical removal of the eyeball is an enucleation
What should a patient who has had a cataract repair avoid?
The lifting of heavy objects Rationale: Post-cataract patients should avoid any activity that increases the intraocular pressure, such as lifting heavy objects, stooping, and bending
What is the first indication of macular degeneration?
The loss of central vision Rationale: Macular degeneration is characterized by the slow loss of central and near vision.
What factors must the nurse consider when assessing readiness to learn when teaching health promotion practices for the visually and hearing impaired? (Select all that apply)
A. Cultural beliefs B. Values C. Habits Rationale: The nurse must consider the patient's culture, beliefs, values, and habits, as well as the special needs of the older adult
Which may contribute to otitis media? (Select all that apply)
A. Exposure to cigarette smoke B. Allergies C. Upper respiratory infections Rationale: Otitis media is usually caused by an upper respiratory infection with gram-negative bacteria, such as Proteus, Klebsiella, and Pseudomonas. In addition, allergy, exposure to cigarette smoke, mycoplasma, and several viruses may be factors
Which of the following are causes of cataracts? (Select all that apply)
A. Long-term use of corticosteroids C. Congenital from exposure to maternal rubella D. Diabetes mellitus F. Smoking Rationale: Among the many causes of cataracts are long-term corticosteroid use, maternal rubella, diabetes mellitus, and smoking
What would a nurse do when the patient arrives in the PACU after a left stapedectomy? (Select all that apply)
A. Turn the patient on his right side D. Leave the bed flat E. Medicate immediately on the complaint of nausea Rationale: The bed is left in the flat position and the patient is positioned with the operated side facing up, the patient is not turned, and the dressing is not changed by the nurse. The patient should be medicated immediately on complaint of nausea to prevent vomiting and possible disruption of the graft
The nurse will assess for _____ when the older adult home health patient complains that the entire right side of his head hurts and cannot chew without pain.
External otitis Rationale: The symptoms of painful head, painful chewing, and pain when the auricle is moved all indicate external otitis, frequently caused by compacted cerumen.
When the patient stares at the black dot on an Amsler grid, what should the nurse ask him to report?
Any distortion of the grid Rationale: Amsler grid, a diagnostic tool for retinal disorders, requires that the patient look at the dot on the grid and report any distortion in the grid lines.
A patient who had an enucleation of the right eye has been admitted PACU. What should the nurse include in the plan of care?
Apply a pressure dressing over the right eye socket Rationale: A pressure dressing will be applied to the right eye socket and the dressing should be checked every hour for the first 24 hours.
What should the nurse advise the 20-year-old to do who has been put on cefaclor (Ceclor) for a resistant otitis media?
Avoid alcoholic beverages Rationale: Drinking alcohol is discouraged while on Ceclor. The drug should be taken in its entirety and stored in the refrigerator. The drug can be taken with or without meals.
What is the first nursing intervention step for the immediate care of a patient with a penetrating wound of the eye?
Lay the patient down flat Rationale: The patient should be placed on his back to prevent loss of the aqueous humor, assessment of the eye for the location of the object and whether the pupil is regular, cover the eye to prevent movement, and obtain medical attention immediately
How should the nurse advise a patient who has severe vertigo from labyrinthitis?
Lie immobile and hold the head in one position until the vertigo lessens Rationale: Lying immobile and holding the head in one position will lessen vertigo
The nurse takes into consideration that the Weber test indicated a conductive hearing loss in a patient because the patient reported hearing the tone:
Louder in his affected ear Rationale: A conductive hearing loss can be diagnosed by a Weber test. A person with a conductive loss will hear the noise louder in his affected ear.
The surgical incision into the eardrum with either a knife or a heated wire loop to relieve pressure in the middle ear is a(n) _____.
Myringotomy Rationale: The opening of the eardrum with a specialized knife or a heated wire loop to relieve pressure in the middle ear is a myringotomy
Progressive deafness caused by the ankylosis of the stapes is the condition of _____.
Otosclerosis Rationale: Progressive deafness related to the ankylosis of the stapes is diagnosed as otosclerosis
What is a common mistake that hinders communication when communicating with the hearing impaired?
Overaccentuating words Rationale: Do not overaccentuate words. Speak in a normal tone; do not shout or raise the pitch of voice
What must a patient do following a left vitrectomy?
Position self in a face-down position for 4 to 5 days Rationale: Following a vitrectomy, the patient must assume a face-down position or turn to face the right side for 4 to 5 days.
Which is a sign of acute angle closure glaucoma (AACG)?
Large fixed pupil Rationale: Signs of AACG would be eye pain, large fixed pupil with reddened sclera, decreased vision, nausea, and vomiting
What should the nurse remind the hearing aid wearer to do when the nurse hears a whistling hearing aid?
Reinsert the ear mold Rationale: The whistling hearing aid is usually caused by a poor fit of the ear mold. Reinsertion of the ear mold usually stops the whistling.
The nurse explains that a pneumatic retinopexy is a repair of a retinal detachment using a bubble of _____ to put pressure on the damaged retina.
Gas Rationale: A pneumatic retinopexy uses a bubble of gas to put pressure on the damaged retina
Four hours after a stapedectomy, the patient complains that hearing has not improved at all. What knowledge would the nurse use to shape a response?
Hearing will not return until edema subsides. Rationale: Hearing improvement will not be noted until edema subsides and the packing is removed
The nurse clarifies that the difference between a photorefractive keratectomy (PRK) and a laser in-situ keratomileusis (LASIK) is that a LASIK:
Removes some internal layers of the cornea Rationale: The LASIK procedure removes some of the internal layers of the cornea affecting the central zone of vision
The 62-year-old home health patient who is recovering from eye surgery complains of a feeling of "grittiness" in the eye and is having blurred vision. The eyes are reddened and have stringy mucus. What do these complaints indicate?
Sjogren syndrome Rationale: The Sjogren syndrome of "dry eye" frequently appears after eye surgery. There is insufficient production of tears. Excessive use of antihistamines, antidepressants, and decongestants may cause this syndrome to appear
Why would the nurse encourage a group of teenagers to protect their eyes with dark sunglasses while using a UV lamp?
The lamp can cause cataracts Rationale: The proteins in the lens of the eye are vulnerable to UV light and can develop cataracts
The patient tells the nurse that he is legally blind. How would this impact the nurse's plan of care for this patient?
The nurse would need to determine how this patient's visual impairment affects normal functioning Rationale: "Legal blindness" refers to individuals with a maximum visual acuity of 20/200 with corrective eyewear and/or visual field sight capacity reduced by 20 degrees. Categories have been established to help determine the exact extent of the vision loss and what assistive measures are appropriate for the individual. The nurse will need more information as to the exact extent of the vision loss for this patient
How would the nurse explain the purpose of photocoagulation to a diabetic patient with diabetic retinopathy?
The procedure will destroy new blood vessels, seal leaking blood vessels, and help prevent retinal edema Rationale: Photocoagulation is useful in diabetic retinopathy to cauterize hemorrhaging vessels and to destroy new vessels.
