Sensory Exam
A client with a history of closed-angle glaucoma is scheduled for abdominal surgery. Because the client is extremely anxious, surgery is to be performed under general anesthesia. What should the nurse teach the client to do to prevent respiratory complications postoperatively? 1. Deep-breathing techniques 2. Performing productive coughing 3. Turning from side to side frequently 4. Pant breathing while gently closing the eyelids
1. Deep-breathing techniques Deep breathing is an intervention to prevent respiratory complications that does not increase intraocular pressure. Coughing is contraindicated because it increases intraocular pressure. Although turning from side to side is permitted, it is not as effective as deep breathing in preventing respiratory complications. Pant breathing is shallow breathing and will not prevent respiratory complications.
Which drug does a nurse anticipate may be prescribed to produce diuresis and inhibit formation of aqueous humor for a client with glaucoma? 1. Chlorothiazide (Diuril) 2. Acetazolamide (Diamox) 3. Bendroflumethiazide (Naturetin) 4. Demecarium bromide (Humorsol)
2. Acetazolamide (Diamox) Acetazolamide is a carbonic anhydrase inhibitor that decreases inflow of aqueous humor and controls intraocular pressure in acute angle-closure glaucoma attack. Chlorothiazide and bendroflumethiazide have no effect on the eye. Demecarium bromide does not affect production of aqueous humor.
A nurse is caring for a client with glaucoma. What rationale associated with the need for treatment of this condition should the nurse include in a teaching program? 1. Total blindness is inevitable 2. Lost vision cannot be restored 3. Use of both eyes usually is restricted 4. Surgery will help the problem only temporarily
2. Lost vision cannot be restored Retinal damage caused by the increased intraocular pressure of glaucoma is progressive and permanent if the disease is not controlled. Early treatment may prevent blindness. One eye may be affected, and there is no restriction on the use of either eye. Surgery can open up drainage and permanently reduce pressure.
The parents of an 18-month-old toddler are anxious to know why their child has experienced several episodes of acute otitis media. What should the nurse explain to the parents about why toddlers are prone to middle ear infections? 1. Immunological differences between adults and young children 2. Structural differences between eustachian tubes of younger and older children 3. Functional differences between eustachian tubes of younger and older children 4. Circumference differences between middle ear cavity size of adults and young children
2. Structural differences between eustachian tubes of younger and older children The eustachian tube in young children is shorter and wider, allowing a reflux of nasopharyngeal secretions. Immunological differences are not a factor in the development of otitis media. There is no difference in the function of the eustachian tube among age groups. The size of the middle ear does not play a role in the occurrence of otitis media in young children.
A client has cataracts in both eyes. The plan is to extract the left cataract. What should the nurse include in the client's postoperative teaching plan? 1. Cover both eyes for 24 hours after surgery 2. Cough and deep breathe every 2 hours for at least 24 hours after surgery 3. Bed rest for 72 to 96 hours after surgery 4. Apply a hard patch over the left eye for six to seven days after surgery
4. Apply a hard patch over the left eye for six to seven days after surgery The eye shield will prevent injury to the newly operated eye. Only the affected eye will be covered. Coughing is contraindicated in clients who have had cataract surgery because it increases intraocular pressure. Bed rest is not necessary; routine activity and ambulation will not cause injury.
A nurse is assessing a client with a diagnosis of dry age-related macular degeneration. Which ocular symptom should the nurse expect the client to report? 1. Attacks of acute pain 2. Constant blurred vision 3. Loss of central vision 4. Decreased peripheral vision
3. Loss of central vision The main characteristic of dry age-related macular degeneration is loss of central vision, which is gradual. Primary closed-angle glaucoma causes pain. Blurred vision may be caused by a refractive error. Loss of peripheral vision does not occur with macular degeneration.
A 2-year-old toddler has hearing loss caused by recurrent otitis media. What treatment does the nurse anticipate that the practitioner will recommend? 1. Ear drops 2. Myringotomy 3. Mastoidectomy 4. Steroid therapy
Correct 2. Myringotomy Myringotomy is a surgical opening into the eardrum to permit drainage of accumulated fluid associated with otitis media. Ear drops are not used because they will obscure the view of the tympanic membrane. Removal of the mastoid will not relieve pressure within inflamed ears. Antibiotics, not steroids, are used for an infectious process.
The nurse is preparing to administer eardrops to a client that has impacted cerumen. Before administering the drops, the nurse will assess the client for which contraindications? Select all that apply. 1. Allergy to the medication 2. Itching in the ear canal 3. Drainage from the ear canal 4. Tympanic membrane rupture 5. Partial hearing loss in the affected ear
1. Allergy to the medication 3. Drainage from the ear canal 4. Tympanic membrane rupture Contraindications to eardrops include allergy to the medication, drainage from the ear canal, and tympanic membrane rupture. Partial hearing loss may occur with impacted cerumen and is not a contraindication to the use of eardrops. Itching may occur with some ear conditions and is not a contraindication to the use of eardrops.
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
1. An opacity of the lens A cataract is a clouding of the crystalline lens or its capsule. A thin film over the cornea, a crystallinization of the pupil, and an increase in the density of the conjunctiva are not the pathophysiology related to cataracts.
A health care provider recently made the diagnosis that a client has glaucoma. The nurse is preparing to administer eye drops to the client. Which ophthalmic solution is contraindicated for this client? 1. Timolol 2. Atropine 3. Pilocarpine 4. Epinephrine
2. Atropine Atropine, a mydriatic ophthalmic solution, is contraindicated for clients with glaucoma because it dilates the pupil, increasing intraocular pressure. Timolol, a beta blocker, decreases aqueous humor production; beta blockers are the preferred initial medications given to reduce intraocular pressure. Pilocarpine, a cholinergic, constricts the pupil, thereby increasing aqueous humor outflow. Epinephrine, an adrenergic agent, enhances aqueous humor outflow, thereby reducing intraocular pressure.
Which statement by the client leads the nurse to conclude that discharge teaching about glaucoma was effective? 1. "I will restrict my fluid intake." 2. "I will use mydriatics regularly." 3. "Bright lights should be avoided." 4. "Bending exercises should be avoided."
Correct 4. "Bending exercises should be avoided." Exercise should not include bending and the Valsalva maneuver; both increase intraocular pressure, which should be avoided. Fluids may be taken as desired because they have no effect on intraocular pressure. Mydriatics are contraindicated because they dilate the pupil, which increases intraocular pressure. Lighting conditions have no effect on intraocular pressure.
A client is being prepared for discharge from an ambulatory surgical clinic after a cataract extraction and an intraocular lens implant. Which statement indicates to the nurse that the discharge teaching was effective? 1. "I should call the clinic if my eye begins to hurt." 2. "I am so glad that I can take a shower tomorrow." 3. "There will be bright flashes of light for a few days." 4. "My vision should show some improvement by tomorrow."
Correct 1. "I should call the clinic if my eye begins to hurt." Pain after a cataract extraction and intraocular lens implant may indicate infection or hemorrhage and should be reported immediately. Soap may irritate the eye, and showers or shampooing of the hair should be avoided as instructed, usually from several days to two weeks. Seeing bright flashes of light is a symptom of retinal detachment and is not expected. Although rapid vision improvement may occur in some people, others may require several weeks to achieve improved visual acuity.
A client who has a detached retina is to have a scleral buckling procedure to attempt to reattach the retina. Before the client is discharged home, the nurse should plan to: 1. Instruct the client to wear dark glasses after the patch is removed 2. Explain to the client that reading will help strengthen the eye muscles 3. Reassure the client that the glasses worn before surgery can still be worn 4. Tell the client that usual activities can be resumed within a couple of weeks
Correct 1. Instruct the client to wear dark glasses after the patch is removed The medications usually prescribed for clients with retinal detachment reduce the eye's ability to adjust to light because straining, as well as excess activity, can increase intraocular pressure. The eye movements associated with reading can be uncomfortable and should not be encouraged at this time. Generally, new lenses will be required in three months or sooner. Clients should avoid straining and not resume usual activities until given permission.
A client with the diagnosis of otosclerosis undergoes a stapedectomy with insertion of a middle ear prosthesis. A few days after the operation the client tells the nurse that there is no improvement in hearing. Before responding what should the nurse conclude that the client is experiencing? 1. Swelling within the ear canal 2. Damage to the organ of Corti 3. Slippage of the graft out of position 4. Perforation of the tympanic membrane
Correct 1. Swelling within the ear canal Edema associated with the inflammatory reaction after surgery limits the conduction of sound. Damage to the organ of Corti should not happen because the inner ear is not involved with this surgery. If the graft slips out of position, the hearing loss will be worse than before surgery. Perforation of the tympanic membrane is unlikely with a stapedectomy and insertion of a middle ear prosthesis.
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.
Correct 2. Hearing aids usually restore some hearing. With a partial hearing loss the auditory ossicles have not yet become fixed; as long as vibrations occur, a hearing aid may be beneficial. Hearing aids usually restore some hearing; stapedectomy usually is not performed unless there was total hearing loss or if what was heard was useless. Although the bass tones are particularly affected, all tones are affected. With conduction hearing loss, bone conduction is more effective than air conduction.
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
Correct 3. Continuation of therapy for life Therapy must be continued for life to prevent damage to the optic nerve from increased intraocular pressure. Cholinergics are used in the treatment of glaucoma; anticholinergics are contraindicated. The surgical replacement of lens is the treatment for cataracts. There is an increase in intraocular pressure with glaucoma; the blood pressure may be unaffected.
After cataract surgery the nurse teaches a client how to self-administer eye drops. The nurse reinforces the use of what technique? 1. Placing the drops on the cornea of the eye 2. Raising the upper eyelid with gentle traction 3. Holding the dropper tip above the conjunctival sac 4. Squeezing the eye shut after instilling the medication
Correct 3. Holding the dropper tip above the conjunctival sac Drops are placed within the lower lid (conjunctival sac). To protect against physical injury and infection, the dropper tip should not touch the eye.The lower lid is retracted for placement of eye drops. Squeezing the eyes shut after administration of the medication should be avoided; this will squeeze medication out of the eye.
A nurse performs a Rinne test during physical assessment of a client. The client indicates that the sound is louder when the vibrating tuning fork is placed against the mastoid bone than when held closely to the ear. What conclusion should the nurse make about these results? 1. This represents an expected finding. 2. The client may have a sensorineural deficit. 3. This is evidence of a conductive hearing loss. 4. The client has an inflammation of the mastoid.
Correct 3. This is evidence of a conductive hearing loss. Conductive hearing loss involves impaired transmission of sound waves to the inner ear so that sound transmitted directly through bone is perceived louder and longer than through air conduction. Clients with normal hearing or sensorineural deficit perceive air conduction of sound waves louder and longer than bone conduction. The Rinne test is not related to inflammation of the mastoid
The nurse is providing preoperative teaching for a client who is to have cataract surgery. Which is appropriate for the nurse to include concerning what the client should do after surgery? Select all that apply. 1. Remain flat for 3 hours. 2. Eat a soft diet for 2 days. 3. Breathe and cough deeply. 4. Avoid bending from the waist. 5. Do not blow your nose.
Correct 4. Avoid bending from the waist. 5. Do not blow your nose. The client needs to avoid activities that cause a sudden rise in intraocular pressure, such as bending from the waist, blowing the nose, sneezing, and coughing. It is not necessary to remain flat in bed for 3 hours after surgery, and the diet is not restricted.
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
Correct 4.Impairment of peripheral vision Open-angle glaucoma has an insidious onset, with increased intraocular pressure on the retina and blood vessels in the eye. Peripheral vision is decreased as the visual field progressively diminishes. Constant blurring may occur with untreated acute angle-closure glaucoma. Pain occurs in acute angle-closure, not open-angle, glaucoma. Occlusions of the central retinal artery or retinal detachment will cause a sudden loss of vision.
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
Correct . 4 Controlling intraocular pressure 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. Pupil dilation increases intraocular pressure because it narrows the canal of Schlemm. Intraocular pressure is not affected by activity of the eye. Although secondary infections are not desirable, the priority is to maintain vision by controlling the pressure.