Sensory Exam 2022

The nurse is assisting with a patient who is having a test to measure intraocular pressure. Which equipment should the nurse expect to be used? 1. A tonometer 2. Ultrasonography 3. An ophthalmoscope 4. A slit-lamp microscope

1. A tonometer Rationale: Estimation of intraocular pressure is measured by using one of several types of tonometer

The nurse has reinforced teaching with a patient about diagnostic tests that evaluate eye muscle balance. Which tests identified by the patient indicate teaching has been effective? (Select all that apply.) 1. Cover test 2. Corneal light reflex 3. Tonometer readings 4. Electroretinography 5. Computed tomography 6. Fluorescein angiography

1. Cover test 2. Corneal light reflex

A nurse is reviewing the medical record of a client who has severe otitis media. Which of the following are expected findings? Select all that apply. 1. Enlarged adenoids 2. Report of a recent cold 3. Client prescription for daily furosemide 4. Light reflux visible on otoscopic exam in the affected ear 5. Ear pain relieved by meclizine

1. Enlarged adenoids (and tonsils) 2. Report of a recent cold

The nurse is providing care for a patient with a sensorineural hearing loss. Which prescribed medications does the nurse question before administering medications to this patient? (Select all that apply.) 1. Gentamicin 2. Furosemide 3. Indomethacin 4. Acetaminophen 5. Warfarin sodium

1. Gentamicin 2. Furosemide 3. Indomethacin

A nurse is collecting data from a child who has myopia. Which of the following findings should the nurse expect? Select all that apply. 1. Headaches 2. Photophobia 3. Difficultly reading 4. Difficultly focusing on close objects 5. Poor school Performance

1. Headaches 3. Difficulty reading 5. Poor school performance

The nurse is administering timolol to a client. Which measurement will the nurse monitor? 1. Heart rate 2. Temperature 3. Blood pressure 4. Respiratory rate

1. Heart rate Option 1: Timolol can cause bradycardia or heart block. Option 2: Temperature is not affected by timolol. Option 3: This is not affected by timolol. Option 4: This is not affected by timolol (although it can cause wheezing).

A nurse is reinforcing teaching for a client who has a new diagnosis of dry macular degeneration. Which of the following instructions should the nurse include in the teaching? 1. Increase intake of deep yellow and orange vegetables 2. Administer eye drops twice daily 3. Avoid bending at the waist 4. Wear an eye patch at night

1. Increase intake of deep yellow and orange vegetables Rationale: Instruct the patient to increase intake of carotenoids and antioxidants to slow progression of the macular degeneration

A patient presents with vertigo, tinnitus, and sensorineural hearing loss and is diagnosed with labyrinthitis. Which patient teaching does the nurse reinforce with this patient? 1. Instruct to not turn the head quickly. 2. Emphasize the importance of taking antihistamines. 3. Use proper methods for cleaning the ear. 4. Hearing will return with rest and medication.

1. Instruct to not turn the head quickly. Rationale: 1. The patient with labyrinthitis should be reminded not to turn the head quickly to avoid vertigo. 2. Antihistamines may or may not be effective in relieving dizziness; there is no specific medication to alleviate this manifestation. 3. Proper ear cleaning is not necessary for the nurse to reinforce with a diagnosis of labyrinthitis; the infection is in the inner ear. 4. Hearing may or may not return when labyrinthitis is resolved; an audiologist will test the patient for the extent of hearing loss.

The nurse is caring for a client with vision loss. Which assistive devices will the nurse suggest to the client? Select all that apply. 1. Large print items 2. Talking watch 3. Handheld magnifying glass 4. Cochlear implant 5. Television magnifiers

1. Large print items 2. Talking watch 3. Handheld magnifying glass 5. Television magnifiers Option 1: This would be helpful for the nurse to suggest. Option 2: This device would be helpful to the visually impaired. Option 3: This is a helpful assistive device for the visually impaired. Option 4: This is for a hearing-impaired individual. Option 5: This is a helpful assistive device for the nurse to suggest.

The nurse is taking a health history on a client who is hard of hearing. Which illness reported in the history can cause hearing loss? 1. Measles 2. Bronchitis 3. Influenza 4. Conjunctivitis

1. Measles Option 1: Measles, mumps, or scarlet fever can effect hearing Option 2: This does not place a client at risk for hearing loss Option 3: This does not place a client at risk for hearing loss Option 4: This does not place a client at risk for hearing loss

The nurse is collecting information about a patient's auditory system during a physical exam. Which process will the nurse perform first? 1. Observation 2. Inspection 3. Palpating 4. Auscultation

1. Observation Rationale: 1. When collecting information about a patient's auditory system, the first action by the nurse is to observe the behaviors of the patient. Note how the patient talks and if there is any slurring of speech. 2. Inspection of the outer ear is performed after observation. 3. Palpating is performed to identify areas of tenderness; special attention is paid to the mastoid bone behind the patient's outer ear. 4. Auscultation is not performed when assessing the auditory system.

The nurse is caring for a client with hearing loss. Which interventions will the nurse implement? Select all that apply. 1. Obtain the client's attention before speaking 2. Smile while speaking 4. Lower the voice pitch 5. Allow extra time for the client to answer

1. Obtain the client's attention before speaking 2. Smile while speaking 4. Lower the voice pitch 5. Allow extra time for the client to answer Option 1: The nurse should get the client's attention before speaking. Option 2: Smiling or chewing gum while speaking can prevent the client from reading lips, if they are able. Option 3: The nurse should speak at a normal rate and volume. Option 4: This will help clients who cannot hear high pitches. Option 5: The client may require additional time to process what was asked before answering.

A patient with otitis media is experiencing severe ear pain. Which nonpharmacological measures does the nurse apply to help relieve this patient's discomfort? (Select all that apply.) 1. Offer a massage. 2. Apply heat to the area. 3. Offer liquid or soft diet. 4. Apply an ice pack to the area. 5. Dim the lights and reduce environmental noise.

1. Offer a massage. 2. Apply heat to the area. 3. Offer liquid or soft diet. Rationale: 1. Nonpharmacological methods, such as relaxation, massage, music, guided imagery, or distraction techniques help to relieve ear pain. 2. Apply heat as ordered to the area to promote comfort. 3. Offer liquid or soft foods to relieve pain when chewing. 4. Ice to the area could cause additional pain. 5. Dimming the lights and reducing environmental noise would be helpful for a patient with an eye injury or condition.

The nurse is caring for a client with swimmer's ear. Which clinical manifestations can the nurse expect to find? Select all that apply. 1. Pain 2. Drainage 3. Swelling 4. Itching 5. Vomiting

1. Pain 2. Drainage 3. Swelling 4. Itching Option 1: Pain is the most common finding in clients with an ear infection. Option 2: Drainage is a common finding. Option 3: Swelling is a common finding. Option 4: Itching is a common finding. Option 5: Vomiting is not a common finding.

The nurse is assisting with the preparation of a patient for a cochlear implant due to profound deafness. Which teaching will the nurse reinforce for this patient? 1. Preparation instructions for surgery 2. Care of the external equipment 3. The impact of hearing for the first time 4. Physical limitations after the procedure

1. Preparation instructions for surgery Rationale: 1. A cochlear implant requires a surgical procedure; the nurse needs to reinforce the instructions that are part of the surgical preparation 2. The care of the external equipment will need to be taught, but at this point, preparation for the procedure needs to be reinforced 3. The impact of hearing for the first time is likely to be addressed by the HCP. At this time, instructions for surgery will be reinforced by the nurse 4. The physical limitations after the procedure will be provided by the HCP; postsurgical review will be appropriate. At this time, the patient needs instructions for surgery preparations

The nurse determines that a patient is experiencing common age-related changes in vision and hearing. Which findings does the nurse identify in the patient? (Select all that apply.) 1. Presbycusis 2. Yellowing of the lens 3. Distorted depth perception 4. Decreased lacrimal secretions 5. Increased pupil size and response to light

1. Presbycusis 2. Yellowing of the lens 3. Distorted depth perception 4. Decreased lacrimal secretions Rationale: 5. Pupil size and response to light decreases with aging.

A nurse in a clinic is caring for a client who has Ménière's disease and is experiencing vertigo. Which of the following actions should the nurse recommend to help control the vertigo? Select all that apply. 1. Reduce exposure to bright lighting 2. Move head slowly when changing positions 3. Do not eat fruit high potassium 4. Plan evenly-spaced daily fluid intake 5. Avoid fluids containing caffeine

1. Reduce exposure to bright lighting 2. Move head slowly when changing positions 4. Plan evenly-spaced daily fluid intake

The nurse is providing teaching to a client receiving atropine for an eye exam. Which instruction will the nurse include in the teaching? 1. Wear dark glasses until the effects of the medication wear off 2. Protect the eye because blink reflex is temporarily lost 3. Monitor the eye for 1 week to detect infection early 4. The eye should be irrigated daily to remove the color stain

1. Wear dark glasses until the effects of the medication wear off Option 1: This is an appropriate teaching point for clients whose eyes have been dilated. Option 2: This describes the instruction for topical anesthetics. Option 3: This describes the instruction for antiangiogenetics. Option 4: This describes instruction for fluorescein sodium

The nurse is reinforcing teaching provided to a patient recovering from a stapedectomy. Which patient statement indicates teaching has been effective? 1. "I will avoid airplane travel for 6 months." 2. "I will cough or sneeze with my mouth open." 3. "I will gently blow my nose with both sides open." 4. "I will keep the ear moist by packing it with cotton balls."

2. "I will cough or sneeze with my mouth open." Rationale: 1. There is no need for the patient to avoid airplane travel for 6 months. 2. It is important to prevent increased pressure to protect the graft site, so the mouth should be open when coughing or sneezing. 3. The nose should be gently blown one side at a time. 4. The ear does not need to be kept moist; there is no need to pack the ear with cotton balls.

A patient has an injury resulting in a major damage to the pinna of the right ear. The patient expresses fear about hearing loss in the damaged ear. Which statement by the nurse will alleviate the patient's fear? 1. "The left ear will become over sensitive to sound." 2. "The impulses for hearing come from the middle and inner ear." 3. "The outside of your ear will need to be surgically reconstructed." 4. "This much damage also indicates severe damage internally."

2. "The impulses for hearing come from the middle and inner ear." Rationale: 1. The left ear does not become more sensitive to sound in this scenario; hearing is not lost from injury to the pinna. 2. The nurse will alleviate the patients fears by sharing that hearing is a process of the middle and inner ear. 3. The outside (pinna) of the ear may or may not be reconstructed, depending on the appearance of the ear and patient wishes 4. Damage to the outer ear is not indicative of damage to the internal part of the ear (middle and inner ear).

The nurse is caring for a client who had an intraocular pressure reading of 40 mm Hg. The client asks what this means. Which response by the nurse is most appropriate? 1. "This test looks at the retina to see if it is detached." 2. "This reading was high, so you may have glaucoma." 3. "This means you have damage to the rod of the eye." 4. "This indicates you have cataracts on your eyes."

2. "This reading was high, so you may have glaucoma." Option 1: Digital imaging looks at the retina. Option 2: This statement is correct. Option 3: Electroretinography is used to test rod or cone diseases. Option 4: This test is used to detect glaucoma.

The nurse is caring for a patient who is diagnosed with a refractive error and asks what this means. What would be the appropriate explanation by the nurse? 1. "You are losing your vision and will become blind." 2. "You will need corrective lenses to see clearly." 3. "The pressure in your eyes is higher than normal." 4. "Your vision was measured as 20/20."

2. "You will need corrective lenses to see clearly." Rationale: A refractory error requires corrective lenses to see clearly.

The nurse cares for patients after eye surgery. Which of these patients would the nurse provide specific positioning instructions to after eye surgery to prevent complications? 1. 19-year-old after removal of congenital cataracts 2. 30-year-old woman after pneumatic retinopexy 3. 52-year-old man after trabeculectomy 4. 82-year-old man after corneal transplant

2. 30-year-old woman after pneumatic retinopexy Rationale: After pneumatic retinopexy, the patient is educated on positions to keep the air bubble in place.

A patient is diagnosed with Ménière disease. Which therapeutic measures does the nurse expect the HCP to prescribe? 1. A minimum of 8 hours of sleep nightly to prevent fatigue 2. A salt-restricted diet and prescribed antihistamines and vasodilators 3. Prophylactic antiemetic medications prescribed for nausea and vomiting 4. Meclizine, tranquilizers, and vagal blockers prescribed to prevent symptoms

2. A salt-restricted diet and prescribed antihistamines and vasodilators Rationale: 1. Ménière disease is not associated with fatigue; a minimum of 8 hours of sleep nightly is not a therapeutic measure for the disorder. 2. Therapeutic management of Ménière disease involves a salt-restricted diet, diuretics, antihistamines, and vasodilators during prophylactic treatment. 3. Nausea and vomiting are manifestations of an acute attack of Ménière disease; antiemetic medications are not prescribed prophylactically for the condition. 4. Meclizine, tranquilizers, and vagal blockers are used to manage the manifestations of an acute attack of Ménière disease, and not prescribed for symptom prevention.

The nurse is collecting data from a patient with diabetes mellitus. The patient's medical history reveals multiple episodes of hyperglycemia requiring medical management. The patient tells the nurse, "I just got new glasses, but I still do not see very well." Which condition does the nurse suspect? 1. Preproliferative retinopathy 2. Background retinopathy 3. Proliferative retinopathy 4. Incomplete retinal detachment

2. Background retinopathy Rationale: 1. Preproliferative retinopathy is the second stage of diabetic retinopathy, which is characterized by swollen and irregularly dilated veins. There are no symptoms related to this stage. 2. Background retinopathy is the first stage of diabetic retinopathy when microaneurysms form in the retina capillary walls. The patient may notice decrease in color discrimination and visual acuity. 3. Proliferative retinopathy is the third state of diabetic retinopathy characterized by the formation of new blood vessels, which are fragile and leak blood into the vitreous and retina. During this stage, retinal detachment may occur. 4. The patient's statement does not support the presence of any type of retinal detachment.

The nurse is reinforcing teaching provided to a patient with open-angle glaucoma. What is most important for the nurse to include in the patient teaching? 1. Regardless of treatment, peripheral vision will be eventually lost. 2. Compliance with drug therapy is essential to prevent loss of vision. 3. Damage to the eye caused by glaucoma is reversible in early stages. 4. Eye pain is experienced until the optic nerve atrophies, causing blindness.

2. Compliance with drug therapy is essential to prevent loss of vision. Rationale: 1. It is not definite that the patient will lose peripheral or any vision. 2. Lifelong compliance with drug therapy is essential to prevent loss of vision. 3. Vision changes cannot be corrected with eyeglasses. 4. Eye pain and optic nerve damage is associated with acute angle glaucoma.

A patient with acute angle glaucoma and a fractured femur that is scheduled for surgery is prescribed the preoperative medications morphine 10 mg intramuscularly (IM) and atropine 0.4 mg IM. Which action does the nurse take? 1. Hold the morphine. 2. Contact the physician. 3. Give medications as ordered. 4. Collect data on patient's pain.

2. Contact the physician. Rationale: 1. There is no reason to hold the morphine. 2. Atropine is contraindicated for patients with acute angle glaucoma. It can cause blindness if given so the physician must be notified. 3. Giving the medications could cause blindness in the patient. 4. The morphine is not being given for pain but rather for preoperative preparation.

During a health history, the nurse suspects that a patient is at risk for a vision problem. Which information within the family history does the nurse use to make this decision? (Select all that apply.) 1. Asthma 2. Diabetes 3. Cataracts 4. Blindness 5. Glaucoma

2. Diabetes 3. Cataracts 4. Blindness 5. Glaucoma Rationale: 1. Asthma does not affect vision

The nurse is caring for a client with a foreign body injury to the eye. Which intervention should the nurse implement? 1. Place a patch over the eye 2. Flush the eye with normal saline 3. Remove the object with tweezers 4. Leave the object

2. Flush the eye with normal saline Option 1: A patch should not be placed over the eye unless the object has been removed and the health-care provider has instructed to do so. Option 2: The nurse should flush the eye with saline. Option 3: The nurse should not remove the object with tweezers. Option 4: The nurse should flush the eye with saline.

A nurse is caring for a male older adult client who has a new diagnosis of glaucoma. Which of the following should the nurse recognize as risk factors associated with this disease? Select all that apply. 1. Sex 2. Genetic predisposition 3. Hypertension 4. Age 5. Diabetes Mellitus

2. Genetic Predisposition 3. Hypertension 4. Age 5. Diabetes Mellitus

The nurse is caring for a patient with presbycusis. Which technique is most important for the nurse to use to increase communication with this patient? 1. Talk in a very loud voice 2. Lower voice pitch 3. Do not smile or chew gum when talking to the patient 4. Allow extra time for patient to respond

2. Lower voice pitch Rationale: With presbycusis, there is an inability to decipher high-frequency sounds, so a lower voice pitch is helpful.

A nurse is reinforcing instructions with a client who has a new prescription for timolol how to insert eye drops. The nurse should reinforce with the client to press on which of the following areas to prevent systemic absorption of the medication? 1. Bony orbit 2. Nasolacrimal duct 3. Conjunctival sac 4. Outer canthus

2. Nasolacrimal duct

A nurse is caring for a client who has diabetes mellitus and reports a gradual loss of peripheral vision. The nurse should recognize this as a manifestation of which of the following diseases? 1. Cataracts 2. Open-angle glaucoma 3. Macular degeneration 4. Angle-closure glaucoma

2. Open-angle glaucoma

The nurse is preparing to administer eye meds as prescribed by the HCP after eye surgery for cataract removal. The HCP prescribes one drop with punctal occlusion. Which action will the nurse perform when administering the medication? 1. Have the nonmedicated eyelid held closed during med admin 2. Place the index finger on the corner of the eye and apply pressure against the nose bone 3. Instruct the patient to squeeze the eye tightly shut once the drop is administered 4. Tilt the head back, apply the drop, ask the patient to blink twice, and blot any leakage

2. Place the index finger on the corner of the eye and apply pressure against the nose bone Rationale: 1. There is no reason for the nurse to have the patient hold the eyelid of the nonmedicated eye closed while the other eye is being medicated 2. Punctal occlusion is placing the index finger against the inner corner of the eye and applying pressure against the nose bone. The action will help to keep the medication in the eye longer and reduce systemic absorption and side effects. Some eye medications can have serious cardiac and respiratory effects. 3. Squeezing the eye tightly shut will force the medication out of the eye; closing the eye shut normally for 1 minute has the same effect as punctal occlusion 4. Tilting the head back and applying the drop is appropriate. However, blinking will allow the medication to leave the eye and limit medication effect

The nurse is collecting information from a patient who reports difficulty seeing the print in the newspaper. The patient is 50 years of age and does not have any condition that requires medical management. Which vision condition does the nurse suspect the patient is experiencing? 1. Myopia 2. Presbyopia 3. Astigmatism 4. Emmetropia

2. Presbyopia Rationale: 1. Myopia (nearsightedness) is when items up close can be seen clearly and distant objects are unclear. It is caused when the eyeball is elongated and light rays focus in front of the retina. 2. Presbyopia is a condition related to aging and occurs when the lens of the eye loses elasticity. The lens is less able to focus light onto the retina to see close objects. The condition occurs around age 40 and is likely this patient's visual difficulty. 3. Astigmatism is caused by uneven curvatures on the cornea causing the light rays to be focused on two different points of the retina. The person with astigmatism will experience blurred vision with distortion. The cause can be from trauma, inflammation, or an autosomal dominant trait. 4. Emmetropia is the term used to define good vision.

The nurse is conducting hearing tests in a neighborhood clinic. The nurse is concerned about the number of young adult patients who exhibit signs of sensorineural hearing loss. For which reason does the nurse suspect this type of hearing loss in this population? 1. High exposure to ototoxic drugs 2. Prolonged exposure to loud noise 3. Trauma from physical contact sports 4. Increased incidences of meningitis

2. Prolonged exposure to loud noise Rationale: 1. Ototoxic drugs are not routinely taken by young adult patients; it is unexpected that this population would experience sensorineural hearing loss for this reason. 2. Young adults have grown up in a time when loud music is popular and often listened to at a high volume with or without earphones. Prolonged exposure to loud noise can cause sensorineural hearing loss. 3. Not all persons in the young adult age category are involved in contact sports. 4. A percentage of young adults have a higher incidence of meningitis, but this is not a condition most closely related to sensorineural hearing loss in this population.

The nurse is giving instructions to a patient who is scheduled for an electronystagmogram due to a diagnosis of vertigo and ringing in the ears. Which finding regarding the patient's medical history will cause the nurse to notify the HCP for the cancellation of this test? 1. The patient has a history of a history of alcohol abuse. 2. The patient has a pacemaker. 3. The patient takes tranquilizers. 4. The patient lives alone.

2. The patient has a pacemaker. Rationale: 1. A history of alcohol abuse does not indicate that the patient currently drinks alcohol; the nurse needs to ascertain if the patient is able to avoid alcohol intake for 1 to 5 days prior to testing. 2. The test is contraindicated for patients with a pacemaker; the nurse will notify the HCP. 3. Tranquilizer use will be discontinued for 1 to 5 days prior to testing. 4. The patient will be advised to avoid tobacco and caffeine for the rest of the day after testing. It is possible that the patient may experience nausea, vertigo, or weakness after the test. However, these manifestations are not noted until after the testing and will not cause cancellation of the test.

The nurse is visiting the home of a patient diagnosed with visual impairment related to macular degeneration. Which observation indicates to the nurse the patient is adjusting to the condition? 1. The patient is in nightclothes in the middle of the afternoon. 2. The patient is moving about in the apartment without problems. 3. The patient's refrigerator contains only condiments, eggs, and milk. 4. The patient has stacks of unopened mail on the kitchen table.

2. The patient is moving about in the apartment without problems. Rationale: 1. With a visually impaired patient, the goal is for independence in performing the activities of daily living. The nurse needs to determine the reason that the patient is not dressed in the middle of the afternoon. 2. When the nurse observes the patient's ability to move about the apartment without difficulty, it is an indication that the patient can be safe and independent in the patient's environment. 3. The nurse expects to see more in the patient's refrigerator than condiments, eggs, and milk. The nurse needs to determine how the patient is meeting nutritional needs. 4. When the nurse sees piles of unopened mail on the patient's kitchen table, the nurse needs to explore the patient's ability to read and care for personal matters.

An adolescent patient is diagnosed by the HCP with keratitis from a herpes simplex infection of the eye. Which patient teaching does the nurse reinforce as a method for pain management? 1. The importance of finishing all the prescribed antiviral medication 2. Wearing sunglasses indoors and outdoors to decrease effects of photophobia 3. Disposing of all eye cosmetics that were used at the time of becoming infected 4. Refraining from using contact lenses until all signs of inflammation are gone

2. Wearing sunglasses indoors and outdoors to decrease effects of photophobia Rationale: 1. It is important for the patient to understand the necessity of completing all antiviral medication; however, this information is related to management of the condition and is not specifically focused on pain management. 2. Keratitis causes photophobia due to the irritation of the cornea. The pain of photophobia can be managed by wearing sunglasses while indoors and outdoors until the condition is resolved. 3. The patient will be advised to dispose of all eye cosmetics that were used up until the time of becoming infected; the purpose is to prevent reinfection. 4. Because keratitis causes an irritation to the cornea, contact lenses are not used until the conjunctiva and surrounding tissues are no longer inflamed.

The National Eye Institute has performed research regarding the impact of nutrition on eye diseases. Which factor does the nurse recognize as an incorrect conclusion from this research? 1. A diet high in green, leafy vegetables lowers the risk of age-related macular degeneration (AMD). 2. With intensive glycemic control, patients with diabetes mellitus do not experience retinopathy. 3. Supplements containing vitamins and minerals will reduce the risk of developing advanced AMD. 4. There is no benefit of supplemented omega-3 fatty acids on AMD; eating fish lowers the rate.

2. With intensive glycemic control, patients with diabetes mellitus do not experience retinopathy. Rationale: 1. A diet high in green, leafy vegetables is high in the antioxidants lutein and zeaxanthin, which lowers the risk for AMD. 2. Patients with diabetes mellitus can reduce the progression of retinopathy by one-third by maintaining intensive glycemic control. 3. Supplements with vitamins and minerals will reduce the risk of developing AMD. 4. Research validates that there is no benefit from omega-3 fatty acid supplements, but eating fish high in omega-3 fatty acids is effective in reducing the rates of AMD.

The nurse is caring for a patient with a history of acute angle-closure glaucoma. The nurse is preparing to administer the patient's medications. Which medications should the nurse question before administration? Select all that apply. 1. cefazolin (Kefzol) 2. cyclopentolate (Cyclogyl) 3. hydroxyzine (Vistaril) 4. ranitidine (Zantac) 5. morphine 6. warfarin (Coumadin)

2. cyclopentolate (Cyclogyl) 3. hydroxyzine (Vistaril) Rationale: Cyclopentolate (Cyclogyl) and hydroxyzine (Vistaril) both dilate the pupil, which increases intraocular pressure and is contraindicated in acute angle-closure glaucoma.

The nurse is assisting with discharge instructions for a patient. Which of these medications would the nurse teach the patient can cause hearing loss? Select all that apply. 1. acetaminophen (Tylenol) 2. erythromycin (E-Mycin) 3. furosmide (Lasix) 4. gentamicin (Garamycin) 5. aspirin (Bayer) 6. tobramycin (Tobrex)

2. erythromycin (E-Mycin) 3. furosmide (Lasix) 4. gentamicin (Garamycin) 5. aspirin (Bayer) 6. tobramycin (Tobrex) Rationale: Erythromycin (E-Mycin), furosemide (Lasix), gentamicin (Garamycin), salicylates (Bayer), and tobramycin (Tobrex) can cause hearing loss.

The nurse is providing teaching to a client with ear pain. Which statement made by the client indicates an understanding of the teaching? 1. "I will apply ice to help alleviate pain." 2. "I will order foods that require chewing." 3. "I can take some acetaminophen for the pain." 4. "I will lay on the affected ear when I sleep."

3. "I can take some acetaminophen for the pain." Option 1: Heat will help alleviate pain. Option 2: The client should consume a liquid or soft diet. Option 3: Acetaminophen can be taken for ear pain. Option 4: The client should lay on the unaffected side; laying on the ear with pain could cause further discomfort.

The caregiver of a patient with macular degeneration voices being increasingly frustrated because of food spills on the patient's clothing. Which explanation does the nurse give to help the caregiver understand what the patient is experiencing? 1. "The patient's vision is blurred." 2. "There is total blindness in one eye occurring." 3. "The central vision is gone and only peripheral vision remains." 4. "There are black dots in the field of vision that cause confusion."

3. "The central vision is gone and only peripheral vision remains."

A nurse is reinforcing teaching with a client who has a new prescription for brimonidine ophthalmic drops and wears soft contact lenses. Which of the following instructions should the nurse include in the teaching? 1. "This medication can stain your contacts." 2. "This medication can cause your pupils to constrict." 3. "This medication can absorb into your contacts." 4. "This medication can slow your heart rate."

3. "This medication can absorb into your contacts."

A patient's Snellen chart findings are 20/60. Which explanation does the nurse provide to the patient regarding this finding? 1. "Your vision is better than normal." 2. "You must be at 60 feet to see what normal vision sees at 20 feet." 3. "You must be at 20 feet to see what normal vision sees at 60 feet." 4. "You are considered legally blind, even though with prescription glasses you'll be able to see."

3. "You must be at 20 feet to see what normal vision sees at 60 feet." Rationale: 1. Normal vision is 20/20, which means the patient can read at 20 feet what the normal eye can read at 20 feet. 2. Inaccurate reading of 20/60 vision 3. For 20/60, the patient has less acute vision and must be at 20 feet to see what normal vision sees at 60 feet 4. Visual impairment occurs at 20/70 and legal blindness at 20/200 or more with correction

The nurse is caring for a group of clients. Which client is at risk for a middle ear congestion? 1. A client who routinely swims 2. A client who had measles as a child 3. A client who regularly has allergies 4. A client who eats food high in sodium

3. A client who regularly has allergies Option 1: This affects the outer ear. Option 2: This can cause hearing loss. Option 3: This can cause middle ear congestion. Option 4: This can affect the amount of endolymph in the inner ear, affecting hearing.

A patient with acute ear pain and drainage comes into the community clinic. Which diagnostic tests does the nurse expect to be performed prior to beginning treatment for this patient? (Select all that apply.) 1. Biopsy 2. Audiometric testing 3. Complete blood count (CBC) 4. Rinne and Weber tests 5. Culture of ear discharge

3. Complete blood count (CBC) 4. Rinne and Weber tests 5. Culture of ear discharge Rationale: 1. A biopsy would be indicated for an ear mass. 2. Audiometric testing would be appropriate for the patient with impacted cerumen. 3. For an external ear infection diagnostic tests include a CBC, specifically white blood cell count, and cultures of discharge. This will help diagnose the infection. 4. The Rinne and Weber tests can indicate conductive hearing impairment. 5. Culture and sensitivity tests isolate the specific infective organism and determine which antibiotics would be most effective to treat the infection.

During a physical examination of a patient, pupillary reflexes are checked. A light is shone into the right eye while it is observed. Pupillary reaction and pupil size are noted. Then a light is shone into the left eye as the right eye is still observed. Which response occurs during the second step of the test? 1. Direct response 2. Indirect response 3. Consensual response 4. Accommodation response

3. Consensual response Rationale: 1. The direct response is what is noted during the first part of the test when the light is shone into the right eye and the responses of that eye are noted. 2. There is no pupillary response labeled "indirect." 3. Consensual response is the second part of this test; the light is shone into the left eye and the right eye is observed for response. 4. There is no pupillary response labeled "accommodation."

The nurse is working at a summer camp for preadolescent children. One of the children comes to the nurse rubbing an eye and stating pain from getting sand in the eye. After the child is effectively treated, which teaching is the nurse prompted to provide to all the attendees? 1. It is dangerous to throw sand at each other 2. Wear sunglasses if it is windy at the beach 3. Do not rub your eye if it has something in it 4. Remove the sand with any available fluid

3. Do not rub your eye if it has something in it Rationale: 1. There is not indication in the question about how the sand got into the child's eye. Another topic should be covered with all attendees 2. Sunglasses may or may not help keep blowing sand out of the eyes 3. The nurse is prompted to provide information about why it is dangerous to rub your eye if it has something in it. The real danger is scratching the delicate surfaces of the ye, such as the cornea. 4. The eye should be allowed to water freely to remove any debris safely. The upper lid is pulled down to wash out the debris and then the ye is gently wiper from the inner to outer canthus.

The nurse in an HCP's office is assisting with the removal of impacted cerumen from the ear canal of an older adult patient. The patient presented with decreased hearing and a sensation of fullness. Which reason does the nurse identify as the most likely cause of the patient's condition? 1. Improper cleaning of the ear canal 2. The presence of hair growth in the ear canal 3. Dryness of secretions from shrinking ear canal glands 4. Exposure to dirt and dust in the working environment

3. Dryness of secretions from shrinking ear canal glands Rationale: 1. Improper cleaning of the ear canal can cause cerumen to be shoved and impacted into the ear canal. However, there is no information in the question to support this cause. 2. Cerumen can become compacted due to an abundant amount of hair growth in the ear canal. However, there is no specific information in the question to support this cause. 3. Because of the patient being older, the most likely cause of the impacted cerumen is related to age. In the older adult, cerumen is drier as secretions decrease because of shrinking ceruminous glands; keratin continues to collect causing an impaction in the ear canal. 4. Exposure to dirt and dust in the environment can contribute to impacted cerumen; however, there is no information in the question to support this cause.

The nurse is assessing a client's vision and notes deviation of the eye toward the nose. Which condition will the nurse document? 1. Exotropia 2. Hypotropia 3. Esotropia 4. Tropiaopia

3. Esotropia Option 1: This is lateral movement. Option 2: This is downward deviation. Option 3: This is a misalignment in which the eye deviates toward the nose. Option 4: Tropia is a misalignment in which the eye deviates away from the visual axis.

The nurse is collecting data from a patient with a detached retina. Which findings does the nurse expect in this patient? (Select all that apply.) 1. Severe pain 2. Blurred vision 3. Flashing lights 4. Loss of peripheral vision 5. Loss of acuity in the affected eye

3. Flashing lights 4. Loss of peripheral vision 5. Loss of acuity in the affected eye Rationale: 1. There is no pain because the retina does not contain sensory nerves. 2. Blurred vision does not occur with a detached retina. 3. Patients experiencing a retinal detachment report a sudden change in vision. Initially, as the retina is pulled, patients report seeing flashing lights and then floaters. The flashing lights are caused by vitreous traction on the retina, and the floaters are caused by hemorrhage of vitreous fluid or blood. 4. On visual examination, the patient typically has a loss of peripheral vision when the visual fields are tested and a loss of acuity in the affected eye. 5. On visual examination, the patient typically has a loss of peripheral vision when the visual fields are tested and a loss of acuity in the affected eye.

The nurse is assisting with the care of a patient being prepared for emergency intervention for a detached retina. If the nurse asks the patient about the ability to maintain a reclining position for 16 hours, which procedure is planned for this patient? 1. Laser surgery 2. Cryopexy 3. Pneumatic retinopexy 4. Scleral buckling

3. Pneumatic retinopexy Rationale: 1. Laser surgery does not require the patient to recline for 16 hours prior to the procedure. 2. Cryopexy does not require the patient to recline for 16 hours prior to the procedure. 3. Pneumatic retinopexy is a procedure that involves injecting air or gas into the eyeball to hold the retina in place. Reclining for about 16 hours before the procedure is required to allow the retina to fall back toward the choroid. Three weeks of specific positioning is required to complete the process of healing. 4. Scleral buckling does not require the patient to recline for 16 hours prior to the procedure.

The nurse is caring for a client with impacted cerumen. Which intervention will the nurse implement? 1. Insert a Q-tip into the ear 2. Administer an oral antibiotic 3. Prepare the client for irrigation 4. Administer an opioid analgesic

3. Prepare the client for irrigation Option 1: The nurse should never insert anything into a client's ear. Option 2: Oral antibiotics may be given for an infection but not impacted cerumen. Option 3: Irrigation is an effective method for removing impacted cerumen. Option 4: Pain medication is not needed for impacted cerumen.

The nurse is contributing to the plan of care for a patient with Meniere disease. What is the primary goal for this patient that the nurse should recommend to include in the plan of care? 1. Prevent dehydration 2. Decrease injury 3. Prevent injury 4. Preserve hearing

3. Prevent injury Rationale: Ménière disease can cause vertigo, which could result in injury.

A nurse is reinforcing teaching with a group of caregivers about possible manifestations of Down syndrome. Which of the following findings should the nurse include? Select all that apply. 1. A large head with bulging fontanels 2. Large ears that are set back 3. Protruding abdomen 4. Broad, short feet and hands 5. Hypotonia

3. Protruding abdomen 4. Broad, short feet and hands 5. Hypotonia

A patient comes to the health clinic for a suspected ear infection. Which of these data collection findings does the nurse expect with an external ear infection? Select all that apply. 1. Dizziness 2. Fullness in the ear 3. Redness 4. Pain 5. Pruritus 6. Swelling

3. Redness 4. Pain 5. Pruritus 6. Swelling Rationale: Redness, pain, pruritus, and swelling are experienced with an external ear infection.

The nurse is preparing to assist the HCP with the incision of a carbuncle in the ear canal of a patient. Which specific manifestation does the nurse associate with the patient's diagnosis? 1. Necrotic tissue spreading toward the auricle 2. An absence of protective earwax in the canal 3. Several hair follicles that have formed an abscess 4. Fungus in the ear canal causing an infection

3. Several hair follicles that have formed an abscess Rationale: 1. Perichondritis is an infection of the auricle that can result in necrosis of the ear cartilage. Necrotic tissue spreading toward the auricle is not associated with a carbuncle. 2. The absence of protective earwax in the ear canal is swimmer's ear and is not associated with a carbuncle in the ear canal. 3. When several hair follicles in the ear canal become infected and form an abscess, it is a carbuncle. Many carbuncles will rupture on their own; some will need to be incised and drained. 4. Otomycosis is an infection of the ear canal caused by a fungus growth.

The nurse who is assisting in the ED is reviewing the medical record of a client who is being evaluated for angle-closure glaucoma. Which of the following findings are indicative of this condition? 1. Insidious onset of painless loss of vision 2. Gradual reduction in peripheral vision 3. Severe pain around eyes 4. Intraocular pressure 12 mm Hg

3. Severe pain around eyes

The nurse is providing care for an older adult client. The nurse notices the patient appears to be having difficulty understanding her and asks that questions and comments be repeated. If the nurse suspects presbycusis, which action does the nurse take to promote better hearing for the patient? 1. Ask the patient if he is having difficulty hearing. 2. Sit closer to and directly in front of the patient. 3. Speak to the patient in a lower tone of voice. 4. Use a slightly louder and slower talking rate.

3. Speak to the patient in a lower tone of voice. Rationale: 1. The nurse can ask the patient to confirm problems with hearing, but should expect the answer to be positive given the patient's actions. 2. Sitting closer and directly in front of the patient may or may not help the patient to hear better; depending on the patient, it may be culturally contraindicated to make this change. 3. Older patients are inclined to develop presbycusis and have difficulty in deciphering higher pitched sounds, like the female voice. The nurse should lower the tone of her voice to promote better hearing. 4. Talking slightly louder and slower will not improve the patient's ability to hear.

A patient is diagnosed with otosclerosis and is scheduled for a stapedectomy. Which postoperative finding does the nurse report to the health care provider (HCP) or the registered nurse (RN) immediately? 1. The patient remains positioned with the surgical ear positioned upward. 2. The side rails of the bed are up in response to the patient feeling dizzy. 3. The patient received an antiemetic for nausea, but vomits after the medication. 4. The earplug placed in the surgical ear is found on the floor next to the patient's bed.

3. The patient received an antiemetic for nausea, but vomits after the medication. Rationale: 1. The patient is positioned correctly if the surgical ear is positioned upward while the patient is lying in bed. 2. It is expected that the patient may feel dizzy following surgery for a stapedectomy; the side rails of the bed need to be in the up position to promote safety and prevent falls. 3. After a stapedectomy, the patient may experience nausea; however, an antiemetic is given to prevent vomiting. If the patient vomits, the HCP or RN needs to be notified immediately. Vomiting can displace the prosthesis. 4. The nurse needs to report if the earplug in the surgical ear is no longer in the ear canal. The earplug is placed to keep the area aseptic. However, there is another issue that requires immediate action.

The nurse is preparing to assess a client's auditory acuity. Which equipment will the nurse use for this exam? 1. Snellen chart 2. Otoscope 3. Tuning fork 4. Ophthalmoscope

3. Tuning fork Option 1: This is used to assess visual acuity. Option 2: This is used to assess ears, but not acuity. Option 3: This is used to assess auditory acuity. Option 4: This is used to assess eyes.

The nurse is conducting an initial screening to determine a patient's gross hearing acuity as part of a complete physical. Which test does the nurse include in the assessment. 1. Romberg 2. Calorie test 3. Whisper voice 4. Otoscopic exam

3. Whisper test Rationale: 3. Auditory function can be grossly evaluated using the three different assessment tests; whisper voice test, Rinne test, Weber's test

A nurse is reinforcing postoperative teaching to a client following cataract surgery. Which of the following statements should the nurse include in the teaching? 1. "You can resume playing golf in 2 days." 2. "You need to toilet your head back when washing your hair." 3. "You can get water in your eyes in 1 day." 4. "You need to limit your housekeeping activities.

4. " You need to limit your housekeeping activities." Rationale: Instruct the patient to limit housekeeping activities following cataract surgery. This activity could cause a rise in IOP or injury to the eye.

While checking a patient's pupils, the nurse notes that the left pupil constricts when a light is shone into the right eye. Which information does this finding suggest to the nurse? 1. Tropia present 2. Esotropia absent 3. Accommodation absent 4. Consensual response present

4. Consensual response present Rationale: 1. Tropia is a deviation of the eye away from the visual axis. 2. Esotropia is deviation of the eye toward the nose. 3. Accommodation is the ability of the pupil to respond to near and far distances. 4. A consensual response occurs when the pupil of one eye constricts when the other eye has a light shone into it.

The nurse is providing care for a school-age patient at a community clinic. The patient exhibits redness and crusting exudate on the lids and corners of each eye, and reports pain and itching. A culture was taken of the exudate and antibiotic drops were prescribed. Which action does the nurse take if the eye culture returns as positive for Neisseria gonorrhoeae? 1. Review the importance of medication administration with the patient's parent. 2. Mail the patient's household literature about prevention of infecting family members. 3. Ask a family member to bring the patient back to the clinic for a follow-up evaluation. 4. Notify the HCP and RN about a possible situation involving sexual abuse of a minor.

4. Notify the HCP and RN about a possible situation involving sexual abuse of a minor. Rationale: 1. The infective organism is bacterial and should respond to the prescribed antibiotic therapy. However, this action is not specific to culture results. 2. The infective organism is contagious and the family needs to know methods of preventing cross contamination to other persons. However, mailing literature does not necessarily meet the needs of prevention. 3. It may be necessary for the patient to be brought back to the clinic for a follow- up evaluation; however, this can be arranged after the nurse notifies the HCP or the RN. 4. The infective organism is responsible for gonorrhea, which is a sexually transmitted infection. When a minor is infected in any way with an organism that is sexually transmitted, the HCP and/or RN should be notified of possible sexual abuse of a minor. All medical professionals are legally required to report such instances.

The nurse performs a visual assessment on a patient and documents the findings using the acronym PERRLA. Which assessment finding does PERRLA indicate? 1. Palpebral angle rigid, right, and left angles 2. Patient's eyes round, regular, lively, active 3. Pupils equilateral, regular, round, little accommodation 4. Pupils equal, round, and reactive to light and accommodation

4. Pupils equal, round, and reactive to light and accommodation

A patient is scheduled to have cataract surgery. Which structure of the patient's eye does the nurse explain will be involved in the procedure? 1. The iris 2. The fibrous tunic 3. The ciliary body 4. The lens

4. The lens Rationale: 1. The iris is the circular curtain, which is anterior to the lens of the eye. It is the structure that determines the color of the patients eyes. 2. The fibrous tunic (sclera and cornea) is the outer layer of the three layers of the eyeball. 3. The ciliary body suspends the iris and the lens, and is located in the middle layer of the eyeball. 4. The lens is the part of eyeball where light and images enter the eye and reflect on the retina to stimulate vision. The lens can form cataracts, which interferes with visual acuity because of the associated opacity changes.

A nurse is reinforcing teaching with a client about preventing otitis externa. Which of the following instructions should the nurse include? 1. Clean the ear with a cotton-tipped swab daily 2. Place earplugs in the ears when sleeping at night 3. Use a cool water irrigation solution to remove earwax 4. Tip the head to the side to remove water from the ears after showering

4. Tip the head to the side to remove water from the ears after showering

A nurse is caring for a client who has suspected Ménière's disease. Which of the following is an expected finding? 1. Presence of a purulent lesion in the external ear canal 2. Feeling of pressure in the ear 3. Bulging, red bilateral tympanic membranes 4. Unilateral hearing loss

4. Unilateral hearing loss

The nurse is explaining how the retina works to a patient who is experiencing visual changes. Which factor shared by the nurse is correct? 1. The retina reacts to chemical stimulation from rods and cones 2. The rods and cones are stimulated by chemical stimulation of the retina 3. The fovea centralis is located directly behind the center of the lens and contains cones 4. The rods of the retina are most sensitive to light and are most responsible for color vision

The fovea centralis is located directly behind the center of the lens and contains cones Rationale: 1. When photons strike the retina, chemical reactions are stimulated in the rods and cones, which generates nerve impulses for transmission. The retina does not react to the chemical stimulation from the rods and cones 2. Thee rods and cones are stimulated by photons, not by chemical stimulation from the retina 3. The fovea centralis is located on the retina directly behind the lens. The area has only cones, which is the area of most acute color vision 4. The cones are most sensitive to light and are most responsible for color vision. Rods are more sensitive to dim light, but only allow shades of gray vision.

The nurse places eyedrops for a patient with an injured eye and covers the eye with a patch as prescribed. Discharge instructions are given to the patient. Which patient statements indicate further instruction is needed? (Select all that apply.) 1. "I should exercise my patched eye four times daily." 2. "I can watch television without moving my eye too much." 3. "I should apply pressure to the tear duct of the eye every 5 minutes." 4. "I should try to open my eyelid under the patch hourly while awake." 5. "I can listen to music or an audiotaped book, but should not read or watch television."

1. "I should exercise my patched eye four times daily." 2. "I can watch television without moving my eye too much." 3. "I should apply pressure to the tear duct of the eye every 5 minutes." 4. "I should try to open my eyelid under the patch hourly while awake." Rationale: 5. Listening to an audio book and taping the patch securely indicate teaching has been effective.

A nurse is reinforcing discharge teaching to a client following middle ear surgery. Which of the following statements by the client indicates understanding of the teaching? 1. "I will avoid blowing my nose." 2. "I should wait until the day after surgery to wash my hair." 3. "I will remove the dressing behind my ear in 7 days." 4. "My hearing should be back to normal right after my surgery."

1. "I will avoid blowing my nose." Rationale: Clients following ear surgery should be advised to avoid blowing their nose, sneezing, or coughing. This can cause pressure on the client's ear or stitches if in place. This can also cause pain and discomfort to the client following ear surgery.

A nurse in a provider's office is reinforcing instructions with a guardian of a toddler how to administer ear drops. Which of the following instructions should the nurse include? Select all. That apply. 1. "Place the child on the unaffected side when you are ready to administer the medication." 2. "Warm the medication by gently rolling it between your hands for a few minutes." 3. "Gently shake medication that is in suspension form." 4. "Keep the child on their side for 5 minutes after instillation of the ear drops." 5. "Tightly pack the ear canal with cotton after instillation of the ear drops."

1. "Place the child on the unaffected side when you are ready to administer the medication." 2. "Warm the medication by gently rolling it between your hands for a few minutes." 3. "Gently shake medication that is in suspension form." 4. "Keep the child on their side for 5 minutes after instillation of ear drops."

The nurse is teaching a client about eye examinations. Which statement made by the client indicates a need for further teaching? 1. "Since I haven't had eye problems, I only need an exam every 5 years." 2. "Because I am 65, I should schedule an eye examination each year." 3. "I need to see my eye doctor every year to get my contact prescription." 4. "Even though I am 55, I have cataracts, so I need to see my eye doctor every year."

1. "Since I haven't had eye problems, I only need an exam every 5 years." Option 1: Exams should be every 2 yr. Option 2: This is a correct statement. Option 3: This is a correct statement. Option 4: This is a correct statement.

A patient has been prepped for an internal eye exam. Anesthetic drops and a mydriatic drug have been administered. Which instruction should the patient be taught for eye safety following the exam? 1. "Wear sunglasses after the exam." 2. "Rub your eye hourly to increase blood circulation." 3. "You may reapply contact lenses when the eye exam is completed." 4. "Flush your eye with water to remove the eye drops."

1. "Wear sunglasses after the exam." Rationale: Because the pupils are dilated, the eyes must be protected from bright light

Prior to measuring a patient's hearing, the nurse obtains a tuning fork. Which hearing tests is the nurse preparing to conduct? (Select all that apply.) Prior to measuring a patient's hearing, the nurse obtains a tuning fork. Which hearing tests is the nurse preparing to conduct? (Select all that apply.) 1. Rinne test 2. Weber test 3. Caloric test 4. Tympanometry 5. Electronystagmogram

1. Rinne test 2. Weber test Rationale: 1. The Rinne test is performed with a tuning fork and is useful for differentiating between conductive and sensorineural hearing loss. 2. The Weber test is also performed using a tuning fork. 3. The caloric test is used to test the function of the eighth cranial nerve and to assess vestibular reflexes of the inner ear that control balance. 4. Tympanometry is a test used to measure compliance of the tympanic membrane and differentiate problems in the middle ear. 5. The electronystagmogram is used to diagnose the causes of unilateral hearing loss of unknown origin, vertigo, or ringing in the ears.

The nurse is attending while the HCP performs an otoscopic exam of the patient's ear. The nurse is aware that the exam is performed primarily for which purpose? 1. To exam the eardrum 2. To look for foreign objects 3. To remove excessive earwax 4. To obtain a sample of drainage

1. To exam the eardrum Rationale: 1. Primarily, the HCP will perform an otoscope exam to visualize the eardrum 2. Routinely, the HCP does not perform an otoscope exam to look for foreign objects. 3. An otoscope examis not performed to remove excessive earwax, which may be identified during a routine otoscope exam 4. An otoscope exam is not performed to obtain a sample of drainage from the ear. Drainage will be obtained through the use of a cotton-tipped swab.

The nurse is preparing a patient with diabetes mellitus for a fluorescein angiography. For which reason does the nurse understand the performance of this test? 1. To find leakage or damage to the blood vessels of the retina 2. To identify the dry form of macular degeneration 3. To find the amount of vision damage related to glaucoma 4. To find abnormalities of the eye structure from hypoglycemia

1. To find leakage or damage to the blood vessels of the retina Rationale: 1. Fluorescein angiography is performed on patients with DM to diagnose and arrange for treatment of diabetic retinopathy 2. Indocyanine green angiography is performed to diagnose the wet form of macular degeneration 3. Fluorescein angiography and indocyanine are not used when testing to find the amount of vision damage related to glaucoma 4. Fluorescein angiography and indocyanine green angiography are not used when testing to find abnormalities of the eye structure from hypoglycemia

A nurse is collecting screening data from a toddler for possible hearing loss. Which of the following findings are indications of a hearing impairment? Select all that apply. 1. Uses monotone speech 2. Speaks loudly 3. Repeats sentences 4. Appears shy 5. Is overly attentive to the surroundings

1. Uses monotone speech 2. Speaks loudly 4. Appears shy

The nurse is assisting in the evaluation of the effectiveness of teaching for a patient who has severe visual impairment. Which statement by the patient indicates additional teaching is needed? 1. "I can do all my self-care if no one moves my hygiene items." 2. "Cooking is still impossible and I am just eating cold foods." 3. "My family helped move everything out of my pathways." 4. "I have someone come weekly for cleaning and laundry."

2. "Cooking is still impossible and I am just eating cold foods." Rationale: 1. When a patient with severe vision impairment is able to perform self-care independently, patient teaching is effective. 2. The patient needs additional teaching about methods and/or agencies that can be helpful in supplying adequate nutrition. 3. When the patient enlists the help of family to make the environment safer, teaching is effective. 4. When the patient understands the need for help with chores that cannot be performed independently, teaching is effective.

The nurse is caring for a client who has diabetes and macular degeneration. Which question is most appropriate for the nurse to ask? 1. "Would you prefer to take insulin pills, so you don't have to do injections?" 2. "Can you afford your medication?" 3. "Do you have a family member who can administer your insulin injections?" 4. "Can you go without your insulin?"

3. "Do you have a family member who can administer your insulin injections?" Option 1: Insulin is not available as an oral medication. Option 2: This is an important question to ask but is not related to the stem. Option 3: It is highly unlikely the client can see the numbers on the syringe to draw up the correct dose; another individual should give the insulin for safety purposes. Option 4: The nurse should not suggest the client quit taking insulin.

The nurse is caring for a patient who is diagnosed with otosclerosis and asks what the disease is. Which is the most appropriate response by the nurse? 1. "Infection of the external ear commonly caused by moisture." 2. "It is a tumor of the eighth cranial nerve." 3. "Hardening of the staples due to new bone growth." 4. "Inflammation of the inner ear caused by pathogens."

3. "Hardening of the staples due to new bone growth." Rationale: Otosclerosis is hardening of the stapes from new bone growth.

The client tells the nurse he has a lot of hard ear wax. Which interventions will the nurse implement? 1. Insert a Q-tip into the ear to remove the wax 2. Use ear candling to soften the hardened wax 3. Administer cerumenolytics as prescribed 4. Tell the client to leave the cerumen in the ear

3. Administer cerumenolytics as prescribed Option 1: Nothing should be inserted into the ear. Option 2: This process involves heat and is an unsafe practice. Option 3: This will soften and remove the earwax from the ear. Option 4: This does not address the client's concern.

A nurse is caring for a client who has a new diagnosis of cataracts. Which of the following manifestations should the nurse expect? Select all that apply. 1. Eye pain 2. Floating spots 3. Blurred vision 4. White pupils 5. Bilateral red reflexes

3. Blurred vision 4. White pupils

The nurse is collecting information about the eyes from the older adult patient. Which finding is unexpected during the exam? 1. The lenses of the eyes are slightly opaque in appearance 2. The patient states that the glare of the pen light is too bright 3. The best color discrimination is between blue, green, and purple 4. The patient has needed reading glasses since the age of 45 years old

3. The best color discrimination is between blue, green, and purple Rationale: 1. It is an expected finding if the lenses of the older adult patient's eyes exhibit some degree of opaqueness 2. As patient's age, they become less tolerant of bright light and more glare intolerant 3. The ability to distinguish colors diminishes with aging. Red, yellow, and orange are the most easily identified. Blue, green, and purple are the most difficult to distinguish 4. Patients become more farsighted with age due to the lens losing elasticity. It is common for patients to require reading glasses around 40 years of age.

The nurse is conducting hearing acuity evaluation on a patient using the Rinne test. The test involves the use of a tuning fork. Which test result will be validated with the documentation "AC greater than BC"? 1. The patient hears the tuning fork twice as long when it is placed on the mastoid bone 2. The patient is unable to hear the tuning fork when it is lifted away from the mastoid bone 3. The patient continues to hear the tuning fork twice as long when it is lifted from the mastoid bone 4. The patient stops hearing the tuning fork when it is moved from in front of the ear and placed on the mastoid bone

3. The patient continues to hear the tuning fork twice as long when it is lifted from the mastoid bone Rationale: 1. Once the patient stops hearing the tuning fork while it is placed on the mastoid bone, it is normally heard twice as long when placed in front of the ear 2. It is expected that the patient will hear the tuning fork for some period of time after it is lifted from the mastoid bone and held in front of the ear 3. Documentation of "AC greater than BC" indicated that the patient hears the conduction of sound through the air twice as long as the conduction of sound through bone. This is considered a normal finding 4. If the patient stops hearing the tuning fork when it is moved away from the front of the ear and placed on the mastoid bone, this is indicative of abnormal neural conduction of sound

The nurse in the emergency department is assisting with the care of a patient with a penetrating wound to the eye. The patient keeps crying out and asking that the uninjured eye be uncovered. Which answer by the nurse provides understanding? 1. "It is less stressful if you cannot see anything about the other eye." 2. "Covering your uninjured eye will keep anything from getting into it." 3. "Being able to see will allow you to look around and get more upset." 4. "Covering the uninjured eye stops ocular movement in the injured one."

4. "Covering the uninjured eye stops ocular movement in the injured one." Rationale: 1. The nurse needs to help keep the patient calm; however, it is not the reason the uninjured eye is covered. 2. The uninjured eye is not necessarily covered to keep anything from getting into it; the goal is to prevent ocular movement in the injured eye. 3. Telling the patient that the ability to look around will just upset them more and does not help to keep the patient calm. 4. The primary reason for covering the uninjured eye when there is a penetrating injury to the other eye is to stop ocular movement that can cause additional damage.

The nurse is reinforcing teaching provided to a patient with primary open-angle glaucoma (POAG) about symptoms to report. Which patient statement regarding symptoms indicates a correct understanding of the teaching? 1. "Hypotension and bradycardia" 2. "Fever and reddened conjunctiva" 3. "Loss of central vision and dizziness" 4. "Headache and seeing halos around lights"

4. "Headache and seeing halos around lights" Rationale: 4 .POAG develops bilaterally. The onset is usually gradual and painless, so the patient may not experience noticeable symptoms or, after time, may experience mild aching in the eyes, headache, halos around lights, or frequent visual changes that are not corrected with eyeglasses.

The nurse is reinforcing teaching about eye hygiene. Which statement made by a client indicates an understanding of the teaching? 1. "I will wipe my eye from outer to inner." 2. "I should rub my eye if I get something in my eye." 3. "If I pull the lower eyelid up, tears will wash out the object." 4. "I should wear safety goggles when working with debris."

4. "I should wear safety goggles when working with debris." Option 1: The eye should be wiped from inner to outer canthus. Option 2: The client should never rub their eye. Option 3: The upper eyelid should be pulled down to allow tears to wash away the object. Option 4: This is a correct statement.

The nurse is reinforcing teaching for a client with a hearing aid. Which statement made by the client indicates an understanding of the teaching? 1. "I need to keep the battery in my hearing aid at all times." 2. "I will use household cleaner to clean my hearing aid regularly." 3. "I will turn the hearing aid volume up and keep it up when it is squealing." 4. "When I am not using my hearing aid, I am going to shut it off."

4. "When I am not using my hearing aid, I am going to shut it off." Option 1: The battery should be removed when not in use to conserve battery use. Option 2: The client should use a dry or soapy, damp cloth. Option 3: The client should turn it up just until it squeals. Option 4: This statement indicates understanding.

A nurse is performing an otoscopic exam of a client. Which of the following is an unexpected finding? 1. Pearly gray tympanic membrane (TM) 2. Malleus visible behind the TM 3. Presence of soft cerumen in the external canal 4. Fluid or bubbles seen behind the TM

4. Fluid or bubbles seen behind the TM

A nurse is assisting with performing a peripheral vision test on a child. Which of the following actions should the nurse take? 1. Place the child 10 feet away from the Snellen chart 2. Show a set of cards to the child one at a time 3. Cover the child's eye while performing the test on the other eye 4. Have the child focus on an object while performing the test

4. Have the child focus on an object while performing the test

The nurse is caring for a patient with macular degeneration. During data collection, which symptom would the nurse anticipate the patient to report? 1. Loss of peripheral vision 2. Sudden darkness 3. Dull ache in the eyes 4. Loss of the central vision

4. Loss of the central vision Rationale: Loss of central vision occurs with macular degeneration.

The nurse in an HCP's office is providing assistance with a patient who has purulent drainage from the ear. Which action by the HCP does the nurse expect? 1. Flushing of the drainage from the ear canal 2. Packing the ear lightly to absorb the drainage 3. Excising the eardrum to promote drainage 4. Obtaining a swab of the drainage for culture

4. Obtaining a swab of the drainage for culture Rationale: 1. When the ear is draining, flushing presents a risk of pushing the exudate deeper into the ear. 2. The ear may or may not be packed lightly to absorb the drainage; the amount of drainage will be the determining factor. 3. When the ear is currently draining, if the middle ear is involved, the eardrum is already perforated. If the drainage source is in the ear canal, the eardrum should be kept intact to avoid infecting the middle ear. 4. When an ear is draining, a swab sample needs to be obtained and sent to the laboratory immediately for culture. Identifying the causative microbe will assist in prescribing the most effective antibiotic.