NR 462 Final Exam

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NR 462 Final Exam
2013-03-14 22:13:00
Nr 462 Final Exam

Final exam
Show Answers:

  1. What is the main priority with someone who experiences vision loss?
  2. What are the ranges on the BCVA vision exam?
    20/70 to 20/200 (second number higher = vision is poor) Legal blindness is BCVA does not exceed 20/200 in better eye
  3. A client asks, “What does the lens of my eye do?” The nurse should explain that the lens of the eye:
    Focuses light rays onto the retina
  4. The client with a cataract tells the nurse that she is afraid of being awake during eye surgery. Which of the following responses by the nurse would be the most appropriate?
    “What is it that disturbs you about the idea of being awake?”
  5. A client is scheduled for removal of a cataract of the right eye. Before surgery, the nurse is to instill drops pf phenylephrine hydrochloride (Neo-Synephrine) into the client’s right eye. This preparation acts in the eye to produce :
    Dilation of the pupil and constriction of blood vessels
  6. A short time after cataract surgery, the client complains of nausea. Which of the following represents the nurse’s best course of action?
    Medicate the client with an antiemetic, as orders
  7. The client is discharged on the day of the cataract surgery. Which of the following nursing diagnoses would be most appropriate for he client at this time?
    Risk for injury related to limited vision after surgery
  8. Which of the following activities should be avoided to achieve the goal of decreasing intraocular pressure after eye surgery?
  9. A client is admitted through the emergency department with a diagnosis of detached retina in the right eye. As the nurse completes the admission history, the client reports that before the physician patched his eye, he saw many spots, or “floaters.” The nurse should explain to client that theses spots were caused by :
    Blood cells released into the eye by the detachment
  10. Which of the following statements would provide the best guide for activity for a client who has been treated for retinal detachment during the rehabilitation period?
    Activity is resumed gradually, and the client can resume her usual activities in 5 to 6 weeks
  11. Scleral buckling, a procedure used to treat retinal detachment, involves:
    Creating a splint to hold the retina together until a scar can form and seal off the tear
  12. The client who has been treated for chronic open-angle glaucoma (COAG) for 5 years asks the clinic nurse, “How does glaucoma damage my eyesight?” The nurse’s reply should be based on the knowledge that COAG:
    Cause increased intraocular pressure
  13. A client has been diagnosed with an acute episode of angle-closure glaucoma. The nurse plan the clients nursing care with the understanding that acute angle-closure glaucoma:
    Is a medical emergency that can rapidly lead to blindness
  14. The nurse has been assigned to a client who is hearing impaired and reads speech. Which of the following strategies should the nurse incorporate when communicating with the client? Select all that apply
    • (A)Avoid being silhouetted against strong light
    • (B) Not blocking out the person’s view of the speaker’s mouth
    • (C) Facing the client when talking
    • (E) Ensuring the client is familiar with the subject material before discussing
  15. A client has vertigo. Which of the following would be most appropriate for the nursing diagnosis: Risk for Injury related to altered immobility and gait disturbances? Select all that apply
    • (A)Assumes safe position when dizzy
    • (B) Experiences no falls
    • (C) Performs vestibular/balance exercises 
    • (E) Keeps head still when dizzy
  16. The client with Meniere’s disease is instructed to modify his diet. The nurse would explain that the most frequently recommended diet modification for Meniere’s disease is:
    Low sodium
  17. The nurse is observing a student who is preparing to perform an ear examination of a 24-year-old client. The nurse will need to intervene if the student:
    Pulls the auricle of the ear down and backward
  18. In which type of diabetes does retinopathy seem to develop more rapidly?
    Type II
  19. Clients with diabetes mellitus require frequent vision assessment. The nurse should instruct the client about which of the following eye problems most likely to be associated with diabetes mellitus?
  20. What is the major cause of blindness in people with diabetes mellitus?
  21. What is the best way to prevent diabetic retinopathy?
    Control blood sugar, blood pressure and blood cholesterol
  22. What has shown to seriously increase the risk of progression to diabetic retinopathy?
  23. A nurse performs the Snellen chart exam on a patient. The doctor later diagnoses the patient legally bling. Which of the following eye exam results would confirm this diagnosis?
    20/200 Vision
  24. Which of the following nursing diagnoses could a nurse use for a patient who is suffering from complete blindness?
    Self care deficits related to visual impairment.
  25. A fifty-year-old blind and deaf patient has been admitted to your floor. As the charge nurse your primary responsibility for this patient is
    Provide a secure environment for the patient
  26. Damage to which cranial nerve will result in changes in vision?
  27. A client has impaired vision. An intervention to best adapt the environment to this loss includes:
    Keep room and pathway free from clutter
  28. The nurse is preparing a teaching plan for a client who is undergoing cataract extraction with intraocular implantation. Which home care measures will the nurse include in the plan?
    • -Avoid activities that require bending over  
    • -Place an eye shield on the surgical eye at bedtime 
    • -Contact the surgeon if a decrease in visual acuity occurs
    • -Take acetaminophen (Tylenol) for minor eye discomfort
  29. The nurse is performing an assessment on a client with a suspected diagnosis of cataract. The chief clinical manifestation that the nurse would expect to note in the early stages of cataract formation is:
    Blurred Vision
  30. Which of the following is an important nursing consideration regarding post- operational cataract surgery?
    Ensure that patient or someone reliable will be able to administer post-surgical eye drops exactly as prescribed by physician.
  31. The nurse is making a care plan for the patient with a scheduled surgery for cataracts. What is the best nursing diagnosis for the nurse to document?
    Sensory perception, disturbed
  32. A client comes to the office with a tentative diagnosis of glaucoma, and is to have testing to determine whether the anterior angle of the eye is open or closed. The patient will require education for which of the following examinations?
    Slit- Lamp Inspection
  33. A patient with glaucoma has medication prescribed to decrease intraocular pressure. Which of the following medication should be questioned by the nurse?
    Artificial tears
  34. A client with history of glaucoma was diagnosed by the community nurse as experiencing Visual Sensory/Perceptual Alterations R/T increased intraocular pressure. The plan of care should focus on:
    Encouraging compliance with drug therapy to prevent loss of vision.
  35. The nurse is evaluating a client's knowledge of miotic eye drop self- administration for the treatment of glaucoma. Which statement best demonstrates the client's understanding of miotic eye drop use?
    "I need to use the drops daily for the rest of my life."
  36. The nurse is providing health teaching to a client who has been prescribed latanoprost (Xalatan) for open-angle glaucoma. While harmless, the nurse would caution the patient about which potential nonocular effects of the drug? Select all that apply.
    • -Darkening and thickening of the upper eyelid
    • -Darkening and thickening of eyelashes 
    • -A slight darkening of the iris color
  37. A scleral buckling procedure is performed on a client with retinal detachment, and the nurse provides home-care instructions to the client. Which statement by the client indicates a need for further instructions?
    I need to clean the eye daily with sterile water and a clean washcloth
  38. When obtaining the health history from a male client with retinal detachment, the nurse expects the client to report:
    Light flashes and floaters in front of the eye
  39. A nurse is preparing a plan of care for a client being admitted to the hospital with a diagnosis of retinal detachment. Which of the following will the nurse include in the plan of care?
    place an eye patch over the affected eye
  40. Patient is experiencing floaters, bright flashes of light, or a shadow or curtain that seems to fall across your visual field. The nurse realizes that this is an indication of:
    retinal detachment
  41. A nurse is caring for a client with a diagnosis of retinal detachment. Suddenly, the patient complains of a burst of black spots or floaters. The nurse interpret this symptom as:
    hemorrhage as a result of the detachment
  42. For a patient with Meniere’s disease the best possible treatment plan includes
    Treatment is different for every patient
  43. A nurse is preparing a plan of care for a client being admitted to the hospital with Meniere's disease. Which of the following would the nurse include in the plan of care?
    tell the patient to avoid moving the head suddenly
  44. A patient is being admitted for Meniere’s disease a nurse would expect to find:
    A patient who is experiencing vertigo and vomiting
  45. According to Maslow’s Hieracrhy, which scenario would be the highest priority of a nurse caring for someone with Meniere’s Disease?
    When assessing your patient, he tells you that he is feeling anxious about getting up because of the unpredictable onset of vertigo and asks you for ativan.
  46. What is Sensorineural hearing loss?
    Sounds may be heard but are unable to be correctly interpreted.
  47. Which disease do you have to use the eye patch after surgery?
    Retinal Detachment
  48. Which disease do you have to wear dark glasses after surgery?
  49. What is the rinne test?
    put tuning for held against mastoid bone
  50. What is the weber test?
    • activated tuning fork placed midline skull,
    • forehead or teeth
  51. What is Minnere's disease?
    abnormal inner ear fluid balance caused by malabsorption of the endolymphatic sac or blockage of the endolymphatic duct