Adult Health - Eye

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nursedaisy98
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256679
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Adult Health - Eye
Updated:
2014-04-20 10:57:27
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NCLEX RN
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Adult Health
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Eye
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  1. The nurse is developing a teaching plan for a client with glaucoma. Which instruction should the nurse include in the plan of care? 
    1. Avoid overuse of the eyes. 
    2. Decrease the amount of salt in the diet. 
    3. Eye medications will need to be administered for life. 
    4. Decrease fluid intake to control the intraocular pressure.
    3. Eye medications will need to be administered for life.
  2. The nurse is performing an admission assessment on a client with a diagnosis of detached retina. Which sign/symptom is associated with this eye disorder? 
    1. Total loss of vision 
    2. Pain in the affected eye 
    3. A yellow discoloration of the sclera 
    4. A sense of a curtain falling across the field of vision
    4. A sense of a curtain falling across the field of vision
  3. The nurse is performing an assessment on a client with a suspected diagnosis of cataract. What is the chief clinical manifestation that the nurse expects to note in the early stages of cataract formation? 
    1. Diplopia 
    2. Eye pain 
    3. Floating spots 
    4. Blurred vision
    4. Blurred vision
  4. The nurse is preparing a teaching plan for a client who is undergoing cataract extraction with intraocular implantation. Which home care measures should the nurse include in the plan? Select all that apply. 
    1. Avoid activities that require bending over. 
    2. Contact the surgeon if eye scratchiness occurs. 
    3. Place an eye shield on the surgical eye at bedtime. 
    4. Episodes of sudden severe pain in the eye are expected. 
    5. Contact the surgeon if a decrease in visual acuity occurs. 
    6. Take acetaminophen (Tylenol) for minor eye discomfort.
    • 1. Avoid activities that require bending over. 
    • 3. Place an eye shield on the surgical eye at bedtime. 
    • 5. Contact the surgeon if a decrease in visual acuity occurs. 
    • 6. Take acetaminophen (Tylenol) for minor eye discomfort.
  5. Tonometry is performed on a client with a suspected diagnosis of glaucoma. The nurse looks at the test results documented in the client's chart, knowing that which is the range for normal intraocular pressure? 
    1. 2 to 7 mm Hg 
    2. 10 to 21 mm Hg 
    3. 22 to 30 mm Hg 
    4. 31 to 35 mm Hg
    2. 10 to 21 mm Hg
  6. A client's vision is tested with a Snellen chart. The results of the tests are documented as 20/60. How should the nurse interpret this finding? 
    1. The client is legally blind. 
    2. The client's vision is normal. 
    3. The client can read at a distance of 60 feet what a client with normal vision can read at 20 feet. 
    4. The client can read only at a distance of 20 feet what a client with normal vision can read at 60 feet.
    4. The client can read only at a distance of 20 feet what a client with normal vision can read at 60 feet.
  7. A client is diagnosed with glaucoma. Which nursing assessment data identifies a risk factor associated with this eye disorder? 
    1. Cardiovascular disease 
    2. Frequent urinary tract infections 
    3. A history of migraine headaches 
    4. Frequent upper respiratory infections
    1. Cardiovascular disease
  8. A client with retinal detachment is admitted to the nursing unit in preparation for a scleral buckling procedure. Which prescription should the nurse anticipate? 
    1. Allowing bathroom privileges only
    2. Elevating the head of the bed to 45 degrees 
    3. Wearing dark glasses to read or watch television 
    4. Placing an eye patch over the client's affected eye
    4. Placing an eye patch over the client's affected eye
  9. The nurse is caring for a client who was recently diagnosed with primary open-angle glaucoma (POAG). Which assessment finding is specific to this type of glaucoma? 
    1. Client report of blurred vision 
    2. Client report of "tunnel vision" 
    3. Client report of ocular erythema 
    4. Client report of halos around lights
    2. Client report of "tunnel vision"
  10. The nurse in the health care clinic is providing instructions to a client regarding the use of a hearing aid. Which statement is most appropriate for the nurse to include? 
    1. "The hearing aid should not be worn if an ear infection is present." 
    2. "The ear mold for the hearing aid should be washed with mild soap and water once a month." 
    3. "The hearing aid should be removed from the ear at the end of the day and then turned off after removal." 
    4. "The hearing aid contains a lifelong battery, so you will not need to be concerned about changing batteries."
    1. "The hearing aid should not be worn if an ear infection is present."
  11. The nurse is preparing to provide care for a client who will need an ear irrigation to remove impacted cerumen. Which interventions should the nurse take when performing the irrigation? Select all that apply. 
    1. Apply some force when instilling the irrigation solution. 
    2. Position the client with the affected side down after the irrigation. 
    3. Warm the irrigating solution to a temperature that is close to body temperature. 
    4. Position the client to turn the head so that the ear to be irrigated is facing upward. 
    5.Direct a slow, steady stream of irrigation solution toward the upper wall of the ear canal.
    • 2. Position the client with the affected side down after the irrigation. 
    • 3. Warm the irrigating solution to a temperature that is close to body temperature. 
    • 5. Direct a slow, steady stream of irrigation solution toward the upper wall of the ear canal.
  12. The home care nurse is visiting a client who was recently diagnosed with a hearing impairment. The nurse should prepare to instruct the client's spouse in which measure that will facilitate communication? 
    1. Speak loudly to the client to facilitate hearing. 
    2. Speak directly into the impaired ear to facilitate hearing. 
    3. Speak in a normal tone and face the client when speaking. 
    4. Speak frequently to the client to provide sensory stimulation.
    3. Speak in a normal tone and face the client when speaking.
  13. A client arrives at the emergency department (ED) with a foreign body in the left ear and tells the nurse that an insect flew into the ear. Which intervention should the nurse implement initially? 
    1. Irrigation of the ear 
    2. Instillation of mineral oil 
    3. Instillation of antibiotic eardrops 
    4. Instillation of corticosteroid ointment
    2. Instillation of mineral oil
  14. The nursing student is caring for a client with a diagnosis of presbycusis. The nursing instructor asks the student to describe the physiology associated with this diagnosis. The nursing instructor determines that the student understands this condition if the student indicates that which is a characteristic of presbycusis? 
    1. A loss of vision associated with aging 
    2. A loss of balance that occurs with aging 
    3. A conductive hearing loss that occurs with aging 
    4. A sensorineural hearing loss that occurs with aging
    4. A sensorineural hearing loss that occurs with aging
  15. The nurse is providing discharge instructions to a client who had a fenestration procedure for the treatment of otosclerosis. The nurse should instruct the client to take which measure? 
    1. Avoid air travel. 
    2. Shower daily to prevent infection. 
    3. Resume all normal activities in 1 week. 
    4. Drink liquids through a straw for the next 2 to 3 weeks.
    1. Avoid air travel.
  16. The nurse is planning care for a client with acute otitis media. To reduce pressure and allow fluid to drain, the nurse anticipates that which measure would most likely be recommended to the client? 
    1. Strict bed rest 
    2. A myringotomy 
    3. A mastoidectomy 
    4. Diphenhydramine (Benadryl)
    2. A myringotomy
  17. The nurse is developing a plan of care for a client with a diagnosis of severe vertigo from Ménière's disease who is being admitted to the hospital. What is the priority nursing intervention in the plan of care? 
    1. Safety measures 
    2. Self-care measures 
    3. Food items to avoid 
    4. Knowledge about medication therapy
    1. Safety measures
  18. The nurse is assigned to care for a client after a mastoidectomy. Which nursing intervention would be a priority in the care of this client? 
    1. Maintain a supine position. 
    2. Change the ear dressing daily. 
    3. Monitor for signs of facial nerve injury. 
    4. Position the client on the affected side to promote drainage.
    3. Monitor for signs of facial nerve injury.
  19. The nurse is performing an assessment on a client with a diagnosis of Ménière's disease. The nurse anticipates that the client is most likely to report which symptom during an acute attack? 
    1. Fatigue 
    2. Tinnitus 
    3. Headache
    4. Insomnia
    2. Tinnitus
  20. The nurse has admitted a client with a diagnosis of an acute attack of Ménière's disease to the hospital. The nurse reviews the health care provider's prescriptions for the client. Which prescription should the nurse question? 
    1. Diazepam (Valium) 
    2. Nicotinic acid (Niacin) 
    3. Ambulation four times daily 
    4. Diphenhydramine (Benadryl)
    3. Ambulation four times daily
  21. The nurse is providing discharge instructions to the client being discharged after a fenestration procedure for the treatment of otosclerosis. Which statement, if made by the client, indicates a need for further instruction? 
    1. "I should use a straw to drink liquids for the next 2 to 3 weeks." 
    2. "I need to avoid washing my hair and showering for at least 1 week." 
    3. "I should avoid movements requiring bending over for at least 3 weeks." 
    4. "I should take stool softeners to avoid straining when having a bowel movement."
    1. "I should use a straw to drink liquids for the next 2 to 3 weeks."
  22. The clinic nurse is performing an otoscopic examination on an adolescent who was hit in the ear with a basketball during a neighborhood game. A perforated eardrum is suspected. Which finding should the nurse expect to observe if the eardrum is perforated? 
    1. A red and bulging eardrum 
    2. Dense white patches on the eardrum 
    3. A colony of black dots on the eardrum 
    4. A round or oval darkened area on the eardrum
    4. A round or oval darkened area on the eardrum
  23. The nurse is caring for a client in the postoperative period following enucleation. The nurse notes bloody staining on the surgical eye dressing. Which nursing action is most appropriate? 
    1. Document the finding. 
    2. Reinforce the dressing. 
    3. Mark the site and continue to monitor. 
    4. Contact the health care provider (HCP).
    4. Contact the health care provider (HCP).
  24. A caloric test is prescribed for a client suspected of having disease of the labyrinth. The nurse should obtain which essential item in preparation for this test? 
    1. An otoscope 
    2. A tongue blade 
    3. An emesis basin 
    4. An ophthalmoscope
    1. An otoscope
  25. The nurse educator is conducting an in-service education session to the nurses employed in the eye and ear surgical unit of a large trauma center. In discussing the topic of cochlear implants, the educator notes that this surgical procedure is contraindicated in which client? 
    1. A client with bilateral profound hearing loss 
    2. A client who communicates primarily by speech 
    3. A client who became deaf before learning to speak 
    4. A client who received no benefit from conventional hearing aids
    3. A client who became deaf before learning to speak
  26. The nurse is observing an unlicensed assistive personnel (UAP) communicating with a client who is deaf. The nurse should intervene if which behavior is observed? 
    1. The UAP is speaking directly to the client. 
    2. The UAP over-enunciates words when speaking. 
    3. The UAP faces the client when speaking to the client. 
    4. The UAP touches the client's arm to gain his or her attention.
    2. The UAP over-enunciates words when speaking.
  27. The nurse is planning a presentation on noise prevention and ear protection for a display booth at a local health fair. The nurse plans to incorporate which important concept regarding hearing loss in the presentation? 
    1. Sitting near loud music is not harmful. 
    2. Prolonged ringing in the ears after loud noises is normal. 
    3. Cup the hands over the ears if loud noise is expected suddenly. 
    4. Ear plugs or other protectors are necessary only with use of power tools.
    3. Cup the hands over the ears if loud noise is expected suddenly.
  28. The nurse instructs a client in the use of a hearing aid. The nurse should include which instructions? 
    1. Hearing aids do not require any care. 
    2. Leave the hearing aid in place while showering. 
    3. Check the battery to ensure that it is working before use. 
    4. A water-soluble lubricant is used on the hearing aid before insertion.
    3. Check the battery to ensure that it is working before use.
  29. The nurse has given a client who is at risk for motion sickness suggestions about medications that can prevent an occurrence. The nurse determines that the client has correctly learned the information if the client states that the medication is taken at what time before the triggering event? 
    1. At least 2 days before 
    2. At least 1 hour before 
    3. At least the day before 
    4. At least a half-day before
    2. At least 1 hour before
  30. The nurse is caring for a client with acute otitis media. The nurse anticipates that which is most likely to be recommended to the client to reduce pressure and allow fluid to drain? 
    1. Strict bed rest 
    2. A myringotomy 
    3. A mastoidectomy 
    4. Administration of diphenhydramine (Benadryl) capsules
    2. A myringotomy
  31. The nurse is developing a plan of care for a client with a diagnosis of Ménière's disease who is being admitted to the hospital. The priority nursing intervention in the plan of care should focus on which item? 
    1. Measures that will ensure safety 
    2. Determining any knowledge deficits 
    3. Knowledge about the treatment plan 
    4. Determining any psychosocial needs
    1. Measures that will ensure safety
  32. A client makes an appointment with an ear specialist because of the frequent recurrence of middle ear infections. In performing an intake assessment of the client, the nurse should ask about which risk factor related to infection of the ears? 
    1. Occupational noise 
    2. Exposure to loud noise 
    3. Congenital abnormalities 
    4. Use of drilling and other power tools
    3. Congenital abnormalities
  33. The nurse is educating a client on how to eliminate whistling from a hearing aid. The nurse recognizes that additional instruction is needed when the client makes which statement? 
    1. "I will cleanse my ear mold." 
    2. "I will try reinserting the hearing aid." 
    3. "I will raise the volume of my hearing aid." 
    4. "I will make sure that my hair is not caught between the ear mold and canal."
    3."I will raise the volume of my hearing aid."
  34. The nurse is developing a plan of care for a client who is scheduled for cataract surgery. The nurse should identify which as the most appropriate problem in the client's plan of care? 
    1. Inability to bathe self 
    2. Lack of adequate nutrition 
    3. Nervousness about the surgery 
    4. Alteration in sensory perception
    4. Alteration in sensory perception
  35. A client arrives at the emergency department with a foreign body in the left ear that has been determined to be an insect. Which intervention would the nurse anticipate to be prescribed initially? 
    1. Irrigation of the ear 
    2. Instillation of viscous lidocaine 
    3. Instillation of antibiotic ear drops 
    4. Instillation of corticosteroid ointment
    2. Instillation of viscous lidocaine
  36. The nurse has conducted discharge teaching for a client who has undergone a fenestration procedure for the treatment of otosclerosis. Which statement, if made by the client, would indicate that teaching was effective? 
    1. "It is okay to take a shower and wash my hair."
    2. "I can resume my tennis lessons starting next week." 
    3. "I should drink liquids through a straw for the next 2 to 3 weeks." 
    4. "I will take stool softeners as prescribed by my health care provider."
    4. "I will take stool softeners as prescribed by my health care provider."
  37. The nurse is reviewing the health care provider's prescriptions for a client with Ménière's disease. Which diet would most likely be prescribed for the client? 
    1. Low-fat diet 
    2. Low-sodium diet 
    3. Low-cholesterol diet 
    4. Low-carbohydrate diet
    2. Low-sodium diet
  38. A nurse provides home care instructions to a client who has undergone cataract removal and placement of an intraocular implant in the right eye. Which statement by the client would indicate a need for further instruction? 
    1. "I need to avoid lying on my right side." 
    2. "I need to wear the metal eye shield at night when I sleep." 
    3. "I should take stool softeners to prevent becoming constipated." 
    4. "I need to remove the eye dressing as soon as I get home and place a warm pack on my eye."
    4. "I need to remove the eye dressing as soon as I get home and place a warm pack on my eye."
  39. The nurse provides dietary instructions to a client with Ménière's disease. The nurse should tell the client that which food or fluid item is acceptable to consume? 
    1. Tea 
    2. Coffee 
    3. Cold-cut meats 
    4. Sugar-free Jell-O
    4. Sugar-free Jell-O
  40. A nurse suspects the client may be experiencing dysfunction in the area of the semicircular canals of the ear if the client experiences which condition? 
    1. Tinnitus 
    2. Disturbance in balance 
    3. Conduction hearing loss 
    4. Sensorineural hearing loss
    2. Disturbance in balance
  41. A client is experiencing blockage of the eustachian tubes. Which activity by the client may forcibly open the eustachian tube? 
    1. Performing the Valsalva maneuver 
    2. Tapping the side of the head lightly 
    3. Using cotton-tipped applicators in the ears
    4. Chewing food using exaggerated mouth movements
    1. Performing the Valsalva maneuver
  42. A nurse is caring for a client diagnosed with Ménière's disease. The nurse plans care, understanding that this disorder is characterized by which manifestation? 
    1. Dizziness 
    2. Blurred vision 
    3. Hemianopsia 
    4. Photophobia
    1. Dizziness

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