Chapter 19: Care of the Eye and Ear Nursing School Test Banks

MULTIPLE CHOICE

1. The nurse decides that assistive personnel can provide care to a patient with contact lenses when the assistive personnel states:

a.

If I am in a hurry, I will use tap water for rinsing the lenses.

b.

Gloves arent necessary; the eye is a clean organ.

c.

I will check with the patient to see if the lenses are disposable.

d.

It is normal for contact lens wearers to have red, teary eyes.

ANS: C

Let the patient be a resource in the care of each device. Although it is the nurses responsibility to ensure that patients do not damage their devices or injure themselves, patients familiar with their devices are likely to have an established routine and helpful tips. The replacement schedule is determined by the type of lenses the patient wears; the patient can provide that information. Tap water can contain microorganisms and may be absorbed into the lens, making it uncomfortable to wear. Clean, powder-free gloves are used to prevent the spread of microorganisms during care of contact lenses. Pain, tearing, discomfort, and redness can indicate conjunctivitis and should be referred to the patients provider if symptoms persist.

DIF: Cognitive Level: Comprehension REF: Text reference: pp. 456-457

OBJ: Identify guidelines used in caring for eye and ear prostheses.

TOP: Contact Lenses KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity

2. When providing eye care for the comatose patient, the nurse should:

a.

place the patient in a prone position for easier access.

b.

use a different corner of the washcloth for each eye.

c.

wipe each eye from outer to inner canthus.

d.

use a sterile medicine cup to instill lubricant.

ANS: B

Use a separate, clean cotton ball or corner of the washcloth for each eye. Place the patient in supine position. Gently wipe each eye from inner to outer canthus. Use an eyedropper to instill the prescribed lubricant (e.g., saline, methylcellulose, liquid tears) as ordered.

DIF: Cognitive Level: Application REF: Text reference: p. 455

OBJ: Identify guidelines used in caring for eye and ear prostheses.

TOP: Eye Care for a Comatose Patient KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

3. In caring for a patient with contact lenses, the nurse should be aware that:

a.

rigid gas-permeable (RGP) lenses are no longer used.

b.

soft contact lenses are smaller than the cornea.

c.

all lenses must be removed periodically.

d.

extended wear lenses can be used for only 6 nights.

ANS: C

It is important to remember that all lenses must be removed periodically to prevent infection and corneal damage, and that proper cleaning is necessary before a lens is reinserted. Two basic types of contact lenses are used today: RGP and soft. Rigid contact lenses are made of firm, durable plastic and are smaller than the cornea. Soft contact lenses are made of a flexible hydrogel plastic and cover the entire cornea and a small rim of the sclera. Although the limit for extended wear lenses is usually 6 nights, certain soft lenses have been approved for continuous wear up to 30 nights.

DIF: Cognitive Level: Application REF: Text reference: p. 455

OBJ: Identify guidelines used in caring for eye and ear prostheses.

TOP: Contact Lenses KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

4. Which of the following nursing interventions would the nurse perform first after a patient sustained a chemical splash injury to the eye?

a.

Assess visual acuity.

b.

Flush the eye with large amounts of irrigation fluid.

c.

Assess level of pain.

d.

Determine whether the pupils are PERRLA.

ANS: B

The first thing the nurse should do when caring for a patient who has sustained a chemical injury to the eye is flush the eye with large amounts of irrigation fluid. Assessing visual acuity, pain, and PERRLA will be performed after the eye has been irrigated appropriately.

DIF: Cognitive Level: Application REF: Text reference: p. 460

OBJ: Identify nursing care for a patient with a chemical splash to the eye.

TOP: Splash to Eye KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

5. The nurse caring for a comatose patient determines that he is wearing contact lenses. Which of the following nursing interventions will the nurse use when removing the contact lenses?

a.

Put on snug, powdered, clean gloves.

b.

Ask the patient to look down to expose the lower eyeball.

c.

Use the fingernail to slide the lens off of the cornea.

d.

Inspect the eye after the lenses have been removed.

ANS: D

After the lenses have been removed, inspect the eye for redness, pain, swelling of the eyelids or conjunctivae, discharge, or excess tearing. Perform hand hygiene. Don snug, powder-free, clean gloves, and place a towel just below the patients face. Ask the patient to look up to expose the lower eyeball to which the lens will be displaced. With the pad of the index finger of the same hand, slide the lens off the cornea down onto the lower sclera. Use of the pad rather than the fingernail prevents injury to the cornea and damage to the lens.

DIF: Cognitive Level: Application REF: Text reference: p. 456

OBJ: Correctly remove, store, clean, and insert a contact lens. TOP: Removal of Contact Lenses

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

6. When removing a soft contact lens, the nurse finds that it is sticking together. What should the nurse do next?

a.

Rub the lens briskly.

b.

Soak the lens in saline.

c.

Place cleansing solution on the lens.

d.

Pry the lens apart with the fingertips.

ANS: B

If the lens edges stick together, place the lens in the palm and soak thoroughly in saline; gently roll the lens back and forth with the index finger. If this is unsuccessful in restoring the shape of the lens, placing the lens in cleansing solution would be the next step. Brisk rubbing may damage the lens. Prying the lens apart could damage it.

DIF: Cognitive Level: Application REF: Text reference: p. 456

OBJ: Correctly remove, store, clean, and insert a contact lens. TOP: Removal of Contact Lenses

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

7. When caring for the patient with an artificial eye, the nurse realizes that:

a.

the prosthesis must be cleansed daily.

b.

implants are always visible.

c.

modern implants move as the companion eye moves.

d.

the prosthesis always is made of glass.

ANS: C

The muscles and other tissues of the eye are sewn around the implant, holding it in place. The implant, therefore, is not visible. Modern implants are made of glass or plastic and are porous so that the tissues of the eye grow into the sphere. Like a healthy eye, this integrated implant moves as the companion eye moves. Cleansing with sterile saline or soap and water is done at intervals of up to a year on the basis of the ocularists recommendations and patient preference.

DIF: Cognitive Level: Comprehension REF: Text reference: p. 458

OBJ: Explain the rationale for maintaining aseptic technique during care of an artificial eye.

TOP: Eye Implants KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity

8. The nurse is caring for an unconscious patient who has an artificial eye. To determine which eye is artificial, she shines a light into the patients eyes. Why does the nurse do this?

a.

The light will cause the eye to move differently than the natural eye.

b.

An artificial eye pupil does not react to changes in light.

c.

It is essential to remove the prosthesis for cleaning.

d.

The implant can be seen only by shining a light.

ANS: B

An artificial eye pupil does not react to changes in light. Modern implants are made of glass or plastic and are porous so that the tissues of the eye grow into the sphere. Like a healthy eye, this integrated implant moves as the companion eye moves. Unless advised by the patients eye care practitioner, the prosthesis usually is not removed unless the patient experiences discomfort, because excessive handling may cause irritation and increased secretions. The muscles and other tissues of the eye are sewn around the implant, holding it in place. The implant, therefore, is not visible.

DIF: Cognitive Level: Application REF: Text reference: p. 458

OBJ: Explain the rationale for maintaining aseptic technique during care of an artificial eye.

TOP: Eye Implants KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

9. When removing and cleansing a patients eye prosthesis, the nurse:

a.

places the patient in a prone position.

b.

retracts the upper eyelid with her thumb and forefinger.

c.

cleans the prosthesis using an alcohol solution.

d.

cleans the prosthesis using mild soap and water.

ANS: D

Clean the prosthesis by washing it with mild soap and warm water or plain saline solution by rubbing well between the thumb and index finger. Position the patient in sitting or supine position with the head elevated. Provide privacy. With the thumb or forefinger of the dominant hand, gently retract the lower eyelid against the lower orbital ridge. Never use alcohol or other products because they are harmful to the prosthesis.

DIF: Cognitive Level: Application REF: Text reference: pp. 458-459

OBJ: Explain proper care of eye and ear prostheses. TOP: Removing Eye Prosthesis

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

10. The patient is brought to the emergency department after receiving a chemical burn to his eyes. The doctor orders immediate eye irrigations. Of the following solutions, which would be the most beneficial for this patient?

a.

Lactated Ringers solution

b.

Normal saline

c.

Tap water

d.

Dextrose and water

ANS: A

Controversy continues over the best solution for irrigating the eye in a health care setting. When a choice of normal intravenous (IV) solutions is available, lactated Ringers solution is more effective than normal saline in restoring pH after a chemical burn to the eye. Often cool tap water is recommended for emergency eye flushing because it is effective and immediately available for first aid. Nevertheless, controversy continues over the best solution for irrigating the eye in a health care setting. Dextrose and water usually are not used for eye irrigation.

DIF: Cognitive Level: Analysis REF: Text reference: p. 460

OBJ: Explain differences in irrigation procedures for removing exudates and chemicals from the eyes. TOP: Eye Irrigation KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

11. When providing care to a patient who has splashed bleach into his eye, the nurse will:

a.

remove the patients contacts immediately.

b.

flush the eye from the outer to the inner canthus.

c.

reinsert contacts as soon as irrigation is done.

d.

irrigate toward the lower conjunctival sac.

ANS: D

Ask the patient to look toward the brow. Gently irrigate with a steady stream toward the lower conjunctival sac. This will minimize the force of the stream on the cornea and will flush irritant out of the eye and away from the other eye and nasolacrimal duct. In an emergency such as first aid for a chemical burn, do not delay flushing by removing the patients contact lens before irrigation. Do not remove the contact unless rapid swelling is occurring. Flush the eye from the inner to the outer canthus. Advise the patient to consult the prescriber before reusing the contact lens.

DIF: Cognitive Level: Application REF: Text reference: p. 461

OBJ: Explain differences in irrigation procedures for removing exudates and chemicals from the eyes. TOP: Eye Irrigation KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

12. The patient is found to have impacted cerumen in his ear canal. The nurse most likely will:

a.

instill 1 to 2 drops of mineral oil.

b.

instill the irrigation under pressure.

c.

occlude the ear canal when irrigating.

d.

straighten the ear canal.

ANS: A

If the patient is found to have impacted cerumen, instill 1 to 2 drops of mineral oil or over-the-counter softener into the ear twice a day for 2 to 3 days before irrigation, to loosen cerumen and ensure easier removal during irrigation. The greatest danger during administration of ear irrigation is rupture of the tympanic membrane. Fluids must not be instilled under pressure or with the irrigating device occluding the ear canal. Always attempt to remove foreign objects in the ear by first simply straightening the ear canal. Cerumen, however, is wax buildup and is not a foreign object.

DIF: Cognitive Level: Application REF: Text reference: p. 464

OBJ: Correctly perform eye and ear irrigations. TOP: Ear Irrigation

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

13. How should the nurse position the ear when performing ear irrigation for a 2-year-old patient?

a.

Instill the irrigating solution quickly and forcefully.

b.

Pull the pinna up and back.

c.

Direct the fluid toward the anterior aspect of the ear canal.

d.

Pull the pinna down and back.

ANS: D

In children age 3 or younger, pull the pinna down and back. Slowly instill irrigating solution by holding the tip of the syringe 1 cm ( inch) above the opening to the ear canal. Allow fluid to drain out during instillation into the basin. Continue until the canal is cleansed or the solution is used. Slow instillation prevents buildup of pressure in the ear canal and ensures contact of the solution with all canal surfaces. For adults and children older than age 3, gently pull the pinna up and back. Direct the fluid toward the superior aspect of the ear canal.

DIF: Cognitive Level: Application REF: Text reference: p. 464

OBJ: Correctly perform eye and ear irrigations. TOP: Ear Irrigation

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

14. How does the nurse assess that a hearing aid is operating correctly?

a.

Speaking very softly behind the patient

b.

Covering the patients unaffected ear and speaking

c.

Determining the patients response to a normal tone of voice

d.

Removing the hearing aid and sending it to be checked by an audiologist

ANS: C

To determine whether the patient can hear clearly using the hearing aid, turn your back to the patient and ask a question slowly and clearly in a normal tone of voice. Depending on your position, the patient may be able to read your lips. The prostheses are limited by the function of the ear structures. The hearing aid may not be the problem in this case.

DIF: Cognitive Level: Comprehension REF: Text reference: p. 466

OBJ: Describe techniques that determine whether a hearing aid functions properly.

TOP: Assessing the Function of the Hearing Aid

KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

15. The nurse is preparing to clean the patients hearing aid. The nurse realizes that she must:

a.

make sure the hearing aid volume is turned on before removing the hearing aid.

b.

hold the hearing aid over the sink when cleansing.

c.

insert a paper clip into the receiver port to cleanse cerumen buildup.

d.

make sure the pressure equalization channel is clear.

ANS: D

The pressure equalization channel is a tiny hole through the entire length of the ear mold; it should be clear for the entire length. Before removing the hearing aid, turn the volume off to prevent feedback (whistling) during removal. Hold the hearing aid over a towel, and wipe the exterior with tissue to remove the cerumen. This prevents breakage if dropped. The receiver port is easily damaged. Never insert anything into the receiver port.

DIF: Cognitive Level: Application REF: Text reference: p. 468

OBJ: Correctly remove, clean, and reinsert a hearing aid. TOP: Cleaning the Hearing Aid

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

16. When instructing a patient on correct technique for inserting a hearing aid into the ear, the nurse will include which of the following instructions?

a.

Pull the outer ear up and out.

b.

Hold the aid with the long portion upright.

c.

Fit the aid snugly in the midline of the canal.

d.

Turn the aid to the desired sound level before insertion.

ANS: C

Hold the hearing aid in the dominant hand and insert the pointed end of the ear mold into the ear canal while following the natural contours of the canal. Pulling up and out on the outer ear has little effect on hearing aid insertion. Instead, hold the hearing aid in the dominant hand and insert the pointed end of the ear mold into the ear canal while following the natural contours of the canal. Turn the volume slowly to high to prevent damage to the hearing aid.

DIF: Cognitive Level: Application REF: Text reference: p. 469

OBJ: Correctly remove, clean, and reinsert a hearing aid. TOP: Inserting the Hearing Aid

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

17. The elderly patient is instructed to store his hearing aid in a(n):

a.

cold place.

b.

container that keeps out moisture.

c.

easy to reach place.

d.

a cup of water.

ANS: B

Hearing aids and batteries should be stored in a dry container with desiccant or in an electronic dryer to prolong life, minimize repairs, and preserve batteries. Advise the patient to avoid exposing the hearing aid to extremes of temperature. Batteries are toxic if swallowed; keep them away from pets and children. Advise the patient to protect the hearing aid from water, alcohol, hair spray or cologne, perspiration, rain, and snow.

DIF: Cognitive Level: Application REF: Text reference: p. 470

OBJ: Correctly remove, clean, and reinsert a hearing aid. TOP: Storage of Hearing Aid

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

MULTIPLE RESPONSE

1. The nurse is preparing to provide eye care for a comatose patient. The nurse realizes that comatose patients do not have natural protective mechanisms to protect the cornea. These protective mechanisms include: (Select all that apply.)

a.

blinking.

b.

squinting.

c.

lubrication.

d.

dilation.

ANS: A, C

Comatose patients do not have the natural protective mechanisms to protect the cornea. These protective mechanisms include blinking and lubrication of the eye. When patients are in a coma, the nurse is responsible for providing this care.

DIF: Cognitive Level: Comprehension REF: Text reference: p. 455

OBJ: Identify guidelines used in caring for eye and ear prostheses.

TOP: Protective Mechanisms KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

2. In teaching a patient with a new eye prosthesis on how to care for his eye, the nurse informs the patient that: (Select all that apply.)

a.

the artificial eye should be checked at least twice a year.

b.

the artificial eye should be cleansed daily using an alcohol product.

c.

an artificial eye usually is replaced every 5 years.

d.

if the prosthesis is not to be reinserted, it should be wrapped in a dry sterile towel.

ANS: A, C

Patients are instructed to have the artificial eye checked and polished at least twice a year to avoid unnecessary discomfort to the patient as a result of protein deposits or scratches on the surface of the artificial eye. An artificial eye usually is replaced every 5 years.

DIF: Cognitive Level: Application REF: Text reference: p. 458

OBJ: Explain proper care of eye and ear prostheses. TOP: Removing Eye Prosthesis

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

COMPLETION

1. The patient is brought into the emergency department after a motor vehicle accident. The patient is unresponsive. The nurse is concerned about whether or not the patient wears contact lenses because contact lenses that are not removed can cause _______________.

ANS:

corneal injury

It is extremely important to determine whether patients wear contact lenses, particularly when patients are admitted to hospitals or agencies in an unresponsive or confused state. If a seriously ill patient is wearing contact lenses, and this fact goes undetected, severe corneal injury can result.

DIF: Cognitive Level: Application REF: Text reference: p. 456

OBJ: Identify guidelines used in caring for eye and ear prostheses.

TOP: Contact Lenses KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

2. ____________ is the complete surgical removal of the eyeball.

ANS:

Enucleation

As a result of tumor, infection, congenital blindness, or severe trauma to the eye, patients may undergo enucleation, the complete surgical removal of the eyeball.

DIF: Cognitive Level: Knowledge REF: Text reference: p. 458

OBJ: Explain the rationale for maintaining aseptic technique during care of an artificial eye.

TOP: Enucleation KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity

3. The substance found in the ear canal that has an antibacterial effect and maintains an acid pH is called ______________.

ANS:

cerumen

Cerumen has an antibacterial effect and maintains an acid pH in the auditory canal.

DIF: Cognitive Level: Comprehension REF: Text reference: p. 465

OBJ: Correctly perform eye and ear irrigations. TOP: Ear Irrigation

KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

4. A _____________ is a small, battery-powered, electronic device that amplifies sound.

ANS:

hearing aid

A hearing aid is a small, battery-powered, electronic device that amplifies sound.

DIF: Cognitive Level: Comprehension REF: Text reference: p. 466

OBJ: Describe techniques that determine whether a hearing aid functions properly.

TOP: Hearing Aid KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity

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