Chapter 22: Nursing Management: Visual and Auditory Problems Nursing School Test Banks

Chapter 22: Nursing Management: Visual and Auditory Problems

Test Bank

MULTIPLE CHOICE

1. The nurse evaluates that wearing bifocals improved the patients myopia and presbyopia by assessing for

a.

strength of the eye muscles.

b.

both near and distant vision.

c.

cloudiness in the eye lenses.

d.

intraocular pressure changes.

ANS: B

The lenses are prescribed to correct the patients near and distant vision. The nurse may also assess for cloudiness of the lenses, increased intraocular pressure, and eye movement, but these data do not evaluate whether the patients bifocals are effective.

DIF: Cognitive Level: Understand (comprehension) REF: 387

TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity

2. A nurse should instruct a patient with recurrent staphylococcal and seborrheic blepharitis to

a.

irrigate the eyes with saline solution.

b.

apply cool compresses to the eyes three times daily.

c.

use a gentle baby shampoo to clean the lids as needed.

d.

schedule an appointment for surgical removal of the lesion.

ANS: C

Baby shampoo is used to soften and remove crusts associated with blepharitis. The other interventions are not used in treating this disorder.

DIF: Cognitive Level: Apply (application) REF: 390

TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

3. When assisting a blind patient in ambulating to the bathroom, the nurse should

a.

take the patient by the arm and lead the patient slowly to the bathroom.

b.

have the patient place a hand on the nurses shoulder and guide the patient.

c.

stay beside the patient and describe any obstacles on the path to the bathroom.

d.

walk slightly ahead of the patient and allow the patient to hold the nurses elbow.

ANS: D

When using the sighted-guide technique, the nurse walks slightly in front and to the side of the patient and has the patient hold the nurses elbow. The other techniques are not as safe in assisting a blind patient.

DIF: Cognitive Level: Apply (application) REF: 388

TOP: Nursing Process: Implementation MSC: NCLEX: Safe and Effective Care Environment

4. A nurse should include which instructions when teaching a patient with repeated hordeolum how to prevent further infection?

a.

Apply cold compresses at the first sign of recurrence.

b.

Discard all open or used cosmetics applied near the eyes.

c.

Wash the scalp and eyebrows with an antiseborrheic shampoo.

d.

Be examined for recurrent sexually transmitted infections (STIs).

ANS: B

Hordeolum (styes) are commonly caused by Staphylococcus aureus, which may be present in cosmetics that the patient is using. Warm compresses are recommended to treat hordeolum. Antiseborrheic shampoos are recommended for seborrheic blepharitis. Patients with adult inclusion conjunctivitis, which is caused by Chlamydia trachomatis, should be referred for sexually transmitted infection (STI) testing.

DIF: Cognitive Level: Apply (application) REF: 389 | 391

TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

5. The nurse developing a teaching plan for a patient with herpes simplex keratitis should include which instruction?

a.

Apply antibiotic drops to the eye several times daily.

b.

Wash hands frequently and avoid touching the eyes.

c.

Apply a new occlusive dressing to the affected eye at bedtime.

d.

Use corticosteroid ophthalmic ointment to decrease inflammation.

ANS: B

The best way to avoid the spread of infection from one eye to another is to avoid rubbing or touching the eyes and to use careful hand washing when touching the eyes is unavoidable. Occlusive dressings are not used for herpes keratitis. Herpes simplex is a virus and antibiotic drops will not be prescribed. Topical corticosteroids are immunosuppressive and typically are not ordered because they can contribute to a longer course of infection and more complications.

DIF: Cognitive Level: Apply (application) REF: 391

TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

6. Which teaching point should the nurse plan to include when caring for a patient whose vision is corrected to 20/200?

a.

How to access audio books

b.

How to use a white cane safely

c.

Where Braille instruction is available

d.

Where to obtain specialized magnifiers

ANS: D

Various types of magnifiers can enhance the remaining vision enough to allow the performance of many tasks and activities of daily living (ADLs). Audio books, Braille instruction, and canes usually are reserved for patients with no functional vision.

DIF: Cognitive Level: Apply (application) REF: 389

TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

7. The nurse is developing a plan of care for an adult patient diagnosed with adult inclusion conjunctivitis (AIC) caused by Chlamydia trachomatis. Which action should be included in the plan of care?

a.

Discussing the need for sexually transmitted infection testing

b.

Applying topical corticosteroids to prevent further inflammation

c.

Assisting with applying for community visual rehabilitation services

d.

Educating about the use of antiviral eyedrops to treat the infection

ANS: A

Patients with AIC have a high risk for concurrent genital Chlamydia infection and should be referred for sexually transmitted infection (STI) testing. AIC is treated with antibiotics. Antiviral and corticosteroid medications are not appropriate therapies. Although some types of Chlamydia infection do cause blindness, AIC does not lead to blindness, so referral for visual rehabilitation is not appropriate.

DIF: Cognitive Level: Apply (application) REF: 390-391

TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

8. Which topic will the nurse teach after a patient has had outpatient cataract surgery and lens implantation?

a.

Use of oral opioids for pain control

b.

Administration of corticosteroid eye drops

c.

Importance of coughing and deep breathing exercises

d.

Need for bed rest for the first 1 to 2 days after the surgery

ANS: B

Antibiotic and corticosteroid eye drops are commonly prescribed after cataract surgery. The patient should be able to administer them using safe technique. Pain is not expected after cataract surgery and opioids will not be needed. Coughing and deep breathing exercises are not needed because a general anesthetic agent is not used. There is no bed rest restriction after cataract surgery.

DIF: Cognitive Level: Apply (application) REF: 395

TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

9. In reviewing a 55-year-old patients medical record, the nurse notes that the last eye examination revealed an intraocular pressure of 28 mm Hg. The nurse will plan to assess

a.

visual acuity.

b.

pupil reaction.

c.

color perception.

d.

peripheral vision.

ANS: D

The patients increased intraocular pressure indicates glaucoma, which decreases peripheral vision. Because central visual acuity is unchanged by glaucoma, assessment of visual acuity could be normal even if the patient has worsening glaucoma. Color perception and pupil reaction to light are not affected by glaucoma.

DIF: Cognitive Level: Apply (application) REF: 398-399

TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

10. A patient with a right retinal detachment had a pneumatic retinopexy procedure. Which information will be included in the discharge teaching plan?

a.

The purpose of maintaining the head in a prescribed position

b.

The use of eye patches to reduce movement of the operative eye

c.

The need to wear dark glasses to protect the eyes from bright light

d.

The procedure for dressing changes when the eye dressing is saturated

ANS: A

Following pneumatic retinopexy, the patient will need to position the head so the air bubble remains in contact with the retinal tear. The dark lenses and bilateral eye patches are not required after this procedure. Saturation of any eye dressings would not be expected following this procedure.

DIF: Cognitive Level: Apply (application) REF: 397

TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

11. A 72-year-old patient with age-related macular degeneration (AMD) has just had photodynamic therapy. Which statement by the patient indicates that the discharge teaching has been effective?

a.

I will need to use bright lights to read for at least the next week.

b.

I will use drops to keep my pupils dilated until my appointment.

c.

I will not use facial lotions near my eyes during the recovery period.

d.

I will cover up with long-sleeved shirts and pants for the next 5 days.

ANS: D

The photosensitizing drug used for photodynamic therapy is activated by exposure to bright light and can cause burns in areas exposed to light for 5 days after the treatment. There are no restrictions on the use of facial lotions, medications to keep the pupils dilated would not be appropriate, and bright lights would increase the risk for damage caused by the treatment.

DIF: Cognitive Level: Apply (application) REF: 398

TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity

12. To determine whether treatment is effective for a patient with primary open-angle glaucoma (POAG), the nurse can evaluate the patient for improvement by

a.

questioning the patient about blurred vision.

b.

noting any changes in the patients visual field.

c.

asking the patient to rate the pain using a 0 to 10 scale.

d.

assessing the patients depth perception when climbing stairs.

ANS: B

POAG develops slowly and without symptoms except for a gradual loss of visual fields. Acute closed-angle glaucoma may present with excruciating pain, colored halos, and blurred vision. Problems with depth perception are not associated with POAG.

DIF: Cognitive Level: Apply (application) REF: 398-399 | 401

TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity

13. A patient with glaucoma who has been using timolol (Timoptic) drops for several days tells the nurse that the eye drops cause eye burning and visual blurriness for a short time after administration. The best response to the patients statement is

a.

Those symptoms may indicate a need for an increased dosage of the eye drops.

b.

The drops are uncomfortable, but it is important to use them to retain your vision.

c.

These are normal side effects of the drug, which should be less noticeable with time.

d.

Notify your health care provider so that different eye drops can be prescribed for you.

ANS: B

Patients should be instructed that eye discomfort and visual blurring are expected side effects of the ophthalmic drops but that the drops must be used to prevent further visual-field loss. The temporary burning and visual blurriness might not lessen with ongoing use, are not relieved by avoiding systemic absorption, and are not symptoms of glaucoma.

DIF: Cognitive Level: Apply (application) REF: 400

TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

14. The nurse is completing the admission database for a patient admitted with abdominal pain and notes a history of hypertension and glaucoma. Which prescribed medications should the nurse question?

a.

Morphine sulfate 4 mg IV

b.

Diazepam (Valium) 5 mg IV

c.

Betaxolol (Betoptic) 0.25% eyedrops

d.

Scopolamine patch (Transderm Scop) 1.5 mg

ANS: D

Scopolamine is a parasympathetic blocker and will relax the iris, causing blockage of aqueous humor outflow and an increase in intraocular pressure. The other medications are appropriate for this patient.

DIF: Cognitive Level: Apply (application) REF: 399

TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

15. A patient who has bacterial endophthalmitis in the left eye is restless, frequently asking whether the eye is healing, and whether removal of the eye will be necessary. Based on the assessment data, which nursing diagnosis ismost appropriate at this time?

a.

Grieving related to current loss of functional vision

b.

Anxiety related to the possibility of permanent vision loss

c.

Situational low self-esteem related to loss of visual function

d.

Risk for falls related to inability to see environmental hazards

ANS: B

The patients restlessness and questioning of the nurse indicate anxiety about the future possible loss of vision. Because the patient can see with the right eye, functional vision is relatively intact. There is no indication of impaired self-esteem at this time.

DIF: Cognitive Level: Apply (application) REF: 402

TOP: Nursing Process: Diagnosis MSC: NCLEX: Physiological Integrity

16. To decrease the risk for future hearing loss, which action should the nurse who is working with college students at the on-campus health clinic implement?

a.

Arrange to include otoscopic examinations for all patients.

b.

Administer influenza immunizations to all students at the clinic.

c.

Discuss the importance of limiting exposure to amplified music.

d.

Perform tympanometry on all patients between the ages of 18 to 24.

ANS: C

The nurse should discuss the impact of amplified music on hearing with young adults and discourage listening to very amplified music, especially for prolonged periods. Tympanometry measures the ability of the eardrum to vibrate and would not help prevent future hearing loss. Although students are at risk for the influenza virus, being vaccinated does not help prevent future hearing loss. Otoscopic examinations are not necessary for all patients.

DIF: Cognitive Level: Apply (application) REF: 408

TOP: Nursing Process: Implementation MSC: NCLEX: Health Promotion and Maintenance

17. A patient diagnosed with external otitis is being discharged from the emergency department with an ear wick in place. Which statement by the patient indicates a need for further teaching?

a.

I will apply the eardrops to the cotton wick in the ear canal.

b.

I can use aspirin or acetaminophen (Tylenol) for pain relief.

c.

I will clean the ear canal daily with a cotton-tipped applicator.

d.

I can use warm compresses to the outside of the ear for comfort.

ANS: C

Insertion of instruments such as cotton-tipped applicators into the ear should be avoided. The other patient statements indicate that the teaching has been successful.

DIF: Cognitive Level: Apply (application) REF: 403

TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity

18. A patient who has undergone a left tympanoplasty should be instructed to

a.

remain on bed rest.

b.

keep the head elevated.

c.

avoid blowing the nose.

d.

irrigate the left ear canal.

ANS: C

Coughing or blowing the nose increases pressure in the eustachian tube and middle ear cavity and disrupts postoperative healing. There is no postoperative need for prolonged bed rest, elevation of the head, or continuous antibiotic irrigation.

DIF: Cognitive Level: Apply (application) REF: 405

TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

19. The nurse is assessing a patient who has recently been treated with amoxicillin for acute otitis media of the right ear. Which finding is a priority to report to the health care provider?

a.

The patient has a temperature of 100.6 F.

b.

The patient complains of popping in the ear.

c.

The patient frequently asks the nurse to repeat information.

d.

The patient states that the right ear has a feeling of fullness.

ANS: A

The fever indicates that the infection may not be resolved and the patient might need further antibiotic therapy. A feeling of fullness, popping of the ear, and decreased hearing are symptoms of otitis media with effusion. These symptoms are normal for weeks to months after an episode of acute otitis media and usually resolve without treatment.

DIF: Cognitive Level: Apply (application) REF: 403

OBJ: Special Questions: Prioritization TOP: Nursing Process: Evaluation

MSC: NCLEX: Physiological Integrity

20. A 42-year-old woman with Mnires disease is admitted with vertigo, nausea, and vomiting. Which nursing intervention will be included in the care plan?

a.

Dim the lights in the patients room.

b.

Encourage increased oral fluid intake.

c.

Change the patients position every 2 hours.

d.

Keep the head of the bed elevated 30 degrees.

ANS: A

A darkened, quiet room will decrease the symptoms of the acute attack of Mnires disease. Because the patient will be nauseated during an acute attack, fluids are administered IV. Position changes will cause vertigo and nausea. The head of the bed can be positioned for patient comfort.

DIF: Cognitive Level: Apply (application) REF: 406

TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

21. Which statement by the patient to the home health nurse indicates a need for more teaching about self-administering eardrops?

a.

I will leave the ear wick in place while administering the drops.

b.

I should lie down before and for 5 minutes after administering the drops.

c.

I will hold the tip of the dropper above the ear while administering the drops.

d.

I should keep the medication refrigerated until I am ready to administer the drops.

ANS: D

Administration of cold eardrops can cause dizziness because of stimulation of the semicircular canals. The other patient actions are appropriate.

DIF: Cognitive Level: Apply (application) REF: 403

TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity

22. An 82-year-old patient who is being admitted to the hospital repeatedly asks the nurse to speak up so that I can hear you. Which action should the nurse take?

a.

Overenunciate while speaking.

b.

Speak normally but more slowly.

c.

Increase the volume when speaking.

d.

Use more facial expressions when talking.

ANS: B

Patient understanding of the nurses speech will be enhanced by speaking at a normal tone, but more slowly. Increasing the volume, overenunciating, and exaggerating facial expressions will not improve the patients ability to comprehend the nurse.

DIF: Cognitive Level: Apply (application) REF: 410

TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

23. A 75-year-old patient with presbycusis is fitted with binaural hearing aids. Which information will the nurse include when teaching the patient how to use the hearing aids?

a.

Experiment with volume and hearing ability in a quiet environment initially.

b.

Keep the volume low on the hearing aids for the first week while adjusting to them.

c.

Add a second hearing aid after making the initial adjustment to the first hearing aid.

d.

Wear the hearing aids for about an hour a day at first, gradually increasing the time of use.

ANS: A

Initially the patient should use the hearing aids in a quiet environment like the home, experimenting with increasing and decreasing the volume as needed. There is no need to gradually increase the time of wear. The patient should experiment with the level of volume to find what works well in various situations. Both hearing aids should be used.

DIF: Cognitive Level: Apply (application) REF: 409

TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

24. Which information will the nurse include for a patient contemplating a cochlear implant?

a.

Cochlear implants require training in order to receive the full benefit.

b.

Cochlear implants are not useful for patients with congenital deafness.

c.

Cochlear implants are most helpful as an early intervention for presbycusis.

d.

Cochlear implants improve hearing in patients with conductive hearing loss.

ANS: A

Extensive rehabilitation is required after cochlear implants in order for patients to receive the maximum benefit. Hearing aids, rather than cochlear implants, are used initially for presbycusis. Cochlear implants are used for sensorineural hearing loss and would not be helpful for conductive loss. They are appropriate for some patients with congenital deafness.

DIF: Cognitive Level: Understand (comprehension) REF: 410

TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

25. Which statement by a patient with bacterial conjunctivitis indicates a need for further teaching?

a.

I will wash my hands often during the day.

b.

I will remove my contact lenses at bedtime.

c.

I will not share towels with my friends or family.

d.

I will monitor my family for eye redness or drainage.

ANS: B

Contact lenses should not be used when patients have conjunctivitis because they can further irritate the conjunctiva. Hand washing is the major means to prevent the spread of conjunctivitis. Infection may be spread by sharing towels or other contact. It is common for bacterial conjunctivitis to spread through a family or other group in close contact.

DIF: Cognitive Level: Apply (application) REF: 390

TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

26. Which information will the nurse include when teaching a patient with keratitis caused by herpes simplex type 1?

a.

Correct use of the antifungal eyedrops natamycin (Natacyn)

b.

How to apply corticosteroid ophthalmic ointment to the eyes

c.

Avoidance of nonsteroidal antiinflammatory drugs (NSAIDs)

d.

Importance of taking all of the ordered oral acyclovir (Zovirax)

ANS: D

Oral acyclovir may be ordered for herpes simplex infections. Corticosteroid ointments are usually contraindicated because they prolong the course of the infection. Herpes simplex I is viral, not parasitic, or fungal. Natamycin may be used for Acanthamoeba keratitis caused by a parasite. NSAIDs can be used to treat the pain associated with keratitis.

DIF: Cognitive Level: Apply (application) REF: 391

TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

27. The nurse at the outpatient surgery unit obtains the following information about a patient who is scheduled for cataract extraction and implantation of an intraocular lens. Which information is most important to report to the health care provider at this time?

a.

The patient has had blurred vision for 3 years.

b.

The patient has not eaten anything for 8 hours.

c.

The patient takes 2 antihypertensive medications.

d.

The patient gets nauseated with general anesthesia.

ANS: C

Mydriatic medications used for pupil dilation are sympathetic nervous system stimulants and may increase heart rate and blood pressure. Using punctal occlusion when administering the mydriatic and monitoring of blood pressure are indicated for this patient. Blurred vision is an expected finding with cataracts. Patients are expected to be NPO for 6 to 8 hours before the surgical procedure. Cataract extraction and intraocular lens implantation are done using local anesthesia.

DIF: Cognitive Level: Apply (application) REF: 387-389

OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment

MSC: NCLEX: Physiological Integrity

28. During the preoperative assessment of the patient scheduled for a right cataract extraction and intraocular lens implantation, it is most important for the nurse to assess

a.

the visual acuity of the patients left eye.

b.

how long the patient has had the cataract.

c.

for a white pupil in the patients right eye.

d.

for a history of reactions to general anesthetics.

ANS: A

Because it can take several weeks before the maximum improvement in vision occurs in the right eye, patient safety and independence are determined by the vision in the left eye. A white pupil in the operative eye would not be unusual for a patient scheduled for cataract removal and lens implantation. The length of time that the patient has had the cataract will not affect the perioperative care. Cataract surgery is done using local anesthetics rather than general anesthetics.

DIF: Cognitive Level: Apply (application) REF: 394

OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment

MSC: NCLEX: Safe and Effective Care Environment

29. The nurse learns that a newly admitted patient has functional blindness and that the spouse has cared for the patient for many years. During the initial assessment of the patient, it is most important for the nurse to

a.

obtain more information about the cause of the patients vision loss.

b.

obtain information from the spouse about the patients special needs.

c.

make eye contact with the patient and ask about any need for assistance.

d.

perform an evaluation of the patients visual acuity using a Snellen chart.

ANS: C

Making eye contact with a partially sighted patient allows the patient to hear the nurse more easily and allows the nurse to assess the patients facial expressions. The patient (rather than the spouse) should be asked about any need for assistance. The information about the cause of the vision loss and assessment of the patients visual acuity are not priorities during the initial assessment.

DIF: Cognitive Level: Apply (application) REF: 388

OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment

MSC: NCLEX: Physiological Integrity

30. Which action could the registered nurse (RN) who is working in the eye and ear clinic delegate to a licensed practical/vocational nurse (LPN/LVN)?

a.

Evaluate a patients ability to administer eye drops.

b.

Use a Snellen chart to check a patients visual acuity.

c.

Teach a patient with otosclerosis about use of sodium fluoride and vitamin D.

d.

Check the patients external ear for signs of irritation caused by a hearing aid.

ANS: B

Using standardized screening tests such as a Snellen chart to test visual acuity is included in LPN education and scope of practice. Evaluation, assessment, and patient teaching are higher level skills that require RN education and scope of practice.

DIF: Cognitive Level: Apply (application) REF: 411

OBJ: Special Questions: Delegation TOP: Nursing Process: Planning

MSC: NCLEX: Safe and Effective Care Environment

31. The occupational health nurse is caring for an employee who is complaining of bilateral eye pain after a cleaning solution splashed into the employees eyes. Which action will the nurse take first?

a.

Apply ice packs to both eyes.

b.

Flush the eyes with sterile saline.

c.

Apply antiseptic ophthalmic ointment to the eyes.

d.

Cover the eyes with dry sterile patches and shields.

ANS: B

Flushing of the eyes immediately is indicated for chemical exposure. Emergency treatment of a burn or foreign-body injury to the eyes includes protecting the eyes from further injury by covering them with dry sterile dressings and protective shields. Flushing of the eyes immediately is indicated only for chemical exposure. In the case of chemical exposure, the nurse should begin treatment by flushing the eyes until the patient has been assessed by a health care provider and orders are available.

DIF: Cognitive Level: Apply (application) REF: 390

OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation

MSC: NCLEX: Physiological Integrity

32. Unlicensed assistive personnel (UAP) perform all the following actions when caring for a patient with Mnires disease who is experiencing an acute attack. Which action by UAP indicates that the nurse should interveneimmediately?

a.

UAP raise the side rails on the bed.

b.

UAP turn on the patients television.

c.

UAP turn the patient to the right side.

d.

UAP place an emesis basin at the bedside.

ANS: B

Watching television may exacerbate the symptoms of an acute attack of Mnires disease. The other actions are appropriate because the patient will be at high fall risk and may suffer from nausea during the acute attack.

DIF: Cognitive Level: Apply (application) REF: 406

OBJ: Special Questions: Delegation TOP: Nursing Process: Implementation

MSC: NCLEX: Safe and Effective Care Environment

33. The nurse at the eye clinic made a follow-up telephone call to a patient who underwent cataract extraction and intraocular lens implantation the previous day. Which information is the priority to communicate to the health care provider?

a.

The patient has questions about the ordered eye drops.

b.

The patient has eye pain rated at a 5 (on a 0 to 10 scale).

c.

The patient has poor depth perception when wearing an eye patch.

d.

The patient complains that the vision has not improved very much.

ANS: B

Postoperative cataract surgery patients usually experience little or no pain, so pain at a level 5 on a 10-point pain scale may indicate complications such as hemorrhage, infection, or increased intraocular pressure. The other information given by the patient indicates a need for patient teaching but does not indicate that complications of the surgery may be occurring.

DIF: Cognitive Level: Apply (application) REF: 395

OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation

MSC: NCLEX: Physiological Integrity

34. Which finding in an emergency department patient who reports being struck in the right eye with a fist is a priority for the nurse to communicate to the health care provider?

a.

The patient complains of a right-sided headache.

b.

The sclera on the right eye has broken blood vessels.

c.

The area around the right eye is bruised and tender to the touch.

d.

The patient complains of a curtain over part of the visual field.

ANS: D

The patients sensation that a curtain is coming across the field of vision suggests retinal detachment and the need for rapid action to prevent blindness. The other findings would be expected with the patients history of being hit in the eye.

DIF: Cognitive Level: Apply (application) REF: 396

OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment

MSC: NCLEX: Physiological Integrity

35. The charge nurse observes a newly hired nurse performing all the following interventions for a patient who has just undergone right cataract removal and an intraocular lens implant. Which one requires that the charge nurse intervene?

a.

The nurse leaves the eye shield in place.

b.

The nurse encourages the patient to cough.

c.

The nurse elevates the patients head to 45 degrees.

d.

The nurse applies corticosteroid drops to the right eye.

ANS: B

Because coughing will increase intraocular pressure, patients are generally taught to avoid coughing during the acute postoperative time. The other actions are appropriate for a patient after having this surgery.

DIF: Cognitive Level: Apply (application) REF: 394

OBJ: Special Questions: Delegation TOP: Nursing Process: Implementation

MSC: NCLEX: Physiological Integrity

36. Which nursing activity is appropriate for the registered nurse (RN) working in the eye clinic to delegate to experienced unlicensed assistive personnel (UAP)?

a.

Instilling antiviral drops for a patient with a corneal ulcer

b.

Application of a warm compress to a patients hordeolum

c.

Instruction about hand washing for a patient with herpes keratitis

d.

Looking for eye irritation in a patient with possible conjunctivitis

ANS: B

Application of cold and warm packs is included in UAP education and the ability to accomplish this safely would be expected for UAP working in an eye clinic. Medication administration, patient teaching, and assessment are high-level skills appropriate for the education and legal practice level of the RN.

DIF: Cognitive Level: Apply (application) REF: 411

OBJ: Special Questions: Delegation TOP: Nursing Process: Implementation

MSC: NCLEX: Safe and Effective Care Environment

37. A patient with a head injury after a motorcycle crash arrives in the emergency department (ED) complaining of shortness of breath and severe eye pain. Which action will the nurse take first?

a.

Administer the ordered analgesic.

b.

Check the patients oxygen saturation.

c.

Examine the eye for evidence of trauma.

d.

Assess each of the cranial nerve functions.

ANS: B

The priority action for a patient after a head injury is to assess and maintain airway and breathing. Because the patient is complaining of shortness of breath, it is essential that the nurse assess the oxygen saturation. The other actions are also appropriate but are not the first action the nurse will take.

DIF: Cognitive Level: Apply (application) REF: 390

OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation

MSC: NCLEX: Physiological Integrity

38. Which prescribed medication should the nurse give first to a patient who has just been admitted to a hospital with acute angle-closure glaucoma?

a.

Morphine sulfate 4 mg IV

b.

Mannitol (Osmitrol) 100 mg IV

c.

Betaxolol (Betoptic) 1 drop in each eye

d.

Acetazolamide (Diamox) 250 mg orally

ANS: B

The most immediate concern for the patient is to lower intraocular pressure, which will occur most rapidly with IV administration of a hyperosmolar diuretic such as mannitol. The other medications are also appropriate for a patient with glaucoma but would not be the first medication administered.

DIF: Cognitive Level: Apply (application) REF: 399

OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation

MSC: NCLEX: Physiological Integrity

39. The priority nursing diagnosis for a patient experiencing an acute attack with Menieres disease is

a.

risk for falls related to dizziness.

b.

impaired verbal communication related to tinnitus.

c.

self-care deficit (bathing and dressing) related to vertigo.

d.

imbalanced nutrition: less than body requirements related to nausea.

ANS: A

All the nursing diagnoses are appropriate, but because sudden attacks of vertigo can lead to drop attacks, the major focus of nursing care is to prevent injuries associated with dizziness.

DIF: Cognitive Level: Apply (application) REF: 405

OBJ: Special Questions: Prioritization TOP: Nursing Process: Diagnosis

MSC: NCLEX: Physiological Integrity

40. Which information about a patient who had a stapedotomy yesterday is most important for the nurse to communicate to the health care provider?

a.

The patient complains of fullness in the ear.

b.

The patients oral temperature is 100.8 F (38.1 C).

c.

The patient says My hearing is worse now than it was right after surgery.

d.

There is a small amount of dried bloody drainage on the patients dressing.

ANS: B

An elevated temperature may indicate a postoperative infection. Although the nurse would report all the data, a temporary decrease in hearing, bloody drainage on the dressing, and a feeling of congestion (because of the accumulation of blood and drainage in the ear) are common after this surgery.

DIF: Cognitive Level: Apply (application) REF: 405

OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment

MSC: NCLEX: Physiological Integrity

41. A 75-year-old patient who lives alone at home tells the nurse, I am afraid of losing my independence because my eyes dont work as well they used to. Which action should the nurse take first?

a.

Discuss the increased risk for falls that is associated with impaired vision.

b.

Explain that there are many ways to compensate for decreases in visual acuity.

c.

Suggest ways of improving the patients safety, such as using brighter lighting.

d.

Ask the patient more about what type of vision problems are being experienced.

ANS: D

The nurses initial action should be further assessment of the patients concerns and visual problems. The other actions may be appropriate, depending on what the nurse finds with further assessment.

DIF: Cognitive Level: Apply (application) REF: 388

OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment

MSC: NCLEX: Safe and Effective Care Environment

42. A patient who received a corneal transplant 2 weeks ago calls the ophthalmology clinic to report that his vision has not improved with the transplant. Which action should the nurse take?

a.

Suggest the patient arrange a ride to the clinic immediately.

b.

Ask about the presence of floaters in the patients visual field.

c.

Remind the patient it may take months to restore vision after transplant.

d.

Teach the patient to continue using prescribed pupil-dilating medications.

ANS: C

Vision may not be restored for up to a year after corneal transplant. Because the patient is not experiencing complications of the surgery, an emergency clinic visit is not needed. Because floaters are not associated with complications of corneal transplant, the nurse will not need to ask the patient about their presence. Corticosteroid drops, not mydriatic drops, are used after corneal transplant surgery.

DIF: Cognitive Level: Apply (application) REF: 392

TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

43. Which action will the nurse take when performing ear irrigation for a patient with cerumen impaction?

a.

Assist the patient to a supine position for the irrigation.

b.

Fill the irrigation syringe with body-temperature solution.

c.

Use a sterile applicator to clean the ear canal before irrigating.

d.

Occlude the ear canal completely with the syringe while irrigating.

ANS: B

Solution at body temperature is used for ear irrigation. The patient should be sitting for the procedure. Use of cotton-tipped applicators to clear the ear may result in forcing the cerumen deeper into the ear canal. The ear should not be completely occluded with the syringe.

DIF: Cognitive Level: Understand (comprehension) REF: 403

TOP: Nursing Process: Implementation MSC: NCLEX: Safe and Effective Care Environment

44. Which action will the nurse include in the plan of care for a patient with benign paroxysmal positional vertigo (BPPV)?

a.

Teach the patient about use of medications to reduce symptoms.

b.

Place the patient in a dark, quiet room to avoid stimulating BPPV attacks.

c.

Teach the patient that canalith repositioning may be used to reduce dizziness.

d.

Speak slowly and in a low-pitch to ensure that the patient is able to hear instructions.

ANS: C

The Epley maneuver is used to reposition ear rocks in BPPV. Medications and placement in a dark room may be used to treat Mnires disease, but are not necessary for BPPV. There is no hearing loss with BPPV.

DIF: Cognitive Level: Apply (application) REF: 406

TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

45. When teaching a patient about the treatment of acoustic neuroma, the nurse will include information about

a.

a low sodium diet.

b.

ways to avoid falls.

c.

how to apply sunscreen.

d.

the chemotherapy side effects.

ANS: B

Intermittent vertigo occurs with acoustic neuroma, so the nurse should include information about how to prevent falls. Diet is not a risk factor for acoustic neuroma and no dietary changes are needed. Sunscreen would be used to prevent skin cancers on the external ear. Acoustic neuromas are benign and do not require chemotherapy.

DIF: Cognitive Level: Apply (application) REF: 406

TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

46. Which patient arriving at the urgent care center will the nurse assess first?

a.

Patient with acute right eye pain that occurred while using home power tools

b.

Patient with purulent left eye discharge, pruritus, and conjunctival inflammation

c.

Patient who is complaining of intense discomfort after an insect crawled into the right ear

d.

Patient who has Mnires disease and is complaining of nausea, vomiting, and dizziness

ANS: A

The history and symptoms suggest eye trauma with a possible penetrating injury. Blindness may occur unless the patient is assessed and treated rapidly. The other patients should be treated as soon as possible, but do not have clinical manifestations that indicate any acute risk for vision or hearing loss.

DIF: Cognitive Level: Analyze (analysis) REF: 389-390

OBJ: Special Questions: Prioritization; Multiple Patients TOP: Nursing Process: Planning

MSC: NCLEX: Safe and Effective Care Environment

47. The nurse is working in an urgent care clinic that has standardized treatment protocols for implementation by nursing staff. After reviewing the history, physical assessment, and vital signs for a 60-year-old patient as shown in the accompanying figure, which action should the nurse take first?

a.

Check the patients blood glucose level.

b.

Take the blood pressure on the left arm.

c.

Use an irrigating syringe to clean the ear canals.

d.

Report the vision change to the health care provider.

ANS: D

The sudden change in peripheral vision may indicate an acute problem, such as retinal detachment, that should be treated quickly to preserve vision. The other data about the patient are not indicative of any acute problem. The other actions are also appropriate, but the highest priority for this patient is prevention of blindness.

DIF: Cognitive Level: Analyze (analysis) REF: 396

OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation

MSC: NCLEX: Safe and Effective Care Environment

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