Flashcards in AEIII Exam 1 Medsurge Questions Deck (168)
1. The client is diagnosed with glaucoma. Which symptom would the nurse expect the
client to report?
1. Halos around lights.
2. Floating spots in the vision.
3. A yellow haze around everything.
4. A curtain coming across vision.
1. In glaucoma, the client is often unaware that he or she has the disease until the client experiences blurred vision, halos
around lights, difficulty focusing, or loss of peripheral vision. Glaucoma is often called the “silent thief.”
2. Floating spots in the vision is a symptom of retinal detachment.
3. A yellow haze around everything is a complaint
of clients experiencing digoxin toxicity.
4. The complaint of a curtain coming across vision is a symptom of retinal detachment.
2. The client is scheduled for right-eye cataract removal surgery in five (5) days. Which
preoperative instruction should be discussed with the client?
1. Administer dilating drops to both eyes for 72 hours prior to surgery.
2. Prior to surgery do not lift or push any objects heavier than 15 pounds.
3. Make arrangements for being in the hospital for at least three (3) days.
4. Avoid taking any type of medication that causes bleeding, such as aspirin.
1. Dilating drops are administered every ten (10) minutes for four (4) doses one (1) hour prior to surgery, not for three (3) days prior to surgery.
2. Lifting and pushing objects should be avoided after surgery, not prior to surgery.
3. All types of cataract removal surgery are usually done in day surgery.
4. To reduce retrobulbar hemorrhage, any anticoagulation therapy is withheld, including
aspirin, nonsteroidal anti inflammatory drugs (NSAIDs), and warfarin (Coumadin).
4. The 65-year-old client is diagnosed with macular degeneration. Which statement by the nurse indicates the client needs more discharge teaching?
1. “I should use magnification devices as much as possible.”
2. “I will look at my Amsler grid at least twice a week.”
3. “I am going to use low-watt light bulbs in my house.”
4. “I am going to contact a low-vision center to evaluate my home.”
1. Magnifying devices used with activities such as
threading a needle will help the client’s visual
sight; therefore, this statement does not indicate
the client needs more teaching.
2. An Amsler grid is a tool to assess macular degeneration that often provides the earliest sign of a worsening of the condition. If the lines of the grid become distorted or faded, the client should call the ophthalmologist.
3. Macular degeneration is the most common cause of visual loss in people older than age 60 years. Any intervention that can help increase vision should be included in the teaching such as bright lighting, not decreased
4. Low-vision centers will send representatives to the client’s home or work to make recommendations about improving lighting, thereby
improving the client’s vision and safety.
5. The nurse who is at a local park sees a young man on the ground and realizes he has
fallen on a stick and it is lodged in his eye. Which action should the nurse implement at the scene?
1. Carefully remove the stick from the eye.
2. Stabilize the stick as best as possible.
3. Flush the eye with water if available.
4. Place the young man in a high-Fowler’s position.
1. A foreign object should never be removed at the scene of the accident because this may cause
2. The foreign object should be stabilized to prevent further movement that could cause
more damage to the eye.
3. Flushing with water may cause further movement of the foreign object and should be avoided.
4. The person should be kept flat and not in a sitting position that may dislodge or cause movement of the foreign object.
6. The employee health nurse is teaching a class on “Preventing Eye Injury.” Which information
should be discussed in the class?
1. Read instructions thoroughly before using tools and chemicals.
2. Wear some type of glasses when working around flying fragments.
3. Always wear a protective helmet with eye shield around dust particles.
4. Pay close attention to the surroundings so that eye injuries will be prevented.
1. Instructions provide precautions that should be used and steps to take if eye injuries occur secondary to the use of tools or chemicals.
2. The employee must wear safety glasses, not just any type of glasses and especially not regular prescription glasses.
3. A protective helmet is usually used to help pre-vent sports eye injuries, not work-related
4. Eye injuries will not be prevented by paying
close attention to the surroundings. They are
prevented by wearing protective glasses or eye
7. The 65-year-old male client who is complaining of blurred vision reports that he thinks
his glasses need to be cleaned all the time. He denies any type of pain in his eyes. Based on these signs/symptoms, which eye disorder would the nurse suspect the client has?
1. Corneal dystrophy.
3. Diabetic retinopathy.
1. Corneal dystrophy is an inherited eye disorder that occurs at about age 20 years and results in decreased vision and the development of blisters
and is usually associated with primary open-angle glaucoma.
2. Conjunctivitis is an inflammation of the conjunctiva, which results in a scratching or
burning sensation, itching, and photophobia.
3. Diabetic retinopathy results from deterioration of the small blood vessels that nourish the
retina; it leads to blindness.
4. A cataract is a lens opacity or cloudiness, resulting in the signs/symptoms discussed
in the stem.
8. The nurse is administering eye drops to the client. Which guidelines should the nurse
adhere to when instilling the drops into one eye? Select all that apply.
1. Do not touch the tip of the medication container to the eye.
2. Apply gently pressure on the outer canthus of the eye.
3. Apply sterile gloves prior to instilling eye drops.
4. Hold the lower lid down and instill drops into the conjunctiva.
5. Gently pat the skin to absorb excess eye drops that run onto the cheek.
1. Touching the tip of the container to the eye could cause eye injury or an eye infection.
2. Gentle pressure should be applied on the inner canthus near the bridge of the nose for
one (1) or two (2) minutes after instilling eye drops.
3. The nurse should wash hands prior to and after instilling medications; this is not a sterile procedure.
4. Medication should not be placed directly on the eye but in the lower part of the eye.
5. Eye drops are meant to go in the eye, not on the skin, so the nurse should use a clean tissue
to remove excess medication.
10. The client diagnosed with glaucoma is prescribed a miotic cholinergic medication. Which data support that the medication has been effective?
1. No redness or irritation of the eyes.
2. A decrease in intraocular pressure.
3. The pupil reacts briskly to light.
4. The client denies any type of floaters.
1. Steroid medication is administered to decrease inflammation.
2. Both systemic and topical medications are used to decrease the intraocular pressure in the eye, which is what causes glaucoma.
3. Glaucoma does not affect the pupillary reaction.
4. Floaters are a complaint of clients with retinal detachment.
11. The client is scheduled for laser-assisted in situ keratomileusis (LASIK) surgery for
severe myopia. Which discharge teaching should the nurse discuss prior to the client’s discharge from day surgery?
1. Wear bilateral eye patches for three (3) days.
2. Wear corrective lenses until the follow-up visit.
3. Do not read any material for at least one (1) week.
4. Teach the client how to instill corticosteroid ophthalmic drops.
1. The client does not have to wear eye patches after this surgery.
2. The purpose of this surgery is to ensure the client does not have to wear any type of corrective lens.
3. The client can read immediately after this surgery.
4. LASIK surgery is an effective, safe, predictable surgery that is performed in day surgery;
there is minimal postoperative care, which includes instilling topical corticosteroid
12. The client is admitted to the emergency department after splashing chemicals into the
eyes. Which intervention should the nurse implement first?
1. Have the client move the eyes in all directions.
2. Administer a broad-spectrum antibiotic.
3. Irrigate the eyes with normal saline solution.
4. Determine when the client had a tetanus shot.
1. Movement of the eye should be avoided until the client has received general anesthesia;
therefore, this is not the first intervention that should be implemented.
2. Parenteral broad-spectrum antibiotics are initiated but not until the eyes are treated first.
3. Before any further evaluation or treatment, the eyes must be thoroughly flushed with sterile normal saline solution.
4. Tetanus prophylaxis is recommended for fullthickness
13. Which statement by the client would indicate that the client is experiencing some
1. “I clean my ears every day after I take a shower.”
2. “I keep turning up the sound on my television.”
3. “My ears hurt, especially when I yawn.”
4. “I get dizzy when I get up from the chair.”
1. Cleaning the ears daily does not indicate the client has a hearing loss.
2. The need to turn up the volume on the television is an early sign of hearing impairment.
3. Pain in the ears is not a clinical manifestation of hearing loss/impairment.
4. This statement may indicate a balance problem secondary to an ear disorder, but it does not
indicate a hearing loss.
14. Which factors increase the client’s risk of developing hearing loss? Select all that apply.
1. Perforation of the tympanic membrane.
2. Chronic exposure to loud noises.
3. Recurrent ear infections.
4. Use of nephrotoxic medications.
5. Multiple piercings in the auricle.
1, 2, 3
1. The tympanic membrane is the eardrum, and if it is punctured it may lead to hearing loss.
2. Loud persistent noise, such as that from heavy machinery, engines, and artillery, over time has been found to cause noiseinduced hearing loss.
3. Multiple ear infections scar the tympanic membrane, which can lead to hearing loss.
4. Nephrotoxic means harmful to the kidneys; ototoxic would be harmful to the ears.
5. Multiple pierced earrings do not lead to hearing loss. The auricle (skin attached to the head)
is composed mainly of cartilage, except for the fat and subcutaneous tissue in the earlobe.
18. The client reports to the nurse that there is a ringing in the ears. Which documentation
would be most appropriate for the nurse to document in the client’s chart?
1. Complaints of vertigo.
2. Complaints of otorrhea.
3. Complaints of tinnitus.
4. Complaints of presbycusis.
1. Vertigo is an illusion of movement in which the client complains of dizziness.
2. Otorrhea is drainage of the ear.
3. Tinnitus is “ringing of the ears.” It is a subjective perception of sound with internal
4. Presbycusis is progressive hearing loss associated
19. Which statement best describes the scientific rationale for the nurse to hold the
otoscope in the right hand in a pencil-hold position when examining the client’s ear?
1. It is usually the most comfortable position to hold the otoscope.
2. This allows the best visualization of the tympanic membrane.
3. This prevents inserting the otoscope too far into the external ear.
4. It ensures that the nurse will not cause pain when examining the ear.
1. This is not the rationale for holding the otoscope in this manner.
2. Holding the otoscope in this manner does not help visualize the membrane any better than
does holding the otoscope in other ways.
3. Inserting the speculum of the otoscope into the external ear can cause ear trauma if not
4. If the ear is inflamed, it may be impossible to prevent hurting the client on examination.
20. The nurse is preparing to administer otic drops into an adult client’s right ear. Which
action should the nurse implement?
1. Grasp the ear lobe and pull back and out when putting drops in the ear.
2. Insert the eardrops without touching the outside of the ear.
3. Instruct the client to close the mouth and blow prior to instilling drops.
4. Pull the auricle down and back prior to instilling drops.
1. This is not the correct way to administer eardrops.
2. The nurse must straighten the ear canal; therefore the outside of the ear must be moved.
3. This will increase pressure in the ear and should not be done prior to administering
4. This will straighten the ear canal so that the eardrops will enter the ear canal and drain
toward the tympanic membrane (eardrum).
21. Which ototoxic medication should the nurse administer cautiously?
1. An oral calcium-channel blocker.
2. An intravenous aminoglycoside antibiotic.
3. An intravenous glucocorticoid.
4. An oral loop diuretic.
1. Calcium channel blockers are not going to affect the client’s hearing.
2. Aminoglycoside antibiotics are ototoxic. Overdosage of these medications can cause
the client to go deaf, which is why peak and trough serum levels are drawn while the
client is taking a medication of this type. These antibiotics are also very nephrotoxic.
3. Steroids cause many adverse effects, but damage to the ear is not one of them.
4. Administering an intravenous push loop diuretic too fast can cause auditory nerve damage,
but an oral loop diuretic does not.
22. Which teaching instruction should the nurse discuss with students who are on the high
school swim team when discussing how to prevent external otitis?
1. Do not wear tight-fitting swim caps.
2. Avoid using silicone earplugs while swimming.
3. Use a drying agent in the ear after swimming.
4. Insert a bulb syringe into each ear to remove excess water.
1. Tight-fitting swim caps or wet suit hoods should be worn because they prevent water
from entering the ear canal.
2. Silicone earplugs should be worn because they keep water from entering the ear canal without reducing hearing significantly.
3. A 2% acetic acid solution or 2% boric acid in ethyl alcohol is effective in drying the canal and restoring its normal acidic environment.
4. A bulb syringe with a Teflon catheter can be used to remove impacted debris from the ear,
but it is not used to remove excess water.
24. The client is scheduled for ear surgery. Which statement indicates the client needs
more preoperative teaching concerning the surgery?
1. “If I have to sneeze or blow my nose, I will do it with my mouth open.”
2. “I may get dizzy after the surgery, so I must be careful when walking.”
3. “I will probably have some hearing loss after surgery, but hearing will return.”
4. “I can shampoo my hair the day after surgery as long as I am careful.”
1. Leaving the mouth open when coughing or sneezing will minimize the pressure changes in
the middle ear.
2. Surgery on the ear may disrupt the client’s equilibrium, increasing the risk for falling.
3. Hearing loss secondary to postoperative edema is common after surgery, but the hearing will
return after the edema subsides.
4. Shampooing, showering, and immersing the head in water are avoided to prevent contamination of the ear canal; therefore,
this comment indicates the client does not understand the preoperative teaching.
1. Which recommendation should the nurse suggest to an elderly client who lives alone when discussing normal developmental changes of the olfactory organs?
1. Suggest installing multiple smoke alarms in the home.
2. Recommend using a night light in the hallway and bathroom.
3. Discuss keeping a high-humidity atmosphere in the bedroom.
4. Encourage the client to smell food prior to eating it.
1. The decreased sense of smell resulting from atrophy of olfactory organs is a safety
hazard and clients may not be able to smell gas leaks or fire, so the nurse should recommend
a carbon monoxide detector and
a smoke alarm. This safety equipment is critical for the elderly.
2. Night lights do not address the client’s sense of smell.
3. High humidity may help with breathing, but it does not help the sense of smell.
4. The client’s sense of smell is decreased; therefore, smelling food before eating is not an
2. The elderly male client tells the nurse, “My wife says her cooking hasn’t changed, but it is bland and tasteless.” Which response by the nurse would be most appropriate?
1. “Would you like me to talk to your wife about her cooking?”
2. “Taste buds change with age, which may be why the food seems bland.”
3. “This happens because the medications sometimes cause a change in taste.”
4. “Why don’t you barbecue food on a grill if you don’t like your wife’s cooking?”
1. The nurse needs to discuss possible causes with the client and not talk to the wife.
2. The acuity of the taste buds decreases with age, which could cause regular foods to seem bland and tasteless.
3. Some medications may cause a metallic taste in the mouth, but medication would not cause
foods to taste bland.
4. Telling the client to cook if he doesn’t like his wife’s food is an argumentative and judgmental
3. The charge nurse is admitting a 90-year-old client to a long-term care facility. Which intervention should the nurse implement?
1. Ensure the client’s room temperature is cool.
2. Talk louder to make sure the client hears clearly.
3. Complete the admission as fast as possible.
4. Provide extra orientation to the surroundings.
1. Because of altered temperature regulation, the client usually needs a warmer room temperature, not a cooler room temperature.
2. The nurse should use a low-pitched, normal level, clear voice. Talking louder or shouting
only makes it harder for the client to understand the nurse.
3. The elderly client requires adequate time to receive and respond to stimuli, to learn, and to react; therefore the nurse should take time and
not rush the admission.
4. Sensory isolation resulting from visual and hearing loss can cause confusion, anxiety, disorientation, and misinterpretation of the
new environment; therefore, the nurse should provide extra orientation.
4. Which assessment technique would be indicated when assessing the client’s cranial
nerves for vibration?
1. Move the big toe up and down and ask in which direction the vibration is felt.
2. Place a tuning fork on the big toe and ask if the vibrations are felt.
3. Tap the client’s cheek with the finger and determine if vibrations are felt.
4. Touch the arm with two sharp objects and ask if one (1) vibration or two (2) is felt.
1. This assesses proprioception, or position sense; direction of the toe must be evaluated.
2. Vibration is assessed by using a lowfrequency tuning fork on a bony prominence
and asking the client whether he or she feels the sensation and, if so, when the sensation ceases.
3. Tapping the cheek assesses for tetany, not cranial nerve involvement.
4. A two-point discrimination test evaluates integration of sensation, but it does not assess for vibration.
5. Which intervention should the nurse include when conducting an in-service on caring for elderly clients that addresses normal developmental sensory changes?
1. Ensure curtains are open when having the client read written material.
2. Provide a variety of written material when discussing a procedure.
3. Assist the client when getting out of the bed and sitting in the chair.
4. Request a telephone for the hearing impaired for all elderly clients.
1. Adequate lighting without a glare should be provided when having the client read written
material; therefore, the curtains should be closed, not open.
2. The nurse should provide material that is short, concise, and concrete, not a variety.
3. Because fewer tactile cues are received from the bottom of the feet, the client may get confused as to body position and location.
Safety is priority and assisting the client getting out of bed and sitting in a chair is appropriate.
4. This is making a judgment. Not all elderly clients are hard of hearing, and telephones for
the hearing impaired require special training for the user.
6. Which situation would make the nurse think the client has glaucoma?
1. An automobile accident because the client not seeing the car in the next lane.
2. The cake tasted funny because the client could not read the recipe.
3. The client has been wearing mismatched clothes and socks.
4. The client ran a stoplight and hit a pedestrian walking in the crosswalk.
1. Loss of peripheral vision as a result of glaucoma causes the client problems with seeing things on each side, resulting in a
“blind spot.” This problem can lead to the client having car accidents when switching
2. This would be indicative of cataracts because clients with cataracts have blurred vision and
cannot read clearly.
3. This would be indicative of cataracts because there is a color shift to yellow–brown and there
is reduced light transmission.
4. This would be indicative of macular degeneration, in which the central vision is affected.
8. The nurse is conducting a Weber test on the client who is suspected of having conductive
hearing loss in the left ear. Where should the nurse place the tuning fork when conducting this test?
1. The tuning fork should be struck to produce vibrations and then placed midline between the ears on top of the head.
2. The right temple area is not an appropriate place to assess for conductive hearing
3. The right occipital area is not the appropriate place to place the tuning fork; this is the area
behind the ear where the Rinne test is performed.
4. The chin area is not the appropriate area to put
the tuning fork.
9. The student nurse asks the nurse, “Which type of hearing loss involves damage to the cochlea or vestibulocochlear nerve?” Which statement is the best response of the nurse?
1. “It is called conductive hearing loss.”
2. “It is called a functional hearing loss.”
3. “It is called a mixed hearing loss.”
4. “It is called sensorineural hearing loss.”
1. Conductive hearing loss results from an external ear disorder, such as impacted cerumen, or
a middle ear disorder, such as otitis media or otosclerosis.
2. Functional (psychogenic) hearing loss is nonorganic and unrelated to detectable structural
changes in the hearing mechanisms. It is usually a manifestation of an emotional disturbance.
3. Mixed hearing loss involves both conductive loss and sensorineural loss. It results from dysfunction of air and bone conduction.
4. Sensorineural hearing loss is described in the stem of the question. It involves damage
to the cochlea or vestibulocochlear nerve.
11. The female client tells the clinic nurse that she is going on a seven (7)-day cruise and is worried about getting motion sickness. Which information should the nurse discuss
with the client?
1. Make an appointment for the client to see the health-care provider.
2. Recommend getting an over-the-counter scopolamine patch.
3. Discourage the client from taking the trip because she is worried.
4. Instruct the client to lie down and the motion sickness will go away.
1. This is not a condition that requires an appointment
with the health-care provider.
2. Anticholinergic medications, such as scopolamine
patches, can be recommended by the nurse; this is not prescribing. Motion
sickness is a disturbance of equilibrium caused by constant motion.
3. Motion sickness can be controlled with medication
and it may not even occur. Therefore, canceling the trip is not providing the client
with appropriate information.
4. This is providing the client with false information. Lying down may or may not help motion
sickness. To be able to enjoy the cruise, the client needs medication.
12. The nurse writes the diagnosis “risk for trauma related to impaired balance” for the
client diagnosed with vertigo. Which nursing intervention should be included in the
plan of care?
1. Provide information about vertigo and its treatment.
2. Assess for level and type of diversional activity.
3. Assess for visual acuity and proprioceptive deficits.
4. Refer the client to a support group and counseling.
1. This would be appropriate for a diagnosis of “knowledge deficit.”
2. This would be appropriate for a diagnosis of “deficient diversional activity” related to environmental
lack of activity.
3. Balance depends on visual, vestibular, and proprioceptive systems; therefore the nurse
should assess these systems for signs/symptoms.
4. This would be appropriate for a diagnosis “ineffective coping.”
13. The nurse is assessing the client’s cranial nerves. Which assessment data indicate that
cranial nerve I is intact?
1. The client can identify cold and hot on the face.
2. The client does not have any tongue tremor.
3. The client has no ptosis of the eyelids.
4. The client is able to identify a peppermint smell.
1. Being able to identify cold and hot on the face indicates an intact trigeminal nerve, cranial
2. Not having any tongue tremor indicates an intact hypoglossal nerve, cranial nerve XI.
3. No ptosis of the eyelids indicates an intact oculomotor nerve (cranial nerve III), trochlear
nerve (IV), and abducens nerve (VI). Tests also assess for ocular motion, conjugate movements,
nystagmus, and papillary reflexes.
4. Cranial nerve I is the olfactory nerve, which involves the sense of smell. With the eyes closed the client must identify familiar
smells to indicate an intact cranial nerve I.