TB Ch 46, 47, 48 Assessment & Care of Eye/Vision & Ear/Hearing problems Flashcards Preview

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Flashcards in TB Ch 46, 47, 48 Assessment & Care of Eye/Vision & Ear/Hearing problems Deck (52)
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1

1. The nurse has given a community group a presentation on eye health. Which statement by a participant indicates a need for more instruction?

a. “I always lose my sunglasses, so I don’t wear them.”
b. “I have diabetes and get an annual eye exam.”
c. “I will not share my contact solution with others.”
d. “I will wear safety glasses when I mow the lawn.”

ANS: A

Clients should be taught to protect their eyes from ultraviolet (UV) exposure by consistently wearing sunglasses when outdoors, when tanning in tanning salons, or when working with UV light. The other statements are correct.

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2. The nurse reads on a client’s chart that the client has exophthalmos. What assessment finding is consistent with this diagnosis?

a. Bulging eyes
b. Drooping eyelids
c. Sunken-in eyes
d. Yellow sclera

ANS: A

Exophthalmos is bulging eyes. Drooping eyelids is ptosis. Sunken-in eyes is enophthalmos. Yellow sclera indicates jaundice.

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3. A client’s chart indicates anisocoria. For what should the nurse assess?

a. Difference in pupil size
b. Draining infection
c. Recent eye trauma
d. Tumor of the eyelid

ANS: A

Anisocoria is a noticeable difference in the size of a person’s pupils. This is a normal finding in a small percentage of the population. Infection, trauma, and tumors are not related.

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4. A client presents to the emergency department reporting a foreign body in the eye. For what diagnostic testing should the nurse prepare the client?

a. Corneal staining
b. Fluorescein angiography
c. Ophthalmoscopy
d. Tonometry

ANS: A

Corneal staining is used when the possibility of eye trauma exists, including a foreign body. Fluorescein angiography is used to assess problems of retinal circulation. Ophthalmoscopy looks at both internal and external eye structures. Tonometry tests the intraocular pressure.

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5. A nurse who is applying eyedrops to a client holds pressure against the corner of the eye nearest the nose after instilling the drops. The client asks what the nurse is doing. What response by the nurse is best?

a. “Doing this allows time for absorption.”
b. “I am keeping the drops in the eye.”
c. “This prevents systemic absorption.”
d. “I am stopping you from rubbing your eye.”

ANS: C

This technique, called punctal occlusion, prevents eyedrops from being absorbed systemically. The other answers are inaccurate

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6. The nurse is administering eyedrops to a client with an infection in the right eye. The drops go in both eyes, and two different bottles are used to administer the drops. The nurse accidentally uses the left eye bottle for the right eye. What action by the nurse is best?

a. Inform the provider of the issue.
b. Obtain a new bottle of eyedrops.
c. Rinse the client’s right eye thoroughly.
d. Wipe the left eye bottle with alcohol.

ANS: B

The nurse has contaminated the “clean” bottle by using it on the infected eye. The nurse needs to obtain a new bottle of solution to use on the left eye. The other actions are not appropriate.

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7. The nurse enters an examination room to help with an eye examination. The client is directed toward the assessment chart shown below:

What is the provider assessing?
a. Color vision
b. Depth perception
c. Spatial perception
d. Visual acuity

ANS: A

This is an Ishihara chart, which is used for assessing color vision. Depth and spatial perception are not typically assessed in a routine vision assessment. Visual acuity is usually tested with a Snellen chart.

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1. The student learning about vision should remember which facts related to the eyes? (Select all that apply.)

a. Aqueous humor controls intraocular pressure.
b. Cones work in low light conditions.
c. Glaucoma occurs due to increased pressure in the eye.
d. Muscles of the iris control light entering the eye.
e. Rods work in low light conditions.

ANS: A, C, D, E

The inflow and outflow of aqueous humor controls the intraocular pressure. Glaucoma results when the pressure is chronically high. Muscles of the iris relax and constrict to control the amount of light entering the eye. Rods work in low light conditions. Cones work in bright light conditions.

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2. The nursing student studying the eye learns that which cranial nerves control its functions? (Select all that apply.)

a. II
b. III
c. VI
d. XII
e. X

ANS: A, B, C

The cranial nerves involved with eye function include II, III, IV, V, VI, and VII

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3. The nursing student learns that age-related changes affect the eyes and vision. Which changes does this include? (Select all that apply.)

a. Decreased eye muscle tone
b. Development of arcus senilis
c. Increase in far point of near vision
d. Decrease in general color perception
e. Increase in point of near vision

ANS: A, B, D, E

Normal age-related changes include decreased eye muscle tone, development of arcus senilis, decreased color perception, and increased point of near vision. The far point of near vision typically decreases.

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1. A client has a corneal ulcer. What information provided by the client most indicates a potential barrier to home care?

a. Chronic use of sleeping pills
b. Impaired near vision
c. Slightly shaking hands
d. Use of contact lenses

ANS: A

Antibiotic eyedrops are often needed every hour for the first 24 hours for corneal ulceration. The client who uses sleeping pills may not wake up each hour or may awaken unable to perform this task. This client might need someone else to instill the eyedrops hourly. Impaired near vision and shaking hands can both make administration of eyedrops more difficult but are not the most likely barriers. Contact lenses should be discarded.

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2. An older client has decided to give up driving due to cataracts. What assessment information is most important to collect?

a. Family history of visual problems
b. Feelings related to loss of driving
c. Knowledge about surgical options
d. Presence of family support

ANS: B

Loss of driving is often associated with loss of independence, as is decreasing vision. The nurse should assess how the client feels about this decision and what its impact will be. Family history and knowledge about surgical options are not related as the client has made a decision to decline surgery. Family support is also useful information, but it is most important to get the client’s perspective on this change.

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3. A client is in the preoperative holding area waiting for cataract surgery. The client says “Oh, yeah, I forgot to tell you that I take clopidogrel, or Plavix.” What action by the nurse is most important?

a. Ask the client when the last dose was.
b. Check results of the prothrombin time (PT) and international normalized ratio (INR).
c. Document the information in the chart.
d. Notify the surgeon immediately.

ANS: D

Clopidogrel is an antiplatelet aggregate and could increase bleeding. The surgeon should be notified immediately. The nurse should find out when the last dose of the drug was, but the priority is to notify the provider. This drug is not monitored with PT and INR. Documentation should occur but is not the priority.

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4. A client does not understand why vision loss due to glaucoma is irreversible. What explanation by the nurse is best?

a. “Because eye pressure was too high, the tissue died.”
b. “Glaucoma always leads to permanent blindness.”
c. “The traumatic damage to your eye was too great.”
d. “The infection occurs so quickly it can’t be treated.”

ANS: A

Glaucoma is caused when the intraocular pressure becomes too high and stays high long enough to cause tissue ischemia and death. At that point, vision loss is permanent. Glaucoma does not have to cause blindness. Trauma can cause glaucoma but is not the most common cause. Glaucoma is not an infection.

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5. A client’s intraocular pressure (IOP) is 28 mm Hg. What action by the nurse is best?

a. Educate the client on corneal transplantation.
b. Facilitate scheduling the eye surgery.
c. Plan to teach about drugs for glaucoma.
d. Refer the client to local Braille classes.

ANS: C

This increased IOP indicates glaucoma. The nurse’s main responsibility is teaching the client about drug therapy. Corneal transplantation is not used in glaucoma. Eye surgery is not indicated at this time. Braille classes are also not indicated at this time.

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6. A client had a retinal detachment and has undergone surgical correction. What discharge instruction is most important?

a. “Avoid reading, writing, or close work such as sewing.”
b. “Dim the lights in your house for at least a week.”
c. “Keep the follow-up appointment with the ophthalmologist.”
d. “Remove your eye patch every hour for eyedrops.”

ANS: A

After surgery for retinal detachment, the client is advised to avoid reading, writing, and close work because they cause rapid eye movements. Dim lights are not indicated. Keeping a postoperative appointment is important for any surgical client. The eye patch is not removed for eyedrops.

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7. A client has been taught about retinitis pigmentosa (RP). What statement by the client indicates a need for further teaching?

a. “Beta carotene, lutein, and zeaxanthin are good supplements.”
b. “I might qualify for a retinal transplant one day soon.”
c. “Since I’m going blind, sunglasses are not needed anymore.”
d. “Vitamin A has been shown to slow progression of RP.”

ANS: C

Sunglasses are needed to prevent the development of cataracts in addition to the RP. The other statements are accurate.

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8. A client has a foreign body in the eye. What action by the nurse takes priority?

a. Administering ordered antibiotics
b. Assessing the client’s visual acuity
c. Obtaining consent for enucleation
d. Removing the object immediately

ANS: A

To prevent infection, antibiotics are provided. Visual acuity in the affected eye cannot be assessed. The client may or may not need enucleation. The object is only removed by the ophthalmologist.

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9. A client who is near blind is admitted to the hospital. What action by the nurse is most important?

a. Allow the client to feel his or her way around.
b. Let the client arrange objects on the bedside table.
c. Orient the client to the room using a focal point.
d. Speak loudly and slowing when talking to the client.

ANS: C

Using a focal point, orient the client to the room by giving descriptions of items as they relate to the focal point. Letting the client arrange the bedside table is a good idea, but not as important as orienting the client to the room for safety. Allowing the client to just feel around may cause injury. Unless the client is also hearing impaired, use a normal tone of voice.

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10. A client had proxymetacaine (Ocu-Caine) instilled in one eye in the emergency department. What discharge instruction is most important?

a. Do not touch or rub the eye until it is no longer numb.
b. Monitor the eye for any bleeding for the next day.
c. Rinse the eye with warm saline solution at home.
d. Use all the eyedrops as prescribed until they are gone.

ANS: A

This drug is an ophthalmic anesthetic. The client can injure the numb eye by touching or rubbing it. Bleeding is not associated with this drug. The client should not be told to rinse the eye. This medication was given in the emergency department and is not prescribed for home use.

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11. A client is taking timolol (Timoptic) eyedrops. The nurse assesses the client’s pulse at 48 beats/min. What action by the nurse is the priority?

a. Ask the client about excessive salivation.
b. Assess the client for shortness of breath.
c. Give the drops using punctal occlusion.
d. Hold the eyedrops and notify the provider.

ANS: D

The nurse should hold the eyedrops and notify the provider because beta blockers can slow the heart rate. Excessive salivation can occur with cholinergic agonists. Shortness of breath is not related. If the drops are given, the nurse uses punctal occlusion to avoid systemic absorption.

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12. A client has been prescribed brinzolamide (Azopt). What assessment by the nurse requires consultation with the provider?

a. Allergy to eggs
b. Allergy to sulfonamides
c. Use of contact lenses
d. Use of beta blockers

ANS: B

Brinzolamide is similar to sulfonamides, so an allergic reaction could occur. The other assessment findings are not related to brinzolamide.

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13. A client is brought to the emergency department after a car crash. The client has a large piece of glass in the left eye. What action by the nurse takes priority?

a. Administer a tetanus booster shot.
b. Ensure the client has a patent airway.
c. Prepare to irrigate the client’s eye.
d. Turn the client on the unaffected side

ANS: B

Airway always comes first. After ensuring a patent airway and providing cervical spine precautions (do not turn the client to the side), the nurse provides other care that may include administering a tetanus shot. The client’s eye may or may not be irrigated.

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14. A nurse is seeing clients in the ophthalmology clinic. Which client should the nurse see first?

a. Client with intraocular pressure reading of 24 mm Hg
b. Client who has had cataract surgery and has worsening vision
c. Client whose red reflex is absent on ophthalmologic examination
d. Client with a tearing, reddened eye with exudate

ANS: B

After cataract surgery, worsening vision indicates an infection or other complication. The nurse should see this client first. The intraocular pressure is slightly elevated. An absent red reflex may indicate cataracts. The client who has the tearing eye may have an infection.

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1. The nurse working in the ophthalmology clinic sees clients with eyelid and eye problems. What information should the nurse understand about these disorders? (Select all that apply.)

a. A chalazion is an inflammation of an eyelid sebaceous gland.
b. An ectropion is the eyelid turning inward.
c. An entropion is the eyelid turning outward.
d. A hordeolum is an infection of the eyelid sweat gland.
e. Keratoconjunctivitis sicca is caused by drugs or diseases.

ANS: A, D, E

A chalazion is an inflammation of one of the sebaceous glands in the eyelid. A hordeolum is an infection of a sweat gland in the eyelid. Keratoconjunctivitis sicca can be caused by drugs or diseases. An ectropion is an outward turning and sagging eyelid, while an entropion is an inward turning of the eyelid.

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2. A client is seen in the ophthalmology clinic with bacterial conjunctivitis. Which statements by the client indicate a good understanding of home management of this condition? (Select all that apply.)

a. “As long as I don’t wipe my eyes, I can share my towel.”
b. “Eye irrigations should be done with warm saline or water.”
c. “I will throw away all my eye makeup when I get home.”
d. “I won’t touch the tip of the eyedrop bottle to my eye.”
e. “When the infection is gone, I can use my contacts again.”

ANS: C, D

Bacterial conjunctivitis is very contagious, and re-infection or cross-contamination between the client’s eyes is possible. The client should discard all eye makeup being used at the time the infection started. When instilling eyedrops, the client must be careful not to contaminate the bottle by touching the tip to the eye or face. The client should be instructed not to share towels. Eye irrigations are not needed. Contacts being used when the infection first manifests also need to be discarded.

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3. A client had cataract surgery. What instructions should the nurse provide? (Select all that apply.)

a. Call the doctor for increased pain.
b. Do not bend over from the waist.
c. Do not lift more than 10 pounds.
d. Sexual intercourse is allowed.
e. Use stool softeners to avoid constipation.

ANS: A, B, C, E

The client should be taught to call the physician for increased pain as this might indicate infection or other complication. To avoid increasing intraocular pressure, clients are taught to not lift more than 10 pounds, to avoid bending at the waist, to avoid straining at stool, and to avoid sexual intercourse for a time after surgery.

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4. A nurse has delegated applying a warm compress to a client’s eye. What actions by the unlicensed assistive personnel (UAP) warrant intervention by the nurse? (Select all that apply.)

a. Heating the wet washcloth in the microwave
b. Holding the cloth on the client using an Ace wrap
c. Turning the cloth so it remains warm on the client
d. Using a clean washcloth for the compress
e. Washing the hands on entering the client’s room

ANS: A, B

The washcloth should be warmed under running warm water. Microwaving it can lead to burns. Gentle pressure is used to hold the compress in place. The other actions are correct.

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1. A nurse is teaching a client about ear hygiene and health. What client statement indicates a need for further teaching?

a. “A soft cotton swab is alright to clean my ears with.”
b. “I make sure my ears are dry after I go swimming.”
c. “I use good earplugs when I practice with the band.”
d. “Keeping my diabetes under control helps my ears.”

ANS: A

Clients should be taught not to put anything larger than their fingertip into their ears. Using a cotton swab, although soft, can cause damage to the ears and cerumen buildup. The other statements are accurate.

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2. The student nurse is performing a Weber tuning fork test. What technique is most appropriate?

a. Holding the vibrating tuning fork 10 to 12 inches from the client’s ear
b. Placing the vibrating fork in the middle of the client’s head
c. Starting by placing the vibrating fork on the mastoid process
d. Tapping the vibrating tuning fork against the bridge of the nose

ANS: B

The Weber tuning fork test includes placing the vibrating tuning fork in the middle of the client’s head and asking in which ear the client hears the vibrations louder. The other techniques are incorrect.