Ca Eye and Ear Disorder

Don Mariano Marcos Memorial State University
South La Union Campus

COLLEGE OF COMMUNITY HEALTH AND ALLIED MEDICAL SCIENCES
Agoo, La Union
Tel. 072.682.0663 Care to learn, Learn to care
Embracing World Class Standards
December 9, 2020
Group 5:
Mejia, Nicole
Narvarte, Clarisa
Navarro, Ma. Josabeth
Regacho, Shane Sharlette
Sirue, Malinda
Nursing clinical scenarios integrating the nursing process, levels

of care/prevention in the nursing management of the Adult Client with an Eye or Ear Disorder:
a. The Eye and Ear
b. Ophthalmic and Otic Medications
Eye Disorders
1. The client is diagnosed with glaucoma. Which symptom should the nurse expect the client to report?
1. Loss of peripheral vision.
2. Floating spots in the vision.
3. A yellow haze around everything.
4. A curtain coming across vision.
Answer: 1. Loss of peripheral vision.

Rationale: In glaucoma, the client is often unaware 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.”
Incorrect Answers: 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 which may cause bleeding, such as aspirin.
Answer: 4. Avoid taking any type of medication which may cause bleeding, such as aspirin.
Rationale: To reduce retrobulbar hemorrhage, any anticoagulation therapy is withheld, including
aspirin, non steroidal anti-inflammatory drugs (NSAIDs), and warfarin (Coumadin).
Incorrect Answers: 1. Dilating drops are administered every 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.
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3. The client is postoperative retinal detachment surgery, and gas tamponade was used to flatten the
retina. Which intervention should the nurse implement first?
1. Teach the signs of increased intra ocular pressure.
2. Position the client as prescribed by the surgeon.
3. Assess the eye for signs/symptoms of complications.
4. Explain the importance of follow-up visits.
Answer: 3. Assess the eye for signs/symptoms of complications.

Rationale: The nurse’s priority must be assessment of complications, which include increased intra
ocular pressure, end ophthalmic is, development of another retinal detachment, or loss of turgor in the
eye.
Incorrect Answers: 1. This should be done, but it is not the first intervention the nurse should
implement.
2. The client will have to be specifically positioned to make the gas bubble float into the best position;
some clients must lie face down or on their side for days, but it is not the first intervention.
4. Follow-up visits are important, but this is not the first intervention the nurse should implement.
4. The 65-year-old client is diagnosed with macular degeneration. Which statement by the client
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 need to use low-watt light bulbs in my house.”
4. “I am going to contact a low-vision center to evaluate my home.”
Answer: 3. “I need to use low-watt light bulbs in my house.”

Rationale: Macular degeneration is the most common cause of visual loss in people older than age 60
years. Any intervention which helps increase vision should be included in the teaching, such as bright
lighting, not decreased lighting.
Incorrect Answers: 1. Magnifying devices used with activities such as threading a needle will help the
client’s vision; therefore, this statement does not indicate the client needs more teaching.
2. An Amsler grid is a tool to assess macular degeneration, often providing the earliest sign of a
worsening condition. If the lines of the grid become distorted or faded, the client should call the
ophthalmologist.
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 who has fallen and has a stick lodged
in his eye. Which intervention 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.
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Answer: 2. Stabilize the stick as best as possible.

Rationale: The foreign object should be stabilized to prevent further movement, which could cause
more damage to the eye.
Incorrect Answers: 1. A foreign object should never be removed at the scene of the accident because
this may cause more damage..
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 because it 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 working with 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 eye injuries will be prevented.
Answer: 1. Read instructions thoroughly before using tools and working with chemicals.
Rationale: Instructions provide precautions and steps to take if eye injuries occur secondary to the use
of tools or chemicals.
Incorrect Answers: 2. The employee must wear safety glasses, not just any type of glasses and especially
not regular prescription glasses.
3. A protective helmet is used to help prevent sports eye injuries, not work-related injuries.
4. Eye injuries will not be prevented by paying close attention to the surroundings. They are prevented
by wearing protective glasses or eye shields.
7. The 65-year-old male client who is complaining of blurred vision reports he thinks his glasses need to
be cleaned all the time, and he denies any type of eye pain. Which eye disorder should the nurse
suspect the client has?
1. Corneal dystrophy.
2. Conjunctivitis.
3. Diabetic retinopathy.
4. Cataracts.
Answer: 4. Cataracts.
Rationale: A cataract is a lens opacity or cloudiness, resulting in the signs/symptoms discussed in the
stem of the question.
Incorrect Answers: 1. Corneal dystrophy is an inherited eye disorder occurring at about age 20 and
results in decreased vision and the development of blisters; it 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.
Agoo, La Union
3. Diabetic retinopathy results from deterioration of the small blood vessels nourished by the retina; it
leads to blindness.
8. The nurse is administering eyedrops to the client. Which guidelines should the nurse adhere to when
instilling the drops into the eye? Select all that apply.
1. Do not touch the tip of the medication container to the eye.
2. Apply gentle pressure on the outer canthus of the eye.
3. Apply sterile gloves prior to instilling eyedrops.
4. Hold the lower lid down and instill drops into the conjunctiva.
5. Gently pat the skin to absorb excess eyedrops on the cheek.
Answer:
1. Do not touch the tip of the medication container to the eye.
4. Hold the lower lid down and instill drops into the conjunctiva.
5. Gently pat the skin to absorb excess eyedrops on the cheek.
Rationale: Touching the tip of the container to the eye may cause eye injury or an eye infection.
Medication should not be placed directly on the eye but in the lower part of the eyelid.
Eyedrops are meant to go in the eye, not on the skin, so the nurse should use a clean tissue to remove
excess medication.
Incorrect Answers: 2. Gentle pressure should be applied on the inner canthus, not outer canthus, near
the bridge of the nose for one (1) or two (2) minutes after instilling eyedrops.
3. The nurse should wash hands prior to and after instilling medications; this is not a sterile procedure.
9. The client has had an enucleation of the left eye. Which intervention should the nurse implement?
1. Discuss the need for special eyeglasses.
2. Refer the client for an ocular prosthesis.
3. Help the client obtain a seeing-eye dog.
4. Teach the client how to instill eyedrops.
Answer: 2. Refer the client for an ocular prosthesis.

Rationale: An enucleation is the removal of the entire eye and part of the optic nerve. An ocular
prosthesis will help maintain the shape of the eye socket after the enucleation.
Incorrect Answers:1. Special eyeglasses are not needed for an enucleation.
3. The client had the left eye removed but is not blind because he or she still has the right eye.
4. The eyeball was totally removed and a pressure dressing was applied; therefore, there will be no need
to instill eyedrops.
10. The client diagnosed with glaucoma is prescribed a miotic cholinergic medication. Which data
indicate the medication has been effective?
1. No redness or irritation of the eyes.
2. A decrease in intraocular pressure.
Agoo, La Union
3. The pupil reacts briskly to light.

4. The client denies any type of floaters.
Answer: 2. A decrease in intraocular pressure.

Rationale: Both systemic and topical medications are used to decrease the intra ocular pressure in the
eye, which causes glaucoma.
Incorrect Answers: 1. Steroid medication is administered to decrease inflammation.
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 instruction 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.
Answer: 4. Teach the client how to instill corticosteroid ophthalmic drops.

Rationale: LASIK surgery is an effective, safe, predictable surgery performed in day surgery; there is
minimal postoperative care. Instilling topical corticosteroid drops helps decrease inflammation and
edema of the eye.
Incorrect Answers: 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.
12. The client comes 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.
Answer: 3. Irrigate the eyes with normal saline solution.

Rationale: Before any further evaluation or treatment, the eyes must be thoroughly flushed with sterile
normal saline solution.
Incorrect Answers: 1. Movement of the eye should be avoided until the client has received general
anesthesia; therefore, this is not the first intervention.
2. Parenteral broad-spectrum antibiotics are initiated but not until the eyes are treated first.
4. Tetanus prophylaxis is recommended for full-thickness ocular wounds.
Ear Disorders:
13. Which statement indicates to the nurse the client is experiencing some hearing loss?
Agoo, La Union
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.”
2. “I keep turning up the sound on my television.”
Answer: 2. “I keep turning up the sound on my television.”
Rationale: The need to turn up the volume on the television is an early sign of hearing impairment.
Incorrect Answers: 1. Cleaning the ears daily does not indicate the client has a hearing loss.
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 risk factors should the nurse discuss with the client concerning reasons for 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.
Answer: 1. Perforation of the tympanic membrane.

2. Chronic exposure to loud noises.
3. Recurrent ear infections.
Rationale: The tympanic membrane is the eardrum, and if it is punctured it may lead to hearing loss.
Loud persistent noise, such as heavy machinery, engines, and artillery, over time may cause noise-
induced hearing loss.
Multiple ear infections scar the tympanic membrane, which can lead to hearing loss.
Incorrect Answers: 4. Nephrotoxic means harmful to the kidneys; ototoxic is 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
15. The nurse is caring for a client diagnosed with acute otitis media. Which signs/symptoms support
this medical diagnosis?
1. Unilateral pain in the ear.
2. Green, foul-smelling drainage.
3. Sensation of congestion in the ear.
4. Reports of hearing loss.
Answer: 1. Unilateral pain in the ear

Rationale: Otalgia (ear pain) is experienced by clients with otitis media.
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Incorrect Answers: 2. A green, foul-smelling drainage supports the diagnosis of external otitis, not of
acute otitis media.
3. A sensation of congestion in the ear supports serous otitis media.
4. Hearing loss supports a diagnosis of chronic otitis media or serous otitis media.
16. The client diagnosed with chronic otitis media is scheduled for a mastoidectomy. Which discharge
teaching should the nurse discuss with the client?
1. Instruct the client to blow the nose with the mouth closed.
2. Explain the client will never be able to hear from the ear.
3. Instill ophthalmic drops in both ears and then insert a cotton ball.
4. Do not allow water to enter the ear for six (6) weeks.
Answer: 4. Do not allow water to enter the ear for six (6) weeks.
Rationale: Water should be prevented from entering the external auditory canal because it may irritate
the surgical incision and is a medium for bacterial growth.
Incorrect Answers: 1. The client should blow the nose with the mouth open to prevent pressure in the
eustachian tube.
2. There may be temporary deafness as a result of postoperative edema, but the hearing will return as
the edema subsides.
3. Ophthalmic drops are used in the eyes, not the ears. Otic drops are used for the ears.
17. The client is diagnosed with Ménière’s disease. Which statement indicates the client understands
the medical management for this disease?
1. “After intravenous antibiotic therapy, I will be cured.”
2. “I will have to use a hearing aid for the rest of my life.”
3. “I must adhere to a low-sodium diet, 2,000 mg/day.”
4. “I should sleep with the head of my bed elevated.”
Answer: “I must adhere to a low-sodium diet, 2,000 mg/day.”

Rationale: Sodium regulates the balance of fluid within the body; therefore, a low-sodium diet is
prescribed to help control the symptoms of Ménière’s disease.
Incorrect Answers: 1. Antibiotics will not cure this disease. Surgery is the only cure for Ménière’s
disease, which may result in permanent deafness as a result of the labyrinth being removed in the
surgery.
2. Ménière’s disease does not lead to deafness unless surgery is performed removing the labyrinth in
attempts to eliminate the attacks of vertigo.
4. Sleeping with the head of the bed elevated will not affect Ménière’s disease.
18. The client is complaining of ringing in the ears. Which data are most appropriate for the nurse to
document in the client’s chart?
1. Complaints of vertigo.
2. Complaints of otorrhea.
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3. Complaints of tinnitus.
4. Complaints of presbycusis.
Answer: Complaints of tinnitus.

Rationale: Tinnitus is “ringing of the ears.” It is a subjective perception of sound with internal origins.
Incorrect Answers: 1. Vertigo is an illusion of movement in which the client complains of dizziness.
2. Otorrhea is drainage of the ear.
4. Presbycusis is progressive hearing loss associated with aging.
19. Which statement best describes the scientific rationale for the nurse holding the otoscope with the
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 the nurse will not cause pain when examining the ear.
Answer: 3. This prevents inserting the otoscope too far into the external ear.
Rationale: Inserting the speculum of the otoscope into the external ear can cause ear trauma if not done
correctly.
Incorrect Answers: 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 holding
the otoscope in other ways.
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 intervention
should the nurse implement?
1. Grasp the earlobe and pull back and out when putting drops in the ear.
2. Insert the ear drops 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.
Answer: 4. Pull the auricle down and back prior to instilling drops
Rationale: This will straighten the ear canal so the ear drops will enter the ear canal and drain toward
the tympanic membrane (eardrum).
Incorrect Answers: 1. This is not the correct way to administer ear drops.
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 ear drops.
21. Which ototoxic medication should the nurse recognize as potentially life altering or threatening to
the client?
1. An oral calcium channel blocker.
2. An intravenous aminoglycoside antibiotic.
3. An intravenous glucocorticoid.
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4. An oral loop diuretic
Answer: 2. An intravenous aminoglycoside antibiotic

Rationale: 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.
Incorrect Answers: 1. Calcium channel blockers are not going to affect the client’s hearing.
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 ear plugs while swimming.
3. Use a drying agent in the ear after swimming.
4. Insert a bulb syringe into each ear to remove excess water.
Answer: 3. Use a drying agent in the ear after swimming.

Rationale: 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.
Incorrect Answers: 1. Tight-fitting swim caps or wetsuit hoods should be worn because they prevent
water from entering the ear canal.
2. Silicone ear plugs should be worn because they keep water from entering the ear canal without
reducing hearing significantly.
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.
23. The client comes to the clinic and is diagnosed with otitis media. Which intervention should the clinic
nurse include in the discharge teaching?
1. Instruct the client not to take any over-the-counter pain medication.
2. Encourage the client to apply cold packs to the affected ear.
3. Tell the client to call the HCP if an abrupt relief of ear pain occurs.
4. Wear a protective ear plug in the affected ear.
Answer: 3. Tell the client to call the HCP if an abrupt relief of ear pain occurs.
Rationale: Pain subsiding abruptly may indicate spontaneous perforation of the tympanic membrane
within the middle ear and should be reported to the HCP.
Incorrect Answers: 1. Mild analgesics such as aspirin or acetaminophen every four (4) hours as needed
to relieve pain and fever are recommended; aspirin may help decrease inflammation of the ear.
2. Heat applied to the affected ear is recommended because heat dilates blood vessels, promoting the
reabsorption of fluid and reducing edema.
Agoo, La Union
4. Ear plugs should not be used in clients with otitis media, but cotton balls could be used to keep otic
antibiotics in the ear canal.
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.”
Answer: 4. “I can shampoo my hair the day after surgery as long as I am careful.”
Rationale: 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.
Incorrect Answers: 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.
25. The nurse is observing the client administer the prescribed eyedrops. Which intervention should the
nurse implement?
1. Praise the client for instilling the eyedrops as recommended.
2. Remind the client to instill the eyedrops from 0.4 to 0.8 inch above the eye.
3. Ask the client if the eyedrops have been warmed to room temperature.
4. Teach the client to instill the eyedrops in the upper conjunctival sac.
Answer: 2. Remind the client to instill the eyedrops from 0.4 to 0.8 inch above the eye.
Rationale: Eyedrops are instilled from one (1) to two (2) cm (0.4 to 0.8 inch) above the eye. The client
should not hold the dropper too high.
Incorrect Answers: 1. The client is holding the dropper too high. Eyedrops are instilled from one (1) to
two (2) cm (0.4 to 0.8 inch) above the eye.
3. Eyedrops can be instilled at room temperature or chilled. If a client has trouble recognizing if the
drops have been instilled, the nurse can recommend refrigerating the drops so the client can feel when
the eyedrops have been administered.
4. Eyedrops are administered in the lower conjunctival sac.
26. The nurse is administering eardrops to a six (6)-year-old client. Which indicates the nurse is aware of
the correct method for instilling eardrops to a child?
1. Pull the pinna upward only to instill the eardrops.
2. Pull the pinna to a neutral position to instill the eardrops.
3. Pull the pinna upward and backward prior to instilling the drops.
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4. Pull the pinna downward and forward to instill the drops.
Answer: 3. Pull the pinna upward and backward prior to instilling the drops.
Rationale: The pinna should be pulled upward and backward for all clients three (3) years of age and
older. Prior to three (3) years of age the pinna is directed upward only.
Incorrect Answers: 1. The pinna should be pulled upward and backward for all clients three (3) years of
age and older. Prior to three (3) years of age the pinna is directed upward only.
2. The pinna should be pulled upward and backward for all clients three (3) years of age and older. Prior
to three (3) years of age the pinna is directed upward only.
4. The pinna should be pulled upward and backward for all clients three (3) years of age and older. Prior
to three (3) years of age the pinna is directed upward only.
27. The nurse is instilling eye ointment. Which should the nurse perform prior to instilling the
medication depicted in the image?
1. Have the client close the eye tightly to rid the eye of tears.
2. Place the nurse’s nondominant hand on the client’s eyebrow.
3. Discard the first bead of ointment, then instill the ointment.
4. Ask the client to look down toward the floor.
Answer: 3. Discard the first bead of ointment, then instill the ointment.
Rationale: The first bead of ointment is considered contaminated and should be discarded.
Incorrect Answers: 1. The client should close the eye gently after the ointment is instilled in order for
the eyelid to spread the ointment over the eye.
2. The nurse’s nondominant thumb or fingers are placed on the cheekbone to pull the lid down to
expose the conjunctival sac.
4. The client should look upward to reduce the amount of blinking during administration.
28. The nurse is assessing a client and performs a whisper test. Which should the nurse implement?
Rank in order of performance.
1. Have the client cover the ear not being tested.
2. Stand 12 to 24 inches to the side of the client.
3. Explain to the client to repeat what the nurse says.
4. Repeat the test for the opposite ear.
5. Ask the client if he/she is willing to participate in the test.
Answer: 5. Ask the client if he/she is willing to participate in the test.

3. Explain to the client to repeat what the nurse says.
1. Have the client cover the ear not being tested.
2. Stand 12 to 24 inches to the side of the client.
4. Repeat the test for the opposite ear.
Rationale: The client should be offered the opportunity to agree to being tested before any further
action is taken.
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Incorrect answer: The nurse should give directions as to what the client is expected to do when he/she
hears what the nurse says.
The client covers the ear not being tested after the nurse has explained the test.
The nurse should stand to the side but not until talking directly to the client.
One ear at a time is tested.
Eyes and Ears:

29. The nurse is caring for a client diagnosed with a cerebrovascular accident (CVA). Which assessment
information should the nurse determine first when placing the client in the assigned room?
1. Determine if the client has loss of vision in the same half of each visual field.
2. Find out if the client prefers the bed by the window or by the bathroom.
3. Request dietary to place the meat at 1200 on each plate and vegetables at 0900 and 1500.
4. Request a physical therapy consult to assess the client’s mobility issues.
Answer: 1. Determine if the client has loss of vision in the same half of each visual field.
Rationale: Homonymous hemianopsia (blindness in the same half of each visual field) is a common
problem after a stroke. Clients disregard objects in that part of the visual field. The nurse would want to
place the client in a room with the bed positioned so that the client will know when someone is entering
the room.
Incorrect Answers:
2. Client preference can be taken into consideration but is not a priority.
3. Requesting dietary to place foods in a certain order will assist the client with visual disturbances to
know where to find the food on the plate but is not first.
4. Physical therapy may need to assess the client, but it is not first.
30. The elderly client has undergone a right-eye cataract removal with an intra ocular implant. Which
discharge instructions should the nurse teach the client?
1. Have the client demonstrate placing the otic drops in the ear.
2. Teach the client to instill the eyedrops as prescribed.
3. Remind the client to keep the lights in the home low at all times.
4. Encourage the client to sleep on two pillows at night.
Answer: 2. Teach the client to instill the eyedrops as prescribed.

Rationale: Postoperatively the client will be prescribed eyedrops for several weeks; the nurse should
teach the client to administer as prescribed.
Incorrect Answers: 1. Otic drops go in the ear, not the eye.
3. The light should be brighter for safety.
4. The client does not need to sleep with the HOB elevated.
Agoo, La Union
31. The nurse is assessing a client who has a “pinpoint” pupil reaction bilaterally and the pupils do not
constrict when the light is shown on the eye. Which should the nurse document?
1. Pupillary response poor.
2. Pupils one (1) mm, equal and nonreactive to light.
3. Pupils two (2) to three (3) mm and non-constrictive to light.
4. Pupils are barely open and don’t constrict to light.
Answer: Pupils one (1) mm, equal and nonreactive to light.

Rationale: Pinpoint describes the least amount of dilation noted, which is 1 mm. Bilateral means both
sides, so equal describes that one side is the same as the other. Nonreactive describes the pupils not
constricting. This is clear and concise.
Incorrect Answers: 1. Pupil response may be poor but this is not professionally documented for a clear
record of the nurse’s observation.
3. Two to 3 mm is not pinpoint, and non constructive is not describing response to light.
4. This is something a layperson might say but is not in professional terms.
32. The emergency department nurse is assessing a client who has a needle in the sclera of the right
eyeball just below the iris. Which should the nurse implement first?
1. Remove the needle with tweezers.
2. Notify an ophthalmologist to care for the client.
3. Stabilize the right eye and place a patch over the left eye.
4. Irrigate the right eye to wash the needle out of the eye.
Answer: 3. Stabilize the right eye and place a patch over the left eye.
Rationale: The nurse should try to stabilize the right eye but not do anything that increases the damage
to it. The left eye is patched to keep it from moving to see what is going on and the right eye moves with
it.
Incorrect Answers: 1. The nurse should leave the needle where it is but try to make sure the client does
not move the eye. The HCP will be the one to remove the obstacle.
2. The ophthalmologist will need to be notified after the nurse has made sure that the client will not
sustain further damage to the eye.
4. The nurse should not do anything, including irrigating the eye, that might move the needle and create
more damage.
33. The physician has prescribed oppress (carteolal HC) ophthalmic drops for an
elderly client with primary open-angle glaucoma. To decrease the systemic effects
associated with the medication's use, the nurse should:
1. Administer the clients oral medication first

2. Ask the client to sit upright as the drop are instilled
3. Place gentle pressure over the puncta after instilling the drop
4. Wash the lids and lashes before instilling new drops
Answer: 3. Place gentle presure over the puncta after instilling the drop
Agoo, La Union
Rationale :Gentle pressure should be applied to the puncta (inner

canthus) to decrease the systemic effects associated with absorption of the drug
Incorrect answers: 1, 2 , and 4 a do not decrease the systemic effects of the medication.
34. Four hours after an extra capsular extraction to remove a cataract, the client
complains of seeing flashes of light in the operative eye. Although the client denies
pain, the nurse should notify the doctor immediately because the clients
complaints suggest the possibility of:
1. Ocular hemorrhage
2. Uveitis
3. Corneal dystrophy
4. Retinal tear
Answer: 4. Retinal tear

Rationale: The nurse should notify the doctor because complaints of
Seeing flashes of light are associated with possible retinal tear. Other symptoms or
retinal tear and detachment include visual floaters and dark spots with absence of
pain.
Incorrect answer: 1 and 2 are accompanied by pain and increased intra ocular pressure. Corneal
dystrophy results n cloudy, blurred vision, not flashes of light; therefore, Answer 3 is incorrect.
35. A home health nurse is making a visit to a client with low vision. Which finding
indicates that the client needs further teaching regarding environmental safety?
1. Throw rugs have been eliminated from the household.
2. Non-breakable dishes are used for meals
3. Hook-and-loop Velero strips locate light switches.
4. Furnishings include a lounge chair and footstool.
Answer: 4. Furnishings include a lounge chair and footstool.

Rationale:. A client with low vision should avoid the use of footstools
because they can result in falls. Chairs with built-in foot rests are a better choice
for such clients.
Incorrect answer: 1,2 and 3, shows that the
client did understand the nurse's teaching regarding ways to increase environmental safety.
36. The nurse is administering medication to four clients. Which client should be
most closely monitored for signs of ototoxicity?
1.A 20-year-old receiving Cipro (ciprofloxacin) for a urinary tract infection
2. A 75-year-old receiving Amikin (amikacin sulfate) for pneumonia.
3. A 46-year-old receiving Ancef (cefazolin sodium) for sinusitis
4. A 6-month-old receiving Augmentin (amosicillin/calvulanate potassium) for acute otitis media
Answer: 2.A 75-year-old receiving Amikin (amikacin sulfate) for pneumonia.

Agoo, La Union
Rationale: Amikin (amikacin sultate) is an aminoglycoside that is capableof producing both ototoxicity
and nephrotoxicity. The fact that the client is elderlyincreases the likelihood of the drug's toxicity.
Incorrect answers: 1,3, and 4 are medications that are not generally associated with ototoxicity.
37. The nurse is formulating a plan of care for a client with an acute episode of Ménières disease. The
nurse should give priority to:
1. Relieving pain
2. Offering extra fluids
3. Reducing noise level
4.Preventing injury
Answer: 4. Preventing injury

Rationale: The nurse should give priority to preventing injury, particularly from talls.
Incorrect answer: Pain is not associated with Ménière'sDisease
Fluid intake is usually restricted to decrease symptoms.
Reducing the noise level might make the client more comfortable, butit does not take priority over
preventing injury.
38. An adolescent client developed hyphema of the left eye after being hit with a baseball. Which
position is recommended for the client?
1.Semi-Fowler's
2.Supine
3.Prone
4. Low Trendelenburg
Answer: 1.Semi-Fowler's
Rationale: The client with hyphema should be placed in semi-Fowlers position. This position helps to
keep blood away from the center of the cornea.
Incorrect answer: 2,3 and 4 do not keep blood away from the center of the cornea. Additional
interventions include keeping the head elevated and applying cold compresses to the eye.
39. A client with reduced vision is being trained to ambulate with a cane. Which observation indicates
that the client is using the cane properly?
1. The client holds the cane in the non-dominant hand.
2. The client taps the cane on the floor with each step.
3. The client moves the cane back and forth above the floor.
4. The client keeps the cane still as he ambulates.
Answer: 3. The client moves the cane back and forth above the floor.
Rationale: The cane should be held in the dominant hand several inches
above the floor. It should be moved back and forth in a sweeping motion as the
Agoo, La Union
client walks to detect objects in his path.

Incorrect answer: 1, 2 , and 4 indicate that the client is using the cane improperly
40. Some improvement in age-related hearing loss might be obtained by supplementing the client's diet
with:
1. Retinol
2. Folacin
3. Ascorbic acid
4. Alpha-tocopherol
Answer: 2. Folacin
Rationale: Supplementing the client's diet with folacin (vitamin B9)might result in the improvement of
age-related hearing loss.
The use of retinol(vitamin A), ascorbic acid (vitamin C), and alpha-tocopherol (Vitamin E) do not result in
improved hearing.
41. Ear irrigations have been ordered for a client with impacted cerumen. When
Performing the irrigation, the nurse should:
1. Use cool water to reduce edema in the ear canal
2. Direct the irrigating solution onto the cerumen
3. Direct the irrigating solution to one side of the ear canal
4. Irrigate the ear continuously until the cerumen is removed
Answer: 3. Direct the irrigating solution to one side of the ear canal
Rationale: Directing the irrigating solution to one side of the ear canal allows the fluid to get behind the
impacted cerumen and helps facilitate its removal.
Incorrect answer: Solution should be warm, not cold.

Directing the irrigation onto the impacted cerumen makes removal more difficult.
Intermittent irrigation, not continuous, is used.
42. The nurse is caring for a client scheduled for a tympanoplasty. Pre-op orders usually include
irrigations of the ear with a solution of sterile water and:
1. Vinegar
2. Baking soda
3. Hydrogen peroxide
4. Glycerin
Answer: 1. Vinegar
Rationale: An irrigating solution of equal parts of sterile water and vinegar are often ordered before a
tympanoplasty to restore the normal pH of the ear.
Agoo, La Union
Incorrect answer: Baking soda, hydrogen peroxide, and glycerin are not used to restore the normal pH
of the ear.
43. Which intervention is most helpful in decreasing the social isolation of a hearing impaired Client who
resides in a nursing home?
1. Obtaining a closed-captioned television for her room
2. Providing activities that do not require her to hear accurately
3. Seating the client with a friend in a quiet corner of the dining room
4. Providing the client books on tape with a headset
Answer: 3. Seating the client with a friend in a quiet corner of the dining room
Rationale: Seating the client with a friend in a quiet area eliminates environmental noises that interfere
with hearing and allows the client to socialize
appropriately with others.
Incorrect answer: Answers 1,2, and 4 are interventions for the hearing- impaired client; however, they
do not help prevent social isolation..
44. The nurse is doing an intake history on a 30-year-old with bilateral progressive
hearing loss. Which finding in the clients history is most significant?
1. The client had recurrent acute otitis media as an infant.
2. The client has a history of osteogenesis imperfect.
3. The client had a tonsillectomy as an adult.
4. The client had otitis externa from swimming.
Answer: 2. The client has a history of osteogenesis imperfect.

Rationale: Clients with a history of osteogenesis Impertecta often develop bilateral progressive hearing
loss in the second and third decades of life.
Incorrect answers 1,3 and 4 are not significant to the client's hearing loss
45. Fundoscopic examination of the clients eyes reveals the presence of "copper wiring" and
"arteriovenous nicking. These ocular changes are associated with:
1. Perpheral vascular disease
2. Sjogren's syndrome
3. Uncontrolled hypertension
4. Fluctuations in blood glucose
Answer: 3. Uncontrolled hypertension
Rationale: Copper wiring and "arteriovenous nicking" are vascular changes associated wIth uncontrolled
hypertension.
Incorrect answer: 1, 2, and 4 are not associated in changes with peripheral vascular disease, Sjogren's
syndrome, or fluctuations in blood glucose.
Agoo, La Union
46. The physician has prescribed maintenance therapy with Pred-Forte prednisolone 1% ophthalmic
drops tor a client with chronic iritis. The use of the medication
predisposes the client to the development of:
1. Acute glaucoma
2. Retinal detachment
3. Corneal dystrophy
4. Cataract formation
Answer: 4. Cataract formation

Rationale: The early formation of cataracts is more common in those who use steroid preparations.
Incorrect answer: 1, 2, and 3, are not associated with the use or steroid medication.
47. A client states that although her eye does not hurt, she is concerned because she
has developed a "curtain-like" loss of vision in one eye. The nurse recognizes that
the clients loss of vision describes:
1. Ocular melanoma
2. Retinitis pigmentosa
3. Retinal detachment
4. Macular degeneration
Answer: 3. Retinal detachment

Rationale: Curtain-like loss of vision is a symptom of retinal detachment.
Incorrect answer: 1, 2, and 4 are incorrect because "curtain-like" loss of vision is not
a characteristic of ocular melanoma, retinitis pigmentosa, or macular degeneration.
48. A client scheduled for a Type II tympanoplasty asks the nurse to explain what is
involved in the surgery. The nurse should tell the client that:
1. A small surgical incision will be made in the eardrum to relieve pressure.
2. The three bones in the middle ear will be replaced with muscle or fascia.
3. The bones in the middle ear will be reconnected to the tympanic membrane to restore hearing.
4. A polyethylene tube will be surgically placed through the tympanic membrane.
Answer: 3. The bones in the middle ear will be reconnected to the tympanic membrane to restore
hearing.
Rationale: A Type ll tympanoplasty involves the reconnection of the bones of the middle ear to the ear
drum as a means of restoring hearing.
Incorrect answer:1 and 4 describe a myringotomy and insertion of PE tubes to relieve pressure on the
tympanic membrane. 2 describes a stapedectomy.
49. Examination with the Snellen chart reveals that a client has a visual acuity of 20/60. The nurse
recognizes that the client:
1. Has better than 20/20 vision
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2. Is by definition legally blind

3. Has a correctible astigmatism
4. Sees at 20 feet what others see at 60 feet
Answer: 4. Sees at 20 feet what others see at 60 feet

Rationale: The client with 20/60 vision can see from a distance of 20 feet what the normal eye sees at
60 feet.
Incorrect answer: A vision of 20/60 is not better than vision of 20/20.
Legally blind is defined as a vision of 20/20.
Astigmatism is not determined by the Snellen chart.
50. The nurse is reinforcing concepts of topographic mapping tor a client with low vision. Which of the
following is an example or topographic mapping?
1. Using the hands of a clock to help the client located foods on his meal tray
2. Labeling items used by the client with large tags printed in Braille
3. Surrounding light switches with brightly colored paper
4. Offering assistance by providing a sensor-tipped cane
Answer: A. Using the hands of a clock to help the client located foods on his meal tray
Rationale: Topographic concepts can be reinforced by using the hands of a clock to help the client
locate items on her tray. For example, milk is at 3 o'clock, peas are at 5 o'clock, and so on.
Incorrect answer: Answers 2, 3, and 4 might assist the client with low vision; however, they do not
reinforce topographic concepts.
References:
Medical-Surgical 3rd Edition; F.A Davis
http://www.afb.orgThe website for the American Foundation for the Blind
http://www.loc.gov.nis The website for the National Library Services for the Blind and
Physically Handicapped
Brunner, L., and D. Suddarth. Textbook of Medical Surgical Nursing 12th ed. Philadelphia: Lippincot,
Williams & Wilkins, 2009.
Ignatavicius, D., and S. Workman. Medical Surgical Nursing: Critical Thinkimg for Collaborative Care. 5th
ed. Philadelphia: Elsevier, 2007.
Lehne, R. Pharmacology for Nursing Care. 7th ed. Philadelphia: Elsevier, 2009.
LeMone, P, and K. Burke. in Medical Surgical Nursing: Critical Tbinking in Client Care ed. Upper Saddle
River, NJ: Pearson Prentice Hall, 2008.
Agoo, La Union
Lewis, S., M. Heitkemper, S. Dirksen, P Obrien, and L. Bucher Medical SurgicalAsessment and
Management of Clinical Problems. 7 ed. Philadelphia: Elsevier, 2007

Ca Eye and Ear Disorder

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Don Mariano Marcos Memorial State University

South La Union Campus

Nursing clinical scenarios integrating the nursing process, levels

Answer: 1. Loss of peripheral vision.

Answer: 3. Assess the eye for signs/symptoms of complications.

Answer: 3. “I need to use low-watt light bulbs in my house.”

Answer: 2. Stabilize the stick as best as possible.

Answer: 2. Refer the client for an ocular prosthesis.

3. The pupil reacts briskly to light.

Answer: 2. A decrease in intraocular pressure.

Answer: 4. Teach the client how to instill corticosteroid ophthalmic drops.

Answer: 3. Irrigate the eyes with normal saline solution.

1. “I clean my ears every day after I take a shower.”

Answer: 2. “I keep turning up the sound on my television.”

Answer: 1. Perforation of the tympanic membrane.

Answer: 1. Unilateral pain in the ear

Answer: “I must adhere to a low-sodium diet, 2,000 mg/day.”

Answer: Complaints of tinnitus.

4. An oral loop diuretic

Answer: 2. An intravenous aminoglycoside antibiotic

Answer: 3. Use a drying agent in the ear after swimming.

4. Pull the pinna downward and forward to instill the drops.

Answer: 5. Ask the client if he/she is willing to participate in the test.

Eyes and Ears:

Answer: 2. Teach the client to instill the eyedrops as prescribed.

Answer: Pupils one (1) mm, equal and nonreactive to light.

1. Administer the clients oral medication first

Rationale :Gentle pressure should be applied to the puncta (inner

Answer: 4. Retinal tear

Answer: 4. Furnishings include a lounge chair and footstool.

Answer: 2.A 75-year-old receiving Amikin (amikacin sulfate) for pneumonia.

Answer: 4. Preventing injury

client walks to detect objects in his path.

Incorrect answer: Solution should be warm, not cold.

Answer: 2. The client has a history of osteogenesis imperfect.

Answer: 3. Uncontrolled hypertension

Answer: 4. Cataract formation

Answer: 3. Retinal detachment

2. Is by definition legally blind

Answer: 4. Sees at 20 feet what others see at 60 feet

http://www.afb.orgThe website for the American Foundation for the Blind

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