Eye and Ear Disorders Compiled

Test Bank - Brunner & Suddarth's Textbook of Medical-Surgical Nursing 14e (Hinkle 2017) 1186
Chapter 63: Assessment and Management of Patients with Eye and

Vision Disorders
1. The registered nurse taking shift report learns that an assigned patient is blind. How should the nurse
best communicate with this patient?
A) Provide instructions in simple, clear terms.
B) Introduce herself in a firm, loud voice at the doorway of the room.
C) Lightly touch the patients arm and then introduce herself.
D) State her name and role immediately after entering the patients room.
Ans: D
Feedback:
There are several guidelines to consider when interacting with a person who is blind or has low vision.
Identify yourself by stating your name and role, before touching or making physical contact with the
patient. When talking to the person, speak directly at him or her using a normal tone of voice. There is
no need to raise your voice unless the person asks you to do so and there is no particular need to simplify
verbal instructions.
2. The nurse has taken shift report on her patients and has been told that one patient has an ocular condition
that has primarily affected the rods in his eyes. Considering this information, what should the nurse do
while caring for the patient?
A) Ensure adequate lighting in the patients room.
B) Provide a dimly lit room to aid vision by limiting contrast.
C) Carefully point out color differences for the patient.
D) Carefully point out fine details for the patient.
Ans: A
Feedback:
The nurse should provide adequate lighting in the patients room, as the rods are mainly responsible for
night vision or vision in low light. If the patients rods are impaired, the patient will have difficulty seeing
in dim light. The cones in the eyes provide best vision for bright light, color vision, and fine detail.
3. A patient who presents for an eye examination is diagnosed as having a visual acuity of 20/40. The
patient asks the nurse what these numbers specifically mean. What is a correct response by the nurse?
A) A person whose vision is 20/40 can see an object from 40 feet away that a person with 20/20 vision
can see from 20 feet away.
B) A person whose vision is 20/40 can see an object from 20 feet away that a person with 20/20 vision
C) A person whose vision is 20/40 can see an object from 40 inches away that a person with 20/20
vision can see from 20 inches away.
D) A person whose vision is 20/40 can see an object from 20 inches away that a person with 20/20
vision can see from 40 inches away.
Ans: B
Feedback:
The Snellen chart is a tool used to measure visual acuity. It is composed of a series of progressively
smaller rows of letters and is used to test distance vision. The fraction 20/20 is considered the standard
of normal vision. Most people can see the letters on the line designated as 20/20 from a distance of 20
feet. A person whose vision is 20/40 can see an object from 20 feet away that a person with 20/20 vision
4. During discharge teaching the nurse realizes that the patient is not able to read medication bottles
accurately and has not been taking her medications consistently at home. How should the nurse
intervene most appropriately in this situation?
A) Ask the social worker to investigate alternative housing arrangements.
B) Ask the social worker to investigate community support agencies.
C) Encourage the patient to explore surgical corrections for the vision problem.
D) Arrange for referral to a rehabilitation facility for vision training.
Ans: B
Feedback:
Managing low vision involves magnification and image enhancement through the use of low-vision aids
and strategies and referrals to social services and community agencies serving those with visual
impairment. Community agencies offer services to patients with low vision, which include training in
independent living skills and a variety of assistive devices for vision enhancement, orientation, and
mobility, preventing patients from needing to enter a nursing facility. A rehabilitation facility is
generally not needed by the patients to learn to use the assistive devices or to gain a greater degree of
independence. Surgical options may or may not be available to the patient.
5. The nurse is providing health education to a patient newly diagnosed with glaucoma. The nurse teaches
the patient that this disease has a familial tendency. The nurse should encourage the patients immediate
family members to undergo clinical examinations how often?
A) At least monthly
B) At least once every 2 years
C) At least once every 5 years
D) At least once every 10 years
Ans: B
Feedback:
Glaucoma has a family tendency and family members should be encouraged to undergo examinations at
least once every 2 years to detect glaucoma early. Testing on a monthly basis is not necessary and
excessive.
6. A patient is exploring treatment options after being diagnosed with age-related cataracts that affect her
vision. What treatment is most likely to be used in this patients care?
A) Antioxidant supplements, vitamin C and E, beta-carotene, and selenium
B) Eyeglasses or magnifying lenses
C) Corticosteroid eye drops
D) Surgical intervention
Ans: D
Feedback:
Surgery is the treatment option of choice when the patients functional and visual status is compromised.
No nonsurgical (medications, eye drops, eyeglasses) treatment cures cataracts or prevents age-related
cataracts. Studies recently have found no benefit from antioxidant supplements, vitamins C and E, beta-
carotene, or selenium. Corticosteroid eye drops are prescribed for use after cataract surgery; however,
they increase the risk for cataracts if used long-term or in high doses. Eyeglasses and magnification may
improve vision in the patient with early stages of cataracts, but have limitations for the patient with
impaired functioning.
7. A patient presents at the ED after receiving a chemical burn to the eye. What would be the nurses initial
intervention for this patient?
A) Generously flush the affected eye with a dilute antibiotic solution.
B) Generously flush the affected eye with normal saline or water.
C) Apply a patch to the affected eye.
D) Apply direct pressure to the affected eye.
Ans: B
Feedback:
Chemical burns of the eye should be immediately irrigated with water or normal saline to flush the
chemical from the eye. Antibiotic solutions, lubricant drops, and other prescription drops may be
prescribed at a later time. Application of direct pressure may extend the damage to the eye tissue and
should be avoided. Patching will be incorporated into the treatment plan at a later time to assist with the
process of re-epithelialization, but at this point in the care of the patient, patching will prevent irrigation
of the eye.
8. The nurse is administering eye drops to a patient with glaucoma. After instilling the patients first
medication, how long should the nurse wait before instilling the patients second medication into the
same eye?
A) 30 seconds
B) 1 minute
C) 3 minutes
D) 5 minutes
Ans: D
Feedback:
A 5-minute interval between successive eye drop administrations allows for adequate drug retention and
absorption. Any time frame less than 5 minutes will not allow adequate absorption.
9. A patient is being discharged home from the ambulatory surgical center after cataract surgery. In
reviewing the discharge instructions with the patient, the nurse instructs the patient to immediately call
the office if the patient experiences what?
A) Slight morning discharge from the eye
B) Any appearance of redness of the eye

C) A scratchy feeling in the eye
D) A new floater in vision
Ans: D
Feedback:
Cataract surgery increases the risk of retinal detachment and the patient must be instructed to notify the
surgeon of new floaters in vision, flashing lights, decrease in vision, pain, or increase in redness. Slight
morning discharge, some redness, and a scratchy feeling may be expected for a few days after surgery.
10. A patient comes to the ophthalmology clinic for an eye examination. The patient tells the nurse that he
often sees floaters in his vision. How should the nurse best interpret this subjective assessment finding?
A) This is a normal aging process of the eye.
B) Glasses will minimize this phenomenon.
C) The patient may be exhibiting signs of glaucoma.
D) This may be a result of weakened ciliary muscles.
Ans: A
Feedback:
As the body ages, the perfect gel-like characteristics of the vitreous humor are gradually lost, and
various cells and fibers cast shadows that the patient perceives as floaters. This is a normal aging
process.
11. A patients ocular tumor has necessitated enucleation and the patient will be fitted with a prosthesis. The
nurse should address what nursing diagnosis when planning the patients discharge education?
A) Disturbed body image
B) Chronic pain
C) Ineffective protection
D) Unilateral neglect
Ans: A
Feedback:
The use of an ocular prosthesis is likely to have a significant impact on a patients body image.
Prostheses are not associated with chronic pain or ineffective protection. The patient experiences a
change in vision, but is usually able to accommodate such changes and prevent unilateral neglect.
12. The nurses assessment of a patient with significant visual losses reveals that the patient cannot count
fingers. How should the nurse proceed with assessment of the patients visual acuity?
A) Assess the patients vision using a Snellen chart.
B) Determine whether the patient is able to see the nurses hand motion.
C) Perform a detailed examination of the patients external eye structures.
D) Palpate the patients periocular regions.
Ans: B
Feedback:
If the patient cannot count fingers, the examiner raises one hand up and down or moves it side to side
and asks in which direction the hand is moving. An inability to count fingers precludes the use of a
Snellen chart. Palpation and examination cannot ascertain visual acuity.
13. The nurse on the medicalsurgical unit is reviewing discharge instructions with a patient who has a
history of glaucoma. The nurse should anticipate the use of what medications?
A) Potassium-sparing diuretics
B) Cholinergics
C) Antibiotics
D) Loop diuretics
Ans: B
Feedback:
Cholinergics are used in the treatment of glaucoma. The action of this medication is to increase aqueous
fluid outflow by contracting the ciliary muscle and causing miosis and opening the trabecular meshwork.
Diuretics and antibiotics are not used in the management of glaucoma.
14. A nurse is teaching a patient with glaucoma how to administer eye drops to achieve maximum
absorption. The nurse should teach the patient to perform what action?
A) Instill the medication in the conjunctival sac.
B) Maintain a supine position for 10 minutes after administration.
C) Keep the eyes closed for 1 to 2 minutes after administration.
D) Apply the medication evenly to the sclera
Ans: A
Feedback:
Eye drops should be instilled into the conjunctival sac, where absorption can best take place, rather than
distributed over the sclera. It is unnecessary to keep the eyes closed or to maintain a supine position after
administration.
15. A patient with chronic open-angle glaucoma is being taught to self-administer pilocarpine. After the
patient administers the pilocarpine, the patient states that her vision is blurred. Which nursing action is
most appropriate?
A) Holding the next dose and notifying the physician
B) Treating the patient for an allergic reaction
C) Suggesting that the patient put on her glasses
D) Explaining that this is an expected adverse effect
Ans: D
Feedback:
Pilocarpine, a miotic drug used to treat glaucoma, achieves its effect by constricting the pupil. Blurred
vision lasting 1 to 2 hours after instilling the eye drops is an expected adverse effect. The patient may
also note difficulty adapting to the dark. Because blurred vision is an expected adverse effect, the drug
does not need to be withheld, nor does the physician need to be notified. Likewise, the patient does not
need to be treated for an allergic reaction. Wearing glasses will not alter this temporary adverse effect.
16. The nurse should recognize the greatest risk for the development of blindness in which of the following
patients?
A) A 58-year-old Caucasian woman with macular degeneration

B) A 28-year-old Caucasian man with astigmatism
C) A 58-year-old African American woman with hyperopia
D) A 28-year-old African American man with myopia
Ans: A
Feedback:
The most common causes of blindness and visual impairment among adults 40 years of age or older are
diabetic retinopathy, macular degeneration, glaucoma, and cataracts. The 58-year-old Caucasian woman
with macular degeneration has the greatest risk for the development of blindness related to her age and
the presence of macular degeneration. Individuals with hyperopia, astigmatism, and myopia are not in a
risk category for blindness.
17. A 6-year-old child is brought to the pediatric clinic for the assessment of redness and discharge from the
eye and is diagnosed with viral conjunctivitis. What is the most important information to discuss with
the parents and child?
A) Handwashing can prevent the spread of the disease to others.
B) The importance of compliance with antibiotic therapy
C) Signs and symptoms of complications, such as meningitis and septicemia
D) The likely need for surgery to prevent scarring of the conjunctiva
Ans: A
Feedback:
The nurse must inform the parents and child that viral conjunctivitis is highly contagious and
instructions should emphasize the importance of handwashing and avoiding sharing towels, face cloths,
and eye drops. Viral conjunctivitis is not responsive to any treatment, including antibiotic therapy.
Patients with gonococcal conjunctivitis are at risk for meningitis and generalized septicemia; these
conditions do not apply to viral conjunctivitis. Surgery to prevent scarring of the conjunctiva is not
associated with viral conjunctivitis.
18. The nurse is admitting a 55-year-old male patient diagnosed with a retinal detachment in his left eye.
While assessing this patient, what characteristic symptom would the nurse expect to find?
A) Flashing lights in the visual field
B) Sudden eye pain

C) Loss of color vision
D) Colored halos around lights
Ans: A
Feedback:
Flashing lights in the visual field is a common symptom of retinal detachment. Patients may also report
spots or floaters or the sensation of a curtain being pulled across the eye. Retinal detachment is not
associated with eye pain, loss of color vision, or colored halos around lights.
19. Several residents of a long-term care facility have developed signs and symptoms of viral conjunctivitis.
What is the most appropriate action of the nurse who oversees care in the facility?
A) Arrange for the administration of prophylactic antibiotics to unaffected residents.
B) Instill normal saline into the eyes of affected residents two to three times daily.
C) Swab the conjunctiva of unaffected residents for culture and sensitivity testing.
D) Isolate affected residents from residents who have not developed conjunctivitis.
Ans: D
Feedback:
To prevent spread during outbreaks of conjunctivitis caused by adenovirus, health care facilities must set
aside specified areas for treating patients diagnosed with or suspected of having conjunctivitis caused by
adenovirus. Antibiotics and saline flushes are ineffective and normally no need to perform testing of
individuals lacking symptoms.
20. A patient has just returned to the surgical floor after undergoing a retinal detachment repair. The
postoperative orders specify that the patient should be kept in a prone position until otherwise ordered.
What should the nurse do?
A) Call the physician and ask for the order to be confirmed.
B) Follow the order because this position will help keep the retinal repair intact.
C) Instruct the patient to maintain this position to prevent bleeding.
D) Reposition the patient after the first dressing change.
Ans: B
Feedback:
For pneumatic retinopexy, postoperative positioning of the patient is critical because the injected bubble
must float into a position overlying the area of detachment, providing consistent pressure to reattach the
sensory retina. The patient must maintain a prone position that would allow the gas bubble to act as a
tamponade for the retinal break. Patients and family members should be made aware of these special
needs beforehand so that the patient can be made as comfortable as possible. It would be inappropriate
to deviate from this order and there is no obvious need to confirm the order.
21. A patient has informed the home health nurse that she has recently noticed distortions when she looks at
the Amsler grid that she has mounted on her refrigerator. What is the nurses most appropriate action?
A) Reassure the patient that this is an age-related change in vision.
B) Arrange for the patient to have her visual acuity assessed.
C) Arrange for the patient to be assessed for macular degeneration.
D) Facilitate tonometry testing.
Ans: C
Feedback:
18, The Amsler grid is a test often used for patients with macular problems, such as macular
degeneration. Distortions would not be attributed to age-related changes and there is no direct need for
testing of intraocular pressure or visual acuity.
22. A 56-year-old patient has come to the clinic for his routine eye examination and is told he needs
bifocals. The patient asks the nurse what change in his eyes has caused his need for bifocals. How
should the nurse respond?
A) You know, you are getting older now and we change as we get older.
B) The parts of our eyes age, just like the rest of us, and this is nothing to cause you to worry.
C) There is a gradual thickening of the lens of the eye and it can limit the eyes ability for
accommodation.
D) The eye gets shorter, back to front, as we age and it changes how we see things.
Ans: C
Feedback:
As a result of a loss of accommodative power in the lens with age, many adults require bifocals or other
forms of visual correction. This is not attributable to a change in the shape of the ocular globe. The nurse
should not dismiss or downplay the patients concerns.
23. The nurse is teaching a patient to care for her new ocular prosthesis. What should the nurse emphasize
during the patients health education?
A) The need to limit exposure to bright light
B) The need to maintain a low Fowlers position when removing the prosthesis
C) The need to perform thorough hand hygiene before handling the prosthesis
D) The need to apply antiviral ointment to the prosthesis daily
Ans: C
Feedback:
Proper hand hygiene must be observed before inserting and removing an ocular prosthesis. There is no
need for a low Fowlers position or for limiting light exposure. Antiviral ointments are not routinely
used.
24. Cytomegalovirus (CMV) is the most common cause of retinal inflammation in patients with AIDS.
What drug, surgically implanted, is used for the acute stage of CMV retinitis?
A) Pilocarpine
B) Penicillin
C) Ganciclovir
D) Gentamicin
Ans: C
Feedback:
The surgically implanted sustained-release insert of ganciclovir enables higher concentrations of

ganciclovir to reach the CMV retinitis. Pilocarpine is a muscarinic agent used in open-angle glaucoma.
Gentamicin and penicillin are antibiotics that are not used to treat CMV retinitis.
25. A patient got a sliver of glass in his eye when a glass container at work fell and shattered. The glass had
to be surgically removed and the patient is about to be discharged home. The patient asks the nurse for a
topical anesthetic for the pain in his eye. What should the nurse respond?
A) Overuse of these drops could soften your cornea and damage your eye.
B) You could lose the peripheral vision in your eye if you used these drops too much.
C) Im sorry, this medication is considered a controlled substance and patients cannot take it home.
D) I know these drops will make your eye feel better, but I cant let you take them home.
Ans: A
Feedback:
Most patients are not allowed to take topical anesthetics home because of the risk of overuse. Patients
with corneal abrasions and erosions experience severe pain and are often tempted to overuse topical
anesthetic eye drops. Overuse of these drops results in softening of the cornea. Prolonged use of
anesthetic drops can delay wound healing and can lead to permanent corneal opacification and scarring,
resulting in visual loss. The nurse must explain the rationale for limiting the home use of these
medications.
26. A patient has been diagnosed with glaucoma and the nurse is preparing health education regarding the
patients medication regimen. The patient states that she is eager to beat this disease and looks forward to
the time that she will no longer require medication. How should the nurse best respond?
A) You have a great attitude. This will likely shorten the amount of time that you need medications.
B) In fact, glaucoma usually requires lifelong treatment with medications.
C) Most people are treated until their intraocular pressure goes below 50 mm Hg.
D) You can likely expect a minimum of 6 months of treatment.
Ans: B
Feedback:
Glaucoma requires lifelong pharmacologic treatment. Normal intraocular pressure is between 10 and 21
mm Hg.
27. An older adult patient has been diagnosed with macular degeneration and the nurse is assessing him for
changes in visual acuity since his last clinic visit. When assessing the patient for recent changes in visual
acuity, the patient states that he sees the lines on an Amsler grid as being distorted. What is the nurses
most appropriate response?
A) Ask if the patient has been using OTC vasoconstrictors.
B) Instruct the patient to repeat the test at different times of the day when at home.
C) Arrange for the patient to visit his ophthalmologist.
D) Encourage the patient to adhere to his prescribed drug regimen.
Ans: C
Feedback:
With a change in the patients perception of the grid, the patient should notify the ophthalmologist
immediately and should arrange to be seen promptly. This is a priority over encouraging drug adherence,
even though this is also important. Vasoconstrictors are not a likely cause of this change and repeating
the test at different times is not relevant.
28. A public health nurse is teaching a health promotion workshop that focuses on vision and eye health.
What should this nurse cite as the most common causes of blindness and visual impairment among
adults over the age of 40? Select all that apply.
A) Diabetic retinopathy
B) Trauma
C) Macular degeneration
D) Cytomegalovirus
E) Glaucoma
Ans: A, C, E
Feedback:
The most common causes of blindness and visual impairment among adults 40 years of age or older are
diabetic retinopathy, macular degeneration, glaucoma, and cataracts. Therefore, trauma and
cytomegalovirus are incorrect.
29. The nurse is providing discharge education to an adult patient who will begin a regimen of ocular
medications for the treatment of glaucoma. How can the nurse best determine if the patient is able to
self-administer these medications safely and effectively?
A) Assess the patient for any previous inability to self-manage medications.
B) Ask the patient to demonstrate the instillation of her medications.
C) Determine whether the patient can accurately describe the appropriate method of administering her
medications.
D) Assess the patients functional status.
Ans: B
Feedback:
The patient or the caregiver at home should be asked to demonstrate actual eye drop administration. This
method of assessment is more accurate than asking the patient to describe the process or determining
earlier inabilities to self-administer medications. The patients functional status will not necessarily
determine the ability to administer medication safely.
30. A patient with low vision has called the clinic and asked the nurse for help with acquiring some low-
vision aids. What else can the nurse offer to help this patient manage his low vision?
A) The patient uses OTC NSAIDs.
B) The patient has a history of stroke.
C) The patient has diabetes.
D) The patient has Asian ancestry.
Ans: C
Feedback:
Diabetes is a risk factor for glaucoma, but Asian ancestry, NSAIDs, and stroke are not risk factors for
the disease.
31. The public health nurse is addressing eye health and vision protection during an educational event. What
statement by a participant best demonstrates an understanding of threats to vision?
A) Im planning to avoid exposure to direct sunlight on my next vacation.
B) Ive never exercised regularly, but Im going to start working out at the gym daily.
C) Im planning to talk with my pharmacist to review my current medications.
D) Im certainly going to keep a close eye on my blood pressure from now on.
Ans: D
Feedback:
Hypertension is a major cause of vision loss, exceeding the significance of inactivity, sunlight, and
adverse effects of medications.
32. A patient has had a sudden loss of vision after head trauma. How should the nurse best describe the
placement of items on the dinner tray?
A) Explain the location of items using clock cues.
B) Explain that each of the items on the tray is clearly separated.
C) Describe the location of items from the bottom of the plate to the top.
D) Ask the patient to describe the location of items before confirming their location.
Ans: A
Feedback:
The food trays composition is likened to the face of a clock. It is unreasonable to expect the patient to
describe the location of items or to state that items are separated.
33. A hospitalized patient with impaired vision must get a picture in his or her mind of the hospital room
and its contents in order to mobilize independently and safely. What must the nurse monitor in the
patients room?
A) That a commode is always available at the bedside
B) That all furniture remains in the same position
C) That visitors do not leave items on the bedside table
D) That the patients slippers stay under the bed
Ans: B
Feedback:
All articles and furniture must remain in the same positions throughout the patients hospitalization. This
will reduce the patients risks for falls. Visual impairment does not necessarily indicate a need for a
commode. Keeping slippers under the bed and keeping the bedside table clear are also appropriate, but
preventing falls by maintaining the room arrangement is a priority.
34. A patient has just arrived to the floor after an enucleation procedure following a workplace accident in
which his left eye was irreparably damaged. Which of the following should the nurse prioritize during
the patients immediate postoperative recovery?
A) Teaching the patient about options for eye prostheses
B) Teaching the patient to estimate depth and distance with the use of one eye
C) Assessing and addressing the patients emotional needs
D) Teaching the patient about his post-discharge medication regimen
Ans: C
Feedback:
When surgical eye removal is unexpected, such as in severe ocular trauma, leaving no time for the
patient and family to prepare for the loss, the nurses role in providing emotional support is crucial. In the
short term, this is a priority over teaching regarding prostheses, medications, or vision adaptation.
35. A patient with a diagnosis of retinal detachment has undergone a vitreoretinal procedure on an outpatient
basis. What subject should the nurse prioritize during discharge education?
A) Risk factors for postoperative cytomegalovirus (CMV)
B) Compensating for vision loss for the next several weeks
C) Non-pharmacologic pain management strategies
D) Signs and symptoms of increased intraocular pressure
Ans: D
Feedback:
Patients must be educated about the signs and symptoms of complications, particularly of increasing IOP
and postoperative infection. CMV is not a typical complication and the patient should not expect vision
loss. Vitreoretinal procedures are not associated with high levels of pain.
36. A patient is ready to be discharged home after a cataract extraction with intraocular lens implant and the
nurse is reviewing signs and symptoms that need to be reported to the ophthalmologist immediately.
Which of the patients statements best demonstrates an adequate understanding?
A) I need to call the doctor if I get nauseated.
B) I need to call the doctor if I have a light morning discharge.

C) I need to call the doctor if I get a scratchy feeling.
D) I need to call the doctor if I see flashing lights.
Ans: D
Feedback:
Postoperatively, the patient who has undergone cataract extraction with intraocular lens implant should
report new floaters in vision, flashing lights, decrease in vision, pain, or increase in redness to the
ophthalmologist. Slight morning discharge and a scratchy feeling can be expected for a few days.
Blurring of vision may be experienced for several days to weeks.
37. A patient has lost most of her vision as a result of macular degeneration. When attempting to meet this
patients psychosocial needs, what nursing action is most appropriate?
A) Encourage the patient to focus on her use of her other senses.
B) Assess and promote the patients coping skills during interactions with the patient.
C) Emphasize that her lifestyle will be unchanged once she adapts to her vision loss.
D) Promote the patients hope for recovery.
Ans: B
Feedback:
The nurse should empathically promote the patients coping with her loss. Focusing on the remaining
senses could easily be interpreted as downplaying the patients loss, and recovery is not normally a
realistic possibility. Even with successful adaptation, the patients lifestyle will be profoundly affected.
38. When administering a patients eye drops, the nurse recognizes the need to prevent absorption by the
nasolacrimal duct. How can the nurse best achieve this goal?
A) Ensure that the patient is well hydrated at all times.
B) Encourage self-administration of eye drops.
C) Occlude the puncta after applying the medication.
D) Position the patient supine before administering eye drops.
Ans: C
Feedback:
Absorption of eye drops by the nasolacrimal duct is undesirable because of the potential systemic side
effects of ocular medications. To diminish systemic absorption and minimize the side effects, it is
important to occlude the puncta. Self-administration, supine positioning, and adequate hydration do not
prevent this adverse effect.
39. A patient with glaucoma has presented for a scheduled clinic visit and tells the nurse that she has begun
taking an herbal remedy for her condition that was recommended by a work colleague. What instruction
should the nurse provide to the patient?
A) The patient should discuss this new remedy with her ophthalmologist promptly.
B) The patient should monitor her IOP closely for the next several weeks.
C) The patient should do further research on the herbal remedy.
D) The patient should report any adverse effects to her pharmacist.
Ans: A
Feedback:
Patients should discuss any new treatments with an ophthalmologist; this should precede the patients
own further research or reporting adverse effects to the pharmacist. Self-monitoring of IOP is not
possible.
40. A patient is scheduled for enucleation and the nurse is providing anticipatory guidance about
postoperative care. What aspects of care should the nurse describe to the patient? Select all that apply.
A) Application of topical antibiotic ointment
B) Maintenance of a supine position for the first 48 hours postoperative
C) Fluid restriction to prevent orbital edema
D) Administration of loop diuretics to prevent orbital edema
E) Use of an ocular pressure dressing
Ans: A, E
Feedback:
Patients who undergo eye removal need to know that they will usually have a large ocular pressure
dressing, which is typically removed after a week, and that an ophthalmic topical antibiotic ointment is
applied in the socket three times daily. Fluid restriction, supine positioning, and diuretics are not
indicated.
Chapter 64: Assessment and Management of Patients with Hearing and

Balance Disorders
1. The clinic nurse is assessing a child who has been brought to the clinic with signs and symptoms that are
suggestive of otitis externa. What assessment finding is characteristic of otitis externa?
A) Tophi on the pinna and ear lobe
B) Dark yellow cerumen in the external auditory canal
C) Pain on manipulation of the auricle
D) Air bubbles visible in the middle ear
Ans: C
Feedback:
Pain when the nurse pulls gently on the auricle in preparation for an otoscopic examination of the ear
canal is a characteristic finding in patients with otitis externa. Tophi are deposits of generally painless
uric acid crystals; they are a common physical assessment finding in patients diagnosed with gout.
Cerumen is a normal finding during assessment of the ear canal. Its presence does not necessarily
indicate that inflammation is present. Air bubbles in the middle ear may be visualized with the otoscope;
however, these do not indicate a problem involving the ear canal.
2. While reviewing the health history of an older adult experiencing hearing loss the nurse notes the patient
has had no trauma or loss of balance. What aspect of this patients health history is most likely to be
linked to the patients hearing deficit?
A) Recent completion of radiation therapy for treatment of thyroid cancer
B) Routine use of quinine for management of leg cramps
C) Allergy to hair coloring and hair spray
D) Previous perforation of the eardrum
Ans: B
Feedback:
Long-term, regular use of quinine for management of leg cramps is associated with loss of hearing
acuity. Radiation therapy for cancer should not affect hearing; however, hearing can be significantly
compromised by chemotherapy. Allergy to hair products may be associated with otitis externa; however,
it is not linked to hearing loss. An ear drum that perforates spontaneously due to the sudden drop in
altitude associated with a high dive usually heals well and is not likely to become infected. Recurrent
otitis media with perforation can affect hearing as a result of chronic inflammation of the ossicles in the
middle ear.
3. A nurse is planning preoperative teaching for a patient with hearing loss due to otosclerosis. The patient
is scheduled for a stapedectomy with insertion of a prosthesis. What information is most crucial to
include in the patients preoperative teaching?
A) The procedure is an effective, time-tested treatment for sensory hearing loss.
B) The patient is likely to experience resolution of conductive hearing loss after the procedure.
C) Several months of post-procedure rehabilitation will be needed to maximize benefits.
D) The procedure is experimental, but early indications suggest great therapeutic benefits.
Ans: B
Feedback:
Stapedectomy is a very successful time-tested procedure, resulting in the restoration of conductive

hearing loss. Lengthy rehabilitation is not normally required.
4. Which of the following nursing interventions would most likely facilitate effective communication with
a hearing-impaired patient?
A) Ask the patient to repeat what was said in order to evaluate understanding.
B) Stand directly in front of the patient to facilitate lip reading.
C) Reduce environmental noise and distractions before communicating.
D) Raise the voice to project sound at a higher frequency.
Ans: C
Feedback:
Communication with the hearing impaired can be facilitated by talking in a quiet space free of
competing noise stimuli and other distractions. Asking the patient to repeat what was said is likely to
provoke frustration in the patient. A more effective strategy would be to repeat the question or
statement, choosing different words. Raising the voice to project sound at higher frequency would make
understanding more difficult. The nurse cannot assume that the patient reads lips. If the patient does read
lips, on average he or she will understand only 50% of words accurately.
5. The nurse is providing discharge education for a patient with a new diagnosis of Mnires disease. What
food should the patient be instructed to limit or avoid?
A) Sweet pickles
B) Frozen yogurt
C) Shellfish
D) Red meat
Ans: A
Feedback:
The patient with Mnires disease should avoid foods high in salt and/or sugar; sweet pickles are high in
both. Milk products are not contraindicated. Any type of meat, fish, or poultry is permitted, with the
exception of canned or pickled varieties. In general, the patient with Mnires disease should avoid or
limit canned and processed foods.
6. Following a motorcycle accident, a 17-year-old man is brought to the ED. What physical assessment
findings related to the ear should be reported by the nurse immediately?
A) The malleus can be visualized during otoscopic examination.
B) The tympanic membrane is pearly gray.
C) Tenderness is reported by the patient when the mastoid area is palpated.
D) Clear, watery fluid is draining from the patients ear.
Ans: D
Feedback:
For the patient experiencing acute head trauma, immediately report the presence of clear, watery
drainage from the ear. The fluid is likely to be cerebrospinal fluid associated with skull fracture. The
ability to visualize the malleus is a normal physical assessment finding. The tympanic membrane is
normally pearly gray in color. Tenderness of the mastoid area usually indicates inflammation. This
should be reported, but is not a finding indicating urgent intervention.
7. A patient has been diagnosed with hearing loss related to damage of the end organ for hearing or cranial
nerve VIII. What term is used to describe this condition?
A) Exostoses
B) Otalgia
C) Sensorineural hearing loss
D) Presbycusis
Ans: C
Feedback:
Sensorineural hearing loss is loss of hearing related to damage of the end organ for hearing or cranial
nerve VIII. Exostoses refer to small, hard, bony protrusions in the lower posterior bony portion of the ear
canal. Otalgia refers to a sensation of fullness or pain in the ear. Presbycusis is the term used to refer to
the progressive hearing loss associated with aging. Both middle and inner ear age-related changes result
in hearing loss.
8. A group of high school students is attending a concert, which will be at a volume of 80 to 90 dB. What is
a health consequence of this sound level?
A) Hearing will not be affected by a decibel level in this range.
B) Hearing loss may occur with a decibel level in this range.
C) Sounds in this decibel level are not perceived to be harsh to the ear.
D) Ear plugs will have no effect on these decibel levels.
Ans: B
Feedback:
Sound louder than 80 dB is perceived by the human ear to be harsh and can be damaging to the inner
ear. Ear protection or plugs do help to minimize the effects of high decibel levels.
9. A patient has undergone diagnostic testing and has been diagnosed with otosclerosis? What ear structure
is primarily affected by this diagnosis?
A) Malleus
B) Stapes
C) Incus
D) Tympanic membrane
Ans: B
Feedback:
Otosclerosis involves the stapes and is thought to result from the formation of new, abnormal bone,
especially around the oval window, with resulting fixation of the stapes.
10. A patient with otosclerosis has significant hearing loss. What should the nurse do to best facilitate
communication with the patient?
A) Sit or stand in front of the patient when speaking.
B) Use exaggerated lip and mouth movements when talking.
C) Stand in front of a light or window when speaking.
D) Say the patients name loudly before starting to talk.
Ans: A
Feedback:
Standing directly in front of a hearing-impaired patient allows him or her to lip-read and see facial
expressions that offer clues to what is being said. Using exaggerated lip and mouth movements can
make lip-reading more difficult by distorting words. Backlighting can create glare, making it difficult for
the patient to lip-read. To get the attention of a hearing-impaired patient, gently touch the patients
shoulder or stand in front of the patient.
11. The nurse in the ED is caring for a 4 year-old brought in by his parents who state that the child will not
stop crying and pulling at his ear. Based on information collected by the nurse, which of the following
statements applies to a diagnosis of external otitis?
A) External otitis is characterized by aural tenderness.
B) External otitis is usually accompanied by a high fever.
C) External otitis is usually related to an upper respiratory infection.
D) External otitis can be prevented by using cotton-tipped applicators to clean the ear.
Ans: A
Feedback:
Patients with otitis externa usually exhibit pain, discharge from the external auditory canal, and aural
tenderness. Fever and accompanying upper respiratory infection occur more commonly in conjunction
with otitis media (infection of the middle ear). Cotton-tipped applicators can actually cause external
otitis so their use should be avoided.
12. A patient diagnosed with arthritis has been taking aspirin and now reports experiencing tinnitus and
hearing loss. What should the nurse teach this patient?
A) The hearing loss will likely resolve with time after the drug is discontinued.
B) The patients hearing loss and tinnitus are irreversible at this point.
C) The patients tinnitus is likely multifactorial, and not directly related to aspirin use.
D) The patients tinnitus will abate as tolerance to aspirin develops.
Ans: A
Feedback:
Tinnitus and hearing loss are signs of ototoxicity, which is associated with aspirin use. In most cases,
this will resolve upon discontinuing the aspirin. Many other drugs cause irreversible ototoxicity.
13. A patient is postoperative day 6 following tympanoplasty and mastoidectomy. The patient has phoned
the surgical unit and states that she is experiencing occasional sharp, shooting pains in her affected ear.
How should the nurse best interpret this patients complaint?
A) These pains are an expected finding during the first few weeks of recovery.
B) The patients complaints are suggestive of a postoperative infection.
C) The patient may have experienced a spontaneous rupture of the tympanic membrane.
D) The patients surgery may have been unsuccessful.
Ans: A
Feedback:
For 2 to 3 weeks after surgery, the patient may experience sharp, shooting pains intermittently as the
eustachian tube opens and allows air to enter the middle ear. Constant, throbbing pain accompanied by
fever may indicate infection and should be reported to the primary care provider. The patients pain does
not suggest tympanic perforation or unsuccessful surgery.
14. The nurse is discussing the results of a patients diagnostic testing with the nurse practitioner. What
Weber test result would indicate the presence of a sensorineural loss?
A) The sound is heard better in the ear in which hearing is better.
B) The sound is heard equally in both ears.
C) The sound is heard better in the ear in which hearing is poorer.
D) The sound is heard longer in the ear in which hearing is better.
Ans: A
Feedback:
A patient with sensorineural hearing loss hears the sound better in the ear in which hearing is better. The
Weber test assesses bone conduction of sound and is used for assessing unilateral hearing loss. A tuning
fork is used. A patient with normal hearing hears the sound equally in both ears or describes the sound
as centered in the middle of the head. A patient whose hearing loss is conductive hears the sound better
in the affected ear.
15. The advanced practice nurse is attempting to examine the patients ear with an otoscope. Because of
impacted cerumen, the tympanic membrane cannot be visualized. The nurse irrigates the patients ear
with a solution of hydrogen peroxide and water to remove the impacted cerumen. What nursing
intervention is most important to minimize nausea and vertigo during the procedure?
A) Maintain the irrigation fluid at a warm temperature.
B) Instill short, sharp bursts of fluid into the ear canal.
C) Follow the procedure with insertion of a cerumen curette to extract missed ear wax.
D) Have the patient stand during the procedure.
Ans: A
Feedback:
Warm water (never cold or hot) and gentle, not forceful, irrigation should be used to remove cerumen.
Too forceful irrigation can cause perforation of the tympanic membrane, and ice water causes vomiting.
Cerumen curettes should not be routinely used by the nurse. Special training is required to use a curette
safely. It is unnecessary to have the patient stand during the procedure.
16. A patient is scheduled to have an electronystagmography as part of a diagnostic workup for Mnires
disease. What question is it most important for the nurse to ask the patient in preparation for this test?
A) Have you ever experienced claustrophobia or feelings of anxiety while in enclosed spaces?
B) Do you currently take any tranquilizers or stimulants on a regular basis?

C) Do you have a history of falls or problems with loss of balance?
D) Do you have a history of either high or low blood pressure?
Ans: B
Feedback:
Electronystagmography measures changes in electrical potentials created by eye movements during

induced nystagmus. Medications such as tranquilizers, stimulants, or antivertigo agents are withheld for
5 days before the test. Claustrophobia is not a significant concern associated with this test; rather, it is
most often a concern for patients undergoing magnetic resonance imaging (MRI). Balance is impaired
by Mnires disease; therefore, a patient history of balance problems is important, but is not relevant to
test preparation. Hypertension or hypotension, while important health problems, should not be affected
by this test.
17. The nurse is planning the care of a patient who is adapting to the use of a hearing aid for the first time.
What is the most significant challenge experienced by a patient with hearing loss who is adapting to
using a hearing aid for the first time?
A) Regulating the tone and volume
B) Learning to cope with amplification of background noise
C) Constant irritation of the external auditory canal
D) Challenges in keeping the hearing aid clean while minimizing exposure to moisture
Ans: B
Feedback:
Each of the answers represents a common problem experienced by patients using a hearing aid for the
first time. However, amplification of background noise is a difficult problem to manage and is the major
reason why patients stop using their hearing aid. All patients learning to use a hearing aid require
support and coaching by the nurse and other members of the health care team. Patients should be
encouraged to discuss their adaptation to the hearing aid with their audiologist.
18. A patient with mastoiditis is admitted to the post-surgical unit after undergoing a radical mastoidectomy.
The nurse should identify what priority of postoperative care?
A) Assessing for mouth droop and decreased lateral eye gaze
B) Assessing for increased middle ear pressure and perforated ear drum
C) Assessing for gradual onset of conductive hearing loss and nystagmus
D) Assessing for scar tissue and cerumen obstructing the auditory canal
Ans: A
Feedback:
The facial nerve runs through the middle ear and the mastoid; therefore, there is risk of injuring this
nerve during a mastoidectomy. When injury occurs, the patient may display mouth droop and decreased
lateral gaze on the operative side. Scar tissue is a long-term complication of tympanoplasty and therefore
would not be evident during the immediate postoperative period. Tympanic perforation is not a common
complication of this surgery.
19. The nurse is assessing a patient with multiple sclerosis who is demonstrating involuntary, rhythmic eye
movements. What term will the nurse use when documenting these eye movements?
A) Vertigo
B) Tinnitus
C) Nystagmus
D) Astigmatism
Ans: C
Feedback:
Vertigo is an illusion of movement where the individual or the surroundings are sensed as moving.
Tinnitus refers to a subjective perception of sound with internal origin. Nystagmus refers to involuntary
rhythmic eye movement. Astigmatism is a defect is visual acuity.
20. The nurse is planning the care of a patient with a diagnosis of vertigo. What nursing diagnosis risk
should the nurse prioritize in this patients care?
A) Risk for disturbed sensory perception
B) Risk for unilateral neglect
C) Risk for falls
D) Risk for ineffective health maintenance
Ans: C
Feedback:
Vertigo is defined as the misperception or illusion of motion, either of the person or the surroundings. A
patient suffering from vertigo will be at an increased risk of falls. For most patients, this is likely to
exceed the patients risk for neglect, ineffective health maintenance, or disturbed sensation.
21. A patient has been diagnosed with serous otitis media for the third time in the past year. How should the
nurse best interpret this patients health status?
A) For some patients, these recurrent infections constitute an age-related physiologic change.
B) The patient would benefit from a temporary mobility restriction to facilitate healing.
C) The patient needs to be assessed for nasopharyngeal cancer.
D) Blood cultures should be drawn to rule out a systemic infection.
Ans: C
Feedback:
A carcinoma (e.g., nasopharyngeal cancer) obstructing the eustachian tube should be ruled out in adults
with persistent unilateral serous otitis media. This phenomenon is not an age-related change and does not
indicate a systemic infection. Mobility limitations are unnecessary.
22. A patient with a sudden onset of hearing loss tells the nurse that he would like to begin using hearing
aids. The nurse understands that the health professional dispensing hearing aids would have what
responsibility?
A) Test the patients hearing promptly.
B) Perform an otoscopy.
C) Measure the width of the patients ear canal.
D) Refer the patient to his primary care physician.
Ans: D
Feedback:
Health care professionals who dispense hearing aids are required to refer prospective users to a
physician if the patient has sudden or rapidly progressive hearing loss. This would be a health priority
over other forms of assessment, due to the possible presence of a pathologic process.
23. The nurse is providing care for a patient who has benefited from a cochlear implant. The nurse should
understand that this patients health history likely includes which of the following? Select all that apply.
A) The patient was diagnosed with sensorineural hearing loss.
B) The patients hearing did not improve appreciably with the use of hearing aids.
C) The patient has deficits in peripheral nervous function.
D) The patients hearing deficit is likely accompanied by a cognitive deficit.
E) The patient is unable to lip-read.
Ans: A, B
Feedback:
A cochlear implant is an auditory prosthesis used for people with profound sensorineural hearing loss
bilaterally who do not benefit from conventional hearing aids. The need for a cochlear implant is not
associated with deficits in peripheral nervous function, cognitive deficits, or an inability to lip-read.
24. A patient presents to the ED complaining of a sudden onset of incapacitating vertigo, with nausea and
vomiting and tinnitus. The patient mentions to the nurse that she suddenly cannot hear very well. What
would the nurse suspect the patients diagnosis will be?
A) Ossiculitis
B) Mnires disease
C) Ototoxicity
D) Labyrinthitis
Ans: D
Feedback:
Labyrinthitis is characterized by a sudden onset of incapacitating vertigo, usually with nausea and
vomiting, various degrees of hearing loss, and possibly tinnitus. None of the other listed diagnosis is
characterized by a rapid onset of symptoms.
25. Which of the following nurses actions carries the greatest potential to prevent hearing loss due to
ototoxicity?
A) Ensure that patients understand the differences between sensory hearing loss and conductive
hearing loss.
B) Educate patients about expected age-related changes in hearing perception.
C) Educate patients about the risks associated with prolonged exposure to environmental noise.
D) Be aware of patients medication regimens and collaborate with other professionals accordingly.
Ans: D
Feedback:
A variety of medications may have adverse effects on the cochlea, vestibular apparatus, or cranial nerve
VIII. All but a few, such as aspirin and quinine, cause irreversible hearing loss. Ototoxicity is not related
to age-related changes, noise exposure, or the differences between types of hearing loss.
26. A child goes to the school nurse and complains of not being able to hear the teacher. What test could the
school nurse perform that would preliminarily indicate hearing loss?
A) Audiometry
B) Rinne test
C) Whisper test
D) Weber test
Ans: C
Feedback:
A general estimate of hearing can be made by assessing the patients ability to hear a whispered phrase or
a ticking watch, testing one ear at a time. The Rinne and Weber tests distinguish sensorineural from
conductive hearing loss. These tests, as well as audiometry, are not usually performed by a registered
nurse in a general practice setting.
27. A nurse is teaching preventative measures for otitis externa to a group of older adults. What action
should the nurse encourage?
A) Rinsing the ears with normal saline after swimming
B) Avoiding loud environmental noises
C) Instilling antibiotic ointments on a regular basis

D) Avoiding the use of cotton swabs
Ans: D
Feedback:
Nurses should instruct patients not to clean the external auditory canal with cotton-tipped applicators and
to avoid events that traumatize the external canal such as scratching the canal with the fingernail or other
objects. Environmental noise should be avoided, but this does not address the risk for ear infection.
Routine use of antibiotics is not encouraged and rinsing the ears after swimming is not recommended.
28. The nurse is reviewing the health history of a newly admitted patient and reads that the patient has been
previously diagnosed with exostoses. How should the nurse accommodate this fact into the patients plan
of care?
A) The nurse should perform the Rinne and Weber tests.
B) The nurse should arrange for audiometry testing as soon as possible.
C) The nurse should collaborate with the pharmacist to assess for potential ototoxic medications.
D) No specific assessments or interventions are necessary to addressing exostoses.
Ans: D
Feedback:
Exostoses are small, hard, bony protrusions found in the lower posterior bony portion of the ear canal;
they usually occur bilaterally. They do not normally impact hearing and no treatments or nursing actions
are usually necessary.
29. The nurse is caring for a patient who has undergone a mastoidectomy. In an effort to prevent
postoperative infection, what intervention should the nurse implement?
A) Teach the patient about the risks of ototoxic medications.
B) Instruct the patient to protect the ear from water for several weeks.
C) Teach the patient to remove cerumen safely at least once per week.
D) Instruct the patient to protect the ear from temperature extremes until healing is complete.
Ans: B
Feedback:
To prevent infection, the patient is instructed to prevent water from entering the external auditory canal
for 6 weeks. Ototoxic medications and temperature extremes do not present a risk for infection. Removal
of cerumen during the healing process should be avoided due to the possibility of trauma.
30. A patient is being discharged home after mastoid surgery. What topic should the nurse address in the
patients discharge education?
A) Expected changes in facial nerve function
B) The need for audiometry testing every 6 months following recovery
C) Safe use of analgesics and antivertiginous agents
D) Appropriate use of OTC ear drops
Ans: C
Feedback:
Patients require instruction about medication therapy, such as analgesics and antivertiginous agents (e.g.,
antihistamines) prescribed for balance disturbance. OTC ear drops are not recommended and changes in
facial nerve function are signs of a complication that needs to be addressed promptly. There is no need
for serial audiometry testing.
31. After mastoid surgery, an 81-year-old patient has been identified as needing assistance in her home.
What would be a primary focus of this patients home care?
A) Preparation of nutritious meals and avoidance of contraindicated foods
B) Ensuring the patient receives adequate rest each day
C) Helping the patient adapt to temporary hearing loss
D) Assisting the patient with ambulation as needed to avoid falling
Ans: D
Feedback:
The caregiver and patient are cautioned that the patient may experience some vertigo and will therefore
require help with ambulation to avoid falling. The patient should not be expected to experience hearing
loss and no foods are contraindicated. Adequate rest is needed, but this is not a primary focus of home
care.
32. A hearing-impaired patient is scheduled to have an MRI. What would be important for the nurse to
remember when caring for this patient?
A) Patient is likely unable to hear the nurse during test.
B) A person adept in sign language must be present during test.
C) Lip reading will be the method of communication that is necessary.
D) The nurse should interact with the patient like any other patient.
Ans: A
Feedback:
During health care and screening procedures, the practitioner (e.g., dentist, physician, nurse) must be
aware that patients who are deaf or hearing-impaired are unable to read lips, see a signer, or read written
materials in the dark rooms required during some diagnostic tests. The same situation exists if the
practitioner is wearing a mask or not in sight (e.g., x-ray studies, MRI, colonoscopy).
33. The nurse and a colleague are performing the Epley maneuver with a patient who has a diagnosis of
benign paroxysmal positional vertigo. The nurses should begin this maneuver by performing what
action?
A) Placing the patient in a prone position
B) Assisting the patient into a sitting position
C) Instilling 15 mL of warm normal saline into one of the patients ears
D) Assessing the patients baseline hearing by performing the whisper test
Ans: B
Feedback:
The Epley maneuver is performed by placing the patient in a sitting position, turning the head to a 45-
degree angle on the affected side, and then quickly moving the patient to the supine position. Saline is
not instilled into the ears and there is no need to assess hearing before the test.
34. A 6-month-old infant is brought to the ED by his parents for inconsolable crying and pulling at his right
ear. When assessing this infant, the advanced practice nurse is aware that the tympanic membrane
should be what color in a healthy ear?
A) Yellowish-white
B) Pink
C) Gray
D) Bluish-white
Ans: C
Feedback:
The healthy tympanic membrane appears pearly gray and is positioned obliquely at the base of the ear
canal. Any other color is suggestive of a pathological process.
35. A child has been experiencing recurrent episodes of acute otitis media (AOM). The nurse should
anticipate that what intervention is likely to be ordered?
A) Ossiculoplasty
B) Insertion of a cochlear implant
C) Stapedectomy
D) Insertion of a ventilation tube
Ans: D
Feedback:
If AOM recurs and there is no contraindication, a ventilating, or pressure-equalizing, tube may be

inserted. The ventilating tube, which temporarily takes the place of the eustachian tube in equalizing
pressure, is retained for 6 to 18 months. Ossiculoplasty is not used to treat AOM and stapedectomy is
performed to treat otosclerosis. Cochlear implants are used to treat sensorineural hearing loss.
36. An older adult with a recent history of mixed hearing loss has been diagnosed with a cholesteatoma.
What should this patient be taught about this diagnosis? Select all that apply
A) Cholesteatomas are benign and self-limiting, and hearing loss will resolve spontaneously.
B) Cholesteatomas are usually the result of metastasis from a distant tumor site.
C) Cholesteatomas are often the result of chronic otitis media.
D) Cholesteatomas, if left untreated, result in intractable neuropathic pain.

E) Cholesteatomas usually must be removed surgically.
Ans: C, E
Feedback:
Cholesteatoma is a tumor of the external layer of the eardrum into the middle ear, often resulting from
chronic otitis media. They usually do not cause pain; however, if treatment or surgery is delayed, they
may burst or destroy the mastoid bone. They are not normally the result of metastasis and are not self-
limiting.
37. The nurse is admitting a patient to the unit who is scheduled to have an ossiculoplasty. What
postoperative assessment will best determine whether the procedure has been successful?
A) Otoscopy
B) Audiometry
C) Balance testing
D) Culture and sensitivity testing of ear discharge
Ans: B
Feedback:
Ossiculoplasty is the surgical reconstruction of the middle ear bones to restore hearing. Consequently,
results are assessed by testing hearing, not by visualizing the ear, testing balance, or culturing ear
discharge.
38. On otoscopy, a red blemish behind the tympanic membrane is suggestive of what diagnosis?
A) Acoustic tumor
B) Cholesteatoma
C) Facial nerve neuroma
D) Glomus tympanicum
Ans: D
Feedback:
In the case of glomus tympanicum, a red blemish on or behind the tympanic membrane is seen on
otoscopy. This assessment finding is not associated with an acoustic tumor, facial nerve neuroma, or
cholesteatoma.
39. The nurse is discharging a patient home after mastoid surgery. What should the nurse include in
discharge teaching?
A) Try to induce a sneeze every 4 hours to equalize pressure.
B) Be sure to exercise to reduce fatigue.
C) Avoid sleeping in a side-lying position.
D) Dont blow your nose for 2 to 3 weeks.
Ans: D
Feedback:
The patient is instructed to avoid heavy lifting, straining, exertion, and nose blowing for 2 to 3 weeks
after surgery to prevent dislodging the tympanic membrane graft or ossicular prosthesis. Side-lying is
not contraindicated; sneezing could cause trauma.
40. An advanced practice nurse has performed a Rinne test on a new patient. During the test, the patient
reports that air-conducted sound is louder than bone-conducted sound. How should the nurse best
interpret this assessment finding?
A) The patients hearing is likely normal.
B) The patient is at risk for tinnitus.
C) The patient likely has otosclerosis.
D) The patient likely has sensorineural hearing loss.
Ans: A
Feedback:
The Rinne test is useful for distinguishing between conductive and sensorineural hearing loss. A person
with normal hearing reports that air-conducted sound is louder than bone-conducted sound.
recommended by the manufacturer in order to prolong the life of the device.
Box 56-7
Client Education Following Myringotomy
▪ Avoid strenuous activities.
▪ Avoid rapid head movements, bouncing, or bending.
▪ Avoid straining on bowel movement.
▪ Avoid drinking through a straw.
▪ Avoid traveling by air.
▪ Avoid forceful coughing.
▪ Avoid contact with persons with colds.
▪ Avoid washing hair, showering, or getting the head wet for 1 week as
prescribed.
▪ Use proper hand hygiene to prevent infection.
▪ Instruct the client that if he or she needs to blow the nose, to blow 1 side at a
time with the mouth open.
▪ Instruct the client to keep ears dry by keeping a ball of cotton coated with
petroleum jelly in the ear and to change the cotton ball daily.
▪ Instruct the client to report excessive ear drainage to the primary health care
provider.
Practice Questions
676. During the early postoperative period, a client who has undergone a cataract
extraction complains of nausea and severe eye pain over the operative site.
What should be the initial nursing action?
1. Call the surgeon.
2. Reassure the client that this is normal.
3. Turn the client onto her or his operative side.
4. Administer the prescribed pain medication and antiemetic.
677. The nurse is developing a teaching plan for a client with glaucoma. Which
instruction should the nurse include in the plan of care?
1. Avoid overuse of the eyes.
2. Decrease the amount of salt in the diet.
3. Eye medications will need to be administered for life.
4. Decrease fluid intake to control the intraocular pressure.
678. The nurse is performing an admission assessment on a client with a
diagnosis of detached retina. Which sign or symptom is associated with this
eye problem?
1. Total loss of vision
2. Pain in the affected eye
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3. A yellow discoloration of the sclera
4. A sense of a curtain falling across the field of vision
679. The nurse is performing an otoscopic examination on a client with
mastoiditis. On examination of the tympanic membrane, which finding
should the nurse expect to observe?
1. A pink-colored tympanic membrane
2. A pearly colored tympanic membrane
3. A transparent and clear tympanic membrane
4. A red, dull, thick, and immobile tympanic membrane
680. A client is diagnosed with a problem involving the inner ear. Which is the
most common client complaint associated with a problem involving this part
of the ear?
1. Pruritus
2. Tinnitus
3. Hearing loss
4. Burning in the ear
681. The nurse is performing an assessment on a client with a suspected diagnosis
of cataract. Which clinical manifestation should the nurse expect to note in
the early stages of cataract formation?
1. Diplopia
2. Eye pain
3. Floating spots
4. Blurred vision
682. A client arrives in the emergency department following an automobile crash.
The client’s forehead hit the steering wheel, and a hyphema is diagnosed.
The nurse should place the client in which position?
1. Flat in bed
2. A semi-Fowler’s position
3. Lateral on the affected side
4. Lateral on the unaffected side
683. The client sustains a contusion of the eyeball following a traumatic injury
with a blunt object. Which intervention should be initiated immediately?
1. Apply ice to the affected eye.
2. Irrigate the eye with cool water.
3. Notify the primary health care provider (PHCP).
4. Accompany the client to the emergency department.
684. A client arrives in the emergency department with a penetrating eye injury
from wood chips that occurred while cutting wood. The nurse assesses the
eye and notes a piece of wood protruding from the eye. What is the initial
nursing action?
1. Apply an eye patch.
2. Perform visual acuity tests.
3. Irrigate the eye with sterile saline.
4. Remove the piece of wood using a sterile eye clamp.
685. The nurse is caring for a client following enucleation to treat an ocular tumor
and notes the presence of bright red drainage on the dressing. Which action
should the nurse take at this time?
1. Document the finding.
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2. Continue to monitor the drainage.
3. Notify the primary health care provider (PHCP).
4. Mark the drainage on the dressing and monitor for any increase in
bleeding.
686. A woman was working in her garden. She accidentally sprayed insecticide
into her right eye. She calls the emergency department, frantic and screaming
for help. The nurse should instruct the woman to take which immediate
action?
1. Irrigate the eyes with water.
2. Come to the emergency department.
3. Call the primary health care provider (PHCP).
4. Irrigate the eyes with diluted hydrogen peroxide.
687. The nurse is preparing a teaching plan for a client who had a cataract
extraction with intraocular implantation. Which home care measures should
the nurse include in the plan? Select all that apply.
1. Avoid activities that require bending over.
2. Contact the surgeon if eye scratchiness occurs.

3. Take acetaminophen for minor eye discomfort.
4. Expect episodes of sudden severe pain in the eye.
5. Place an eye shield on the surgical eye at bedtime.
6. Contact the surgeon if a decrease in visual acuity occurs.
688. Tonometry is performed on a client with a suspected diagnosis of glaucoma.
The nurse looks at the documented test results and notes an intraocular
pressure (IOP) value of 23. What should be the nurse’s initial action?
1. Apply normal saline drops.
2. Note the time of day the test was done.
3. Contact the primary health care provider (PHCP).
4. Instruct the client to sleep with the head of the bed flat.
689. The nurse is caring for a client following craniotomy for removal of an
acoustic neuroma. Assessment of which cranial nerve would identify a
complication specifically associated with this surgery?
1. Cranial nerve I, olfactory
2. Cranial nerve IV, trochlear
3. Cranial nerve III, oculomotor
4. Cranial nerve VII, facial nerve
690. The nurse notes that the primary health care provider has documented a
diagnosis of presbycusis on a client’s chart. Based on this information, what
action should the nurse take?
1. Speak loudly but mumble or slur the words.
2. Speak loudly and clearly while facing the client.
3. Speak at normal tone and pitch, slowly and clearly.
4. Speak loudly and directly into the client’s affected ear.
691. A client with Meniere’s disease is experiencing severe vertigo. Which
instruction should the nurse give to the client to assist in controlling the
1965
vertigo?
1. Increase sodium in the diet.
2. Avoid sudden head movements.
3. Lie still and watch the television.
4. Increase fluid intake to 3000 mL a day.
692. The nurse is preparing to test the visual acuity of a client, using a Snellen
chart. Which identifies the accurate procedure for this visual acuity test?
1. The right eye is tested, followed by the left eye, and then both
eyes are tested.
2. Both eyes are assessed together, followed by an assessment of the
right eye and then the left eye.
3. The client is asked to stand at a distance of 40 feet (12 meters)
from the chart and to read the largest line on the chart.
4. The client is asked to stand at a distance of 40 feet (12 meters)
from the chart and to read the line that can be read 200 feet (60
meters) away by an individual with unimpaired vision.
693. A client’s vision is tested with a Snellen chart. The results of the tests are
documented as 20/60. What action should the nurse implement based on this
finding?
1. Provide the client with materials on legal blindness.
2. Instruct the client that he or she may need glasses when driving.
3. Inform the client of where he or she can purchase a white cane
with a red tip.
4. Inform the client that it is best to sit near the back of the room
when attending lectures.
694. The nurse is caring for a hearing-impaired client. Which approach will
facilitate communication?
1. Speak loudly.
2. Speak frequently.
3. Speak at a normal volume.
4. Speak directly into the impaired ear.
Answers
676. Answer: 1
Rationale: Severe pain or pain accompanied by nausea following a cataract

extraction is an indicator of increased intraocular pressure and should be reported to
the surgeon immediately. Options 2, 3, and 4 are inappropriate actions.
Test-Taking Strategy: Note the strategic word, initial, and the word severe.
Eliminate option 2 because this is not a normal condition. The client should not be
turned to the operative side; therefore, eliminate option 3. From the remaining
options, focusing on the strategic word will direct you to the correct option.
Level of Cognitive Ability: Analyzing
Client Needs: Physiological Integrity
Integrated Process: Nursing Process—Implementation
Content Area: Complex Care: Emergency Situations/Management
1966
Health Problem: Adult Health: Eye: Cataracts
Priority Concepts: Clinical Judgment; Pain
Reference: Ignatavicius, Workman, Rebar (2018), p. 971.
677. Answer: 3
Rationale: The administration of eye drops is a critical component of the

treatment plan for the client with glaucoma. The client needs to be instructed that
medications will need to be taken for the rest of her or his life. Options 1, 2, and 4 are
not accurate instructions.
Test-Taking Strategy: Focus on the subject, client teaching for glaucoma.
Recalling that medications are an integral component of the treatment plan will
assist in directing you to the correct option.
Level of Cognitive Ability: Applying
Integrated Process: Teaching and Learning
Content Area: Adult Health: Eye
Health Problem: Adult Health: Eye: Glaucoma
Priority Concepts: Client Education; Sensory Perception
678. Answer: 4
Rationale: A characteristic manifestation of retinal detachment described by the

client is the feeling that a shadow or curtain is falling across the field of vision. No
pain is associated with detachment of the retina. Options 1 and 3 are not
characteristics of this problem. A retinal detachment is an ophthalmic emergency,
and even more so if visual acuity is still normal.
Test-Taking Strategy: Focus on the subject, manifestations of retinal detachment.
Thinking about the pathophysiology associated with this problem will direct you to
the correct option.
Integrated Process: Nursing Process—Assessment
Health Problem: Adult Health: Eye: Retinal Detachment
Priority Concepts: Clinical Judgment; Sensory Perception
679. Answer: 4
Rationale: Otoscopic examination in a client with mastoiditis reveals a red, dull,

thick, and immobile tympanic membrane, with or without perforation. Postauricular
lymph nodes are tender and enlarged. Clients also have a low-grade fever, malaise,
anorexia, swelling behind the ear, and pain with minimal movement of the head.
Test-Taking Strategy: Focus on the subject, the assessment findings in mastoiditis.
Think about the pathophysiology associated with mastoiditis and remember that
1967
mastoiditis reveals a red, dull, thick, and immobile tympanic membrane.
Content Area: Adult Health: Ear
Health Problem: Adult Health: Ear: Inflammatory/Infections/Structural Problems
Priority Concepts: Infection; Inflammation
Reference: Lewis et al. (2017), pp. 384-385.
680. Answer: 2
Rationale: Tinnitus is the most common complaint of clients with otological

problems, especially problems involving the inner ear. Symptoms of tinnitus range
from mild ringing in the ear, which can go unnoticed during the day, to a loud
roaring in the ear, which can interfere with the client’s thinking process and
attention span. Options 1, 3, and 4 are not associated specifically with problems of
the inner ear.
Test-Taking Strategy: Note the strategic word, most. Recalling the anatomy and
the function of the inner ear will direct you to the correct option.
Health Problem: Adult Health: Ear: Vertigo/Tinnitus
681. Answer: 4
Rationale: A gradual, painless blurring of central vision is the chief clinical

manifestation of a cataract. Early symptoms include slightly blurred vision and a
decrease in color perception. Options 1, 2, and 3 are not characteristics of a cataract.
Test-Taking Strategy: Note the strategic word, early. Remember the
pathophysiology related to cataract development. As a cataract develops, the lens of
the eye becomes opaque. This description will assist in directing you to the correct
option.
682. Answer: 2
Rationale: A hyphema is the presence of blood in the anterior chamber. Hyphema
1968
is produced when a force is sufficient to break the integrity of the blood vessels in
the eye and can be caused by direct injury, such as a penetrating injury from a BB or
pellet, or indirectly, such as from striking the forehead on a steering wheel during an
accident. The client is treated by bed rest in a semi-Fowler’s position to assist gravity
in keeping the hyphema away from the optical center of the cornea.
Test-Taking Strategy: Focus on the subject, care of the client who has sustained a
hyphema. Remember that placing the client flat will produce an increase in pressure
at the injured site. Also, note that the correct option is the one that identifies a
position different from the other options.
Health Problem: Adult Health: Eye: Inflammation/Infections/Injuries
Priority Concepts: Safety; Tissue Integrity
Reference: Jarvis (2016), p. 321.
683. Answer: 1
Rationale: Treatment for a contusion begins at the time of injury. Ice is applied
immediately. The client then should be seen by a PHCP and receive a thorough eye
examination to rule out the presence of other eye injuries.
Test-Taking Strategy: Focus on the strategic word, immediately. Recalling the
principles related to initial treatment of injuries and noting the type of injury
sustained will direct you to the correct option.
Priority Concepts: Clinical Judgment; Tissue Integrity
684. Answer: 2
Rationale: If the eye injury is the result of a penetrating object, the object may be
noted protruding from the eye. This object must never be removed except by the
ophthalmologist, because it may be holding ocular structures in place. Application of
an eye patch or irrigation of the eye may disrupt the foreign body and cause further
tearing of the cornea.
Test-Taking Strategy: Note the strategic word, initial, and note the word
penetrating. This should indicate that a laceration has occurred and that interventions
are directed at preventing further disruption of the integrity of the eye. The only
option that will prevent further disruption is to assess visual acuity.
1969
685. Answer: 3
Rationale: If the nurse notes the presence of bright red drainage on the dressing, it
must be reported to the PHCP, because this indicates hemorrhage. Options 1, 2, and
4 are inappropriate at this time.
Test-Taking Strategy: Determine if an abnormality exists. Note the words, bright
red. Since an abnormality does exist, eliminate options that state to document and
continue to monitor because an action is needed.
Health Problem: Adult Health: Eye: Ocular tumors, retinoblastoma
Reference: Lewis et al. (2017), pp. 382-383.
686. Answer: 1
Rationale: In this type of accident, the client is instructed to irrigate the eyes
immediately with running water for at least 20 minutes, or until the emergency
medical services personnel arrive. In the emergency department, the cleansing agent
of choice is usually normal saline. Calling the PHCP and going to the emergency
department delays necessary intervention. Hydrogen peroxide is never placed in the
eyes.
Test-Taking Strategy: Note the strategic word, immediate. Focus on the type of
injury and eliminate options 2 and 3 because they delay necessary intervention.
Next, eliminate option 4 because hydrogen peroxide is never placed in the eyes.
Priority Concepts: Client Education; Tissue Integrity
Reference: Lewis et al. (2017), p. 371.
687. Answer: 1, 3, 5, 6
Rationale: Following eye surgery, some scratchiness and mild eye discomfort may
occur in the operative eye and usually is relieved by mild analgesics. If the eye pain
becomes severe, the client should notify the surgeon, because this may indicate
hemorrhage, infection, or increased intraocular pressure (IOP). The nurse also would
instruct the client to notify the surgeon of increased purulent drainage, increased
1970
redness, or any decrease in visual acuity. The client is instructed to place an eye
shield over the operative eye at bedtime to protect the eye from injury during sleep
and to avoid activities that increase IOP, such as bending over.
Test-Taking Strategy: Focus on the subject, postoperative care following eye
surgery. Recalling that the eye needs to be protected and that increased IOP is a
concern will assist in determining the home care measures to be included in the plan.
Priority Concepts: Client Education; Safety
688. Answer: 2
Rationale: Tonometry is a method of measuring intraocular fluid pressure.

Pressures between 10 and 21 mm Hg are considered within the normal range.
However, IOP is slightly higher in the morning. Therefore, the initial action is to
check the time the test was performed. Normal saline drops are not a specific
treatment for glaucoma. It is not necessary to contact the PHCP as an initial action.
Flat positions may increase the pressure.
Test-Taking Strategy: Focus on the subject, normal IOP, and note the strategic
word, initial. Remember that normal IOP is between 10 and 21 mm Hg and the
pressure may be higher in the morning.
689. Answer: 4
Rationale: An acoustic neuroma (or vestibular schwannoma) is a unilateral benign

tumor that occurs where the vestibulocochlear or acoustic nerve (cranial nerve VIII)
enters the internal auditory canal. It is important that an early diagnosis be made,
because the tumor can compress the trigeminal and facial nerves and arteries within
the internal auditory canal. Treatment for acoustic neuroma is surgical removal via a
craniotomy. Assessment of the trigeminal and facial nerves is important. Extreme
care is taken to preserve remaining hearing and preserve the function of the facial
nerve. Acoustic neuromas rarely recur following surgical removal.
Test-Taking Strategy: Focus on the subject, a complication following surgery.
Think about the anatomical location of an acoustic neuroma and the nerves that the
neuroma can compress to direct you to the correct option.
1971
Health Problem: Adult Health: Ear: Hearing Loss
Reference: Ignatavicius, Workman, Rebar (2018), pp. 951, 996.
690. Answer: 3
Rationale: Presbycusis is a type of hearing loss that occurs with aging. Presbycusis
is a gradual sensorineural loss caused by nerve degeneration in the inner ear or
auditory nerve. When communicating with a client with this condition, the nurse
should speak at a normal tone and pitch, slowly and clearly. It is not appropriate to
speak loudly, mumble or slur words, or speak into the client’s affected ear.
Test-Taking Strategy: Focus on the subject, presbycusis and the effective method
to communicate. Visualize each of the communication techniques to direct you to the
correct option.
Health Problem: Adult Health: Ear: Hearing Loss
Priority Concepts: Communication; Sensory Perception
Reference: Ignatavicius, Workman, Rebar (2018), pp. 997-998.
691. Answer: 2
Rationale: The nurse instructs the client to make slow head movements to prevent
worsening of the vertigo. Dietary changes such as salt and fluid restrictions that
reduce the amount of endolymphatic fluid are sometimes prescribed. Lying still and
watching television will not control vertigo.
Test-Taking Strategy: Focus on the subject, preventing vertigo. Note the
relationship between vertigo and avoiding sudden head movements in the correct
option.
Client Needs: Safe and Effective Care Environment
Health Problem: Adult Health: Ear: Vertigo/Tinnitus
Reference: Ignatavicius, Workman, Rebar (2018), pp. 995-996.
692. Answer: 1
Rationale: Visual acuity is assessed in 1 eye at a time, and then in both eyes
together, with the client comfortably standing or sitting. The right eye is tested with
the left eye covered; then the left eye is tested with the right eye covered. Both eyes
1972
are then tested together. Visual acuity is measured with or without corrective lenses,
and the client stands at a distance of 20 feet (6 meters) from the chart.
Test-Taking Strategy: Remember that normal visual acuity as measured by a
Snellen chart is 20/20 vision. This should assist in eliminating options 3 and 4,
because they are comparable or alike in that they indicate standing at a distance of
40 feet (12 meters). From the remaining options, remember that it is best and most
accurate to test each eye separately and then test both eyes together.
Client Needs: Health Promotion and Maintenance
Content Area: Adult Health: Health Assessment/Physical Exam: Eye
Health Problem: N/A
Reference: Jarvis (2016), pp. 289-290, 303.
693. Answer: 2
Rationale: Vision that is 20/20 is normal—that is, the client is able to read from 20
feet (6 meters) what a person with normal vision can read from 20 feet (6 meters). A
client with a visual acuity of 20/60 can only read at a distance of 20 feet (6 meters)
what a person with normal vision can read at 60 feet (18 meters). With this vision,
the client may need glasses while driving in order to read signs and to see far ahead.
The client should be instructed to sit in the front of the room for lectures to aid in
visualization. This is not considered to be legal blindness.
Test-Taking Strategy: Focus on the subject, interpreting a Snellen chart result.
Note the test result, 20/60, and recall the associated interventions for this result. Also,
eliminate options 1 and 3, as they are comparable or alike, implying that the test
results indicate blindness.
Content Area: Adult Health: Health Assessment/Physical Exam: Eye
Health Problem: Adult Health: Eye: Visual problems/refractive errors
694. Answer: 3
Rationale: Speaking in a normal tone to the client with impaired hearing and not
shouting are important. The nurse should talk directly to the client while facing the
client and speak clearly. If the client does not seem to understand what is said, the
nurse should express it differently. Moving closer to the client and toward the better
ear may facilitate communication, but the nurse should avoid talking directly into
the impaired ear.
Test-Taking Strategy: Focus on the subject, an effective communication technique
for the hearing impaired. Remember that it is important to speak in a normal tone.
1973
▪ Loratadine
▪ Cetirizine
▪ Diphenhydramine
▪ Fexofenadine
▪ Levocetirizine
▪ Phenylephrine
▪ Pseudoephedrine
Practice Questions
695. Betaxolol hydrochloride eye drops have been prescribed for a client with
glaucoma. Which nursing action is most appropriate related to monitoring
for side and adverse effects of this medication?
1. Assessing for edema
2. Monitoring temperature
3. Monitoring blood pressure
4. Assessing blood glucose level
696. The nurse is preparing to administer eye drops. Which interventions should
the nurse take to administer the drops? Select all that apply.
1. Wash hands.
2. Put gloves on.
3. Place the drop in the conjunctival sac.
4. Pull the lower lid down against the cheekbone.
5. Instruct the client to squeeze the eyes shut after instilling the
eye drop.
6. Instruct the client to tilt the head forward, open the eyes, and
look down.
697. The nurse prepares a client for ear irrigation as prescribed by the primary
health care provider. Which action should the nurse take when performing
the procedure?
1. Warm the irrigating solution to 98.6° F (37.0° C).
2. Position the client with the affected side up following the
irrigation.
3. Direct a slow, steady stream of irrigation solution toward the
eardrum.
4. Assist the client to turn her or his head so that the ear to be
irrigated is facing upward.
698. The nurse is providing instructions to a client who will be self-administering
eye drops. To minimize systemic absorption of the eye drops, the nurse
should instruct the client to take which action?
1. Eat before instilling the drops.
2. Swallow several times after instilling the drops.
1994
3. Blink vigorously to encourage tearing after instilling the drops.
4. Occlude the nasolacrimal duct with a finger after instilling the
drops.
699. A client is prescribed an eye drop and an eye ointment for the right eye. How
should the nurse best administer the medications?
1. Administer the eye drop first, followed by the eye ointment.
2. Administer the eye ointment first, followed by the eye drop.
3. Administer the eye drop, wait 15 minutes, and administer the eye
ointment.
4. Administer the eye ointment, wait 15 minutes, and administer the
eye drop.
700. Which medication, if prescribed for the client with glaucoma, should the
nurse question?
1. Betaxolol
2. Pilocarpine
3. Erythromycin
4. Atropine sulfate
701. A miotic medication has been prescribed for the client with glaucoma, and
the client asks the nurse about the purpose of the medication. Which
response should the nurse provide to the client?
1. “The medication will help dilate the eye to prevent pressure from
occurring.”
2. “The medication will relax the muscles of the eyes and prevent
blurred vision.”
3. “The medication causes the pupil to constrict and will lower the
pressure in the eye.”
4. “The medication will help block the responses that are sent to the
muscles in the eye.”
702. A client was just admitted to the hospital to rule out a gastrointestinal (GI)
bleed. The client has brought several bottles of medications prescribed by
different specialists. During the admission assessment, the client states,
“Lately, I have been hearing some roaring sounds in my ears, especially
when I am alone.” Which medication would the nurse identify as the cause
of the client’s complaint?
1. Doxycycline
2. Atropine sulfate
3. Acetylsalicylic acid
4. Diltiazem hydrochloride
703. In preparation for cataract surgery, the nurse is to administer cyclopentolate
eye drops at 9:00 a.m. for surgery that is scheduled for 9:15 a.m. What initial
action should the nurse take in relation to the characteristics of the
medication action?
1. Provide lubrication to the operative eye prior to giving the eye
drops.
2. Call the surgeon, as this medication will further constrict the
operative pupil.
3. Consult the surgeon, as there is not sufficient time for the dilative
effects to occur.
1995
4. Give the medication as prescribed; the surgeon needs optimal
constriction of the pupil.
Answers
695. Answer: 3
Rationale: Hypotension, dizziness, nausea, diaphoresis, headache, fatigue,

constipation, and diarrhea are side and adverse effects of the medication. Nursing
interventions include monitoring the blood pressure for hypotension and assessing
the pulse for strength, weakness, irregular rate, and bradycardia. Options 1, 2, and 4
are not specifically associated with this medication.
Test-Taking Strategy: Note the strategic words, most appropriate. Use the ABCs—
airway, breathing, and circulation—to direct you to the correct option.
Content Area: Pharmacology: Eye and Ear: Glaucoma Medications
Priority Concepts: Safety; Sensory Perception
696. Answer: 1, 2, 3, 4
Rationale: To administer eye medications, the nurse should wash hands and put
gloves on. The client is instructed to tilt the head backward, open the eyes, and look
up. The nurse pulls the lower lid down against the cheekbone and holds the bottle
like a pencil with the tip downward. Holding the bottle, the nurse gently rests the
wrist of the hand on the client’s cheek and squeezes the bottle gently to allow the
drop to fall into the conjunctival sac. The client is instructed to close the eyes gently
and not to squeeze the eyes shut to prevent the loss of medication.
Test-Taking Strategy: Focus on the subject, the procedure for administering eye
drops. Use guidelines related to standard precautions and visualize this procedure.
This will assist in determining the correct interventions.
Content Area: Skills: Medication Administration
Health Problem: N/A
Priority Concepts: Clinical Judgment; Safety
697. Answer: 1
Rationale: Before ear irrigation, the nurse should inspect the tympanic membrane
to ensure that it is intact. The irrigating solution should be warmed to 98.6° F (37.0°
1996
C), because a solution temperature that is not close to the client’s body temperature
will cause ear injury, nausea, and vertigo. The nurse should check the temperature of
the solution on the inner forearm. The affected side should be down following the
irrigation to assist in drainage of the fluid. When irrigating, a direct and slow steady
stream of irrigation solution is directed toward the wall of the canal, not toward the
eardrum. The client is positioned sitting, facing forward with the head in a natural
position; if the ear is faced upward, the nurse would not be able to visualize the
canal.
Test-Taking Strategy: Focus on the subject, the procedure for performing ear
irrigation. Think about the purpose of this procedure and keep safety in mind.
Visualizing each step and the information in the options will assist in eliminating the
incorrect ones.
Content Area: Foundations of Care: Safety
Health Problem: N/A
Reference: Perry et al. (2018), p. 494.
698. Answer: 4
Rationale: Applying pressure on the nasolacrimal duct prevents systemic

absorption of the medication. Options 1, 2, and 3 will not prevent systemic
absorption.
Test-Taking Strategy: Focus on the subject, systemic effects. Eating and
swallowing are comparable or alike and are not related to the systemic absorption
of eye drops. Blinking vigorously to produce tearing may result in the loss of the
administered medication.
Content Area: Foundations of Care: Client Teaching
Health Problem: N/A
Reference: Lilley et al. (2017), p. 130.
699. Answer: 1
Rationale: When an eye drop and an eye ointment are scheduled to be

administered at the same time, the eye drop is administered first. The instillation of
two medications is separated by 3 to 5 minutes.
Test-Taking Strategy: Note the strategic word, best. Focus on the subject, the
guidelines for administering eye medications. Eliminate options 3 and 4 first because
of the words 15 minutes. Next, thinking about the consistency and absorption of a
drop versus ointment will direct you to the correct option.
1997
Content Area: Skills: Medication Administration
Health Problem: N/A
Reference: Potter et al. (2017), p. 631.
700. Answer: 4
Rationale: Options 1 and 2 are miotic agents used to treat glaucoma. Option 3 is
an anti-infective medication used to treat bacterial conjunctivitis. Atropine sulfate is
a mydriatic and cycloplegic (also anticholinergic) medication, and its use is
contraindicated in clients with glaucoma. Mydriatic medications dilate the pupil and
can cause an increase in intraocular pressure in the eye.
Test-Taking Strategy: Focus on the subject, the medication that the nurse should
question. Recalling the classifications of the medications identified in the options
will assist in answering the question. Remember that mydriatics dilate the pupil and
that these medications are contraindicated in glaucoma.
Integrated Process: Nursing Process—Analysis
Priority Concepts: Collaboration; Safety
Reference: Burchum, Rosenthal (2016), pp. 120, 1272-1273
701. Answer: 3
Rationale: Miotics cause pupillary constriction and are used to treat glaucoma.
They lower the intraocular pressure, thereby increasing blood flow to the retina and
decreasing retinal damage and loss of vision. Miotics cause a contraction of the
ciliary muscle and a widening of the trabecular meshwork. Options 1, 2, and 4 are
incorrect.
Test-Taking Strategy: Note that the client has glaucoma. Recall that prevention of
increased intraocular pressure is the goal in the client with glaucoma. Options 1, 2,
and 4 are comparable or alike and describe actions related to mydriatic medications,
which primarily dilate the pupils and relax the ciliary muscles.
702. Answer: 3
1998
Rationale: Aspirin (acetylsalicylic acid) is contraindicated for GI bleeding and is
potentially ototoxic. The client should be advised to notify the prescribing primary
health care provider so the medication can be discontinued and/or a substitute that
is less toxic to the ear can be taken instead. Options 1, 2, and 4 do not have effects
that are potentially associated with hearing difficulties.
Test-Taking Strategy: Focus on the subject, the medication that may be causing
the client’s complaint. Review the classifications and/or therapeutic effects as well as
the side and adverse effects of each medication in the options. Of the medications
identified, only aspirin can cause ototoxicity. In addition, it is contraindicated for GI
bleed.
Integrated Process: Nursing Process—Analysis
Content Area: Pharmacology: Pain: Nonopioid Analgesics
Health Problem: Adult Health: Ear: Vertigo/tinnitus
Reference: Hodgson, Kizior (2018), pp. 87-89.
703. Answer: 3
Rationale: Cyclopentolate is a rapidly acting mydriatic and cycloplegic

medication. Cyclopentolate is effective in 25 to 75 minutes, and accommodation
returns in 6 to 24 hours. Cyclopentolate is used for preoperative mydriasis, not pupil
constriction. The nurse should consult with the surgeon about the time of
administration of the eye drops, because 15 minutes is not adequate time for dilation
to occur.
Test-Taking Strategy: Note the strategic word, initial. Options 2 and 4 are
comparable or alike and are eliminated first (miosis refers to a constricted pupil).
Note that the question identifies a client being prepared for eye surgery. The pupil
would need to be dilated for the surgical procedure.
Content Area: Pharmacology: Eye and Ear Medications: Mydriatic, Cycloplegic,
Anticholinergics
Reference: Lilley et al. (2017), p. 916.
1999
876 UNIT XV Eye and Ear Disorders of the Adult Client
b . Insects are killed before rem oval, unless 2. Pain in the affected eye
they can be coaxed out by flash light or a 3. A yellow discoloration of the sclera
hum m ing noise; lidocaine m ay be placed 4. A sense of a curtain falling across the field of
r
in the ear to relieve pain. vision
a
E
c. Mineral oil or diluted alcoh ol is instilled to
/
e
suffocate the insect, which then is rem oved
y
744. The nurse is perform ing an otoscopic exam ination
E
—
using ear forceps. on a client with m astoiditis. On exam ination of the
d . Use a sm all ear forceps to rem ove the object;
t
tym panic m em brane, which finding should the
l
u
avoid pushing the object farth er into the
d
nurse expect to observe?
A
can al and dam aging the tym pan ic 1. A pink-colored tym panic m em brane
m em brane. 2. A pearly colored tym pan ic m em brane
3. A transparent and clear tym panic m em brane
4. A red, dull, thick, and im m obile tym pan ic
CRITICAL THINKING What Should You Do? m em brane
Answer: This situation is an emergency. The nurse should
immediately accompany the client to a room and notify the 745. A client is diagnosed with a disorder involving the
health care provider to assess the client. A penetrating eye inn er ear. Which is the m o st com m on client com -
wound is a serious injury that can cause loss of sight or plain t associated with a disorder involving this part
require loss of the eye (surgical removal). The object is of the ear?
removed onlybyan ophthalmologist, because it maybe hold- 1. Pruritus
ing eye structures in place. X-rays and computed tomography 2. Tin nitus
(CT) scans of the orbit are usually obtained to ensure that the 3. Hearing loss
orbit of the eye is intact and to look for fractures that might 4. Burning in the ear
entrap orbital muscles. Magnetic resonance imaging (MRI)
is contraindicated because of the possibility of metal-
746. The nurse is perform ing an assessm ent on a client
containing projectile movement during the procedure. Sur-
with a suspected diagnosis of cataract. Which clin-
gery is usually needed to remove the foreign object. ical m anifestation should the nurse expect to note
Reference: Ignatavicius, Workman (2016), p. 992. in the early stages of cataract form ation ?
1. Diplopia
2. Eye pain
P R AC T I C E Q U E S T I O N S 3. Floating spots
4. Blurred vision
741. During the early postoperative period, a client who
has undergone a cataract extraction com plains of 747. Aclient arrives in the emergency department follow-
nausea and severe eye pain over the operative site. ing an automobile crash. The client’s forehead hit the
What should be the in itial nursing action? steering wheel and a hyphema is diagnosed. The
1. Call the health care provider (HCP). nurse should place the client in which position?
2. Reassure the client that this is norm al. 1. Flat in bed
3. Turn the clien t onto his or her operative side. 2. A sem i-Fowler’s position
4. Adm in ister the prescribed pain m edication and 3. Lateral on the affected side
antiem etic. 4. Lateral on the unaffected side
742. The nurse is developing a teaching plan for a client
with glaucom a. Which instruction should the 748. The client sustains a contusion of the eyeball follow-
nurse include in the plan of care? ing a traumatic injury with a blunt object. Which
1. Avoid overuse of the eyes. intervention should be initiated immediately?
2. Decrease the am ount of salt in the diet. 1. Apply ice to the affected eye.
3. Eye m edication s will need to be adm inistered 2. Irrigate the eye with cool water.
for life. 3. Notify the health care provider (HCP).
4. Decrease fluid intake to control the intraocular 4. Accom pany the client to the em ergency
pressure. departm ent.
743. The nurse is perform ing an adm ission assessm ent 749. A client arrives in the em ergency departm ent with a
on a client with a diagn osis of detach ed retina. penetrating eye injury from wood chips that
Which sign or sym ptom is associated with this occurred while cutting wood. The nurse assesses
eye disorder? the eye and notes a piece of wood protruding from
1. Total loss of vision the eye. What is the in itial nursing action?
CHAPTER 60 The Eye and the Ear 877
1. Apply an eye patch. 2. Cranial nerve IV, trochlear

2. Perform visual acuity tests. 3. Cranial nerve III, oculom otor
3. Irrigate the eye with sterile salin e. 4. Cranial nerve VII, facial nerve
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4. Rem ove the piece of wood using a sterile
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eye clam p. 755. The nurse notes that the health care provider has
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docum ented a diagn osis of presbycusis on a client’s
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750. The nurse is caring for a clien t following enucle-
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chart. Based on this inform ation , what action
ation and notes the presence of brigh t red drainage should the nurse take?
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on the dressing. Which action should the nurse 1. Speak loudly, but m um ble or slur the words.
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take at this tim e? 2. Speak loudly and clearly while facin g the client.
1. Docum ent the finding. 3. Speak at norm al tone and pitch, slowly and
2. Continue to m onitor the drainage. clearly.
3. Notify the health care provider (HCP). 4. Speak loudly and directly into the client’s
4. Mark the drainage on the dressing and m onitor affected ear.
for any increase in bleeding.
756. A client with Meniere’s disease is experien cing
751. A wom an was working in her garden. She acciden- severe vertigo. Which instruction should the nurse
tally sprayed insecticide into her right eye. She calls give to the client to assist in controlling the vertigo?
the em ergency departm ent, frantic and scream in g 1. In crease sodium in the diet.
for help. The nurse should instruct the wom an to 2. Avoid sudden head m ovem ents.
take which im m ediate action? 3. Lie still and watch the television.
1. Irrigate the eyes with water. 4. Increase fluid intake to 3000 m L a day.
2. Com e to the em ergency departm ent.
3. Call the health care provider (HCP). 757. The nurse is preparing to test the visual acuity of a
4. Irrigate the eyes with diluted hydrogen clien t, using a Snellen chart. Which identifies the
peroxide. accurate procedure for this visual acuity test?
1. The right eye is tested, followed by the left eye,
752. The nurse is preparing a teaching plan for a and then both eyes are tested.
client who had a cataract extraction with intraocular 2. Both eyes are assessed together, followed by
implantation. Which hom e care m easures should an assessm ent of the right eye and then the
the nurse include in the plan? Select all that apply. left eye.
1. Avoid activities that require bending over. 3. The client is asked to stand at a distance of 40 feet
2. Contact the surgeon if eye scratchiness occurs. (12 m eters) from the chart and to read the larg-
3. Take acetaminophen for minor eye discomfort. est line on the chart.
4. Expect episodes of sudden severe pain in 4. The clien t is asked to stand at a distance of
the eye. 40 feet (12 m eters) from the chart and to read
5. Place an eye shield on the surgical eye at the line that can be read 200 feet (60 m eters)
bedtim e. away by an individual with unim paired vision.
6. Contact the surgeon if a decrease in visual
acuity occurs. 758. Aclient’s vision is tested with a Snellen chart. The results
of the tests are documented as 20/60. What action
753. Tonom etry is perform ed on a clien t with a sus- should the nurse implement based on this finding?
pected diagnosis of glaucom a. The nurse looks at 1. Provide the client with m aterials on legal
the docum ented test results and notes an intraocu- blindness.
lar pressure (IOP) value of 23. What should be the 2. Instruct the client that he or she m ay need
nurse’s in itial action? glasses when driving.
1. Apply norm al saline drops. 3. Inform the client of where he or she can pur-
2. Note the tim e of day the test was done. chase a white cane with a red tip.
3. Contact the health care provider (HCP). 4. Inform the client that it is best to sit near the
4. Instruct the client to sleep with the head of the back of the room when atten ding lectures.
bed flat.
759. The nurse is caring for a hearing-im paired client.
754. The nurse is caring for a client following craniotom y Which approach will facilitate com m un ication ?
for rem oval of an acoustic neurom a. Assessm ent of 1. Speak loudly.
which cranial nerve would identify a com plication 2. Speak frequently.
specifically associated with this surgery? 3. Speak at a norm al volum e.
1. Cranial nerve I, olfactory 4. Speak directly into the im paired ear.
AN S W E R S
tender and enlarged. Clients also have a low-grade fever, m al-
741. 1 aise, anorexia, swelling behind the ear, and pain with m inim al
Ra tiona le: Severe pain or pain accom panied by nausea follow-
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m ovem ent of the head.
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ing a cataract extraction is an indicator of increased intraocular Test-Ta king Stra tegy: Focus on the subject, the assessm ent
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pressure and should be reported to the HCP im m ediately. findings in m astoiditis. Think about the pathophysiology asso-
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Options 2, 3, and 4 are inappropriate actions. ciated with m astoiditis and rem em ber that m astoiditis reveals a
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Test-Ta king Stra tegy: Note the strategic word, initial, and the red, dull, thick, and im m obile tym panic m em brane.
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word severe. Elim inate option 2 because this is not a norm al Review: Mastoiditis
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condition. The client should not be turned to the operative
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side; therefore, elim inate option 3. From the rem aining Client Needs: Physiological Integrity
options, focusing on the strategic word will direct you to Integra ted Process: Nursing Process—Assessm ent
the correct option. Content Area : Adult Health—Ear
Review: Postoperative com plications of cataract surgery Priority Concepts: Infection; Inflam m ation
Level of Cognitive Ability: Analyzing Reference: Ignatavicius, Workm an (2016), p. 1007.
Integra ted Process: Nursing Process—Im plem entation
Content Area: Critical Care—Emergency Situations/Management 745. 2
Priority Concepts: Clinical Judgm ent; Pain Ra tiona le: Tinnitus is the m ost com m on com plaint of clients
Reference: Lewis et al. (2014), p. 395. with otological disorders, especially disorders involving the
inner ear. Sym ptom s of tinnitus range from m ild ringing in
742. 3 the ear, which can go unnoticed during the day, to a loud roar-
Ra tiona le: The adm inistration of eye drops is a critical com po- ing in the ear, which can interfere with the client’s thinking pro-
nent of the treatm ent plan for the client with glaucom a. The cess and attention span. Options 1, 3, and 4 are not associated
client needs to be instructed that m edications will need to be specifically with disorders of the inner ear.
taken for the rest of his or her life. Options 1, 2, and 4 are Test-Ta king Stra tegy: Note the strategic word, most. Recalling
not accurate instructions. the anatom y and the function of the inner ear will direct you to
Test-Ta king Stra tegy: Focus on the subject, client teaching for the correct option.
glaucom a. Recalling that m edications are an integral com po- Review: In n er ear disorders
nent of the treatm ent plan will assist in directing you to the cor- Level of Cognitive Ability: Analyzing
rect option. Client Needs: Physiological Integrity
Review: Teaching plan for the client with glaucom a Integra ted Process: Nursing Process—Assessm ent
Level of Cognitive Ability: Applying Content Area : Adult Health—Ear
Client Needs: Physiological Integrity Priority Concepts: Clinical Judgm ent; Sensory Perception
Integra ted Process: Teaching and Learning Reference: Ignatavicius, Workm an (2016), pp. 1007–1008.
Content Area : Adult Health—Eye
Priority Concepts: Client Education; Sensory Perception 746. 4
Reference: Lewis et al. (2014), p. 401. Ra tiona le: A gradual, painless blurring of central vision is the
chief clinical m anifestation of a cataract. Early sym ptom s
743. 4 include slightly blurred vision and a decrease in color percep-
Ra tiona le: Acharacteristic m anifestation of retinal detachm ent tion. Options 1, 2, and 3 are not characteristics of a cataract.
described by the client is the feeling that a shadow or curtain is Test-Ta king Stra tegy: Note the strategic word, early. Rem ember
falling across the field of vision. No pain is associated with the pathophysiology related to cataract developm ent. As a cata-
detachm ent of the retina. Options 1 and 3 are not characteris- ract develops, the lens of the eye becomes opaque. This descrip-
tics of this disorder. A retinal detachm ent is an ophthalm ic tion will assist in directing you to the correct option.
em ergency and even m ore so if visual acuity is still norm al. Review: Cataracts
Test-Ta king Stra tegy: Focus on the subject, m anifestations Level of Cognitive Ability: Analyzing
of retinal detachm ent. Thinking about the pathophysiology Client Needs: Physiological Integrity
associated with this disorder will direct you to the correct Integra ted Process: Nursing Process—Assessm ent
option. Content Area : Adult Health—Eye
Review: Retin al detach m en t Priority Concepts: Clinical Judgm ent; Sensory Perception
Level of Cognitive Ability: Analyzing Reference: Lewis et al. (2014), p. 393.
Integra ted Process: Nursing Process—Assessm ent 747. 2
Content Area : Adult Health—Eye Ra tiona le: A hyphem a is the presence of blood in the anterior
Priority Concepts: Clinical Judgm ent; Sensory Perception cham ber. Hyphem a is produced when a force is sufficient to
Reference: Ignatavicius, Workm an (2016), pp. 989–990. break the integrity of the blood vessels in the eye and can be
caused by direct injury, such as a penetrating injury from a
744. 4 BB or pellet, or indirectly, such as from striking the forehead
Ra tiona le: Otoscopic exam ination in a client with m astoiditis on a steering wheel during an accident. The client is treated
reveals a red, dull, thick, and im m obile tym panic m em brane, by bed rest in a sem i-Fowler’s position to assist gravity in keep-
with or without perforation. Postauricular lym ph nodes are ing the hyphem a away from the optical center of the cornea.
Test-Ta king Stra tegy: Focus on the subject, care of the client Review: Postoperative com plications following en ucleation
who has sustained a hyphem a. Rem em ber that placing the cli- Level of Cognitive Ability: Applying
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ent flat will produce an increase in pressure at the injured site. Client Needs: Physiological Integrity
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Also, note that the correct option is the one that identifies a Integra ted Process: Nursing Process—Im plem entation
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position different from the other options. Content Area : Critical Care—Em ergency Situations/
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Review: Hyph em a Managem ent
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Level of Cognitive Ability: Applying Priority Concepts: Clinical Judgm ent; Tissue Integrity
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Client Needs: Physiological Integrity Reference: Lewis et al. (2014), p. 402.
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Content Area : Critical Care—Em ergency Situations/ 751. 1
Managem ent Ra tiona le: In this type of accident, the client is instructed to
Priority Concepts: Safety; Tissue Integrity irrigate the eyes im m ediately with running water for at least
Reference: Jarvis (2016), p. 321. 20 m inutes, or until the em ergency m edical services personnel
arrive. In the em ergency departm ent, the cleansing agent of
748. 1
choice is usually norm al saline. Calling the HCP and going
Ra tiona le: Treatm ent for a contusion begins at the tim e of
to the em ergency departm ent delays necessary intervention.
injury. Ice is applied im m ediately. The client then should be
Hydrogen peroxide is never placed in the eyes.
seen by an HCP and receive a thorough eye exam ination to rule
Test-Ta king Stra tegy: Note the strategic word, immediate.
out the presence of other eye injuries.
Focus on the type of injury and elim inate options 2 and 3
Test-Ta king Stra tegy: Focus on the strategic word, immedi-
because they delay necessary intervention. Next, elim inate
ately. Recalling the principles related to initial treatm ent of
option 4 because hydrogen peroxide is never placed in the eyes.
injuries and noting the type of injury sustained will direct
Review: Im m ediate interventions for a ch em ical eye in jury
you to the correct option.
Review: Em ergency treatm ent of eye in juries
Content Area : Critical Care—Em ergency Situations/
Managem ent
Content Area : Critical Care—Em ergency Situations/
Priority Concepts: Client Education; Tissue Integrity
Managem ent
References: Ignatavicius, Workm an (2016), p. 991; Lewis et al.
Priority Concepts: Clinical Judgm ent; Tissue Integrity
(2014), p. 390.
Reference: Ignatavicius, Workm an (2016), p. 992.
749. 2 752. 1, 3, 5, 6
Ra tiona le: If the eye injury is the result of a penetrating object, Ra tiona le: Following eye surgery, som e scratchiness and m ild
the object m ay be noted protruding from the eye. This object eye discom fort m ay occur in the operative eye and usually is
m ust never be rem oved except by the ophthalm ologist because relieved by m ild analgesics. If the eye pain becom es severe,
it m ay be holding ocular structures in place. Application of an the client should notify the surgeon because this m ay indicate
eye patch or irrigation of the eye m ay disrupt the foreign body hem orrhage, infection, or increased intraocular pressure
and cause further tearing of the cornea. (IOP). The nurse also would instruct the client to notify the sur-
Test-Ta king Stra tegy: Note the strategic word, initial, and note geon of increased purulent drainage, increased redness, or any
the word penetrating. This should indicate that a laceration has decrease in visual acuity. The client is instructed to place an eye
occurred and that interventions are directed at preventing fur- shield over the operative eye at bedtim e to protect the eye from
ther disruption of the integrity of the eye. The only option that injury during sleep and to avoid activities that increase IOP,
will prevent further disruption is to assess visual acuity. such as bending over.
Review: Em ergency treatm ent of eye in juries Test-Ta king Stra tegy: Focus on the subject, postoperative care
Level of Cognitive Ability: Applying following eye surgery. Recalling that the eye needs to be pro-
Client Needs: Physiological Integrity tected and that increased IOP is a concern will assist in deter-
Integra ted Process: Nursing Process—Im plem entation m ining the hom e care m easures to be included in the plan.
Content Area: Critical Care—Emergency Situations/Management Review: Cataract extraction with intraocular im plant
Priority Concepts: Clinical Judgm ent; Tissue Integrity Level of Cognitive Ability: Analyzing
Reference: Ignatavicius, Workm an (2016), p. 992. Client Needs: Physiological Integrity
Integra ted Process: Teaching and Learning
750. 3 Content Area : Adult Health—Eye
Ra tiona le: If the nurse notes the presence of bright red drain- Priority Concepts: Client Education; Safety
age on the dressing, it m ust be reported to the HCP, because Reference: Lewis et al. (2014), p. 395.
this indicates hem orrhage. Options 1, 2, and 4 are inappropri-
ate at this tim e. 753. 2
Test-Ta king Stra tegy: Determ in e if an abn orm ality exists. Ra tiona le: Tonom etry is a m ethod of m easuring intraocular
Note the words, bright red. Since an abnorm ality does exist, fluid pressure. Pressures between 10 and 21 m m Hg are consid-
elim inate options that state to docum ent and continue to m on- ered within the norm al range. However, IOP is slightly higher
itor because an action is needed. in the m orning. Therefore, the initial action is to check the tim e
the test was perform ed. Norm al saline drops are not a specific changes such as salt and fluid restrictions that reduce the
treatm ent for glaucom a. It is not necessary to contact the HCP am ount of endolym phatic fluid are som etim es prescribed.
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as an initial action. Flat positions m ay increase the pressure. Lying still and watching television will not control vertigo.
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Test-Ta king Stra tegy: Focus on the subject, norm al IOP, and Test-Ta king Stra tegy: Focus on the subject, preventing vertigo.
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note the strategic word, initial. Rem em ber that norm al IOP is Note the relationship between vertigo and avoiding sudden
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between 10 and 21 m m Hg and the pressure m ay be higher in head m ovem ents in the correct option.
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the m orning. Review: Measures that reduce vertigo in the client with
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Review: Norm al in traocular pressure Men iere’s disease
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Level of Cognitive Ability: Analyzing Level of Cognitive Ability: Applying
Client Needs: Physiological Integrity Client Needs: Safe and Effective Care Environm ent
Integra ted Process: Nursing Process—Im plem entation Integra ted Process: Teaching and Learning
Content Area : Adult Health—Eye Content Area : Adult Health—Ear
Priority Concepts: Clinical Judgm ent; Sensory Perception Priority Concepts: Client Education; Safety
Reference: Ignatavicius, Workm an (2016), p. 974. Reference: Ignatavicius, Workm an, (2016), pp. 1008–1009.
754. 4 757. 1
Ra tiona le: An acoustic neurom a (or vestibular schwannom a) Ra tiona le: Visual acuity is assessed in 1 eye at a tim e, and then
is a unilateral benign tum or that occurs where the vestibuloco- in both eyes together, with the client com fortably standing or
chlear or acoustic nerve (cranial nerve VIII) enters the internal sitting. The right eye is tested with the left eye covered; then the
auditory canal. It is im portant that an early diagnosis be m ade left eye is tested with the right eye covered. Both eyes are then
because the tum or can com press the trigem inal and facial tested together. Visual acuity is m easured with or without cor-
nerves and arteries within the internal auditory canal. Treat- rective lenses and the client stands at a distance of 20 feet
m ent for acoustic neurom a is surgical rem oval via a craniot- (6 m eters) from the chart.
om y. Assessm ent of the trigem inal and facial nerves is Test-Ta king Stra tegy: Rem em ber that norm al visual acuity as
im portant. Extrem e care is taken to preserve rem aining hearing m easured by a Snellen chart is 20/20 vision. This should assist
and preserve the function of the facial nerve. Acoustic neuro- in elim inating options 3 and 4 because they are com parable or
m as rarely recur following surgical rem oval. alike in that they indicate standing at a distance of 40 feet
Test-Ta king Stra tegy: Focus on the subject, a com plication (12 m eters). From the rem aining options, rem em ber that it
following surgery. Think about the anatom ical location of an is best and m ost accurate to test each eye separately and then
acoustic neurom a and the nerves that the neurom a can com - test both eyes together.
press to direct you to the correct option. Review: Visual acuity testing with use of a Sn ellen ch art
Review: Surgical treatm ent for acoustic n eurom a Level of Cognitive Ability: Applying
Level of Cognitive Ability: Analyzing Client Needs: Health Prom otion and Maintenance
Client Needs: Physiological Integrity Integra ted Process: Nursing Process—Assessm ent
Integra ted Process: Nursing Process—Assessm ent Content Area : Adult Health—Health Assessm ent/Physical Exam
Content Area : Adult Health—Ear Priority Concepts: Clinical Judgm ent; Sensory Perception
Priority Concepts: Clinical Judgm ent; Sensory Perception Reference: Jarvis (2016), pp. 289–290, 303.
Reference: Ignatavicius, Workm an (2016), pp. 958, 1009.
758. 2
755. 3 Ra tiona le: Vision that is 20/20 is norm al—that is, the client is
Ra tiona le: Presbycusis is a type of hearing loss that occurs with able to read from 20 feet (6 m eters) what a person with norm al
aging. Presbycusis is a gradual sensorineural loss caused by vision can read from 20 feet (6 m eters). A client with a visual
nerve degeneration in the inner ear or auditory nerve. When acuity of 20/60 can only read at a distance of 20 feet (6 m eters)
com m unicating with a client with this condition, the nurse what a person with norm al vision can read at 60 feet
should speak at a norm al tone and pitch, slowly and clearly. (18 m eters). With this vision, the client m ay need glasses
It is not appropriate to speak loudly, m um ble or slur words, while driving in order to read signs and to see far ahead. The
or speak into the client’s affected ear. client should be instructed to sit in the front of the room for
Test-Ta king Stra tegy: Focus on the subject, presbycusis and lectures to aid in visualization. This is not considered to be
the effective m ethod to com m unicate. Visualize each of the legal blindness.
com m unication techniques to direct you to the correct option. Test-Ta king Stra tegy: Focus on the subject, interpreting a
Review: Presbycusis Snellen chart result. Note the test result, 20/ 60, and recall
Level of Cognitive Ability: Applying the associated interventions for this result. Also, elim inate
Client Needs: Physiological Integrity options 1 and 3, as they are com parable or alike, im plying that
Integra ted Process: Nursing Process—Im plem entation the test results indicate blindness.
Content Area : Adult Health—Ear Review: Interpretation of visual acuity test results
Priority Concepts: Com m unication; Sensory Perception Level of Cognitive Ability: Analyzing
Reference: Ignatavicius, Workm an (2016), p. 1010. Client Needs: Physiological Integrity
756. 2 Content Area : Adult Health—Eye
Ra tiona le: The nurse instructs the client to m ake slow head Priority Concepts: Clinical Judgm ent; Sensory Perception
m ovem ents to prevent worsening of the vertigo. Dietary Reference: Jarvis (2016), pp. 289–290, 303.
759. 3 Review: Effective com m unication techniques for the h earin g

Ra tiona le: Speaking in a norm al tone to the client with im paired
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im paired hearing and not shouting are im portant. The nurse Level of Cognitive Ability: Applying
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should talk directly to the client while facing the client and speak Client Needs: Psychosocial Integrity
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clearly. If the client does not seem to understand what is said, the Integra ted Process: Com m unication and Docum entation
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nurse should express it differently. Moving closer to the client Content Area : Adult Health—Ear
—
and toward the better ear m ay facilitate com m unication, but Priority Concepts: Com m unication; Sensory Perception
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the nurse should avoid talking directly into the im paired ear. Reference: Ignatavicius, Workm an (2016), p. 1014.
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Test-Ta king Stra tegy: Focus on the subject, an effective com -
m unication technique for the hearing im paired. Rem em ber
that it is im portant to speak in a norm al tone.
CHAPTER 61 Eye and Ear Medications 889
3. These m edication s reduce respiratory tissue

P R AC T I C E Q U E S T I O N S
hyperem ia and edem a to open obstructed eusta-
chian tubes. 760. Betaxolol h ydroch loride eye drops h ave been
prescribed for a clien t with glaucom a. Wh ich
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4. These m edications are used for acute otitis m edia.
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B. Side and adverse effects n ursin g action is m o st ap p ro p riate related to
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1. Drowsiness m on itorin g for side an d adverse effects of th is
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m edication ?
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2. Blurred vision
3. Dry m ucous m em branes 1. Assessing for edem a
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C. Interventions 2. Monitoring tem perature
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1. In form the clien t that drowsiness, blurred vision , 3. Monitoring blood pressure
and a dry m outh m ay occur. 4. Assessing blood glucose level
2. In struct the client to increase fluid intake unless
contraindicated and to suck on hard candy to 761. The nurse is preparing to adm inister eye drops.
alleviate the dry m outh. Which interventions should the nurse take to
3. In struct the client to avoid hazardous activities if adm inister the drops? Select all th at apply.
drowsiness occurs. 1. Wash hands.
4. In struct the client with hypertension to consult 2. Put gloves on.
the HCP prior to the use of these m edication s. 3. Place the drop in the conjunctival sac.
4. Pull the lower lid down against the
XVI. Ceruminolytic Medication
cheekbone.
A. Carbam ide peroxide 5. Instruct the client to squeeze the eyes shut
B. Description after instillin g the eye drop.
1. Em ulsifies and loosens cerum en deposits
6. Instruct the client to tilt the head forward,
2. Used to loosen and rem ove im pacted wax from
open the eyes, and look down .
the ear canal
C. Side and adverse effects 762. The nurse prepares a clien t for ear irrigation as
1. Irritation prescribed by the health care provider. Which
2. Redness or swelling of the ear canal action should the nurse take when perform ing
D. Interven tions the procedure?
1. Instruct the client not to use drops m ore often 1. Warm the irrigating solution to 98.6 °F (37.0 °C).
than prescribed.
2. Position the client with the affected side up
2. Moisten a cotton plug with m edication and insert
following the irrigation.
the cotton plug after instilling the ear drops.
3. Direct a slow, steady stream of irrigation solu-
3. Keep the container tigh tly closed and away from tion toward the eardrum .
m oisture. 4. Assist the client to turn his or her head so that
4. Avoid touch ing the ear with the dropper. the ear to be irrigated is facing upward.
5. Thirty m inutes after instillation, gently irrigate
the ear as prescribed with warm water, using a
763. The nurse is providing instructions to a client who
soft rubber bulb ear syrin ge. will be self-adm inistering eye drops. To m inim ize
6. Irrigation m ay be done with hydrogen peroxide
system ic absorption of the eye drops, the nurse
solution as prescribed to flush cerum en deposits
should instruct the clien t to take which action?
out of the ear canal. 1. Eat before instillin g the drops.
7. For a chronic cerum en im paction, 1 or 2 drops 2. Swallow several tim es after instilling the drops.
of m ineral oil (if prescribed) will soften the wax. 3. Blink vigorously to encourage tearing after
8. Instruct the client to notify the HCP if redness,
instilling the drops.
pain, or swelling persists.
4. Occlude the nasolacrim al duct with a finger
after instilling the drops.
CRITICAL THINKING What Should You Do?
Answer: Ifthe client lives alone and has a physical condition that 764. A client is prescribed an eye drop and an eye oint-
may affect instilling the eye drops, the nurse should arrange for m ent for the right eye. How should the nurse best
a home care nurse to assess the client and the home situation. If adm inister the m edication s?
the client is unable to instill eye drops independently, a friend, 1. Adm in ister the eye drop first, followed by the
neighbor, or family member can be taught the technique if pos- eye ointm en t.
sible. In addition, adaptive equipment that positions the bottle 2. Adm inister the eye ointm ent first, followed by
of eye drops directlyover the eye can be purchased and used by the eye drop.
the client who has difficulty instilling eye drops. 3. Adm inister the eye drop, wait 15 m inutes, and
References: Ignatavicius, Workman (2016), pp. 970, 975; adm inister the eye ointm ent.
Perry et al. (2014), p. 516. 4. Adm in ister the eye ointm ent, wait 15 m inutes,
and adm inister the eye drop.
765. Which m edication , if prescribed for the client with assessm ent, the client states, “Lately, I have been
glaucom a, should the nurse question? hearing som e roaring sounds in m y ears, especially
1. Betaxolol when I am alone.” Which m edication would
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2. Pilocarpin e the nurse identify as the cause of the clien t’s
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3. Erythrom ycin com plaint?
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4. Atropine sulfate 1. Doxycyclin e
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2. Atropine sulfate
766. A m iotic m edication has been prescribed for the 3. Acetylsalicylic acid
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clien t with glaucom a and the client asks the nurse 4. Diltiazem hydroch loride
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about the purpose of the m edication. Which
response should the nurse provide to the client?
768. In preparation for cataract surgery, the nurse is to
1. “The m edication will help dilate the eye to pre-
adm inister cyclopentolate eye drops at 0900 for
vent pressure from occurring.”
surgery that is scheduled for 0915. What in itial
2. “The m edication will relax the m uscles of the
action should the nurse take in relation to the char-
eyes and prevent blurred vision.”
acteristics of the m edication action?
3. “The m edication causes the pupil to constrict
1. Provide lubrication to the operative eye prior to
and will lower the pressure in the eye.”
giving the eye drops.
4. “The m edication will help block the responses
2. Call the surgeon, as this m edication will further
that are sent to the m uscles in the eye.”
constrict the operative pupil.
3. Consult the surgeon, as there is not sufficient
767. Aclient was just adm itted to the hospital to rule out
tim e for the dilative effects to occur.
a gastrointestinal (GI) bleed. The client has
4. Give the m edication as prescribed; the surgeon
brought several bottles of m edication s prescribed
needs optim al constriction of the pupil.
by different specialists. Durin g the adm ission
AN S W E R S precautions and visualize this procedure. This will assist in

determ ining the correct interventions.
760. 3 Review: Procedure for adm inistering eye m edication s
Ra tiona le: Hypotension, dizziness, nausea, diaphoresis, head- Level of Cognitive Ability: Analyzing
ache, fatigue, constipation, and diarrhea are side and adverse Client Needs: Physiological Integrity
effects of the m edication. Nursing interventions include m on- Integra ted Process: Nursing Process—Im plem entation
itoring the blood pressure for hypotension and assessing the Content Area : Pharm acology—Eye and Ear Medications
pulse for strength, weakness, irregular rate, and bradycardia. Priority Concepts: Clinical Judgm ent; Safety
Options 1, 2, and 4 are not specifically associated with this Reference: Ignatavicius, Workm an (2016), p. 975.
m edication.
Test-Ta king Stra tegy: Note the strategic words, most appropri- 762. 1
ate. Use the ABCs—airway–breath in g–circulation —to direct Ra tionale: Before ear irrigation, the nurse should inspect the
you to the correct option. tympanic membrane to ensure that it is intact. The irrigating
Review: Betaxolol h ydroch loride solution should be warm ed to 98.6 °F (37.0 °C) because a solu-
Level of Cognitive Ability: Analyzing tion temperature that is not close to the client’s body tempera-
Client Needs: Physiological Integrity ture will cause ear injury, nausea, and vertigo. The affected side
Integra ted Process: Nursing Process—Im plem entation should be down following the irrigation to assist in drainage of
Content Area : Pharm acology—Eye and Ear Medications the fluid. When irrigating, a direct and slow steady stream of irri-
Priority Concepts: Safety; Sensory Perception gation solution is directed toward the wall of the canal, not
References: Burchum , Rosenthal (2016), pp. 1269–1270; toward the eardrum. The client is positioned sitting, facing for-
Ignatavicius, Workm an (2016), p. 988. ward with the head in a natural position; if the ear is faced
upward, the nurse would not be able to visualize the canal.
761. 1, 2, 3, 4 Test-Taking Strategy: Focus on the subject, the procedure for
Ra tiona le: To adm inister eye medications, the nurse should performing ear irrigation. Think about the purpose of this proce-
wash hands and put gloves on. The client is instructed to tilt dure and keep safety in mind. Visualizing each step and the infor-
the head backward, open the eyes, and look up. The nurse pulls mation in the options will assist in eliminating the incorrect ones.
the lower lid down against the cheekbone and holds the bottle Review: The procedure for ear irrigation
like a pencil with the tip downward. Holding the bottle, the nurse Level of Cognitive Ability: Applying
gently rests the wrist of the hand on the client’s cheek and Client Needs: Physiological Integrity
squeezes the bottle gently to allow the drop to fall into the con- Integra ted Process: Nursing Process—Im plem entation
junctival sac. The client is instructed to close the eyes gently and Content Area : Pharm acology—Eye and Ear Medications
not to squeeze the eyes shut to prevent the loss of medication. Priority Concepts: Safety; Sensory Perception
Test-Ta king Stra tegy: Focus on the subject, the procedure for References: Ignatavicius, Workm an (2016), p. 1005; Perry
adm inistering eye drops. Use guidelines related to standard et al. (2014), pp. 511–512.
CHAPTER 61 Eye and Ear Medications 891
763. 4 increasing blood flow to the retina and decreasing retinal dam -
Ra tiona le: Applying pressure on the nasolacrim al duct pre- age and loss of vision. Miotics cause a contraction of the ciliary
vents system ic absorption of the m edication. Options 1, 2, m uscle and a widening of the trabecular m eshwork. Options 1,
and 3 will not prevent system ic absorption. 2, and 4 are incorrect.
r
a
E
Test-Ta king Stra tegy: Focus on the subject, system ic effects. Test-Ta king Stra tegy: Note that the client has glaucom a.
/
Eating and swallowing are com parable or alike and are not Recall that prevention of increased intraocular pressure is
e
y
E
related to the system ic absorption of eye drops. Blinking vigor- the goal in the client with glaucom a. Options 1, 2, and 4
—
ously to produce tearing m ay result in the loss of the adm inis- are com parable or alike and describe actions related to m y-
t
driatic m edications, which prim arily dilate the pupils and
l
tered m edication.
u
d
Review: The procedure for adm inistering eye drops relax the ciliary m uscles.
A
Level of Cognitive Ability: Applying Review: The action of a m iotic agen t
Client Needs: Physiological Integrity Level of Cognitive Ability: Applying
Integra ted Process: Teaching and Learning Client Needs: Physiological Integrity
Content Area : Pharm acology—Eye and Ear Medications Integra ted Process: Nursing Process—Im plem entation
Priority Concepts: Client Education; Safety Content Area : Pharm acology—Eye and Ear Medications
Reference: Lilley et al. (2014), p. 128. Priority Concepts: Client Education; Safety
References: Ignatavicius, Workm an (2016), pp. 987–988;
764. 1 Lilley et al. (2014), pp. 921–923.
Ra tiona le: When an eye drop and an eye ointm ent are sched-
uled to be adm inistered at the sam e tim e, the eye drop is 767. 3
adm inistered first. The instillation of two m edications is sepa- Ra tiona le: Aspirin is contraindicated for GI bleeding and is
rated by 3 to 5 m inutes. potentially ototoxic. The client should be advised to notify
Test-Ta king Stra tegy: Note the strategic word, best. Focus on the prescribing health care provider so the m edication
the subject, the guidelines for adm inistering eye m edications. can be discontinued and/or a substitute that is less toxic
Elim inate options 3 and 4 first because of the words 15 minutes. to the ear can be taken instead. Options 1, 2, and 4 do not
Next, thinking about the consistency and absorption of a drop have effects that are potentially associated with hearing
versus ointm ent will direct you to the correct option. difficulties.
Review: Guidelines for adm inistering eye drops and eye Test-Ta king Stra tegy: Focus on the subject, the m edication
oin tm en t that m ay be causing the client’s com plaint. Review the classifi-
Level of Cognitive Ability: Applying cations and/or therapeutic effects as well as the side and
Client Needs: Physiological Integrity adverse effects of each m edication in the options. Of the m ed-
Integra ted Process: Nursing Process—Im plem entation ications identified, only aspirin can cause ototoxicity. In addi-
Content Area : Pharm acology—Eye and Ear Medications tion, it is contraindicated for GI bleed.
Priority Concepts: Clinical Judgm ent; Safety Review: Medications that can cause ototoxicity
Reference: Perry et al. (2014), p. 516. Level of Cognitive Ability: Analyzing
765. 4 Integra ted Process: Nursing Process—Analysis
Ra tiona le: Options 1 and 2 are m iotic agents used to treat glau- Content Area : Pharm acology—Eye and Ear Medications
com a. Option 3 is an antiinfective m edication used to treat bac- Priority Concepts: Safety; Sensory Perception
terial conjunctivitis. Atropine sulfate is a m ydriatic and Reference: Ignatavicius, Workm an (2016), p. 765.
cycloplegic (also anticholinergic) m edication, and its use is
contraindicated in clients with glaucom a. Mydriatic m edica- 768. 3
tions dilate the pupil and can cause an increase in intraocular Ra tiona le: Cyclopentolate is a rapidly acting m ydriatic and
pressure in the eye. cycloplegic m edication. Cyclopentolate is effective in 25 to
Test-Taking Strategy: Focus on the subject, the m edication that 75 m inutes, and accom m odation returns in 6 to 24 hours.
the nurse should question. Recalling the classifications of the Cyclopentolate is used for preoperative m ydriasis, not pupil
medications identified in the options will assist in answering constriction. The nurse should consult with the surgeon about
the question. Remember that m ydriatics dilate the pupil and the tim e of adm inistration of the eye drops since 15 m inutes is
that these m edications are contraindicated in glaucom a. not adequate tim e for dilation to occur.
Review: Miotic agen ts used to treat glaucom a Test-Ta king Stra tegy: Note the strategic word, initial. Options
Level of Cognitive Ability: Analyzing 2 and 4 are com parable or alike and are elim inated first (m io-
Client Needs: Physiological Integrity sis refers to a constricted pupil). Note that the question iden-
Integra ted Process: Nursing Process—Analysis tifies a client being prepared for eye surgery. The pupil
Content Area : Pharm acology—Eye and Ear Medications would need to be dilated for the surgical procedure.
Priority Concepts: Collaboration; Safety Review: The action and purpose of cyclopen tolate
References: Burchum , Rosenthal (2016), pp. 120, 1272–1273; Level of Cognitive Ability: Analyzing
Ignatavicius, Workm an (2016), p. 662. Client Needs: Physiological Integrity
766. 3 Content Area : Pharm acology—Eye and Ear Medications
Ra tiona le: Miotics cause pupillary constriction and are used to Priority Concepts: Clinical Judgm ent; Safety
treat glaucom a. They lower the intraocular pressure, thereby Reference: Lilley et al. (2014), p. 933.
572 MED-SURG SUCCESS
PRACTICE QUESTIONS
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.
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.
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 intraocular 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.
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.”
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.
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.
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.
CHAPTER 14 SENSORY DEFICITS 573
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 gently 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.
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.
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.
3. The pupil reacts briskly to light.
4. The client denies any type of floaters.
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.
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.
Ear Disorders
13. Which statement indicates to the nurse the client is experiencing some hearing loss?
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.”
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.
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.
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.
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.”
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.
3. Complaints of tinnitus.
4. Complaints of presbycusis.
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.
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 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.
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.
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.
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.
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.”
PRACTICE QUESTIONS ANSWERS AND RATIONALES
Eye Disorders 3. The nurse’s priority must be assessment

of complications, which include increased
1. 1. In glaucoma, the client is often unaware intraocular pressure, endophthalmitis,
he or she has the disease until the client development of another retinal detach-
experiences blurred vision, halos around ment, or loss of turgor in the eye.
lights, difficulty focusing, or loss of 4. Follow-up visits are important, but this is
peripheral vision. Glaucoma is often not the first intervention the nurse should
called the “silent thief.” implement.
2. Floating spots in the vision is a symptom of TEST-TAKING HINT: When the question asks
retinal detachment. which intervention should be implemented
3. A yellow haze around everything is a first, all four (4) answer options are possi-
complaint of clients experiencing digoxin ble interventions but only one (1) should
toxicity. be implemented first. Remember to apply
4. The complaint of a curtain coming across the nursing process to help select the cor-
vision is a symptom of retinal detachment. rect answer. Assessment is the first part of
TEST-TAKING HINT: The signs/symptoms of the nursing process.
eye disorders are confusing. The test taker Content – Medical: Category of Health Alteration –
must know which complaints will be made Neurosensory: Integrated Nursing Process –
by the client with a specific eye disorder. Implementation: Client Needs – Safe Effective Care
Environment, Management of Care: Cognitive
Content – Medical: Category of Health Alteration –
Level – Application.
Neurosensory: Integrated Nursing Process –
Assessment: Client Needs – Physiological Integrity, 4. 1. Magnifying devices used with activities such
Reduction of Risk Potential: Cognitive Level – Analysis. as threading a needle will help the client’s
2. 1. Dilating drops are administered every vision; therefore, this statement does not
10 minutes for four (4) doses one (1) hour indicate the client needs more teaching.
prior to surgery, not for three (3) days prior 2. An Amsler grid is a tool to assess macular
to surgery. degeneration, often providing the earliest
2. Lifting and pushing objects should be sign of a worsening condition. If the lines of
avoided after surgery, not prior to surgery. the grid become distorted or faded, the
3. All types of cataract removal surgery are client should call the ophthalmologist.
usually done in day surgery. 3. Macular degeneration is the most com-
4. To reduce retrobulbar hemorrhage, mon cause of visual loss in people older
any anticoagulation therapy is withheld, than age 60 years. Any intervention
including aspirin, nonsteroidal anti- which helps increase vision should be
inflammatory drugs (NSAIDs), and included in the teaching, such as bright
warfarin (Coumadin). lighting, not decreased lighting.
4. Low-vision centers will send representatives
TEST-TAKING HINT: The test taker must
to the client’s home or work to make rec-
notice the adjectives; these descriptors are
ommendations about improving lighting,
important when selecting a correct answer.
thereby improving the client’s vision and
The test taker should notice “preoperative”
safety.
and “prior to surgery.”
TEST-TAKING HINT: This question is asking
Content – Surgical: Category of Health Alteration – which statement indicates more teaching is
Neurosensory: Integrated Nursing Process – Planning: needed. Therefore, three (3) options will
Client Needs – Physiological Integrity, Reduction of
indicate the client understands appropriate
Risk Potential: Cognitive Level – Synthesis.
discharge teaching and only one (1) will
3. 1. This should be done, but it is not the first indicate the client does not understand
intervention the nurse should implement. the teaching.
2. The client will have to be specifically posi-
tioned to make the gas bubble float into the
Neurosensory: Integrated Nursing Process – Evaluation:
best position; some clients must lie face Client Needs – Safe Effective Care Environment,
down or on their side for days, but it is not Management of Care: Cognitive Level – Synthesis.
the first intervention.
575
5. 1. A foreign object should never be removed decreased vision and the development of
at the scene of the accident because this blisters; it is usually associated with primary
may cause more damage. open-angle glaucoma.
2. The foreign object should be stabilized 2. Conjunctivitis is an inflammation of the
to prevent further movement which conjunctiva, which results in a scratching
could cause more damage to the eye. or burning sensation, itching, and
3. Flushing with water may cause further photophobia.
movement of the foreign object and should 3. Diabetic retinopathy results from deteriora-
be avoided. tion of the small blood vessels nourished by
4. The person should be kept flat and not in a the retina; it leads to blindness.
sitting position because it may dislodge or 4. A cataract is a lens opacity or cloudiness,
cause movement of the foreign object. resulting in the signs/symptoms
TEST-TAKING HINT: In an emergency discussed in the stem of the question.
situation, the first responder should first TEST-TAKING HINT: The test taker must
“do no harm.” The test taker should know the signs/symptoms of eye disorders,
examine each option and decide what will especially those commonly occurring in the
happen if this option is performed—will it elderly. Option “2” could be ruled out
help, harm, or stabilize the client? If the because -itis means inflammation and none
test taker determines one (1) action may of the signs/symptoms is inflammatory.
not help, then stabilization becomes the
priority. Neurosensory: Integrated Nursing Process –
Content – Medical: Category of Health Alteration – Diagnosis: Client Needs – Safe Effective Care
Neurosensory: Integrated Nursing Process – Environment, Management of Care: Cognitive
Implementation: Client Needs – Safe Effective Level – Analysis.
Care Environment, Management of Care: Cognitive
8. 1. Touching the tip of the container to
the eye may cause eye injury or an eye
6. 1. Instructions provide precautions and infection.
steps to take if eye injuries occur sec- 2. Gentle pressure should be applied on the
ondary to the use of tools or chemicals. inner canthus, not outer canthus, near
2. The employee must wear safety glasses, not the bridge of the nose for one (1) or
just any type of glasses and especially not two (2) minutes after instilling eyedrops.
regular prescription glasses. 3. The nurse should wash hands prior to and
3. A protective helmet is used to help prevent after instilling medications; this is not a
sports eye injuries, not work-related sterile procedure.
injuries. 4. Medication should not be placed directly
4. Eye injuries will not be prevented by paying on the eye but in the lower part of the
close attention to the surroundings. They eyelid.
are prevented by wearing protective glasses 5. Eyedrops are meant to go in the eye,
or eye shields. not on the skin, so the nurse should
TEST-TAKING HINT: The test taker must use a clean tissue to remove excess
make sure what the question is asking and medication.
must pay close attention to adjectives. An TEST-TAKING HINT: This is an alternate-type
“employee health nurse” is in the work- question requiring the test taker to select
place. If the test taker is going to select an all the correct options. The test taker
option with a word such as “always,” should not second-guess the question. All
“never,” or “only,” he or she must be five (5) options can be selected or only one
absolutely sure it is an intervention never (1). The test taker should read each option,
questioned. In health care, there are very and if it is correct, select it.
few absolutes.
Content – Medical: Category of Health Alteration – Neurosensory: Integrated Nursing Process –
Neurosensory: Integrated Nursing Process – Planning: Implementation: Client Needs – Safe Effective Care
Client Needs – Health Promotion and Maintenance: Environment, Management of Care: Cognitive
Cognitive Level – Synthesis. Level – Knowledge.
7. 1. Corneal dystrophy is an inherited eye disor- 9. 1. Special eyeglasses are not needed for an
der occurring at about age 20 and results in enucleation.
2. An enucleation is the removal of the drops helps decrease inflammation and

entire eye and part of the optic nerve. edema of the eye.
An ocular prosthesis will help maintain TEST-TAKING HINT: Option “3” has the
the shape of the eye socket after the absolute word “any,” so the test taker
enucleation. could eliminate it. LASIK is a corrective
3. The client had the left eye removed but is surgery, and if the problem is corrected,
not blind because he or she still has the then corrective lenses should not be
right eye. necessary.
4. The eyeball was totally removed and
a pressure dressing was applied; Content – Surgical: Category of Health Alteration –
therefore, there will be no need to Neurosensory: Integrated Nursing Process –
Planning: Client Needs – Physiological Integrity,
instill eyedrops.
Physiological Adaptation: Cognitive Level – Synthesis.
TEST-TAKING HINT: In some questions, the
test taker must know the definition of the 12. 1. Movement of the eye should be avoided
word (“enucleation”) to be able to apply it until the client has received general
in a clinical situation. anesthesia; therefore, this is not the first
intervention.
Content – Medical: Category of Health Alteration – 2. Parenteral broad-spectrum antibiotics
Neurosensory: Integrated Nursing Process – are initiated but not until the eyes are
Implementation: Client Needs – Safe Effective Care
treated first.
3. Before any further evaluation or
treatment, the eyes must be thor-
10. 1. Steroid medication is administered to oughly flushed with sterile normal
decrease inflammation. saline solution.
2. Both systemic and topical medications 4. Tetanus prophylaxis is recommended for
are used to decrease the intraocular full-thickness ocular wounds.
pressure in the eye, which causes TEST-TAKING HINT: If the test taker is not
glaucoma. sure of the answer, the test taker should
3. Glaucoma does not affect the pupillary select the answer directly addressing the
reaction. client’s condition. Options “1” and “3”
4. Floaters are a complaint of clients with directly affect the eyes, but when choos-
retinal detachment. ing between these two options, the test
TEST-TAKING HINT: To determine the taker should ask, “How will moving
effectiveness of a medication, the nurse the eyes help treat the eyes?” and then
must know the signs/symptoms of the eliminate option “1.”
disease process. If the test taker knew
glaucoma was the result of an increase in
intraocular pressure, then the medication Implementation: Client Needs – Safe Effective
is effective if there was a decrease in Care Environment, Management of Care: Cognitive
intraocular pressure. Level – Application.
Assessment: Client Needs – Physiological Integrity, Ear Disorders
Pharmacological and Parenteral Therapies: Cognitive
Level – Analysis. 13. 1. Cleaning the ears daily does not indicate
the client has a hearing loss.
11. 1. The client does not have to wear eye 2. The need to turn up the volume on the
patches after this surgery. television is an early sign of hearing
2. The purpose of this surgery is to ensure impairment.
the client does not have to wear any type 3. Pain in the ears is not a clinical manifesta-
of corrective lens. tion of hearing loss/impairment.
3. The client can read immediately after this 4. This statement may indicate a balance
surgery. problem secondary to an ear disorder, but
4. LASIK surgery is an effective, safe, it does not indicate a hearing loss.
predictable surgery performed in day
TEST-TAKING HINT: If the test taker has no
surgery; there is minimal postoperative
idea of the answer, option “2” is the only
care. Instilling topical corticosteroid
answer which has anything to do with 16. 1. The client should blow the nose with the
sound. mouth open to prevent pressure in the
eustachian tube.
2. There may be temporary deafness as a
Assessment: Client Needs – Physiological Integrity, result of postoperative edema, but the
Reduction of Risk Potential: Cognitive Level – hearing will return as the edema subsides.
Analysis. 3. Ophthalmic drops are used in the eyes, not
the ears. Otic drops are used for the ears.
14. 1. The tympanic membrane is the 4. Water should be prevented from enter-
eardrum, and if it is punctured it ing the external auditory canal because
may lead to hearing loss. it may irritate the surgical incision and
2. Loud persistent noise, such as heavy is a medium for bacterial growth.
machinery, engines, and artillery,
TEST-TAKING HINT: The test taker must be
over time may cause noise-induced
aware of adjectives. In option “3,” the test
hearing loss.
taker should know “ophthalmic” refers to
3. Multiple ear infections scar the
the eye, which causes the test taker to
tympanic membrane, which can lead
eliminate this as a possible answer.
to hearing loss.
4. Nephrotoxic means harmful to the kid- Content – Surgical: Category of Health Alteration –
neys; ototoxic is harmful to the ears. Neurosensory: Integrated Nursing Process – Planning:
5. Multiple pierced earrings do not lead to Client Needs – Physiological Integrity, Reduction of Risk
hearing loss. The auricle (skin attached to Potential: Cognitive Level – Synthesis.
the head) is composed mainly of cartilage, 17. 1. Antibiotics will not cure this disease.
except for the fat and subcutaneous tissue Surgery is the only cure for Ménière’s
in the earlobe. disease, which may result in permanent
TEST-TAKING HINT: This alternate-type deafness as a result of the labyrinth being
question requires the test taker to select removed in the surgery.
multiple correct answers. Many options can 2. Ménière’s disease does not lead to deafness
be eliminated as incorrect answers when unless surgery is performed removing the
the test taker knows medical terminology— labyrinth in attempts to eliminate the
nephro- means kidney-related—and normal attacks of vertigo.
anatomy of the body—auricle means “skin 3. Sodium regulates the balance of fluid
attached to the head.” within the body; therefore, a low-
sodium diet is prescribed to help control
Neurosensory: Integrated Nursing Process – the symptoms of Ménière’s disease.
Diagnosis: Client Needs – Safe Effective Care 4. Sleeping with the head of the bed elevated
Environment, Management of Care: Cognitive will not affect Ménière’s disease.
Level – Knowledge. TEST-TAKING HINT: Sleeping with the
15. 1. Otalgia (ear pain) is experienced by HOB elevated is not a medical treatment;
clients with otitis media. therefore, option “4” can be eliminated as
2. A green, foul-smelling drainage supports a possible answer. The test taker must
the diagnosis of external otitis, not of read the stem carefully.
acute otitis media. Content – Medical: Category of Health Alteration –
3. A sensation of congestion in the ear Neurosensory: Integrated Nursing Process –
supports serous otitis media. Evaluation: Client Needs – Safe Effective Care
4. Hearing loss supports a diagnosis of Environment, Management of Care: Cognitive
chronic otitis media or serous otitis media. Level – Synthesis.
TEST-TAKING HINT: If the test taker were 18. 1. Vertigo is an illusion of movement in
not sure of the answer, the adjective which the client complains of dizziness.
“acute” in the stem should cause the test 2. Otorrhea is drainage of the ear.
taker to think “pain,” which is included in 3. Tinnitus is “ringing of the ears.” It is a
option “1.” subjective perception of sound with
internal origins.
Neurosensory: Integrated Nursing Process – 4. Presbycusis is progressive hearing loss
Assessment: Client Needs – Physiological Integrity, associated with aging.
Reduction of Risk Potential: Cognitive Level – Analysis.
TEST-TAKING HINT: The test taker who is 21. 1. Calcium channel blockers are not going to
familiar with medical terminology can affect the client’s hearing.
rule out options based on the understand- 2. Aminoglycoside antibiotics are oto-
ing of medical terms. toxic. Overdosage of these medications
can cause the client to go deaf, which
is why peak and trough serum levels
Implementation: Client Needs – Safe Effective Care are drawn while the client is taking a
Environment, Management of Care: Cognitive medication of this type. These antibi-
Level – Application. otics are also very nephrotoxic.
3. Steroids cause many adverse effects, but
19. 1. This is not the rationale for holding the damage to the ear is not one of them.
otoscope in this manner. 4. Administering an intravenous push loop
2. Holding the otoscope in this manner does diuretic too fast can cause auditory nerve
not help visualize the membrane any damage, but an oral loop diuretic does
better than holding the otoscope in other not.
ways.
TEST-TAKING HINT: The test taker must be
3. Inserting the speculum of the otoscope
cautious of adjectives. The word “oral” in
into the external ear can cause ear
option “4” eliminates this option as a
trauma if not done correctly.
possible correct answer.
4. If the ear is inflamed, it may be impossi-
ble to prevent hurting the client on Content – Medical: Category of Health Alteration –
examination. Drug Administration: Integrated Nursing Process –
TEST-TAKING HINT: The scientific rationale Implementation: Client Needs – Physiological
Integrity, Pharmacological and Parenteral Therapies:
is the critical-thinking component of
Cognitive Level – Application.
nursing; the test taker must understand
the “why” of nursing interventions. 22. 1. Tight-fitting swim caps or wetsuit hoods
should be worn because they prevent wa-
ter from entering the ear canal.
Diagnosis: Client Needs – Safe Effective Care 2. Silicone ear plugs should be worn because
Environment, Management of Care: Cognitive they keep water from entering the ear canal
Level – Analysis. without reducing hearing significantly.
3. A 2% acetic acid solution or 2% boric
20. 1. This is not the correct way to administer acid in ethyl alcohol is effective in
eardrops. drying the canal and restoring its
2. The nurse must straighten the ear canal; normal acidic environment.
therefore, the outside of the ear must be 4. A bulb syringe with a Teflon catheter
moved. can be used to remove impacted debris
3. This will increase pressure in the ear and from the ear, but it is not used to remove
should not be done prior to administering excess water.
eardrops.
TEST-TAKING HINT: If the test taker has no
4. This will straighten the ear canal so
idea what the correct answer is, the test
the eardrops will enter the ear canal
taker should evaluate the answer options
and drain toward the tympanic
to see if two are similar. In this question,
membrane (eardrum).
both options “1” and “2” say to not use
TEST-TAKING HINT: The test taker should ear protectors. Because there cannot be
notice options “1” and “4” are opposite, two correct answers, these two could be
which should clue the test taker into eliminated as possible correct answers.
either eliminating both or deciding one
(1) of these two (2) is the correct answer. Content – Medical: Category of Health Alteration –
Either way, the test taker now has a Neurosensory: Integrated Nursing Process –
50/50 chance of selecting the correct Planning: Client Needs – Health Promotion and
Maintenance: Cognitive Level – Synthesis.
answer.
23. 1. Mild analgesics such as aspirin or aceta-
Drug Administration: Integrated Nursing Process – minophen every four (4) hours as needed
Implementation: Client Needs – Physiological to relieve pain and fever are recom-
Integrity, Pharmacological and Parenteral Therapies: mended; aspirin may help decrease
Cognitive Level – Application. inflammation of the ear.
2. Heat applied to the affected ear is recom- 2. Surgery on the ear may disrupt the client’s
mended because heat dilates blood vessels, equilibrium, increasing the risk for falling.
promoting the reabsorption of fluid and 3. Hearing loss secondary to postoperative
reducing edema. edema is common after surgery, but the
3. Pain subsiding abruptly may indicate hearing will return after the edema
spontaneous perforation of the tym- subsides.
panic membrane within the middle ear 4. Shampooing, showering, and immers-
and should be reported to the HCP. ing the head in water are avoided to
4. Ear plugs should not be used in clients prevent contamination of the ear canal;
with otitis media, but cotton balls could therefore, this comment indicates
be used to keep otic antibiotics in the the client does not understand the
ear canal. preoperative teaching.
TEST-TAKING HINT: The test taker must TEST-TAKING HINT: This is an “except”
use basic principles when answering ques- question. The stem states “needs more
tions. Cold causes constriction and heat teaching”; therefore, three (3) of the op-
dilates. Except for aspirin not being tions reflect an appropriate understanding
administered to children to prevent of the teaching and only one (1) indicates
Reye’s syndrome, mild analgesics can be a misunderstanding of the teaching.
administered for almost any discomfort.
Content – Surgical: Category of Health Alteration –
Neurosensory: Integrated Nursing Process – Evaluation: Client Needs – Physiological Integrity,
Planning: Client Needs – Physiological Integrity, Physiological Adaptation: Cognitive Level – Synthesis.
24. 1. Leaving the mouth open when coughing

or sneezing will minimize the pressure
changes in the middle ear.
SENSORY DEFICITS COMPREHENSIVE

EXAMINATION
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.
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 is 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?”
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.
4. Which assessment technique should the nurse implement 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.
5. Which intervention should the nurse include when conducting an in-service on caring
for elderly clients addressing 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.
6. Which situation makes the nurse suspect the client has glaucoma?
1. An automobile accident because the client did not see 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.
7. The client with a retinal detachment has just undergone a gas tamponade repair.
Which discharge instruction should the nurse include in the teaching?
1. The client must lie flat with the face down.
2. The head of the bed must be elevated 45 degrees.
3. The client should wear sunglasses when outside.
4. The client should avoid reading for three (3) weeks.
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. A
2. B
3. C
4. D
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.”
10. The client has undergone a bilateral stapedectomy. Which action by the client
warrants immediate intervention by the nurse?
1. The client is ambulating without assistance.
2. The client is sneezing with the mouth open.
3. There is some slight serosanguineous drainage.
4. The client reports hearing popping in the affected ear.
11. The female client tells the clinic nurse 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.
12. The nurse writes the diagnosis “risk for injury 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.
13. The nurse is assessing the client’s cranial nerves. Which assessment data indicate
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.
14. The elderly client is complaining of abdominal discomfort. Which scientific rationale
should the nurse remember when addressing an elderly client’s perception of pain?
1. Elderly clients react to pain the same way any other age group does.
2. The elderly client usually requires more pain medication.
3. Reaction to painful stimuli may be decreased with age.
4. The elderly client should use the Wong scale to assess pain.
15. Which instruction should the nurse discuss with the client when completing a
sensory assessment?
1. Instruct the client to lie flat without a pillow during the assessment.
2. Instruct the client to keep both eyes shut during the assessment.
3. During the assessment the client must be in a treatment room.
4. Keep the lights off during the client’s sensory assessment.
16. Which signs/symptoms should the nurse expect to find when assessing the client
with an acoustic neuroma?
1. Incapacitating vertigo and otorrhea.
2. Nystagmus and complaints of dizziness.
3. Nausea and vomiting.
4. Unilateral hearing loss and tinnitus.
17. Which assessment technique should the nurse use to assess the client’s optic nerve?
1. Have the client identify different smells.
2. Have the client discriminate between sugar and salt.
3. Have the client read the Snellen chart.
4. Have the client say “ah” to assess the rise of the uvula.
18. Which referral is most important for the nurse to implement for the client with
permanent hearing loss?
1. Aural rehabilitation.
2. Speech therapist.
3. Social worker.
4. Vocational rehabilitation.
19. Which instruction should the nurse discuss with the female client with viral
conjunctivitis?
1. Contact the HCP if pain occurs.
2. Do not share towels or linens.
3. Apply warm compresses to the eyes.
4. Apply makeup very lightly.
20. The client is two (2) hours postoperative right ear mastoidectomy. Which assessment
data should be reported to the health-care provider?
1. Complaints of aural fullness.
2. Hearing loss in the affected ear.
3. No vertigo.
4. Facial drooping.
21. Which behavior by the male client should make the nurse suspect the client has a
hearing loss? Select all that apply.
1. The client reports hearing voices in his head.
2. The client becomes irritable very easily.
3. The client has difficulty making decisions.
4. The client’s wife reports he ignores her.
5. The client does not dominate a conversation.
22. The client with cataracts who has had intraocular lens implants is being discharged
from the day surgery department. Which discharge instructions should the nurse
discuss with the client?
1. Do not push or pull objects heavier than 50 pounds.
2. Lie on the affected eye with two pillows at night.
3. Wear glasses or metal eye shields at all times.
4. Bend and stoop carefully for the rest of your life.
23. The nurse is assessing the client’s sensory system. Which assessment data indicate an
abnormal stereognosis test?
1. The client is unable to identify which way the toe is being moved.
2. The client cannot discriminate between sharp and dull objects.
3. The toes contract and draw together when the sole of the foot is stroked.
4. The client is unable to identify a key in the hand with both eyes closed.
24. Which statement by the daughter of an 80-year-old female client who lives alone
warrants immediate intervention by the nurse?
1. “I put a night-light in my mother’s bedroom.”
2. “I got carbon monoxide detectors for my mother’s house.”
3. “I changed my mother’s furniture around.”
4. “I got my mother large-print books.”
25. The 72-year-old client tells the nurse food does not taste good anymore and he has
lost a little weight. Which information should the nurse discuss with the client?
1. Suggest using extra seasoning when cooking.
2. Instruct the client to keep a seven (7)-day food diary.
3. Refer the client to a dietitian immediately.
4. Recommend eating three (3) meals a day.
26. The male client diagnosed with type 2 diabetes mellitus tells the nurse he has begun
to see yellow spots. Which interventions should the nurse implement? List in order
of priority.
1. Notify the health-care provider.
2. Check the client’s hemoglobin A1c.
3. Assess the client’s vision using the Amsler grid.
4. Teach the client about controlling blood glucose levels.
5. Determine where the spots appear to be in the client’s field of vision.
SENSORY DEFICITS COMPREHENSIVE EXAMINATION
ANSWERS AND RATIONALES
1. 1. The decreased sense of smell resulting Content – Medical: Category of Health Alteration –
from atrophy of olfactory organs is a Neurosensory: Integrated Nursing Process –
safety hazard, and clients may not be Implementation: Client Needs – Safe Effective
able to smell gas leaks or fire, so the Care Environment, Management of Care:
Cognitive Level – Application.
nurse should recommend a carbon
monoxide detector and a smoke alarm. 4. 1. This assesses proprioception, or position
This safety equipment is critical for the sense; direction of the toe must be
elderly. evaluated.
2. Night lights do not address the client’s 2. Vibration is assessed by using a low-
sense of smell. frequency tuning fork on a bony
3. High humidity may help with breathing, prominence and asking the client
but it does not help the sense of smell. whether he or she feels the sensation
4. The client’s sense of smell is decreased; and, if so, when the sensation ceases.
therefore, smelling food before eating is not 3. Tapping the cheek assesses for tetany, not
an appropriate intervention. cranial nerve involvement.
Content – Medical: Category of Health Alteration – 4. A two-point discrimination test evaluates
Neurosensory: Integrated Nursing Process – Planning: integration of sensation, but it does not as-
Client Needs – Physiological Integrity, Physiological sess for vibration.
Adaptation: Cognitive Level – Synthesis. Content – Medical: Category of Health Alteration –
2. 1. The nurse needs to discuss possible causes Neurosensory: Integrated Nursing Process –
with the client and not talk to the wife. Assessment: Client Needs – Safe Effective Care
2. The acuity of the taste buds decreases
Level – Analysis.
with age, which could cause regular
foods to seem bland and tasteless. 5. 1. Adequate lighting without a glare should
3. Some medications may cause a metallic be provided when having the client read
taste in the mouth, but medication does not written material; therefore, the curtains
cause foods to taste bland. should be closed, not open.
4. Telling the client to cook if he doesn’t like 2. The nurse should provide short, concise,
his wife’s food is an argumentative and and concrete material, not a variety of
judgmental response. material.
Content – Medical: Category of Health Alteration – 3. Because fewer tactile cues are received
Neurosensory: Integrated Nursing Process – from the bottom of the feet, the client
Implementation: Client Needs – Physiological may get confused as to body position
Integrity, Physiological Adaptation: Cognitive and location. Safety is priority, and
assisting the client getting out of bed
3. 1. Because of altered temperature regulation, and sitting in a chair is appropriate.
the client usually needs a warmer 4. This is making a judgment. Not all elderly
room temperature, not a cooler room clients are hard of hearing, and telephones
temperature. for the hearing impaired require special
2. The nurse should use a low-pitched, training for the user.
normal-volume, clear voice. Talking louder Content – Medical: Category of Health Alteration –
or shouting only makes it harder for the Neurosensory: Integrated Nursing Process – Planning:
client to understand the nurse. Client Needs – Health Promotion and Maintenance:
Cognitive Level – Synthesis.
3. The elderly client requires adequate time to
receive and respond to stimuli, to learn, and 6. 1. Loss of peripheral vision as a result of
to react; therefore, the nurse should take glaucoma causes the client problems
time and not rush the admission. with seeing things on each side, result-
4. Sensory isolation resulting from visual ing in a “blind spot.” This problem can
and hearing loss can cause confusion, lead to the client having car accidents
anxiety, disorientation, and misinterpre- when switching lanes.
tation of the new environment; 2. This is indicative of cataracts because
therefore, the nurse should provide clients with cataracts have blurred vision
extra orientation. and cannot read clearly.
585
3. This is indicative of cataracts because there Content – Medical: Category of Health Alteration –
is a color shift to yellow–brown and there is Neurosensory: Integrated Nursing Process –
reduced light transmission. Diagnosis: Client Needs – Safe Effective Care
4. This is indicative of macular degeneration, Environment, Management of Care: Cognitive
Level – Knowledge.
in which the central vision is affected.
Content – Medical: Category of Health Alteration – 10. 1. Balance disturbance, or true vertigo,
Neurosensory: Integrated Nursing Process – rarely occurs with other middle-ear
Evaluation: Client Needs – Safe Effective Care surgical procedures, but it does occur
for a short time after a stapedectomy.
Level – Synthesis.
Safety is an important issue, and
7. 1. If gas tamponade is used to flatten the ambulating without assistance requires
retina, the client may have to be spe- intervention by the nurse.
cially positioned to make the gas bubble 2. Pressure changes in the middle ear will be
float into the best position; clients must minimal if the client sneezes or blows the
lie face down or on the side for days. nose with the mouth open instead of
2. The HOB should not be elevated after this closed.
surgery. 3. Slightly bloody or serosanguineous
3. There is no need for the client to wear drainage is normal after ear surgery.
sunglasses; this surgery does not cause 4. Popping and crackling in the operative ear
photophobia. is normal for about three (3) to five (5)
4. The client does not need to avoid reading. weeks after surgery.
Content – Surgical: Category of Health Alteration – Content – Surgical: Category of Health Alteration –
Neurosensory: Integrated Nursing Process – Planning: Neurosensory: Integrated Nursing Process –
Client Needs – Physiological Integrity, Physiological Assessment: Client Needs – Safe Effective Care
Adaptation: Cognitive Level – Synthesis. Environment, Management of Care: Cognitive
Level – Analysis.
8. 1. The tuning fork should be struck to
produce vibrations and then placed 11. 1. This is not a condition requiring an ap-
midline between the ears on top of pointment with the health-care provider.
the head. 2. Anticholinergic medications, such as
2. The right temple area is not an appropriate scopolamine patches, can be recom-
place to assess for conductive hearing loss. mended by the nurse; this is not
3. The right occipital area is not the appropri- prescribing. Motion sickness is a
ate place to place the tuning fork; this is the disturbance of equilibrium caused
area behind the ear where the Rinne test is by constant motion.
performed. 3. Motion sickness can be controlled with
4. The chin area is not the appropriate area to medication and it may not even occur.
put the tuning fork. Therefore, discussing canceling the trip is
Content – Medical: Category of Health Alteration – not providing the client with appropriate
Neurosensory: Integrated Nursing Process – Assessment: information.
Client Needs – Safe Effective Care Environment, 4. This is providing the client with false in-
Management of Care: Cognitive Level – Knowledge. formation. Lying down may or may not
9. 1. Conductive hearing loss results from an ex- help motion sickness. To be able to enjoy
ternal ear disorder, such as impacted ceru- the cruise, the client needs medication.
men, or a middle ear disorder, such as otitis Content – Medical: Category of Health Alteration –
media or otosclerosis.
2. Functional (psychogenic) hearing loss is Physiological Adaptation: Cognitive Level – Synthesis.
nonorganic and unrelated to detectable
structural changes in the hearing mecha- 12. 1. This is appropriate for a diagnosis of
nisms. It is usually a manifestation of an “knowledge deficit.”
emotional disturbance. 2. This is appropriate for a diagnosis of
3. Mixed hearing loss involves both conductive “deficient diversional activity” related to
loss and sensorineural loss. It results from environmental lack of activity.
dysfunction of air and bone conduction. 3. Balance depends on visual, vestibular,
4. Sensorineural hearing loss is described and proprioceptive systems; therefore,
in the stem of the question. It involves the nurse should assess these systems
damage to the cochlea or vestibulo- for signs/symptoms.
cochlear nerve.
4. This is appropriate for a diagnosis of 4. There is no reason the lights should be off
“ineffective coping.” during the sensory assessment; the client
Content – Medical: Category of Health Alteration – should close his or her eyes.
Neurosensory: Integrated Nursing Process – Content – Medical: Category of Health
Diagnosis: Client Needs – Safe Effective Care Alteration – Neurosensory: Integrated Nursing
Environment, Management of Care: Cognitive Process – Planning: Client Needs – Physiological
Level – Analysis. Integrity, Physiological Adaptation: Cognitive
13. 1. Being able to identify cold and hot on the
face indicates an intact trigeminal nerve, 16. 1. Vertigo and otorrhea are not the signs/
cranial nerve V. symptoms of an acoustic neuroma.
2. Not having any tongue tremor indicates an 2. Neither nystagmus, an involuntary rhyth-
intact hypoglossal nerve, cranial nerve XI. mic movement of the eyes, nor dizziness is
3. No ptosis of the eyelids indicates an intact a sign of an acoustic neuroma.
oculomotor nerve (cranial nerve III), 3. Nausea and vomiting are not signs/
trochlear nerve (IV), and abducens nerve symptoms of an acoustic neuroma.
(VI). Tests also assess for ocular motion, 4. An acoustic neuroma is a slow-
conjugate movements, nystagmus, and growing, benign tumor of cranial nerve
papillary reflexes. VII. It usually arises from the Schwann
4. Cranial nerve I is the olfactory nerve, cells of the vestibular portion of the
which involves the sense of smell. With nerve and results in unilateral hearing
the eyes closed, the client must identify loss and tinnitus, with or without
familiar smells to indicate an intact vertigo.
cranial nerve I. Content – Medical: Category of Health Alteration –
Neurosensory: Integrated Nursing Process – Assessment: Client Needs – Physiological Integrity,
Assessment: Client Needs – Physiological Integrity, Reduction of Risk Potential: Cognitive Level –
Reduction of Risk Potential: Cognitive Level – Analysis.
Analysis.
17. 1. This assesses cranial nerve I, the olfactory
14. 1. This is an inaccurate statement. nerve.
2. The elderly client usually requires less 2. This assesses cranial nerve IX, the glos-
pain medication because of the effects of sopharyngeal nerve.
the normal aging process on the liver 3. This assesses cranial nerve II, the optic
(metabolism) and renal system (excretion). nerve, along with visual field testing
3. Decreased reaction to painful stimuli is and ophthalmoscopic examination.
a normal developmental change; there- 4. This assesses cranial nerve X, the vagus
fore, complaints of pain may be more nerve.
serious than the client’s perception Content – Medical: Category of Health Alteration –
might indicate and thus such com- Neurosensory: Integrated Nursing Process –
plaints require careful evaluation. Assessment: Client Needs – Safe Effective Care
4. The Wong scale is used to assess pain for Environment, Management of Care: Cognitive
Level – Analysis.
the pediatric client, not the adult client.
Content – Medical: Category of Health Alteration – 18. 1. The purpose of aural rehabilitation is
Neurosensory: Integrated Nursing Process – to maximize the communication skills
Diagnosis: Client Needs – Safe Effective Care of the client who is hearing impaired.
It includes auditory training, speech
Level – Analysis.
reading, speech training, and the
15. 1. The client should be in the sitting use of hearing aids and hearing
position during a sensory assessment. guide dogs.
2. The eyes are closed so tactile, superfi- 2. A speech therapist may be part of the
cial pain, vibration, and position sense aural rehabilitation team, but the most
(proprioception) can be assessed important referral is aural rehabilitation.
without the client seeing what the 3. The client may or may not need financial
nurse is doing. assistance, but the most important referral
3. The sensory assessment can be conducted is aural rehabilitation.
at the bedside; there is no reason to take 4. The client may or may not need assistance
the client to the treatment room. with employment because of hearing loss,
but the most important referral is the Under these circumstances, the client
aural rehabilitation. may become irritable very easily.
Content – Medical: Category of Health Alteration – 3. Loss of self-confidence makes it
Neurosensory: Integrated Nursing Process – increasingly difficult for a person who
Implementation: Client Needs – Safe Effective Care is hearing impaired to make a decision.
Environment, Management of Care: Cognitive 4. Often it is not the person with the
hearing loss but a significant other who
19. 1. The client should be aware eye pain notices hearing loss; hearing loss is
(a sandy sensation and sensitivity to light) usually gradual.
will occur with conjunctivitis. 5. Many clients who are hearing impaired
2. Viral conjunctivitis is a highly conta- tend to dominate the conversation
gious eye infection. It is easily spread because, as long as it is centered on the
from one person to another; therefore, client, they can control it and are not as
the client should not share personal likely to be embarrassed by some mistake.
items. Content – Surgical: Category of Health Alteration –
3. Cold compresses should be placed over Neurosensory: Integrated Nursing Process –
the eyes for about 10 minutes four (4) to Assessment: Client Needs – Physiological Integrity,
Reduction of Risk Potential: Cognitive Level –
five (5) times a day to soothe the pain.
Analysis.
4. The client must not apply any makeup
until the disease is over and should discard 22. 1. The client should not lift, push, or pull
all old makeup to help prevent reinfection. objects heavier than 15 pounds; 50 pounds
Content – Medical: Category of Health Alteration – is excessive.
Neurosensory: Integrated Nursing Process – 2. The client should avoid lying on the side
Planning: Client Needs – Physiological Integrity, of the affected eye at night.
Physiological Adaptation: Cognitive Level – Synthesis. 3. The eyes must be protected by wearing
20. 1. Aural fullness or pressure after surgery is glasses or metal eye shields at all times
caused by residual blood or fluid in the following surgery. Very few answer
middle ear. This is an expected occurrence options with “all” will be correct, but if
after surgery, and the nurse should admin- the option involves ensuring safety, it
ister the prescribed analgesic. may be the correct option.
2. Hearing in the operated ear may be 4. The client should avoid bending or
reduced for several weeks because of stooping for an extended period—but
edema, accumulation of blood and tissue not forever.
fluid in the middle ear, and dressings or Content – Surgical: Category of Health Alteration –
packing, so this does not need to be Neurosensory: Integrated Nursing Process –
reported to the health-care provider.
3. Vertigo (dizziness) is uncommon after this
surgery, but if it occurs the nurse should 23. 1. This is an abnormal finding for testing
administer an antiemetic or antivertigo proprioception, or position sense.
medication and does not need to report it 2. This is an abnormal finding for assessing
to the health-care provider. superficial pain perception.
4. The facial nerve, which runs through 3. This is a normal Babinski’s reflex in an
the middle ear and mastoid, is at risk adult client.
for injury during mastoid surgery; 4. Stereognosis is a test evaluating higher
therefore, a facial paresis should be cortical sensory ability. The client is
reported to the health-care provider. instructed to close both eyes and
Content – Surgical: Category of Health Alteration – identify a variety of objects (e.g.,
Neurosensory: Integrated Nursing Process – keys, coins) placed in one hand by
Assessment: Client Needs – Physiological Integrity, the examiner.
Reduction of Risk Potential: Cognitive Level – Content – Surgical: Category of Health Alteration –
Analysis. Neurosensory: Integrated Nursing Process –
21. 1. Voices in the head may indicate Assessment: Client Needs – Physiological Integrity,
Reduction of Risk Potential: Cognitive
schizophrenia, but it is not a symptom
Level – Analysis.
of hearing loss.
2. Fatigue may be the result of straining 24. 1. With normal aging comes decreased
to hear, and a client may tire easily peripheral vision, constricted visual field,
when listening to a conversation. and tactile alterations. A night-light
addresses safety issues and warrants praise, 26. In order of priority: 5, 3, 2, 1, 4.

not intervention. 5. The nurse should question the client
2. Carbon monoxide detectors help ensure further to obtain information such as
safety in the mother’s home, so this com- which eye is affected, how long the
ment doesn’t warrant intervention. client has been seeing the spots, and
3. Decreased peripheral vision, con- whether this ever occurred before.
stricted visual fields, and tactile 3. The Amsler grid is helpful in
alterations are associated with normal determining losses occurring in
aging. The client needs a familiar the visual fields.
arrangement of furniture for safety. 2. The hemoglobin A1c laboratory tests
Moving the furniture may cause the results indicate glucose control over
client to trip or fall. The nurse should the past two (2) to three (3) months.
intervene in this situation. Diabetic retinopathy is directly related
4. As a result of normal aging, vision may to poor blood glucose control.
become impaired, and the provision of 1. The health-care provider should
large-print books warrants praise. be notified to plan for laser surgery
Content – Surgical: Category of Health Alteration – on the eye.
Neurosensory: Integrated Nursing Process – 4. The client should be instructed about
Evaluation: Client Needs – Safe Effective Care controlling blood glucose levels, but
Environment, Management of Care: Cognitive this can wait until the immediate
situation is resolved or at least until
25. 1. The acuity of taste buds decreases with measures to address the potential loss
age, which may cause a decreased of eyesight have been taken.
appetite and subsequent weight loss. Content – Surgical: Category of Health Alteration –
Extra seasoning may help the food Neurosensory: Integrated Nursing Process –
taste better to the client. Implementation: Client Needs – Safe Effective Care
2. This may be an appropriate intervention if
Level – Analysis.
excessive weight is lost or if seasoning the
food does not increase appetite, but it is
not necessary at this time.
3. The client does not need a dietary consult
for food not tasting good. The nurse can
address the client’s concern.
4. This recommendation does not address
the client’s comment about food not
tasting good.
Content – Surgical: Category of Health Alteration –
Planning: Client Needs – Safe Effective Care
TEST
The Client with Health Problems of the Eyes,
15 Ears, Nose, and Throat
■ The Client with Cataracts
■ The Client with a Retinal Detachment
■ The Client with Glaucoma
■ The Client with Adult Macular Degeneration
■ The Client Undergoing Nasal Surgery
■ The Client with a Hearing Disorder
■ The Client with Ménière’s Disease
■ The Client with Cancer of the Larynx
■ Managing Care Quality and Safety
■ Answers, Rationales, and Test Taking Strategies
The Client with Cataracts 3. The client has had a cataract removed. The
nurse’s discharge instructions should include which
1. The nurse is observing a student nurse of the following?
administer eyedrops, as shown in the figure. What ■ 1. Keep the head aligned straight.
should the nurse instruct the student to do? ■ 2. Utilize bright lights in the home.
■ 1. Move the dropper to the inner canthus. ■ 3. Use an eye shield at night.
■ 2. Have the client raise her eyebrows. ■ 4. Change the eye patch as needed.
■ 3. Administer the drops in the center of the
lower lid.
4. The client with a cataract tells the nurse that
she is afraid of being awake during eye surgery.
■ 4. Have the client squeeze both eyes after
Which of the following responses by the nurse
administering the drops.
would be the most appropriate?
■ 1. “Have you ever had any reactions to local
anesthetics in the past?”
■ 2. “What is it that disturbs you about the idea of
being awake?”
■ 3. “By using a local anesthetic, you won’t have
nausea and vomiting after the surgery.”
■ 4. “There’s really nothing to fear about being
awake. You’ll be given a medication that will
help you relax.”
5. A client tells the nurse his vision is blurred
and hazy throughout the entire day. The nurse
should recommend that the client do which of the
2. A client is having a cataract removed and following?
will use eyeglasses after the surgery. The nurse ■ 1. Purchase a pair of magnifying glasses.
should develop a teaching plan that includes which ■ 2. Wear glasses with tinted lenses.
of the following? Select all that apply. ■ 3. Schedule an appointment with an optician.
■ 1. Images will appear to be one-third larger. ■ 4. Schedule an appointment with an
■ 2. Look through the center of the glasses. ophthalmologist.
■ 3. The changes will be immediate.
■ 4. Use handrails when climbing stairs.
■ 5. Stay out of the sun for 2 weeks.
667
668 The Nursing Care of Adults with Medical and Surgical Health Problems
6. The nurse is to instill drops of phenylephrine 11. To decrease intraocular pressure following
hydrochloride (Neo-Synephrine) into the client’s cataract surgery, the nurse should instruct the client
eye prior to cataract surgery. Which of the following to avoid:
is the expected outcome? ■ 1. Lying supine.
■ 1. Dilation of the pupil and blood vessels. ■ 2. Coughing.
■ 2. Dilation of the pupil and constriction of blood ■ 3. Deep breathing.
vessels. ■ 4. Ambulation.
■ 3. Constriction of the pupil and constriction of
blood vessels.
12. After cataract removal surgery, the client is
instructed to report sharp pain in the operative eye
■ 4. Constriction of the pupil and dilation of
because this could indicate which of the following
blood vessels.
postoperative complications?
7. A short time after cataract surgery, the client ■ 1. Detached retina.
complains of nausea. The nurse should first: ■ 2. Prolapse of the iris.
■ 1. Instruct the client to take a few deep breaths ■ 3. Extracapsular erosion.
until the nausea subsides. ■ 4. Intraocular hemorrhage.
■ 2. Explain that this is a common feeling that
will pass quickly.
■ 3. Tell the client to call the nurse promptly if The Client with a Retinal
vomiting occurs. Detachment
■ 4. Medicate the client with an antiemetic, as
ordered. 13. The client is diagnosed in the emergency
8. Which of the following is a potential department with a detached retina in the right eye.
complication following cataract surgery? Select all The nurse should do which of the following first?
that apply. ■ 1. Apply compresses to the eye.
■ 1. Acute bacterial endophthalmitis. ■ 2. Instruct the client to lie prone.
■ 2. Retrobulbar hemorrhage. ■ 3. Remove all bed pillows.
■ 3. Rupture of the posterior capsule. ■ 4. Promote measures that limit mobility.
■ 4. Suprachoroidal hemorrhage.
■ 5. Vision loss.
14. A client with detachment of the retina is to
patch both eyes. The expected outcome of patching
9. The nurse is instructing the client about is to:
postoperative care following cataract removal. What ■ 1. Reduce rapid eye movements.
position should the nurse teach the client to use? ■ 2. Decrease the irritation caused by light enter-
■ 1. Remain in a semi–Fowler’s position. ing the damaged eye.
■ 2. Position the feet higher than the body. ■ 3. Protect the injured eye from infection.
■ 3. Lie on the operative side. ■ 4. Rest the eyes to promote healing.
■ 4. Place the head in a dependent position. 15. The client with retinal detachment in the
10. After returning home, a client who has had right eye is extremely apprehensive. He states, “I’m
cataract surgery will need to continue to instill eye afraid of going blind. It would be so hard to live that
drops in the affected eye. The client is instructed to way.” What factor should the nurse consider before
apply slight pressure against the nose at the inner responding to his statement?
canthus of the eye after instilling the eyedrops. The ■ 1. Repeat surgery is impossible, so if this proce-
rationale that supports applying pressure is that it: dure fails, vision loss is inevitable.
■ 1. Prevents the medication from entering the ■ 2. The surgery will only delay blindness in the
tear duct. right eye, but vision is preserved in the left
■ 2. Prevents the drug from running down the eye.
client’s face. ■ 3. More and more services are available to help
■ 3. Allows the sensitive cornea to adjust to the newly blind people adapt to daily living.
medication. ■ 4. Optimism is justified because surgical treat-
■ 4. Facilitates distribution of the medication over ment has a 90% to 95% success rate.
the eye surface.
The Client with Health Problems of the Eyes, Ears, Nose, and Throat 669
16. Which of the following statements would 21. The expected outcome of using miotics to
provide the best guide for activity during the reha- treat glaucoma is:
bilitation period for a client who has been treated ■ 1. Paralyzing ciliary muscles.
for retinal detachment? ■ 2. Constricting intraocular vessels.
■ 1. Activity is resumed gradually, and the cli- ■ 3. Constricting the pupil.
ent can resume her usual activities in 5 to 6 ■ 4. Relaxing ciliary muscles.
weeks.
■ 2. Activity level is determined by the client’s
22. Which of the following should the nurse pro-
vide as part of the information to prepare the client
tolerance; she can be as active as she wishes.
for tonometry?
■ 3. Activity level will be restricted for several
■ 1. Oral pain medication will be given before the
months, so she should plan on being seden-
procedure.
tary.
■ 2. It is a painless procedure with no adverse
■ 4. Activity level can return to normal and may
effects.
include regular aerobic exercises.
■ 3. Blurred or double vision may occur after the
17. Which of the following goals is a priority procedure.
for a client who has undergone surgery for retinal ■ 4. Medication will be given to dilate the pupils
detachment? before the procedure.
■ 1. Control pain.
■ 2. Prevent an increase in intraocular pressure.
23. A client uses timolol maleate (Timoptic) eye-
drops. The expected outcome of this beta-adrenergic
■ 3. Promote a low-sodium diet.
blocker is to control glaucoma by:
■ 4. Maintain a darkened environment.
■ 1. Constricting the pupils.
■ 2. Dilating the canals of Schlemm.
■ 3. Reducing aqueous humor formation.
The Client with Glaucoma ■ 4. Improving the ability of the ciliary muscle to
contract.
18. A client with glaucoma is to receive 3 gtt of
acetazolamide (Diamox) in the left eye. What should 24. The nurse observes the client instill eye-
the nurse do? drops. The client says, “I just try to hit the middle
■ 1. Ask the client to close his right eye while of my eyeball so the drops don’t run out of my eye.”
administering the drug in the left eye. The nurse explains to the client that this method
■ 2. Have the client look up while the nurse may cause:
administers the eyedrops. ■ 1. Scleral staining.
■ 3. Have the client lift his eyebrows while the ■ 2. Corneal injury.
nurse positions the hand with the dropper on ■ 3. Excessive lacrimation.
the client’s forehead. ■ 4. Systemic drug absorption.
■ 4. Wipe the eyes with a tissue following admin- 25. Which of the following clinical manifesta-
istration of the drops. tions should the nurse asessess when a client has
19. A client who has been treated for chronic acute angle-closure glaucoma?
open-angle glaucoma (COAG) for 5 years asks the ■ 1. Gradual loss of central vision.
nurse, “How does glaucoma damage my eyesight?” ■ 2. Acute light sensitivity.
The nurse’s reply should be based on the knowledge ■ 3. Loss of color vision.
that COAG: ■ 4. Sudden eye pain.
■ 1. Results from chronic eye inflammation. 26. A client has been diagnosed with an acute
■ 2. Causes increased intraocular pressure. episode of angle-closure glaucoma. The nurse plans
■ 3. Leads to detachment of the retina. the client’s nursing care with the understanding that
■ 4. Is caused by decreased blood flow to the acute angle-closure glaucoma:
retina. ■ 1. Frequently resolves without treatment.
20. The nurse should assess clients with chronic ■ 2. Is typically treated with sustained bed rest.
open-angle glaucoma (COAG) for: ■ 3. Is a medical emergency that can rapidly lead
■ 1. Eye pain. to blindness.
■ 2. Excessive lacrimation. ■ 4. Is most commonly treated with steroid
■ 3. Colored light flashes. therapy.
■ 4. Decreasing peripheral vision.
The Client with Adult Macular 31. When the nurse enters the client’s room, the
Degeneration nurse perceives that the client is staring straight
ahead. Which of the following is the best course of
27. The nurse should assess an older adult with action for the nurse to take next?
macular degeneration for: ■ 1. Hold an interdisciplinary meeting on the
■ 1. Loss of central vision. client’s behalf promptly.
■ 2. Loss of peripheral vision. ■ 2. Consult with psychiatry.
■ 3. Total blindness. ■ 3. Listen to the client and observe the body
■ 4. Blurring of vision. language.
■ 4. Address the client by first name upon enter-
28. A 75-year-old male client has a history of ing the room.
macular degeneration. While he is in the hospital,
the priority nursing goal will be:
■ 1. To provide education regarding community
The Client Undergoing Nasal Surgery
services for clients with adult macular degen-
eration (AMD).
■ 2. To provide health care related to monitoring
32. A 27-year-old female is admitted for elective
nasal surgery for a deviated septum. Which of the
his eye condition.
following would be an important initial clue that
■ 3. To promote a safe, effective care environment.
bleeding was occurring even if the nasal drip pad
■ 4. To improve vision.
remained dry and intact?
29. Although all of the following measures might ■ 1. Complaints of nausea.
be useful in reducing the visual disability of a cli- ■ 2. Repeated swallowing.
ent with adult macular degeneration (AMD), which ■ 3. Rapid respiratory rate.
measure should the nurse teach the client primarily ■ 4. Feelings of anxiety.
as a safety precaution?
■ 1. Wear a patch over one eye.
33. The client is ready for discharge after sur-
gery for a deviated septum. Which of the following
■ 2. Place personal items on the sighted side.
discharge instructions would be appropriate?
■ 3. Lie in bed with the unaffected side toward
■ 1. Avoid activities that elicit Valsalva’s maneuver.
the door.
■ 2. Take aspirin to control nasal discomfort.
■ 4. Turn the head from side to side when
■ 3. Avoid brushing the teeth until the nasal pack-
walking.
ing is removed.
30. The nurse is assessing a client with macu- ■ 4. Apply heat to the nasal area to control swelling.
lar degeneration. Identify the illustration that best
depicts what clients with this disorder typically see.
34. Which of the following statements would
indicate to the nurse that the client who has under-
gone repair of her nasal septum has understood the
discharge instructions?
■ 1. “I should not shower until my packing is
removed.”
■ 2. “I will take stool softeners and modify my
diet to prevent constipation.”
■ 3. “Coughing every 2 hours is important to pre-
vent respiratory complications.”
■ 4. “It is important to blow my nose each day to
remove the dried secretions.”
The Client with a Hearing Disorder
35. To approach a deaf client, the nurse should

do which of the following first?
■ 1. Knock on the room’s door loudly.
■ 2. Close and open the vertical blinds rapidly.
■ 3. Talk while walking into the room.
■ 4. Get the client’s attention.
36. A 75-year-old client who has been taking 41. The best method to remove cerumen from a
furosemide (Lasix) regularly for 4 months tells the client’s ear involves:
nurse that he is having trouble hearing. What would ■ 1. Inserting a cotton-tipped applicator into the
be the nurse’s best response to this statement? external canal.
■ 1. Tell the client that because he is 75 years old, ■ 2. Irrigating the ear gently.
it is inevitable that his hearing should begin ■ 3. Using aural suction.
to deteriorate. ■ 4. Using a cerumen curette.
■ 2. Have the client immediately report the hear-
ing loss to his physician.
42. To prepare the irrigation solution used for
removal of cerumen, the nurse should use:
■ 3. Schedule the client for audiometric testing
■ 1. Normal saline.
and a hearing aid.
■ 2. Sterile water.
■ 4. Tell the client that the hearing loss is only
■ 3. Antiseptic solution.
temporary; when his system adjusts to the
■ 4. Warm tap water.
furosemide, his hearing will improve.
37. The nurse has been assigned to a client who 43. A client is about to have a tympanoplasty,
and asks the nurse what the surgical procedure
is hearing impaired and reads speech. Which of the
involves. The nurse begins the conversation by:
following strategies should the nurse incorporate
■ 1. Assessing the client’s understanding of what
when communicating with the client? Select all that
the physician has explained.
apply.
■ 2. Describing the surgical procedure.
■ 1. Avoiding being silhouetted against strong
■ 3. Educating the client that the procedure will
light.
close the perforation and prevent recurrent
■ 2. Not blocking out the person’s view of the
infection.
speaker’s mouth.
■ 4. Informing the client that the procedure will
■ 3. Facing the client when talking.
improve hearing.
■ 4. Having bright light behind so the individual
can see. 44. An older adult takes two 81 mg aspirin tab-
■ 5. Ensuring the client is familiar with the sub- lets daily to prevent a heart attack. The client reports
ject material before discussing. having a constant “ringing” in both ears. How
■ 6. Talking to the client while doing other nurs- should the nurse respond to the client’s comment?
ing procedures. ■ 1. Tell the client that “ringing” in the ears is
associated with the aging process.
38. The client with a hearing aid does not seem ■ 2. Refer the client to have a Weber test.
to be able to hear the nurse. The nurse should do
■ 3. Schedule the client for audiometric testing.
which of the following?
■ 4. Explain to the client that the “ringing” may
■ 1. Contact the client’s audiologist.
be related to the aspirin.
■ 2. Cleanse the hearing aid ear mold in normal
saline.
■ 3. Irrigate the ear canal.
■ 4. Check the hearing aid’s placement. The Client with Ménière’s Disease
39. Sensorineural hearing loss results from 45. A client has vertigo. Which of the following
which of the following conditions? actions would be most appropriate for the nursing
■ 1. Presence of fluid and cerumen in the external diagnosis of Risk for injury related to altered immo-
canal. bility and gait disturbances? Select all that apply.
■ 2. Sclerosis of the bones of the middle ear. ■ 1. The client assumes safe position when dizzy.
■ 3. Damage to the cochlear or vestibulocochlear ■ 2. The client experiences no falls.
nerve. ■ 3. The client performs vestibular/balance
■ 4. Emotional disturbance resulting in a func- exercises.
tional hearing loss. ■ 4. The client demonstrates family involvement.
40. A 65-year-old male has hearing loss and a ■ 5. The client keeps head still when dizzy.
sensation of fullness in both ears. The nurse exam- 46. The client with Ménière’s disease is
ines his ears with the understanding that a common instructed to modify his diet. The nurse should
cause of hearing loss in older adults is related to: explain that the most frequently recommended diet
■ 1. Accumulation of cerumen in the external modification for Ménière’s disease is:
canal. ■ 1. Low sodium.
■ 2. Accumulation of cerumen in the internal ■ 2. High protein.
canal. ■ 3. Low carbohydrate.
■ 3. External otitis. ■ 4. Low fat.
■ 4. Exostosis.
47. Which of the following statements indicates 52. The nurse is developing a care plan with
the client understands the expected course of a client who had a laryngectomy 3 days ago. The
Ménière’s disease? nurse should instruct the client to do which of the
■ 1. “The disease process will gradually extend to following to assure adequate nutrition. Select all
the eyes.” that apply.
■ 2. “Control of the episodes is usually possible, ■ 1. Weigh weekly and report weight loss.
but a cure is not yet available.” ■ 2. When eating, sit and lean slightly forward.
■ 3. “Continued medication therapy will cure the ■ 3. Have serum albumin level checked regularly.
disease.” ■ 4. Administer enteral tube feedings as ordered.
■ 4. “Bilateral deafness is an inevitable outcome ■ 5. Manipulate the nasogastric tube daily.
of the disease.”
53. The client with a laryngectomy is being dis-
48. The risk for injury during an attack of charged. The nurse should determine that the client
Ménière’s disease is high. The nurse should instruct understands to do which of the following self-care
the client to take which immediate action when measures? Select all that apply.
experiencing vertigo? ■ 1. Provide humidification in the home.
■ 1. “Place your head between your knees.” ■ 2. Use a protective shield over the stoma for
■ 2. “Concentrate on rhythmic deep breathing.” bathing.
■ 3. “Close your eyes tightly.” ■ 3. Consume a liberal intake of fluids (2 to
■ 4. “Assume a reclining or flat position.” 3 L/day).
■ 4. Limit spicy seasonings on food.
49. The nurse should assess the client with ■ 5. Follow a low-fiber diet.
Ménière’s disease for the intended outcomes of
which of the following medications that are com- 54. After a total laryngectomy, the client has a
monly used to manage the disease? Select all that feeding tube. The feeding tube is effective if the tube
apply. feedings:
■ 1. Antihistamines. ■ 1. Meet the fluid and nutritional needs of the
■ 2. Antiemetics. client.
■ 3. Diuretics. ■ 2. Prevent aspiration.
■ 4. Non-steroidal anti-inflammatory drugs ■ 3. Prevent fistula formation.
(NSAIDs). ■ 4. Maintain an open airway.
■ 5. Antipyretics.
55. Complications associated with a tracheos-
50. A client with Ménière’s disease continues to tomy tube include:
have disabling attacks of vertigo and elects to have ■ 1. Decreased cardiac output.
a labyrinthectomy. A priority nursing diagnosis for ■ 2. Damage to the laryngeal nerve.
the client before surgery is: ■ 3. Pneumothorax.
■ 1. Deficient diversional activity related to inabil- ■ 4. Acute respiratory distress syndrome (ARDS).
ity to participate secondary to vertigo.
■ 2. Risk for injury related to vertigo.
56. A priority goal for the hospitalized client
who 2 days earlier had a total laryngectomy with
■ 3. Powerlessness related to inability to influence
creation of a new tracheostomy would be to:
effects of disease process
■ 1. Decrease secretions.
■ 4. Social isolation related to hearing loss.
■ 2. Instruct the client in caring for the tracheos-
tomy.
■ 3. Relieve anxiety related to the tracheostomy.
The Client with Cancer of the Larynx ■ 4. Maintain a patent airway.
51. Following a laryngectomy, the nurse notices
that the client has saliva collecting beneath the skin Managing Care Quality and Safety
flaps. This finding is indicative of which of the fol-
lowing?
■ 1. Skin necrosis.
57. The client with glaucoma is scheduled for
a hip replacement. Which of the following orders
■ 2. Carotid artery rupture.
would require clarification before the nurse carries
■ 3. Stomal stenosis.
it out?
■ 4. Development of a fistula.
■ 1. Administer morphine sulfate.
■ 2. Administer atropine sulfate.
■ 3. Teach deep-breathing exercises.
■ 4. Teach leg lifts and muscle-setting exercises.
58. To ensure safety for a hospitalized blind client, to distribute the medication; squeezing or rubbing
the nurse should: her eyes might cause the medication to drip out of
■ 1. Require that the client has a sitter for each the eye.
shift. CN: Safety and infection control;
■ 2. Require that the client stays in bed until the CL: Apply
nurse can assist.
■ 3. Orient the client to the room environment. 2. 1, 2, 4. The use of glasses following cataract
■ 4. Keep the side rails up when the client is surgery does not totally restore binocular vision.
alone. Glasses will cause images to appear larger and
peripheral vision will be distorted; the client should
59. The nurse is taking care of a client who had a look through the center of the glasses and turn his or
laryngectomy yesterday. To assure client safety, the her head to view objects in the periphery. The client
nurse should give “hand-off reports” at which of the should also use caution when walking or climbing
following times? Select all that apply. stairs until he or she has adjusted to the change in
■ 1. Change of shift. vision. Changes in vision following cataract surgery
■ 2. Change of nurses. are not immediate and the nurse can instruct the
■ 3. When nurse goes to lunch. client to be patient while adjusting to the changes.
■ 4. When unit clerk goes to a staff meeting. The client does not need to stay out of the sun, but
■ 5. When new medication orders are written. should wear dark glasses to prevent discomfort from
60. The nurse is admitting a client with glau- photophobia.
coma. The client brings prescribed eye drops from CN: Physiological adaptation;
home and insists on using them in the hospital. The CL: Create
nurse should:
■ 1. Allow the client to keep the eye drops at the 3. 3. Using an eye shield at night prevents rub-
bedside and use as prescribed on the bottle. bing the eye. The head should be turned to the side
■ 2. Place the eye drops in the hospital medica- to scan the entire visual field to compensate for
tion drawer and administer as labeled on the impaired peripheral vision. Eye medications may
bottle. initially cause sensitivity to bright light. The sur-
■ 3. Explain to the client that the physician will geon changes the eye patch on the second postop-
write an order for the eye drops to be used at erative day.
the hospital. CN: Reduction of risk potential;
■ 4. Ask the client’s wife to assist the client in CL: Synthesize
administering the eye drops while the client
is in the hospital. 4. 2. The nurse should give a client who seems
fearful of surgery an opportunity to express her feel-
ings. Only after identifying the client’s concerns can
the nurse intervene appropriately. Asking the client
Answers, Rationales, and Test about previous reactions to local anesthetics may
be warranted, but it does not address the client’s
Taking Strategies concerns in this instance. Telling the client that she
will not have nausea or vomiting ignores the client’s
feelings of fear and does not provide any data about
The answers and rationales for each question follow
the client’s feelings. More data would help the nurse
below, along with keys ( ) to the client need
plan care. Telling the client that there is nothing
(CN) and cognitive level (CL) for each question. Use
to be afraid of minimizes her feelings and does not
these keys to further develop your test-taking skills.
address her concerns. Premature explanations and
For additional information about test-taking skills
clichés do not provide needed assessment data and
and strategies for answering questions, refer to pages
ignore the client’s feelings.
10–21, and pages 25–26 in Part 1 of this book.
CN: Psychosocial adaptation;
CL: Synthesize
The Client with Cataracts 5. 4. An ophthalmologist is a physician who
specializes in the treatment of disorders of the eye,
1. 3. The student has positioned the dropper and the nurse should advise the client to see a
and the client correctly to prevent injury to the cli- physician. An optician makes glasses and it is not
ent’s eye. The student should administer the drops known at this point what the best treatment for the
in the center of the lower lid. Following administra- client is. Magnifying glasses, or glasses with tinted
tion of the eyedrops, the client should blink her eyes lenses, do not correct hazy or blurred vision. If
glasses are needed to correct refractive errors, they conjunctival sac. Applying pressure will not prevent
should be prescription glasses. the drug from running down the face as long as the
drops are instilled in the eye. Pressure does not
CN: Health promotion and maintenance;
affect the cornea or facilitate distribution of the
CL: Synthesize
medication over the eye surface.
6. 2. Instilled in the eye, phenylephrine hydro- CN: Pharmacological and parenteral
chloride (Neo-Synephrine) acts as a mydriatic, caus-
therapies; CL: Apply
ing the pupil to dilate. It also constricts small blood
vessels in the eye. 11. 2. Coughing is contraindicated after cataract
extraction because it increases intraocular pressure.
CN: Pharmacological and parenteral
Other activities that are contraindicated because
therapies; CL: Evaluate
they increase intraocular pressure include: turning
7. 4. A prescribed antiemetic should be admin- to the operative side, sneezing, crying, and strain-
istered as soon as the client complains of nausea fol- ing. Lying supine, ambulating, and deep breathing
lowing a cataract extraction. Vomiting can increase do not affect intraocular pressure.
intraocular pressure, which should be avoided after
CN: Physiological adaptation;
eye surgery because it can cause complications.
CL: Synthesize
Deep breathing is unlikely to relieve nausea. Postop-
erative nausea may be common; however, it doesn’t 12. 4. Sudden, sharp pain after eye surgery
necessarily pass quickly and can lead to vomiting. should suggest to the nurse that the client may be
Telling the client to call only if vomiting occurs experiencing intraocular hemorrhage. The physician
ignores the client’s need for comfort and interven- should be notified promptly. Detached retina and
tion to prevent complications. prolapse of the iris are usually painless. Extracapsu-
lar erosion is not characterized by sharp pain.
therapies; CL: Synthesize CN: Physiological adaptation;
CL: Analyze
8. 1, 5. Acute bacterial endophthalmitis can
occur in about 1 out of 1,000 cases. Organisms that
are typically involved include Staphylococcus epi-
dermidis, S. aureus, and Pseudomonas and Proteus The Client with a Retinal
species. Vision loss is one result of acute bacterial Detachment
infection. In addition, vision loss can be the result
of malposition of the intraocular lens implant or 13. 4. Promoting measures that limit mobil-
opacification of the posterior capsule. Retrobulbar ity may prevent further injury. Following surgical
hemorrhage is a complication that may occur right repair of a detached retina, cool or warm com-
before surgery and is a result of retrobulbar infiltra- presses are applied to edematous eyelids, if ordered.
tion of anesthetic agents. Rupture of the posterior The client should avoid lying face down, stooping,
capsule and suprachoroidal hemorrhage are both or bending pre-operatively. It is not necessary to
complications that can result during surgery. remove all pillows.
CN: Physiological adaptation; CN: Physiological adaptation;
CL: Analyze CL: Synthesize
9. 1. The nurse should instruct the client to 14. 1. Patching the eyes helps decrease random
remain in a semi-Fowler’s position or on the non- eye movements that could enlarge and worsen reti-
operative side. Positioning the feet higher than the nal detachment. Although clients with eye injuries
body does not affect the operative eye; placing the frequently are light-sensitive, and preventing infec-
head in a dependent position could increase pres- tion is important, the specific goal is to reduce rapid
sure within the eyes. eye movements. Resting the eye is an indirect way
of stating the objective.
CN: Reduction of risk potential;
CL: Synthesize CN: Physiological adaptation;
CL: Evaluate
10. 1. Applying pressure against the nose at the
inner canthus of the closed eye after administering 15. 4. Untreated retinal detachment results in
eyedrops prevents the medication from entering increasing detachment and eventual blindness, but
the lacrimal (tear) duct. If the medication enters 90% to 95% of clients can be successfully treated
the tear duct, it can enter the nose and pharynx, with surgery. If necessary, the surgical procedure
where it may be absorbed and cause toxic symp- can be repeated about 10 to 14 days after the first
toms. Eyedrops should be placed in the eye’s lower procedure. Many more services are available for
newly blind people, but ideally this client will not tear duct. Flashes of light is a common symptom of
need them. Surgery does not delay blindness. retinal detachment.
CN: Physiological adaptation; CN: Physiological adaptation;
CL: Synthesize CL: Analyze
16. 1. The scarring of the retinal tear needs time 21. 3. A miotic agent constricts the pupil and
to heal completely. Therefore, resumption of activity contracts ciliary musculature. These effects widen
should be gradual; the client may resume her usual the filtration angle and permit increased outflow
activities in 5 to 6 weeks. Successful healing should of aqueous humor. Miotics also cause vasodilation
allow the client to return to her previous level of of the intraocular vessels, where intraocular fluids
functioning. leave the eye, also increasing aqueous humor out-
flow. Mydriatics cause cycloplegia, or paralysis of
CN: Basic care and comfort;
the ciliary muscle.
CL: Synthesize
17. 2. After surgery to correct a detached retina, therapies; CL: Evaluate
prevention of increased intraocular pressure is the
priority goal. Control of pain with analgesics is the 22. 2. Tonometry, which measures intraocular
second goal. Following a low-sodium diet or main- pressure, is a simple, noninvasive, and painless
taining a darkened environment is not a goal for this procedure that requires no particular preparation or
client. postprocedure care and carries no adverse effects. It
is not necessary to dilate the pupils for tonometry.
CL: Synthesize CN: Reduction of risk potential;
CL: Synthesize
23. 3. Timolol maleate (Timoptic) is commonly
The Client with Glaucoma administered to control glaucoma. The drug’s action
is not completely understood, but it is believed to
18. 2. The client should look up while the nurse reduce aqueous humor formation, thereby reducing
instills the eyedrops. The client will need to keep intraocular pressure. Timolol does not constrict the
both eyes open while the nurse administers the drug. pupils; miotics are used for pupillary constriction
If the client raises his eyebrows while the nurse’s and contraction of the ciliary muscle. Timolol does
hand is positioned on the eyebrows, the movement not dilate the canal of Schlemm.
of the forehead may cause the dropper to move and
injure the eye. The client should gently blink his CN: Pharmacological and parenteral
eyes after the eyedrops have been instilled. Using therapies; CL: Evaluate
a tissue to wipe the eyes could remove some of the 24. 2. The cornea is sensitive and can be injured
medication; excess fluid can be removed with a cot- by eyedrops falling onto it. Therefore, eyedrops
ton ball. should be instilled into the lower conjunctival sac
CN: Pharmacological and parenteral of the eye to avoid the risk of corneal damage. The
therapies; CL: Apply drops do not cause scleral staining or excessive
lacrimation. Systemic absorption occurs when eye-
19. 2. In COAG, there is an obstruction to the drops enter the tear ducts.
outflow of aqueous humor, leading to increased
intraocular pressure. The increased intraocu- CN: Pharmacological and parenteral
lar pressure eventually causes destruction of the therapies; CL: Evaluate
retina’s nerve fibers. This nerve destruction causes 25. 4. Acute angle-closure glaucoma produces
painless vision loss. The exact cause of glaucoma abrupt changes in the angle of the iris. Clinical man-
is unknown. Glaucoma does not lead to retinal ifestations include severe eye pain, colored halos
detachment. around lights, and rapid vision loss. Gradual loss of
CN: Physiological adaptation; central vision is associated with macular degenera-
CL: Analyze tion. The loss of color vision, or achromatopsia, is
a rare symptom that occurs when a stroke damages
20. 4. Although COAG is usually asymptom- the fusiform gyrus. It most often affects only half of
atic in the early stages, peripheral vision gradually the visual field.
decreases as the disorder progresses. Eye pain is not
a feature of COAG but is common in clients with CN: Physiological adaptation;
angle-closure glaucoma. Excessive lacrimation is CL: Analyze
not a symptom of COAG; it may indicate a blocked
26. 3. Acute angle-closure glaucoma is a medical 30. In macular degeneration the center vision is
emergency that rapidly leads to blindness if left blackened out and only the outer visual fields are
untreated. Treatment typically involves miotic drugs clear.
and surgery, usually iridectomy or laser therapy.
Both procedures create a hole in the periphery of
CL: Analyze
the iris, which allows the aqueous humor to flow
into the anterior chamber. Bed rest does not affect
the progression of acute angle-closure glaucoma.
Steroids are not a treatment for acute angle-closure
glaucoma; in fact, they are associated with the
development of glaucoma.
CN: Physiological adaptation; CL: Apply
The Client with Adult Macular

Degeneration
27. 1. Macular degeneration generally involves
loss of central vision. Gradual blurring of vision can
occur as the disease progresses and may result in
blindness; however, loss of central vision is the most
common finding. Tiny yellowish spots, known as 31. 3. By listening to the client should they
drusen, develop beneath the retina. Loss of periph- speak and by noting body language, the nurse may
eral vision is characteristic of glaucoma. be better able to ascertain the client’s physical and
cognitive status. The nurse should not utilize the
CN: Physiological adaptation; first name of a client unless a client provides per-
CL: Analyze mission to do so. To consult with psychiatry would
28. 3. AMD generally affects central vision. not be appropriate unless ordered by the primary
Confusion may result related to the changes in the care physician. An interdisciplinary meeting would
environment and the inability to see the environ- not enable the nurse to understand why the client
ment clearly. Therefore, providing safety is the is staring straight ahead. Perhaps the client is only
priority goal in the care of this client. Educating deep in thought.
him regarding community resources or monitoring CN: Reduction of risk potential;
his AMD may have been done at an earlier date or CL: Synthesize
can be done after assessing his knowledge base and
experience with the disease process. Improving his
vision may not be possible. The Client Undergoing Nasal Surgery
CN: Safety and infection control;
CL: Synthesize 32. 2. Because of the dense packing, it is rela-
tively unusual for bleeding to be apparent through
29. 4. To expand the visual field, the partially the nasal drip pad. Instead, the blood runs down the
sighted client should be taught to turn the head from
throat, causing the client to swallow frequently. The
side to side when walking. Neglecting to do so may
back of the throat can be assessed with a flashlight.
result in accidents. This technique helps maximize
An accumulation of blood in the stomach may cause
the use of remaining sight. A patch does not address
nausea and vomiting, but is not an initial sign of
the problem of hemianopsia. Appropriate client
bleeding. Increased respiratory rate occurs in shock
positioning and placement of personal items will
and is not an early sign of bleeding in the client after
increase the client’s ability to cope with the problem
nasal surgery. Feelings of anxiety are not indicative
but will not affect safety.
of nasal bleeding.
CL: Synthesize
CL: Synthesize
of the client’s knowledge and educational level, 48. 4. The client needs to assume a safe and
the nurse then can describe the procedure and its comfortable position during an attack, which may
benefits. last several hours. The client’s location when the
CN: Reduction of risk potential; attack occurs may dictate the most reasonable posi-
CL: Synthesize tion. Ideally, the client should lie down immediately
in a reclining or flat position to control the vertigo.
44. 4. Tinnitus (ringing in the ears) is an adverse The danger of a serious fall is real. Placing the head
effect of aspirin. Aspirin contains salicylate, which between the knees will not help prevent a fall and
is an ototoxic drug that can induce reversible hear- is not practical because the attack may last several
ing loss and tinnitus. The nurse should encourage hours. Concentrating on breathing may be a useful
the client to inform the physician of the symptom. distraction, but it will not help prevent a fall. Clos-
Tinnitus is not a function of aging. The Weber test ing the eyes does not help prevent a fall.
and audiometric testing are useful for determining
hearing loss but are not necessarily helpful in the CN: Safety and infection control;
management or diagnosis of drug-induced tinnitus. CL: Synthesize
CN: Pharmacological and parenteral 49. 1, 2, 3. Since the symptoms of Ménière’s

therapies; CL: Synthesize disease are associated with a change in the fluid
volume of the inner ear, a wide variety of medi-
cations may be used in an attempt to control the
The Client with Ménière’s Disease signs/symptoms of Ménière’s disease, including
antihistamines, antiemetics, tranquilizers, and
diuretics. NSAIDs and antipyretics play no signifi-
45. 1, 2, 3, 5. Assessment of vertigo, includ- cant role in Ménière’s disease management.
ing history, onset, description of attacks, duration,
frequency, and associated ear symptoms, is impor- CN: Pharmacological and parenteral
tant. Vestibular/balance therapy or exercises should therapies; CL: Analyze
be taught and practiced. The client needs to be
instructed to sit down when dizzy and decrease the
50. 2. The client’s Risk for injury related to
vertigo is the highest priority nursing diagnosis
amount of head movement. The client will benefit
preoperatively. The client should be instructed
from recognizing whether he or she experiences an
how to manage attacks of vertigo safely. Deficient
“aura” before an attack so appropriate action can
diversional activity related to inability to participate
be taken. Finally, it is recommended that the client
secondary to vertigo is an appropriate nursing diag-
keep the eyes open and look straight ahead when
nosis, but it is not a priority. Powerlessness related
lying down. These expected outcomes will prevent
to inability to influence effects of the disease process
the problem of injury. Family involvement is essen-
is a possible diagnosis, but more data are required
tial when dealing with a client experiencing vertigo
before making such a diagnosis. Social isolation
but is not applicable for this particular nursing
related to hearing loss is a possible diagnosis for the
diagnosis.
client after surgery. The client retains the ability to
CN: Reduction of risk potential; hear with Ménière’s disease; however, total hearing
CL: Synthesize loss is a possible complication of labyrinthectomy.
46. 1. A low-sodium diet is frequently an effec- CN: Physiological adaptation;
tive mechanism for reducing the frequency and CL: Analyze
severity of the disease episodes. About three-quar-
ters of clients with Ménière’s disease respond to
treatment with a low-salt diet. A diuretic may also The Client with Cancer of the Larynx
be ordered. Other dietary changes, such as high
protein, low carbohydrate, and low fat, do not have 51. 4. A salivary fistula is suspected when there
an effect on Ménière’s disease. is saliva collecting beneath skin flaps or leaking
CN: Basic care and comfort; CL: Apply through the suture line or drain site. Salivary fistula
or skin necrosis usually precedes carotid artery rup-
47. 2. There is no cure for Ménière’s disease, but ture. Stomal stenosis may be present when there is
the wide range of medical and surgical treatments suprasternal and intercostal retractions and difficult
allows for adequate control in many clients. The breathing.
disease often worsens, but it does not spread to the
eyes. The hearing loss is usually unilateral. CN: Physiological adaptation;
CL: Analyze
CL: Evaluate
52. 1, 2, 3, 4. The nurse should monitor nutritional secretions, and clients may require frequent suction-
status through frequent weighing and checking the ing to maintain patency. Decreasing secretions may
serum albumin level. The nurse also should admin- be a component of a client’s care after laryngectomy
ister enteral tube feedings until there is sufficient and tracheostomy, and relieving anxiety is always
healing of pharynx, and the client can consume suf- an important goal; however, the primary goal is to
ficient oral feedings to meet body needs. The nurse maintain a patent airway. Instruction in care of a tra-
should avoid manipulation of the nasogastric tube cheostomy is a priority later in the client’s recovery.
during this time so it does not disrupt the suture CN: Physiological adaptation;
line. The nurse should place the client in sitting CL: Synthesize
position, leaning slightly forward, which allows
the larynx to move forward and the hypopharynx
to partially open; the epiglottis normally prevents Managing Care Quality and Safety
fluid and food from entering the larynx during
swallowing.
57. 2. Atropine sulfate causes pupil dilation.
CN: Physiological adaptation; CL: Create This action is contraindicated for the client with
glaucoma because it increases intraocular pressure.
53. 1, 2, 3. The nurse should advise the client to The drug does not have this effect on intraocular
provide humidification at home. Instruct the client
pressure in people who do not have glaucoma.
to use a protective shield for bathing, showering,
Morphine causes pupil constriction. Deep-breathing
or shampooing or cutting hair to prevent aspira-
exercises will not affect glaucoma. The client should
tion. The nurse can also encourage the client to
resume taking all medications for glaucoma immedi-
obtain a fluid intake of 2 to 3 L daily to help liquefy
ately after surgery.
secretions. To counteract any loss of smell and
impairment of taste sensation, the client can add CN: Pharmacological and parenteral
additional seasoning to food. The client should fol- therapies; CL: Synthesize
low a high-fiber diet and use stool softeners because
the client may not be able to hold the breath and
58. 3. The priority goal of care for a client who
is blind is safety and preventing injury. The initial
bear down for bowel movements.
action is to orient the client to a new environment.
CN: Health promotion and maintenance; Taking time to identify the objects and where they
CL: Evaluate are located in the room can achieve this goal. It is
unrealistic to have someone stay with the client at
54. 1. The goal of postoperative care is to main- all times or for the client to stay in bed until the
tain physiologic integrity. Therefore, inserting a
nurse can assist. Using side rails creates unneces-
feeding tube is a strategy to ensure the fluid and
sary barriers and may be a safety hazard.
nutritional needs of the client as the surgical site is
healing. The feeding tube does help prevent aspi- CN: Safety and infection control;
ration by preventing ingested fluid from leaking CL: Synthesize
through the wound into the trachea before healing
occurs; however, the primary rationale is to meet
59. 1, 2, 3. Effective communication is essential
when managing client safety and preventing errors.
the client’s nutritional and fluid needs. A trache-
“Handoff reports” should be made at shift change,
oesophageal fistula is a rare complication of total
when there is a change of nurses or when the nurse
laryngectomy and may occur if radiation therapy
leaves the unit, and when the client is discharged or
has compromised wound healing. A feeding tube
transfers to another unit. There does not need to be
does not help maintain an open airway.
a handoff report when the unit clerk leaves the unit
CN: Reduction of risk potential; or when new medication orders are written.
CL: Evaluate
55. 2. Tracheostomy tubes carry several potential CL: Apply
complications, including laryngeal nerve damage,
bleeding, and infection. Tracheostomy tubes alone
60. 3. In order to prevent medication errors, cli-
ents may not use medications they bring from home;
do not affect cardiac output or cause acute respira-
the physician will order the eye drops as required.
tory distress. The tube is inserted in the trachea, not
It is not safe to place the eye drops in the client’s
the lung, so there is no risk of pneumothorax.
medication box or to permit the client to use them
CN: Physiological adaptation; at the bedside. The nurse should ask the wife to take
CL: Apply the eye drops home.
56. 4. The main goal for a client with a new CN: Safety and infection control;
tracheostomy is to maintain a patent airway. A fresh CL: Synthesize
tracheostomy frequently causes bleeding and excess

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Test Bank - Brunner & Suddarth's Textbook of Medical-Surgical Nursing 14e (Hinkle 2017) 1186

Chapter 63: Assessment and Management of Patients with Eye and

A) Provide instructions in simple, clear terms.

B) Introduce herself in a firm, loud voice at the doorway of the room.

C) Lightly touch the patients arm and then introduce herself.

A) Ensure adequate lighting in the patients room.

B) Provide a dimly lit room to aid vision by limiting contrast.

C) Carefully point out color differences for the patient.

D) Carefully point out fine details for the patient.

A) Ask the social worker to investigate alternative housing arrangements.

B) Ask the social worker to investigate community support agencies.

D) Arrange for referral to a rehabilitation facility for vision training.

independence. Surgical options may or may not be available to the patient.

B) At least once every 2 years

C) At least once every 5 years

D) At least once every 10 years

A) Antioxidant supplements, vitamin C and E, beta-carotene, and selenium

B) Eyeglasses or magnifying lenses

C) Corticosteroid eye drops

intervention for this patient?

A) Generously flush the affected eye with a dilute antibiotic solution.

B) Generously flush the affected eye with normal saline or water.

C) Apply a patch to the affected eye.

D) Apply direct pressure to the affected eye.

A) Slight morning discharge from the eye

B) Any appearance of redness of the eye

C) A scratchy feeling in the eye

D) A new floater in vision

A) This is a normal aging process of the eye.

B) Glasses will minimize this phenomenon.

C) The patient may be exhibiting signs of glaucoma.

D) This may be a result of weakened ciliary muscles.

A) Disturbed body image

A) Assess the patients vision using a Snellen chart.

C) Perform a detailed examination of the patients external eye structures.

D) Palpate the patients periocular regions.

A) Instill the medication in the conjunctival sac.

B) Maintain a supine position for 10 minutes after administration.

C) Keep the eyes closed for 1 to 2 minutes after administration.

D) Apply the medication evenly to the sclera

A) Holding the next dose and notifying the physician

B) Treating the patient for an allergic reaction

C) Suggesting that the patient put on her glasses

D) Explaining that this is an expected adverse effect

A) A 58-year-old Caucasian woman with macular degeneration

B) A 28-year-old Caucasian man with astigmatism

C) A 58-year-old African American woman with hyperopia

D) A 28-year-old African American man with myopia

A) Handwashing can prevent the spread of the disease to others.

B) The importance of compliance with antibiotic therapy

C) Signs and symptoms of complications, such as meningitis and septicemia

D) The likely need for surgery to prevent scarring of the conjunctiva

A) Flashing lights in the visual field

B) Sudden eye pain

C) Loss of color vision

D) Colored halos around lights

A) Arrange for the administration of prophylactic antibiotics to unaffected residents.

A) Call the physician and ask for the order to be confirmed.

C) Instruct the patient to maintain this position to prevent bleeding.

D) Reposition the patient after the first dressing change.

A) Reassure the patient that this is an age-related change in vision.

B) Arrange for the patient to have her visual acuity assessed.

C) Arrange for the patient to be assessed for macular degeneration.

D) Facilitate tonometry testing.