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The nurse is collecting data for a patient with a report of vision loss. Which of these symptoms does the nurse understand is most indicative of cataract formation?
a.
Loss of visual acuity
b.
Loss of central vision
c.
Floating filaments in vision
d.
Visual fatigue
ANS: A
Symptoms of cataract formation may include halos around lights, difficulty reading fine print or seeing in bright light, increased sensitivity to glare such as when driving at night, double or hazy vision, and decreased color vision.
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A patient asks the nurse, “What causes cataracts in older people?” Which of these statements should form the basis for the nurse’s response?
a.
“Cataracts usually result from chronic systemic diseases.”
b.
“Cataracts may form as a result of exposure to ultraviolet light over time.”
c.
“Cataracts are believed to result from eye injuries sustained early in life.”
d.
“Cataracts usually result from the prolonged use of toxic substances.”
ANS: B
Factors that contribute to cataract development may include age and longer exposure to ultraviolet radiation (sunlight). Other causes are diabetes, smoking, steroids, nutritional deficiencies, alcohol consumption, intraocular infections, trauma, and congenital defects.
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The nurse is caring for a patient with acute angle glaucoma and a fractured femur who is scheduled for surgery. The nurse reviews the preoperative medications, which are morphine 10 mg intramuscularly (IM), and atropine 0.4 mg IM. Which of these actions would be appropriate for the nurse to take?
a.
Collect data on patient’s pain.
b.
Contact the physician.
c.
Hold the morphine.
d.
Give medications as ordered.
ANS: B
Atropine is contraindicated for patients with acute angle glaucoma. It can cause blindness if given so the physician must be notified.
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The nurse is reinforcing teaching for a patient with open-angle glaucoma. Which of the following statements is most important to include in the patient teaching?
a.
Compliance with drug therapy is essential to prevent loss of vision.
b.
Damage to the eye caused by glaucoma is reversible in early stages.
c.
Regardless of treatment, peripheral vision will be eventually lost.
d.
Eye pain is experienced until the optic nerve atrophies, causing blindness.
ANS: A
Lifelong compliance with drug therapy is essential to prevent loss of vision.
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The nurse is caring for a patient who has been prescribed pilocarpine 1% eye drops every 6 hours. The nurse understands that which of these is the expected outcome for this medication?
a.
Prevention of dryness of the cornea and conjunctiva
b.
Reduction of inflammation of the iris and choroids
c.
Dilation of the pupil by paralyzing the ciliary muscle
d.
Promotion of drainage of aqueous humor from the anterior chamber of the eye
ANS: D
Promotion of drainage of aqueous humor from the anterior chamber of the eye reduces pressure in the eye as the fluid does not build up.
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The nurse is teaching a patient with glaucoma how to instill eyedrops. The nurse would instruct the patient to take which of the following actions?
a.
Look straight ahead while pulling down the lower eyelid.
b.
Look up while pulling lower lid outward.
c.
Squeeze the eyelids shut for 2 minutes after instillation.
d.
If the eye waters, wipe from the outer canthus to the inner canthus.
ANS: B
Tilt head backward and look up toward the ceiling. Gently pull the lower lid down and out. This forms a pocket to catch the eyedrop. Approach the patient’s eye from the side and instill the prescribed amount of medication (see Box 51-4).
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The nurse is caring for a patient who has macular degeneration. The patient’s caregiver becomes increasingly frustrated with the patient due to food spills on the patient’s clothing. Which of these explanations would help the caregiver understand what the patient is experiencing?
a.
“The patient’s vision is blurred.”
b.
“The central vision is gone and only peripheral vision remains.”
c.
“There is total blindness in one eye occurring.”
d.
“There are black dots in the field of vision that cause confusion.”
ANS: B
In macular degeneration, central vision is gone, and only peripheral vision remains, so it is hard to see things in front of oneself.
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The nurse is caring for a patient who had a stapedectomy. What is the priority nursing action to maintain safety?
a.
Have patient cough and deep breathe.
b.
Put the side rails up.
c.
Check for drainage.
d.
Test hearing capability.
ANS: B
Activity orders may vary after stapedectomy. The patient may be dizzy and a fall risk, so use of safety rails can protect the patient.
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The nurse is assisting with the discharge of a patient from a clinic after evaluation of a perforated eardrum. The patient is advised not to shower. Which of these, if stated by a patient, indicates to the nurse correct understanding of the teaching?
a.
Showering would disturb equilibrium.
b.
Water should not enter the ear.
c.
Motion of the ear would cause pain.
d.
The patient should move as little as possible.
ANS: B
Water should not enter the ear.
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The nurse is contributing to the plan of care for a patient who had a myringoplasty. The postoperative plan of care should include what nursing intervention?
a.
Restricting fluids
b.
Encouraging visitors to speak loudly
c.
Avoiding excessive movement
d.
Coughing each hour
ANS: C
Avoid excessive movement to prevent dislodging the graft after myringoplasty.
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The nurse is assisting with the auditory assessment phase of the physical examination for a high school swimming team. The nurse identifies a student who has pain and itching of the ear. The nurse would anticipate treatment for which of these disorders?
a.
Chronic mastoiditis
b.
External otitis
c.
Furunculosis
d.
Otitis media
ANS: B
The most common sign of external otitis is pain along with pruritus (itching).
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The nurse is collecting data for a patient who has Ménière’s disease. Which of these findings should the nurse expect?
a.
Nystagmus, nausea, and edema
b.
Blurred vision, vomiting, and arthralgia
c.
Syncope, headache, and diplopia
d.
Hearing loss, vertigo, and tinnitus
ANS: D
A triad of symptoms of vertigo, hearing loss, and tinnitus characterizes Ménière’s disease.
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The nurse is caring for a patient who has an acute attack of Ménière’s disease. What action should the nurse take first?
a.
Administer prescribed diuretics.
b.
Ensure that the patient is on fluid restriction.
c.
Help the patient into bed with side rails up.
d.
Administer an antianxiety medication.
ANS: C
Help the patient into bed with side rails up so that a fall does not occur due to vertigo.
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The nurse is caring for a patient who has otitis media that develops into a chronic condition. The nurse should be observant for which of these complications?
a.
Tonsillitis
b.
Cerebral edema
c.
Sore throat
d.
Hearing loss
ANS: D
If the infection continues longer than 3 months, chronic otitis media results and can lead to hearing loss.
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The nurse is collecting data for a patient who has a bulging eardrum. The nurse recognizes that this indicates which of the following?
a.
Otitis media
b.
Hematoma in the middle ear
c.
External ear infection
d.
Normal tympanic membrane
ANS: A
Otoscopic examination reveals a reddened, bulging tympanic membrane in otitis media.
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The nurse is collecting data for a patient with an inner ear disorder. Which of these findings is most concerning to the nurse?
a.
Nausea
b.
Headache
c.
Otalgia
d.
Vertigo
ANS: D
Vertigo is to be noted, due to an increased risk for falls.
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The nurse is caring for a patient after a left stapedectomy. When the patient is returned from surgery, which of the following positions should the nurse chose?
a.
Left ear upward
b.
Right ear upward
c.
Flat
d.
Prone
ANS: A
The operative ear is placed upward when lying in bed to prevent pressure or drainage on the site.
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An 85-year-old individual is seen at a clinic after a relative notices that the patient sits about 2 feet away from the television and is not interested in going out anymore. Which of these findings supports visual impairment?
a.
The patient watches television.
b.
The patient does not go out anymore.
c.
The patient has not moved to a new home in 45 years.
d.
The patient visits with a relative occasionally.
ANS: B
The patient does not go out anymore due to safety concerns and the reduced ability to see.
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The home health nurse visits a 74-year-old patient who lives alone and finds signs of possible visual impairment. Which of the following actions should the nurse recommend?
a.
Make adjustments in lifestyle.
b.
Avoid travel.
c.
Schedule an eye examination.
d.
Accept visual impairment as part of aging.
ANS: C
Schedule an eye examination so that the need for interventions can be made.
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The nurse is caring for a patient who has been diagnosed with myopia and asks what it is. How should the nurse respond?
a.
“It is farsightedness.”
b.
“It is blindness.”
c.
“It is nearsightedness.”
d.
“It is cataract development.”
ANS: C
Myopia is nearsightedness or the ability to see things close up but not far away.
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The nurse is reinforcing teaching for a patient being treated for myopia. Which of the following statements by the patient would indicate a correct understanding of the teaching?
a.
Corrective concave lenses
b.
Cataract surgery
c.
Mydriatic ophthalmic drops
d.
Corrective convex lenses
ANS: A
Myopia is corrected with concave lenses.
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The nurse is teaching a patient about conjunctivitis. Which of these, if stated by a patient, indicates to the nurse correct understanding of the most important means to prevent spread of conjunctivitis?
a.
“Patch the eyes.”
b.
“Wash hands.”
c.
“Irrigate the eyes.”
d.
“Keep the eyes moist.”
ANS: B
Conjunctivitis is very contagious, and hand washing is essential to prevent the spread of it.
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A patient with diabetic retinopathy is being discharged home. Which patient statement indicates understanding of the discharge plan to maintain vision?
a.
“I should reduce my insulin dosage.”
b.
“I should avoid being in the sun.”
c.
“I will need to schedule routine eye examinations every 3 years.”
d.
“I should keep my diabetes under control.”
ANS: D
Controlling diabetes is essential to preventing complication development.
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The nurse is reinforcing teaching for symptoms to report for a patient with primary open-angle glaucoma (POAG). Which of the following statements by the patient would indicate a correct understanding of the teaching?
a.
“Hypotension and bradycardia.”
b.
“Fever and reddened conjunctiva.”
c.
“Headache and seeing halos around lights.”
d.
“Loss of central vision and dizziness.”
ANS: C
POAG develops bilaterally. The onset is usually gradual and painless, so the patient may not experience noticeable symptoms or, after time, may experience mild aching in the eyes, headache, halos around lights, or frequent visual changes that are not corrected with eyeglasses.
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The nurse is caring for a patient who is to have cataract surgery. The patient says, “Are you sure this surgery is safe?” Which of the following nursing actions is most appropriate?
a.
Ask the surgeon to talk to the patient.
b.
Give the patient a sedative for relaxation.
c.
Encourage visitors to distract the patient.
d.
Reassure the patient that everything will be all right.
ANS: A
The surgeon needs to talk with the patient to ensure understanding and informed consent. It is not the nurse’s role to do so.
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The nurse is having difficulty communicating with a hearing-impaired patient. Which of these nursing actions is most important?
a.
Speaking softly
b.
Facing the patient when speaking
c.
Avoiding verbal communication
d.
Speaking rapidly
ANS: B
Facing the patient when speaking allows the patient to read lips.
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The nurse is reinforcing teaching for a patient after a stapedectomy. Which of the following statements by the patient would indicate a correct understanding of the teaching?
a.
“I will avoid airplane travel for 6 months.”
b.
“I will keep the ear moist by packing it with cotton balls.”
c.
“I will gently blow my nose with both sides open.”
d.
“I will cough or sneeze with my mouth open.”
ANS: D
It is important to prevent increased pressure to protect the graft site, so the mouth should be open when coughing or sneezing.
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The nurse is to perform an ear irrigation to remove cerumen on a patient. Which of the following does the nurse understand would contraindicate this procedure?
a.
Previous external ear infection
b.
Previous hearing loss
c.
Previous perforated eardrum
d.
Chronic, severe earache
ANS: C
A previous perforated eardrum would contraindicate an ear irrigation to prevent damage to the ear.
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The nurse is reinforcing teaching for a patient who has just been diagnosed with Ménière’s disease. Which of these, if stated by a patient, indicates to the nurse correct understanding of how to manage the vertigo?
a.
“Increase sodium intake.”
b.
“Increase fluid intake.”
c.
“Avoid sudden movement.”
d.
“Listen to soft music.”
ANS: C
The patient should avoid turning the head quickly to help alleviate the vertigo.
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The nurse finds a patient with Ménière’s disease crying and saying, “I don’t understand why this is happening to me.” Which of these outcomes is most appropriate for the nurse to recommend for the patient’s plan of care?
a.
Maintain fluid volume.
b.
Prevent injury.
c.
Prevent ear infection.
d.
Decrease anxiety.
ANS: D
The patient is anxious due to the uncertainty of the disorder. The goal is to reduce the anxiety through education.
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The nurse is reinforcing teaching for a patient with Ménière’s disease. Which of these discharge orders would the nurse question?
a.
Increase daily sodium intake to 4 g.
b.
During an attack, lie down and keep head still.
c.
Ask for assistance when ambulating.
d.
Return if symptoms worsen.
ANS: A
A salt-restricted diet should be ordered to reduce fluid retention in the inner ear.
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After surgery for a detached retina, a patient is experiencing nausea and is prescribed prochlorperazine (Compazine), 10 mg IM prn every 6 hours. Compazine is available as 5 mg/mL. The nurse should administer ____________________ mL in each dose.
ANS:
2
two
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