Nursing Interventions
While administering ear drops to a toddler, a nurse by pulls the auricle down and back. The mother asks, "Why are you pulling the ear that way?" Which of the following responses should the nurse make?
A. "This opens the ear canal, allowing medication to reach the inner ear region."
B. "When I use this technique, your child experiences less pain."
C. "This is the safest and easiest way to administer this medication."
D. "When I use this technique the medication will not run out of the ear."
A. "This opens the ear canal, allowing medication to reach the inner ear region."
Which of the following would be an inaccurate clinical manifestation of a retinal detachment?
A. Pain
B. Sudden onset of a greater number of floaters
C. Cobwebs
D. Bright flashing lights
A. Pain
Patient may report the sensation of a shade or curtain coming across the vision of one eye, cobwebs, bright flashing lights, or the sudden onset of a great number of floaters. Patients do not complain of pain.
Which is the most common cause of visual loss in people older than 60 years of age?
A. Glaucoma
B. Macular degeneration
C. Cataracts
D. Retinal detachment
B. Macular degeneration is the most common cause of visual loss in people older than 60 years of age.
A nurse is teaching a client about medications for glaucoma. What is the main marker of glaucoma control with medication?
A. Changing the opacity of the lens
B. Lowering intraocular pressure to target pressure
C. Reducing the appearance of optic nerve head
D. Increasing the visual field
B. Lowering intraocular pressure to target pressure
Which symptom is related to vertigo?
A. Loss of consciousness
B. Spinning sensation
C. Fainting
D. Syncope
B. Spinning sensation.
Vertigo is defined as the misperception or illusion of motion of the person or the surroundings. Most people with vertigo describe a spinning sensation or say they feel as though objects are moving around them.
A nurse is providing postoperative care for a patient who has just had cataract removal surgery. Which of the following interventions should the nurse include in the care plan?
A. Instruct the patient to lie on their side for the first 24 hours to promote healing.
B. Advise the patient to avoid bending over or lifting heavy objects to prevent increased intraocular pressure.
C. Encourage the patient to rub their eyes frequently to relieve any itching or discomfort.
D. Recommend that the patient resume normal activities, including driving, immediately after surgery.
Answer: B. Advise the patient to avoid bending over or lifting heavy objects to prevent increased intraocular pressure.
The nurse is developing a plan of care for a patient with severe vertigo. What expected outcome statement would be a priority for this patient?
A. Patient will experience no falls due to balance disorder.
B. Patient will take medications as prescribed.
C. Patient will perform exercises as prescribed.
D. Patient will have decreased fear and anxiety.
A. Although all of these are expected outcomes for a patient with vertigo, the priority expected outcome is that the patient will experience no falls due to the balance disturbance, as falls poses the greatest risk to the patient's health.
A nurse is teaching a patient about the proper care of their hearing aids. Which of the following instructions is the most important for the patient to follow?
A. "Clean the hearing aid with water and soap daily to ensure it remains free of bacteria."
B. "Remove the hearing aid before using hair products to prevent damage from chemicals."
C. "Store the hearing aid in a humid environment to keep it from drying out."
D. "Adjust the volume frequently to ensure the hearing aid provides the best sound quality."
Answer: B. "Remove the hearing aid before using hair products to prevent damage from chemicals."
Removing the hearing aid before using hair products is crucial because chemicals in products like hairspray and shampoo can damage the hearing aid. This precaution helps in maintaining the device's functionality and longevity.
During his annual physical examination, a retired airplane mechanic reports noticeable hearing loss. The nurse practitioner prescribes a series of hearing tests to confirm or rule out noise-induced hearing loss, which is classified as a:
A. Conduction problem
B. Sensorineural loss
C. Mixed cause
D. Psychogenic issue
B. Sensorineural loss
Noise-induced hearing loss refers to hearing loss that follows a long period of exposure to loud noise. It is inherent in jobs that involve heavy machinery, noisy engines, and artillery.
Which instruction regarding swimming should the nurse give to the client who is recovering from otitis externa?
A. Wear a scarf
B. Avoid cold water
C. Avoid swimming for 7–10 days
D. Insert a loose cotton ball in the external ear
C. Avoid swimming for 7–10 days.
The nurse should advise the client to avoid swimming for 7 to 10 days to allow the canal to heal completely. Wearing a scarf or inserting cotton does not help prevent recurrence of the disorder. Avoiding cold water does not help to improve the client's condition.
The nurse is administering eye drops to a client with glaucoma. After instilling the client's first medication, how long should the nurse wait before instilling the client's second medication into the same eye?
A. 30 seconds
B. 1 minute
C. 3 minutes
D. 5 minutes
D. 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.
`Leslie Waterman, a 57-year-old corrections officer, is being seen at the ophthalmic group where you practice nursing. He's concerned about his vision changes where he sees distance much more clearly than nearby sights. What is the term used to describe his visual condition?
A. Hyperopia
B. Emmetropia
C. Myopia
D. Astigmatism
A. Hyperopia is farsightedness. People who are hyperopic see objects that are far away better than objects that are close.
A nurse is providing education to a patient diagnosed with bacterial conjunctivitis. Which of the following statements should the nurse include in the teaching plan? (Select all that apply.)
A. "You should avoid touching or rubbing your eyes to prevent spreading the infection to others."
B. "It is important to wash your hands frequently, especially after applying eye drops or touching your eyes."
C. "You can use over-the-counter antihistamines to treat the bacterial conjunctivitis symptoms."
D. "Do not share towels, pillows, or other personal items with others to reduce the risk of transmission."
E. "You should complete the full course of prescribed antibiotics, even if your symptoms improve before finishing the medication."
F. "It is safe to resume contact lens use immediately once symptoms start to improve."
Answer: A, B, D, E
Avoiding touching or rubbing the eyes (A) is important to prevent the spread of infection to other areas or other people.
Washing hands frequently (B) is essential to minimize the risk of spreading the infection to others or to other parts of the body.
Not sharing personal items (D) helps reduce the risk of transmission of bacterial conjunctivitis.
Completing the full course of prescribed antibiotics (E) is crucial to ensure the infection is fully eradicated and to prevent antibiotic resistance.
Over-the-counter antihistamines (C) are not appropriate for treating bacterial conjunctivitis, as they are typically used for allergic conjunctivitis.
Resuming contact lens use (F) should be avoided until the infection is fully resolved and advised by a healthcare provider to prevent further irritation or complications.
What aspect should the nurse closely monitor for in clients who have been administered salicylates, loop diuretics, quinidine, quinine, or aminoglycosides?
A. Signs of hypotension
B. Reduced urinary output
C. Tinnitus and sensorineural hearing loss
D. Impaired facial movement
C. Tinnitus and sensorineural hearing loss
It is important that nurses are knowledgeable about the ototoxic effects of certain medications such as salicylates, loop diuretics, quinidine, quinine, and aminoglycosides. Signs and symptoms of ototoxicity include tinnitus and sensorineural hearing loss. Hypotension, reduced urinary output, and impaired facial movement are not signs of ototoxicity.
A client with Meniere's disease has a nursing diagnosis of risk for injury related to gait disturbances and vertigo. Which of the following would be most appropriate to include in this client's plan of care?
A. Moving the head from side-to-side when vertigo occurs
B. Sitting down at the first sign of feeling dizzy
C. Closing the eyes when lying down during an episode of vertigo
D. Performing self-care activities when the vertigo first starts
B. Sitting down at the first sign of feeling dizzy.
For a nursing diagnosis of risk for injury, the client should sit down at the first sign of feeling dizzy. The client also should place a pillow on each side of the head to avoid movement, keep the eyes open, and stare straight ahead when lying down and perform self-care activity during vertigo-free periods
Which of the following characteristics accurately distinguishes a sty (hordeolum) from a chalazion?
A. A sty presents as a red, tender, and painful lump on the eyelid, while a chalazion presents as a non-tender, firm lump.
B. A sty is a chronic condition that causes a hard, painless nodule, while a chalazion is an acute infection with redness and pain.
C. A sty typically affects the meibomian glands, while a chalazion affects the sebaceous glands of the eyelid.
D. A sty usually presents with a non-red, soft swelling, while a chalazion presents with a red, tender lump.
Answer: A. A sty presents as a red, tender, and painful lump on the eyelid, while a chalazion presents as a non-tender, firm lump.
Rationale:
After a fall at home, a client hits their head on the corner of a table. Shortly after the accident, the client arrives at the ED, unable to see out of their left eye. The client tells the nurse that symptoms began with seeing spots or moving particles in the field of vision but that there was no pain in the eye. The client is very upset that the vision will not return. What is the most likely cause of this client's symptoms?
A. retinal detachment
B. angle-closure glaucoma
C. eye trauma
D. chalazion
A. retinal detachment. A detached retina is associated with a hole or tear in the retina caused by stretching or degenerative changes. Retinal detachment may follow a sudden blow, penetrating injury, or eye surgery.
A 52-year-old comes to the clinic for a follow-up examination after being diagnosed with glaucoma. The client states, "I'm hoping that I don't have to use these drops for very long." Which response by the nurse would be most appropriate?
A. "Most clients need to use the drops for only about a few months."
B. "If the drops don't work, surgery may be needed to cure your condition."
C. "You'll need to use the drops for the rest of your life to control the glaucoma."
D. "These drops are just the first step to make sure that your vision doesn't get worse."
C. "You'll need to use the drops for the rest of your life to control the glaucoma." The nurse needs to provide additional information to the client that the condition can be controlled but not cured.
The patient with glaucoma is usually started on the lowest dose of medication. Which of the following is the preferred initial topical medication?
A. Beta-blockers
B. Prostaglandins
C. Carbonic anhydrase inhibitors
D. Alpha-agonists
A. Beta-blockers
Because of their efficacy, minimal dosing (can be used once each day), and low cost, beta-blockers are the preferred initial topical medications. Beta-blockers decrease the production of aqueous humor, with a resultant decrease in IOP.
A nurse needs to change a dressing on an abdominal wound for a patient who is hearing-impaired and whose speech is difficult to understand. Which of the following is the best approach for the nurse?
A. Write down the steps of the procedure for the patient to read before beginning the treatment.
B. Change the dressing while the patient is reading the steps of the treatment because distraction decreases anxiety.
C. Use nonverbal signals of agreement (head nodding), even if unsure, to instill confidence and trust.
D. Minimize misunderstandings by completing the patient's sentences (e.g., fill-in-the-blanks) to decrease the patient's embarrassment.
A. Written communication is an excellent resource and means of mutual understanding. Distraction is not appropriate because a hearing-impaired person needs the care provider's full attention. Do not pretend to understand or complete the person's sentences for them.
Which of the following interventions should the nurse implement to ensure the safety and comfort of a blind patient in the hospital? (Select all that apply.)
A. Place a large print label on the patient’s meal trays for identification.
B. Ensure that the patient’s call light is always within easy reach and clearly explain its location.
C. Use verbal communication to provide clear instructions and describe the environment.
D. Provide a braille or tactile label system for identifying personal items and room features.
E. Keep the patient’s room clutter-free to prevent accidents and facilitate easy navigation.
Answer: A, B, D
Rationale:
Hearing loss (A) is one of the hallmark symptoms of Meniere's disease, often fluctuating in nature.
Ringing in the ears (tinnitus) (B) is another key symptom of Meniere's disease.
Vertigo (D) is a defining feature of Meniere's disease, characterized by episodic and severe spinning sensations.
Severe headache (C) is not typically part of the classic triad of Meniere's disease symptoms.
Nausea and vomiting (E) are often associated with vertigo and can occur during an episode but are not considered part of the classic triad.
A nurse is educating a patient about glaucoma and its types. Which of the following statements accurately distinguishes between open-angle glaucoma and closed-angle glaucoma? (Select all that apply.)
A. Open-angle glaucoma is characterized by a sudden onset of severe eye pain and blurred vision, while closed-angle glaucoma develops gradually and often without symptoms.
B. Closed-angle glaucoma is considered a medical emergency due to its rapid onset and potential for vision loss, while open-angle glaucoma progresses more slowly and may not present with noticeable symptoms for years.
C. Open-angle glaucoma typically has a gradual increase in intraocular pressure, while closed-angle glaucoma often presents with a sudden and significant rise in intraocular pressure.
D. Open-angle glaucoma commonly leads to peripheral vision loss, whereas closed-angle glaucoma primarily affects central vision.
Answer: B, C
Closed-angle glaucoma (B) is indeed a medical emergency because of its sudden onset and risk of rapid vision loss. It usually presents with severe symptoms such as eye pain and blurred vision, while open-angle glaucoma (B) progresses more slowly and may not have noticeable symptoms for years.
Open-angle glaucoma (C) is characterized by a gradual increase in intraocular pressure due to the slow clogging of the drainage canals. In contrast, closed-angle glaucoma (C) often presents with a sudden and significant rise in intraocular pressure due to the acute blockage of the drainage angle.
Open-angle glaucoma (D) typically causes peripheral vision loss as it progresses, whereas closed-angle glaucoma (D) can also affect central vision but is more noted for its sudden onset and associated symptoms.
After surgery for removal of cataract, a client is being discharged, and the nurse has completed discharge instruction. Which client statement indicates that the outcome of the teaching plan has been met?
A. "I need to wear sunglasses for the first 3 to 4 days even when I'm inside."
B. "Dots or flashing lights in my vision are to be expected for the first few days."
C. "I should avoid pulling or pushing any object that weighs more than 15 lbs."
D. "I need to keep the eye patch on for about a week after surgery."
C. "I should avoid pulling or pushing any object that weighs more than 15 lbs."
After cataract surgery, the client needs to avoid lifting, pulling, or pushing any object that weighs more than 15 pounds to prevent putting excessive pressure on the surgical site. Sunglasses should be worn when outdoors during the day because the eye is sensitive to light. Dots, flashing lights, a decrease in vision, pain, and increased redness need to be reported to the physician immediately. The eye patch is worn for 24 hours after surgery, followed by eyeglasses worn during the day and a metal shield worn at night for 1 to 4 weeks.
A nurse is preparing to administer ofloxacin otic drops to an adult client who has otitis externa. Which of the following actions should the nurse take?
A. Hold the dropper against the ear canal while instilling the medication.
B. Apply gentle pressure with a finger to the tragus of the ear.
C. Chill the medication prior to administration.
D. Straighten the external auditory canal by pulling it down and back.
B. Apply gentle pressure with a finger to the tragus of the ear.
Which of the following symptoms are part of the classic triad associated with Meniere's disease? (Select all that apply.)
A. Hearing loss
B. Ringing in the ears (tinnitus)
C. Severe headache
D. Vertigo
E. Nausea and vomiting
Answer: A, B, D
Rationale:
Hearing loss (A) is one of the hallmark symptoms of Meniere's disease, often fluctuating in nature.
Ringing in the ears (tinnitus) (B) is another key symptom of Meniere's disease.
Vertigo (D) is a defining feature of Meniere's disease, characterized by episodic and severe spinning sensations.
Severe headache (C) is not typically part of the classic triad of Meniere's disease symptoms.
Nausea and vomiting (E) are often associated with vertigo and can occur during an episode but are not considered part of the classic triad.