Vision & Hearing

Vision & Hearing 1

100

The nurse is teaching the client with vertigo about safety precautions for fall prevention. Which statement by the client indicates a further need for instruction? (A) "I may need to use a cane." (B) "I should keep my grandkids' toys out of the hallway." (C) "Moving more slowly may help the vertigo subside." (D) "Taking my medication will allow me to drive my car again."

"Taking my medication will allow me to drive my car again."

200

The client recently diagnosed with Ménière's disease is struggling with tinnitus. How does the nurse provide support to this client? (A) Provides further assessment (B) Suggests a quiet environment (C) Suggests temporary removal of a hearing aid (D) Refers the client to the American Tinnitus Association

Refers the client to the American Tinnitus Association

300

The client has recently been diagnosed with 20/200 vision bilaterally. How does the nurse best offer increased support? (A) Provides instructions in a loud, clear voice (B) Refers the family to local services for the blind (C) Tells the client to find a support group (D) Writes instructions down in very large print

Refers the family to local services for the blind

400

A nurse is providing post-mortem care to a client who has donated a cornea. Which action is appropriate for the nurse to implement? (A) Applies a warm pack to the eyes (B) Elevates the lower extremities (C) Instills antibiotic drops into the eyes (D) Contacts the recipient family

Instills antibiotic drops into the eyes

500

The nurse has just received change-of-shift report about these clients. Which client needs to be assessed first? (A) A client with Ménière's disease who is reporting severe nausea and is requesting an antiemetic (B) A client who has had removal of an acoustic neuroma and has complete hearing loss on the surgical side (C) A client with labyrinthitis who has a temperature of 102.4° F (39.1° C) and a headache (D) A client who has acute otitis media and is reporting drainage from the affected ear

A client with labyrinthitis who has a temperature of 102.4° F (39.1° C) and a headache

Vision & Hearing 2

100

The client has a purulent drainage in the inner canthus of the eye. Before examining the eye, what must the nurse do first? (A) Administer a Snellen test. (B) Obtain an informed consent. (C) Instill antibiotic drops. (D) Put on gloves.

Put on gloves.

200

The client is in the immediate postoperative period after tympanoplasty. How does the nurse position the client? (A) On the affected side (B) Supine, with eyes toward the ceiling (C) With the head elevated 60 degrees (D) With the affected ear facing up

With the affected ear facing up

300

The client with visual limitations has been admitted to the intensive care unit (ICU). Which action is most important to implement for this client? (A) Allowing the client's seeing eye dog in the unit (B) Ensuring that all health care team members are aware of the client's visual limitations (C) Keeping the client bedridden for safety (D) Addressing the client in a loud, clear voice

Ensuring that all health care team members are aware of the client's visual limitations

400

The client with new-onset diminished vision is being discharged and is concerned about living independently. Which technique best facilitates independent self-care for the client? (A) Building on the remaining vision (B) Keeping the floor free of clutter (C) Suggesting a seeing eye animal companion (D) Teaching Braille

Building on the remaining vision

500

The nurse is providing discharge instructions to the client with glaucoma. Which actions does the nurse instruct the client to avoid? Select all that apply. (A) Bending over to tie shoes (B) Sitting with legs elevated (C) Sleeping on more than two pillows (D) Blowing the nose frequently (E) Lifting a 5-pound bag of flour

Bending over to tie shoes, Blowing the nose frequently, Lifting a 5-pound bag of flour

Vision & Hearing 3

100

Which technique is the correct way to instill eardrops? (A) Maintaining the head in the same position for 2 minutes after instillation (B) Placing the medication bottle in a bowl of warm water before instillation (C) Rinsing the ear canal with hydrogen peroxide before instillation (D) Checking to see whether the eardrum is intact before instillation

Placing the medication bottle in a bowl of warm water before instillation

200

A client with glaucoma is being assessed for new symptoms. Which symptom indicates a high priority need for reassessment of intraocular pressure in the client with glaucoma? (A) Burning in the eye (B) Inability to differentiate colors (C) Increased sensitivity to light (D) Gradual vision changes

Gradual vision changes

300

The older adult client reports nausea during removal of impacted cerumen from the ear canal. What does the nurse do next? (A) Administers an antiemetic (B) Calls the physician (C) Stops irrigation immediately (D) Uses less water to irrigate

Stops irrigation immediately

400

The client has recently had cataract surgery. About which symptom does the nurse instruct the client to notify the physician? (A) Increased tearing (B) Itching of the eye (C) Reduction in vision (D) Swollen eyelid

Reduction in vision

500

The nurse is teaching the client who will soon be fitted for a hearing aid about proper care and use. Which statement by the client indicates that teaching was effective? (A) "Background noises will be difficult for me to hear." (B) "I should wear my hearing aid only to work at first." (C) "I should just get a smaller hearing aid because I don't have much money." (D) "Listening to the radio and television will help me get used to new sounds."

"Listening to the radio and television will help me get used to new sounds."

Vision & Hearing 4

100

The client is returning home after cataract surgery with a patch over the affected eye. Which statement by the client's spouse indicates a need for further instruction on providing a safe home environment? (A) "I will get some books on tape for entertainment." (B) "I will be sure to pick up all clutter and loose carpets from the floor." (C) "I will rearrange the furniture for better flow before my spouse gets home." (D) "I will place a nonskid mat in the bathtub."

"I will rearrange the furniture for better flow before my spouse gets home."

200

The client has a bilateral corneal disorder and must instill anti-infective eyedrops every hour for the first 24 hours. Which comment by the client indicates a need for further instruction by the nurse? (A) "I have two bottles of eyedrops because I will require a lot of medication." (B) "I won't be able to wear my contacts for a while." (C) "I must apply the drops throughout the night." (D) "I must wash my hands before and between eye applications and after putting the drops in.''

"I have two bottles of eyedrops because I will require a lot of medication."

300

The bedridden client with reduced vision has been admitted. Which nursing interventions will ease the client's hospital stay? Select all that apply. (A) Announce name and purpose when entering the client's room. (B) Explain food positions on the tray using a compass as the example. (C) Orient the client to the location of the call light, and keep it in that place. (D) Orient the client to the room surroundings and equipment. (E) Speak in a loud, clear voice.

All except "Speak in a loud, clear voice."

400

The older adult client with a new diagnosis of hearing loss is deeply concerned about not being able to hear at her neighborhood council meetings. Which nursing intervention best addresses the client's concern? (A) Suggests that the client discuss with the chairperson about asking everyone speaking at the meeting to speak louder (B) Refers the client to the Center for the Visually Impaired for support (C) Arranges for a sign language specialist to attend the meetings to teach everyone how to communicate with the hearing impaired member (D) Refers the client to the Hearing Loss Association of America

Refers the client to the Hearing Loss Association of America

500

The nurse is teaching the client about open-angle glaucoma management. Which statement by the client indicates a need for further instruction? (A) "I must wait 10 to 15 minutes between different eyedrop medications." (B) "I must press on the inside of my eye to prevent washout." (C) "It is important to not skip a dose." (D) "These eyedrops will not cure my glaucoma."

"I must press on the inside of my eye to prevent washout."

Vision & Hearing 5

100

The nurse is teaching the mother of a teenage client with conjunctivitis how to administer eye ointment. Which statement by the mother indicates correct understanding of the nurse's instruction? (A) "My child should look down at the floor during instillation." (B) "I will place the ointment in the lower lid." (C) "My child should rub the eye gently after instillation to increase absorption." (D) "I will press gently on the inner canthus for 1 minute."

"I will place the ointment in the lower lid."

200

The nurse is reviewing postoperative instructions with the client undergoing stapedectomy. Which statement by the client indicates a need for further teaching? (A) "I may have problems with vertigo after the surgery." (B) "I should not drink from a straw for several weeks." (C) "I will have to take antibiotics after the surgery." (D) "I will be able to hear as soon as my dressing is removed."

"I will be able to hear as soon as my dressing is removed."

300

The nurse is performing an otoscopic examination of the client's ear and sees a greenish white drainage. What does the nurse do next? (A) Disposes of the otoscope tip and washes his or her hands before examining the other ear (B) Reports the finding to the physician immediately (C) Sends a specimen for culture (D) Suctions out the drainage

Disposes of the otoscope tip and washes his or her hands before examining the other ear

400

Which client is most in need of immediate examination by an ophthalmologist? (A) 58-year old with glasses who reports an inability to see colors well and is feeling as though his or her glasses are always smudged (B) 40-year-old with glasses and a reddened sclera who reports brow pain, headache, and seeing colored halos around lights (C) 76-year-old with seborrhea of the eyebrows and eyelids who reports burning and itching of the eyes (D) 39-year-old with contacts who reports an inability to tolerate bright lights and has visible purulent drainage on eyelids and eyelashes

40-year-old with glasses and a reddened sclera who reports brow pain, headache, and seeing colored halos around lights

500

The nurse is caring for a client who is admitted with mastoiditis. Which of these assessment data obtained by the nurse requires the most immediate action? (A) The eardrum is red, thick appearing, and immobile. (B) The lymph nodes are swollen and painful to touch. (C) The client reports a headache and a stiff neck. (D) The client's oral temperature is 100.1° F (37.8° C).

The client reports a headache and a stiff neck.