Chapter 46A
When performing an eye or vision assessment, which comment by the client alerts the nurse that immediate care by an ophthalmologist is needed?
A. “One eye is green and the other eye is blue.”
B. “My eyes are red and itchy.”
C. “My vision has been getting worse gradually.”
D. “Something hit my eye while I was cutting grass.”
D
The client who is experiencing trauma, a foreign body in the eye, sudden ocular pain, or sudden redness should be seen immediately by an ophthalmologist.
Clients with a family history of which eye disorder may have problems with increased intraocular pressure (IOP), requiring additional assessment?
A. Anisocoria
B. Presbyopia
C. Diabetic retinopathy
D. Correct Glaucoma
D
Glaucoma can be caused by increased IOP, which reduces blood flow to the eyes. Adults with a family history of glaucoma should have their IOP measured once or twice a year.
What is the action of miotic drugs that constrict the pupils in the client with glaucoma?
A. Decrease the inflammatory process
B. Enhance aqueous circulation to site of absorption
C. Increase the production of vitreous humor
D. Vasoconstrict the blood vessels in the eye
B
Miotics are used to improve the flow of fluid (aqueous humor) and circulation and decrease intraocular pressure in clients with glaucoma.
The nurse is reviewing postoperative instructions with a 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.”
D
Further teaching is necessary if the client states that he will be able to hear as soon as the dressing is removed. Hearing is initially worse after a stapedectomy. The client would be informed that improvement in hearing may not occur until 6 weeks after surgery. At first, the ear packing interferes with hearing, and swelling in the ear after surgery reduces hearing, but these conditions are temporary.
Vertigo, nausea, and vomiting are common after surgery because of the nearness of the surgical site to inner ear structures. Clients must not drink through a straw for 2 to 3 weeks after surgery. Antibiotics are used to reduce the risk for infection.
The nurse is assessing a client with recent changes in hearing. After taking a medication history, which drugs does the nurse identify as possible causes of the client’s hearing change? (Select all that apply.)
A. Acetaminophen (Tylenol)
B. Beta blockers
C. Erythromycin
D. Ibuprofen (Advil)
E. Insulin
F. Furosemide (Lasix)
C, D, F
The nurse identifies erythromycin, ibuprofen, and furosemide (Lasix) as medications known to increase the risk for hearing change related to ototoxicity and hearing problems.
The nurse providing education on eye protection suggests the special need for protective eyewear for which clients? (Select all that apply.)
A. Cab driver
B. College student
C. Lifeguard
D. Racquetball player
E. Registered nurse
C, D
Lifeguards are in need of eye protection from ultraviolet (UV) A and UVB rays because of exposure to the sun. People who play racquetball need to wear protective eyewear to prevent possible eye injury
The nurse is teaching a client who is scheduled for an ultrasonography of the eye. Which statement by the client indicates a need for further instruction?
A. “I’ll have to wear a bandage over my eye after the test.”
B. “I will be awake during this test.”
C. “I won’t hear the high-frequency sound waves.”
D. “This test will help determine whether my retina is detached.”
A
The client does not have to wear a bandage after the test because no special follow-up care is needed after an ultrasonography of the eye. However, the client should be reminded not to rub or touch the eye until the effects of the anesthetic drops have worn off.
The nurse is providing postmortem care to a client who will donate a cornea. Which action is appropriate for the nurse to implement?
A. Apply a warm pack to the eyes.
B. Elevate the lower extremities.
C. Instill antibiotic drops into the eyes.
D. Contact the recipient family.
C
Antibiotic eye drops, such as Neosporin (polymyxin B, neomycin, bacitracin) or tobramycin, is appropriate to instill into the corneal donor’s eyes to prevent infection.
An older adult client reports nausea during irrigation of the ear canal to remove impacted cerumen. What does the nurse do next?
A. Administer an antiemetic.
B. Call the health care provider.
C. Stop irrigation immediately.
D. Use less water to irrigate.
C
If nausea, vomiting, or dizziness develops in the client, the nurse needs to next stop the irrigation immediately. The client’s nausea may be a sign of vertigo.
Antiemetics would not be administered immediately in this case. The client’s nausea may be a symptom of vertigo, and further assessment is required first. The health care provider would not be notified before further assessment of the client is done by the nurse. Using less water will not alleviate the client’s nausea
An older adult client comes in for a routine visit. During the assessment he is irritable and says, “Speak up and quit mumbling!” How will the nurse respond?
A. Apologizes and speaks louder and clearer
B. Asks whether the client has a hearing loss
C. Shout to ensure that the client can hear
D. Suggests that the client move to a soundproof examination room to improve his hearing
A
The nurse would repeat and speak more clearly first and then determine whether further assessment is needed.
he nurse is teaching a client about visual changes that occur with age. Which statement does the nurse include?
A. “It may take your eyes longer to adjust in a darkened room.”
B. “Most visual changes occur before age 40.”
C. “When the sclera starts to turn yellow, this means you might have problems with your liver.”
D. “You probably will have to move reading materials closer to your eyes.”
A
The nurse teaches the client that, “It may take your eyes longer to adjust in a dark room.” With increasing age, the iris has less ability to dilate, which leads to difficulty in adapting to dark environments.
Which eye procedure requires informed consent from the client?
A. Eye drop instillation
B. Correct Fluorescein angiography
C. Ophthalmoscopy
D. Snellen test
B
Fluorescein angiography is an invasive test and requires informed consent from the client.
A client with glaucoma is being assessed for new symptoms. Which symptom indicates a high priority need for reassessment of intraocular pressure?
A. Burning in the eye
B. Inability to differentiate colors
C. Increased sensitivity to light
D. Correct Gradual vision changes
D
Gradual vision changes are an indication of increased intraocular pressure and indicate a high priority for reassessment
The nurse is preparing a client for electronystagmography. Which statement by the client indicates that teaching was effective?
A. “I can’t drink caffeine 24 to 48 hours before the test.”
B. “I should drink more fluids 4 hours before the test.”
C. “I’ll be placed in a soundproof booth for the test.”
D. “I’ll be sedated for the test.”
A
The client must avoid caffeine-containing beverages for 24 to 48 hours before the test. Electronystagmography (ENG) is a test to assess for central and peripheral disease of the vestibular system in the ear by detecting and recording nystagmus (involuntary eye movements). This response is accurate because the eyes and ears depend on each other for balance.
The client must fast for several hours before electronystagmography. Fluids are carefully introduced after the test is completed to prevent nausea and vomiting. The client is placed in a soundproof booth for an audiometry test. Sedation is not given for the test. The examiners will ask the client to name names or do simple math problems during the test to ensure that he or she stays alert.
Which type of drug therapy does the nurse anticipate giving to a client with Ménière’s disease to decrease endolymph volume?
A. Antihistamines
B. Antipyretics
C. Diuretics
D. Nicotinic acid
C
Mild diuretics are prescribed to decrease endolymph volume. Ménière’s disease causes an excess of endolymphatic fluid that distorts the entire inner-canal system. This distortion decreases hearing by dilating the cochlear duct, causes vertigo because of damage to the vestibular system, and stimulates tinnitus
A. Instilling the drops into the inner canthus
B. Opening the eye by raising the upper eyelid
C. Placing the eye drop in the lower lid pocket
D. Touching the bottle tip to the eyeball
C
To instill eye drops, the lower eyelid is gently pulled down against the cheek to form a pocket, and the medication is instilled.
Which systemic disorders may affect the eye and vision and require yearly eye examination by an ophthalmologist? (Select all that apply.)
A. Anemia
B. Diabetes mellitus
C. Hepatitis
D. Hypertension
E. Multiple sclerosis (MS)
B, D, E
Clients who are diabetic are at risk for diabetic retinopathy and are in need of annual eye examinations. Clients with elevated blood pressure need to have annual eye examinations because of the increased risk for retinal damage. Clients with MS should have annual examinations because of changes that occur with the neurologic effects of MS that impact visual acuity.
A 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 clock face 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.
A, B, C, D
Staff would always introduce themselves to clients, with or without visual issues. Using a standard clock face to explain food locations on the tray will assist the client with self-feeding. Providing room orientation to the client is important to improve his or her ability for self-care. Orienting the client to the room and equipment in the room will allow him or her to have increased comfort with surroundings.
Which type of hearing loss is most likely to be reversible when treated appropriately?
A. Conductive hearing loss
B. Sensorineural hearing loss
C. Mixed conductive–sensorineural hearing loss
D. Central hearing loss
A
Conductive hearing loss is most likely to be reversible when treated appropriately. This type of hearing loss is often the result of an obstruction in the ear canal or a retracted or bulging tympanic membrane.
Sensorineural loss is the result of damage to the eighth cranial nerve, a defect in the cochlea, or damage in the brain. Mixed conductive sensorineural hearing loss is the result of both conductive and sensorineural hearing loss. Central hearing loss results when the brain is unable to process signals from the ear. None of these types of hearing loss is likely to be reversible.
The nurse is caring for a client who is admitted with mastoiditis. Which 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).
C
The most immediate action is required when the client reports a headache and a stiff neck. These complaints may indicate meningitis, which is a serious illness requiring further assessment and immediate intervention.
A client is admitted to the emergency department with metal shards in the right eye. Which test is contraindicated for this client?
A. Magnetic resonance imaging (MRI)
B. Ophthalmoscopy
C. Radioisotope scanning
D. Snellen chart
A
Because the client has metal in the eye, MRI is an absolute contraindication.
A client who is using eye drops in both eyes develops a viral infection in one eye and asks the nurse what to do. What is the nurse’s best response?
A. “As long as you don’t touch the eyes with the dropper, it will be OK.”
B. “Just wash your hands between eyes and put drops in the uninfected eye first.”
C. “The other eye will probably get infected anyway.”
D. “You will need to use a separate bottle of drops for each eye".
D
The best response is that the client will need a separate bottle of eye drops for each eye. Because of the risk of transmitting the infection to the uninfected eye, clients would receive two bottles of drops labeled “right” and “left” to use in the correct eyes.
Which client is most in need of immediate examination by an ophthalmologist?
A. A 58-year-old with glasses who reports an inability to see colors well and is feeling as though the glasses are always smudged
B. Correct A 40-year-old with glasses and a reddened sclera who reports brow pain, headache, and seeing colored halos around lights
C. A 76-year-old with seborrhea of the eyebrows and eyelids who reports burning and itching of the eyes
D. A 39-year-old with contacts who reports an inability to tolerate bright lights and has visible purulent drainage on eyelids and eyelashes
B
The 40-year-old client with glasses and a reddened sclera who reports brow pain, headache, and seeing colored halos around lights is most in need of an ophthalmologic examination. This client is exhibiting signs and symptoms of increased intraocular pressure (IOP). This is a priority because the optic nerve can be damaged, which can cause possible blindness. Acute angle-closure glaucoma can occur in people 40 years of age and older.
The nurse has just received change-of-shift report about these clients. Which client needs to be assessed first?
A. Client with Ménière’s disease who is reporting severe nausea and is requesting an antiemetic
B. Client who has had removal of an acoustic neuroma and has complete hearing loss on the surgical side
C. Client with labyrinthitis who has a temperature of 102.4° F (39.1° C) and a headache
D. Client who has acute otitis media and is reporting drainage from the affected ear
C
The client with an elevated temperature and headache with labyrinthitis must be assessed first. This may indicate that the client has developed meningitis requiring immediate intervention.
Severe nausea is an expected finding with Ménière’s disease. Complete hearing loss on the surgical side is an expected postoperative finding after an acoustic neuroma. Drainage from the affected ear can be an expected finding with otitis media.
An older adult client reports ear pain. Otoscopic examination for otitis media by the nurse practitioner (NP) reveals a dull and retracted membrane. What does the NP do next?
A. Continues further assessment
B. Irrigates the ear
C. Prescribes antibiotics for probable otitis media
D. Tests hearing acuity
A
The NP needs to perform further assessments. A dull and retracted membrane is not the only indication of otitis media for the older adult client. This finding may be a normal age-related change.