Deck 52: Nursing Care of Patients With Sensory Disorders: Vision and Hearing

Question 1

The nurse is visiting the home of a patient diagnosed with visual impairment related to macular degeneration. Which observation indicates to the nurse the patient is adjusting to the condition?

A)The patient is in nightclothes in the middle of the afternoon.
B)The patient is moving about in the apartment without problems.
C)The patient's refrigerator contains only condiments, eggs, and milk.
D)The patient has stacks of unopened mail on the kitchen table.

Answer 1

The patient is moving about in the apartment without problems.

Question 2

The nurse is preparing to assist the HCP with the incision of a carbuncle in the ear canal of a patient. Which specific manifestation does the nurse associate with the patient's diagnosis?

A)Necrotic tissue spreading toward the auricle
B)An absence of protective earwax in the canal
C)Several hair follicles that have formed an abscess
D)Fungus in the ear canal causing an infection

Answer 2

Several hair follicles that have formed an abscess

Question 3

The nurse is assisting in the evaluation of the effectiveness of teaching for a patient who has severe visual impairment. Which statement by the patient indicates additional teaching is needed?

A)"I can do all my self-care if no one moves my hygiene items."
B)"Cooking is still impossible and I am just eating cold foods."
C)"My family helped move everything out of my pathways."
D)"I have someone come weekly for cleaning and laundry."

Answer 3

"Cooking is still impossible and I am just eating cold foods."

Question 4

The nurse in an HCP's office is assisting with the removal of impacted cerumen from the ear canal of an older adult patient. The patient presented with decreased hearing and a sensation of fullness. Which reason does the nurse identify as the most likely cause of the patient's condition?

A)Improper cleaning of the ear canal
B)The presence of hair growth in the ear canal
C)Dryness of secretions from shrinking ear canal glands
D)Exposure to dirt and dust in the working environment

Question 5

The nurse is reinforcing teaching provided to a patient with open-angle glaucoma. What is most important for the nurse to include in the patient teaching?

A)Regardless of treatment, peripheral vision will be eventually lost.
B)Compliance with drug therapy is essential to prevent loss of vision.
C)Damage to the eye caused by glaucoma is reversible in early stages.
D)Eye pain is experienced until the optic nerve atrophies, causing blindness.

Question 6

The nurse in the emergency department is assisting with the care of a patient with a penetrating wound to the eye. The patient keeps crying out and asking that the uninjured eye be uncovered. Which answer by the nurse provides understanding?

A)"It is less stressful if you cannot see anything about the other eye."
B)"Covering your uninjured eye will keep anything from getting into it."
C)"Being able to see will allow you to look around and get more upset."
D)"Covering the uninjured eye stops ocular movement in the injured one."

Question 7

The nurse is collecting information from a patient who reports difficulty seeing the print in the newspaper. The patient is 50 years of age and does not have any condition that requires medical management. Which vision condition does the nurse suspect the patient is experiencing?

A)Myopia
B)Presbyopia
C)Astigmatism
D)Emmetropia

Question 8

A patient is diagnosed with otosclerosis and is scheduled for a stapedectomy. Which postoperative finding does the nurse report to the health care provider (HCP) or the registered nurse (RN) immediately?

A)The patient remains positioned with the surgical ear positioned upward.
B)The side rails of the bed are up in response to the patient feeling dizzy.
C)The patient received an antiemetic for nausea, but vomits after the medication.
D)The earplug placed in the surgical ear is found on the floor next to the patient's bed.

Question 9

A patient is diagnosed with Ménière disease. Which therapeutic measures does the nurse expect the HCP to prescribe?

A)A minimum of 8 hours of sleep nightly to prevent fatigue
B)A salt-restricted diet and prescribed antihistamines and vasodilators
C)Prophylactic antiemetic medications prescribed for nausea and vomiting
D)Meclizine, tranquilizers, and vagal blockers prescribed to prevent symptoms

Question 10

The nurse is assisting with the care of a patient being prepared for emergency intervention for a detached retina. If the nurse asks the patient about the ability to maintain a reclining position for 16 hours, which procedure is planned for this patient?

A)Laser surgery
B)Cryopexy
C)Pneumatic retinopexy
D)Scleral buckling

Question 11

The nurse is providing care for an older adult client. The nurse notices the patient appears to be having difficulty understanding her and asks that questions and comments be repeated. If the nurse suspects presbycusis, which action does the nurse take to promote better hearing for the patient?

A)Ask the patient if he is having difficulty hearing.
B)Sit closer to and directly in front of the patient.
C)Speak to the patient in a lower tone of voice.
D)Use a slightly louder and slower talking rate.

Question 12

The nurse is collecting data from a patient with diabetes mellitus. The patient's medical history reveals multiple episodes of hyperglycemia requiring medical management. The patient tells the nurse, "I just got new glasses, but I still do not see very well." Which condition does the nurse suspect?

A)Preproliferative retinopathy
B)Background retinopathy
C)Proliferative retinopathy
D)Incomplete retinal detachment

Question 13

The nurse is conducting hearing tests in a neighborhood clinic. The nurse is concerned about the number of young adult patients who exhibit signs of sensorineural hearing loss. For which reason does the nurse suspect this type of hearing loss in this population?

A)High exposure to ototoxic drugs
B)Prolonged exposure to loud noise
C)Trauma from physical contact sports
D)Increased incidences of meningitis

Question 14

The nurse is reinforcing teaching provided to a patient with primary open-angle glaucoma (POAG) about symptoms to report. Which patient statement regarding symptoms indicates a correct understanding of the teaching?

A)"Hypotension and bradycardia"
B)"Fever and reddened conjunctiva"
C)"Loss of central vision and dizziness"
D)"Headache and seeing halos around lights"

Question 15

The nurse is providing care for a school-age patient at a community clinic. The patient exhibits redness and crusting exudate on the lids and corners of each eye, and reports pain and itching. A culture was taken of the exudate and antibiotic drops were prescribed. Which action does the nurse take if the eye culture returns as positive for Neisseria gonorrhoeae?

A)Review the importance of medication administration with the patient's parent.
B)Mail the patient's household literature about prevention of infecting family members.
C)Ask a family member to bring the patient back to the clinic for a follow-up evaluation.
D)Notify the HCP and RN about a possible situation involving sexual abuse of a minor.

Question 16

A patient presents with vertigo, tinnitus, and sensorineural hearing loss and is diagnosed with labyrinthitis. Which patient teaching does the nurse reinforce with this patient?

A)Instruct to not turn the head quickly.
B)Emphasize the importance of taking antihistamines.
C)Use proper methods for cleaning the ear.
D)Hearing will return with rest and medication.

Question 17

A patient with acute angle glaucoma and a fractured femur that is scheduled for surgery is prescribed the preoperative medications morphine 10 mg intramuscularly (IM) and atropine 0.4 mg IM. Which action does the nurse take?

A)Hold the morphine.
B)Contact the physician.
C)Give medications as ordered.
D)Collect data on patient's pain.

Question 18

An adolescent patient is diagnosed by the HCP with keratitis from a herpes simplex infection of the eye. Which patient teaching does the nurse reinforce as a method for pain management?

A)The importance of finishing all the prescribed antiviral medication
B)Wearing sunglasses indoors and outdoors to decrease effects of photophobia
C)Disposing of all eye cosmetics that were used at the time of becoming infected
D)Refraining from using contact lenses until all signs of inflammation are gone

Question 19

The caregiver of a patient with macular degeneration voices being increasingly frustrated because of food spills on the patient's clothing. Which explanation does the nurse give to help the caregiver understand what the patient is experiencing?

A)"The patient's vision is blurred."
B)"There is total blindness in one eye occurring."
C)"The central vision is gone and only peripheral vision remains."
D)"There are black dots in the field of vision that cause confusion."

Question 20

The nurse is reinforcing teaching provided to a patient recovering from a stapedectomy. Which patient statement indicates teaching has been effective?

A)"I will avoid airplane travel for 6 months."
B)"I will cough or sneeze with my mouth open."
C)"I will gently blow my nose with both sides open."
D)"I will keep the ear moist by packing it with cotton balls."

Question 21

A patient with otitis media is experiencing severe ear pain. Which nonpharmacological measures does the nurse apply to help relieve this patient's discomfort? (Select all that apply.)

A)Offer a massage.
B)Apply heat to the area.
C)Offer liquid or soft diet.
D)Apply an ice pack to the area.
E)Dim the lights and reduce environmental noise.

Question 22

A patient with acute ear pain and drainage comes into the community clinic. Which diagnostic tests does the nurse expect to be performed prior to beginning treatment for this patient? (Select all that apply.)

A)Biopsy
B)Audiometric testing
C)Complete blood count (CBC)
D)Rinne and Weber tests
E)Culture of ear discharge

Question 23

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 administers ____________________ mL in each dose.

Question 24

The nurse is collecting data from a patient with a detached retina. Which findings does the nurse expect in this patient? (Select all that apply.)

A)Severe pain
B)Blurred vision
C)Flashing lights
D)Loss of peripheral vision
E)Loss of acuity in the affected eye

Question 25

The nurse is providing care for a patient with a sensorineural hearing loss. Which prescribed medications does the nurse question before administering medications to this patient? (Select all that apply.)

A)Gentamicin
B)Furosemide
C)Indomethacin
D)Acetaminophen
E)Warfarin sodium