Question 1

Which of the following nursing diagnoses is priority when caring for a client who is experiencing an acute attack of Ménière's disease?

Accepted Answer

All the nursing diagnoses are appropriate, but because sudden acute attacks of vertigo, the major focus of nursing care is to prevent injuries associated with impaired balance.

Question 2

A client with hearing loss asks the nurse about the use of a cochlear implant. Which of the following information will the nurse include when replying to the client?

Accepted Answer

Extensive rehabilitation is required after cochlear implants in order for clients to receive the maximum benefit. Hearing aids, rather than cochlear implants, are used initially for presbycusis. Cochlear implants are used for sensorineural hearing loss and would not be helpful for conductive loss. They are appropriate for some clients with congenital deafness.

Question 3

Which of the following actions is an example of an approach magnification?

Accepted Answer

Approach magnification is a simple but sometimes overlooked technique for enhancing the client's residual vision. The nurse can recommend that the client sit closer to the television or hold books closer to the eyes, which the client may be reluctant to do unless encouraged. Using a telescopic lens is an optical device. Using a black-tipped marker to write is a contrast enhancement technique. Reading large-type print books may be helpful but is not an approach magnification action unless the book was brought close to the eyes, which is not indicated in the answer choice.

Question 4

The charge nurse observes a newly hired nurse caring for a client who has just arrived in the postanaesthesia care unit after having right cataract removal and an intraocular lens implant. Which of the following interventions requires that the charge nurseintervene?

Accepted Answer

Because coughing will increase intraocular pressure, clients are generally taught to avoid coughing during the acute postoperative time. The other actions are appropriate for a client after having this surgery.

Question 5

The nurse is caring for a client with an acute attack of Ménière's disease. Which of the following actions carried out by a family member that is visiting the client should the nurse intervene?

Accepted Answer

Watching television may exacerbate the symptoms of an acute attack of Ménière's disease. The other actions are appropriate.

Question 6

The nurse is caring for a client with neural presbycusis. Which of the following hearing changes should the nurse expect with this type of presbycusis?

Accepted Answer

The hearing change with a neural presbycusis is a loss of speech discrimination. Loss of high-pitched sounds accompanies a sensory presbycusis. A metabolic presbycusis has a hearing change that is uniform for all frequencies, accompanied by recruitment. A cochlear presbycusis has a hearing change that is a range of hearing loss that increases from low to high frequencies.

Question 7

The nurse is admitting a client with a head injury after a motor vehicle accident who has shortness of breath and severe eye pain. Which of the following actions should the nurse take first?

Accepted Answer

The priority action for a client after a head injury is to assess and maintain airway and breathing. Because the client is complaining of shortness of breath, it is essential that the nurse assess the oxygen saturation. The other actions also are appropriate but are not the first action the nurse will take.

Question 8

The nurse is admitting a client for surgery who has functional blindness for several years and is cared for by the client's spouse. Which of the following actions is most important to implement during the initial assessment?

Accepted Answer

Making eye contact with a partially sighted client allows the client to hear the nurse more easily and allows the nurse to assess the client's facial expressions. The client (rather than the spouse) should be asked about any need for assistance. The information about the cause of the vision loss and assessment of the client's visual acuity are not priorities during the initial assessment.

Question 9

The home health nurse observes a client taking these actions when self-administering eardrops. Which of the following client actions indicates a need for more teaching?

Accepted Answer

Administration of cold eardrops can cause dizziness because of stimulation of the semicircular canals. The other client actions are appropriate.

Question 10

The camp nurse is caring for a client who is complaining of bilateral eye pain after a campfire log exploded, sending sparks into the client's eyes. Which of the following actions should the nurse take first?

Accepted Answer

Emergency treatment of a burn or foreign-body injury to the eyes includes protecting the eyes from further injury by covering them with dry sterile dressings and protective shields. Flushing of the eyes immediately is indicated only for chemical exposure. Except in the case of chemical exposure, the nurse should not begin treatment until the client has been assessed by a health care provider and orders are available.

Question 11

The nurse is assessing the presence or absence of contact lenses in an unconscious client. Which of the following directions should the nurse shine a pen light?

Accepted Answer

The nurse must know whether the client has contact lenses in and assesses the eye by shining a light obliquely on the eyeball to help the nurse visualize a contact lens.

Question 12

The nurse is caring for a client who had a stapedotomy yesterday. Which of the following findings is most important for the nurse to communicate to the health care provider?

Accepted Answer

An elevated temperature following any surgery may indicate a postoperative infection. Although the nurse would report all the data, a temporary decrease in hearing, bloody drainage on the dressing, and a feeling of congestion because of the accumulation of blood and drainage in the ear are common after this surgery.

Question 13

An older-adult client with presbycusis is fitted with binaural hearing aids. Which of the following information should the nurse include when teaching the client how to use the hearing aids?

Accepted Answer

Initially the client should use the hearing aids in a quiet environment like the home, experimenting with increasing and decreasing the volume as needed. There is no need to gradually increase the time of wear. The client should experiment with the level of volume to find what works well in various situations. Both hearing aids should be used.

Question 14

The nurse is admitting an older-adult client and the client repeatedly asks the nurse to "speak up so that I can hear you." Which of the following actions should the nurse take?

Accepted Answer

Client understanding of the nurse's speech will be enhanced by speaking at a normal tone, but more slowly. Increasing the volume, overenunciating, and exaggerating facial expressions will not improve the client's ability to comprehend the nurse.

Question 15

Which of the following information should the nurse include when teaching a client with keratitis caused by herpes simplex type 1?

Accepted Answer

Oral acyclovir may be ordered for herpes simplex infections. Corticosteroid ointments are usually contraindicated because they prolong the course of the infection. Although povidone-iodine gel may be applied to the skin around the eyes for herpes zoster (varicella) infections, it is not used for herpes simplex infections. NSAIDs can be used to treat the
pain associated with keratitis.

Question 16

The nurse is admitting a client to the outpatient surgery unit who is scheduled for cataract extraction and implantation of an intraocular lens. Which of the following information has the most immediate implications for the client's care?

Accepted Answer

Mydriatic medications used for pupil dilation are sympathetic nervous system stimulants and may increase heart rate and blood pressure. Using punctal occlusion when administering the mydriatic to minimize systemic effects and monitoring of blood pressure are indicated for this client. Clients are expected to be NPO for 6-8 hours before the surgical procedure. Blurred vision is an expected finding with cataracts. Cataract extraction and intraocular lens implantation are done using local anaesthesia.

Question 17

Which of the following interventions should the nurse implement for a client who has just been diagnosed with viral conjunctivitis?

Accepted Answer

Good hand hygiene is the major means to prevent the spread of conjunctivitis. Antiviral drops and eye irrigation will not be helpful in shortening the disease process. Contact lenses should not be used when clients have conjunctivitis because they can further irritate the conjunctiva.

Question 18

Which of the following assessment findings in a client who was struck in the right eye with a baseball is a priority for the nurse to communicate to the health care provider in the emergency department?

Accepted Answer

The client's sensation that a curtain is coming across the field of vision suggests retinal detachment and the need for rapid action to prevent blindness. The other findings would be expected with the client's history of being hit in the eye with a ball.

Question 19

These medications are prescribed by the health care provider for a client who has just been admitted to hospital with acute angle-closure glaucoma. Which of the following medications should the nurse give first?

Accepted Answer

The most immediate concern for the client is to lower intraocular pressure, which will occur most rapidly with IV administration of a hyperosmolar diuretic such as mannitol. The other medications also are appropriate for a client with glaucoma but would not be the first medication administered.

Question 20

A client who had cataract extraction and intraocular lens implantation the previous day calls the eye clinic and gives the nurse all of this information. Which of the following information is the priority to communicate to the health care provider?

Accepted Answer

Postoperative cataract surgery clients usually experience little or no pain, so pain at a 5 on a 10-point pain level may indicate complications such as hemorrhage, infection, or increased intraocular pressure. The other information given by the client indicates a need for client teaching but does not indicate that complications of the surgery may be occurring.

Quiz 24: Nursing Management Visual and Auditory Problems