Chapter 22: Nursing Management: Visual and Auditory Problems My Nursing Test Banks

Lewis: Medical-Surgical Nursing, 8th Edition

Chapter 22: Nursing Management: Visual and Auditory Problems

Test Bank

MULTIPLE CHOICE

1. To evaluate the effectiveness of the prescribed bifocals for a patient with myopia and presbyopia, the nurse in the eye clinic will check the patient for

a.

strength of the eye muscles.

b.

both near and distant vision.

c.

cloudiness in the eye lenses.

d.

intraocular pressure changes.

ANS: B

The lenses are prescribed to correct the patients near and distant vision. The nurse also may assess for cloudiness of the lenses, increased intraocular pressure, and eye movement, but these data will not evaluate whether the patients bifocals are effective.

DIF: Cognitive Level: Comprehension REF: 403-404 TOP: Nursing Process: Evaluation

MSC: NCLEX: Physiological Integrity

2. A patient is seen in the ophthalmology clinic and diagnosed with recurrent staphylococcal and seborrheic blepharitis. The nurse will plan to teach the patient about

a.

saline irrigation of the eyes.

b.

surgical removal of the lesion.

c.

using baby shampoo to clean the lids.

d.

the use of cool compresses to the eyes.

ANS: C

Baby shampoo is used to soften and remove crusts associated with blepharitis. The other interventions are not used in treating this disorder.

DIF: Cognitive Level: Application REF: 408-409 TOP: Nursing Process: Planning

MSC: NCLEX: Physiological Integrity

3. Which action should the nurse take when assisting a totally blind patient to walk to the bathroom?

a.

Take the patient by the arm and lead the patient slowly to the bathroom.

b.

Have the patient place a hand on the nurses shoulder and guide the patient.

c.

Stay beside the patient and describe any obstacles on the path to the bathroom.

d.

Walk slightly ahead of the patient and allow the patient to hold the nurses elbow.

ANS: D

When using the sighted-guide technique, the nurse walks slightly in front and to the side of the patient and has the patient hold the nurses elbow. The other techniques are not as safe in assisting a blind patient.

DIF: Cognitive Level: Application REF: 407

TOP: Nursing Process: Implementation MSC: NCLEX: Safe and Effective Care Environment

4. A patient is seen at a clinic for repeated hordeolum of the eyes during the last 6 months. To help prevent further infection, the nurse advises the patient to

a.

apply cold compresses at the first sign of recurrence.

b.

discard all open or used cosmetics used near the eyes.

c.

wash the scalp and eyebrows with an antiseborrheic shampoo.

d.

be evaluated for the presence of sexually transmitted diseases (STDs).

ANS: B

Hordeolum (styes) are commonly caused by Staphylococcus aureus, which may be present in cosmetics that the patient is using. Warm compresses are recommended to treat hordeolum. Antiseborrheic shampoos are recommended for seborrheic blepharitis. Patients with adult inclusion conjunctivitis, which is caused by Chlamydia trachomatis, should be referred for STD testing.

DIF: Cognitive Level: Application REF: 408 | 410-411

TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

5. Which topic will the nurse plan to include when teaching the patient with herpes simplex keratitis of the left eye about management of the infection?

a.

How to apply an occlusive dressing to the affected eye

b.

Need for frequent hand washing and avoiding touching the eyes

c.

Application of antibiotic drops to the left eye several times daily

d.

Use of corticosteroid ophthalmic ointment to decrease inflammation

ANS: B

The best way to avoid the spread of infection from one eye to another is to avoid rubbing or touching the eyes and to use careful hand washing when touching the eyes is unavoidable. Occlusive dressings are not used for herpes keratitis. Herpes simplex is a virus and antibiotic drops will not be prescribed. Topical corticosteroids typically are not ordered because they can contribute to a longer course of infection and more complications.

DIF: Cognitive Level: Application REF: 409 TOP: Nursing Process: Planning

MSC: NCLEX: Physiological Integrity

6. A new patient with 20/200 vision (with the use of corrective lenses) is being cared for by the nurse in the eye clinic. The nurse will plan to teach the patient about

a.

how to use a cane safely.

b.

how to access audio books.

c.

where Braille instruction is available.

d.

where to obtain specialized magnifiers.

ANS: D

Various types of magnifiers can enhance the remaining vision enough to allow the performance of many tasks and activities of daily living (ADLs). Audio books, Braille instruction, and canes usually are reserved for patients with no functional vision.

DIF: Cognitive Level: Application REF: 407 TOP: Nursing Process: Planning

MSC: NCLEX: Physiological Integrity

7. A patient is diagnosed with adult inclusion conjunctivitis (AIC) caused by Chlamydia trachomatis. Which of these actions will be included in the plan of care?

a.

Discussing the need for sexually transmitted disease testing

b.

Applying topical corticosteroids to prevent further inflammation

c.

Assisting with applying for community visual rehabilitation services

d.

Educating about the use of antiviral eyedrops to treat the infection

ANS: A

Patients with AIC have a high risk for concurrent genital Chlamydia infection and should be referred for STD testing. AIC is treated with antibiotics; antiviral and corticosteroid medications are not appropriate therapies. Although some types of Chlamydia infection do cause blindness, AIC does not lead to blindness, so referral for visual rehabilitation is not appropriate.

DIF: Cognitive Level: Application REF: 409 TOP: Nursing Process: Planning

MSC: NCLEX: Physiological Integrity

8. Which topic will the nurse include in patient teaching after a patient has had outpatient cataract surgery and lens implantation?

a.

Use of oral opioids for pain control

b.

Administration of antibiotic eyedrops

c.

Importance of coughing and deep breathing exercises

d.

Need for bed rest for the first 24 hours after the surgery

ANS: B

Antibiotic and corticosteroid eyedrops are commonly prescribed after cataract surgery, and the patient should be able to administer them using safe technique. Pain is not expected after cataract surgery and opioids will not be needed. Coughing and deep breathing exercises are not needed since a general anesthetic agent is not used. There is no bed rest restriction after cataract surgery.

DIF: Cognitive Level: Application REF: 414-415

TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

9. In reviewing a 50-year-old patients medical record, the nurse notes that the last eye examination revealed an intraocular pressure of 28 mm Hg. The nurse will plan to assess

a.

visual acuity.

b.

pupil reaction.

c.

color perception.

d.

peripheral vision.

ANS: D

The patients increased intraocular pressure indicates glaucoma, which decreases peripheral vision. Because central visual acuity is unchanged by glaucoma, assessment of visual acuity could be normal even if the patient has worsening glaucoma. Color perception and pupil reaction to light are not affected by glaucoma.

DIF: Cognitive Level: Application REF: 419 TOP: Nursing Process: Planning

MSC: NCLEX: Physiological Integrity

10. A patient with a left retinal detachment has a pneumatic retinopexy procedure. Which information will be included in the discharge teaching plan?

a.

The use of bilateral eye patches to reduce movement of the operative eye

b.

The need to wear dark or tinted glasses to protect the eyes from bright light

c.

The procedure for sterile dressing changes when the eye dressing is saturated

d.

The purpose of maintaining the head in a prescribed position for several weeks

ANS: D

Following pneumatic retinopexy, the patient will need to position the head so the air bubble remains in contact with the retinal tear. The dark lenses and bilateral eye patches are not required after this procedure. Saturation of any eye dressings would not be expected following this procedure.

DIF: Cognitive Level: Application REF: 417 TOP: Nursing Process: Planning

MSC: NCLEX: Physiological Integrity

11. A patient with age-related macular degeneration has just had photodynamic therapy. Which statement by the patient indicates that the discharge teaching has been effective?

a.

I will need to use bright lights to read for at least the next week.

b.

I will use drops to keep my pupils dilated until my appointment.

c.

I will not use facial lotions near my eyes during the recovery period.

d.

I will keep covered with long-sleeved shirts and pants for the next 5 days.

ANS: D

The photosensitizing drug used for photodynamic therapy is activated by exposure to bright light and can cause burns in areas exposed to light for 5 days after the treatment. There are no restrictions on use of facial lotions, medications to keep the pupils dilated would not be appropriate, and bright lights would increase the risk for damage caused by the treatment.

DIF: Cognitive Level: Application REF: 418 TOP: Nursing Process: Evaluation

MSC: NCLEX: Physiological Integrity

12. To determine whether treatment is effective for a patient with primary open-angle glaucoma (POAG), the nurse will evaluate the patient for improvement in

a.

eye pain.

b.

visual field.

c.

blurred vision.

d.

depth perception.

ANS: B

POAG develops slowly and without symptoms except for a gradual loss of visual field. Acute closed-angle glaucoma may present with excruciating pain, colored halos, and blurred vision. Problems with depth perception are not associated with POAG.

DIF: Cognitive Level: Application REF: 419 TOP: Nursing Process: Evaluation

MSC: NCLEX: Physiological Integrity

13. A patient with glaucoma who has been using timolol (Timoptic) drops for several days tells the nurse that the eyedrops cause eye burning and visual blurriness for a short time after administration. The best response to the patients statement is

a.

These are normal side effects of the drug, which should become less noticeable with time.

b.

If you occlude the puncta after you administer the drops, it will help relieve these side effects.

c.

The drops are uncomfortable, but it is very important for you to use them as prescribed to retain your vision.

d.

These symptoms are caused by glaucoma and may indicate a need for an increased dosage of the eyedrops.

ANS: C

Patients should be instructed that eye discomfort and visual blurring are expected side effects of the ophthalmic drops but that the drops must be used to prevent further visual-field loss. The temporary burning and visual blurriness might not lessen with ongoing use, are not relieved by avoiding systemic absorption, and are not symptoms of glaucoma.

DIF: Cognitive Level: Application REF: 420

TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

14. A patient who is being admitted to the hospital for abdominal pain and nausea tells the nurse about a history of glaucoma. Which of these prescribed medications should the nurse question?

a.

morphine sulfate 4 mg IV

b.

diazepam (Valium) 5 mg IV

c.

betaxolol (Betoptic) 0.25% eyedrops

d.

scopolamine patch (Transderm Scop) 1.5 mg

ANS: D

Scopolamine is a parasympathetic blocker and will relax the iris, causing blockage of aqueous humor outflow and an increase in intraocular pressure. The other medications are appropriate for this patient.

DIF: Cognitive Level: Application REF: 419

TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

15. A patient who has bacterial endophthalmitis in the left eye is restless, frequently asking whether the eye is healing and whether removal of the eye will be necessary. Based on the assessment data, which nursing diagnosis is appropriate?

a.

Grieving related to current loss of functional vision

b.

Anxiety related to the possibility of permanent vision loss

c.

Situational low self-esteem related to loss of visual function

d.

Risk for falls related to inability to see environmental hazards

ANS: B

The patients restlessness and questioning of the nurse indicate anxiety about the future possible loss of vision. Because the patient can see with the right eye, functional vision is relatively intact and the patient is not at a high risk for falls. There is no indication of impaired self-esteem at this time.

DIF: Cognitive Level: Application REF: 422 TOP: Nursing Process: Diagnosis

MSC: NCLEX: Physiological Integrity

16. To decrease the risk for future hearing loss, which action should the nurse working with college students at the on-campus health clinic implement?

a.

Arrange to include otoscopic examinations for all patients.

b.

Administer rubella immunizations to all students at the clinic.

c.

Discuss the importance of limiting exposure to very amplified music.

d.

Teach patients to regularly irrigate the ear to decrease cerumen impaction.

ANS: C

The nurse should discuss the impact of amplified music on hearing with young adults and discourage listening to very amplified music, especially for prolonged periods. Cerumen may need to be regularly removed for older patients, but this is not a routine need for younger adults. Only women of childbearing age who have not been previously vaccinated or exposed to rubella will require immunization. Otoscopic examinations are not necessary for all patients.

DIF: Cognitive Level: Application REF: 429-430

TOP: Nursing Process: Implementation MSC: NCLEX: Health Promotion and Maintenance

17. A patient with external otitis has an ear wick placed and a new prescription for antibiotic otic drops. After the nurse provides patient teaching, which patient statement indicates that more instruction is needed?

a.

I may use aspirin or acetaminophen (Tylenol) for pain relief.

b.

I should apply the eardrops to the cotton wick in my ear canal.

c.

I should clean my ear canal daily with a cotton-tipped applicator.

d.

I may use warm compresses to the outside of my ear for comfort.

ANS: C

Insertion of instruments such as cotton-tipped applicators into the ear should be avoided. The other patient statements indicate that the teaching has been successful.

DIF: Cognitive Level: Application REF: 424-425 TOP: Nursing Process: Evaluation

MSC: NCLEX: Physiological Integrity

18. A patient with chronic otitis media is scheduled for a tympanoplasty. Before surgery, the nurse teaches the patient that postoperative expectations include

a.

keeping the head elevated.

b.

the need for prolonged bed rest.

c.

avoidance of coughing or blowing the nose.

d.

continuous antibiotic irrigation of the ear canal.

ANS: C

Coughing or blowing the nose increases pressure in the eustachian tube and middle ear cavity and disrupts postoperative healing. There is no postoperative need for prolonged bed rest, elevation of the head, or continuous antibiotic irrigation.

DIF: Cognitive Level: Application REF: 426

TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

19. The nurse is assessing a patient who has recently been treated with amoxicillin (Amoxil) for acute otitis media of the right ear. Which assessment data obtained by the nurse is of most concern?

a.

The patient has a temperature of 100.6 F.

b.

The patient complains of popping in the ear.

c.

The patient frequently asks the nurse to repeat information.

d.

The patient states that the right ear has a feeling of fullness.

ANS: A

The fever indicates that the infection may not be resolved and the patient might need further antibiotic therapy. A feeling of fullness, popping of the ear, and decreased hearing are symptoms of otitis media with effusion. These symptoms are normal for weeks to months after an episode of acute otitis media and usually resolve without treatment.

DIF: Cognitive Level: Application REF: 425

TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

20. A patient with Mnires disease is admitted with vertigo, nausea, and vomiting. Which nursing intervention will be included in the care plan?

a.

Keep the patients room darkened.

b.

Encourage oral fluids to 3000 ml daily.

c.

Change the patients position every 2 hours.

d.

Keep the head of the bed elevated 30 degrees.

ANS: A

A darkened, quiet room will decrease the symptoms of the acute attack of Mnires disease. Since the patient will be nauseated during an acute attack, fluids are administered intravenously. Position changes will cause vertigo and nausea. The head of the bed can be positioned for patient comfort.

DIF: Cognitive Level: Application REF: 428 TOP: Nursing Process: Planning

MSC: NCLEX: Physiological Integrity

21. The home health nurse observes a patient taking these actions when self-administering eardrops. Which patient action indicates a need for more teaching?

a.

The patient leaves the ear wick in place while administering the drops.

b.

The patient lies down before and for 2 minutes after administering the drops.

c.

The patient gets the eardrops out of the refrigerator just before administering the drops.

d.

The patient holds the tip of the dropper 1 cm above the ear while administering the drops.

ANS: C

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

DIF: Cognitive Level: Application REF: 424 TOP: Nursing Process: Evaluation

MSC: NCLEX: Physiological Integrity

22. When the nurse is admitting a 78-year-old patient, the patient repeatedly asks the nurse to speak up so that I can hear you. Which action should the nurse take?

a.

Overenunciate while speaking.

b.

Speak normally but more slowly.

c.

Increase the volume when speaking.

d.

Use more facial expressions when talking.

ANS: B

Patient understanding of the nurses 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 patients ability to comprehend the nurse.

DIF: Cognitive Level: Application REF: 432

TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

23. An older adult patient with presbycusis is fitted with binaural hearing aids. Which information will the nurse include when teaching the patient how to use the hearing aids?

a.

Experiment with volume and hearing ability in a quiet environment initially.

b.

Keep the volume low on the hearing aids for the first week while adjusting to them.

c.

Add the second hearing aid after making the initial adjustment to the first hearing aid.

d.

Wear the hearing aids for about an hour a day at first, gradually increasing the time of use.

ANS: A

Initially the patient 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 patient should experiment with the level of volume to find what works well in various situations. Both hearing aids should be used.

DIF: Cognitive Level: Application REF: 430

TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

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

a.

Cochlear implants require training in order to receive the full benefit.

b.

Cochlear implants are not useful for patients with congenital deafness.

c.

Cochlear implants are most helpful as an early intervention for presbycusis.

d.

Cochlear implants improve hearing in patients with conductive hearing loss.

ANS: A

Extensive rehabilitation is required after cochlear implants in order for patients 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 patients with congenital deafness.

DIF: Cognitive Level: Comprehension REF: 431-432

TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

25. Which teaching will the nurse implement for a patient who has just been diagnosed with viral conjunctivitis?

a.

Explain the purpose of antiviral eyedrops.

b.

Show how to perform eye irrigation safely.

c.

Instruct about how to insert soft contact lenses.

d.

Demonstrate appropriate hand-washing technique.

ANS: D

Hand washing 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 patients have conjunctivitis because they can further irritate the conjunctiva.

DIF: Cognitive Level: Application REF: 409 | 410

TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

26. Which information will the nurse include when teaching a patient with keratitis caused by herpes simplex type 1?

a.

Application of corticosteroid ophthalmic ointment to the eyes.

b.

Application of povidone-iodine (Betadine) gel around the eye.

c.

Avoidance of nonsteroidal anti-inflammatory drugs (NSAIDs).

d.

Importance of taking all of the ordered oral acyclovir (Zovirax).

ANS: D

Oral acyclovir may be ordered for herpes simplex infections. Corticosteroid ointments are usually contraindicated because they prolong the course of the infection. Although Betadine 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.

DIF: Cognitive Level: Application REF: 409

TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

27. The nurse at the outpatient surgery unit obtains all of this information about a patient who is scheduled for cataract extraction and implantation of an intraocular lens. Which information has the most immediate implications for the patients care?

a.

The patient has not eaten anything for 8 hours.

b.

The patient takes three antihypertensive medications.

c.

The patient gets nauseated with general anesthesia.

d.

The patient has had blurred vision for several years.

ANS: B

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 and monitoring of blood pressure are indicated for this patient. Patients are expected to be NPO for 6 to 8 hours before the surgical procedure. Blurred vision is an expected finding with cataracts. Cataract extraction and intraocular lens implantation are done using local anesthesia.

DIF: Cognitive Level: Application REF: 413

TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

28. A patient is scheduled for a right cataract extraction and intraocular lens implantation at an ambulatory surgical center in 2 weeks. During the preoperative assessment of the patient in the physicians office, it is most important for the nurse to assess

a.

the visual acuity of the patients left eye.

b.

for a white pupil in the patients right eye.

c.

how long that the patient has had the cataract.

d.

for a history of reactions to general anesthetics.

ANS: A

Because it can take several weeks before the maximum improvement in vision occurs in the right eye, patient safety and independence are determined by the vision in the left eye. Cataract surgery is done using local anesthetics rather than general anesthetics. A white pupil in the operative eye would not be unusual for a patient scheduled for cataract removal and lens implantation. The length of time that the patient has had the cataract will not impact on the perioperative care.

DIF: Cognitive Level: Application REF: 414

OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment

MSC: NCLEX: Safe and Effective Care Environment

29. When admitting a patient for surgery, the nurse learns that the patient has functional blindness and that the spouse has cared for the patient for many years. During the initial assessment of the patient, it is most important for the nurse to

a.

obtain more information about the cause of the patients vision loss.

b.

obtain information from the spouse about the patients special needs.

c.

make eye contact with the patient and ask about any need for assistance.

d.

perform an evaluation of the patients visual acuity using a Snellen chart.

ANS: C

Making eye contact with a partially sighted patient allows the patient to hear the nurse more easily and allows the nurse to assess the patients facial expressions. The patient (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 patients visual acuity are not priorities during the initial assessment.

DIF: Cognitive Level: Application REF: 406-407

OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment

MSC: NCLEX: Physiological Integrity

30. Which action should the RN who is working in the eye and ear clinic delegate to an LPN/LVN?

a.

Use a Snellen chart to check a patients visual acuity.

b.

Evaluate a patients ability to insert soft contact lenses.

c.

Teach a patient with otosclerosis about use of sodium fluoride and vitamin D.

d.

Assess the external auditory canal for signs of irritation caused by a hearing aid.

ANS: A

Using standardized screening tests such as a Snellen chart to test visual acuity is included in LPN education and scope of practice. Evaluation, assessment, and patient education are higher level skills that require RN education and scope of practice.

DIF: Cognitive Level: Application REF: 433

OBJ: Special Questions: Delegation TOP: Nursing Process: Planning

MSC: NCLEX: Safe and Effective Care Environment

31. The camp nurse is caring for a patient who is complaining of bilateral eye pain after a campfire log exploded, sending sparks into the patients eyes. Which of these actions will the nurse take first?

a.

Apply ice packs to the eyes.

b.

Flush the eyes with sterile saline.

c.

Cover the eyes with dry sterile patches and protective eye shields.

d.

Apply antiseptic ophthalmic ointment from the first aid kit to the eyes.

ANS: C

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 patient has been assessed by a health care provider and orders are available.

DIF: Cognitive Level: Application REF: 408

OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation

MSC: NCLEX: Physiological Integrity

32. The nurse notes that nursing assistive personnel (NAP) perform all the following actions when caring for a patient with Mnires disease who is experiencing an acute attack. Which action by NAP indicates that the nurse should intervene immediately?

a.

NAP raise the side rails on the bed.

b.

NAP turn on the patients television.

c.

NAP turn the patient to the right side.

d.

NAP place an emesis basin at the bedside.

ANS: B

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

DIF: Cognitive Level: Application REF: 428

OBJ: Special Questions: Delegation TOP: Nursing Process: Implementation

MSC: NCLEX: Safe and Effective Care Environment

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

a.

The patient has eye pain rated at a 5 (on a 0-10 scale).

b.

The patient has questions about the ordered eyedrops.

c.

The patient has poor depth perception when wearing an eye patch.

d.

The patient complains that the vision has not improved very much.

ANS: A

Postoperative cataract surgery patients 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 patient indicates a need for patient teaching but does not indicate that complications of the surgery may be occurring.

DIF: Cognitive Level: Application REF: 414-415

OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation

MSC: NCLEX: Physiological Integrity

34. Which assessment finding in a patient 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?

a.

The patient complains of a right-sided headache.

b.

The sclerae on the right eye have broken blood vessels.

c.

The area around the right eye is bruised and tender to the touch.

d.

The patient complains of a curtain blocking part of the visual field.

ANS: D

The patients 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 patients history of being hit in the eye with a ball.

DIF: Cognitive Level: Application REF: 416

OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment

MSC: NCLEX: Physiological Integrity

35. The charge nurse observes a newly hired nurse performing all of the following interventions for a patient who has just arrived in the postanesthesia care unit after having right cataract removal and an intraocular lens implant. Which one requires that the charge nurse intervene?

a.

The nurse leaves the eye shield in place.

b.

The nurse encourages the patient to cough.

c.

The nurse elevates the patients head to 45 degrees.

d.

The nurse applies corticosteroid drops to the right eye.

ANS: B

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

DIF: Cognitive Level: Application REF: 414

OBJ: Special Questions: Delegation TOP: Nursing Process: Implementation

MSC: NCLEX: Physiological Integrity

36. Which of these nursing activities is appropriate for the RN working in the eye clinic to delegate to experienced nursing assistive personnel (NAP)?

a.

Application of a warm compress to a patients hordeolum

b.

Assessment of a patient with possible bacterial conjunctivitis

c.

Instruction about hand washing for a patient with herpes keratitis

d.

Administration of antiviral drops to a patient with a corneal ulcer

ANS: A

Application of cold and warm packs is included in NAP education and the ability to accomplish this safely would be expected for a nursing assistant working in an eye clinic. Medication administration, patient teaching, and assessment are high-level skills appropriate for the education and legal practice level of the RN.

DIF: Cognitive Level: Application REF: 408

OBJ: Special Questions: Delegation TOP: Nursing Process: Implementation

MSC: NCLEX: Safe and Effective Care Environment

37. A patient with a head injury after a motor vehicle accident arrives in the emergency department (ED) complaining of shortness of breath and severe eye pain. Which action will the nurse take first?

a.

Elevate the head to 45 degrees.

b.

Administer the ordered analgesic.

c.

Check the patients oxygen saturation.

d.

Examine the eye for evidence of trauma.

ANS: C

The priority action for a patient after a head injury is to assess and maintain airway and breathing. Because the patient 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.

DIF: Cognitive Level: Application REF: 408

OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation

MSC: NCLEX: Physiological Integrity

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

a.

morphine sulfate 4 mg intravenously

b.

betaxolol (Betoptic) 1 drop in each eye

c.

acetazolamide (Diamox) 250 mg orally

d.

mannitol (Osmitrol) 100 mg intravenously

ANS: D

The most immediate concern for the patient 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 patient with glaucoma but would not be the first medication administered.

DIF: Cognitive Level: Application REF: 421

OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation

MSC: NCLEX: Physiological Integrity

39. The priority nursing diagnosis for a patient with Mnires disease who is experiencing an acute attack is

a.

risk for falls related to dizziness.

b.

impaired verbal communication related to tinnitus.

c.

self-care deficit (bathing and dressing) related to vertigo.

d.

imbalanced nutrition: less than body requirements related to nausea.

ANS: A

All the nursing diagnoses are appropriate, but because sudden attacks of vertigo can lead to drop attacks, the major focus of nursing care is to prevent injuries associated with dizziness.

DIF: Cognitive Level: Application REF: 428-429

OBJ: Special Questions: Prioritization TOP: Nursing Process: Diagnosis

MSC: NCLEX: Physiological Integrity

40. Which information about a patient who had a stapedotomy yesterday is most important for the nurse to communicate to the health care provider?

a.

The patient complains of congestion in the ear.

b.

The patients oral temperature is 100.6 F (38.1 C).

c.

The patient says My hearing is worse now than it was right after surgery.

d.

There is a small amount of dried bloody drainage on the patients dressing.

ANS: B

An elevated temperature 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.

DIF: Cognitive Level: Application REF: 427

OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment

MSC: NCLEX: Physiological Integrity

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