Chapter 27: Care of Patients with Disorders of the Eyes and Ears My Nursing Test Banks

Chapter 27: Care of Patients with Disorders of the Eyes and Ears

MULTIPLE CHOICE

1. The nurse notices that the patient must hold the newspaper at arms length and squint to read. The most likely diagnosis will be:

a.

myopia.

b.

hyperopia.

c.

presbyopia.

d.

astigmatism.

ANS: B

The person with hyperopia cannot see things near at hand and must change the distance from the eyes in order to focus. The person with myopia cannot see things in the distance. Presbyopia refers to the hardening of the ciliary bodies of the eyes. Astigmatism refers to a visual defect resulting from a warped lens or an irregular curvature of the cornea.

DIF: Cognitive Level: Application REF: 594 OBJ: 1 (theory)

TOP: Refraction Errors: Hyperopia KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity: Physiological Adaptation

2. The nurse explains that a photorefractive keratectomy (PRK) is a very brief surgery that corrects myopia by:

a.

using a laser to remove a thin layer of the cornea.

b.

using a laser to reshape the cornea, then replace the outer layer.

c.

making tiny cuts in the cornea to flatten it.

d.

using a laser to reshape the fundus.

ANS: A

A PRK uses a laser to remove a thin layer of the cornea. The LASIK procedure uses a laser to reshape the cornea and replace the outer layer. Making tiny cuts in the cornea to flatten it refers to a radial keratotomy.

DIF: Cognitive Level: Comprehension REF: 595 OBJ: 4 (theory)

TOP: PRK: Technique KEY: Nursing Process Step: Implementation

MSC: NCLEX: Health Promotion and Maintenance

3. A patient has developed keratitis. When planning care, the nurse would anticipate that the first intervention to improve the patients comfort would be the use of:

a.

eye shields.

b.

artificial tears.

c.

cold compresses.

d.

warm compresses.

ANS: B

Keratitis is an inflammation of the cornea caused by irritation or infection. Artificial tears will reduce the irritation. Antibiotics can be given in the event of a bacterial infection. Eye shields and compresses are not indicated in the management of this condition.

DIF: Cognitive Level: Comprehension REF: 595 OBJ: 4 (theory)

TOP: Keratitis: Initial Remedy KEY: Nursing Process Step: Planning

MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

4. The patient with a corneal transplant asks how long he must wear the eye shield at night. The nurses best response is that wearing the shield at night will be necessary for _____ month(s).

a.

1

b.

2

c.

3

d.

6

ANS: A

Nightly wearing of the eye shield following a corneal transplant is recommended for 1 month following surgery.

DIF: Cognitive Level: Comprehension REF: 596 OBJ: 2 (theory)

TOP: Corneal Transplant: Eye Shield Use

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential

5. The nurse is discussing the postoperative period with a patient with a corneal transplant. Which statement concerning the improvement of vision indicates understanding?

a.

I will have my full vision restored within 48 to 72 hours.

b.

It will take about 24 hours before I see improvement in my vision.

c.

My vision will show improvement in about 2 weeks.

d.

It may take about a month before my vision shows improvement.

ANS: C

Increasing visual acuity may take up to 2 weeks before improvement in vision is noted.

DIF: Cognitive Level: Comprehension REF: 596 OBJ: 2 (theory)

TOP: Corneal Transplant: Recovery Time

KEY: Nursing Process Step: Evaluation

MSC: NCLEX: Physiological Integrity: Physiological Adaptation

6. The patient who had a corneal transplant is taught that inflammatory changes (redness, swelling, and pain) in the corneal graft are best indicators of which complication?

a.

Graft rejection

b.

Allergy to graft

c.

Infection

d.

Revascularization

ANS: A

Inflammatory symptoms are indicative of graft rejection.

DIF: Cognitive Level: Comprehension REF: 596 OBJ: 2 (theory)

TOP: Corneal Transplant: Graft Rejection

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential

7. The nurse in the walk-in clinic assesses a small piece of rock embedded in the right eye of a man who was breaking up rocks with a sledge hammer. The most appropriate action by the nurse would be to:

a.

flush the eye with a continuous stream of warm water.

b.

instill artificial tears and cover the injured eye with a dressing.

c.

irrigate the eye with cool water and apply a pressure dressing.

d.

cover both eyes with a dressing and refer to the physician.

ANS: D

Covering both eyes to decrease sympathetic movement in the injured eye and sending the patient to the physician is the standard of care for an embedded object. There should be no attempt to remove it.

DIF: Cognitive Level: Application REF: 597 OBJ: 3 (theory)

TOP: Eye Injury: Embedded Object KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential

8. The nurse is observing a patient applying eye ointment. Which action indicates understanding of the correct application of eye ointment?

a.

The patient applies the ointment from the inner to outer canthus.

b.

The patient applies the ointment in the center of the conjunctival sac.

c.

The patient applies the ointment liberally from the outer to inner canthus.

d.

The patient applies the ointment directly to the sclera.

ANS: A

Ointment should be applied in a thin line from the inner to the outer canthus in the conjunctival sac.

DIF: Cognitive Level: Comprehension REF: 607 OBJ: 2 (clinical)

TOP: Eye Medications: Ointment KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

9. Before enucleation, the patient is taught that, aside from removing the eye, the surgeon will:

a.

suture an artificial eye in the socket to preserve normal appearance.

b.

suture an implant to eye muscles to which the prosthesis can be attached.

c.

place iodoform dressing in the socket to preserve shape for the prosthesis.

d.

suture the orbit closed and apply a removable eye patch to wear until a prosthesis is fitted.

ANS: B

An orbital implant is sutured in place to maintain shape and muscle function for eye movement. The prosthesis will be attached on this implant.

DIF: Cognitive Level: Application REF: 597 OBJ: 4 (theory)

TOP: Enucleation: Preoperative Teaching

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

10. The patient with glaucoma is prescribed an Ocusert miotic. The medication should be replaced with what frequency?

a.

Daily

b.

Semiweekly

c.

Weekly

d.

Biweekly

ANS: C

Eye medications that are delivered per Ocuserts are replaced every week.

DIF: Cognitive Level: Comprehension REF: 602 OBJ: 2 (clinical)

TOP: Ocuserts: Replacement Frequency KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Pharmacological and Parenteral Therapies

11. The nurse is administering dipivefrin (Propine). What assessment finding may be noted in response to this medication?

a.

BP 80/50

b.

Pulse 112

c.

Respirations 16

d.

Temperature 98.8

ANS: B

Sympathomimetic drugs such as dipivefrin are used to reduce intraocular pressure by increasing aqueous outflow. They can cause tachycardia and hypertension.

DIF: Cognitive Level: Application REF: 603 OBJ: 4 (theory)

TOP: Sympathomimetic Drugs: Side Effects

KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity: Pharmacological and Parenteral Therapies

12. The nurse explains that the classic early warning symptom of a detached retina is:

a.

tearing and swelling of the eye.

b.

flashing colored lights in the eye.

c.

bleeding into the anterior chamber.

d.

intense brow pain.

ANS: B

Seeing flashing colored lights is an early warning symptom of retinal detachment.

DIF: Cognitive Level: Comprehension REF: 606 OBJ: 4 (theory)

TOP: Retinal Detachment: Early Symptoms

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Physiological Adaptation

13. The patient is scheduled to have surgery to manage glaucoma. The patient correctly explains that the procedure will:

a.

increase outflow of aqueous humor.

b.

reduce amount of vitreous humor.

c.

widen pupils.

d.

reduce pain.

ANS: A

Glaucoma is a condition that causes increased ocular pressure. Surgical management for the condition seeks to provide an increased outflow of aqueous humor.

DIF: Cognitive Level: Comprehension REF: 604 OBJ: 1 (clinical)

TOP: Glaucoma: Surgical Intervention KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential

14. A patient is suspected of having macular degeneration. During the assessment the patient is asked to focus on an image. What evidence will support the diagnosis?

a.

The patient only sees disconnected pieces of the image.

b.

The patient sees a dark spot in center of what is viewed.

c.

The patient sees nothing in the peripheral vision.

d.

The patient sees wavy lines and bright flashing lights.

ANS: B

The person with macular degeneration sees a dark spot in his central vision. Peripheral vision is not affected until later in the disease.

DIF: Cognitive Level: Application REF: 609 OBJ: 4 (theory)

TOP: Macular Degeneration: Early Signs

KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity: Physiological Adaptation

15. To help reduce the nausea and vomiting experienced by a patient with Mnires disease, the nurse would caution the patient to avoid:

a.

drinking coffee.

b.

moving the head or eyes suddenly.

c.

bending over at the waist.

d.

facing backward in a moving vehicle.

ANS: B

Rapid movement of the head and/or eyes can increase the nausea and vomiting in a patient with Mnires disease.

DIF: Cognitive Level: Comprehension REF: 613 OBJ: 4 (theory)

TOP: Mnires Disease: Reduction of Nausea and Vomiting

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

16. The nurse is reviewing the plan of care for a patient following a tympanoplasty. The nurse correctly notes which intervention in the immediate postoperative care?

a.

Keeping the patient flat in bed for 2 to 3 hours

b.

Encouraging deep breathing and coughing

c.

Repositioning the patient quickly to reduce nausea and vomiting

d.

Turning the head toward the operated side

ANS: A

Immediately postoperatively, the patient with a tympanoplasty is placed flat with head turned to the nonoperative side. Coughing is discouraged. Any repositioning should be done slowly to prevent nausea.

DIF: Cognitive Level: Application REF: 615 OBJ: 4 (clinical)

TOP: Tympanoplasty: Immediate Postoperative Care

KEY: Nursing Process Step: Planning

MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

17. The nurse is caring for a patient who has come to the ambulatory care clinic after experiencing a chemical burn to the eye. Which solution is preferred for use when irrigating the eye?

a.

Normal saline

b.

Tap water

c.

Sterile water

d.

50% solution of sterile water and normal saline

ANS: A

The preferred solution for use when irrigating the eye is an IV bag of normal saline. In the event that normal saline is not available, the next option would be tap water.

DIF: Cognitive Level: Comprehension REF: 597 OBJ: 3 (theory)

TOP: Removal of Foreign Bodies from the Eye

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

18. The nurse is preparing to discharge a patient from the ambulatory care clinic who has been treated with irrigation after having gotten a large amount of sand in his eyes following an ATV accident. The patient reports that his eyes hurt and feel irritated. What action by the nurse is most appropriate?

a.

Instruct the patient that these feelings are normal after an eye irrigation.

b.

Instruct the patient that the prescribed ointment will help to soothe the eye irritation.

c.

Repeat the eye irrigation with a solution of 50% sterile water and normal saline.

d.

Notify the physician.

ANS: D

The continued sensation of grittiness or irritation may signal the presence of a corneal abrasion. To prevent further injuries, the nurse should notify the physician.

DIF: Cognitive Level: Application REF: 597 OBJ: 3 (theory)

TOP: Removal of Foreign Bodies from the Eye

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

MULTIPLE RESPONSE

19. The nurse is caring for a patient following a left corneal transplant. When positioning the patient, the nurse correctly assists the patient into which positions? (Select all that apply.)

a.

Flat on back

b.

On back with head on small pillow

c.

Left side-lying

d.

Right side-lying

e.

High Fowlers

ANS: A, B, D

Flat on back, on back with head on small pillow, and positioned on nonoperative side are acceptable as all these positions place no undue pressure on the transplant. Allowing the patient to rest on the operative side or in high Fowlers position would place excessive pressure on the operative site.

DIF: Cognitive Level: Application REF: 611 OBJ: 2 (theory)

TOP: Corneal Transplant: Postoperative Positioning

KEY: Nursing Process Step: Planning

MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential

20. A patient comes to the ambulatory care clinic with reports of getting hay into the eyes while farming. When providing care to the patient, which actions may be included in the plan of care? (Select all that apply.)

a.

Flush the eye with warm water.

b.

Gently evert the upper lid to inspect underneath.

c.

Sweep the eye with a dampened cotton swab.

d.

Pull the upper lid over the lower lid to sweep underneath the upper lid.

e.

Ask the patient to rub the eyes with the lids closed to produce more tears.

ANS: A, B, C, D

The goals of treatment will be to remove the foreign objects from the eyes and to prevent further injury to the eye. Rubbing an irritated eye may cause a corneal abrasion. All other options are acceptable.

DIF: Cognitive Level: Application REF: 597 OBJ: 3 (theory)

TOP: Eye: Foreign Body Removal KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

21. The nurse reviews the classic symptoms of a cataract, which are: (Select all that apply.)

a.

nystagmus.

b.

troubled by glare.

c.

increased myopia.

d.

color distortion.

e.

night blindness.

ANS: B, C, D, E

A cataract is opacity of the lens that produces an effect similar to one a person would get when looking through a sheet of falling water. A cataract causes a blurring of vision because the lens, which is normally transparent, becomes cloudy and opaque. Nystagmus is not a symptom of a cataract. All other options are classic symptoms of a person with a developing cataract.

DIF: Cognitive Level: Comprehension REF: 598 OBJ: 4 (theory)

TOP: Cataract: Classic Symptoms KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity: Physiological Adaptation

22. Postoperative teaching for a person who has had a cataract removed from the left eye would include: (Select all that apply.)

a.

sleeping on the right side.

b.

taking a stool softener to avoid straining at stool.

c.

bending over from the waist; not stooping.

d.

providing instruction for instilling eyedrops.

e.

providing instruction on signs of complications.

ANS: A, B, D, E

The patient should not bend from the waist as the position increases intraocular pressure.

DIF: Cognitive Level: Application REF: 599 OBJ: 5 (theory)

TOP: Cataract: Postoperative Teaching KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential

23. Following a scleral buckling procedure, the postoperative nursing care would include: (Select all that apply.)

a.

placing the patient in a supine lateral position for 24 to 48 hours.

b.

placing pillows under the abdomen to increase gravity pull on gas bubbles in the eye.

c.

warning the patient that vision does not return immediately.

d.

instructing the patient to wear an eye shield at night and while napping.

e.

instructing the patient to change the eye patch every day.

ANS: B, C, D, E

The patient should be placed in a supine lateral position for 16 to 24 hours. All other options are postoperative instructions for the patient with a scleral buckling procedure.

DIF: Cognitive Level: Application REF: 606 OBJ: 5 (theory)

TOP: Scleral Buckling: Postoperative Care

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

24. The nurse has completed the assessment on a newly admitted patient. Which findings would be associated with the development of cataracts? (Select all that apply.)

a.

Two-pack-a-day smoker for the last 10 years

b.

Radiation therapy for cancer completed 1 month ago

c.

Postmenopausal hormone replacement therapy

d.

Asthmatic on long-term corticosteroid protocol

ANS: A, D

A cataract is opacity of the lens that produces an effect similar to one a person would get when looking through a sheet of falling water. Cataracts cause a blurring of vision because the lens, which is normally transparent, becomes cloudy and opaque. Most often cataracts occur as a result of aging and are found in people over age 50. Traumatic cataracts may occur from a physical blow, extreme heat, or chemical toxins. Cigarette smoking increases the risk of developing cataracts. Heavy drinking also is implicated. Chronic use of corticosteroids predisposes to the development of cataracts.

DIF: Cognitive Level: Application REF: 598 OBJ: 4 (theory)

TOP: Cataracts: Etiology KEY: Nursing Process Step: Assessment

MSC: NCLEX: Health Promotion and Maintenance

COMPLETION

25. Accommodation is accomplished through the interaction of the ciliary bodies and the _____.

ANS:

lens

Ciliary muscles and ligaments change the shape of the lens to provide accommodation, which is the bending of light rays to focus on the retina.

DIF: Cognitive Level: Knowledge REF: 598 OBJ: 1 (theory)

TOP: Accommodation: Physiology KEY: Nursing Process Step: Planning

MSC: NCLEX: Health Promotion and Maintenance

MATCHING

Place the steps of eye irrigation in appropriate sequence.

a.

Ask patient to turn head to affected side.

b.

Don gloves.

c.

Direct continuous stream of fluid from inner to outer canthus.

d.

Instruct patient to lie supine.

e.

Hold lids apart with thumb and finger.

f.

Have patient close eyes to move debris from upper eyelid to conjunctival sac.

26. Step 1

27. Step 2

28. Step 3

29. Step 4

30. Step 5

31. Step 6

26. ANS: D DIF: Cognitive Level: Analysis REF: 596

OBJ: 2 (clinical) TOP: Eye Irrigation: Technique

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Health Promotion and Maintenance

27. ANS: A DIF: Cognitive Level: Analysis REF: 596

OBJ: 2 (clinical) TOP: Eye Irrigation: Technique

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Health Promotion and Maintenance

28. ANS: B DIF: Cognitive Level: Analysis REF: 596

OBJ: 2 (clinical) TOP: Eye Irrigation: Technique

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Health Promotion and Maintenance

29. ANS: E DIF: Cognitive Level: Analysis REF: 596

OBJ: 2 (clinical) TOP: Eye Irrigation: Technique

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Health Promotion and Maintenance

30. ANS: C DIF: Cognitive Level: Analysis REF: 596

OBJ: 2 (clinical) TOP: Eye Irrigation: Technique

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Health Promotion and Maintenance

31. ANS: F DIF: Cognitive Level: Analysis REF: 596

OBJ: 2 (clinical) TOP: Eye Irrigation: Technique

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Health Promotion and Maintenance

Arrange the steps of the pathophysiological process of open-angle glaucoma in the correct order.

a.

Intraocular pressure exceeding 25 mm Hg

b.

Optic nerve and retina damaged by ischemia

c.

Permanent and irreversible vision impairment

d.

Overproduction of aqueous humor

e.

Continued high intraocular pressure restricting blood flow to optic nerve and retina

32. Step 1

33. Step 2

34. Step 3

35. Step 4

36. Step 5

32. ANS: D DIF: Cognitive Level: Application REF: 601

OBJ: 4 (theory) TOP: Glaucoma: Pathophysiology

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Physiological Adaptation

33. ANS: A DIF: Cognitive Level: Application REF: 601

OBJ: 4 (theory) TOP: Glaucoma: Pathophysiology

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Physiological Adaptation

34. ANS: E DIF: Cognitive Level: Application REF: 601

OBJ: 4 (theory) TOP: Glaucoma: Pathophysiology

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Physiological Adaptation

35. ANS: B DIF: Cognitive Level: Application REF: 601

OBJ: 4 (theory) TOP: Glaucoma: Pathophysiology

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Physiological Adaptation

36. ANS: C DIF: Cognitive Level: Application REF: 601

OBJ: 4 (theory) TOP: Glaucoma: Pathophysiology

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Physiological Adaptation

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