Saunders Eye and Ear Study Mode

The nurse notes documentation that a client has conductive hearing loss. The nurse plans care knowing that this kind of hearing loss can be caused by which circumstances? Select all that apply.

Acute otitis media with effusion

A physical obstruction to the transmission of sound waves

A conductive hearing loss is as a result of a physical obstruction to the transmission of sound waves. Acute otitis media with effusion, a fluid buildup in the middle ear, can block the transmission of sound waves. A sensorineural hearing loss occurs as a result of a pathological process in the inner ear, a defect in the 8th cranial nerve, or a defect of the sensory fibers that lead to the cerebral cortex.

The nurse is preparing to assist the primary health care provider to test the extraocular movements in a client and muscle weakness in the eyes. The nurse anticipates that which physical assessment technique will be done?

Testing the six cardinal positions of gaze

Rationale:Testing the six cardinal positions of gaze is done to check for muscle weakness in the eyes. The client is asked to hold the head steady, then to follow movement of an object through the positions of gaze. The client should follow the object in a parallel manner with the two eyes. The Ishihara chart is used to detect color blindness. A Snellen eye chart is used to determine visual acuity and cranial nerve II (optic nerve) functioning. Testing the corneal light reflex, shining a penlight in the eyes of a client gazing straight ahead, should demonstrate the corneal reflection in the exact position in each eye and parallel alignment.

The nurse is reinforcing home-care instructions to a client and family regarding care after left cataract surgery with lens implant. Which statements made by the client indicate an understanding of the instructions? Select all that apply.

"I will not sleep lying on my left side."

"I will sit at the table to eat breakfast."

"I will sit in my recliner with my feet elevated."

"I will not lift anything heavier than 10 pounds."

Rationale:After cataract surgery, the client should not assume positions that will increase the intraocular pressure. This could lead to injury to the surgical site and damage the lens implant. The client should not sleep on the side of the body that was operated on. The client may resume activities such as sitting upright at a table or sitting in a recliner with the feet elevated. The client should not lift anything heavier than 10 lbs. The client should not perform activities that would increase the pressure within the eye, such as bending over to tie shoes or performing pushups.

Which intervention would be implemented for the older client with presbycusis who has a hearing loss?

Use low-pitched tones.

Presbycusis refers to the age-related, irreversible, degenerative changes of the inner ear that lead to decreased hearing acuity. As a result of these changes, the older client has a decreased response to high-frequency sounds. Low-pitched tones of voice are more easily heard and interpreted by the older client. Speaking loudly, softly, or slowly is not helpful.

The nurse is preparing to reinforce a teaching plan for a client who is undergoing cataract extraction with intraocular implant. Which home care measures would the nurse include in the plan? Select all that apply.

To avoid activities that require bending over

To take acetaminophen for minor eye discomfort

To place an eye shield on the surgical eye at bedtime

To contact the surgeon if a decrease in visual acuity occurs

Rationale:After eye surgery, some scratchiness and mild eye discomfort may occur in the operative eye, and is usually relieved by mild analgesics. If the eye pain becomes severe, the client should notify the surgeon because this may indicate hemorrhage, infection, or increased intraocular pressure. The nurse would also instruct the client to notify the surgeon of purulent drainage, increased redness, or any decrease in visual acuity. The client is instructed to place an eye shield over the operative eye at bedtime to protect the eye from injury during sleep and to avoid activities that increase intraocular pressure such as bending over.

The nurse is assisting with developing a teaching plan for the client with glaucoma. Which instruction would the nurse suggest to include in the plan of care?

Eye medications may need to be administered for the rest of your life.

The administration of eye drops is a critical component of the treatment plan for the client with glaucoma. The client needs to be instructed that medications may need to be taken for the rest of his or her life. Limiting fluids and reducing salt will not decrease intraocular pressure.

The nurse is assigned to care for a client with a detached retina. Which finding would the nurse expect to be documented in the client's record?

A sense of a curtain falling across the field of vision

Rationale:A characteristic clinical manifestation of retinal detachment described by clients is the feeling that a shadow or curtain is falling across the field of vision. There is no pain associated with detachment of the retina. A retinal detachment is an ophthalmic emergency and even more so if visual acuity is still normal.

The nurse is assigned to care for a client with a diagnosis of detached retina. Which findings would indicate that bleeding has occurred as a result of retinal detachment? Select all that apply.

Vision may be cloudy

Complaints of a burst of black spots or floaters

Complaints of a sudden burst of black spots or floaters indicate that bleeding has occurred as a result of the detachment. Vision may also be cloudy.

A client arrives in the emergency department after an automobile crash. The client's forehead hit the steering wheel, and a hyphema has been diagnosed. Which position would the nurse prepare to position the client?

On bed rest in a semi-Fowler's position

A hyphema is the presence of blood in the anterior chamber. It is produced when a force is sufficient to break the integrity of the blood vessels in the eye. It can be caused by direct injury, such as a penetrating injury from a BB pellet, or indirectly, such as from striking the forehead on a steering wheel during an accident. The client is treated by bed rest in a semi-Fowler's position to assist gravity in keeping the hyphema away from the optical center of the cornea.

The nurse is caring for a client after enucleation and notes the presence of bright red drainage on the dressing. The nurse would take which appropriate action?

Report the finding to the registered nurse (RN).

If the nurse notes the presence of bright red drainage on the dressing, it must be reported to the registered nurse because this can indicate hemorrhage

The nurse is preparing to administer eardrops to an adult client. The nurse administers the eardrops by which technique?

Pulling the pinna up and back

For an adult, the nurse tilts the client's head slightly away and pulls the pinna up and back. Asking the client to stand and lean to one side is inappropriate and unsafe.

A client arrives at the emergency department with a foreign body in the left ear that has been determined to be an insect. Which initial intervention would the nurse anticipate to be prescribed?

Instillation of mineral oil or diluted alcohol

Rationale:Insects are killed before removal unless they can be coaxed out by a flashlight or a humming noise. Mineral oil or diluted alcohol is instilled into the ear to suffocate the insect, which is then removed by using ear forceps. When the foreign object is vegetable matter, irrigation is not used because this material expands with hydration and the impaction becomes worse.

The nurse notes that the primary health care provider (PHCP) has documented a diagnosis of presbycusis on the client's chart. Which explanation would the nurse give to the client to explain this condition?

A sensorineural hearing loss that occurs with aging

Presbycusis is a type of hearing loss that occurs with aging. It is a gradual sensorineural loss caused by nerve degeneration in the inner ear or auditory nerve.

The nurse is assigned to care for a client hospitalized with Ménière's disease. The nurse expects that which would most likely be prescribed for the client?

Low-sodium diet

Dietary changes such as salt and fluid restrictions that reduce the amount of endolymphatic fluid are sometimes prescribed.

A client is diagnosed with glaucoma. Which data gathered by the nurse indicate a risk factor associated with glaucoma?

Cardiovascular disease

Hypertension, cardiovascular disease, diabetes mellitus, and obesity are associated with the development of glaucoma. Smoking, ingestion of caffeine or large amounts of alcohol, illicit drugs, corticosteroids, altered hormone levels, posture, and eye movements may cause varying transient increases in intraocular pressure.

Betaxolol hydrochloride eye drops have been prescribed for the client with glaucoma. Which nursing action is most appropriate related to monitoring for the side/adverse effects of this medication?

Monitoring blood pressure

Hypotension, dizziness, nausea, diaphoresis, headache, fatigue, constipation, and diarrhea are systemic effects of the medication. Nursing interventions include monitoring the blood pressure for hypotension and assessing the pulse for strength, weakness, irregular rate, and bradycardia

The nurse assists with preparing the client for ear irrigation as prescribed by the primary health care provider (PHCP). Which action would the nurse plan to take?

Warm the irrigating solution to 98°F (36.6°C).

Rationale:Irrigation solutions that are not close to the client's body temperature can be uncomfortable and may cause injury, nausea, and vertigo. The client is positioned so that the ear to be irrigated is facing downward, because this allows gravity to assist with the removal of the ear wax and solution. After the irrigation, the client is to lie on the affected side to finish draining the irrigating solution. A slow, steady stream of solution should be directed toward the upper wall of the ear canal and not toward the eardrum. Too much force could cause the tympanic membrane to rupture.

In preparation for cataract surgery, the nurse is to administer cyclopentolate eye drops. The nurse administers the eye drops knowing that which is the purpose of this medication?

To dilate the pupil of the operative eye

Cyclopentolate is a rapidly acting mydriatic and cycloplegic medication. Cyclopentolate is effective in 25 to 75 minutes, and accommodation returns in 6 to 24 hours. Cyclopentolate is used for preoperative mydriasis.

The nurse is providing instructions to a client who will be self-administering eye drops. To minimize the systemic effects that eye drops can produce, the client is instructed to perform which action?

Occlude the nasolacrimal duct with a finger over the inner canthus for 30 to 60 seconds after instilling the drops.

Applying pressure on the nasolacrimal duct prevents systemic absorption of the medication.

The client is receiving an eye drop and an eye ointment to the right eye. Which action would the nurse take?

Administer the eye drop first, followed by the eye ointment.

When an eye drop and an eye ointment is scheduled to be administered at the same time, the eye drop is administered first.

The nurse is caring for a client with glaucoma. Which medication prescribed for the client would the nurse question?

Atropine sulfate

Options 1 (Betaxolol), 2 (Pilocarpine), and 4 (Pilocarpine hydrochloride) are miotic agents used to treat glaucoma. Option 3 (atropine sulfate) is a mydriatic and cycloplegic medication, and its use is contraindicated in clients with glaucoma. Mydriatic medications dilate the pupil and can cause an increase in intraocular pressure in the eye.

The nurse is preparing to administer eye drops. Which interventions would the nurse take to administer the drops? Select all that apply.

Wash hands.

Put on gloves.

Place the drop in the conjunctival sac.

Pull the lower lid down against the cheekbone.

Rationale:To administer eye medications, the nurse would wash hands and put on gloves. The client is instructed to tilt the head backward, open the eyes, and look up. The nurse pulls the lower lid down against the cheekbone and holds the bottle like a pencil, with the tip downward. Holding the bottle, the nurse gently rests the wrist of the hand on the client's cheek and squeezes the bottle gently to allow the drop to fall into the conjunctival sac. The client is instructed to close the eyes gently and not to squeeze the eyes shut to prevent the loss of medication.

A client was just admitted to the hospital to rule out a gastrointestinal bleed. The client has brought several bottles of medications prescribed by different specialists. During the admission assessment, the client states, "Lately, I have been hearing some roaring sounds in my ears, especially when I am alone." Which medication would the nurse determine to be the cause of the client's complaint?

Acetylsalicylic acid

Aspirin is contraindicated for gastrointestinal bleeding and is potentially ototoxic. The client should be advised to notify the prescribing primary health care provider (PHCP) so that the medication can be discontinued and/or a substitute that is less toxic to the ear can be taken instead.

Pilocarpine hydrochloride is prescribed for the client with glaucoma. Which medication would the nurse plan to have available in the event of systemic toxicity?

Atropine sulfate

Systemic absorption of pilocarpine hydrochloride can produce toxicity and includes manifestations of vertigo, bradycardia, tremors, hypotension, and seizure. Atropine sulfate must be available in the event of systemic toxicity. Pindolol, timolol maleate, and carteolol hydrochloride are beta-blockers.

A miotic medication has been prescribed for the client with glaucoma. The client asks the nurse about the purpose of the medication. The nurse would tell the client which purpose?

"The medication causes the pupil to constrict and will lower the pressure in the eye."

Miotics cause pupillary constriction and are used to treat glaucoma. They lower the intraocular pressure, thereby increasing blood flow to the retina and decreasing retinal damage and loss of vision. Miotics cause a contraction of the ciliary muscle and a widening of the trabecular meshwork.

A client is brought to the emergency department by the ambulance team after collapse at home. Cardiopulmonary resuscitation is attempted but is unsuccessful. The wife of the client tells the nurse that the client is an organ donor and that their eyes are to be donated. Which action would the nurse take next?

Close the eyes, elevate the head of the bed, and place a small ice pack on the eyes.

When a corneal donor dies, antibiotic eye drops may be prescribed and instilled. The eyes are closed, and a small ice pack is placed on the closed eyes. The head of the bed is raised to 30 degrees to prevent edema. Within 2 to 4 hours, the eyes are enucleated. The cornea is usually transplanted within 24 to 48 hours. Option 1 is incorrect because dry dressings are not applied. Some organ donation protocols indicate using normal saline-moistened gauze. Option 2 is not an immediate action. In addition, the client should have a signed donor card, living will, or an organ donor-identified driver's license stating his or her wishes. Additional legal documentation should not be required. Agency procedures regarding donor care should be followed.

The nurse is reviewing the record of a client with mastoiditis. The nurse would expect to note which signs and symptoms? Select all that apply.

Headache

Swelling directly behind the ear

Red and immobile tympanic membrane

Otoscopic examination in a client with mastoiditis reveals a red, dull, thick, and immobile tympanic membrane with or without perforation. Signs and symptoms of mastoiditis include mastoid swelling (directly behind the ear) and soreness, headache, malaise, and an elevated white blood cell (WBC) count. Thick, purulent drainage from the ear may be seen.

A client is diagnosed with labyrinthitis. Which are signs and symptoms of labyrinthitis? Select all that apply.

Severe dizziness

Nausea and vomiting

Abnormal jerking movement of eyes

Signs and symptoms of labyrinthitis include vertigo, nausea, vomiting, headache, anorexia, nystagmus, and sensorineural hearing loss on the affected side. The client may also experience anorexia.

The nurse is reviewing the health care record of a client with a diagnosis of otosclerosis. Which signs and symptoms would the nurse note? Select all that apply.

Tinnitus

Difficulty hearing voices of others

Bone conduction better than air conduction

Rationale:Otosclerosis involves the formation of spongy bone in the capsule of the labyrinth of the ear, often causing the auditory ossicles to become fixed and less able to vibrate when sound enters the ear. The primary symptom of otosclerosis is slowly progressive hearing loss in the absence of infection. In the early stages, the client may report tinnitus. The Rinne test reveals bone conduction to be greater than air conduction. The client often complains of difficulty hearing the voices of others, yet his own voice sounds unusually loud. In response to this, he may lower his voice to the point that he can scarcely be heard by others.

The nurse provides discharge instructions to the client who was hospitalized for an acute attack of Ménière's disease. Which statement made by the client indicates a need for further teaching?

"It is not necessary to restrict salt in my diet."

Management during remission of Ménière's disease includes diuretics to decrease the fluid and thereby decrease pressure in the endolymphatic system. Antihistamines, vasodilators, and diuretics may be prescribed for the client. A low-salt diet may also be prescribed for the client to reduce fluid retention. The major goal of treatment is to preserve the client's hearing; careful medical management helps achieve this in most clients with Ménière's disease.

The nurse is reinforcing instructions to a client regarding the use of a hearing aid. Which statement by the client indicates a need for FURTHER teaching?

"I should turn the hearing aid off after removing it from my ear."

Nurses should have a basic knowledge of the care of a hearing aid to assist the client in its use. The client should be instructed to turn the hearing aid off before removing it from the ear to prevent squealing feedback. The hearing aid should be turned off when not in use, and the client should keep an extra battery available at all times. The client should wash the ear mold frequently with mild soap and water using a pipe cleaner to cleanse the cannula. The client should not wear the hearing aid during an ear infection.

Tonometry is performed on the client with a suspected diagnosis of glaucoma. The nurse reviews the test and determines that the intraocular pressure is normal if which result is noted?

15 mm Hg

Tonometry is the method of measuring intraocular fluid pressure using a calibrated instrument that indents or flattens the corneal apex. Pressures between approximately 10 and 21 mm Hg are considered within the normal range; therefore, the other options are incorrect.

The nurse is providing discharge instructions to a client who is postoperative cataract surgery on the left eye. Which statement indicates a need for FURTHER teaching?

"If I have severe eye pain, I will take the narcotic pain pill that my doctor will prescribe for me."

After cataract surgery the most important thing is to prevent strain on the operative eye. The client should not lift more than 5 pounds. The client should protect the eye during the day with glasses and use sunglasses for outside wear. The client should wear a protective eye shield at night. A mild analgesic is usually ordered as needed. Postoperative clients with cataract surgery should not have severe pain. If a client complains of severe pain, the surgeon is notified. Severe pain may indicate hemorrhage or rising pressure within the eye.

The nurse is reviewing the health record of a client diagnosed with a cataract. Which are signs and symptoms of cataract formation? Select all that apply.

Floaters in visual field

Difficulty in night vision

Decreased color perception

Signs and symptoms of a cataract include hazy, blurred, or double vision (diplopia), and floaters in visual field. There is increasing nearsightedness, complaints that colors are faded or appear yellowish or brownish, and difficulty with night vision. Uncomplicated cataracts are usually painless, but the client may have photophobia (intolerance of light).

During the early postoperative stage, a client who had a cataract extraction complains of nausea and severe eye pain over the operative site. Which action would the nurse implement?

Report the client's complaints.

Severe pain or pain accompanied by nausea is an indicator of increased intraocular pressure and should be reported to the registered nurse and primary health care provider immediately. The remaining options are incorrect.

The nurse reinforces home care instructions to a client after cataract removal and placement of an intraocular implant in the right eye. Which statement by the client indicates a need for further teaching?

"I need to remove the eye dressing as soon as I get home and place a warm pack on my eye."

Rationale:After cataract surgery, a dressing is applied to the eye. It usually is removed later on the day of surgery or the following day. The client should not place a warm pack on the eye unless this is specifically prescribed because of the risk of infection and increased edema in the surgical area. The client is instructed to wear a metal or plastic eye shield to protect the eye from accidental injury and is instructed not to rub the eye. Glasses may be worn during the day. The client is instructed not to sleep on the side of the body that was operated on to prevent pressure and edema in the affected eye. The use of stool softeners is recommended to prevent constipation and straining.

The nurse provides dietary instructions to a client with Ménière's disease. The nurse tells the client that which food or fluid item is acceptable to consume?

Sugar-free Jell-O

The underlying pathological changes of Ménière's disease include overproduction and defective absorption of endolymph. This increases the volume and pressure within the membranous labyrinth until distention results in rupture and mixing of the endolymph and perilymph fluids. Dietary therapy frequently is quite helpful in controlling the symptoms associated with Ménière's disease. The nurse encourages the client to follow a low-salt diet and to avoid caffeine, sugar, monosodium glutamate, and alcohol.

The nurse is caring for a client who will be undergoing surgical treatment for Ménière's disease. The nurse plans care based on which expected outcome?

The surgery relieves pressure from accumulation of inner ear fluid in the endolymphatic sac.

Surgical treatment for Ménière's disease involves relief from accumulation of inner ear fluid in the endolymphatic sac. Procedures may be directed toward relief of pressure by the bony structures surrounding the sac or toward opening the sac and diverting the flow of endolymph by a shunt to the mastoid bone or to the subarachnoid space. The remaining options are procedures unrelated to Ménière's disease.

An older client confides to the visiting nurse the fear of falling while going to the bathroom at night. Considering the visual changes affecting the older client, the nurse would make which recommendation?

"Keep a red light on in the bathroom at night."

Rationale:Because it takes longer to adapt to changes from dark to light and vice versa, older people are at greater risk for falls and injuries. Any place where there is a sudden change from dark to light or from light to dark can be dangerous. Getting up during the night is hazardous for an older client. Eyes adapt to the dark by using the rod receptors, which are sensitive to short blue-green wavelengths. Red wavelengths are longer and are perceived by the cones. Thus, a red light in the bathroom at night allows for adequate vision to function in the dark without the need for adaptation.

The instructor is quizzing the student nurse concerning care of a visually impaired client. Which statement indicates a need for further teaching?

"I will take the client's arm to lead while we are walking."

Measures to support the client with impaired vision and to prevent injury include announcing yourself when entering or leaving the room and speaking in a normal tone of voice. People tend to act as if those who cannot see also cannot hear, so a tendency exists to raise one's voice when talking to the visually impaired. Advise the client what to expect during procedures. Keep doors either open or closed so that the ambulatory client does not run into a partially closed door. To lead a blind person, have him or her take your arm.

The nurse is assigned to administer the prescribed eye drops for a client preparing for cataract surgery. Which type of eye drops would the nurse expect to be prescribed?

A mydriatic medication

A mydriatic medication produces mydriasis or dilation of the pupil. Mydriatic medications are used preoperatively in the cataract client. These medications act by dilating the pupils. They also constrict blood vessels. A miotic agent would constrict the pupil. An osmotic agent would act to decrease intraocular pressure. A thiazide diuretic would promote the excretion of body fluid. A thiazide diuretic is not likely to be prescribed for a client with a cataract.

A client is being discharged from the ambulatory care unit following cataract removal, and the nurse provides instructions regarding home care. Which statement by the client indicates an understanding of the instructions?

"I will wear my eye shield at night and my glasses during the day."

The client is instructed to wear a metal or plastic shield to protect the eye from accidental injury and is instructed not to rub the eye. Glasses may be worn during the day. Aspirin or medications containing aspirin are not to be administered or taken by the client, and the client is instructed to take acetaminophen as needed for pain. The client is instructed not to sleep on the same side of the body that underwent surgery. The client is not to lift more than 5 pounds.

A client with retinal detachment is admitted to the outpatient nursing unit in preparation for a scleral buckling procedure. Which prescription would the nurse anticipate?

Placing an eye patch over the client's affected eye

Rationale:The nurse places an eye patch over the client's affected eye to reduce eye movement. Some clients may need bilateral patching. Depending on the location and size of the retinal break, activity restrictions, including watching television, may be needed immediately. These restrictions are necessary to prevent further tearing or detachment and to promote drainage of any subretinal fluid. The nurse positions the client as prescribed by the primary health care provider.

The nurse would check for vision loss in a client with which condition?

Diabetes mellitus

Elevated blood glucose levels can cause temporary blurred vision. Over time, permanent retinal changes can occur in clients with diabetes mellitus.

The nurse is assisting the primary health care provider with performing a Rinne tuning fork test on a client. The nurse expects that the steps of the testing will be performed in which priority order? Arrange the actions in the order that they would be performed. All options must be used.

1. Tap tuning fork to activate.

2. Place base of tuning fork on the mastoid bone.

3.Have client indicate when the sound disappears.

4. Move the tuning fork close to the ear canal.

5. Ask the client if he or she hears the sound and to indicate when the sound disappears.

6. Document whether bone or air conduction is better.

The nurse is caring for a client following craniotomy for removal of an acoustic neuroma. The nurse understands that assessment of which cranial nerve would identify a complication specifically associated with this surgery?

Cranial nerve VII, facial nerve

Treatment for acoustic neuroma is surgical removal via a craniotomy. Extreme care is taken to preserve remaining hearing and preserve the function of the facial nerve. Acoustic neuromas rarely reoccur following surgical removal.

The nurse is assigned to care for a client with a diagnosis of Ménière's disease. After reinforcing discharge instructions, which client statement indicates a need for FURTHER teaching?

"I will become totally deaf if I don't follow instructions."

Ménière's disease is a disorder of the labyrinth of the inner ear. The hearing loss is unilateral, meaning that only one ear is affected. Biofeedback, self-hypnosis, and relaxation techniques may be recommended to help the client learn to live with Ménière's disease. A low-salt diet is sometimes prescribed for people with Ménière's disease. Caffeine, alcohol, chocolate, and nicotine may aggravate or trigger an attack.

The nurse is caring for a client hospitalized with an acute attack from Ménière's disease. The client verbalizes concern because the client has experienced a hearing loss as a result of the attack. Which response would the nurse make to the client regarding the hearing loss?

"The attack leaves a hearing loss in the involved ear."

After the acute phase, remission occurs, but symptoms will recur with 2 or 3 acute attacks per year. As this pattern of attacks and remissions develops, fewer symptoms occur during the acute phase. A complete remission eventually occurs with some degree of hearing loss varying from slight to complete. It takes several weeks before all symptoms subside after an attack leaving a loss of hearing in the involved ear.

The nurse is reviewing the primary health care provider's prescriptions for a client admitted to the hospital with a diagnosis of an acute attack of Ménière's disease. Which prescription noted on the client's chart should the nurse question?

The administration of a vasoconstrictor

Medical interventions during the acute phase of Ménière's disease include using atropine or diazepam to decrease the autonomic nervous system function. Diphenhydramine may be prescribed for its antihistamine effects, and a vasodilator also will be prescribed. The client will remain on bed rest during the acute attack and when allowed to be out of bed, will need assistance with walking, sitting, or standing.

A client with a diagnosis of otosclerosis is admitted to the ambulatory care unit for stapedectomy, and the nurse reinforces instructions to the client regarding home care following the procedure. Which statement by the client indicates a need for further teaching?

"I need to avoid air travel for at least 6 months."

Following stapedectomy, the client is instructed to keep water out of the ear canal for at least 3 weeks and to avoid swimming for 6 weeks. The client is also instructed to avoid coughing and sneezing and to avoid bending and lifting heavy objects or other strenuous activities for at least 3 weeks. Air travel is avoided for 4 weeks. If the client develops sudden hearing loss, fever, or severe persistent vertigo or dizziness, the primary health care provider should be notified.

The nurse is reinforcing discharge instructions with a client who is being discharged following a fenestration procedure for the treatment of otosclerosis. Which would be included on the list of instructions prepared for the client?

"You need to avoid air travel."

Following ear surgery, clients need to avoid straining when having a bowel movement. Clients must be instructed to avoid drinking with a straw for 2 to 3 weeks, air travel, and coughing excessively. Clients need to avoid getting their head wet, washing their hair, and showering for 1 week. Clients also must avoid rapidly moving the head, bouncing, and bending over for 3 weeks.

A myringotomy is performed on a client in the ambulatory care center. The ambulatory care nurse calls the client 24 hours after the procedure to evaluate the status of the client. The client reports to the nurse that a small amount of brownish drainage has been coming from the ear. Which instruction would the nurse provide to the client?

"Continue to monitor the drainage because this is normal and may occur for 24 to 48 hours following the surgery."

A small amount of brownish or reddish drainage is normal for 24 to 48 hours following the surgery. Excessive drainage, especially clear fluid, should be reported immediately. Options 1, 2, and 3 are inaccurate instructions.

A client has been diagnosed with cataracts. Which signs and symptoms would the nurse expect to note? Select all that apply.

Photophobia

Blurred vision

Decreased color perception

A client with glaucoma has suffered significant eye damage before diagnosis and now has impaired vision. The nurse determines that the client needs FURTHER assistance in adapting to this situation if the client makes which statement?

There is no difficulty driving at dusk."

The client with impaired vision that may accompany glaucoma needs to take action to maintain safety in dim lighting. This includes moving carefully in dim lighting, using nightlights along paths traveled in the home at night, and not driving at dusk or dawn. Satisfactory adjustment also is indicated by recognition of the need for ongoing eye examinations and the presence of a supportive family.

A client reports to the health care clinic for an eye examination, and a diagnosis of primary open-angle glaucoma is suspected. Which question will elicit information regarding the signs/symptoms associated with this disorder?

"Have you had difficulty with peripheral vision?"

Because glaucoma is usually symptom free, the client may first note changes in peripheral visual acuity. If pain occurs with glaucoma, it is usually late in the course of structural changes with an intraocular pressure of 40 to 50 mm Hg or higher. More severe pain is characteristic of absolute glaucoma (total vision loss). Glare from bright lights is a complaint of a client with a cataract. Blurred central vision occurs with macular degeneration.

These are signs and symptoms of glaucoma. Which sign or symptom is found only in narrow-angle glaucoma?

Severe pain in and around eye

Narrow-angle, or acute, glaucoma is a medical emergency in which there is severe pain in the eye accompanied by the appearance of colored halos around lights, blurred vision, and pain in and around the eye. Nausea and vomiting may occur. Normal intraocular pressure is 10 to 21 mm Hg.

The nurse in the outpatient unit is preparing a client who is scheduled for a laser trabeculoplasty for the treatment of primary open-angle glaucoma. Which instructions would the nurse reinforce to the client?

"You may return to work 1 or 2 days following the procedure."

Rationale:Laser trabeculoplasty is performed in the outpatient setting and requires about 30 minutes. The client will experience little discomfort and may resume all normal activities including returning to work within 1 or 2 days. The treatment prevents further visual loss, but the lost vision cannot be restored.

A clinic nurse is reviewing the record of a client recently diagnosed with a cataract. Which clinical manifestations associated with this disorder would the nurse expect to be documented in the client's record? Select all that apply.

Increasing nearsightedness

Need for more light when reading

Painless progressive loss of vision

A cataract is any opacity of the crystalline lens of the eye. The classic symptom of cataracts is painless progressive loss of vision in one or both eyes. Signs and symptoms of a cataract include hazy, blurred, or double vision (diplopia) and floaters in the visual field. There is increasing nearsightedness, complaints that colors are faded or appear yellowish or brownish, and difficulty with night vision. There may be a need to increase lighting when reading.

Prescriptive glasses are prescribed for a client with bilateral aphakia, and the nurse reinforces instructions to the client regarding the use of the glasses. Which statement by the client indicates the need for FURTHER teaching?

"The prescriptive glasses will correct my visual field of sight."

Only central vision is corrected with these prescriptive glasses, and the peripheral vision is distorted. Prescriptive glasses provide approximately 30% magnification of central vision.

Aphakia (absence of the lens of the eye) can be corrected by prescriptive glasses, contact lenses, or intraocular lenses. Only central vision is corrected with these prescriptive glasses, and the peripheral vision is distorted. Prescriptive glasses provide approximately 30% magnification of central vision. This requires adjustment to daily activities and safety precautions. Because of the magnification, objects viewed centrally appear distorted, and it is difficult to judge distances such as when driving a car.

A client is brought to the ambulatory care department by the spouse 1 day following a cataract extraction procedure. A diagnosis of hyphema is made, which occurred as a result of the surgical procedure. The nurse reinforces instructions to the client and spouse regarding the treatment for the complication and makes which statement?

"Maintain bed rest and patching of both eyes."

Hyphema is bleeding into the anterior chamber of the eye that occurs postoperatively as a complication of cataract surgery. Treatment includes bed rest and bilateral eye patching for 2 to 5 days during which absorption occurs. The client should be instructed to monitor for signs of increased intraocular pressure, which commonly causes sudden ocular pain. Miotics and cycloplegics may be prescribed. Occasionally, irrigation of the anterior chamber may be done to remove the blood.

The nurse is reinforcing preoperative instructions to a client scheduled for cataract surgery and prepares a written list of instructions for the client. Which statement by the client indicates a need for FURTHER teaching?

"I can drink any liquids that I want to on the morning of the surgery."

The client should be instructed that no oral intake is permitted for 6 to 12 hours before the surgical procedure. Local or general anesthesia will be administered, and the client may receive medication to produce relaxation. Eyelashes may be cut before surgery and will grow back but will grow slowly. Eye medications such as mydriatics, cycloplegics, or beta blockers may be administered before the surgical procedure.

The nurse collects data from a client with a diagnosis of macular degeneration of the eye. The nurse would expect the client to report which symptoms? Select all that apply.

Blurred central vision

Bending of straight lines

Inability to see color vividness

The most common symptom of macular degeneration is blurred central vision that often occurs suddenly. Clients complain of difficulty with reading and seeing fine detail. Formation of a central scotoma (blind spot) occurs in some clients. Clients may complain of visual distortion usually described as a bending or irregularity of straight lines. Peripheral vision is spared, so although affected persons cannot see to read, drive, watch television clearly, or distinguish faces, they do have the ability to walk. The client may be unable to see the vividness of colors or to see details.

The nurse is reinforcing instructions to a client with a diagnosis of hordeolum regarding the treatment plan. Which instruction would the nurse include in the teaching plan for the client?

Apply a warm compress for 15 minutes 4 times daily.

Rationale:Hordeolum is commonly known as a sty. Therapeutic management includes the application of a warm compress for 15 minutes 4 times daily and installation of an ophthalmic antibiotic ointment to combat the infectious organism and prevent the spread of infection to surrounding lid glands. The warm compress promotes comfort and aids in bringing purulent contents to a head causing rupture with drainage. If a sty does not rupture spontaneously, it can be incised with a small sterile instrument by the primary health care provider. The client should be told not to press on or squeeze the sty to induce rupture because such pressure could force infectious material into the venous system and transmit infection to the brain.

The nurse in the ambulatory care unit is caring for a client following cataract extraction. The client suddenly complains of nausea and severe eye pain in the surgical eye. The nurse would take which action?

Notify the registered nurse.

Rationale:Severe pain or pain accompanied by nausea is an indicator of increased intraocular pressure and should be reported to the registered nurse who will notify the primary health care provider immediately. The other options are incorrect nursing actions. Ice is not applied to the surgical site unless prescribed. The client is not positioned on the operative side because of the risk of increasing intraocular edema from swelling. Although pain medication and an antiemetic may be prescribed, the client's symptoms indicate a serious complication requiring primary health care provider notification.

A client arrives in the emergency department with a foreign body in the eye. Which action would the nurse plan to perform first?

Apply an eye patch to both eyes.

If a foreign body is in the eye, no attempt to remove it should be made. Both eyes should be patched to prevent further eye movement, until the primary health care provider can see the client. The eye should not be irrigated with any solution, and no ointment should be applied. The primary health care provider may eventually check for corneal abrasions once the object is removed.

The nurse is reviewing the plan of care developed by a nursing student for a client scheduled for keratoplasty. The nurse discusses the plan with the student if which incorrect intervention is listed in the plan?

Administering medications that will dilate the pupil

Keratoplasty is done by removing damaged corneal tissue and replacing it with corneal tissue from a human donor (live or cadaver). Preoperative preparation of the recipient's eye may include obtaining a culture and sensitivity with conjunctival swabs, instilling antibiotic ophthalmic medication, and cutting the eyelashes. Some ophthalmologists prescribe a medication such as 2% pilocarpine to constrict the pupil before surgery.

The nurse is providing discharge instructions to a client following a keratoplasty. Which statement by the client indicates the need for FURTHER teaching?

"Sutures are removed in 2 weeks."

Depending on the type of procedure performed, the client is told that sutures are usually left in place for as long as 6 months. After the sutures are removed and complete healing has occurred, prescription glasses or contact lenses will be prescribed

The nurse is caring for a client following enucleation. On data collection, the nurse notes staining and bleeding on the dressing. The nurse would take which action?

Notify the registered nurse.

Postoperative nursing care includes observing the dressing and reporting any staining or bleeding to the surgeon. Options 1 (document the findindgs), 2 (reinforce the dressing), and 4 (mark the amount of staining with a black pen) are inaccurate nursing actions if staining or bleeding is present on the dressing following enucleation. The nurse should notify the registered nurse, who would then notify the primary health care provider immediately.

The nurse is providing client and family instructions for a client who has been recently diagnosed with glaucoma. Which statement indicates that the client's family member needs FURTHER teaching regarding the eye drop application of pilocarpine hydrochloride? Select all that apply.

"I should apply the eye drops directly over my family member's pupil."

"I have to contact the prescriber if my family member develops a small pupil."

"I need to wipe off the tip of the eye drop bottle with a tissue between administrations."

Rationale:Option 1 indicates incorrect understanding: The eye drops should not be given directly over the pupil. Option 3 indicates incorrect understanding: The intended effect of the medication is pupil constriction, and it is not necessary to notify the prescriber. Option 5 indicates incorrect understanding: Wiping off the eye drop bottle with a tissue would easily transmit infection. Option 2 indicates understanding of using the conjunctival sac as the correct administration site. Option 4 indicates correct understanding that the correct number of drops should be applied.

The nurse is providing client teaching regarding glaucoma. Which instructions are important to include in the teaching plan? Select all that apply.

Follow a low-sodium, minimal-caffeine diet with plenty of fiber.

Be sure to report halos of light or increased eye pain to your primary health care provider.

Halos of light and increased eye pain are symptoms of increased intraocular pressure, which should be reported immediately. Low sodium and minimal caffeine intake help lower the intraocular pressure. Eating fiber will prevent constipation. Intraocular pressure is increased when the client strains to have a bowel movement. Most eye drops to treat glaucoma constrict rather than dilate the pupil. The client most likely will need to use glaucoma medications for the rest of his or her life. The eye drops should be placed in the conjunctival sac, not directly over the pupil.

While at home, the nurse receives a telephone call from a neighbor who reports that while accidentally breaking a mirror, a piece of glass flew into her eye. Which is the appropriate initial nursing action after observing that the large glass shard is protruding from the neighbor's eye?

Secure a paper cup over the affected eye.

Rationale:If an eye injury is the result of a penetrating object, the object may be noted protruding from the eye as in this case. This object must never be removed except by an ophthalmologist because it may be holding ocular structures in place. Irrigation of the eye may disrupt the foreign body and cause further tearing of the cornea. The appropriate initial action by the nurse is to protect the affected eye with a covering, such as a paper cup, that will not apply pressure to either the protruding object or to the eye itself. The nurse can then accompany the neighbor to the emergency department.

The nurse is caring for a client following enucleation. Which postsurgical observation requires immediate attention by the nurse?

Bright red drainage on the dressing

Rationale:If the nurse notes bright red drainage on the dressing, it must be reported immediately because this can indicate hemorrhage. Complaints of pain are expected in the postoperative period. A blood pressure of 122/84 mm Hg is near normal range. A respiratory rate of 22 breaths per minute, although slightly elevated, does not warrant immediate notification of the registered nurse.

Which actions would be performed when communicating with a client with presbycusis? Select all that apply.

Speak slowly and distinctly.

Face client when speaking.

Use short sentences and phrases.

Rationale:Presbycusis is a type of hearing loss that occurs with aging. It is a gradual sensorineural loss caused by nerve degeneration in the inner ear or auditory nerve. Here are some communication techniques: Speak slowly and distinctly. Ensure that the client can see your face clearly. Do not turn away while speaking. Provide adequate lighting directed toward your face. A strong light behind you creates a glare and makes it hard to see your features. Have a writing pad or Magic Slate available, and use it if the client cannot understand you or if you do not understand the client.

The nurse determines that the client diagnosed with Ménière's disease understands the reinforced dietary instructions when the client states that which food will be avoided in the diet?

Hot dogs

Dietary changes such as salt and fluid restrictions that reduce the amount of endolymphatic fluid are sometimes prescribed for the client with Ménière's disease. Although cereal products contain sodium, the amount is not as high as that found in hot dogs. Apple juice and Brussels sprouts are low-sodium foods.

The nurse is assisting in developing a plan of care for a client following the surgical removal of an acoustic neuroma. Which assessment will be included in the plan of care for this specific intervention?

Assessment of cranial nerve VII (facial)

Treatment for acoustic neuroma is surgical removal via a craniotomy. Extreme care is taken to preserve the remaining hearing and the function of the facial nerve. Cranial nerve VII is the facial nerve. Assessment of the remaining cranial nerves is not specific to this type of surgery.

A client is being discharged from the ambulatory care unit following cataract removal. Which instruction from the discharge teaching plan would the nurse reinforce?

Take acetaminophen if any discomfort occurs.

Rationale:The client is instructed to wear a metal or plastic shield to protect the eye from accidental injury and is instructed not to rub the eye. Glasses may be worn during the day, and an eye shield is worn at night. Aspirin or medications containing aspirin are not to be administered or taken by the client, and the client is instructed to take acetaminophen as needed for pain. The client is instructed not to sleep on the side of the body that was operated on because this will cause edema and increased intraocular pressure. The client is not to lift more than 5 pounds.

A client has been diagnosed with macular degeneration. The nurse would expect which signs and symptoms noted with macular degeneration? Select all that apply.

Blurred vision

Inability to see the vividness of colors

Objects that appear to be the wrong size

Macular degeneration is bilateral and progressive. Early symptoms may be an inability to see the vividness of colors or to see details. Blurred vision, presence of scotomas, or distortion of vision gradually occurs. Objects may appear to be the wrong size or shape, or straight lines may appear crooked or wavy. As central vision deteriorates, there may be a large dark spot or empty place over the center of what is viewed. The remaining options (Increasing nearsightedness, Increasing complaints about glare) are signs of cataracts.

Which diagnostic test would verify the diagnosis of macular degeneration?

Amsler grid test

In the Amsler grid test, a client with macular degeneration will see distorted or blurred lines. The tonometer measures intraocular pressure, which will be elevated in glaucoma. The Snellen chart determines visual acuity and is expressed in a ratio. Normal vision is considered to be 20/20. The Ishihara chart book determines color-blindness. In addition, genetic tests are available to determine the risk for macular degeneration.

The primary health care provider will perform a caloric test. Which is the priority order of the actions to perform this test? Arrange the actions in the order that they should be performed. All options must be used.

1. Explain the purpose and procedure to the client

2. Note if the client has had central nervous system depressants, alcohol, or barbiturates

3. Check for the presence of nystagmus, postural deviation (Romberg sign), and past-pointing

4. Examine and clean the ear canal.

5. Place emesis basin under ear to be tested then irrigate the suspected ear with hot or cold water

6. Irrigate until the client complains of nausea and dizziness or nystagmus is observed

Rationale:Explain the purpose and the procedure to the client and that the caloric test will irrigate the ears to assess for dizziness. Note if the client has had central nervous system depressants, alcohol, or barbiturates because they alter test response. Before the test, the client is examined for the presence of nystagmus, postural deviation (Romberg sign), and past-pointing. This examination provides the baseline values for comparison during the test. The ear canal should be examined and cleaned before testing. The ear on the suspected side is irrigated first because the client's response may be minimal. After an emesis basin is placed under the ear, the hot or cold irrigation solution is directed into the external auditory canal until the client complains of nausea and dizziness, or nystagmus is observed. This usually occurs in 20 to 30 seconds. If after 3 minutes no symptoms occur, the irrigation is stopped. The client is tested again for nystagmus, past-pointing, and Romberg sign. After approximately 5 minutes, the procedure is repeated on the other side.

A perforated eardrum is suspected in a client who was hit in the ear with a basketball. A tympanoplasty was performed. The nurse is giving the client discharge instructions. Which client statement indicates a need for further teaching?

"I will drink from the plastic bottle mouth since I can't use drinking straws."

Rationale:Some discharge instructions concerning tympanoplasty include sneezing, coughing, and nose blowing because all of these actions could disturb the operative site. If necessary, blow the nose gently one side at a time. Cough or sneeze with the mouth open. Continue this for 1 week after surgery. Do not drink through a straw for 2 to 3 weeks. Avoid drinking directly from the mouth of a plastic bottle because negative pressure occurs if the bottle opening is sealed. Keep the ear dry for 4 to 6 weeks after surgery by placing a cotton ball covered with petroleum jelly (such as Vaseline) in the ear canal. Do not fly until the surgeon allows it.

The nurse is assisting in performing a confrontation test on a client seen in the clinic. The nurse understands that this test is performed to determine what?

The ability to demonstrate effective peripheral vision

The confrontation test is a gross measurement of peripheral vision. In the Amsler grid test, a client with macular degeneration will see distorted or blurred lines. The tonometer measures intraocular pressure, which will be elevated in glaucoma. The Snellen chart determines visual acuity and is expressed in a ratio; 20/20 is considered to be normal.

The nurse in a health care clinic is assisting in testing the client for accommodation. Arrange the actions and observations in the order that they should occur. All options must be used.

1. Focus on distant object.

2. Pupils dilate.

3. Focus on close object.

4. Pupils constrict.

5. Document findings.

The nurse tests for accommodation by asking the client to focus on a distant object. This process dilates the pupils. The client is then asked to shift the gaze to a near object such as a finger held about 3 inches from the nose. A normal response includes pupillary constriction and convergence of the axes of the eyes.

A client has bilateral aphakia. When reinforcing teaching instructions regarding the prescribed eyeglasses, the nurse determines the need for FURTHER teaching when the client makes which statement?

"My peripheral vision will not be distorted."

Rationale:Aphakia is the absence of the eye's lens and is corrected by prescriptive glasses, contact lenses, or an intraocular lens implanted surgically. Although glasses can be used for this disorder, they have several disadvantages. With the use of glasses, only central vision is corrected and peripheral vision is distorted. There is approximately 30% magnification of central vision. This requires adjustment to daily activities and safety precautions. Because of the magnification, objects viewed centrally appear distorted. It is difficult for the client to judge distances such as when driving a car.

The nurse has reinforced instructions to a client who is scheduled for a cataract extraction. Which statement by the client indicates a need for FURTHER teaching?

"No eating or drinking for at least 18 hours before the surgery."

The client scheduled for cataract surgery should be instructed that oral intake may be restricted for 6 to 12 hours preoperatively. It is not necessary that the client take nothing per mouth (NPO) for 18 hours before surgery.

The nurse in the recovery room area is preparing to care for a client following cataract extraction of the right eye. Which position does the nurse prepare to place the client?

On the left side with the head of the bed elevated

Following cataract extraction, the client should be positioned comfortably on the nonoperative side with the head of the bed elevated. The client should not be placed on the operative side because this position will promote swelling and edema in the operative area. A supine position will also promote edema and swelling.

A client who sustained an eye injury arrives at the emergency department. Which is the initial nursing action?

Obtain a history regarding the cause of the injury.

In the event of an eye injury, the initial nursing action is to determine the cause of the injury and when the injury occurred. Treatment depends on the cause of the injury.

A client arrives at the emergency department for treatment of an injury to the eye after being hit by a baseball bat. On data collection, the nurse notes that the eye is bleeding. Which nursing action is appropriate?

Cover the eye with cold, sterile saline gauze.

The appropriate nursing action following blunt trauma injury to the eye is to cover the eye with sterile gauze saturated with cold, sterile saline. The nurse should avoid applying pressure and should allow the eye to bleed. The eye should not be irrigated without a primary health care provider's prescription. Skull series are prescribed by the primary health care provider.

A client arrives in the emergency department following an eye injury from a chemical solution. Which is the initial nursing action?

Test the eye pH with litmus paper.

Rationale:If a client sustained a chemical injury to the eye, the client's head should be tilted to the side of the affected eye and irrigated thoroughly. The pH of the eye should be tested with litmus paper before, during, and after irrigation. The primary health care provider should be notified. A pressure dressing is not placed on the eye in this type of injury. Covering the eye with sterile saline solution is not an appropriate action and would delay necessary and immediate treatment. A medical history would be obtained once initial treatment is initiated.

The nurse is reviewing the preoperative prescriptions of a client scheduled for a keratoplasty. Which prescriptions noted in the client's chart would the nurse question?

Administer medication to dilate the affected pupil.

In the preoperative period, the primary health care provider may prescribe medications such as 2% pilocarpine to constrict the pupil before a keratoplasty. The nurse would question a prescription that indicated dilation of the pupil. Preoperative preparation may include obtaining a culture and sensitivity with conjunctival swabs, instilling antibiotic eye medication, and cutting the eyelashes.

The nurse has reinforced instructions to a client following a right keratoplasty. Which statement by the client indicates a need for further teaching?

"In 1 week, I'll return to have the sutures removed."

Following keratoplasty, sutures are usually left in place for as long as 6 months. The client is instructed not to lie on the operative side and should avoid sudden head movement. The client is instructed to instill antibiotic medication because infection is a critical complication of this procedure. An eye shield should be worn during sleep for about 2 months postoperatively.

A client reporting recent right eye discomfort is diagnosed with chalazion of the right eye. The nurse reinforces instructions to the client regarding care to the eye. Which statement by the client indicates an understanding of the measures?

"I should apply warm packs to my eye."

A chalazion is a cyst that results from blockage of sebaceous material in a meibomian gland. Application of warm compresses over the affected eyelid three or four times per day is a common treatment in the early stages. The condition is not contagious, and it is not necessary for the client to use separate washcloths and towels.

The nurse is reinforcing home care instructions to a client who has a hordeolum (sty) of the right eye. Which statement by the client indicates an understanding of the instructions?

"I should apply antibiotic ointment as prescribed."

Rationale:Therapeutic management of a hordeolum includes application of warm compresses for 15 minutes 4 times daily and the installation of antibiotic ointment to combat infectious organisms. The client is told not to press on or squeeze the sty because such pressure could force infectious material into the venous system of the eyelids and face, which can transmit infection to the brain.

The nurse is assisting the primary health care provider in performing a caloric test on a client. Following instillation of cool water into the ear, the nurse observes the presence of nystagmus. The nurse would document the findings of this test as indicative of which result?

Normal

The caloric test is useful in testing the function of cranial nerve VIII. Water that is warmer or cooler than body temperature is infused into the ear. A normal response is demonstrated by the onset of vertigo (spinning sensation) and nystagmus (involuntary eye movements) within 20 to 30 seconds. Positive, abnormal, and inconclusive results are incorrect.

The nurse is assisting the primary health care provider in performing a caloric test on a client. Following instillation of warm water into the ear, the client complains of vertigo. The nurse documents the findings of this test as indicative of which result?

Normal

The caloric test is useful in testing the function of cranial nerve VIII. Water that is warmer or cooler than body temperature is infused into the ear. A normal response is demonstrated by the onset of vertigo (spinning sensation) and nystagmus (involuntary eye movements) within 20 to 30 seconds.

The nurse is assisting a primary health care provider in performing a caloric test on a client. Following instillation of warm water into the ear, the nurse notes that nystagmus does NOT occur. The nurse would document the findings of this test as indicative of which result?

Positive

The caloric test is useful in testing the function of cranial nerve VIII. Water that is warmer or cooler than body temperature is infused into the ear. A normal response is demonstrated by the onset of vertigo (spinning sensation) and nystagmus (involuntary eye movements) within 20 to 30 seconds. No nystagmus indicates dysfunction of cranial nerve VIII.

A caloric test is prescribed for a client suspected of having a disease of the labyrinth. The nurse obtains which essential item in preparation for this test?

An otoscope

A caloric test is contraindicated in a client with a perforated tympanic membrane (air may be used as a substitute) or if the client has an acute disease of the labyrinth. An otoscopic examination should be performed before the caloric test to rule out perforation and to determine whether the ear canals contain cerumen, which must be removed before the test. An ophthalmoscope, tongue blade, and emesis basin are not essential items.

A nursing instructor asks a student about cochlear implants. The student understands that which clients are candidates for such a procedure? Select all that apply.

A client who has a profound hearing loss in both ears

A client who has received no benefit from conventional hearing aids

Rationale:Adults who were born deaf or became deaf before learning to speak are usually not candidates for this type of surgery. Criteria for a cochlear implant are bilateral profound hearing loss, the client who communicates primarily by speech, the client who receives no benefit from conventional hearing aids, evidence of strong family and social support, and the client who has realistic expectations of the outcome of the implant. Cause of deafness such as infection is not a consideration for the procedure.

The nurse is reinforcing discharge instructions to a client going home after same-day eye surgery. During the postoperative period, the nurse stresses that the client may safely perform which activity?

Watch television.

Rationale:The client is taught to avoid doing activities that raise intraocular pressure because it could cause complications in the postoperative period. For this reason, the client should avoid bending over, lifting heavy objects, straining, sneezing, and making sudden movements. The client is also taught to avoid activities that cause rapid eye movements because these would be irritating in the presence of postoperative inflammation. For this reason, the client is told not to read. Watching television is permissible because the eye does not need to move rapidly with this activity, and it does not increase the intraocular pressure.

A client who had previously undergone cataract surgery tells the nurse that she has begun seeing flashing lights and floaters in the eye. Based on the client's history, the nurse interprets that the client is at risk for which?

Detached retina

Clients with a history of cataract surgery, myopia, trauma, or a family history of retinal conditions are at greater risk for developing a detached retina. Signs and symptoms include sudden onset of flashing lights or floaters. The client may also have loss of peripheral vision or a sudden shadow in the field of vision. Clients with these risk factors should be taught the signs and symptoms of a detached retina and should report them promptly.

A client diagnosed with primary open-angle glaucoma has been prescribed pilocarpine ophthalmic drops. The nurse has given the client instructions on how to administer the eye drops. Which client statement indicates a need for FURTHER teaching?

"I will drop the eye drop in the middle of my eye."

This is the procedure for administering eye drops. Remove the cap and place it on the table on its side or upside down. With the client sitting or reclining, ask the client to look up at the ceiling and tilt the head slightly toward the eye receiving the drop. With a tissue beneath the fingers, retract the lower lid downward, exposing the conjunctival sac. Stabilize the eye drop container above the eye and drop the designated number of drops directly into the conjunctival sac. Do not place drops on the cornea. Block the entrance to the lacrimal gland by placing a finger over it. Carefully replace the cap on the container without contaminating the dropper tip. Ask the client to close the eyelids gently and move the eyes from side to side under the lids to distribute the medication.