Reading...
Play button
Play button
Use LEFT and RIGHT arrow keys to navigate between flashcards;
Use UP and DOWN arrow keys to flip the card;
H to show hint;
A reads text to speech;
35 Cards in this Set
- Front
- Back
|
A nurse is performing an assessment on a patient who presents with hearing problems. Which of the following, if reported by the patient, indicate a hearing condition affecting the inner ear?
a. Headaches b. Feeling as if ear is being plugged c. Ringing of the ears d. Purulent drainage |
C. Ringing of the ears
Tinnitus (continuous ringing or noise perception in the ear) is a common hearing problem affecting the inner ear. (ch. 51, p 1126) |
|
|
A nurse is teaching a patient w/ an acute ear infection about proper instillation of eardrops. Which patient statement would require for additional teaching?
a. The bottle of eardrops should be in a warm water before instillation b. Head should be tilted in the direction of the affected ear to maximize absorption c. Cotton ball should be placed in the ear after instillation d. Hands should be washed before and after procedure |
B. Head should be tilted in the direction of the affected ear to maximize absorption
The head should be tilted in the opposite direction of the affected ear before placing drops in the ear. Cotton ball should be inserted in the opening of the ear canal to act as packing. (ch. 51, p 1121) |
|
|
A nursing student is observing an ear irrigation procedure for the patient. What potential side effect should the nursing student monitor regarding the procedure?
a. Bleeding b. Purulent drainage c. Swelling of the external ear d. Nausea |
D. Nausea
Patients who are undergoing ear irrigation should be monitored for signs of nausea. The procedure should be stopped if the patient feels nauseated. (ch. 51, p 1123) |
|
|
A 30-year-old patient just received educational teaching about ear irrigation procedure. Which of the following patient statements indicate that the teaching has been successful?
a. If wax doesn’t drain out, I have to wait 10 minutes before trying again b. Mineral oil should be used every 6 hours for 2 days to soften dry, impacted cerumen c. I should use no less than 70ml of fluid for irrigation d. Gentle, firm pressure should be applied when irrigating |
A. If wax doesn’t drain out, I have to wait 10 minutes before trying again
Mineral oil is used 3 times a day for 2 days to soften dry, impacted cerumen. After completion of irrigation, have patient turn head to the side just irrigated to drain any remaining fluid. (ch. 51, p 1123) |
|
|
A patient w/ acute otitis media asked the nurse why his primary care provider ordered for him to take an antihistamine together w/ his other medications. The nurse should answer the patient based on the fact that antihistamines:
a. Prevent secondary ear infection b. Decrease mucus production c. Promotes excretion of excess mucus d. Prevents perforation of tympanic membrane |
B. Decrease mucus production
Antihistamines and decongestants are prescribed for patients w/ otitis media to decrease mucus production and fluid in the middle ear. The body can then reabsorb the fluid, reducing pressure and pain. (ch. 51, p 1124) |
|
|
A nurse is tasked to prepare a patient w/ otitis media for surgical reopening of the ear drum. All of the following interventions are indicated for the patient, except:
a. Encourage relaxation techniques such as deep breathing b. Antibiotic therapy before and after procedure c. Prepare patient for administration of general anesthesia d. Clean external canal w/ betadine |
C. Prepare patient for administration of general anesthesia
Preoperative care includes cleaning external canal w/ bacteriostatic solution such as betadine. The procedure is usually done w/ out anesthesia and relaxation techniques are encouraged to relieve anxiety related to the procedure. (ch. 51, p 1124-1125) |
|
|
A nurse is performing discharge care teaching for a patient who had a left ear surgery. Which statement, if made by the patient, indicate a need for further teaching?
a. I have to avoid washing my hair for at least 1 week b. I shouldn’t place anything in the left ear for 6 weeks c. Bending over and rapid head movement should be avoided for 3 weeks d. I have to stay away from people who have a cold |
B. I shouldn’t place anything in the left ear for 6 weeks
The ear should be kept dry for 6 weeks by placing a ball of cotton coated w/ petroleum jelly in the left ear. The cotton ball should be changed daily. (ch. 51, p 1125) |
|
|
A nurse is assigned to care for a 45-year-old patient diagnosed w/ Meniere’s disease. In developing a care plan for the patient, the nurse should know that the condition:
a. Is manifested by bilateral sensorineural hearing loss b. Is more common in Caucasian women c. Is caused by an under production of endolymph fluid d. Is manifested by rapid eye movements |
D. Is manifested by rapid eye movements
Meniere’s disease is more common in Caucasian men ages 20-50 years. It is caused by an over production of endolymph fluid and manifested by unilateral sensorineural hearing loss and rapid eye movements. (ch. 51, p 1127-1128) |
|
|
A nurse is assigned to care for a 65-year-old patient diagnosed w/ presbycusis. The patient asked the nurse what the condition means. The nurse should answer the question based on the fact that:
a. It is a conductive hearing loss that occurs as a result of aging b. It is caused by buildup of cerumen c. It is caused by an infection of the middle ear d. It is a sensorineural hearing loss that occurs as a result of aging |
D. It is a sensorineural hearing loss that occurs as a result of aging
Presbycusis is a sensorineural hearing loss that occurs w/ aging due to breadown or atrophy of nerve cells in the cochlea, loss of elasticity of basilar membrane, or decreased blood supply to the inner ear. (ch. 51, p 1130) |
|
|
A nurse is performing assessment of a patient who has a potential conductive hearing loss. Which assessment finding would help indicate a confirmation of the diagnosis of conductive hearing loss?
a. Hearing poorly in loud environment b. Speaking softly c. Occasional dizziness d. Normal appearance of external canal |
B. Speaking softly
Conductive hearing loss occurs when sound waves are blocked from contact w/ inner-ear nerve fibers because of external-ear or middle-ear disorders. Assessment findings for conductive hearing loss include hearing best in a noisy environment and speaking softly. (ch. 51, p 1129-1130) |
|
|
A nurse is administering routine antibiotics for a 65-year-old patient. Which of the following lab values would the nurse note to assess for ototoxicity of the medications?
a. HgB and Hct b. CBC and platelets c. BUN and creatinine d. ALT and AST |
C. BUN and creatinine
When ototoxic drugs are given to patients w/ reduced renal function, increased ototoxicity can result because drug elimination is slower. (ch. 51, p 1130) |
|
|
A nursing diagnosis of “Disturbed sensory perception (auditory)” is assigned for a 75-year-old patient w/ potential sensorineural hearing loss. To facilitate health promotion and maintenance, which of the following interventions should be included in the plan of care for the patient?
a. Encourage use of hearing aids b. Inform patient about possible tympanoplasty procedure c. Use foam ear inserts when in a loud environment d. Observe contact precautions when using Q-tips to clean ear canal |
C. Use foam ear inserts when in a loud environment
Prolonged exposure to loud noises can damage hair cells of the cochlea. Wearing protective ear devices, such as foam ear inserts should be used when persistent loud noises are in the environment. Hearing aids are less effective for sensorineural hearing loss and may make hearing worse by amplifying background noise. (ch. 51, p 1130-1132) |
|
|
A nurse is teaching a patient about proper ear irrigation procedure. Which of the following instructions should the nurse include in the teaching? [select all that apply]
a. Use a syringe that has an elbow tip b. Warm irrigation solution to 98°F c. Apply short, sudden bursts of pressure against top of ear canal d. Position the affected side up following irrigation e. Mineral oil may be used to soften up dried cerumen f. Use no more than 5-10mL to irrigate purulent fluid |
A. Use a syringe that has an elbow tip
B. Warm irrigation solution to 98°F E. Mineral oil may be used to soften up dried cerumen The safest type of ear syringe to use is the one that has a right-angle or “elbow” in the tip. Blasts or bursts of sudden pressure should be avoided. Irrigation shouldn’t be done if blood, pus, or other fluid is draining from the ear. (ch. 50, p 1113; ch. 51, p 1123) |
|
|
A patient received instructions regarding use of his hearing aid. Which of the following statements by the patient indicate that the teaching is successful?
a. I can use a toothpick to clean the middle of the part that goes into the ear b. Cosmetics can be applied 1 hour prior to hearing aid placement c. Hearing aid should be removed before bed and turned off after removal d. I have to go to the clinic if battery replacement is needed |
A. I can use a toothpick to clean the middle of the part that goes into the ear
Debris from the hole in the middle of the part that goes into the ear can be cleaned w/ a toothpick or a pipe cleaner. Hearing aid should be turned off before removal to prevent feedback squeaking. (ch. 51, p 1133) |
|
|
The patient asks why keeping intraocular pressure (IOP) in the normal range is so important. How should the nurse respond?
a. Increased IOP changes shape of the eyeball, leading to near-sightedness b. Decreased IOP changes shape of the eyeball, leading to far-sightedness c. Increased IOP reduces eye blood flow, leading to glaucoma and blindness d. Reduced IOP increases eye blood flow, leading to cataracts and blindness |
C. Increased IOP reduces eye blood flow, leading to glaucoma and blindness
If intraocular pressure becomes too high, the extra pressure presses on the blood vessels in the eye and prevents blood from flowing through them, a condition called glaucoma. (ch. 48, p 1071) |
|
|
Which intervention for safety should the nurse teach an older adult who is taking an oral drug that keeps her pupils constricted?
a. Open drapes or curtains and turn lights on to increase room lighting b. Don’t drink caffeinated beverages because they will make the problem worse c. Keep eyes closed when showering or bathing to prevent water from entering eyes d. Avoid bending or coughing to prevent sudden increased intraocular pressure |
A. Open drapes or curtains and turn lights on to increase room lighting
Taking a drug that causes pupillary constriction reduces an older adult’s low-light vision and can lead to accidents. Increasing environmental light can reduce the risk for falls and other accidents. (ch. 48, p 1074-1075) |
|
|
During a health visit, the patient reported using an OTC eye drops medication regularly. When teaching about side effects of the drug, the nurse would note which of the following for the patient?
a. Altered LOC b. Decreased urine output c. Pruritus d. Tinnitus |
C. Pruritus
Ocular drug effects include pruritus (itching), foreign body sensation, redness, tearing, and sensitivity to light. (ch. 48, p 1076) |
|
|
During a health visit, the patient reported using Ketorolac (acular) eye drops. When teaching about side effects of the drug, the nurse would note which of the following for the patient?
a. Check for any unusual pain or reduced vision b. Refrigerate and protect drug from light c. Assess for itching lids d. Check for bleeding |
D. Check for bleeding
NSAIDs such as Ketorolac disrupt platelet aggregation and places patient at a high risk for bleeding. (ch. 49, p 1876) |
|
|
During a home care visit, the home health nurse noted creamy white, dry, and crusty drainage on the eyelids of an older-adult patient who had a recent cataract removal surgery. Which of the following should be the nurse’s next action?
a. Contact surgeon immediately b. Document finding as normal c. Administer prophylactic eye drops d. Clean affected eye with dilute hydrogen peroxide |
B. Document finding as normal
Creamy white, dry, crusty drainage on the eyelids and lashes are normal. Yellow or green drainage indicates infection and must be reported. (ch. 49, p 1094) |
|
|
A patient asked the nurse why he has to put pressure on the corner of the eye after instilling prescribed eye drops. The nurse should respond that applying pressure:
a. Allows for systemic absorption of the drug b. Allows for multiple drops to be instilled at one time c. Prevents systemic absorption of the drug d. Reduces eye irritation during instillation |
C. Prevents systemic absorption of the drug
Punctal occlusion (placing pressure on the corner of the eye near the nose) immediately after eyedrop instillation prevents systemic absorption of the drug. (ch. 49, p 1097) |
|
|
After an eye exam, the patient asked the nurse what the ophthalmologist meant when she said he has a 20/50 vision. How should the nurse respond to the patient?
a. You can read at a distance of 50 feet what a person w/ normal vision can read at 20 feet b. You are at a greater risk for developing a chronic eye condition c. Your doctor will have to perform another test to confirm a diagnosis d. You can read at a distance of 20 feet what a person w/ normal vision can read at 50 feet |
D. You can read at a distance of 20 feet what a person w/ normal vision can read at 50 feet
Visual acuity tests measure both distance and near vision. The snellen chart is a simple tool to measure distance vision. 20/50 means that the patient can see at 20 feet from the chart what a “healthy eye” can see at 50 feet. (ch. 48, p 1077-1078) |
|
|
A nurse is performing discharge teaching for a patient who underwent cataract extraction surgery. Which of the following patient statements indicate a need for further teaching?
a. I have to avoid vigorous romantic activity for a while b. I have to call the doctor if my eyes become reddened and itchy c. I can watch TV when I get home d. I should place an eye shield on my eye when going to sleep |
B. I have to call the doctor if my eyes become reddened and itchy
Mild eye itching is normal, as is a “bloodshot appearance”. Eye drops are often prescribed for 4 – 6 weeks after cataract surgery. Activities that increase intraocular pressure, like vigorous romantic activity, should be avoided. (ch. 49, p 1091, 1094) |
|
|
A hypertensive patient newly diagnosed w/ glaucoma is ordered to take Timolol. In teaching for side effects of the drug, the nurse should instruct the patient to monitor which of the following?
a. Elevated blood glucose levels b. Pupils will remain dilated c. Low BP d. Pruritus |
C. Low BP
Beta-blockers induce hypoglycemia and also mask hypoglycemic symptoms. These drugs potentiate the effects of systemic beta blockers and can cause an unsafe drop in BP and HR. (ch. 49, p 1099) |
|
|
As part of a pre-op procedure for the patient going for cataract extraction surgery, the nurse is ordered to administer cycloplegic eye drops. The purpose of administering the eye drops is:
a. Prophylactic antibiotic for the eye b. Dilate the pupil of the eye c. Constrict the pupil of the eye d. Prevent excessive blood loss during surgery |
B. Dilate the pupil of the eye
Cycloplegic eye drops are pre-op mydriatics that induce dilation of the pupil. (ch. 49, p 1093; see also: notes – Cataracts) |
|
|
A nurse is teaching a patient how to properly administer eye drops on both eyes. Which of the following instructions should be included in the teaching? [select all that apply]
a. Tilt head forward, open eyes, and look forward b. Rest hand holding the bottle against the mouth c. Gently pull lower lid down using non-dominant hand against the cheek d. Place pressure on the corner of the eye near the nose after administration e. Wait 3-5 minutes before administering 2nd eye drops to eye f. Blink eyes after administering eye drops |
B. Rest hand holding the bottle against the mouth
C. Gently pull lower lid down using non-dominant hand against the cheek D. Place pressure on the corner of the eye near the nose after administration Head should be tilted backward, eyes open, and look at ceiling. The patient should wait for at least 10 minutes before administering 2nd eye drops to the eye and the eyes should be kept closed for about 1 minute after administration. (ch. 48, p 1076) |
|
|
Which of the following assessment questions should the nurse ask to a patient suspected of having macular degeneration?
a. Do you experience any blurred vision? b. Are you having difficulty seeing out to the side of your eyes? c. Are you experiencing any eye discomfort or pain? d. Are you experiencing frequent nausea and vomiting? |
A. Do you experience any blurred vision?
In macular degeneration, central vision declines, and patients describe mild blurring and distortion at first. Eventually, the person loses all central vision. (ch. 49, p 1100-1101) |
|
|
An older adult patient w/ glaucoma received teaching about how to prevent increased intraocular pressure (IOP). Which of the following patient statements indicate a need for further teaching?
a. I shouldn’t place my head in a dependent position b. I have to limit my fluid intake to prevent increasing the pressure c. I shouldn’t lift anything more than 20 pounds d. I may have to take a stool softener to prevent straining |
B. I have to limit my fluid intake to prevent increasing the pressure
Patients should be encouraged to eat a high-fiber diet and increase fluid intake (if not contraindicated) to prevent constipation and straining. (ch. 49, p 1091) |
|
|
The nurse is caring for a patient who just had a cataract surgery on her right eye. The nurse noted swollen conjunctiva and eyelids of the right eye. What should be the nurse’s next action?
a. Administer optical corticosteroids b. Contact physician c. Document finding as normal d. Administer cycloplegic drops |
C. Document finding as normal
Swollen conjunctiva, sclera, and eyelids are normal findings after cataract extraction surgery. Discomfort at the site is controlled by a mild analgesic such as Tylenol. (ch. 49, p 1094-1095) |
|
|
When reviewing a patient assessment form, the nurse noted an intraocular pressure finding of 30mmHg. The nurse would assess the patient for signs and symptoms of which condition?
a. Cataract b. Macular degeneration c. Glaucoma d. Presbyopia |
C. Glaucoma
Glaucoma is a group of ocular diseases resulting in increased intraocular pressure. In open-angle glaucoma, the tonometry reading is between 22 and 32 mmHg (normal reading is 10 – 21 mmHg). (ch. 49, p 1095, 1097) |
|
|
A patient w/ myopia asks the nurse how the condition is treated. How should the nurse respond?
a. Surgery may be needed to correct the condition b. You may have to wear eye glasses w/ a convex lens c. You may have to wear eye glasses w/ a biconcave lens d. Daily prescribed eye drops slow the progression of the condition |
C. You may have to wear eye glasses w/ a biconcave lens
Myopia (nearsightedness) occurs when eye overrefracts or overbends light. Near vision is normal but distance vision is poor. It is corrected w/ a biconcave lens in eye glasses or contact lenses. (ch. 48, p 1073) |
|
|
When reviewing a patient assessment form, the nurse noted the patient’s visual acuity as 20/200. The finding indicates that the patient:
a. Can read at 200 feet what a person w/ normal vision can read at 20 feet b. Has macular degeneration c. Has late manifestations of increased intraocular pressure d. Is legally blind |
D. Is legally blind
Patients are legally blind if their best visual acuity w/ corrective lenses is 20/200 or less in the better eye or if the widest diameter of the visual field in that eye is no greater than 20 degrees. (ch. 49, p 1106) |
|
|
During a med-surg exam, one of the questions asks about proper interventions for an eye condition where the focal point of light that enters the eye is behind the retina. The nursing student taking the exam should note that the question is asking for interventions for what specific condition?
a. Glaucoma b. Myopia c. Hyperopia d. Presbyopia |
C. Hyperopia
Hyperopia (farsightedness) occurs when the eye doesn’t refract light enough. As a result, images actually fall (converge) behind the retina. Vision beyond 20 ft is normal, but near vision is poor. (ch. 48, p 1073) |
|
|
Which factor predisposes a patient to a much higher risk of developing macular degeneration?
a. Smoking b. Frequent increased intraocular pressure c. Sedentary lifestyle d. Previous eye trauma |
A. Smoking
Macular degeneration is the deterioration of the macula and can be atrophic or exudative. This type of degeneration is more common and progresses at a faster rate among smokers than among non-smokers. (ch. 49, p 1100-1101) |
|
|
In caring for a patient diagnosed of having cataract formation, the nurse planning the care of the patient should know that treatment focuses on which part of the eye?
a. Pupil b. Lens c. Cornea d. Iris |
B. Lens
A cataract is an opacity of the lens that distorts the image projected onto the retina. With aging, the lens gradually loses water and increases in density. (ch. 49, p 1091) |
|
|
During a health visit, a patient w/ glaucoma is ordered to take Apraclonidine (lopidine) eye drops. As part of the care, the nurse should assess the patient for which of the following?
a. Any allergic reactions to Sulfa drugs b. History of asthma or COPD c. Use of MAOIs d. Use of any oral beta blockers |
C. Use of MAOIs
MAOIs increase BP as do the adrenergic agonists (Apraclonidine). When taken together, the patient may experience hypertensive crisis. (ch. 49, p 1099-1100) |
