Saunders NCLEX RN - Eyes/Ears questions and answers well illustrated.

Saunders NCLEX RN - Eyes/Ears questions and answers well illustrated. The nurse is developing a teaching plan for a client with glaucoma. Which instruction should the nurse include in the plan of care? 1. Avoid overuse of the eyes. 2. Decrease the amount of salt in the diet. 3. Eye medications will need to be administered for life. 4. Decrease fluid intake to control the intraocular pressure. - correct answers.3. Eye medications will need to be administered for life. The nurse is performing an admission assessment on a client with a diagnosis of detached retina. Which sign or symptom is associated with this eye disorder? 1. Total loss of vision 2. Pain in the affected eye 3. A yellow discoloration of the sclera 4. A sense of a curtain falling across the field of vision - correct answers.4. A sense of a curtain falling across the field of vision The nurse is performing an assessment on a client with a suspected diagnosis of cataract. Which clinical manifestation should the nurse expect to note in the early stages of cataract formation? 1. Diplopia 2. Eye pain 3. Floating spots 4. Blurred vision - correct answers.4. Blurred vision The nurse is preparing a teaching plan for a client who had a cataract extraction with intraocular implantation. Which home care measures should the nurse include in the plan? Select all that apply. 1. Avoid activities that require bending over. 2. Contact the surgeon if eye scratchiness occurs. 3. Take acetaminophen for minor eye discomfort. 4. Expect episodes of sudden severe pain in the eye. 5. Place an eye shield on the surgical eye at bedtime. 6. Contact the surgeon if a decrease in visual acuity occurs. - correct answers.1. Avoid activities that require bending over. 3. Take acetaminophen for minor eye discomfort. 5. Place an eye shield on the surgical eye at bedtime. 6. Contact the surgeon if a decrease in visual acuity occurs. Tonometry is performed on a client with a suspected diagnosis of glaucoma. The nurse looks at the documented test results and notes an intraocular pressure (IOP) value of 23. What should be the nurse's initial action? 1. Apply normal saline drops. 2. Note the time of day the test was done. 3. Contact the health care provider (HCP). 4. Instruct the client to sleep with the head of the bed flat. - correct answers.2. Note the time of day the test was done. A client's vision is tested with a Snellen chart. The results of the tests are documented as 20/60. What action should the nurse implement based on this finding? 1. Provide the client with materials on legal blindness. 2. Instruct the client that he or she may need glasses when driving. 3. Inform the client of where he or she can purchase a white cane with a red tip. 4. Inform the client that it is best to sit near the back of the room when attending lectures. - correct answers.2. Instruct the client that he or she may need glasses when driving. A client is diagnosed with glaucoma. Which piece of nursing assessment data identifies a risk factor associated with this eye disorder? 1. Cardiovascular disease 2. Frequent urinary tract infections 3. A history of migraine headaches 4. Frequent upper respiratory infections - correct answers.1. Cardiovascular disease A client with retinal detachment is admitted to the nursing unit in preparation for a repair procedure. Which prescription should the nurse anticipate? 1. Allowing bathroom privileges only 2. Elevating the head of the bed to 45 degrees 3. Wearing dark glasses to read or watch television 4. Placing an eye patch over the client's affected eye - correct answers.4. Placing an eye patch over the client's affected eye The nurse is caring for a client who was recently diagnosed with primary open-angle glaucoma (POAG). Which assessment finding is specific to this type of glaucoma? 1. Client report of blurred vision 2. Client report of "tunnel vision" 3. Client report of ocular erythema 4. Client report of halos around lights - correct answers.2. Client report of "tunnel vision" The nurse in the health care clinic is providing instructions to a client regarding the use of a hearing aid. Which statement is most appropriate for the nurse to include? 1. "The hearing aid should not be worn if an ear infection is present." 2. "The ear mold for the hearing aid should be washed with mild soap and water once a month." 3. "The hearing aid should be removed from the ear at the end of the day and then turned off after removal." 4. "The hearing aid contains a lifelong battery, so you will not need to be concerned about changing batteries." - correct answers.1. "The hearing aid should not be worn if an ear infection is present." The nurse is preparing to provide care for a client who will need an ear irrigation to remove impacted cerumen. Which interventions should the nurse take when performing the irrigation? Select all that apply. 1. Apply some force when instilling the irrigation solution. 2. Position the client with the affected side down after the irrigation. 3. Warm the irrigating solution to a temperature that is close to body temperature. 4. Position the client to turn the head so that the ear to be irrigated is facing upward. 5. Direct a slow, steady stream of irrigation solution toward the upper wall of the ear canal. - correct answers.2. Position the client with the affected side down after the irrigation. 3. Warm the irrigating solution to a temperature that is close to body temperature. 5. Direct a slow, steady stream of irrigation solution toward the upper wall of the ear canal. The home care nurse is visiting a client who was recently diagnosed with a hearing impairment. The nurse should prepare to instruct the client's spouse in which measure that will facilitate communication? 1. Speak loudly to the client to facilitate hearing. 2. Speak directly into the impaired ear to facilitate hearing. 3. Speak in a normal tone and face the client when speaking. 4. Speak frequently to the client to provide sensory stimulation. - correct answers.3. Speak in a normal tone and face the client when speaking. A client arrives at the emergency department with a foreign body in the left ear and tells the nurse that an insect flew into the ear. Which intervention should the nurse implement initially? 1. Irrigation of the ear 2. Instillation of mineral oil 3. Instillation of antibiotic eardrops 4. Instillation of corticosteroid ointment - correct answers.2. Instillation of mineral oil