SENSORIAL

A client comes to the emergency department with periorbital ecchymosis of the right eye. Which is the nurse’s priority action?. an ice pack to the affected eye. Patching the eye to prevent eye movement. Assessing the client’s vision in both eyes. Irrigating the affected eye with normal saline.

The client has been treated with radiation therapy to the eye. What will the nurse teach the client?. a. “Have your intraocular pressure measured every year, starting at age 40.”. b. “Always wear dark glasses when going out in the sunlight.”. c. “See your ophthalmologist for a complete eye examination yearly.”. d. “Examine the sclera weekly for a bluish tinge.”.

Which is the priority nursing diagnosis for a client who has a severe visual impairment?. a. Risk for Injury. b. Chronic Confusion. c. Risk for Loneliness. d. Disturbed Body Image.

What will the nurse recommend to the client starting therapy with meclizine (Antivert)?. “Take the medicine once daily, at the same time every day.”. “Avoid caffeinated coffee or soft drinks while taking this medication.”. “Do not take Antivert before bedtime, because it can cause insomnia.”. “Take the entire course of Antivert, even if the dizziness improves.”.

A client with a ruptured tympanic membrane asks the nurse if his hearing will be affected permanently. Which is the nurse’s best response?. “Possibly, although the eardrum usually heals spontaneously in 1 to 2 weeks. Any persistent hearing problem should be evaluated.”. “No, antibiotics will help resolve the infection and cure your hearing impairment.”. “Yes, and it will be important for you to be fitted with a hearing aid as soon as possible.”. “Yes, any time the eardrum is ruptured it will form a scar and cause some degree of permanent hearing loss.”.

The nurse assesses a client post–cataract surgery and finds white, dry, crusty drainage on the client’s eyelid and lashes. What will the nurse do next?. Obtain a specimen of the drainage for culture. Clean away the drainage and apply the prescribed drops. Contact the physician for an antibiotic order. Arrange for the client to be seen by the ophthalmologist today.

The nurse is caring for a client who has just been diagnosed with profound hearing loss. The client tells the nurse, “The doctors must have made a mistake. There’s no way I can be deaf!” Which is the nurse’s best response?. “Why do you think that the doctors made a mistake?”. “I can tell that you are anxious and scared about your hearing.”. “Lots of people lead productive lives after losing their hearing.”. “The doctors did extensive tests to make sure that the diagnosis was correct.”.

The nurse assesses several clients. Which one is most likely to have secondary open-angle glaucoma?. A client with a gradual onset of blurred vision. A client who has recently had eye surgery. A client who sees halos around lights. A client with reactive pupils and clear sclera.

An older adult client who has a mature cataract in the right eye states, “Now I have lost the sight in my right eye because I waited too long for treatment.” How will the nurse best respond to the client?. “Yes, this type of blindness could have been prevented by earlier treatment.”. “It is fortunate that you came for treatment in time to save the sight of your other eye.”. “Nothing you could have done would have made any difference.”. “Surgery can still save the sight in your eye.”.

The nurse is caring for a client with external otitis. Which assessment finding indicates to the nurse that the client’s infection has worsened?. The client now reports tinnitus and vertigo at night. The client now has a positive Rinne test, with AC > BC. The tympanic membrane is pearly gray with white patches. The auricular lymph nodes have increased in size over the last 24 hours.

Which clinical manifestation alerts the nurse to the possibility of a vitreous humor hemorrhage?. Presence of a red reflex. Reddened whites of the eye. Red haze or floaters in the line of vision. Swelling of the upper and lower eyelids.

The client requires a hearing aid but tells the nurse that he cannot afford to pay for it right now. What is the nurse's best response?. ´´Your insurance company should help pick up some of the cost so you won´t have to pay to much.´´. ´The hospital can set up a payment plan to help you pay for the new hearing aid.´´. ."I'll ask the social worker about organizations that help pay for hearing aids.". ¨´You can check around to see who has the lowest price on the type of hearing aids that you need.´´.

When performing the client’s physical assessment, the nurse notes that the client has conductive hearing loss. Which finding does the nurse expect to see in the client’s medical history?. History of diabetes with peripheral neuropathy. Frequent episodes of otitis media during childhood. History of frequent impactions of cerumen in the ear canals. History of osteomyelitis treated with IV gentamicin Garamycin).

The nurse is caring for a client with Meniere’s disease. The client asks the nurse how to prevent another acute episode from occurring. Which is the nurse’s best response?. “Stop or reduce cigarette smoking.”. “Use aspirin for pain rather than acetaminophen (Tylenol).”. “Reduce the amount of saturated fats in your diet.”. “Avoid crowds and people with upper respiratory infections.”.

The nurse is providing discharge instructions for a client who will be going home following tympanoplasty surgery. Which statement by the client indicates that additional teaching is needed?. “I will wear earplugs whenever I am in noisy areas.”. “I will only occlude one nostril when I blow my nose.”. “I will wait 3 weeks before I resume my aerobics workouts.”. “I will use a cotton swab to clean drainage from my inside my ear.”.

Which is the correct technique for irrigating the eye?. From the middle out. From the inner canthus to the outer canthus. From the outer canthus to the inner canthus. Against the inner aspect of the eyelid.

The nurse is caring for a client with Meniere’s disease. What will the nurse recommend to a client to reduce the symptoms of vertigo?. “Take salt and potassium supplements daily.”. “Drink at least eight glasses of water every day.”. “Blow your nose hard when dizziness first begins.”. “When dizziness begins, lie down and keep your head still.”.

Which is the most important information for the nurse to teach a client who is receiving cycloplegic drug therapy?. “Do not drive or operate machinery until the drug wears off.”. “Use at least a 30 SPF sunscreen agent when going outdoors.”. “Remain on bedrest for 24 hours.”. “Turn up the lights because acuity will be decreased in low-light environments.”.

A client is using an ophthalmic beta-blocking agent for the treatment of glaucoma. Which instruction will the nurse give to the client to prevent orthostatic hypotension?. “Change positions quickly after administering the drops.”. “Take your pulse at least four times daily.”. “Apply pressure to the inside corner of your eye when administering the drops.”. Lay down for 10 minutes after administering the drops.”.

Which is the most precaution for the nurse to teach the client being treated for posterior uveitis?. Correct technique for eyedrop instillation. Clinical manifestations of retinal hemorrhage. Correct technique for insertion of contact lenses. Proper timing of opioid analgesics.

Which instruction will the nurse provide about a cephalexin (Keflex) prescription that the client will be taking at home after tympanoplasty surgery?. Be sure to finish all the Keflex pills, even if you feel fine.". The Keflex may turn your urine an orange color while you are taking it.´. Have the Keflex on an empty stomach and do not lie down for at least 30 minutes afterward.´´. Use sunscreen and avoid prolonged exposure to sunlight while you are taking Keflex.´´.

A client having the intraocular pressure measured asks the nurse why this is necessary every year. How will the nurse respond?. Elevated eye pressure can cause high, your eyes will dry out.". " if eye pressure is too high, your eyes will dry out". “Elevated eye pressure can press on blood vessels in the eye”.

which is the best approach for the nurse to use to obtain a history from a client with sudden hearing loss?. Question the client´s wife. Write out the questions for the client to answer. Obtain the information from the client´s old chart. Check with the client´s primary health care provider.

Which assessment alerts the nurse to the possible presence of a cataract?. Loss of central vision. Loss of peripheral vision. Dull aching in the eye and brow areas. Blurred vision and reduced color perception.

The nurse is caring for a client with otitis media and notes purulent drainage in the ear canal during the physical assessment. Which is the nurse’s priority intervention?. Obtaining a specimen of the drainage for culture. Irrigating the ear canal with sterile normal saline. Gently examining the client’s ear with an otoscope. Placing a cotton ball in the ear canal to absorb the drainage.

The nurse is caring for an older client whose ear canals are impacted with hard cerumen. Which is the best intervention for the nurse to implement to facilitate removal of the cerumen?. Instruct the client to put a few drops of mineral oil into each ear every evening and schedule the irrigation for 3 days later. Aim the irrigation fluid directly at the center of the cerumen to facilitate dissolving the impaction. Administer 10 mg of prochlorperazine Compazine) to prevent nausea during irrigation of the ears. Irrigate the ears with 35 to 40 ml of sterile normal saline and repeat as needed until the cerumen is cleared.