Ch46 Nursing Care Of Patients With Test Questions & Answers - Medical Surgical Nursing 7e | Test Bank by LeMone, Burke, Bauldoff by LeMone, Burke, Gerene Bauldoff. DOCX document preview.
LeMone & Burke's Medical-Surgical Nursing, 7e (Bauldoff/Gubrud/Carno)
Chapter 46 Nursing Care of Patients with Eye and Ear Disorders
1) A patient who became blind in the left eye because of an industrial accident says, "I still have one good eye, and I can still do a lot." What should the nurse realize this patient is demonstrating?
1. Acceptance
2. Denial
3. Remorse
4. Anticipatory grieving
Page Ref: 1693
Cognitive Level: Analyzing
Client Need & Sub: Psychosocial Integrity: Grief and Loss
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.5. Deliver compassionate, patient-centered, evidence-based care that respects patient and family preferences | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 46.1 Describe the pathophysiology and manifestations of eye disorders, and outline the interprofessional care and nursing care of patients with these disorders.
MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with eye and ear disorders.
2) The nurse is instructing a patient on the self-instillation of eye drops for acute conjunctivitis. What is the most important step for the nurse to teach this patient?
1. Ensure proper hand hygiene before instilling the drops.
2. Rub the eyes only when necessary.
3. Reuse cotton swabs as needed.
4. Insert contact lenses after the eye drops have been instilled.
Page Ref: 1695
Cognitive Level: Applying
Client Need & Sub: Physiological Integrity: Reduction of Risk Potential
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning
Learning Outcome: 46.1 Describe the pathophysiology and manifestations of eye disorders, and outline the interprofessional care and nursing care of patients with these disorders.
MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with eye and ear disorders.
3) A patient is learning how to apply and care for a new set of contact lenses. What should the nurse include when teaching the patient about the use of these lenses? Select all that apply.
1. Wash hands before and after applying the lenses.
2. Eye pain is a common complaint and should not be a concern.
3. Distilled water is the best solution for the lenses.
4. Once applied, only remove when cloudy.
5. Contact eye physician if eyes become red or tear.
Page Ref: 1697
Cognitive Level: Applying
Client Need & Sub: Physiological Integrity: Reduction of Risk Potential
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning
Learning Outcome: 46.1 Describe the pathophysiology and manifestations of eye disorders, and outline the interprofessional care and nursing care of patients with these disorders.
MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with eye and ear disorders.
4) A patient comes into the clinic complaining of "black spots and a curtain dropping" in the right eye. Which health problem should the nurse suspect is occurring with this patient?
1. Detached retina
2. Conjunctivitis
3. Sty
4. Cataract
Page Ref: 1718
Cognitive Level: Analyzing
Client Need & Sub: Physiological Integrity: Reduction of Risk Potential
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 46.1 Describe the pathophysiology and manifestations of eye disorders, and outline the interprofessional care and nursing care of patients with these disorders.
MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with eye and ear disorders.
5) A patient is diagnosed with a corneal abrasion. What should the nurse instruct this patient?
1. Do not share or use another person's eye makeup.
2. Only share a towel with family members.
3. Gently rub the eyes when itchy.
4. Use the prescribed eye drops until the symptoms disappear.
Page Ref: 1701
Cognitive Level: Applying
Client Need & Sub: Physiological Integrity: Reduction of Risk Potential
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning
Learning Outcome: 46.1 Describe the pathophysiology and manifestations of eye disorders, and outline the interprofessional care and nursing care of patients with these disorders.
MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with eye and ear disorders.
6) A patient with an ectropion continues to experience eye dryness and corneal abrasions. What intervention might be indicated for this patient?
1. Corrective surgery
2. Corrective lenses
3. UV protective sunglasses
4. Contact lenses
Page Ref: 1702
Cognitive Level: Analyzing
Client Need & Sub: Physiological Integrity: Reduction of Risk Potential
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning
Learning Outcome: 46.1 Describe the pathophysiology and manifestations of eye disorders, and outline the interprofessional care and nursing care of patients with these disorders.
MNL Learning Outcome: 2. Consider intraprofessional care for patients with eye and ear disorders.
7) A patient is hospitalized with blunt trauma to the left eye. To best minimize eye movement, what should the nurse do?
1. Patch or provide an eye shield for both eyes.
2. Place the patient in a side-lying position, with the eye up.
3. Keep the bed position flat.
4. Patch the unaffected eye.
Page Ref: 1704
Cognitive Level: Applying
Client Need & Sub: Physiological Integrity: Reduction of Risk Potential
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 46.1 Describe the pathophysiology and manifestations of eye disorders, and outline the interprofessional care and nursing care of patients with these disorders.
MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with eye and ear disorders.
8) An older patient with a mobility disorder is being discharged after having a cataract removed as an outpatient. For what should the nurse assess this patient?
1. Ability to administer eye drops post-procedure
2. Ability to read discharge instructions
3. Ability to drive
4. Ability to ambulate
Page Ref: 1707
Cognitive Level: Applying
Client Need & Sub: Physiological Integrity: Reduction of Risk Potential
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 46.1 Describe the pathophysiology and manifestations of eye disorders, and outline the interprofessional care and nursing care of patients with these disorders.
MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with eye and ear disorders.
9) The nurse assesses a reduction in a patient's peripheral vision. Which additional measure would be a priority during the assessment of this patient?
1. Intraocular pressure assessment
2. Cranial nerve assessment
3. Neck range of motion assessment
4. Retinal assessment
Page Ref: 1707
Cognitive Level: Applying
Client Need & Sub: Physiological Integrity: Reduction of Risk Potential
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 46.1 Describe the pathophysiology and manifestations of eye disorders, and outline the interprofessional care and nursing care of patients with these disorders.
MNL Learning Outcome: 2. Consider intraprofessional care for patients with eye and ear disorders.
10) A patient with COPD is being treated for glaucoma. Which medication should the nurse expect to be prescribed for this patient?
1. Adrenergic agonist
2. Beta-blocker
3. Calcium channel blocker
4. Antibiotic
Page Ref: 1710
Cognitive Level: Analyzing
Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning
Learning Outcome: 46.1 Describe the pathophysiology and manifestations of eye disorders, and outline the interprofessional care and nursing care of patients with these disorders.
MNL Learning Outcome: 2. Consider intraprofessional care for patients with eye and ear disorders.
11) A patient diagnosed with exudative macular degeneration reads as primary recreation. What should the nurse suggest to this patient?
1. Obtain books on tape or CD.
2. Find another activity that does not require reading.
3. Spend more time with friends and family.
4. Listen to music instead of watching so much television.
Page Ref: 1712
Cognitive Level: Applying
Client Need & Sub: Psychosocial Integrity: Coping Mechanisms
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 46.1 Describe the pathophysiology and manifestations of eye disorders, and outline the interprofessional care and nursing care of patients with these disorders.
MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with eye and ear disorders.
12) A school-age child is having difficulty walking and seeing during the night. Which health problem should the nurse suspect is occurring with this patient?
1. Retinitis pigmentosa
2. Early macular degeneration
3. Detached retina
4. Glaucoma
Page Ref: 1719
Cognitive Level: Analyzing
Client Need & Sub: Physiological Integrity: Physiological Adaptation
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 46.1 Describe the pathophysiology and manifestations of eye disorders, and outline the interprofessional care and nursing care of patients with these disorders.
MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with eye and ear disorders.
13) A patient experiences an increase in ear pain when the auricle is pulled up and back. Which health problem should the nurse suspect is occurring with this patient?
1. Otitis externa
2. Otitis media
3. Otitis interna
4. Mastoiditis
Page Ref: 1720
Cognitive Level: Analyzing
Client Need & Sub: Physiological Integrity: Physiological Adaptation
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 46.2 Describe the pathophysiology and manifestations of ear disorders, and outline the interprofessional care and nursing care of patients with these disorders.
MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with eye and ear disorders.
14) A patient is seen for hearing loss and odd popping noises in the left ear after "having a cold." Which potential problem should be considered for this patient?
1. Serous otitis media
2. Otitis externa
3. Acute otitis media
4. Otitis interna
Page Ref: 1723
Cognitive Level: Analyzing
Client Need & Sub: Physiological Integrity: Physiological Adaptation
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 46.2 Describe the pathophysiology and manifestations of ear disorders, and outline the interprofessional care and nursing care of patients with these disorders.
MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with eye and ear disorders.
15) A patient with chronic acute otitis media infections is having tympanostomy tubes placed. What should post-tube placement instructions for this patient include?
1. Avoid getting any water into the ears.
2. Wash hair only with warm water.
3. Make sure showers are completed within 10 minutes.
4. Avoid gum chewing.
Page Ref: 1724
Cognitive Level: Applying
Client Need & Sub: Physiological Integrity: Reduction of Risk Potential
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning
Learning Outcome: 46.2 Describe the pathophysiology and manifestations of ear disorders, and outline the interprofessional care and nursing care of patients with these disorders.
MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with eye and ear disorders.
16) A patient with chronic otitis media is diagnosed with a cholesteatoma. What would be the treatment of choice for this patient?
1. Surgery
2. Nothing; it will resolve on its own
3. Antibiotics
4. Tympanostomy tubes
Page Ref: 1726
Cognitive Level: Analyzing
Client Need & Sub: Physiological Integrity: Reduction of Risk Potential
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning
Learning Outcome: 46.2 Describe the pathophysiology and manifestations of ear disorders, and outline the interprofessional care and nursing care of patients with these disorders.
MNL Learning Outcome: 2. Consider intraprofessional care for patients with eye and ear disorders.
17) A patient is experiencing a severe episode of Ménière disease. Which medication should the nurse expect to be prescribed to help reduce the sensation of spinning and nausea occurring in this patient?
1. Meclizine hydrochloride (Antivert)
2. Morphine sulfate
3. Digoxin (Lanoxin)
4. Droperidol (Inapsine)
Page Ref: 1728
Cognitive Level: Analyzing
Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning
Learning Outcome: 46.2 Describe the pathophysiology and manifestations of ear disorders, and outline the interprofessional care and nursing care of patients with these disorders.
MNL Learning Outcome: 2. Consider intraprofessional care for patients with eye and ear disorders.
18) The nurse is instructing a patient who has a hearing and balance disorder. What should be included in these instructions? Select all that apply.
1. Change positions slowly.
2. Turn the whole body, rather than just the head.
3. Stand very still with the onset of vertigo.
4. Increase pace of ambulation.
5. Avoid reclining while taking antivertigo medication.
Page Ref: 1729
Cognitive Level: Applying
Client Need & Sub: Physiological Integrity: Reduction of Risk Potential
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning
Learning Outcome: 46.2 Describe the pathophysiology and manifestations of ear disorders, and outline the interprofessional care and nursing care of patients with these disorders.
MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with eye and ear disorders.
19) An older patient often responds incorrectly to questions or during general conversation. For which health problem should this patient be assessed?
1. Hearing disorder
2. History of strokes
3. Level of education
4. Cognitive impairment
Page Ref: 1735
Cognitive Level: Analyzing
Client Need & Sub: Health Promotion and Maintenance: Health Screening
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 46.2 Describe the pathophysiology and manifestations of ear disorders, and outline the interprofessional care and nursing care of patients with these disorders.
MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with eye and ear disorders.
20) A patient who is a single parent of two young children has recently lost vision in one eye following a car accident. Which problem should the nurse address as being high priority with this patient?
1. Grieving
2. Change in family functioning
3. Possible change in self-esteem
4. Potential for injury
5. Fear of future trauma
Page Ref: 1693-1694
Cognitive Level: Analyzing
Client Need & Sub: Psychosocial Integrity: Coping Mechanisms
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.5. Deliver compassionate, patient-centered, evidence-based care that respects patient and family preferences | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 46.1 Describe the pathophysiology and manifestations of eye disorders, and outline the interprofessional care and nursing care of patients with these disorders.
MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with eye and ear disorders.
21) A patient who has been blind since birth is admitted to the hospital. Which action should the nurse take when caring for this patient? Select all that apply.
1. Orient the patient verbally and physically to the layout of the room.
2. Leave the room door partially open.
3. Place signs to remind staff not to move equipment.
4. Ensure the television is on at all times.
5. Tell the patient you will leave the light on 24 hours a day.
Page Ref: 1693-1694
Cognitive Level: Applying
Client Need & Sub: Safe and Effective Care Environment: Safety and Infection Control
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.5. Deliver compassionate, patient-centered, evidence-based care that respects patient and family preferences | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 46.1 Describe the pathophysiology and manifestations of eye disorders, and outline the interprofessional care and nursing care of patients with these disorders.
MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with eye and ear disorders.
22) A patient is recovering from a myringotomy for acute otitis media. What should the nurse emphasize with this patient?
1. Avoid sudden changes in barometric pressure.
2. Ear irrigations should be placed on the wall of the external canal.
3. Sterile, cotton-tipped swabs can be used to clean the ear drainage.
4. Swimming is restricted for approximately two weeks.
Page Ref: 1725
Cognitive Level: Applying
Client Need & Sub: Physiological Integrity: Reduction of Risk Potential
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning
Learning Outcome: 46.2 Describe the pathophysiology and manifestations of ear disorders, and outline the interprofessional care and nursing care of patients with these disorders.
MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with eye and ear disorders.
23) A patient is recovering from keratoplasty. What information should be included in the nursing plan of care? Select all that apply.
1. Wear an eye shield the first 24 hours and then at night until several weeks postoperatively as directed by healthcare provider.
2. Avoid lifting, sneezing, coughing, or bending over at the waist.
3. Report any change noted, such as increased pain, drainage, bleeding, floaters, and cloudiness.
4. Administer all eyedrops and ointments in a sterile manner.
5. Administer mydriatics during the postoperative period.
Page Ref: 1699
Cognitive Level: Applying
Client Need & Sub: Physiological Integrity: Reduction of Risk Potential
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning
Learning Outcome: 46.1 Describe the pathophysiology and manifestations of eye disorders, and outline the interprofessional care and nursing care of patients with these disorders.
MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with eye and ear disorders.
24) The nurse is planning care for a patient with severe symptoms of tinnitus, vertigo, sensorineural hearing deficit, nausea, and vomiting. What issue should the nurse identify as a priority for this patient?
1. Anticipating future attacks
2. Ensuring adequate nutritional intake
3. Problems with interpersonal relationships
4. Difficulty sleeping
Page Ref: 1729
Cognitive Level: Applying
Client Need & Sub: Safe and Effective Care Environment: Safety and Infection Control
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning
Learning Outcome: 46.2 Describe the pathophysiology and manifestations of ear disorders, and outline the interprofessional care and nursing care of patients with these disorders.
MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with eye and ear disorders.
25) The nurse is identifying interventions for a patient with a hearing deficit. What should be included in this patient's plan of care? Select all that apply.
1. Speak face-to-face, but do not overarticulate your words.
2. Offer alternative methods of communication, such as paper and pencil.
3. Use facial and hand gestures while talking.
4. Speak loudly and in a higher pitch for easier understanding of words.
5. Restate in exactly the same words if not understood the first time.
Page Ref: 1735
Cognitive Level: Applying
Client Need & Sub: Psychosocial Integrity: Coping Mechanisms
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning
Learning Outcome: 46.2 Describe the pathophysiology and manifestations of ear disorders, and outline the interprofessional care and nursing care of patients with these disorders.
MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with eye and ear disorders.
26) The nurse is preparing to conduct a physical assessment on a patient with otosclerosis. Which finding should the nurse anticipate in this patient?
1. Rinne test results show that bone conduction is equal or greater than air conduction.
2. Severe vertigo is present when questioned.
3. Purulent drainage is observed or reported with cyanosis of the tympanic membrane.
4. Diminished hearing is noted in the lower tones, such as a man's speaking voice.
Page Ref: 1726
Cognitive Level: Analyzing
Client Need & Sub: Health Promotion and Maintenance: Techniques of Physical Assessment
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 46.2 Describe the pathophysiology and manifestations of ear disorders, and outline the interprofessional care and nursing care of patients with these disorders.
MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with eye and ear disorders.
27) A patient is being treated for an eye infection. Which instruction should the nurse provide the patient about self-care? Select all that apply.
1. "You should wash your hands before cleansing your eye and putting in eyedrops."
2. "You can soak your lids with warm saline to soften crusts and exudates."
3. "You should not share towels, makeup, or contact lenses with anyone else."
4. "You can apply warm compresses to ease inflammation."
5. "You can rub your eyes with a clean, soft cloth for itching."
Page Ref: 1695, 1696
Cognitive Level: Applying
Client Need & Sub: Safe and Effective Care Environment: Safety and Infection Control
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning
Learning Outcome: 46.1 Describe the pathophysiology and manifestations of eye disorders, and outline the interprofessional care and nursing care of patients with these disorders.
MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with eye and ear disorders.
28) The nurse is reviewing medications prescribed for patients with open-angle glaucoma. Which medication should the nurse question?
1. Timolol (Timoptic), beta-adrenergic blocker, for a 60-year-old with congestive heart failure (CHF)
2. Dorzolamide (Trusopt), a carbonic anhydrase inhibitor, for a patient with asthma and chronic obstructive pulmonary disease (COPD)
3. Acetazolamide (Diamox) for a 20-year-old male
4. Brimonidine (Alphagan), an adrenergic agonist, for a healthy 40-year-old
Page Ref: 1711
Cognitive Level: Analyzing
Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 46.1 Describe the pathophysiology and manifestations of eye disorders, and outline the interprofessional care and nursing care of patients with these disorders.
MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with eye and ear disorders.
29) A patient with keratitis is to have diagnostic testing. What should the nurse anticipate being prescribed for this patient?
1. Fluorescein staining with slit-lamp examination
2. Photoreactive keratectomy
3. Computed tomography (CT) scan
4. Glycerol test
Page Ref: 1694
Cognitive Level: Applying
Client Need & Sub: Physiological Integrity: Reduction of Risk Potential
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning
Learning Outcome: 46.1 Describe the pathophysiology and manifestations of eye disorders, and outline the interprofessional care and nursing care of patients with these disorders.
MNL Learning Outcome: 2. Consider intraprofessional care for patients with eye and ear disorders.
30) A young child is being seen with an impaction of the ear canal by a large plastic bead. Which procedure should the nurse expect to be used to remove this object?
1. Suction using a soft piece of tubing
2. Instillation of lidocaine drops
3. Instillation of mineral oil
4. Forceps
Page Ref: 1722
Cognitive Level: Applying
Client Need & Sub: Physiological Integrity: Reduction of Risk Potential
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 46.2 Describe the pathophysiology and manifestations of ear disorders, and outline the interprofessional care and nursing care of patients with these disorders.
MNL Learning Outcome: 2. Consider intraprofessional care for patients with eye and ear disorders.
31) A young soldier recovering from enucleation due to traumatic injury is concerned that his significant other will not want to continue the relationship. What is an appropriate response by the nurse?
1. "You'll probably get your temporary prosthesis in a week and your permanent one in 1 or 2 months. Most people won't know which eye is which."
2. "I wouldn't worry; your girlfriend is not going to give up on you."
3. "Your hearing aid will be nearly invisible; no one will know you have one."
4. "Why don't you tell a couple of your friends to bring you a pizza? That will cheer you up."
Page Ref: 1719-1720
Cognitive Level: Applying
Client Need & Sub: Psychosocial Integrity: Coping Mechanisms
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation/Caring
Learning Outcome: 46.1 Describe the pathophysiology and manifestations of eye disorders, and outline the interprofessional care and nursing care of patients with these disorders.
MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with eye and ear disorders.
32) The nurse is talking with a member of the family of a patient who had surgery for a cochlear implant. Which statement by the family member is correct?
1. "A cochlear implant won't replace normal hearing; it will improve sound perception."
2. "It will be much nicer than a hearing aid, as nothing needs to be worn or will be visible."
3. "The speaking voice will improve, too."
4. "It will be less expensive than a hearing aid since you don't have much equipment."
Page Ref: 1734
Cognitive Level: Analyzing
Client Need & Sub: Physiological Integrity: Reduction of Risk Potential
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.9. Monitor client outcomes to evaluate the effectiveness of psychobiological interventions | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Evaluation/Communication and Documentation
Learning Outcome: 46.2 Describe the pathophysiology and manifestations of ear disorders, and outline the interprofessional care and nursing care of patients with these disorders.
MNL Learning Outcome: 2. Consider intraprofessional care for patients with eye and ear disorders.
33) The nurse is completing a health history interview of a patient with a suspected diagnosis of retinitis pigmentosa. What question should the nurse ask this patient during the interview? Select all that apply.
1. Do you have any health problems that have a genetic basis?
2. Do you know if your parents have had or your children are experiencing any symptoms similar to what you are experiencing?
3. What is your current occupation?
4. Have you ever suffered blunt trauma to the head?
5. Have you ever been told you were HIV positive?
Page Ref: 1719
Cognitive Level: Applying
Client Need & Sub: Physiological Integrity: Physiological Adaptation
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 46.1 Describe the pathophysiology and manifestations of eye disorders, and outline the interprofessional care and nursing care of patients with these disorders.
MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with eye and ear disorders.
34) The nurse is teaching a community education class on prevention of eye injuries and care of someone with an eye injury. What should be included in this presentation? Select all that apply.
1. Eye protection devices should be worn when participating in high-risk sports or occupations.
2. Use of seat belts and air bags prevents eye injuries in automobile crashes.
3. In case of injury, immediately flush the eye with copious amounts of water if a chemical splash occurs.
4. Loose, visible objects can be removed using a clean, moistened cotton-tipped swab.
5. If an object appears to penetrate the eye, gently remove it using sterile gauze and seek medical attention.
Page Ref: 1705
Cognitive Level: Applying
Client Need & Sub: Physiological Integrity: Reduction of Risk Potential
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning
Learning Outcome: 46.1 Describe the pathophysiology and manifestations of eye disorders, and outline the interprofessional care and nursing care of patients with these disorders.
MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with eye and ear disorders.
35) A patient with a hordeolum (sty) asks what caused the disorder. What is the nurse's best response?
1. "This may be due to the dandruff on your scalp and eyebrows."
2. "This is possibly a side-effect of a medication you are taking."
3. "It is a result of eversion of the eyelid and associated with the aging process."
4. "It may be due to squinting when you are in the sun and not wearing sunglasses."
Page Ref: 1701
Cognitive Level: Applying
Client Need & Sub: Physiological Integrity: Reduction of Risk Potential
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.4. Communicate effectively with all members of the healthcare team, including the patient and the patient's support network | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation/Communication and Documentation
Learning Outcome: 46.1 Describe the pathophysiology and manifestations of eye disorders, and outline the interprofessional care and nursing care of patients with these disorders.
MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with eye and ear disorders.
36) The nurse is asked by a patient with diabetes actions to take to preserve vision. What is the best response by the nurse?
1. "The risk of developing blindness is related to how long you've had diabetes, and how well your blood sugar and hypertension are controlled."
2. "Blindness from diabetes is due to the small blood vessels in the eye becoming hardened and clogged and not being able to transport oxygen and nutrients to the retina."
3. "This is only a problem with type 2 diabetes, so you won't have this problem."
4. "Laser photocoagulation surgery will treat any problems that develop and stop the progression of diabetic retinopathy."
Page Ref: 1717
Cognitive Level: Applying
Client Need & Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning
Learning Outcome: 46.1 Describe the pathophysiology and manifestations of eye disorders, and outline the interprofessional care and nursing care of patients with these disorders.
MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with eye and ear disorders.
37) The nurse is preparing to provide eardrops for a patient. Place the following steps in the correct order when administering this medication.
Choice 1. Warm the medication by placing it in the hand or pocket for a few minutes.
Choice 2. Tilt the patient's head toward the unaffected side.
Choice 3. Straighten the ear canal by pulling the pinna up and back, using the nondominant hand.
Choice 4. Insert the prescribed number of drops into the ear canal.
Choice 5. Have the patient remain in position for approximately 5 minutes.
Choice 6. Loosely place a cotton ball at the auditory meatus for 15 to 20 minutes.
Page Ref: 1721
Cognitive Level: Analyzing
Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 46.2 Describe the pathophysiology and manifestations of ear disorders, and outline the interprofessional care and nursing care of patients with these disorders.
MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with eye and ear disorders.
38) The nurse knows that a patient may develop sensorineural hearing loss as a result of ototoxic drugs. Which patient would be at the highest risk for this type of hearing deficit?
1. Patient with methicillin-resistant Staphylococcus aureus (MRSA) on high doses of vancomycin (Vancocin)
2. Patient on low-dose aspirin to prevent stroke
3. Patient on steroids (Prednisone) for chronic spondylolisthesis
4. Patient using atorvastatin (Lipitor) to prevent heart disease and stroke
Page Ref: 1731
Cognitive Level: Analyzing
Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 46.2 Describe the pathophysiology and manifestations of ear disorders, and outline the interprofessional care and nursing care of patients with these disorders.
MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with eye and ear disorders.
39) During an assessment, the nurse notes that a patient has conjunctival erythema around the cornea. On which health problem should the nurse focus when continuing with the assessment of this patient? Select all that apply.
1. Acute uveitis
2. Corneal trauma
3. Corneal infection
4. Acute conjunctivitis
5. Acute angle-closure glaucoma
Page Ref: 1695
Cognitive Level: Analyzing
Client Need & Sub: Physiological Integrity: Reduction of Risk Potential
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 46.1 Describe the pathophysiology and manifestations of eye disorders, and outline the interprofessional care and nursing care of patients with these disorders.
MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with eye and ear disorders.
40) A patient with acute angle-closure glaucoma is prescribed the prostaglandin analog bimatoprost (Lumigan). What should the nurse include when instructing the patient about this medication? Select all that apply.
1. This drug causes the iris to darken.
2. This drug causes eyelashes to grow.
3. Use once daily at bedtime as directed.
4. Remove contact lenses before using this drug.
5. Skin discoloration around eyebrows will reverse.
Page Ref: 1711
Cognitive Level: Applying
Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning
Learning Outcome: 46.1 Describe the pathophysiology and manifestations of eye disorders, and outline the interprofessional care and nursing care of patients with these disorders.
MNL Learning Outcome: 2. Consider intraprofessional care for patients with eye and ear disorders.
41) The nurse provides a training session to a group of lifeguards at a community pool on actions to prevent the development of otitis externa. Which participant statements indicate that no additional teaching is required? Select all that apply.
1. "I should use a tight-fitting swim cap."
2. "I should use silicone earplugs when in the water."
3. "I can use a cotton swab to absorb water in the ear."
4. "I can use a hair dryer on the low setting to dry the ear canal."
5. "I should make sure the pool water has been disinfected before entering."
Page Ref: 1721
Cognitive Level: Analyzing
Client Need & Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Evaluation/Teaching/Learning
Learning Outcome: 46.2 Describe the pathophysiology and manifestations of ear disorders, and outline the interprofessional care and nursing care of patients with these disorders.
MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with eye and ear disorders.
42) A patient with conductive hearing loss has selected a behind-the-ear hearing aid with earmold. What should the nurse reinforce with the patient as advantages of this device? Select all that apply.
1. Easy to manipulate
2. Most versatile and reliable
3. Comfortable and least visible
4. Allows fine amplification level adjustments
5. Can be incorporated into the temple of eyeglasses
Page Ref: 1733
Cognitive Level: Applying
Client Need & Sub: Health Promotion and Maintenance: Self-Care
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning
Learning Outcome: 46.2 Describe the pathophysiology and manifestations of ear disorders, and outline the interprofessional care and nursing care of patients with these disorders.
MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with eye and ear disorders.
Document Information
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