Chapter 10: Visual and Auditory Problems

Question 1

The nurse is reviewing medications that have been prescribed for several clients who have disorders of the eye. Which medication prescription is the most important to discuss with the health care provider?

1. Timolol for open-angle glaucoma
2. Cromolyn sodium for allergic conjunctivitis
3. Atropine for acute angle-closure glaucoma
4. Ranibizumab for wet age-related macular degeneration

Answer 1

Ans: 3
Atropine should not be used for acute angle-closure glaucoma. Atropine causes dilation of the pupil, which impedes outflow of aqueous humor and increases intraocular pressure. This action could precipitate or worsen the condition. Focus: Prioritization.

Question 2

The nurse is working in an ambulatory care clinic. A client calls to report redness of the sclera, itching of the eyes, and increased lacrimation for several hours. What should the nurse direct the caller to do first?

1. “Please call your health care provider” (e.g., decline to advise).
2. “Apply a cool compress to your eyes.”
3. “If you are wearing contact lenses, remove them.”
4. “Take an over-the-counter antihistamine.”

Answer 2

Ans: 3
If the client is wearing contact lenses, the lenses may be causing the symptoms, and removing them will prevent further eye irritation or damage. Policies on giving telephone advice vary among institutions, and knowledge of the facility policy is essential. The other options may be appropriate, but additional information is needed before suggesting anything else. Focus: Prioritization.

Question 3

At a community health clinic, the nurse is teaching a community group about the prevention of accidental eye injuries. What is the most important thing to stress?

1. Workplace policies for handling chemicals should be followed.
2. Children and parents should be cautious about aggressive play.
3. Protective eyewear should be worn during sports or hazardous work.
4. Emergency eyewash stations should be established in the workplace.

Answer 3

Ans: 3
Most accidental eye injuries (90%) could be prevented by wearing protective eyewear for sports and hazardous work. Other options should be considered in the overall prevention of injuries. Focus: Prioritization.

Question 4

A nursing student is assisting an older client who is alert, conversant, and cognitively intact. The client has decreased vision related to macular degeneration. When would the supervising nurse intervene?

1. Student puts call bell and personal items within reach and locates each item by guiding the client’s hand.
2. Student closes the curtains and turns off all of the lights at the end of the shift to encourage rest and sleep.
3. Student talks to the client about family and asks, “So, when was the last time that you saw your uncle?”
4. Student assists during mealtime by opening packages and describing location of foods by using clock coordinates.

Answer 4

Ans: 2
For clients who retain some vision, the room should be well-lit; even at night, there should be a night light. Other options are correct actions. Words such as “see, “look,” or “view” are parts of normal speech, and it’s acceptable and natural to use these terms (e.g., “Well, it looks like you had a quiet day today”). Focus: Supervision.

Question 5

Which clients would be best to assign to the most experienced nurse in an ambulatory care center that specializes in vision problems and eye surgery? Select all that apply.

1. Client who requires postoperative instructions after cataract surgery
2. Client who needs an eye pad and a metal shield applied
3. Client who requests a home health referral for dressing changes and eyedrop instillation
4. Client who needs teaching about self-administration of eyedrops
5. Client who requires an assessment for recent and sudden loss of sight 6. Client who requires preoperative teaching for laser trabeculoplasty

Answer 5

Ans: 1, 3, 5, 6
Providing postoperative and preoperative instructions, making home health referrals, and assessing for needs related to loss of vision should be done by an experienced nurse who can give specific details and specialized information about follow-up eye care and adjustment to loss. The principles of applying an eye pad and shield and teaching the administration of eyedrops are basic procedures that should be familiar to all nurses. Focus: Assignment.

Question 6

Place the following steps for eyedrop administration in the correct order.

1. Gently press on the lacrimal duct for 1 minute.
2. Gently pull tissue underneath eye downward to expose lower conjunctival sac.
3. Have the client gently close the eye and move it around.
4. Have the client look up and instill the number of prescribed drops.
5. Hold the dropper and stabilize hand on the client’s forehead.
6. Have the client sit down and tilt his or her head slightly backward.

Answer 6

Ans: 6, 2, 5, 4, 3, 1
Have the client sit with the head tilted back. Pulling down the lower conjunctival sac creates a small pocket for the drops. Stabilizing the hand prevents accidentally poking the client’s eye. Having the client look up prevents the drops from falling on the cornea and stimulating the blink reflex. When the client gently moves the eye, the medication is distributed. Pressing on the lacrimal duct prevents systemic absorption. Focus: Prioritization.

Question 7

Which tasks are appropriate to assign to an LPN/LVN who is functioning under the supervision of an RN? Select all that apply.

1. Administering sulfacetamide sodium 10% to a child with conjunctivitis
2. Reviewing hand-washing and hygiene practices with clients who have eye infections
3. Showing clients how to gently cleanse eyelid margins to remove crusting
4. Assessing nutritional factors for a client with age-related macular degeneration
5. Reviewing the health history of a client to identify risk for ocular manifestations
6. Performing a routine check of a client’s visual acuity using the Snellen eye chart

Answer 7

Ans: 1, 2, 3, 6
Administering medications, reviewing and demonstrating standard procedures, and performing standardized assessments with predictable outcomes in noncomplex cases are within the scope of the LPN/LVN. Assessing for systemic manifestations and behaviors, risk factors, and nutritional factors is the responsibility of the RN. Focus: Assignment.

Question 8

The nurse is on a camping trip. A man is chopping wood and gets struck in the eye with a piece of debris. On examination, a wood splinter is protruding from his eyeball. What should the nurse do first?

1. Have the man lie in the back seat of the car and drive him to the emergency department.
2. Gently remove the piece of wood and place a sterile dressing over the eye.
3. Stabilize the area by carefully resting a plastic cup on the orbital rim and taping it in place.
4. Flush the eye with copious amounts of clean tepid water; then check visual acuity.

Answer 8

Ans: 3
Penetrating objects should not be removed or disturbed by anyone except an eye specialist because the object may be creating a tamponade effect. Removing or disrupting the object could result in additional damage to the eye. The man needs to have emergency care, and 911 should be called, but if there are no emergency services available, the man should sit in the back seat of the car with a seat belt in place for transport to the nearest facility. After a penetrating eye injury has been assessed and treated by an ophthalmologist, there is a possibility that based on the ophthalmologist’s recommendations, foreign body removal, flushing, and dressing application could be accomplished in the emergency department; however, penetrating objects frequently require surgical removal. Antibiotics and a tetanus immunization are administered before the client is transferred to the operating room. Focus: Prioritization.

Question 9

The nurse is interviewing an older woman and discovers that she has been taking her glaucoma eyedrops by mouth for the past week. What should the nurse do first?

1. Obtain a prescription for tonometry so that her intraocular pressure can be checked.
2. Try to determine how frequently and how much she has been ingesting.
3. Ask her how she decided to take the drops orally instead of instilling them as eyedrops.
4. Call the Poison Control Center and be prepared to describe untoward side effects.

Answer 9

Ans: 2
Try to find out the amount and frequency that she has been taking the drops by mouth. This information will be needed when calling the ophthalmologist or Poison Control. A good follow-up question is to try to find out why she is taking the drops by mouth. She may be very confused, or there may have been an error of omission in client education by all health care team members who were involved in the initial prescription. Focus: Prioritization; Test Taking Tip: Remember that the first step of nursing process is assessment and gathering sufficient data. Always assess first unless taking the time to assess would be life threatening.

Question 10

The nurse is working in a community health clinic and a client needs instructions for the care of a hordeolum (stye) on the right upper eyelid. What is the first intervention that the client should try?

1. Apply warm compresses four times per day.
2. Gently perform hygienic eyelid scrubs.
3. Obtain a prescription for antibiotic drops.
4. Contact the ophthalmologist.

Answer 10

Ans: 1
Warm compresses usually provide relief. If the problem persists, eyelid scrubs and antibiotic drops would be appropriate. The ophthalmologist could be consulted, but other providers such as the family physician or the nurse practitioner could give a prescription for antibiotics. Focus: Prioritization.

Question 11

Which finding should be immediately reported to the health care provider?

1. A change in color vision
2. Crusty yellow drainage on the eyelashes
3. Increased lacrimation
4. A curtainlike shadow across the visual field

Answer 11

Ans: 4
A curtainlike shadow is a symptom of retinal detachment, which is an emergency situation. A change in color vision is a symptom of cataract. Crusty drainage is associated with conjunctivitis. Increased lacrimation is associated with many eye irritants, such as allergies, contact lenses, or foreign bodies. Focus: Prioritization; Test Taking Tip: NCLEX® Examination questions frequently test the ability to identify life-threatening conditions, or in this case, the risk for permanent disability. In preparing to take the NCLEX® Examination, pay attention to signs and symptoms that signal life- threatening conditions and those that could lead to permanent injury.

Question 12

In the care of a client who has sustained recent blindness, which tasks would be appropriate to delegate to unlicensed assistive personnel (UAP)? Select all that apply.

1. Counseling the client to express grief or loss
2. Assisting the client with ambulating in the hall
3. Orienting the client to the surroundings
4. Encouraging independence
5. Obtaining supplies for hygienic care
6. Storing personal items to reduce clutter

Answer 12

Ans: 2, 5
Assisting the client with ambulating in the hall and obtaining supplies are within the scope of practice of the UAP. Counseling for emotional problems, orienting the client to the room, and encouraging independence require formative evaluation to gauge readiness, and these activities should be the responsibility of the RN. Storing items and rearranging furniture are inappropriate actions because the client needs be able to consistently locate objects in the immediate environment. Focus: Delegation; Test Taking Tip: Remember to differentiate whether the question is about an acute or chronic condition. The nurse could delegate more tasks to the UAP if the client’s condition is chronic. For example, a client who has been blind for a long time is less likely to need the nurse to prompt or assess independence. However, for a client with a severely depressed respiratory rate, the nurse would not delegate performing this vital sign to the UAP.

Question 13

After cataract surgery, the client experiences all of the symptoms listed below. Which symptom needs to be immediately reported to the health care provider?

1. A scratchy sensation in the operative eye
2. Loss of depth perception with the patch in place
3. Poor vision 6 to 8 hours after patch removal
4. Pain not relieved by prescribed medication

Answer 13

Ans: 4
Pain may signal hemorrhage, infection, or increased ocular pressure. A scratchy sensation and loss of depth perception with the patch in place are common. Adequate vision may not return for 24 hours. Focus: Prioritization.

Question 14

A client reports a sudden excruciating pain in the left eye with the visual change of colored halos around lights and blurred vision. Which interventions should the nurse expect and perform for this emergency condition? Select all that apply.

1. Prepare the client for photodynamic therapy.
2. Instill a mydriatic agent, such as phenylephrine.
3. Instill a miotic agent, such as pilocarpine.
4. Administer an oral hyperosmotic agent, such as isosorbide.
5. Apply a cool compress to the forehead.
6. Provide a darkened, quiet, and private space for the client.

Answer 14

Ans: 3, 4, 5, 6
The client’s symptoms are suggestive of angle-closure glaucoma. Immediate inventions include instillation of miotics, which open the trabecular network and facilitate aqueous outflow, and intravenous or oral administration of hyperosmotic agents to move fluid from the intracellular space to the extracellular space. Applying cool compresses and providing a dark, quiet space are appropriate comfort measures. Photodynamic therapy is a treatment for age-related macular degeneration. Use of mydriatics is contraindicated because dilation of the pupil will further block the outflow. Focus: Prioritization.

Question 15

The nurse is preparing to administer a beta-adrenergic blocking glaucoma agent. Which statement made by the client warrants additional assessment and notification of the health care provider?

1. “My blood pressure runs a little high if I gain too much weight.”
2. “Occasionally, I have palpitations, but they pass very quickly.”
3. “My joints feel stiff today, but that’s just my arthritis.”
4. “My pulse rate is a little low today because I take digoxin.”

Answer 15

Ans: 4
All beta-adrenergic blockers are contraindicated in bradycardia. Alpha-adrenergic agents can cause tachycardia and hypertension. Carbonic anhydrase inhibitors should not be given to clients with rheumatoid arthritis who are taking high dosages of aspirin. Focus: Prioritization; Test Taking Tip: Beta-adrenergic blockers “block” the receptor sites for epinephrine and norepinephrine, which are responsible for the “fight-or-flight” response; therefore, remember these medications will slow the pulse rate.

Question 16

The nurse is supervising a new nurse who has just finished assessing a client for redness and discomfort to the right eye. The new nurse documents “visual acuity N/A.” What should the supervising nurse do?

1. Do nothing; the documentation is minimal but acceptable.
2. Ask her to explain the rationale for the documentation.
3. Reassess the client’s eye and vision to validate findings.
4. Suggest contacting the clinical educator for documentation tips.

Answer 16

Ans: 2
Asking the nurse to explain the documentation is a way of assessing her knowledge of documentation, her understanding of how the client’s report guides the focused assessment, and her understanding of the use of abbreviations. The nurse may have a good reason for charting “N/A,” but a reader could misunderstand. For example, “visual acuity N/A” could be interpreted as the nurse making a clinical judgment that assessing vision was not applicable (important) for this client. The documentation is not acceptable because the client’s report indicates that vision should be tested if at all possible. Redoing the assessment does not help the nurse to correct mistakes. Contacting the educator for assistance is an option that is based on assessment of her rationale. Focus: Supervision, Prioritization.

Question 17

Which tasks are appropriate to assign to an LPN/LVN who is functioning under the supervision of a team leader or RN? Select all that apply.

1. Irrigating the ear canal to loosen impacted cerumen
2. Administering amoxicillin to a child with otitis media
3. Reminding the client not to blow the nose after tympanoplasty
4. Counseling a client with Ménière disease
5. Suggesting communication techniques for the family of a hearing-impaired older adult
6. Assessing a client with labyrinthitis for headache and level of consciousness

Answer 17

Ans: 1, 2, 3
Irrigating the ear, giving medication, and reminding the client about postoperative instructions that were given by an RN are within the scope of practice of the LPN/LVN. Counseling clients and families and assessing for meningitis signs in a client with labyrinthitis are the responsibilities of the RN. Focus: Assignment.

Question 18

The nurse is interviewing an older adult client who reports that “lately there has been a roaring sound in my ears.” What additional assessments should the nurse include? Select all that apply.

1. Obtain a medication history.
2. Ask about exposure to loud noises.
3. Observe the canal for earwax or foreign body.
4. Assess for signs and symptoms of ear infection.
5. Ask about method of ear hygiene.
6. Ask about diet and nutrition.

Answer 18

Ans: 1, 2, 3, 4, 5
Medications such as aspirin or diuretics (and many others) can cause tinnitus (ringing in the ears). Loud noises, impacted earwax or foreign bodies in the ear canal, or ear infections can also cause tinnitus. Ask about method of hygiene; insertion of cotton-tipped swabs may be contributing to the impaction of earwax. Diet and nutrition should always be assessed for older adult clients, but in this case, there is no direct relationship to the client’s report of roaring sound. Focus: Prioritization.

Question 19

A cheerful older widow comes to the community clinic for her annual checkup. She is in reasonably good health, but she has a hearing loss of 40 dB. She confides, “I don’t get out much. I used to be really active, but the older I get, the more trouble I have hearing. It can be really embarrassing.” What is the priority nursing concept to consider in planning care for this client?

1. Cognition
2. Sensory perception
3. Mood and affect
4. Anxiety

Answer 19

Ans: 2
This client has a hearing loss, and it seems likely that a referral for a hearing aid or rehabilitation program will allow her to participate in her baseline social habits. Focus: Prioritization.

Question 20

The client reports tinnitus. The nurse decides to review the client’s medication list to determine if any medications may be causing or contributing to this adverse effect. Which combination of drugs is cause for greatest concern?

1. Gentamycin and ethacrynic acid
2. Furosemide and metoprolol
3. Vancomycin and nitroglycerin patch
4. Aspirin and calcium supplement

Answer 20

Ans: 1
The combination of gentamycin and ethacrynic acid can have additive effects because both are considered ototoxic. Furosemide, vancomycin, and aspirin are also considered ototoxic drugs. There could be a few clients who report tinnitus with metoprolol, nitroglycerin, and calcium supplements, but these drugs are generally not known to have ototoxic effects. Focus: Prioritization.

Question 21

Which physical assessment findings should be reported to the health care provider?

1. Pearly gray or pink tympanic membrane
2. Dense whitish ring at the circumference of the tympanum
3. Bulging red or blue tympanic membrane
4. Cone of light at the innermost part of the tympanum

Answer 21

Ans: 3
A bulging red or blue tympanic membrane is a possible sign of otitis media or perforation. The other signs are considered normal anatomy. Focus: Prioritization.

Question 22

Which description by a client reporting vertigo is cause for greatest concern?

1. Dizziness with hearing loss
2. Episodic vertigo
3. Vertigo without hearing loss
4. “Merry-go-round” vertigo

Answer 22

Ans: 3
The client reporting vertigo without hearing loss should be further assessed for nonvestibular causes, such as cardiovascular or metabolic. The other descriptions are more commonly associated with inner ear or labyrinthine causes. Focus: Prioritization.

Question 23

DELETE AFTER ENTRY

Answer 23

DELETE AFTER ENTRY

Question 24

The nurse is caring for several clients who are having problems with their ears. Which client condition is cause for greatest concern?

1. Has discomfort of the ear preceded by a viral infection; the tympanic membrane is erythematous
2. Has been treated with antibiotics for recurrent acute otitis media four times within the past 6 months
3. Reports rapid onset ear pain with pruritus and a sensation of fullness that started after cleaning the ear canal with a finger
4. Reports progressive severe otic pain with purulent discharge and is positive for human immunodeficiency virus

Answer 24

Ans: 4
Progressive severe otic pain with purulent discharge and granulation tissue of the external auditory canal are signs or symptoms of necrotizing otitis externa. This is a rare but potentially fatal condition because bacteria can spread from the ear to the brain and cause meningitis. Immunocompromised clients, such as those who are positive for human immunodeficiency virus and older clients with diabetes, have an increased risk for this condition. Option 1 describes acute otitis media, which is treated with antibiotics. Option 2, recurrent acute otitis media, can be treated with short-term antibiotic therapy, prophylactic antibiotic therapy, or tympanostomy tubes. Option 3 is describing swimmer’s ear; this condition readily responds to antibiotic and antifungal eardrops. Focus: Prioritization; Test Taking Tip: Recall that any immunocompromised person has an increased risk for infection. Signs and symptoms that signal infection should be immediately reported to the health care provider because even minor infections can become life threatening.

Question 25

The nurse performed postoperative stapedectomy teaching several days ago for a client. Which comment by the client is cause for greatest concern?

1. “I’m going to take swimming lessons in a couple of months.”
2. “I have to take a long overseas flight in several weeks.”
3. “I can’t wait to get back to my regular weightlifting class.”
4. “I have been coughing a lot with my mouth open.”

Answer 25

Ans: 3
Heavy lifting should be strictly avoided for at least 3 weeks after stapedectomy. Water in the ear and air travel should be avoided for at least 1 week. Coughing and sneezing should be performed with the mouth open to prevent increased pressure in the ear. Focus: Prioritization.

Question 26

After examining the client’s ear canal with an otoscope, the health care provider instructs the nurse to irrigate the ear canal. Place the following steps for ear irrigation in the correct order.

1. Place the tip of the syringe at an angle in the external canal.
2. Watch for fluid return and signs of cerumen.
3. If cerumen does not appear, wait 10 minutes and repeat the irrigation.
4. Fill a syringe with warm irrigating solution.
5. After completion of the irrigation, have the client turn the head to the side to facilitate drainage.
6. Apply gentle but continuous pressure to the syringe plunger.

Answer 26

Ans: 4, 1, 6, 2, 3, 5
First, the health care provider or the nurse should use an otoscope to assess the ear (perforation, acute infection, or organic foreign bodies are contraindications for irrigation). The syringe is filled with warm fluid and angled in the ear canal to allow the fluid to flow along the side of the canal, not directly at the eardrum. Continuous gentle pressure is applied rather than a pumping action. Fluid should return with cerumen. If not, the nurse waits at least 10 minutes and repeats the irrigation. Tipping the head allows gravity drainage of fluid from the ear canal. Focus: Prioritization.

Question 27

A nursing student is preparing the equipment to irrigate a client’s ear canal. In which circumstances would the supervising nurse intervene before the student starts the irrigation? Select all that apply.

1. Client has a probable perforated eardrum.
2. Client has a foreign body, probably a bean, in the ear canal.
3. Client has a foreign body, probably an insect, in the ear canal.
4. Client has hearing loss related to impacted cerumen.
5. Client is currently being treated for acute otitis media.
6. Client has used ear candles in the past to remove ear wax.

Answer 27

Ans: 1, 2, 3, 5
Ear canal irrigation is not performed if the client has a perforated eardrum or otitis media because of potential to spread the infection to the inner ear. Vegetable matter or other organic matter can swell if it gets wet, so this would worsen the impaction. For insects, attempts should be made to coax the insect out with a flashlight if they are alive or smothering with oil before attempting removal. Hearing loss related to impacted cerumen is alleviated with earwax softeners and irrigation. Clients should be advised not to use ear candles or to insert other foreign objects into the ear canal. Focus: Supervision.

Question 28

The nurse is working in a clinic that specializes in the care of clients with ear disorders. A client tells the nurse that he has been taking meclizine. Which question is the nurse most likely to ask to evaluate the effectiveness of the medication?

1. Has the medication helped to relieve the pain in the ear canal?
2. Are you still experiencing the whirling and turning sensations?
3. Have you been able to hear better since you started the medication?
4. Are you still having the itching and discomfort in the outer ear?

Answer 28

Ans: 2
Meclizine can be helpful for clients who have vertigo (sensation of whirling or turning in space). Meclizine is also prescribed for the symptoms of motion sickness. Focus: Prioritization.

Question 29

Phenylephrine, an adrenergic agonist, has been prescribed as a topical application for a client as an aid to intraocular surgery. Although systemic toxicity is unlikely, which adverse physiologic response is the greatest concern?

1. Cardiovascular response, such as hypertension or ventricular dysrhythmias
2. Renal response, such as urinary retention or urinary incontinence
3. Respiratory response, such as bronchospasm or mucus plugs
4. Musculoskeletal response, such as bone pain or joint stiffness

Answer 29

Ans: 1
Topical phenylephrine usually does not cause systemic reactions because the amount of absorption is very small. Cardiac responses (hypertension, dysrhythmias, or cardiac arrest) are the greatest concern. Other possible reactions may include sweating, tremors, agitation, or confusion. Focus: Prioritization.

Question 30

An older client tells the home health nurse that several days ago, he had ranibizumab injected into his eye for treatment of wet age-related macular degeneration. He is now experiencing redness, light sensitivity, and pain. What should the nurse tell the client?

1. These are common side effects that should pass after a few more days.
2. Contact the health care provider (HCP) immediately for possible eye infection.
3. Rest eyes as much as possible and wear sunglasses if lights are too bright.
4. Inform the HCP before next the treatment so that the dosage can be adjusted.

Answer 30

Ans: 2
Ranibizumab is an angiogenesis inhibitor that is directly injected into the vitreous humor of the eye. The purpose of the medication injection is to inhibit the growth of new blood vessels in clients who have neovascular age- related macular degeneration. The biggest concern about adverse effects of the treatment is endophthalmitis. This can be caused by bacteria, virus, or fungus. Redness, light sensitivity, or pain are signs of possible endophthalmitis that should be immediately reported to the provider. Focus: Prioritization.

Question 31

For a client who has multiple risk factors for primary open-angle glaucoma (POAG), which sign or symptom should be investigated as an early sign of POAG?

1. Loss of central visual field
2. Seeing halos around lights
3. Mild eye aching
4. Loss of peripheral vision

Answer 31

Ans: 3
POAG develops slowly, and irreversible damage to the optic nerve can occur before any signs or symptoms are manifested; however, mild eye aching or headaches should be investigated as possible early signs of POAG. Loss of peripheral vision, seeing halos, and loss of central vision are late signs. Focus: Prioritization.