Chapter 53 (test 2)

Question 1

The nurse is aware that the patient has 20/40 vision. This means that the patient can see at 20 feet what the normal eye can see at which distance?
a. 10 feet
b. 20 feet
c. 30 feet
d. 40 feet

Answer 1

ANS: B

Question 2

The patient tells the nurse that he is legally blind. In which way will this information impact the plan of care for this patient?
a. The patient would be considered totally blind.
b. This patient probably has some light perception, but no usable vision.
c. This patient has some usable vision, which enables function at an acceptable level.
d. The nurse would need to determine how this patient’s visual impairment affects
normal functioning.

Answer 2

ANS: D

Question 3

One of the housekeepers splashes a chemical in the eyes. Which action should be the first priority?
a. Transport to a health care provider immediately.
b. Cover the eyes with a sterile gauze.
c. Irrigate with H2O for 5 minutes.
d. Irrigate with normal saline solution for 20 minutes.

Answer 3

ANS: D

Question 4

Which type of hearing loss does a tympanoplasty correct?
a. Conductive hearing loss
b. Sensorineural hearing loss
c. Congenital hearing loss
d. Functional hearing loss

Answer 4

ANS: A

Question 5

The 62-year-old patient reports a feeling of “grittiness” in the eye and is having blurred vision. The eyes are reddened and have stringy mucus. Which disorder do these symptoms indicate?
a. Sjögren syndrome
b. Early cataracts
c. Macular degeneration
d. Retinal detachment

Answer 5

ANS: A

Question 6

Four hours after a stapedectomy, the patient complains that hearing has not improved at all. Knowledge of which fact will the nurse use to shape a response?
a. A large percentage of stapedectomies are not successful.
b. It will take at least 10 days for the graft to heal.
c. Hearing will not return until edema subsides.
d. Hearing will improve after irrigation of the ear.

Answer 6

ANS: C

Question 7

The nurse is working with a nursing assistant who is communicating with a patient who is hearing impaired. Which action by the nursing assistant would cause the nurse tointervene?
a. Overaccentuating words
b. Facing the patient when speaking
c. Speaking in conversational tones
d. Speaking into the ear with the hearing aid

Answer 7

ANS: A

Question 8

Which term describes the process when the lens of the eye changes its curvature to focus on the retina?
a. Accommodation
b. Constriction
c. Convergence
d. Refraction

Answer 8

ANS: A

Question 9

When the newly blind patient asks the nurse how to obtain assistance, who might the nurse suggest contacting?
a. American Red Cross
b. American Foundation for the Blind for a list of agencies
c. Local hospital social worker
d. The public health department

Answer 9

ANS: B

Question 10

The nurse clarifies that the difference between a photorefractive keratectomy (PRK) and a laser in-situ keratomileusis (LASIK) is that a LASIK is intended to improve vision in which way?
a. reshapes the central cornea.
b. makes partial-thickness radial incisions in the cornea.
c. removes some internal layers of the cornea.
d. implants intracorneal rings.

Answer 10

ANS: C

Question 11

Which technique does the cataract treatment of phacoemulsification involve?
a. “Drying” the cataract with hypertonic saline
b. Removing the lens through the anterior capsule
c. The insertion of a new lens
d. Breaking the cataract with ultrasound

Answer 11

ANS: D

Question 12

Which report made by a 64-year-old patient during a health interview would alert the nurse to the possibility of cataracts?
a. Pain in the eyes
b. Difficulty driving at night
c. Loss of peripheral vision
d. Dry eyes

Answer 12

ANS: B

Question 13

Which action should a patient who has had a cataract repair avoid?
a. The use of eye patches
b. The use of sunglasses
c. The lifting of heavy objects
d. Reading for long periods of time

Answer 13

ANS: C

Question 14

Which anatomical change is associated with diabetes retinopathy?
a. Capillaries in retina hemorrhage
b. Long-term overdosing of insulin
c. Retinal detachment
d. Aging

Answer 14

ANS: A

Question 15

When the patient in the emergency room reports seeing flashing lights and a curtain down over the right eye, the nurse recognizes this as a symptom of which condition?
a. Detached retina
b. Macular degeneration
c. Early sign of cataract
d. Diabetic retinopathy

Answer 15

ANS: A

Question 16

A patient reports that the entire right side of the head hurts and being unable to chew without pain. The nurse recognizes the patient has symptoms of which disorder?
a. mumps
b. external otitis
c. otitis media
d. labyrinthitis

Answer 16

ANS: B

Question 17

The nurse takes into consideration that the Weber test indicated a conductive hearing loss in a patient because the patient reported hearing the tone in which way?
a. equally in both ears.
b. as a shrill noise.
c. louder in his affected ear.
d. very faintly.

Answer 17

ANS: C

Question 18

Which reminder should the nurse provide to the hearing aid wearer when the nurse hears a whistling hearing aid?

a. Reinsert the ear mold.
b. Change the battery.
c. Recharge the hearing aid.
d. Wash the ear mold with warm water.

Answer 18

ANS: A

Question 19

Which advice will the nurse provide the 20 year old who has been put on cefaclor for a resistant otitis media?
a. Store suspension at room temperature.
b. Discontinue drug when symptoms abate.
c. Avoid alcoholic beverages.
d. Take with meals only.

Answer 19

ANS: C

Question 20

The nurse will provide which advise for a patient who has severe vertigo from labyrinthitis?
a. Lean against a wall and not move the head forward until vertigo lessens.
b. Bend at the waist and take several deep breaths.
c. Drink an iced drink slowly.
d. Lie immobile and hold the head in one position until the vertigo lessens.

Answer 20

ANS: D

Question 21

Which action do miotic eye drops have for a patient with glaucoma?
a. Dilate the pupil and sharpen vision.
b. Lubricate and moisten the dry eye.
c. Irrigate the surface of the eye.
d. Constrict the pupil and open the canal of Schlemm.

Answer 21

ANS: D

Question 22

The nurse expects to see which aspect in the plan of care following a tympanoplasty?
a. Elevating head of bed with operative side facing upward
b. Enforcing bed rest for 72 hours
c. Frequent turning, coughing, and deep breathing
d. Continuous irrigation of the ear canal with antibiotic solutions

Answer 22

ANS: A

Question 23

When the patient stares at the black dot on an Amsler grid, which abnormality should the nurse ask him to report?
a. Any color visible on the grid
b. Fading of the edges of the grid
c. Any distortion of the grid
d. Movement of the black dot

Answer 23

ANS: C

Question 24

A patient who had an enucleation of the right eye has been admitted postoperatively to the nursing unit. Which aspect does the nurse expect to see in the plan of care?
a. Turn, cough, and deep breathe every 3 hours.
b. Apply a pressure dressing over the right eye socket.
c. Document dressing Data Collection every 2 hours.
d. Turn on the affected side.

Answer 24

ANS: B

Question 25

The nurse will advise the patient to take which action following a left vitrectomy?
a. Remain flat in bed for 48 hours.
b. Position self in a face-down position for 4 to 5 days.
c. Assume a side-lying position with the left side down for 3 days.
d. Keep head upright and cushioned with pillows for 24 hours.

Answer 25

ANS: B

Question 26

In which way will the nurse explain the purpose of photocoagulation to a diabetic patient with diabetic retinopathy?
a. The procedure will destroy the retina, which is not getting enough blood supply.
b. The procedure will reduce edema in the macula of the eye.
c. The procedure will vaporize fatty deposits that appear in the retina.
d. The procedure will destroy new blood vessels, seal leaking vessels, and help
prevent retinal edema.

Answer 26

ANS: D

Question 27

Which change is the first indication of macular degeneration?
a. The loss of peripheral vision
b. The loss of central vision
c. The loss of color discrimination
d. Eye fatigue

Answer 27

ANS: B

Question 28

Which finding is a sign of acute angle closure glaucoma (AACG)?
a. Large fixed pupil
b. Nystagmus
c. Bluish color in sclera
d. Drooping eyelid

Answer 28

ANS: A

Question 29

For which reason is otitis media found more frequently in children 6 to 36 months?
a. Eustachian tubes in children are shorter and straighter.
b. Infection descends via the eustachian tube to the throat.
c. Children’s eustachian tubes are more vertical and longer.
d. Otitis media is seen equally in both children and adults.

Answer 29

ANS: A

Question 30

For which reason will the nurse encourage a group of teenagers to protect their eyes with dark sunglasses while using a UV lamp?
a. The lamp can cause cataracts.
b. The lamp can cause presbycusis.
c. The lamp can cause keratitis.
d. The lamp can cause ectropion.

Answer 30

ANS: A

Question 31

The nurse counsels the 16-year-old boy that playing his music at high volume can result in impairment in hearing related to which issue?
a. damaged tympanic membrane.
b. protective buildup of cerumen.
c. damage of the fine hair cells in the organ of Corti.
d. rupture of the oval window.

Answer 31

ANS: C

Question 32

Which anatomical part is the most interior part of the eye?
a. Choroid
b. Cornea
c. Aqueous humor
d. Retina
e. Lens
f. Iris

Answer 32

ANS: A

Question 33

Which action is the first nursing intervention step for the immediate care of a patient with a penetrating wound of the eye?
a. Assess eye, do not remove object.
b. Cover both eyes with an eye shield or cup.
c. Check for the irregularity of the pupil.
d. Obtain medical attention immediately.

Answer 33

ANS: C

Question 34

mult resp

Which condition may cause conductive hearing loss. (Select all that apply.)
a. Buildup of cerumen
b. Foreign bodies
c. Otosclerosis of external auditory canal
d. Trauma
e. Exposure to ototoxic drugs
f. Otitis media with effusion

Answer 34

ANS: A, B, C, F

Question 35

mult resp

Which may contribute to otitis media? (Select all that apply.)
a. Exposure to cigarette smoke
b. Allergies
c. Upper respiratory infections
d. Swimming
e. Trauma
f. Prolonged exposure to loud noise

Answer 35

ANS: A, B, C

Question 36

mult resp

Which factor must the nurse consider when assessing readiness to learn when teaching health promotion practices for the visually and hearing impaired? (Select all thatapply.)
a. Cultural beliefs
b. Values
c. Habits
d. Income
e. Occupation

Answer 36

ANS: A, B, C

Question 37

mult resp

Which is a cause of cataracts? (Select all that apply.)
a. Long-term use of corticosteroids
b. Hypotension
c. Congenital from exposure to maternal rubella
d. Diabetes mellitus
e. Exposure to sand and dust
f. Smoking

Answer 37

ANS: A, C, D, F

Question 38

mult resp

Which action will the nurse take when the patient arrives to the nursing unit after a left stapedectomy? (Select all that apply.)
a. Turn the patient to the right side.
b. Change dressing as it becomes soiled.
c. Turn patient every 2 hours.
d. Leave the bed flat.
e. Contact the surgeon if the patient reports hearing is not improved

Answer 38

ANS: A, D, E

Question 39

mult resp

Which action should the nurse take when assisting a blind person to walk in an unfamiliar hospital environment? (Select all that apply.)
a. Discourage the use of the cane.
b. Advise the patient to walk quickly.
c. Describe the surroundings.
d. Encourage the patient to ask for verbal cues.
e. Place patient hand on nurse’s shoulder or elbow.

Answer 39

ANS: C, D, E