Exam 4 - Sensory Flashcards
Common clinical manifestations of cataract
- Bilateral or unilateral opacity.
- Increasingly blurred vision and visual distortion
- Decreased visual acuity
- The refractive power of the anterior segment often increases to produce an acquired myopia
- Glare or the abnormal presence of light in the visual field
- Double vision
- Seeing ‘halos’ around light
- Fading or yellowing of colors
(Disorder fact sheet)
Nursing interventions for a client with a vision impairment
- Assistive devices, environment, and behavior
- Provide an unchanging, structured environment with items in fixed locations
- Adequate light, glare reduction, and contrasting colors may be helpful
(Slide 39)
Nursing interventions for a client with a hearing impairment
- Aimed at maximizing hearing ability and allowing for compensation for other senses
- Lighting and positioning so individual can see speaker’s lips
- Speech should be at normal rate, rhythm, and volume
- Amplifiers or implanted hearing devices may be used
(Slide 61)
Types of conditions or behaviors that would put a person at risk for retinal detachment
- Trauma is one of leading causes, so any behavior that could lead to trauma
- Advancing age (25% of people between 61-70 develop posterior vitreous detachment)
- Myopia
- Family history of retinal detachment
- History of congenital eye disease (glaucoma, cataracts)
- Hereditary vitreopathies with abnormal vitreous gel
(Slide 31)
Presbycussis - what is it & who is at risk for it
- Sensorineural hearing loss; can be conductive impairment
- Gradual onset, bilateral, and results in difficulty hearing high-pitched tones and conversational speech
- Loses high-pitched tones first
- Most common form in older adults
(Slide 71)
Management & education regarding vertigo in a client with Meniere’s disease
- Antiemetic and anticholinergic medications - systematic relief during exacerbations
- Surgical interventions
- Sodium-restricted diet
- Movement may make symptoms worse, so client may lie still, which is not good for their overall health and quality of life. So nurses need to encourage clients to be physically active, but avoid sudden movements
The nurse is performing an admission assessment on a client with a diagnosis of detached retina. Which of the following is associated with this eye disorder?
- Total loss of vision
- Pain in the affected eye
- A yellow discoloration of the sclera
- A sense of a curtain falling across the field of vision
- A sense of a curtain falling across the field of vision
A characteristic manifestation of retinal detahment described by the client is the feeling that a shadow or curtain is falling across the field of vision. No pain is associated with detachment of the retina. Options 1 and 3 are not characteristic of this disorder. A retinal detachment is an ophthalmic emergency and even more so if visual acuity is still normal.
The nurse is performing an assessment on a client with a suspected diagnosis of cataract. The chief clinical manifestation that the nurse would expect to note in the early stages of cataract formation is:
- Diplopia
- Eye pain
- Floating spots
- Blurred vision
- Blurred vision
A gradual, painless blurring of central vision is the chief clinical manifestation of a cataract. Early symptoms include slightly blurred vision and a decrease in color perception. Options 1, 2, and 3 are not signs of a cataract.
The nurse is caring for a hearing-impaired client. Which of the following approaches will facilitate communication?
- Speak loudly.
- Speak frequently.
- Speak at a normal volume.
- Speak directly into the impaired ear.
- Speak in a normal volume
Speaking in a normal tone to the client with impaired hearing and not shouting are important. The nurse should talk directly to the client while facing the client and speak clearly. If the client does not seem to understand what is said, the nurse should express it differently. Moving closer to the client and toward the better ear may facilitate communication, but the nurse should avoid talking directly into the impaired ear.
The nurse notes that the physician has documented a diagnosis of presbycusis on the client’s chart. The nurse plans care knowing that the condition is:
- Tinnitus that occurs with aging
- Nystagmus that occurs with aging
- A conductive hearing loss that occurs with aging
- A sensorineural hearing loss that occurs with aging
- A sensorineural hearing loss that occurs with aging
Presbycusis is a type of hearing loss that occurs with aging. Presbycusis is a gradual sensorineural loss caused by nerve degeneration in the inner ear or auditory nerve. Options 1, 2, and 3 are not correct.
A client with Meniere’s disease is experiencing severe vertigo. Which instruction should the nurse give to the client to assist in controlling the vertigo?
- Increase sodium in the diet
- Avoid sudden head movements
- Lie still and watch the television
- Increase fluid intake to 3000 mL a day
- Avoid sudden head movements
The nurse instructs the client to make slow head movements to prevent worsening of the vertigo. Dietary changes such as salt and fluid restrictions that reduce the amount of endolymphatic fluid are sometimes prescribed. Lying still and watching television will not control vertigo.
Which client is at highest risk for retinal detachment?
- A 4-year-old with amblyopia
- A 17-year-old who plays physical contact sports
- A 33-year-old with severe ptosis and diplopia
- A 72-year-old with nystagmus and Bell’s palsy
- A 17-year-old who plays physical contact sports
Participating in physical contact sports puts this person at highest risk for retinal detachment because trauma is a leading cause. The other pathologies (amblyopia, ptosis, diplopia, nystagmus, and Bell’s palsy) will affect eye function but have minimal likelihood of causing retinal detachment.
A client is walking down the hall, and he begins to experience vertigo. What is the most important nursing action when this occurs?
- Have the client sit in a chair in a brightly lit room.
- Administer meclizine (Antivert) PO.
- Help the client sit or lie down.
- Assess whether the problem is vertigo or dizziness.
- Help the client sit or lie down.
The client experiencing vertigo is severely imbalanced and at high risk of falling; thus, client safety is the priority. He should be assisted to sit or lie down immediately, or he may fall. The client should be safely sitting or lying down before any treatment or further assessment can continue. Sitting a chair is not bad, but it is not as safe as having the client lie down, and a quiet, darkened room is preferable during an acute attack.
A client is being admitted for problems with Meniere’s disease. What is most important for the nurse to assess to promote the client’s safety?
- Diet history
- Screening hearing tests
- Effect on client’s activities of daily living (ADLs)
- Frequency and severity of attacks
- Frequency and severity of attacks
The nurse must assess the frequency and severity of attacks to plan best for the client’s safety. Although hearing tests and diet may be of some significance, they will not protect the client immediately. After the client’s immediate safety needs are met, the nurse will want to determine the effect that Meniere’s disease has on the client’s ADLs.
A client comes to the clinic with decreased hearing. Examination of the ear canal reveals a large amount of cerumen. What is the recommended method for removal of the cerumen?
- Curettage with suction and irrigation
- Warm sterile solution irrigation
- Cool tap water irrigation
- Cotton swab applicator
- Warm sterile solution irrigation
Rationale: Although the structures of the outer ear are not sterile, sterile drops and solutions are used for irrigations in case the tympanic membrane is ruptured. The addition of nonsterile solutions may result in possible infections of the middle ear. Cool irrigants will be uncomfortable and tap water is not considered to be sterile. Curettage with suction and irrigation and use of a cotton swab applicator can damage the tympanic membrane.
