MSS Ch 14 Eye and Ear Disorders Comprehensive Exam

Question 1

Which recommendation should the nurse suggest to an elderly client who lives alone when discussing normal developmental changes of the olfactory organs?

1. Suggest installing multiple smoke alarms in the home.
2. Recommend using a night light in the hallway and bathroom.
3. Discuss keeping a high-humidity atmosphere in the bedroom.
4. Encourage the client to smell food prior to eating it.

Answer 1

1. The decreased sense of smell resulting from atrophy of olfactory organs is a safety hazard, and clients may not be able to smell gas leaks or fire, so the nurse should recommend a carbon monoxide detector and a smoke alarm. This safety equipment is critical for the elderly.
2. Night lights do not address the client’s sense of smell.
3. High humidity may help with breathing, but it does not help the sense of smell.
4. The client’s sense of smell is decreased; therefore, smelling food before eating is not an appropriate intervention.

Question 2

The elderly male client tells the nurse, “My wife says her cooking hasn’t changed, but it is bland and tasteless.” Which response by the nurse is most appropriate?

1. “Would you like me to talk to your wife about her cooking?”
2. “Taste buds change with age, which may be why the food seems bland.”
3. “This happens because the medications sometimes cause a change in taste.”
4. “Why don’t you barbecue food on a grill if you don’t like your wife’s cooking?”

Answer 2

1. The nurse needs to discuss possible causes with the client and not talk to the wife.
2. The acuity of the taste buds decreases with age, which could cause regular foods to seem bland and tasteless.
3. Some medications may cause a metallic taste in the mouth, but medication does not cause foods to taste bland.
4. Telling the client to cook if he doesn’t like his wife’s food is an argumentative and judgmental response.

Question 3

The charge nurse is admitting a 90-year-old client to a long-term care facility. Which intervention should the nurse implement?

1. Ensure the client’s room temperature is cool.
2. Talk louder to make sure the client hears clearly.
3. Complete the admission as fast as possible.
4. Provide extra orientation to the surroundings.

Answer 3

1. Because of altered temperature regulation, the client usually needs a warmer room temperature, not a cooler room temperature.
2. The nurse should use a low-pitched, normal-volume, clear voice. Talking louder or shouting only makes it harder for the client to understand the nurse.
3. The elderly client requires adequate time to receive and respond to stimuli, to learn, and to react; therefore, the nurse should take time and not rush the admission.
4. Sensory isolation resulting from visual and hearing loss can cause confusion, anxiety, disorientation, and misinterpretation of the new environment; therefore, the nurse should provide extra orientation.

Question 4

Which assessment technique should the nurse implement when assessing the client’s cranial nerves for vibration?

1. Move the big toe up and down and ask in which direction the vibration is felt.
2. Place a tuning fork on the big toe and ask if the vibrations are felt.
3. Tap the client’s cheek with the finger and determine if vibrations are felt.
4. Touch the arm with two sharp objects and ask if one (1) vibration or two (2) is felt.

Answer 4

1. This assesses proprioception, or position sense; direction of the toe must be evaluated.
2. Vibration is assessed by using a low- frequency tuning fork on a bony prominence and asking the client whether he or she feels the sensation and, if so, when the sensation ceases.
3. Tapping the cheek assesses for tetany, not cranial nerve involvement.
4. A two-point discrimination test evaluates integration of sensation, but it does not as- sess for vibration.

Question 5

Which intervention should the nurse include when conducting an in-service on caring for elderly clients addressing normal developmental sensory changes?

1. Ensure curtains are open when having the client read written material.
2. Provide a variety of written material when discussing a procedure.
3. Assist the client when getting out of the bed and sitting in the chair.
4. Request a telephone for the hearing impaired for all elderly clients.

Answer 5

1. Adequate lighting without a glare should be provided when having the client read written material; therefore, the curtains should be closed, not open.
2. The nurse should provide short, concise, and concrete material, not a variety of material.
3. Because fewer tactile cues are received from the bottom of the feet, the client may get confused as to body position and location. Safety is priority, and assisting the client getting out of bed and sitting in a chair is appropriate.
4. This is making a judgment. Not all elderly clients are hard of hearing, and telephones for the hearing impaired require special training for the user.

Question 6

Which situation makes the nurse suspect the client has glaucoma?

1. An automobile accident because the client did not see the car in the next lane.
2. The cake tasted funny because the client could not read the recipe.
3. The client has been wearing mismatched clothes and socks.
4. The client ran a stoplight and hit a pedestrian walking in the crosswalk.

Answer 6

1. Loss of peripheral vision as a result of glaucoma causes the client problems with seeing things on each side, resulting in a “blind spot.” This problem can lead to the client having car accidents when switching lanes.
2. This is indicative of cataracts because clients with cataracts have blurred vision and cannot read clearly.
3. This is indicative of cataracts because there is a color shift to yellow–brown and there is reduced light transmission.
4. This is indicative of macular degeneration, in which the central vision is affected.

Question 7

The client with a retinal detachment has just undergone a gas tamponade repair. Which discharge instruction should the nurse include in the teaching?

1. The client must lie flat with the face down.
2. The head of the bed must be elevated 45 degrees.
3. The client should wear sunglasses when outside.
4. The client should avoid reading for three (3) weeks.

Answer 7

1. If gas tamponade is used to flatten the retina, the client may have to be specially positioned to make the gas bubble float into the best position; clients must lie face down or on the side for days.
2. The HOB should not be elevated after this surgery.
3. There is no need for the client to wear sunglasses; this surgery does not cause photophobia.
4. The client does not need to avoid reading.

Question 8

The nurse is conducting a Weber test on the client who is suspected of having conductive hearing loss in the left ear. Where should the nurse place the tuning fork when conducting this test?

Answer 8

1. The tuning fork should be struck to produce vibrations and then placed midline between the ears on top of the head.
2. The right temple area is not an appropriate place to assess for conductive hearing loss.
3. The right occipital area is not the appropriate place to place the tuning fork; this is the area behind the ear where the Rinne test is performed.
4. The chin area is not the appropriate area to put the tuning fork.

Question 9

The student nurse asks the nurse, “Which type of hearing loss involves damage to the cochlea or vestibulocochlear nerve?” Which statement is the best response of the nurse?

1. “It is called conductive hearing loss.”
2. “It is called a functional hearing loss.”
3. “It is called a mixed hearing loss.”
4. “It is called sensorineural hearing loss.”

Answer 9

1. Conductive hearing loss results from an ex- ternal ear disorder, such as impacted ceru- men, or a middle ear disorder, such as otitis media or otosclerosis.
2. Functional (psychogenic) hearing loss is nonorganic and unrelated to detectable structural changes in the hearing mecha- nisms. It is usually a manifestation of an emotional disturbance.
3. Mixed hearing loss involves both conductive loss and sensorineural loss. It results from dysfunction of air and bone conduction.
4. Sensorineural hearing loss is described in the stem of the question. It involves damage to the cochlea or vestibulocochlear nerve.

Question 10

The client has undergone a bilateral stapedectomy. Which action by the client warrants immediate intervention by the nurse?

1. The client is ambulating without assistance.
2. The client is sneezing with the mouth open.
3. There is some slight serosanguineous drainage.
4. The client reports hearing popping in the affected ear.

Answer 10

1. Balance disturbance, or true vertigo, rarely occurs with other middle-ear surgical procedures, but it does occur for a short time after a stapedectomy. Safety is an important issue, and ambulating without assistance requires intervention by the nurse.
2. Pressure changes in the middle ear will be minimal if the client sneezes or blows the nose with the mouth open instead of closed.
3. Slightly bloody or serosanguineous drainage is normal after ear surgery.
4. Popping and crackling in the operative ear is normal for about three (3) to five (5) weeks after surgery.

Question 11

The female client tells the clinic nurse she is going on a seven (7)-day cruise and is worried about getting motion sickness. Which information should the nurse discuss with the client?

1. Make an appointment for the client to see the health-care provider.
2. Recommend getting an over-the-counter scopolamine patch.
3. Discourage the client from taking the trip because she is worried.
4. Instruct the client to lie down and the motion sickness will go away.

Answer 11

1. This is not a condition requiring an ap- pointment with the health-care provider.
2. Anticholinergic medications, such as scopolamine patches, can be recom- mended by the nurse; this is not prescribing. Motion sickness is a disturbance of equilibrium caused by constant motion.
3. Motion sickness can be controlled with medication and it may not even occur. Therefore, discussing canceling the trip is not providing the client with appropriate information.
4. This is providing the client with false in- formation. Lying down may or may not help motion sickness. To be able to enjoy the cruise, the client needs medication.

Question 12

The nurse writes the diagnosis “risk for injury related to impaired balance” for the client diagnosed with vertigo. Which nursing intervention should be included in the plan of care?

1. Provide information about vertigo and its treatment.
2. Assess for level and type of diversional activity.
3. Assess for visual acuity and proprioceptive deficits.
4. Refer the client to a support group and counseling.

Answer 12

1. This is appropriate for a diagnosis of “knowledge deficit.”
2. This is appropriate for a diagnosis of “deficient diversional activity” related to environmental lack of activity.
3. Balance depends on visual, vestibular, and proprioceptive systems; therefore, the nurse should assess these systems for signs/symptoms.
4. This is appropriate for a diagnosis of “ineffective coping.”

Question 13

The nurse is assessing the client’s cranial nerves. Which assessment data indicate cranial nerve I is intact?

1. The client can identify cold and hot on the face.
2. The client does not have any tongue tremor.
3. The client has no ptosis of the eyelids.
4. The client is able to identify a peppermint smell.

Answer 13

1. Being able to identify cold and hot on the face indicates an intact trigeminal nerve, cranial nerve V.
2. Not having any tongue tremor indicates an intact hypoglossal nerve, cranial nerve XI.
3. No ptosis of the eyelids indicates an intact oculomotor nerve (cranial nerve III), trochlear nerve (IV), and abducens nerve (VI). Tests also assess for ocular motion, conjugate movements, nystagmus, and papillary reflexes.
4. Cranial nerve I is the olfactory nerve, which involves the sense of smell. With the eyes closed, the client must identify familiar smells to indicate an intact cranial nerve I.

Question 14

The elderly client is complaining of abdominal discomfort. Which scientific rationale should the nurse remember when addressing an elderly client’s perception of pain?

1. Elderly clients react to pain the same way any other age group does.
2. The elderly client usually requires more pain medication.
3. Reaction to painful stimuli may be decreased with age.
4. The elderly client should use the Wong scale to assess pain.

Answer 14

1. This is an inaccurate statement.
2. The elderly client usually requires less pain medication because of the effects of the normal aging process on the liver (metabolism) and renal system (excretion).
3. Decreased reaction to painful stimuli is a normal developmental change; therefore, complaints of pain may be more serious than the client’s perception might indicate and thus such com- plaints require careful evaluation.
4. The Wong scale is used to assess pain for the pediatric client, not the adult client.

Question 15

Which instruction should the nurse discuss with the client when completing a sensory assessment?

1. Instruct the client to lie flat without a pillow during the assessment.
2. Instruct the client to keep both eyes shut during the assessment.
3. During the assessment the client must be in a treatment room.
4. Keep the lights off during the client’s sensory assessment.

Answer 15

1. The client should be in the sitting position during a sensory assessment.
2. The eyes are closed so tactile, superficial pain, vibration, and position sense (proprioception) can be assessed without the client seeing what the nurse is doing.
3. The sensory assessment can be conducted at the bedside; there is no reason to take the client to the treatment room.
4. There is no reason the lights should be off during the sensory assessment; the client should close his or her eyes.

Question 16

Which signs/symptoms should the nurse expect to find when assessing the client with an acoustic neuroma?

1. Incapacitating vertigo and otorrhea.
2. Nystagmus and complaints of dizziness.
3. Nausea and vomiting.
4. Unilateral hearing loss and tinnitus.

Answer 16

1. Vertigo and otorrhea are not the signs/ symptoms of an acoustic neuroma.
2. Neither nystagmus, an involuntary rhythmic movement of the eyes, nor dizziness is a sign of an acoustic neuroma.
3. Nausea and vomiting are not signs/ symptoms of an acoustic neuroma.
4. An acoustic neuroma is a slow-growing, benign tumor of cranial nerve VII. It usually arises from the Schwann cells of the vestibular portion of the nerve and results in unilateral hearing loss and tinnitus, with or without vertigo.

Question 17

Which assessment technique should the nurse use to assess the client’s optic nerve?

1. Have the client identify different smells.
2. Have the client discriminate between sugar and salt.
3. Have the client read the Snellen chart.
4. Have the client say “ah” to assess the rise of the uvula.

Answer 17

1. This assesses cranial nerve I, the olfactory nerve.
2. This assesses cranial nerve IX, the glos- sopharyngeal nerve.
3. This assesses cranial nerve II, the optic nerve, along with visual field testing and ophthalmoscopic examination.
4. This assesses cranial nerve X, the vagus nerve.

Question 18

Which referral is most important for the nurse to implement for the client with permanent hearing loss?

1. Aural rehabilitation.
2. Speech therapist.
3. Social worker.
4. Vocational rehabilitation.

Answer 18

1. The purpose of aural rehabilitation is to maximize the communication skills of the client who is hearing impaired. It includes auditory training, speech reading, speech training, and the use of hearing aids and hearing guide dogs.
2. A speech therapist may be part of the aural rehabilitation team, but the most important referral is aural rehabilitation.
3. The client may or may not need financial assistance, but the most important referral is aural rehabilitation.
4. The client may or may not need assistance with employment because of hearing loss, but the most important referral is the aural rehabilitation.

Question 19

Which instruction should the nurse discuss with the female client with viral conjunctivitis?

1. Contact the HCP if pain occurs.
2. Do not share towels or linens.
3. Apply warm compresses to the eyes.
4. Apply makeup very lightly.

Answer 19

1. The client should be aware eye pain (a sandy sensation and sensitivity to light) will occur with conjunctivitis.
2. Viral conjunctivitis is a highly contagious eye infection. It is easily spread from one person to another; therefore, the client should not share personal items.
3. Cold compresses should be placed over the eyes for about 10 minutes four (4) to five (5) times a day to soothe the pain.
4. The client must not apply any makeup until the disease is over and should discard all old makeup to help prevent reinfection.

Question 20

The client is two (2) hours postoperative right ear mastoidectomy. Which assessment data should be reported to the health-care provider?

1. Complaints of aural fullness.
2. Hearing loss in the affected ear.
3. No vertigo.
4. Facial drooping.

Answer 20

1. Aural fullness or pressure after surgery is caused by residual blood or fluid in the middle ear. This is an expected occurrence after surgery, and the nurse should admin- ister the prescribed analgesic.
2. Hearing in the operated ear may be reduced for several weeks because of edema, accumulation of blood and tissue fluid in the middle ear, and dressings or packing, so this does not need to be reported to the health-care provider.
3. Vertigo (dizziness) is uncommon after this surgery, but if it occurs the nurse should administer an antiemetic or antivertigo medication and does not need to report it to the health-care provider.
4. The facial nerve, which runs through the middle ear and mastoid, is at risk for injury during mastoid surgery; therefore, a facial paresis should be reported to the health-care provider.

Question 21

Which behavior by the male client should make the nurse suspect the client has a hearing loss? Select all that apply.

1. The client reports hearing voices in his head.
2. The client becomes irritable very easily.
3. The client has difficulty making decisions.
4. The client’s wife reports he ignores her.
5. The client does not dominate a conversation.

Answer 21

1. Voices in the head may indicate schizophrenia, but it is not a symptom of hearing loss.
2. Fatigue may be the result of straining to hear, and a client may tire easily when listening to a conversation. Under these circumstances, the client may become irritable very easily.
3. Loss of self-confidence makes it increasingly difficult for a person who is hearing impaired to make a decision.
4. Often it is not the person with the hearing loss but a significant other who notices hearing loss; hearing loss is usually gradual.
5. Many clients who are hearing impaired tend to dominate the conversation because, as long as it is centered on the client, they can control it and are not as likely to be embarrassed by some mistake

Question 22

The client with cataracts who has had intraocular lens implants is being discharged from the day surgery department. Which discharge instructions should the nurse discuss with the client?

1. Do not push or pull objects heavier than 50 pounds.
2. Lie on the affected eye with two pillows at night.
3. Wear glasses or metal eye shields at all times.
4. Bend and stoop carefully for the rest of your life.

Answer 22

1. The client should not lift, push, or pull objects heavier than 15 pounds; 50 pounds is excessive.
2. The client should avoid lying on the side of the affected eye at night.
3. The eyes must be protected by wearing glasses or metal eye shields at all times following surgery. Very few answer options with “all” will be correct, but if the option involves ensuring safety, it may be the correct option.
4. The client should avoid bending or stooping for an extended period—but not forever.

Question 23

The nurse is assessing the client’s sensory system. Which assessment data indicate an abnormal stereognosis test?

1. The client is unable to identify which way the toe is being moved.
2. The client cannot discriminate between sharp and dull objects.
3. The toes contract and draw together when the sole of the foot is stroked.
4. The client is unable to identify a key in the hand with both eyes closed.

Answer 23

1. This is an abnormal finding for testing proprioception, or position sense.
2. This is an abnormal finding for assessing superficial pain perception.
3. This is a normal Babinski’s reflex in an adult client.
4. Stereognosis is a test evaluating higher cortical sensory ability. The client is instructed to close both eyes and identify a variety of objects (e.g., keys, coins) placed in one hand by the examiner.

Question 24

Which statement by the daughter of an 80-year-old female client who lives alone warrants immediate intervention by the nurse?

1. “I put a night-light in my mother’s bedroom.”
2. “I got carbon monoxide detectors for my mother’s house.”
3. “I changed my mother’s furniture around.”
4. “I got my mother large-print books.”

Answer 24

1. With normal aging comes decreased peripheral vision, constricted visual field, and tactile alterations. A night-light addresses safety issues and warrants praise, 26. not intervention.
2. Carbon monoxide detectors help ensure safety in the mother’s home, so this comment doesn’t warrant intervention.
3. Decreased peripheral vision, constricted visual fields, and tactile alterations are associated with normal aging. The client needs a familiar arrangement of furniture for safety. Moving the furniture may cause the client to trip or fall. The nurse should intervene in this situation.
4. As a result of normal aging, vision may become impaired, and the provision of large-print books warrants praise.

Question 25

The 72-year-old client tells the nurse food does not taste good anymore and he has lost a little weight. Which information should the nurse discuss with the client?

1. Suggest using extra seasoning when cooking.
2. Instruct the client to keep a seven (7)-day food diary.
3. Refer the client to a dietitian immediately.
4. Recommend eating three (3) meals a day.

Answer 25

1. The acuity of taste buds decreases with age, which may cause a decreased appetite and subsequent weight loss. Extra seasoning may help the food taste better to the client.
2. This may be an appropriate intervention if excessive weight is lost or if seasoning the food does not increase appetite, but it is not necessary at this time.
3. The client does not need a dietary consult for food not tasting good. The nurse can address the client’s concern.
4. This recommendation does not address the client’s comment about food not tasting good.

Question 26

The male client diagnosed with type 2 diabetes mellitus tells the nurse he has begun to see yellow spots. Which interventions should the nurse implement? List in order of priority.

1. Notify the health-care provider.
2. Check the client’s hemoglobin A1c.
3. Assess the client’s vision using the Amsler grid.
4. Teach the client about controlling blood glucose levels.
5. Determine where the spots appear to be in the client’s field of vision.

Answer 26

In order of priority: 5, 3, 2, 1, 4.

5. The nurse should question the client further to obtain information such as which eye is affected, how long the client has been seeing the spots, and whether this ever occurred before.
6. The Amsler grid is helpful in determining losses occurring in the visual fields.
7. The hemoglobin A1c laboratory tests results indicate glucose control over the past two (2) to three (3) months. Diabetic retinopathy is directly related to poor blood glucose control.
8. The health-care provider should be notified to plan for laser surgery on the eye.
9. The client should be instructed about controlling blood glucose levels, but this can wait until the immediate situation is resolved or at least until measures to address the potential loss of eyesight have been taken.