Sensory System

Question 1

Priority nursing intervention for chemical splash in the eyes (608)

Answer 1

Flush with water for >15 minutes.

Question 2

How do you use the Snellen chart (608)

Answer 2

Stand 20’ from the chart.

Cover one eye.

Read above or below the 20/20 line.

Repeat using the other eye.

Document.

Question 3

Hyperopia

Answer 3

Far sightedness.

Question 4

Myopia

Answer 4

Near sightedness.

Question 5

Strabismus

Answer 5

Cross-eyed.

Question 6

Astigmatism

Answer 6

Irregular shape of the cornea.

Question 7

Sjogren’s syndrome (615, 616)

Answer 7

Immunologic disorder characterized by deficient fluid production by the lacrimal, salivary, and other glands. Abnormal dryness of the mouth, eyes, and other mucous membranes.

Question 8

Patient teaching for vertigo (640)

Answer 8

Lie down immediately.

Call for help before an attack.

Pull over if driving.

Stay immobile.

Ask for assistance.

Take medications.

Question 9

Medications that constrict the iris (625)

Answer 9

Miotics - agents that cause the pupils to constrict. This allows for the aqueous humor fluid to drain through the canal of Schlemm.

Example is pilocarpine.

Question 10

Glaucoma (624)

Answer 10

Group of diseases characterized by increasing IOP due to obstruction of the outflow of aqueous humor. Results in optic nerve atrophy and progressive loss of peripheral vision.

Question 11

Cataracts

Answer 11

Crystalline opacity or clouding of the lens.

Question 12

Signs and symptoms of retinal detachment

Answer 12

Flashing lights, floaters, progressive vision restriction.

“Curtain is being drawn down across the eye.”

Question 13

Best treatment for macular degeneration (dry type) (621)

Answer 13

AKA non-exudative nonneovascular macular degeneration. Lipid deposits lead to atrophy and degradation of tissue.

There is no treatment for dry type.

Question 14

Photocoagulation (621, 630)

Answer 14

Wet type ARMD treatment by laser to destroy abnormal blood vessels. Laser also destroys photoreceptor cells and the retina. Used to seal leaks and destroy offensive tissues.

Question 15

Structure responsible for balance and coordination

Answer 15

Semicircular canals

Question 16

Observations for presentation of diabetic retinopathy (618)

Answer 16

Disorder of retinal blood vessels, caused by capillary microaneurysms, hemorrhage, and exudate. Dilated and tortuous vessels with narrowing of the arteries. Opacities, hemorrhage, and microaneurysms are observed.

Question 17

Post-op care for a cataract patient (617, 618)

Answer 17

Patient teaching: antibiotic and corticosteroid medications, avoid activities that increase IOP. Use of eye shields, contact doctor if there’s pain, avoid bending, stooping, coughing, or lifting. Administer drops directly into conjunctival sac.

Question 18

Home modifications for the visually impaired

Answer 18

Removal of area rugs, adequate lighting, and other obvious interventions.

Question 19

Post-op care for cataract surgery (618)

Answer 19

Antibiotics - prevents infection.

Corticosteroids - minimize inflammatory response.

Contact doctor for erythema, pain, drainage, or vision changes.

Question 20

Increase in intraoccular pressure

Answer 20

g l a u c o m a

Question 21

Post-op care for stapeectomy (644)

Answer 21

External ear packing must be in place for to ensure healing. Keep in place for 5-6 days. 24 hour bed rest following surgery. Resume activity gradually. Lay flat on the operative side upwards. Open mouth when coughing or sneezing.

Question 22

How to assist blind patient with ambulation

Answer 22

Stand about 1-foot in front of the patient and allow them to hold the back of your arm.

Question 23

Major diagnostic eye test for any underlying structure of the eye (606)

Answer 23

Amsler’s grid test - detect defects of macular area of the retina.

Tangent screen - evaluates peripheral vision.

Goldmann Perimetry - evaluates glaucoma

Slit-lamp - examine conjunctiva, lens, vitreous humor, iris, and cornea.

Fluorescein angiography - examine the microvascular structures of the eye, assess patency of the lacrimal system, and to assess for corneal abrasion.

Question 24

Number one objective with an infectious eye disorder (615)

Answer 24

Pain

Prevent spread of infection

Question 25

Legal blindness

Answer 25

20/200 with corrective eyewear and/or visual field sight capacity reduced to 20 degrees. (The normal visual field range is 180 degrees.)

Question 26

What’s the use of atropine for a patient undergoing cataract surgery (627)

Answer 26

Dilates the pupils and paralyzes the muscles of accommodation.

Question 27

Signs and symptoms of keratitis (615)

Answer 27

Inflammation of the cornea presents with severe eye pain.

Also photophobia, tearing, edema, and visual disturbances.

Question 28

Ear implants

Answer 28

c o c h l e a r i m p l a n t s

Question 29

How to approach a patient with hearing deficit on one side

Answer 29

Approach from the face.

Question 30

Visual condition of macular degeneration

Answer 30

Loss at the center of the visual field.

Question 31

Surgical fixation of the retina (623)

Answer 31

Pneumatic Retinopexy

Cryoretinopexy

Question 32

Cyclogyl

Answer 32

Antocholinergic drug that dilates pupils and temporarily paralyzes the cilliary muscles. Used in the treatment of glaucoma, during diagnostic tests, agent for angle closure glaucoma.

Question 33

Test for patient presenting with difficulty reading a newspaper

Answer 33

Snellen Test

Question 34

Signs and symptoms of blepharitis (613)

Answer 34

Pruritus, erythema of the eyelids, eyelid pain, photophobia, and excessive tearing.

Question 35

Treatment of conjunctivitis due to allergies (615)

Answer 35

Warm NS compresses for 10-20 minutes 2-4x daily. Lid scrubbing using no tear baby shampoo. Eye irrigations. Medication administration. Should not wear contact lenses during suppuration period.

Question 36

Best patient position for keratoplasty

Answer 36

Supine

Question 37

Instructions given to patient and family having had keratoplasty (630)

Answer 37

Avoid bending, lifting, and straining for about 1 month to avoid increase in IOP. Family must thoroughly wash hands before coming into contact with area. Avoid powders, perfumes, and propellants which may cause sneezing. Do not rub area and limit reading.

Question 38

Romberg Test

Answer 38

Close your eyes and see how long you can hold your balance.

Question 39

Weber’s test (631)

Answer 39

Tuning fork test. Assesses auditory acuity. Tuning fork on the forehead and sound should be equal in both ears.

Neural loss of hearing (nerve) - louder on unaffected side.

Conduction loss of hearing (physical) - louder on affected side.

Question 40

Reason for increased incidence of otitis media in children

Answer 40

Shorter eustachian tubes

Question 41

Medications for labyrinthitis (639)

Answer 41

Inflammation of the labyrinthine canals of the inner ear. Most common cause of vertigo. Can be viral or bacterial in nature.

Although no specific treatment available, treat with antibiotics, drammamine, and antivert for the vertigo.

Question 42

How are the symptoms of Meniere’s disease managed (641, 642)

Answer 42

Chronic inner ear disease characterized by recurrent episodes of deafness, progressive unilateral nerve deafness, and tinnitus. Disease is idiopathic. Can follow a middle ear infection or trauma to the head.

Avoid caffeine and smoking. Valium, bendaryl, and fentanyl with innovar may be used for vertigo. Bed rest, sedation, and entiemetics may be given. Keep patient in a quiet dark room with little background noise for ease of tinnitus.

Question 43

Name for turning the eyelids outwards (616)

Answer 43

Ectropion

Question 44

Endropion (616)

Answer 44

Turning inward of eyelid.

Question 45

Medication for pressure given to a patient with glaucoma

Answer 45

Mannitol (osmotic diuretic)

Question 46

Contact lens care (613)

Answer 46

DO
• Wash and rinse hands thoroughly before handling a lens. • Keep fingernails clean. • Remove lenses from their storage case one at a time and place on the eye. • Start with the same lens (left or right) at each insertion. • Use lens-placement technique learned from eye specialist. • Use proper lens care products and clean the lenses as directed by the manufacturer. • Keep the lens storage kit clean. • Wear lenses daily and follow the prescribed wearing schedule. • Remove a lens if it becomes uncomfortable. • Avoid potential corneal abrasions. • Report any signs of photophobia, dryness, excessive burning, or tearing. • Keep regular appointments with the eye specialist. • Remove lenses during sunbathing, showering, or swimming.

DO NOT
• Use soaps that contain cream or perfume for cleansing lenses.
• Let fingernails touch lenses. • Mix up lenses. • Exceed prescribed wearing time. • Use saliva to wet lenses. • Use homemade saline solution or tap water to wet or clean lenses. • Borrow or mix lens care solutions.

Question 47

Changes in vision for older adults (607)

Answer 47

Multiple changes in vision that normally occur with aging in- clude the following: —Changes in accommodation, resulting in increased diffi-
culty focusing on close objects (presbyopia), which leads
to difficulty reading or doing other close work —Decreased color perception and discrimination, particu-
larly with shades of blue, green, and violet —Poor adaptation to changes in light, resulting in “night
blindness” and increased sensitivity to glare due to in-
creased opacity of the lens and decreased pupil size —Alterations in depth perception, leading to increased risk
of falls —Decreased secretion of tears, resulting in complaints of
dryness or pruritus, which leads to a high risk for irritation
of the cornea —Increased incidence of moving particles or “floaters” that
interfere with visually based tasks. Older adults experience an increased incidence of eye dis- orders, including cataracts, retinal detachment, macular de- generation, and glaucoma. A third of all individuals older than 70 years of age have sig- nificant hearing loss.
Hearing loss in older adults is most often sensorineural (presbycusis) and involves loss of the high frequencies. Hearing loss results in distortion of speech, which can lead to failure to respond to directions or inappropriate behaviors often misinterpreted as disorientation.
Hearing loss can lead to social isolation when the person cannot understand and participate in normal conversation. A decreased number of receptors in the nasal cavities and papillae of the tongue results in changes in smell and taste. Most affected are the sweet and salty tastes.
Medications often affect the taste of food and can contribute to altered nutrition.

Question 48

Retinal detachment patient teaching (623)

Answer 48

Retinal Detachment
Return to sedentary activity in 2 weeks; no heavy lifting or active physical activity for 6 weeks, or as instructed by physician. Check with physician about shampooing hair.
Limit reading for 3 weeks or as instructed by physician. Use correct technique for administration of eye medications. Report to ophthalmologist any signs of further detachment (flashes of light, increase in floaters, blurred vision). Report for medical follow-up visits as instructed.

Eyepatches are applied over only the operative eye or both eyes, pro- viding the required rest of the eye for 1 or 2 days. Safety measures are essential because the eyes are patched.
Depending on the procedures, the position of the head postoperatively may vary. If air is injected into the vitreous, the head is positioned with the unaf- fected eye upward and the patient lying on the abdo- men or sitting forward for 4 to 5 days.