TB Ch 46, 47, 48 Assessment & Care of Eye/Vision & Ear/Hearing problems

Question 1

1. The nurse has given a community group a presentation on eye health. Which statement by a participant indicates a need for more instruction?

a. “I always lose my sunglasses, so I don’t wear them.”
b. “I have diabetes and get an annual eye exam.”
c. “I will not share my contact solution with others.”
d. “I will wear safety glasses when I mow the lawn.”

Answer 1

ANS: A

Clients should be taught to protect their eyes from ultraviolet (UV) exposure by consistently wearing sunglasses when outdoors, when tanning in tanning salons, or when working with UV light. The other statements are correct.

Question 2

2. The nurse reads on a client’s chart that the client has exophthalmos. What assessment finding is consistent with this diagnosis?

a. Bulging eyes
b. Drooping eyelids
c. Sunken-in eyes
d. Yellow sclera

Answer 2

ANS: A

Exophthalmos is bulging eyes. Drooping eyelids is ptosis. Sunken-in eyes is enophthalmos. Yellow sclera indicates jaundice.

Question 3

3. A client’s chart indicates anisocoria. For what should the nurse assess?

a. Difference in pupil size
b. Draining infection
c. Recent eye trauma
d. Tumor of the eyelid

Answer 3

ANS: A

Anisocoria is a noticeable difference in the size of a person’s pupils. This is a normal finding in a small percentage of the population. Infection, trauma, and tumors are not related.

Question 4

4. A client presents to the emergency department reporting a foreign body in the eye. For what diagnostic testing should the nurse prepare the client?

a. Corneal staining
b. Fluorescein angiography
c. Ophthalmoscopy
d. Tonometry

Answer 4

ANS: A

Corneal staining is used when the possibility of eye trauma exists, including a foreign body. Fluorescein angiography is used to assess problems of retinal circulation. Ophthalmoscopy looks at both internal and external eye structures. Tonometry tests the intraocular pressure.

Question 5

5. A nurse who is applying eyedrops to a client holds pressure against the corner of the eye nearest the nose after instilling the drops. The client asks what the nurse is doing. What response by the nurse is best?

a. “Doing this allows time for absorption.”
b. “I am keeping the drops in the eye.”
c. “This prevents systemic absorption.”
d. “I am stopping you from rubbing your eye.”

Answer 5

ANS: C

This technique, called punctal occlusion, prevents eyedrops from being absorbed systemically. The other answers are inaccurate

Question 6

6. The nurse is administering eyedrops to a client with an infection in the right eye. The drops go in both eyes, and two different bottles are used to administer the drops. The nurse accidentally uses the left eye bottle for the right eye. What action by the nurse is best?

a. Inform the provider of the issue.
b. Obtain a new bottle of eyedrops.
c. Rinse the client’s right eye thoroughly.
d. Wipe the left eye bottle with alcohol.

Answer 6

ANS: B

The nurse has contaminated the “clean” bottle by using it on the infected eye. The nurse needs to obtain a new bottle of solution to use on the left eye. The other actions are not appropriate.

Question 7

7. The nurse enters an examination room to help with an eye examination. The client is directed toward the assessment chart shown below:

What is the provider assessing?

a. Color vision
b. Depth perception
c. Spatial perception
d. Visual acuity

Answer 7

ANS: A

This is an Ishihara chart, which is used for assessing color vision. Depth and spatial perception are not typically assessed in a routine vision assessment. Visual acuity is usually tested with a Snellen chart.

Question 8

1. The student learning about vision should remember which facts related to the eyes? (Select all that apply.)

a. Aqueous humor controls intraocular pressure.
b. Cones work in low light conditions.
c. Glaucoma occurs due to increased pressure in the eye.
d. Muscles of the iris control light entering the eye.
e. Rods work in low light conditions.

Answer 8

ANS: A, C, D, E

The inflow and outflow of aqueous humor controls the intraocular pressure. Glaucoma results when the pressure is chronically high. Muscles of the iris relax and constrict to control the amount of light entering the eye. Rods work in low light conditions. Cones work in bright light conditions.

Question 9

2. The nursing student studying the eye learns that which cranial nerves control its functions? (Select all that apply.)

a. II
b. III
c. VI
d. XII
e. X

Answer 9

ANS: A, B, C

The cranial nerves involved with eye function include II, III, IV, V, VI, and VII

Question 10

3. The nursing student learns that age-related changes affect the eyes and vision. Which changes does this include? (Select all that apply.)

a. Decreased eye muscle tone
b. Development of arcus senilis
c. Increase in far point of near vision
d. Decrease in general color perception
e. Increase in point of near vision

Answer 10

ANS: A, B, D, E

Normal age-related changes include decreased eye muscle tone, development of arcus senilis, decreased color perception, and increased point of near vision. The far point of near vision typically decreases.

Question 11

1. A client has a corneal ulcer. What information provided by the client most indicates a potential barrier to home care?

a. Chronic use of sleeping pills
b. Impaired near vision
c. Slightly shaking hands
d. Use of contact lenses

Answer 11

ANS: A

Antibiotic eyedrops are often needed every hour for the first 24 hours for corneal ulceration. The client who uses sleeping pills may not wake up each hour or may awaken unable to perform this task. This client might need someone else to instill the eyedrops hourly. Impaired near vision and shaking hands can both make administration of eyedrops more difficult but are not the most likely barriers. Contact lenses should be discarded.

Question 12

2. An older client has decided to give up driving due to cataracts. What assessment information is most important to collect?

a. Family history of visual problems
b. Feelings related to loss of driving
c. Knowledge about surgical options
d. Presence of family support

Answer 12

ANS: B

Loss of driving is often associated with loss of independence, as is decreasing vision. The nurse should assess how the client feels about this decision and what its impact will be. Family history and knowledge about surgical options are not related as the client has made a decision to decline surgery. Family support is also useful information, but it is most important to get the client’s perspective on this change.

Question 13

3. A client is in the preoperative holding area waiting for cataract surgery. The client says “Oh, yeah, I forgot to tell you that I take clopidogrel, or Plavix.” What action by the nurse is most important?

a. Ask the client when the last dose was.
b. Check results of the prothrombin time (PT) and international normalized ratio (INR).
c. Document the information in the chart.
d. Notify the surgeon immediately.

Answer 13

ANS: D

Clopidogrel is an antiplatelet aggregate and could increase bleeding. The surgeon should be notified immediately. The nurse should find out when the last dose of the drug was, but the priority is to notify the provider. This drug is not monitored with PT and INR. Documentation should occur but is not the priority.

Question 14

4. A client does not understand why vision loss due to glaucoma is irreversible. What explanation by the nurse is best?

a. “Because eye pressure was too high, the tissue died.”
b. “Glaucoma always leads to permanent blindness.”
c. “The traumatic damage to your eye was too great.”
d. “The infection occurs so quickly it can’t be treated.”

Answer 14

ANS: A

Glaucoma is caused when the intraocular pressure becomes too high and stays high long enough to cause tissue ischemia and death. At that point, vision loss is permanent. Glaucoma does not have to cause blindness. Trauma can cause glaucoma but is not the most common cause. Glaucoma is not an infection.

Question 15

5. A client’s intraocular pressure (IOP) is 28 mm Hg. What action by the nurse is best?

a. Educate the client on corneal transplantation.
b. Facilitate scheduling the eye surgery.
c. Plan to teach about drugs for glaucoma.
d. Refer the client to local Braille classes.

Answer 15

ANS: C

This increased IOP indicates glaucoma. The nurse’s main responsibility is teaching the client about drug therapy. Corneal transplantation is not used in glaucoma. Eye surgery is not indicated at this time. Braille classes are also not indicated at this time.

Question 16

6. A client had a retinal detachment and has undergone surgical correction. What discharge instruction is most important?

a. “Avoid reading, writing, or close work such as sewing.”
b. “Dim the lights in your house for at least a week.”
c. “Keep the follow-up appointment with the ophthalmologist.”
d. “Remove your eye patch every hour for eyedrops.”

Answer 16

ANS: A

After surgery for retinal detachment, the client is advised to avoid reading, writing, and close work because they cause rapid eye movements. Dim lights are not indicated. Keeping a postoperative appointment is important for any surgical client. The eye patch is not removed for eyedrops.

Question 17

7. A client has been taught about retinitis pigmentosa (RP). What statement by the client indicates a need for further teaching?

a. “Beta carotene, lutein, and zeaxanthin are good supplements.”
b. “I might qualify for a retinal transplant one day soon.”
c. “Since I’m going blind, sunglasses are not needed anymore.”
d. “Vitamin A has been shown to slow progression of RP.”

Answer 17

ANS: C

Sunglasses are needed to prevent the development of cataracts in addition to the RP. The other statements are accurate.

Question 18

8. A client has a foreign body in the eye. What action by the nurse takes priority?

a. Administering ordered antibiotics
b. Assessing the client’s visual acuity
c. Obtaining consent for enucleation
d. Removing the object immediately

Answer 18

ANS: A

To prevent infection, antibiotics are provided. Visual acuity in the affected eye cannot be assessed. The client may or may not need enucleation. The object is only removed by the ophthalmologist.

Question 19

9. A client who is near blind is admitted to the hospital. What action by the nurse is most important?

a. Allow the client to feel his or her way around.
b. Let the client arrange objects on the bedside table.
c. Orient the client to the room using a focal point.
d. Speak loudly and slowing when talking to the client.

Answer 19

ANS: C

Using a focal point, orient the client to the room by giving descriptions of items as they relate to the focal point. Letting the client arrange the bedside table is a good idea, but not as important as orienting the client to the room for safety. Allowing the client to just feel around may cause injury. Unless the client is also hearing impaired, use a normal tone of voice.

Question 20

10. A client had proxymetacaine (Ocu-Caine) instilled in one eye in the emergency department. What discharge instruction is most important?

a. Do not touch or rub the eye until it is no longer numb.
b. Monitor the eye for any bleeding for the next day.
c. Rinse the eye with warm saline solution at home.
d. Use all the eyedrops as prescribed until they are gone.

Answer 20

ANS: A

This drug is an ophthalmic anesthetic. The client can injure the numb eye by touching or rubbing it. Bleeding is not associated with this drug. The client should not be told to rinse the eye. This medication was given in the emergency department and is not prescribed for home use.

Question 21

11. A client is taking timolol (Timoptic) eyedrops. The nurse assesses the client’s pulse at 48 beats/min. What action by the nurse is the priority?

a. Ask the client about excessive salivation.
b. Assess the client for shortness of breath.
c. Give the drops using punctal occlusion.
d. Hold the eyedrops and notify the provider.

Answer 21

ANS: D

The nurse should hold the eyedrops and notify the provider because beta blockers can slow the heart rate. Excessive salivation can occur with cholinergic agonists. Shortness of breath is not related. If the drops are given, the nurse uses punctal occlusion to avoid systemic absorption.

Question 22

12. A client has been prescribed brinzolamide (Azopt). What assessment by the nurse requires consultation with the provider?

a. Allergy to eggs
b. Allergy to sulfonamides
c. Use of contact lenses
d. Use of beta blockers

Answer 22

ANS: B

Brinzolamide is similar to sulfonamides, so an allergic reaction could occur. The other assessment findings are not related to brinzolamide.

Question 23

13. A client is brought to the emergency department after a car crash. The client has a large piece of glass in the left eye. What action by the nurse takes priority?

a. Administer a tetanus booster shot.
b. Ensure the client has a patent airway.
c. Prepare to irrigate the client’s eye.
d. Turn the client on the unaffected side

Answer 23

ANS: B

Airway always comes first. After ensuring a patent airway and providing cervical spine precautions (do not turn the client to the side), the nurse provides other care that may include administering a tetanus shot. The client’s eye may or may not be irrigated.

Question 24

14. A nurse is seeing clients in the ophthalmology clinic. Which client should the nurse see first?

a. Client with intraocular pressure reading of 24 mm Hg
b. Client who has had cataract surgery and has worsening vision
c. Client whose red reflex is absent on ophthalmologic examination
d. Client with a tearing, reddened eye with exudate

Answer 24

ANS: B

After cataract surgery, worsening vision indicates an infection or other complication. The nurse should see this client first. The intraocular pressure is slightly elevated. An absent red reflex may indicate cataracts. The client who has the tearing eye may have an infection.

Question 25

1. The nurse working in the ophthalmology clinic sees clients with eyelid and eye problems. What information should the nurse understand about these disorders? (Select all that apply.)

a. A chalazion is an inflammation of an eyelid sebaceous gland.
b. An ectropion is the eyelid turning inward.
c. An entropion is the eyelid turning outward.
d. A hordeolum is an infection of the eyelid sweat gland.
e. Keratoconjunctivitis sicca is caused by drugs or diseases.

Answer 25

ANS: A, D, E

A chalazion is an inflammation of one of the sebaceous glands in the eyelid. A hordeolum is an infection of a sweat gland in the eyelid. Keratoconjunctivitis sicca can be caused by drugs or diseases. An ectropion is an outward turning and sagging eyelid, while an entropion is an inward turning of the eyelid.

Question 26

2. A client is seen in the ophthalmology clinic with bacterial conjunctivitis. Which statements by the client indicate a good understanding of home management of this condition? (Select all that apply.)

a. “As long as I don’t wipe my eyes, I can share my towel.”
b. “Eye irrigations should be done with warm saline or water.”
c. “I will throw away all my eye makeup when I get home.”
d. “I won’t touch the tip of the eyedrop bottle to my eye.”
e. “When the infection is gone, I can use my contacts again.”

Answer 26

ANS: C, D

Bacterial conjunctivitis is very contagious, and re-infection or cross-contamination between the client’s eyes is possible. The client should discard all eye makeup being used at the time the infection started. When instilling eyedrops, the client must be careful not to contaminate the bottle by touching the tip to the eye or face. The client should be instructed not to share towels. Eye irrigations are not needed. Contacts being used when the infection first manifests also need to be discarded.

Question 27

3. A client had cataract surgery. What instructions should the nurse provide? (Select all that apply.)

a. Call the doctor for increased pain.
b. Do not bend over from the waist.
c. Do not lift more than 10 pounds.
d. Sexual intercourse is allowed.
e. Use stool softeners to avoid constipation.

Answer 27

ANS: A, B, C, E

The client should be taught to call the physician for increased pain as this might indicate infection or other complication. To avoid increasing intraocular pressure, clients are taught to not lift more than 10 pounds, to avoid bending at the waist, to avoid straining at stool, and to avoid sexual intercourse for a time after surgery.

Question 28

4. A nurse has delegated applying a warm compress to a client’s eye. What actions by the unlicensed assistive personnel (UAP) warrant intervention by the nurse? (Select all that apply.)

a. Heating the wet washcloth in the microwave
b. Holding the cloth on the client using an Ace wrap
c. Turning the cloth so it remains warm on the client
d. Using a clean washcloth for the compress
e. Washing the hands on entering the client’s room

Answer 28

ANS: A, B

The washcloth should be warmed under running warm water. Microwaving it can lead to burns. Gentle pressure is used to hold the compress in place. The other actions are correct.

Question 29

1. A nurse is teaching a client about ear hygiene and health. What client statement indicates a need for further teaching?

a. “A soft cotton swab is alright to clean my ears with.”
b. “I make sure my ears are dry after I go swimming.”
c. “I use good earplugs when I practice with the band.”
d. “Keeping my diabetes under control helps my ears.”

Answer 29

ANS: A

Clients should be taught not to put anything larger than their fingertip into their ears. Using a cotton swab, although soft, can cause damage to the ears and cerumen buildup. The other statements are accurate.

Question 30

2. The student nurse is performing a Weber tuning fork test. What technique is most appropriate?

a. Holding the vibrating tuning fork 10 to 12 inches from the client’s ear
b. Placing the vibrating fork in the middle of the client’s head
c. Starting by placing the vibrating fork on the mastoid process
d. Tapping the vibrating tuning fork against the bridge of the nose

Answer 30

ANS: B

The Weber tuning fork test includes placing the vibrating tuning fork in the middle of the client’s head and asking in which ear the client hears the vibrations louder. The other techniques are incorrect.

Question 31

3. The client’s chart indicates a sensorineural hearing loss. What assessment question does the nurse ask to determine the possible cause?

a. “Do you feel like something is in your ear?”
b. “Do you have frequent ear infections?”
c. “Have you been exposed to loud noises?”
d. “Have you been told your ear bones don’t move?”

Answer 31

ANS: C

Sensorineural hearing loss can occur from damage to the cochlea, the eighth cranial nerve, or the brain. Exposure to loud music is one etiology. The other questions relate to conductive hearing loss.

Question 32

4. The nurse works with clients who have hearing problems. Which action by a client best indicates goals for an important diagnosis have been met?

a. Babysitting the grandchildren several times a week
b. Having an adaptive hearing device for the television
c. Being active in community events and volunteer work
d. Responding agreeably to suggestions for adaptive devices

Answer 32

ANS: C

Clients with hearing problems can become frustrated and withdrawn. The client who is actively engaged in the community shows the best evidence of psychosocial adjustment to hearing loss. Babysitting the grandchildren is a positive sign but does not indicate involvement outside the home. Having an adaptive device is not the same as using it, and watching TV without evidence of other activities can also indicate social isolation. Responding agreeably does not indicate the client will actually follow through.

Question 33

5. A client has external otitis. On what comfort measure does the nurse instruct the client?

a. Applying ice four times a day
b. Instilling vinegar-and-water drops
c. Use of a heating pad to the ear
d. Using a home humidifier

Answer 33

ANS: C

A heating pad on low or a warm moist pack can provide comfort to the client with otitis externa. The other options are not warranted.

Question 34

6. An older adult in the family practice clinic reports a decrease in hearing over a week. What action by the nurse is most appropriate?

a. Assess for cerumen buildup.
b. Facilitate audiological testing.
c. Perform tuning fork tests.
d. Review the medication list.

Answer 34

ANS: A

All options are possible actions for the client with hearing loss. The first action the nurse should take is to look for cerumen buildup, which can decrease hearing in the older adult. If this is normal, medications should be assessed for ototoxicity. Further auditory testing may be needed for this client.

Question 35

7. A client had a myringotomy. The nurse provides which discharge teaching?

a. Buy dry shampoo to use for a week.
b. Drink liquids through a straw.
c. Flying is not allowed for 1 month.
d. Hot water showers will help the pain.

Answer 35

ANS: A

The client cannot shower or get the head wet for 1 week after surgery, so using dry shampoo is a good suggestion. The other instructions are incorrect: straws are not allowed for 2 to 3 weeks, flying is not allowed for 2 to 3 weeks, and the client should not shower.

Question 36

8. A client is going on a cruise but has had motion sickness in the past. What suggestion does the nurse make to this client?

a. Avoid alcohol on the cruise ship.
b. Change positions slowly on the ship.
c. Change your travel plans.
d. Try scopolamine (Transderm Scop).

Answer 36

ANS: D

Scopolamine can successfully treat the vertigo and dizziness associated with motion sickness. Avoiding alcohol and changing positions slowly are not effective. Telling the client to change travel plans is not a caring suggestion.

Question 37

9. A nurse is teaching a community group about noise-induced hearing loss. Which client who does not use ear protection should the nurse refer to an audiologist as the priority?

a. Client with an hour car commute on the freeway each day
b. Client who rides a motorcycle to work 20 minutes each way
c. Client who sat in the back row at a rock concert recently
d. Client who is a tree-trimmer and uses a chainsaw 6 to 7 hours a day

Answer 37

ANS: D

A chainsaw becomes dangerous to hearing after 2 hours of exposure without hearing protection. This client needs to be referred as the priority. Normal car traffic is safe for more than 8 hours. Motorcycle noise is safe for about 8 hours. The safe exposure time for a front-row rock concert seat is 3 minutes, but this client was in the back, and so had less exposure. In addition, a one-time exposure is less damaging than chronic exposure.

Question 38

10. A nursing student is instructed to remove a client’s ear packing and instill eardrops. What action by the student requires intervention by the registered nurse?

a. Assessing the eardrum with an otoscope
b. Inserting a cotton ball in the ear after the drops
c. Warming the eardrops in water for 5 minutes
d. Washing the hands and removing the packing

Answer 38

ANS: D

The student should wash his or her hands, don gloves, and then remove the packing. The other actions are correct.

Question 39

11. A nurse is irrigating a client’s ear when the client becomes nauseated. What action by the nurse is most appropriate for client comfort?

a. Have the client tilt the head back.
b. Re-position the client on the other side.
c. Slow the rate of the irrigation.
d. Stop the irrigation immediately.

Answer 39

ANS: D

During ear irrigation, if the client becomes nauseated, stop the procedure. The other options are not helpful.

Question 40

12. A client hospitalized for a wound infection has a blood urea nitrogen of 45 mg/dL and creatinine of 4.2 mg/dL. What action by the nurse is best?

a. Assess the ordered antibiotics for ototoxicity.
b. Explain how kidney damage causes hearing loss.
c. Use ibuprofen (Motrin) for pain control.
d. Teach that hearing loss is temporary.

Answer 40

ANS: A

Some medications are known to be ototoxic. Diminished kidney function slows the excretion of drugs from the body, worsening the ototoxic effects. The nurse should assess the antibiotics the client is receiving for ototoxicity. The other options are not warranted.

Question 41

13. A nurse is teaching a community group about preventing hearing loss. What instruction is best?

a. Always wear a bicycle helmet.
b. Avoid swimming in ponds or lakes.
c. Don’t go to fireworks displays.
d. Use a soft cotton swab to clean ears.

Answer 41

ANS: A

Avoiding head trauma is a practical way to help prevent hearing loss. Swimming can lead to hearing loss if the client has repeated infections. Fireworks displays are loud, but usually brief and only occasional. Nothing smaller than the client’s fingertip should be placed in the ear canal.

Question 42

14. A client has severe tinnitus that cannot be treated adequately. What action by the nurse is best?

a. Advise the client to take antianxiety medication.
b. Educate the client on nerve cutting procedures.
c. Refer the client to online or local support groups.
d. Teach the client side effects of furosemide (Lasix).

Answer 42

ANS: C

If the client’s tinnitus cannot be treated, he or she will have to learn to cope with it. Referring the client to tinnitus support groups can be helpful. The other options are not warranted.

Question 43

15. A client has labyrinthitis and is prescribed antibiotics. What instruction by the nurse is most important for this client?

a. Immediately report headache or stiff neck.
b. Keep all follow-up appointments.
c. Take the antibiotics with a full glass of water.
d. Take the antibiotic on an empty stomach.

Answer 43

ANS: A

Meningitis is a complication of labyrinthitis. The client should be taught to take all antibiotics as prescribed and to report manifestations of meningitis such as fever, headache, or stiff neck. Keeping follow-up appointments is important for all clients. Without knowing what antibiotic was prescribed, the nurse cannot instruct the client on how to take it.

Question 44

16. A client with Ménière’s disease is in the hospital when the client has an attack of this disorder. What action by the nurse takes priority?

a. Assess vital signs every 15 minutes.
b. Dim or turn off lights in the client’s room.
c. Place the client in bed with the upper siderails up.
d. Provide a cool, wet cloth for the client’s face.

Answer 44

ANS: C

Clients with Ménière’s disease can have vertigo so severe that they can fall. The nurse should assist the client into bed and put the siderails up to keep the client from falling out of bed due to the intense whirling feeling. The other actions are not warranted for clients with Ménière’s disease.

Question 45

17. A client is scheduled to have a tumor of the middle ear removed. What teaching topic is most important for the nurse to cover?

a. Expecting hearing loss in the affected ear
b. Managing postoperative pain
c. Maintaining NPO status prior to surgery
d. Understanding which medications are allowed the day of surgery

Answer 45

ANS: A

Removal of an inner ear tumor will likely destroy hearing in the affected ear. The other teaching topics are appropriate for any surgical client.

Question 46

1. A nursing student studying the auditory system learns about the structures of the inner ear. What structures does this include? (Select all that apply.)

a. Cochlea
b. Epitympanum
c. Organ of Corti
d. Semicircular canals
e. Vestibule

Answer 46

ANS: A, C, D, E

The cochlea, organ of Corti, semicircular canals, and vestibule are all part of the inner ear. The epitympanum is in the middle ear.

Question 47

2. A client has Ménière’s disease with frequent attacks. About what drugs does the nurse plan to teach the client? (Select all that apply.)

a. Broad-spectrum antibiotics
b. Chlorpromazine hydrochloride (Thorazine)
c. Diphenhydramine (Benadryl)
d. Meclizine (Antivert)
e. Nonsteroidal anti-inflammatory drugs (NSAIDs)

Answer 47

ANS: B, C, D

Drugs such as chlorpromazine, diphenhydramine, and meclizine can all be used to treat Ménière’s disease. Antibiotics and NSAIDs are not used.

Question 48

3. A client is scheduled for a tympanoplasty. What actions by the nurse are most appropriate? (Select all that apply.)

a. Administer preoperative antibiotics.
b. Assess for allergies to local anesthetics.
c. Ensure that informed consent is on the chart.
d. Give ordered antivertigo medications.
e. Teach that hearing improves immediately.

Answer 48

ANS: A, C

Preoperatively, the nurse administers antibiotics and ensures that informed consent is on the chart. Local anesthetics can be used, but general anesthesia is used more often. Antivertigo medications are not used. Hearing will be decreased immediately after the operation until the ear packing is removed.

Question 49

4. A client has a hearing aid. What care instructions does the nurse provide the unlicensed assistive personnel (UAP) in the care of this client? (Select all that apply.)

a. Be careful not to drop the hearing aid when handling.
b. Soak the hearing aid in hot water for 20 minutes.
c. Turn the hearing aid off when the client goes to bed.
d. Use a toothpick to clean debris from the device.
e. Wash the device with soap and a small amount of warm water.

Answer 49

ANS: A, C, D, E

All these actions except soaking the hearing aid are proper instructions for the nurse to give to the UAP. While some water is used to clean the hearing aid, excessive wetting should be avoided.

Question 50

5. A hospitalized client has Ménière’s disease. What menu selections demonstrate good knowledge of the recommended diet for this disorder? (Select all that apply.)

a. Chinese stir fry with vegetables
b. Broiled chicken breast
c. Chocolate espresso cookies
d. Deli turkey sandwich and chips
e. Green herbal tea with meals

Answer 50

ANS: B, E

The diet recommendations for Ménière’s disease include low-sodium, caffeine-free foods and fluids distributed evenly throughout the day. Plenty of water is also needed. The broiled chicken breast and herbal tea are the best selections. The stir fry is high in sodium and possibly monosodium glutamate (MSG, also not recommended). The cookies have caffeine, and the sandwich and chips are high in sodium.

Question 51

6. A client is scheduled for a stapedectomy in 2 weeks. What teaching instructions are most appropriate? (Select all that apply.)

a. Avoid alcohol use before surgery.
b. Blow the nose gently if needed.
c. Clean the telephone often.
d. Sneeze with the mouth open.
e. Wash the external ear daily.

Answer 51

ANS: B, C, D, E

It is imperative that the client having a stapedectomy is free from ear infection. Teaching includes ways to prevent such infections, such as blowing the nose gently, cleaning objects that come into contact with the ear, sneezing with the mouth open, and washing the external ear daily. Avoiding alcohol will not help prevent ear infections.

Question 52

7. A client is admitted to the nursing unit after having a tympanoplasty. What activities does the nurse delegate to the unlicensed assistive personnel (UAP)? (Select all that apply.)

a. Administer prescribed antibiotics.
b. Keep the head of the client’s bed flat.
c. Remind the client to lie on the operative side.
d. Remove the iodoform gauze in 8 hours.
e. Take and record postoperative vital signs.

Answer 52

ANS: B, E

The UAP can keep the head of the client’s bed flat and take/record vital signs. The nurse administers medications. The client should lie flat with the head turned so the operative side is up. The nurse or surgeon removes the gauze packing.