TEST 15 : The Client with Health Problems of the Eyes, Ears, Nose, and Throat

Question 1

The Client with Cataracts
1. The nurse is observing a student nurse administer eyedrops, as shown in the figure. What
should the nurse instruct the student to do?
1. Move the dropper to the inner canthus.
2. Have the client raise the eyebrows.
3. Administer the drops in the center of the lower lid.
4. Have the client squeeze both eyes after administering the drops.

Answer 1

The Client with Cataracts
1. 3. The student has positioned the dropper and the client correctly to prevent injury to the
client’s eye. The student should administer the drops in the center of the lower lid. Following
administration of the eyedrops, the client should blink the eyes to distribute the medication; squeezing
or rubbing the eyes might cause the medication to drip out of the eye.
CN: Safety and infection control; CL: Apply

Question 2

2. One day after cataract surgery the client is having discomfort from bright light. The nurse
   should advise the client to
3. Dim lights in the house and stay inside for one week.
4. Attach sun shields to existing eyeglasses when in direct sunlight.
5. Use sunglasses that wrap around the side of the face when in bright light.
6. Patch the affected eye when in bright light.

Answer 2

2. 3. To prevent discomfort from bright light the client should wear sunglasses that cover the front
      and side of the face, thus minimizing light that comes into the eye from any direction. It is not
      necessary to remain in dim light or inside. Attaching sun shields or sunglasses to existing glasses will
      not cover the eye sufficiently and bright light will come in on the side of the face. It is not necessary
      to patch the affected eye.
      CN: Basic care and comfort; CL: Synthesize

Question 3

3. A client is having a cataract removed and will use eyeglasses after the surgery. The nurse
   should develop a teaching plan that includes which of the following? Select all that apply.
4. Images will appear to be one-third larger.
5. Look through the center of the glasses.
6. The changes will be immediate.
7. Use handrails when climbing stairs.
8. Stay out of the sun for 2 weeks.

Answer 3

3. 1, 2, 4. The use of glasses following cataract surgery does not totally restore binocular vision.
   Glasses will cause images to appear larger and peripheral vision will be distorted; the client should
   look through the center of the glasses and turn his or her head to view objects in the periphery. The
   client should also use caution when walking or climbing stairs until he or she has adjusted to the
   change in vision. Changes in vision following cataract surgery are not immediate, and the nurse can
   instruct the client to be patient while adjusting to the changes. The client does not need to stay out of
   the sun but should wear dark glasses to prevent discomfort from photophobia.
   CN: Physiological adaptation; CL: Create

Question 4

4. The client has had a cataract removed. The nurse's discharge instructions should include which
of the following?
1. Keep the head aligned straight.
2. Utilize bright lights in the home.
3. Use an eye shield at night.
4. Change the eye patch as needed.

Answer 4

4. 3. Using an eye shield at night prevents rubbing the eye. The head should be turned to the side
      to scan the entire visual field to compensate for impaired peripheral vision. Eye medications may
      initially cause sensitivity to bright light. The surgeon changes the eye patch on the second
      postoperative day.
      CN: Reduction of risk potential; CL: Synthesize

Question 5

5. The client with a cataract tells the nurse about being afraid of being awake during eye surgery.
   Which of the following responses by the nurse would be the most appropriate?
6. “Have you ever had any reactions to local anesthetics in the past?”
7. “What is it that disturbs you about the idea of being awake?”3. “By using a local anesthetic, you won’t have nausea and vomiting after the surgery.”
8. “There’s really nothing to fear about being awake. You’ll be given a medication that will help
   you relax.”

Answer 5

5. 2. The nurse should give a client who seems fearful of surgery an opportunity to express her
      feelings. Only after identifying the client’s concerns can the nurse intervene appropriately. Asking the
      client about previous reactions to local anesthetics may be warranted, but it does not address the
      client’s concerns in this instance. Telling the client that she will not have nausea or vomiting ignores
      the client’s feelings of fear and does not provide any data about the client’s feelings. More data would
      help the nurse plan care. Telling the client that there is nothing to be afraid of minimizes her feelings
      and does not address her concerns. Premature explanations and clichés do not provide the neededassessment data and ignore the client’s feelings.
      CN: Psychosocial integrity; CL: Synthesize

Question 6

6. A client tells the nurse about the vision being blurred and hazy throughout the entire day. The
   nurse should recommend that the client do which of the following?
7. Purchase a pair of magnifying glasses.
8. Wear glasses with tinted lenses.
9. Schedule an appointment with an optician.
10. Schedule an appointment with an ophthalmologist.

Answer 6

6. 4. An ophthalmologist is a physician who specializes in the treatment of disorders of the eye,
      and the nurse should advise the client to see a physician. An optician makes glasses, and it is not
      known at this point what the best treatment for the client is. Magnifying glasses, or glasses with tinted
      lenses, do not correct hazy or blurred vision. If glasses are needed to correct refractive errors, they
      should be prescription glasses.
      CN: Health promotion and maintenance; CL: Synthesize

Question 7

7. The nurse is to instill drops of phenylephrine hydrochloride (Neo-Synephrine) into the client’s
   eye prior to cataract surgery. Which of the following is the expected outcome?
8. Dilation of the pupil and blood vessels.
9. Dilation of the pupil and constriction of blood vessels.
10. Constriction of the pupil and constriction of blood vessels.
11. Constriction of the pupil and dilation of blood vessels.

Answer 7

7. 2. Instilled in the eye, phenylephrine hydrochloride (Neo-Synephrine) acts as a mydriatic,
      causing the pupil to dilate. It also constricts small blood vessels in the eye.
      CN: Pharmacological and parenteral therapies; CL: Evaluate

Question 8

8. A short time after cataract surgery, the client has nausea. The nurse should first:
9. Instruct the client to take a few deep breaths until the nausea subsides.
10. Explain that this is a common feeling that will pass quickly.
11. Tell the client to call the nurse promptly if vomiting occurs.
12. Medicate the client with an antiemetic, as prescribed.

Answer 8

8. 4. A prescribed antiemetic should be administered as soon as the client has nausea following a
      cataract extraction. Vomiting can increase intraocular pressure, which should be avoided after eye
      surgery because it can cause complications. Deep breathing is unlikely to relieve nausea.
      Postoperative nausea may be common; however, it doesn’t necessarily pass quickly and can lead to
      vomiting. Telling the client to call only if vomiting occurs ignores the client’s need for comfort and
      intervention to prevent complications.
      CN: Pharmacological and parenteral therapies; CL: Synthesize

Question 9

9. Which of the following is a potential complication following cataract surgery? Select all that
apply.
1. Acute bacterial endophthalmitis.
2. Retrobulbar hemorrhage.
3. Rupture of the posterior capsule.
4. Suprachoroidal hemorrhage.
5. Vision loss.

Answer 9

9. 1, 5. Acute bacterial endophthalmitis can occur in about 1 out of 1,000 cases. Organisms that
   are typically involved include Staphylococcus epidermidis, Staphylococcus aureus, and
   Pseudomonas and Proteus species. Vision loss is one result of acute bacterial infection. In addition,
   vision loss can be the result of malposition of the intraocular lens implant or opacification of the
   posterior capsule. Retrobulbar hemorrhage is a complication that may occur right before surgery and
   is a result of retrobulbar infiltration of anesthetic agents. Rupture of the posterior capsule and
   suprachoroidal hemorrhage are both complications that can result during surgery.
   CN: Physiological adaptation; CL: Analyze

Question 10

10. The nurse is instructing the client about postoperative care following cataract removal. What
    position should the nurse teach the client to use?
11. Remain in a semi-Fowler’s position.
12. Position the feet higher than the body.
13. Lie on the operative side.
14. Place the head in a dependent position.

Answer 10

10. 1. The nurse should instruct the client to remain in a semi-Fowler’s position or on the
       nonoperative side. Positioning the feet higher than the body does not affect the operative eye; placing
       the head in a dependent position could increase pressure within the eyes.
       CN: Reduction of risk potential; CL: Synthesize

Question 11

11. After returning home, a client who has had cataract surgery will need to continue to instill
    eyedrops in the affected eye. The client is instructed to apply slight pressure against the nose at the
    inner canthus of the eye after instilling the eyedrops. The expected outcome of applying pressure is
    that the pressure:
12. Prevents the medication from entering the tear duct.
13. Prevents the drug from running down the client’s face.
14. Allows the sensitive cornea to adjust to the medication.
15. Facilitates distribution of the medication over the eye surface.

Answer 11

11. 1. Applying pressure against the nose at the inner canthus of the closed eye after administering
       eyedrops prevents the medication from entering the lacrimal (tear) duct. If the medication enters the
       tear duct, it can enter the nose and pharynx, where it may be absorbed and cause toxic symptoms.
       Eyedrops should be placed in the eye’s lower conjunctival sac. Applying pressure will not prevent
       the drug from running down the face as long as the drops are instilled in the eye. Pressure does not
       affect the cornea or facilitate distribution of the medication over the eye surface.
       CN: Pharmacological and parenteral therapies; CL: Apply

Question 12

12. To decrease intraocular pressure following cataract surgery, the nurse should instruct theclient to avoid:
13. Lying supine.
14. Coughing.
15. Deep breathing.
16. Ambulation.

Answer 12

12. 2. Coughing is contraindicated after cataract extraction because it increases intraocular
       pressure. Other activities that are contraindicated because they increase intraocular pressure include
       turning to the operative side, sneezing, crying, and straining. Lying supine, ambulating, and deepbreathing do not affect intraocular pressure.
       CN: Physiological adaptation; CL: Synthesize

Question 13

13. After cataract removal surgery, the client is instructed to report sharp pain in the operative
    eye because this could indicate which of the following postoperative complications?
14. Detached retina.
15. Prolapse of the iris.
16. Extracapsular erosion.
17. Intraocular hemorrhage.

Answer 13

13. 4. Sudden, sharp pain after eye surgery should suggest to the nurse that the client may be
       experiencing intraocular hemorrhage. The physician should be notified promptly. Detached retina and
       prolapse of the iris are usually painless. Extracapsular erosion is not characterized by sharp pain.
       CN: Physiological adaptation; CL: Analyze

Question 14

The Client with a Retinal Detachment
14. The client is diagnosed in the emergency department with a detached retina in the right eye.
The nurse should do which of the following first?
1. Apply compresses to the eye.
2. Instruct the client to lie prone.
3. Remove all bed pillows.
4. Promote measures that limit mobility.

Answer 14

The Client with a Retinal Detachment
14. 4. Promoting measures that limit mobility may prevent further injury. Following surgical
repair of a detached retina, cool or warm compresses are applied to edematous eyelids, if
prescribed. The client should avoid lying face down, stooping, or bending preoperatively. It is not
necessary to remove all pillows.
CN: Physiological adaptation; CL: Synthesize

Question 15

15. A client with detachment of the retina is to patch both eyes. The expected outcome of patching
    is to:
16. Reduce rapid eye movements.
17. Decrease the irritation caused by light entering the damaged eye.
18. Protect the injured eye from infection.
19. Rest the eyes to promote healing.

Answer 15

15. 1. Patching the eyes helps decrease random eye movements that could enlarge and worsen
       retinal detachment. Although clients with eye injuries frequently are light sensitive, and preventing
       infection is important, the specific goal is to reduce rapid eye movements. Resting the eye is an
       indirect way of stating the objective.
       CN: Physiological adaptation; CL: Evaluate

Question 16

16. The client with retinal detachment in the right eye is extremely apprehensive and tells the
    nurse, “I’m afraid of going blind. It would be so hard to live that way.” What factor should the nurse
    consider before responding to this statement?
17. Repeat surgery is impossible, so if this procedure fails, vision loss is inevitable.
18. The surgery will only delay blindness in the right eye, but vision is preserved in the left eye.
19. More and more services are available to help newly blind people adapt to daily living.
20. Optimism is justified because surgical treatment has a 90% to 95% success rate.

Answer 16

16. 4. Untreated retinal detachment results in increasing detachment and eventual blindness, but
       90% to 95% of clients can be successfully treated with surgery. If necessary, the surgical procedure
       can be repeated about 10 to 14 days after the first procedure. Many more services are available for
       newly blind people, but ideally this client will not need them. Surgery does not delay blindness.
       CN: Physiological adaptation; CL: Synthesize

Question 17

17. Which of the following statements would provide the best guide for activity during the
    rehabilitation period for a client who has been treated for retinal detachment?
18. Activity is resumed gradually; the client can resume usual activities in 5 to 6 weeks.
19. Activity level is determined by the client’s tolerance; clients can be as active as they wish.
20. Activity level will be restricted for several months; the client should plan on being sedentary.
21. Activity level can return to normal; clients can resume regular aerobic exercises.

Answer 17

17. 1. The scarring of the retinal tear needs time to heal completely. Therefore, resumption of
       activity should be gradual; the client may resume usual activities in 5 to 6 weeks. Successful healing
       should allow the client to return to a previous level of functioning.
       CN: Basic care and comfort; CL: Synthesize

Question 18

18. Which of the following goals is a priority for a client who has undergone surgery for retinal
    detachment?
19. Control pain.
20. Prevent an increase in intraocular pressure.
21. Promote a low-sodium diet.
22. Maintain a darkened environment.

Answer 18

18. 2. After surgery to correct a detached retina, prevention of increased intraocular pressure is
       the priority goal. Control of pain with analgesics is the second goal. Following a low-sodium diet or
       maintaining a darkened environment is not a goal for this client.
       CN: Physiological adaptation; CL: Synthesize

Question 19

The Client with Glaucoma
19. A client with glaucoma is to receive 3 gtt of acetazolamide in the left eye. What should the
nurse do?
1. Ask the client to close the right eye while administering the drug in the left eye.
2. Have the client look up while the nurse administers the eyedrops.
3. Have the client lift the eyebrows while the nurse positions the hand with the dropper on the
client’s forehead.
4. Wipe the eyes with a tissue following administration of the drops.

Answer 19

The Client with Glaucoma
19. 2. The client should look up while the nurse instills the eyedrops. The client will need to keep
both eyes open while the nurse administers the drug. If the client raises the eyebrows while the
nurse’s hand is positioned on the eyebrows, the movement of the forehead may cause the dropper to
move and injure the eye. The client should gently blink the eyes after the eyedrops have been instilled.
Using a tissue to wipe the eyes could remove some of the medication; excess fluid can be removed
with a cotton ball.
CN: Pharmacological and parenteral therapies; CL: Apply

Question 20

20. A client who has been treated for chronic open-angle glaucoma (COAG) for 5 years asks the
    nurse, “How does glaucoma damage my eyesight?” The nurse’s reply should be based on the
    knowledge that COAG:
21. Results from chronic eye inflammation.
22. Causes increased intraocular pressure.
23. Leads to detachment of the retina.
24. Is caused by decreased blood flow to the retina.

Answer 20

20. 2. In COAG, there is an obstruction to the outflow of aqueous humor, leading to increased
       intraocular pressure. The increased intraocular pressure eventually causes destruction of the retina’s
       nerve fibers. This nerve destruction causes painless vision loss. The exact cause of glaucoma is
       unknown. Glaucoma does not lead to retinal detachment.
       CN: Physiological adaptation; CL: Analyze

Question 21

21. The nurse should assess clients with chronic open-angle glaucoma (COAG) for:
22. Eye pain.
23. Excessive lacrimation.
24. Colored light flashes.
25. Decreasing peripheral vision.

Answer 21

21. 4. Although COAG is usually asymptomatic in the early stages, peripheral vision gradually
       decreases as the disorder progresses. Eye pain is not a feature of COAG but is common in clients
       with angle-closure glaucoma. Excessive lacrimation is not a symptom of COAG; it may indicate a
       blocked tear duct. Flashes of light are a common symptom of retinal detachment.
       CN: Physiological adaptation; CL: Analyze

Question 22

22. Which of the following should the nurse provide as part of the information to prepare the
    client for tonometry?
23. Oral pain medication will be given before the procedure.
24. It is a painless procedure with no adverse effects.
25. Blurred or double vision may occur after the procedure.
26. Medication will be given to dilate the pupils before the procedure.

Answer 22

22. 2. Tonometry, which measures intraocular pressure, is a simple, noninvasive, and painless
       procedure that requires no particular preparation or postprocedure care and carries no adverse
       effects. It is not necessary to dilate the pupils for tonometry.
       CN: Reduction of risk potential; CL: Synthesize

Question 23

23. A client uses timolol maleate (Timoptic) eyedrops. The expected outcome of this drug is to
    control glaucoma by:
24. Constricting the pupils.
25. Dilating the canals of Schlemm.
26. Reducing aqueous humor formation.
27. Improving the ability of the ciliary muscle to contract.

Answer 23

23. 3. Timolol maleate (Timoptic) is commonly administered to control glaucoma. The drug’s
       action is not completely understood, but it is believed to reduce aqueous humor formation, thereby
       reducing intraocular pressure. Timolol does not constrict the pupils; miotics are used for pupillary
       constriction and contraction of the ciliary muscle. Timolol does not dilate the canal of Schlemm.
       CN: Pharmacological and parenteral therapies; CL: Evaluate

Question 24

24. The nurse observes the client instill eyedrops. The client says, “I just try to hit the middle of
    my eyeball so the drops don’t run out of my eye.” The nurse explains to the client that this method may
    cause:
25. Scleral staining.
26. Corneal injury.
27. Excessive lacrimation.
28. Systemic drug absorption.

Answer 24

24. 2. The cornea is sensitive and can be injured by eyedrops falling onto it. Therefore, eyedrops
       should be instilled into the lower conjunctival sac of the eye to avoid the risk of corneal damage. The
       drops do not cause scleral staining or excessive lacrimation. Systemic absorption occurs when
       eyedrops enter the tear ducts.
       CN: Pharmacological and parenteral therapies; CL: Evaluate

Question 25

25. Which of the following clinical manifestations should the nurse assess when a client hasacute angle-closure glaucoma?
26. Gradual loss of central vision.
27. Acute light sensitivity.
28. Loss of color vision.
29. Sudden eye pain.

Answer 25

25. 4. Acute angle-closure glaucoma produces abrupt changes in the angle of the iris. Clinical
       manifestations include severe eye pain, colored halos around lights, and rapid vision loss. Gradual
       loss of central vision is associated with macular degeneration. The loss of color vision, or
       achromatopsia, is a rare symptom that occurs when a stroke damages the fusiform gyrus. It most often
       affects only half of the visual field.
       CN: Physiological adaptation; CL: Analyze

Question 26

26. A client has been diagnosed with an acute episode of angle-closure glaucoma. The nurse
    plans the client’s nursing care with the understanding that acute angle-closure glaucoma:
27. Frequently resolves without treatment.
28. Is typically treated with sustained bed rest.
29. Is a medical emergency that can rapidly lead to blindness.
30. Is most commonly treated with steroid therapy.

Answer 26

26. 3. Acute angle-closure glaucoma is a medical emergency that rapidly leads to blindness if left
       untreated. Treatment typically involves miotic drugs and surgery, usually iridectomy or laser therapy.
       Both procedures create a hole in the periphery of the iris, which allows the aqueous humor to flow
       into the anterior chamber. Bed rest does not affect the progression of acute angle-closure glaucoma.
       Steroids are not a treatment for acute angle-closure glaucoma; in fact, they are associated with the
       development of glaucoma.
       CN: Physiological adaptation; CL: Apply

Question 27

The Client with Adult Macular Degeneration

27. The nurse should assess an older adult with macular degeneration for:
28. Loss of central vision.
29. Loss of peripheral vision.
30. Total blindness.
31. Blurring of vision.

Answer 27

The Client with Adult Macular Degeneration
27. 1. Macular degeneration generally involves loss of central vision. Gradual blurring of visioncan occur as the disease progresses and may result in blindness; however, loss of central vision is the
most common finding. Tiny yellowish spots, known as drusen, develop beneath the retina. Loss of
peripheral vision is characteristic of glaucoma.
CN: Physiological adaptation; CL: Analyze

Question 28

28. A client has a history of macular degeneration. While in the hospital, the priority nursing goal
    will be to:
29. Provide education regarding community services for clients with adult macular degeneration
    (AMD).
30. Provide health care related to monitoring the eye condition.
31. Promote a safe, effective care environment.
32. Improve vision.

Answer 28

28. 3. AMD generally affects central vision. Confusion may result related to the changes in the
       environment and the inability to see the environment clearly. Therefore, providing safety is the
       priority goal in the care of this client. Educating him regarding community resources or monitoring his
       AMD may have been done at an earlier date or can be done after assessing his knowledge base and
       experience with the disease process. Improving his vision may not be possible.
       CN: Safety and infection control; CL: Synthesize

Question 29

29. Which measure should the nurse teach the client with adult macular degeneration (AMD) as a
    safety precaution?
30. Wear a patch over one eye.
31. Place personal items on the sighted side.
32. Lie in bed with the unaffected side toward the door.
33. Turn the head from side to side when walking.

Answer 29

29. 4. To expand the visual field, the partially sighted client should be taught to turn the head from
       side to side when walking. Neglecting to do so may result in accidents. This technique helps
       maximize the use of remaining sight. A patch does not address the problem of hemianopsia.
       Appropriate client positioning and placement of personal items will increase the client’s ability to
       cope with the problem but will not affect safety.
       CN: Safety and infection control; CL: Synthesize

Question 30

30. The nurse is assessing a client with macular degeneration. Identify the illustration that best
    depicts what clients with this disorder typically see.
31. Clear photo
32. Peripheral Vision is a blur
33. Central Vision is a blur
34. Whole photo is a blur

Answer 30

30. 3. In macular degeneration, the center vision is blackened out and only the outer visual fields are
       clear.
       CN: Physiological adaptation; CL: Analyze

Question 31

31. When the nurse enters the client’s room, the nurse perceives that the client is staring straight
    ahead. Which of the following is the best course of action for the nurse to take next?
32. Hold an interdisciplinary meeting on the client’s behalf promptly.
33. Consult with psychiatry.
34. Listen to the client and observe the body language.
35. Address the client by first name upon entering the room.

Answer 31

31. 3. By listening to the client should they speak and by noting body language, the nurse may be
       better able to ascertain the client’s physical and cognitive status. The nurse should not utilize the first
       name of a client unless a client provides permission to do so. To consult with psychiatry would not be
       appropriate unless prescribed by the primary care physician. An interdisciplinary meeting would not
       enable the nurse to understand why the client is staring straight ahead. Perhaps the client is only deep
       in thought.
       CN: Reduction of risk potential; CL: Synthesize

Question 32

32. The nurse is assisting a client who has new-onset vision loss to transition to home from the
    hospital. The client can see shadow and light in the right eye only. When at home, the client is at
    greatest risk for which of the following?
33. Loss of sensory perception.
34. Injury from falls.
35. Denial of changes in vision.
36. Isolation from social activities.

Answer 32

32. 2. Because of the client’s recent vision loss, the client is at high risk for injury. Sensoryalterations often affect other areas of functional ability, including leaving clients with sensory deficits
       at risk for injuries as a result. Disturbed sensory perception, denial and difficulty adjusting to the
       vision loss, and social isolation may also be of concern, and may accompany changes in sensory
       function, but they are not of higher priority than risk for injury.
       CN: Management of care; CL: Analyze

Question 33

The Client Undergoing Nasal Surgery
33. A young adult is admitted for elective nasal surgery for a deviated septum. Which of the
following would be an important indicator of bleeding even if the nasal drip pad remained dry and
intact?
1. Presence of nausea.
2. Repeated swallowing.
3. Rapid respiratory rate.
4. Feelings of anxiety.

Answer 33

The Client Undergoing Nasal Surgery
33. 2. Because of the dense packing, it is relatively unusual for bleeding to be apparent through
the nasal drip pad. Instead, the blood runs down the throat, causing the client to swallow frequently.
The back of the throat can be assessed with a flashlight. An accumulation of blood in the stomach may
cause nausea and vomiting but is not an initial sign of bleeding. Increased respiratory rate occurs in
shock and is not an early sign of bleeding in the client after nasal surgery. Feelings of anxiety are not
indicative of nasal bleeding.
CN: Physiological adaptation; CL: Synthesize

Question 34

34. The client is ready for discharge after surgery for a deviated septum. Which of the following
    discharge instructions would be appropriate?
35. Avoid activities that elicit Valsalva’s maneuver.
36. Take aspirin to control nasal discomfort.
37. Avoid brushing the teeth until the nasal packing is removed.
38. Apply heat to the nasal area to control swelling.

Answer 34

34. 1. The client should be instructed to avoid any activities that cause Valsalva’s maneuver (eg,
       straining at stool, vigorous coughing, exercise) to reduce stress on suture lines and bleeding. The
       client should not take aspirin because of its antiplatelet properties, which may cause bleeding. Oral
       hygiene is important to rid the mouth of old dried blood and to enhance the client’s appetite. Cool
       compresses, not heat, should be applied to decrease swelling and control discoloration of the area.
       CN: Reduction of risk potential; CL: Synthesize

Question 35

35. Which of the following statements indicate that the client who has undergone repair of the
    nasal septum has understood the discharge instructions?
36. “I should not shower until my packing is removed.”
37. “I will take stool softeners and modify my diet to prevent constipation.”
38. “Coughing every 2 hours is important to prevent respiratory complications.”
39. “It is important to blow my nose each day to remove the dried secretions.”

Answer 35

35. 2. Constipation can cause straining during defecation, which can induce bleeding. Showering
       is not contraindicated. The client should take measures to prevent coughing. The client should avoid
       blowing the nose for 48 hours after the packing is removed. Thereafter, the client should blow the
       nose gently using the open-mouth technique to minimize bleeding in the surgical area.
       CN: Physiological adaptation; CL: Evaluate

Question 36

The Client with a Hearing Disorder

36. To approach a deaf client, the nurse should do which of the following first?
37. Knock on the room’s door loudly.
38. Close and open the vertical blinds rapidly.
39. Talk while walking into the room.
40. Get the client’s attention.

Answer 36

The Client with a Hearing Disorder
36. 4. The nurse should avoid startling the client who is deaf and should obtain the attention of the
client before speaking. The client who is deaf cannot hear knocking on the door or talking. Opening
the blinds is not a helpful way to get the client’s attention.
CN: Psychosocial integrity; CL: Synthesize

Question 37

37. A 75-year-old client who has been taking furosemide (Lasix) regularly for 4 months tells the
    nurse that he is having trouble hearing. What would be the nurse’s best response to this statement?
38. Tell the client that because he is 75 years old, it is inevitable that his hearing should begin to
    deteriorate.
39. Have the client immediately report the hearing loss to his physician.
40. Schedule the client for audiometric testing and a hearing aid.
41. Tell the client that the hearing loss is only temporary; when his system adjusts to the
    furosemide, his hearing will improve.

Answer 37

37. 2. Furosemide may cause ototoxicity. The nurse should tell the client to promptly report the
       hearing loss, dizziness, or tinnitus to help prevent permanent ear damage. Hearing loss is not
       inevitable, and it is inappropriate to make assumptions about the cause of symptoms without a
       thorough evaluation. The client’s system will not “adjust,” and hearing loss will not resolve.
       CN: Pharmacological and parenteral therapies; CL: Synthesize

Question 38

38. The son of an older adult reports that his father just “stares off into space” more and more in
    the last several months, but then eagerly smiles and nods once the son can get his attention. The nurse
    should assess the client further for which of the following?
39. Dementia.
40. Hearing loss.
41. Anger.
42. Depression.

Answer 38

38. 2. Blank looks, decreased attention span, positioning of the head toward sound, and
       smiling/nodding in agreement once attention is gained are all behaviors that indicate hearing loss in
       adults. It is common to confuse sensory deficits for a change in cognitive status. The nurse should
       focus assessments of sensory function on considering any pathophysiology of existing or new-onset
       deficits and consider all client factors that might contribute to deficits.CN: Basic care and comfort; CL: Analyze

Question 39

39. The nurse has been assigned to a client who is hearing impaired and reads speech. Which of
    the following strategies should the nurse incorporate when communicating with the client? Select all
    that apply.
40. Avoiding being silhouetted against strong light.
41. Not blocking out the person’s view of the speaker’s mouth.
42. Facing the client when talking.
43. Having bright light behind so the individual can see.
44. Ensuring the client is familiar with the subject material before discussing.
45. Talking to the client while doing other nursing procedures.

Answer 39

39. 1, 2, 3, 5. When working with a client who is hearing impaired and speech reads, the
    presenter must face the person directly and devote full attention to the communication process. In
    addition, it will be useful for the client that the speaker not be too silhouetted against strong light, that
    the speaker’s mouth not be blocked from the client’s view, and that there are no objects in the mouth of
    the speaker. Finally, it is recommended that the presenter provide the client with the needed
    information to study before reviewing. This will provide the client with the ability to use contextual
    clues in speech reading.
    CN: Basic care and comfort; CL: Synthesize

Question 40

40. Eardrops have been prescribed to be instilled in the adult client’s left ear to soften cerumen.
    To position the client, the nurse must do which of the following? Select all that apply.
41. Have the client lie on the left side.
42. Straighten the client’s eustachian tube.
43. Gently pull the auricle up and back.
44. Gently pull the ear lobe down and back.
45. Chill the eardrops prior to administering.

Answer 40

40. 2, 3. The nurse should have the client lie on the side opposite the affected ear. To straighten
    the client’s ear canal, pull the auricle of the ear up and back for an adult; for an infant or a young
    child, gently pull the auricle down and back. Pulling the ear lobe does not aid in the instillation of
    eardrops. The eustachian tube is the auditory tube that extends from the middle ear to the nasopharynx.
    The eardrops should be administered at body temperature.
    CN: Pharmacological and parenteral therapies; CL: Apply

Question 41

41. The client with a hearing aid does not seem to be able to hear the nurse. The nurse should do
    which of the following first?
42. Contact the client’s audiologist.
43. Cleanse the hearing aid ear mold in normal saline.3. Irrigate the ear canal.
44. Check the hearing aid’s placement.

Answer 41

41. 4. Inadequate amplification can occur when a hearing aid is not placed properly. The certified
       audiologist is licensed to dispense hearing aids. The ear mold is the only part of the hearing aid that
       may be washed frequently; it should be washed daily with soap and water. Irrigation of the ear canal
       is done to remove impacted cerumen or a foreign body.
       CN: Physiological adaptation; CL: Synthesize

Question 42

42. Sensorineural hearing loss results from which of the following conditions?
43. Presence of fluid and cerumen in the external canal.
44. Sclerosis of the bones of the middle ear.
45. Damage to the cochlear or vestibulocochlear nerve.
46. Emotional disturbance resulting in a functional hearing loss.

Answer 42

42. 3. A sensorineural hearing loss results from damage to the cochlear or vestibulocochlear
       nerve. Presence of fluid and cerumen in the external canal or sclerosis of the bones of the middle ear
       results in a conductive hearing loss. Hearing loss resulting from an emotional disturbance is called a
       psychogenic hearing loss.
       CN: Physiological adaptation; CL: Apply

Question 43

43. An older adult has hearing loss and a sensation of fullness in both ears. The nurse should
    examine the ears for which of the following?:
44. Accumulation of cerumen in the external canal.
45. Accumulation of cerumen in the internal canal.
46. External otitis.
47. Exostosis.

Answer 43

43. 1. Cerumen (ear wax) commonly gets impacted in older clients in the external canal. Otalgia
       is the “fullness” sensation or pain that an older client may experience when the cerumen becomes
       impacted. External otitis is an inflammation of the outer ear and would not explain the symptoms the
       client is experiencing. Exostosis is a bony growth that arises from the surface of a bone and would not
       explain the symptoms the client is experiencing.
       CN: Health promotion and maintenance; CL: Analyze

Question 44

44. The best method to remove cerumen from a client’s ear involves:
45. Inserting a cotton-tipped applicator into the external canal.
46. Irrigating the ear gently.
47. Using aural suction.
48. Using a cerumen curette.

Answer 44

44. 2. Irrigation is the first strategy to loosen cerumen. Successful removal of the cerumen
       involves gentle irrigation behind the impacted cerumen. The flow of the water must be behind the
       impaction to remove the cerumen from the canal. A cotton-tipped applicator or other device is not
       appropriate because it can cause damage to the eardrum. Use of aural suction or a cerumen curette is
       appropriate only if the impacted cerumen cannot be removed by irrigation.
       CN: Reduction of risk potential; CL: Apply

Question 45

45. The nurse should use which of the following solutions to remove cerumen from the client's
ears?
1. Normal saline.
2. Sterile water.
3. Antiseptic solution.
4. Warm tap water.

Answer 45

45. 1. Normal saline is the solution that is generally used to irrigate the ear. Sterile water will
       cause tissue damage. An antiseptic solution is not typically used unless an infection is present. Warm
       tap water may cause tissue damage.CN: Pharmacological and parenteral therapies; CL: Apply

Question 46

46. A client is about to have a tympanoplasty and asks the nurse what the surgical procedure
    involves. The nurse begins the conversation by:
47. Assessing the client’s understanding of what the physician has explained.
48. Describing the surgical procedure.
49. Educating the client that the procedure will close the perforation and prevent recurrent
    infection.
50. Informing the client that the procedure will improve hearing.

Answer 46

46. 1. The nurse should first assess the client’s knowledge base. Working within the framework of
       the client’s knowledge and educational level, the nurse then can describe the procedure and its
       benefits.
       CN: Reduction of risk potential; CL: Synthesize

Question 47

47. An older adult takes two 81-mg aspirin tablets daily to prevent a heart attack. The client
    reports having a constant “ringing” in both ears. How should the nurse respond to the client’s
    comment?
48. Tell the client that “ringing” in the ears is associated with the aging process.
49. Refer the client to have a Weber test.
50. Schedule the client for audiometric testing.
51. Explain to the client that the “ringing” may be related to the aspirin.

Answer 47

47. 4. Tinnitus (ringing in the ears) is an adverse effect of aspirin. Aspirin contains salicylate,
       which is an ototoxic drug that can induce reversible hearing loss and tinnitus. The nurse should
       encourage the client to inform the physician of the symptom. Tinnitus is not a function of aging. The
       Weber test and audiometric testing are useful for determining hearing loss but are not necessarily
       helpful in the management or diagnosis of drug-induced tinnitus.
       CN: Pharmacological and parenteral therapies; CL: Synthesize

Question 48

The Client with Ménière’s Disease
48. A client has vertigo. Which of the following goals would be most appropriate to prevent
injury related to altered immobility and gait disturbances? Select all that apply.
1. The client assumes safe position when dizzy.
2. The client experiences no falls.
3. The client performs vestibular/balance exercises.
4. The client demonstrates family involvement.
5. The client keeps head still when dizzy.

Answer 48

The Client with Ménière’s Disease
48. 1, 2, 3, 5. Assessment of vertigo, including history, onset, description of attacks, duration,
frequency, and associated ear symptoms, is important. Vestibular/balance therapy or exercises should
be taught and practiced. The client needs to be instructed to sit down when dizzy and decrease the
amount of head movement. The client will benefit from recognizing whether he or she experiences an
“aura” before an attack so appropriate action can be taken. Finally, it is recommended that the client
keep the eyes open and look straight ahead when lying down. These expected outcomes will prevent
the problem of injury. Family involvement is essential when dealing with a client experiencing
vertigo but is not essential for this client who must manage the vertigo with or without family
involvement.
CN: Reduction of risk potential; CL: Synthesize

Question 49

49. The client with Ménière’s disease is instructed to modify the diet. The nurse should explain
    that the most frequently recommended diet modification for Ménière’s disease is:
50. Low sodium.
51. High protein.
52. Low carbohydrate.
53. Low fat.

Answer 49

49. 1. A low-sodium diet is frequently an effective mechanism for reducing the frequency and
       severity of the disease episodes. About three-quarters of clients with Ménière’s disease respond to
       treatment with a low-salt diet. A diuretic may also be prescribed. Other dietary changes, such as high
       protein, low carbohydrate, and low fat, do not have an effect on Ménière’s disease.
       CN: Basic care and comfort; CL: Apply

Question 50

50. Which of the following statements indicates the client understands the expected course of
    Ménière’s disease?
51. “The disease process will gradually extend to the eyes.”
52. “Control of the episodes is usually possible, but a cure is not yet available.”
53. “Continued medication therapy will cure the disease.”
54. “Bilateral deafness is an inevitable outcome of the disease.”

Answer 50

50. 2. There is no cure for Ménière’s disease, but the wide range of medical and surgical
       treatments allows for adequate control in many clients. The disease often worsens, but it does not
       spread to the eyes. The hearing loss is usually unilateral.
       CN: Physiological adaptation; CL: Evaluate

Question 51

51. The risk for injury during an attack of Ménière’s disease is high. The nurse should instruct the
    client to take which immediate action when experiencing vertigo?
52. “Place your head between your knees.”
53. “Concentrate on rhythmic deep breathing.”
54. “Close your eyes tightly.”
55. “Assume a reclining or flat position.”

Answer 51

51. 4. The client needs to assume a safe and comfortable position during an attack, which may last
       several hours. The client’s location when the attack occurs may dictate the most reasonable position.
       Ideally, the client should lie down immediately in a reclining or flat position to control the vertigo.
       The danger of a serious fall is real. Placing the head between the knees will not help prevent a fall
       and is not practical because the attack may last several hours. Concentrating on breathing may be a
       useful distraction, but it will not help prevent a fall. Closing the eyes does not help prevent a fall.
       CN: Safety and infection control; CL: Synthesize

Question 52

52. The nurse should assess the client with Ménière’s disease for the intended outcomes of which
    of the following medications that are commonly used to manage the disease? Select all that apply.
53. Antihistamines.
54. Antiemetics.
55. Diuretics.
56. Nonsteroidal anti-inflammatory drugs (NSAIDs).
57. Antipyretics.

Answer 52

52. 1, 2, 3. Since the symptoms of Ménière’s disease are associated with a change in the fluidvolume of the inner ear, a wide variety of medications may be used in an attempt to control the
    signs/symptoms of Ménière’s disease, including antihistamines, antiemetics, tranquilizers, and
    diuretics. NSAIDs and antipyretics play no significant role in Ménière’s disease management.
    CN: Pharmacological and parenteral therapies; CL: Analyze

Question 53

The Client with Cancer of the Larynx
53. Following a laryngectomy, the nurse notices that the client has saliva collecting beneath the
skin flaps. This finding is indicative of which of the following?
1. Skin necrosis.
2. Carotid artery rupture.
3. Stomal stenosis.
4. Development of a fistula.

Answer 53

The Client with Cancer of the Larynx
53. 4. A salivary fistula is suspected when there is saliva collecting beneath skin flaps or leaking
through the suture line or drain site. Salivary fistula or skin necrosis usually precedes carotid artery
rupture. Stomal stenosis may be present when there is suprasternal and intercostal retractions and
difficult breathing.
CN: Physiological adaptation; CL: Analyze

Question 54

54. The nurse is developing a care plan with a client who had a laryngectomy 3 days ago. The
    nurse should instruct the client to do which of the following to assure adequate nutrition. Select all
    that apply.
55. Weigh weekly and report weight loss.
56. When eating, sit and lean slightly forward.
57. Have serum albumin level checked regularly.
58. Administer enteral tube feedings as prescribed.
59. Manipulate the nasogastric tube daily.

Answer 54

54. 1, 2, 3, 4. The nurse should monitor nutritional status through frequent weighing and checking
    the serum albumin level. The nurse also should administer enteral tube feedings until there is
    sufficient healing of pharynx, and the client can consume sufficient oral feedings to meet body needs.
    The nurse should avoid manipulation of the nasogastric tube during this time so it does not disrupt the
    suture line. The nurse should place the client in sitting position, leaning slightly forward, which
    allows the larynx to move forward and the hypopharynx to partially open; the epiglottis normally
    prevents fluid and food from entering the larynx during swallowing.
    CN: Physiological adaptation; CL: Create

Question 55

55. The client with a laryngectomy is being discharged. The nurse should determine that the client
    understands to do which of the following self-care measures? Select all that apply.
56. Provide humidification in the home.
57. Use a protective shield over the stoma for bathing.
58. Consume a liberal intake of fluids (2 to 3 L/day).
59. Limit spicy seasonings on food.
60. Follow a low-fiber diet.

Answer 55

55. 1, 2, 3. The nurse should advise the client to provide humidification at home. Instruct the
    client to use a protective shield for bathing, showering, or shampooing or cutting hair to prevent
    aspiration. The nurse can also encourage the client to obtain a fluid intake of 2 to 3 L daily to help
    liquefy secretions. To counteract any loss of smell and impairment of taste sensation, the client can
    add additional seasoning to food. The client should follow a high-fiber diet and use stool softeners
    because the client may not be able to hold the breath and bear down for bowel movements.
    CN: Health promotion and maintenance; CL: Evaluate

Question 56

56. After a total laryngectomy, the client has a feeding tube. The feeding tube is effective if the
    tube feedings:
57. Meet the fluid and nutritional needs of the client.
58. Prevent aspiration.
59. Prevent fistula formation.
60. Maintain an open airway.

Answer 56

56. 1. The goal of postoperative care is to maintain physiologic integrity. Therefore, inserting a
       feeding tube is a strategy to ensure the fluid and nutritional needs of the client as the surgical site is
       healing. The feeding tube does help prevent aspiration by preventing ingested fluid from leaking
       through the wound into the trachea before healing occurs; however, the primary rationale is to meet
       the client’s nutritional and fluid needs. A tracheoesophageal fistula is a rare complication of total
       laryngectomy and may occur if radiation therapy has compromised wound healing. A feeding tube
       does not help maintain an open airway.
       CN: Reduction of risk potential; CL: Evaluate

Question 57

57. Complications associated with having a tracheostomy tube include:
58. Decreased cardiac output.
59. Damage to the laryngeal nerve.
60. Pneumothorax.
61. Acute respiratory distress syndrome (ARDS).

Answer 57

57. 2. Tracheostomy tubes carry several potential complications, including laryngeal nerve
       damage, bleeding, and infection. Tracheostomy tubes alone do not affect cardiac output or cause acute
       respiratory distress. The tube is inserted in the trachea, not the lung, so there is no risk of
       pneumothorax.
       CN: Physiological adaptation; CL: Apply

Question 58

58. A priority goal for the hospitalized client who 2 days earlier had a total laryngectomy with
    creation of a new tracheostomy is to:
59. Decrease secretions.
60. Instruct the client in caring for the tracheostomy.
61. Relieve anxiety related to the tracheostomy.
62. Maintain a patent airway.

Answer 58

58. 4. The main goal for a client with a new tracheostomy is to maintain a patent airway. A fresh
       tracheostomy frequently causes bleeding and excess secretions, and clients may require frequentsuctioning to maintain patency. Decreasing secretions may be a component of a client’s care after
       laryngectomy and tracheostomy, and relieving anxiety is always an important goal; however, the
       primary goal is to maintain a patent airway. Instruction in care of a tracheostomy is a priority later in
       the client’s recovery.
       CN: Physiological adaptation; CL: Synthesize

Question 59

Managing Care Quality and Safety
59. The client with glaucoma is scheduled for a hip replacement. Which of the following
prescriptions would require clarification before the nurse carries it out?
1. Administer morphine sulfate.
2. Administer atropine sulfate.
3. Teach deep-breathing exercises.
4. Teach leg lifts and muscle-setting exercises.

Answer 59

Managing Care Quality and Safety
59. 2. Atropine sulfate causes pupil dilation. This action is contraindicated for the client with
glaucoma because it increases intraocular pressure. The drug does not have this effect on intraocular
pressure in people who do not have glaucoma. Morphine causes pupil constriction. Deep-breathing
exercises will not affect glaucoma. The client should resume taking all medications for glaucoma
immediately after surgery.
CN: Pharmacological and parenteral therapies; CL: Synthesize

Question 60

60. To ensure safety for a hospitalized blind client, the nurse should:
61. Require that the client has a sitter for each shift.
62. Request that the client stays in bed until the nurse can assist.
63. Orient the client to the room environment.
64. Keep the side rails up when the client is alone.

Answer 60

60. 3. The priority goal of care for a client who is blind is safety and preventing injury. The initial
       action is to orient the client to a new environment. Taking time to identify the objects and where they
       are located in the room can achieve this goal. It is unrealistic to have someone stay with the client at
       all times or for the client to stay in bed until the nurse can assist. Using side rails creates unnecessary
       barriers and may be a safety hazard.
       CN: Safety and infection control; CL: Synthesize

Question 61

61. The nurse is taking care of a client who had a laryngectomy yesterday. To assure client safety,
    the nurse should give “hand-off reports” at which of the following times? Select all that apply.
62. Change of shift.
63. Change of nurses.
64. When nurse goes to lunch.
65. When unit clerk goes to a staff meeting.
66. When new medication prescriptions are written.

Answer 61

61. 1, 2, 3. Effective communication is essential when managing client safety and preventing
    errors. “Hand-off reports” should be made at shift change, when there is a change of nurses or when
    the nurse leaves the unit, and when the client is discharged or transfers to another unit. There does not
    need to be a handoff report when the unit clerk leaves the unit or when new medication prescriptions
    are written.
    CN: Safety and infection control; CL: Apply

Question 62

62. The nurse is admitting a client with glaucoma. The client brings prescribed eyedrops from
    home and insists on using them in the hospital. The nurse should:
63. Allow the client to keep the eyedrops at the bedside and use as prescribed on the bottle.
64. Place the eyedrops in the hospital medication drawer and administer as labeled on the bottle.
65. Explain to the client that the physician will write a prescription for the eyedrops to be used at
    the hospital.
66. Ask the client’s wife to assist the client in administering the eyedrops while the client is in the
    hospital.

Answer 62

62. 3. In order to prevent medication errors, clients may not use medications they bring from
       home; the physician will prescribe the eyedrops as required. It is not safe to place the eyedrops in the
       client’s medication box or to permit the client to use them at the bedside. The nurse should ask the
       wife to take the eyedrops home.
       CN: Safety and infection control; CL: Synthesize

Question 63

63. The nurse is assigned to care for a client with an ocular prosthesis who is having surgery
    under a local anesthetic. Prior to surgery, the nurse should:
64. Maintain surgical asepsis when caring for the prosthesis.
65. Leave the prosthesis in place.
66. Cleanse the ocular prosthesis with full-strength hydrogen peroxide.
67. Instruct the client to cleanse the prosthesis daily.

Answer 63

63. 2. The nurse should maintain medical asepsis to care for an ocular prosthesis. Because the
       client will have a local anesthetic, the nurse should leave the prosthesis in place. Daily removal and
       cleansing is not necessary and may be irritating to the socket; removal for cleansing once or twice a
       month is sufficient. The nurse should never use anything stronger than liquid soap and water to
       cleanse an ocular prosthesis.
       CN: Reduction of risk potential; CL: Apply