Ear 1. The nurse is performing a voice test to assess hearing. Which of the following describes the accurate procedure for performing this test? A. Stand 4 feet away from the client to ensure that the client can hear at this distance. B. Whisper a statement and ask the client to repeat it. C. Whisper a statement with the examiners back facing the client D. Whisper a statement while the client blocks both ears.
2. During a hearing assessment, the nurse notes that the sound lateralizes to the clients left ear with the Weber test. The nurse analyzes this result as: 1. A normal finding 2. A conductive hearing loss in the right ear 3. A sensorineural or conductive loss 4. The presence of nystagmus
3. The nurse is caring for a client that is hearing impaired. Which of the following approaches will facilitate communication? 1. Speak frequently 2. Speak loudly 3. Speak directly into the impaired ear 4. Speak in a normal tone
4. The nurse has conducted discharge teaching for a client who had a fenestration procedure for the treatment of otosclerosis. Which of the following, if stated by the client, would indicate that teaching was effective? 1. “I should drink liquids through a straw for the next 2-3 weeks.” 2. “It’s ok to take a shower and wash my hair.” 3. “I will take stool softeners as prescribed by my doctor.” 4. “I can resume my penis lessons starting next week.” 5. A client arrives at the emergency room with a foreign body in the left ear that has been determined to be an insect. Which intervention would the nurse anticipate to be prescribed initially? 1. Irrigation of the ear 2. Instillation of diluted alcohol 3. Instillation of antibiotic ear drops 4. Instillation of corticosteroids ear drops 6. The nurse has notes that the physician has a diagnosis of presbycusis on the client’s chart. The nurse plans care knowing the condition is: 1. A sensorineural hearing loss that occurs with aging 2. A conductive hearing loss that occurs with aging. 3. Tinnitus that occurs with aging 4. Nystagmus that occurs with aging 7. A client with Meniere’s disease is experiencing severe vertigo. Which instruction would the nurse give to the client to assist in controlling the vertigo? 1. Increase fluid intake to 3000 ml a day 2. Avoid sudden head movements 3. Lie still and watch the television 4. Increase sodium in the diet 8. The nurse is reviewing the physician’s orders for a client with Meniere’s disease. Which diet will most likely be prescribed? 1. Low-cholesterol diet 2. Low-sodium diet 3. Low-carbohydrate diet 4. Low-fat diet 9. A client is diagnosed with a disorder involving the inner ear. Which of the following is the most common client complaint associated with a disorder in this part of the ear? 1. Hearing loss 2. Pruritus 3. Tinnitus 4. Burning of the ear 10. A nurse would question an order to irrigate the ear canal in which of the following circumstances? 1. Ear pain 2. Hearing loss 3. Otitis externa 4. Perforated tympanic membrane 11. Which of the following interventions is essential when instilling Cortisporin suspension, 2 gtt right ear? 1. Verifying the proper client and route 2. Warming the solution to prevent dizziness 3. Holding an emesis basin under the client’s ear 4. Positioning the client in the semi-fowlers position 12. When teaching the client about Meniere’s disease, which of the following instructions would a nurse give about vertigo? 1. Report dizziness at once 2. Drive in daylight hours only 3. Get up slowly, turning the entire body 4. Change your position using the logroll method 13. The part of the ear that contains the receptors for hearing is the: 1. Utricle 2. Cochlea 3. Middle ear 4. Tympanic cavity 14. The ear bones that transmit vibrations to the oval window of the cochlea are found in the: 1. Inner ear 2. Outer ear 3. Middle ear 4. Eustachian tube 15. Nerve deafness would most likely result from an injury or infection that damaged the: 1. Vagus nerve 2. Cochlear nerve 3. Vestibular nerve 4. Trigeminal nerve 16. A labyrinthectomy can be preformed to treat Meniere’s syndrome. This procedure results in: 1. Anosmia 2. Absence of pain 3. Reduction in cerumen 4. Permanent irreversible deafness 17. Otosclerosis is a common cause of conductive hearing loss. Which such a partial hearing loss: 1. Stapedectomy is the procedure of choice 2. Hearing aids usually restore some hearing 3. The client is usually unable to hear bass tones 4. Air conduction is more effective than bone conduction 18. A client who is complaining of tinnitus is describing a symptom that is: 1. Objective 2. Subjective 3. Functional 4. Prodromal 19. Physiologically, the middle ear, containing the three ossicles, serves primarily to: 1. Maintain balance 2. Translate sound waves into nerve impulses 3. Amplify the energy of sound waves entering the ear 4. Communicate with the throat via the Eustachian tube.

Answers : Ear 1. 2. The examiner stands 1-2 feet away from the client and asks the client to block one external ear canal. The nurse whispers a statement and asks the client to repeat it. Each ear is tested separately. 2. 3. In the Weber tuning fork test the nurse places the vibrating tuning fork in the middle of the client’s head, at the midline of the forehead, or above the upper lip over the teeth. Normally, the sound is heard in equally in both ears by bone conduction. If the client has a sensorineural hearing loss in one ear, the sound is heard in the other ear. If the client has a conductive hearing loss in one ear, the sound is heard in that ear. 3. 4. Speaking in a normal tone to the client with impaired hearing and not shouting are important. The nurse should talk directly to the client while facing the client and speak clearly. If the client does not seem to understand what is said, the nurse should express it differently. Moving closer to the client and toward the better ear may facilitate communication, but the nurse should avoid talking directly into the impaired ear. 4. 3. Following ear surgery, the client needs to avoid straining while having a bowel movement. The client needs to be instructed to avoid drinking through a straw for 2-3 weeks, air travel, and coughing excessively. The client needs to avoid getting his or her hair wet, washing hair, showering for 1 week, and rapidly moving the head, bouncing, and bending over for 3 weeks. 5. 2. Insects are killed before removal unless they can be coaxed out by a flashlight or a humming noise. Mineral oil or diluted alcohol is instilled into the ear to suffocate the insect, which then is removed by using forceps. When the foreign object is vegetable matter, irrigation is not used because this material expands with hydration and the impaction becomes worse. 6. 1. Presbycusis is a type of hearing loss that occurs with aging. Presbycusis is a gradual sensorineural loss caused by nerve degeneration in the inner ear or auditory nerve. 7. 2. The nurse instructs the client to make slow head movements to prevent worsening of the vertigo. Dietary changes such as salt and fluid restrictions that reduce the amount of endolymphatic fluid sometimes are prescribed. Lying still and watching television will not control vertigo. 8. 2. Dietary changes such as salt and fluid restrictions that reduce the amount of endolymphatic fluid sometimes are prescribed. 9. 3. Tinnitus is the most common complaint of clients with otological disorders, especially disorders involving the inner ear. Symptoms of tinnitus range from mild ringing in the ear, which can go unnoticed during the day, to a loud roaring in the ear, which can interfere with the client’s thinking process and attention span. 10. 4. Irrigation of the ear canal is contraindicated with perforation of the tympanic membrane because the solution entering the inner ear may cause dizziness, nausea, vomiting, and infection. 11. 1. When giving medications, a nurse follows the five R’s of medication administration. The drops may be warmed to prevent pain or dizziness, but this action is not essential. An emesis basin would be used for irrigation of the ear. Put the client in the lateral position to prevent the drops from draining out for 5 minutes, not semi-fowlers position. 12. 3. Turning the entire body, not the head, will prevent vertigo. Dizziness is expected but can be prevented. The client shouldn’t drive as he may reflexively turn the wheel to correct vertigo. Turning the client in bed slowly and smoothly will be helpful; logrolling isn’t needed. 13. 2. The dendrites of the cochlear nerve terminate on the hair cells of the organ of Corti in the cochlea. 14. 3. The bones in the middle ear transmit and amplify air pressure waves from the tympanic membrane to the oval window of the cochlea, which is the inner ear. The tympanic membrane separates the other from the middle ear. 15. 2. Because the organ of hearing is the organ of Corti, located in the cochlea, nerve deafness would most likely accompany damage to the cochlear nerve. 16. 4. The labyrinth is the inner ear and consists of the vestibule, cochlea, semicircular canals, utricle, saccule, cochlear duct, and membraneous semicircular canals. A labrinthectomy is preformed to alleviate the symptoms of vertigo but results in deafness, because the organ of Corti and cochlear nerve are located in the inner ear. 17. 2. With a partial hearing loss that auditory ossicles have not yet become fixed; as long as vibrations occur, a hearing aid may be beneficial. 18. 2. A subjective symptom such as ringing in the ears can be felt only by the client. 19. 3. The middle ear contains the three ossicles—malleus, incus, and stapes—which, along with the tympanic membrane and oval window, form an amplifying system.

Eye 1. The clinic nurse is preparing to test the visual acuity of a client using a Snellen’s chart. Which of the following identifies the accurate procedure for this visual acuity test? A. Both eyes are assessed together, followed by the assessment of the right and then the left eye. B. The right eye is tested followed by the left eye, and then both eyes are tested. C. The client is asked to stand at a distance of 40ft. from the chart and is asked to read the largest line on the chart. D. The client is asked to stand at a distance of 40ft from the chart and to read the line than can be read 200 ft away by an individual with unimpaired vision.
2. The clinic nurse notes that the following several eye examinations, the physician has documented a diagnosis of legal blindness in the client’s chart. The nurse reviews the results of the Snellen’s chart test expecting to note which of the following? 1. 20/20 vision 2. 20/40 vision 3. 20/60 vision 4. 20/200 vision 3. The client’s vision is tested with a Snellen’s chart. The results of the tests are documented as 20/60. The nurse interprets this as: 1. The client can read at a distance of 60 feet what a client with normal vision can read at 20 feet. 2. The client is legally blind. 3. The client’s vision is normal 4. The client can read only at a distance of 20 feet what a client with normal vision can read at 60 feet. 4. Tonometry is performed on the client with a suspected diagnosis of glaucoma. The nurse analyzes the test results as documented in the client’s chart and understands that normal intraocular pressure is: 1. 2-7 mmHg 2. 10-21 mmHg 3. 22-30 mmHg 4. 31-35 mmHg 5. The nurse is developing a plan of care for the client scheduled for cataract surgery. The nurse documents which more appropriate nursing diagnosis in the plan of care? 1. Self-care deficit 2. Imbalanced nutrition 3. Disturbed sensory perception 4. Anxiety 6. The nurse is performing an assessment in a client with a suspected diagnosis of cataract. The chief clinical manifestation that the nurse would expect to note in the early stages of cataract formation is: 1. Eye pain 2. Floating spots 3. Blurred vision 4. Diplopia 7. In preparation for cataract surgery, the nurse is to administer prescribed eye drops. The nurse reviews the physicians orders, expecting which type of eye drops to be instilled? 1. An osmotic diuretic 2. A miotic agent 3. A mydriatic medication 4. A thiazide diuretic 8. During the early postoperative period, the client who had a cataract extraction complains of nausea and severe eye pain over the operative site. The initial nursing action is to: 1. Call the physician 2. Administer the ordered main medication and antiemetic 3. Reassure the client that this is normal. 4. Turn the client on his or her operative side 9. The client is being discharged from the ambulatory care unit following cataract removal. The nurse provides instructions regarding home care. Which of the following, if stated by the client, indicates an understanding of the instructions? 1. “I will take Aspirin if I have any discomfort.” 2. “I will sleep on the side that I was operated on.” 3. “I will wear my eye shield at night and my glasses during the day.” 4. “I will not lift anything if it weighs more that 10 pounds.” 10. The client with glaucoma asks the nurse is complete vision will return. The most appropriate response is: 1. “Although some vision as been lost and cannot be restored, further loss may be prevented by adhering to the treatment plan.” 2. “Your vision will return as soon as the medications begin to work.” 3. “Your vision will never return to normal.” 4. “Your vision loss is temporary and will return in about 3-4 weeks.” 11. The nurse is developing a teaching plan for the client with glaucoma. Which of the following instructions would the nurse include in the plan of care? 1. Decrease fluid intake to control the intraocular pressure 2. Avoid overuse of the eyes 3. Decrease the amount of salt in the diet 4. Eye medications will need to be administered lifelong. 12. The nurse is performing an admission assessment on a client with a diagnosis of detached retina. Which of the following is associated with this eye disorder? 1. Pain in the affected eye 2. Total loss of vision 3. A sense of a curtain falling across the field of vision 4. A yellow discoloration of the sclera. 13. The nurse is caring for a client with a diagnosis of detached retina. Which assessment sign would indicate that bleeding has occurred as a result of the retinal detachment? 1. Complaints of a burst of black spots or floaters 2. A sudden sharp pain in the eye 3. Total loss of vision 4. A reddened conjunctiva 14. The client sustains a contusion of the eyeball following a traumatic injury with a blunt object. Which intervention is initiated immediately? 1. Notify the physician 2. Irrigate the eye with cold water 3. Apply ice to the affected eye 4. Accompany the client to the emergency room 15. The client arrives in the emergency room with a penetrating eye injury from wood chips while cutting wood. The nurse assesses the eye and notes a piece of wood protruding from the eye, what is the initial nursing action? 1. Remove the piece of wood using a sterile eye clamp 2. Apply an eye patch 3. Perform visual acuity tests 4. Irrigate the eye with sterile saline. 16. The client arrives in the emergency room after sustaining a chemical eye injury from a splash of battery acid. The initial nursing action is to: 1. Begin visual acuity testing 2. Irrigate the eye with sterile normal saline 3. Swab the eye with antibiotic ointment 4. Cover the eye with a pressure patch. 17. The nurse is caring for a client following enucleation. The nurse notes the presence of bright red blood drainage on the dressing. Which nursing action is appropriate? 1. Notify the physician 2. Continue to monitor the drainage 3. Document the finding 4. Mark the drainage on the dressing and monitor for any increase in bleeding. 18. When using a Snellen alphabet chart, the nurse records the client’s vision as 20/40. Which of the following statements best describes 20/40 vision? 1. The client has alterations in near vision and is legally blind. 2. The client can see at 20 feet what the person with normal vision can see at 40 feet. 3. The client can see at 40 feet what the person with normal vision sees at 20 feet. 4. The client has a 20% decrease in acuity in one eye, and a 40% decrease in the other eye. 19. Which of the following instruments is used to record intraocular pressure? 1. Goniometer 2. Ophthalmoscope 3. Slit lamp 4. Tonometer 20. After the nurse instills atropine drops into both eyes for a client undergoing ophthalmic examination, which of the following instructions would be given to the client? 1. “Be careful because the blink reflex is paralyzed.” 2. “Avoid wearing your regular glasses when driving.” 3. “Be aware that the pupils may be unusually small.” 4. “Wear dark glasses in bright light because the pupils are dilated.” 21. Which of the following procedures or assessments must the nurse perform when preparing a client for eye surgery? 1. Clipping the client’s eyelashes 2. Verifying the affected eye has been patched 24 hours before surgery 3. Verifying the client has been NPO since midnight, or at least 8 hours before surgery. 4. Obtaining informed consent with the client’s signature and placing the forms on the chart. 22. Cataract surgery results in aphakia. Which of the following statements best describes this term? 1. Absence of the crystalline lens 2. A “keyhole” pupil 3. Loss of accommodation 4. Retinal detachment 23. When developing a teaching session on glaucoma for the community, which of the following statements would the nurse stress? 1. Glaucoma is easily corrected with eyeglasses 2. White and Asian individuals are at the highest risk for glaucoma. 3. Yearly screening for people ages 20-40 years is recommended. 4. Glaucoma can be painless and vision may be lost before the person is aware of a problem. 24. For a client having an episode of acute narrow-angle glaucoma, a nurse expects to give which of the following medications? 1. Acetazolamide (Diamox) 2. Atropine 3. Furisemide (Lasix) 4. Urokinase (Abbokinase) 25. Which of the following symptoms would occur in a client with a detached retina? 1. Flashing lights and floaters 2. Homonymous hemianopia 3. Loss of central vision 4. Ptosis 26. A male client has just had a cataract operation without a lens implant. In discharge teaching, the nurse will instruct the client’s wife to: 1. Feed him soft foods for several days to prevent facial movement 2. Keep the eye dressing on for one week 3. Have her husband remain in bed for 3 days 4. Allow him to walk upstairs only with assistance.

Answers : Eye 1. 2. Visual acuity is assessed in one eye at a time, and then in both eyes together with the client comfortably standing or sitting. The right eye is tested with the left eye covered; then the left eye is tested with the right eye covered. Both eyes then are tested together. Visual acuity is measured with or without corrective lenses and the client stands at a distance of 20ft. from the chart. 2. 4. Legal blindness is defined as 20/200 or less with corrected vision (glasses or contact lenses) or visual acuity of less than 20 degrees of the visual field in the better eye. 3. 4. Vision that is 20/20 is normal, that is, the client is able to read from 20 feet what a person with normal vision can read from 20 feet. A client with a visual acuity of 20/60 only can read at a distance of 20 feet of what a person with normal vision can read at 60 feet. 4. 2. Tonometry is the method of measuring intraocular fluid pressure using a calibrated instrument that indents or flattens the corneal apex. Pressures between 10 and 21 mmHg are considered within normal range. 5. 3. The most appropriate nursing diagnosis for the client scheduled for cataract surgery is Disturbed sensory perception (visual) related to lens extraction and replacement. Although the other options identify nursing diagnoses that may be appropriate, they are not related specifically to cataract surgery. 6. 3. A gradual, painless blurring of central vision is the chief clinical manifestation of a cataract. Early symptoms include slightly blurred vision and a decrease in color perception. 7. 3. A mydriatic medication produces mydriasis or dilation of the pupil. Mydriatic medications are used preoperatively in the cataract client. These medication act by dilating the pupils. They also constrict blood vessels. An osmotic diuretic may be used to decrease intraocular pressure. A miotic medication constricts the pupil. A thiazide diuretic is not likely to be prescribed for a client with a cataract. 8. 1. Severe pain or pain accompanied by nausea is an indicator of increased intraocular pressure and should be reported to the physician immediately. The other options are inappropriate. 9. 3. The client is instructed to wear a metal or plastic shield to protect the eye from accidental and is instructed not to rub the eye. Glasses may be worn during the day. Aspirin or medications containing aspirin are not to be administered or taken by the client and the client is instructed to take acetaminophen as needed for pain. The client is instructed not to sleep on the side of the body on which the operation occurred. The client is not to lift more than 5 pounds. 10. 1. Vision loss to glaucoma is irreparable. The client should be reassured that although some vision has been lost and cannot be restored, further loss may be prevented by adhering to the treatment plan. Option C does not provide reassurance to the client. 11. 4. The administration of eye drops is a critical component of the treatment plan for the client with glaucoma. The client needs to be instructed that medications will need to be taken for the rest of his or her life. 12. 3. A characteristic manifestation of retinal detachment described by the client is the feeling that a shadow or curtain is falling across the field of vision. No pain is associated with detachment of the retina. Options B and D are not characteristics of this disorder. A retinal detachment is an ophthalmic emergency and even more so if visual acuity is still normal. 13. 1. Complaints of a sudden burst of black spots or floaters indicate that bleeding has occurred as a result of the detachment. 14. 3. Treatment for contusion begins at the time of injury. Ice is applied immediately. The client then should be seen by a physician and receive a thorough eye examination to rule out the presence of other eye injuries. 15. 3. If the laceration is the result of a penetrating injury, an object may be noted protruding from the eye. This object must never be removed except by the ophthalmologist because it may be holding ocular structures in place. Application of an eye patch or irrigation of the eye may disrupt the foreign body and cause further tearing of the sclera. (The only option that will prevent further disruption is to assess visual acuity.) 16. 2. Emergency care following a chemical burn to the eye includes irrigating the eye immediately with sterile normal saline or ocular irrigating solution. In the emergency department, the irrigation should be maintained for at least 10 minutes. Following this emergency treatment, visual acuity is assessed. 17. 1. If the nurse notes the presence of bright red drainage on the dressing, it must be reported to the physician because this indicated hemorrhage. 18. 2. The numerator refers to the client’s vision while comparing the normal vision in the denominator. 19. 4. A tonometer is a device used in glaucoma screening to record intraocular pressure. A goniometer measures joint movement and angles. An ophthalmoscope examines the interior of the eye, especially the retina. A slit lamp evaluates structures in the anterior chamber in the eye. 20. 4. Atropine, an anticholinergic drug, has mydriatic effects causing pupil dilation. This allows more light onto the retina and may cause photophobia and blurred vision. Atropine doesn’t paralyze the blink reflex or cause miosis (pupil constriction). Driving may be contraindicated to blurred vision. 21. 3. Maintaining NPO status for at least 8 hours before surgical procedures prevents vomiting and aspiration. There is no need to patch an eye before most surgeries or to clip the eyelashes unless specifically ordered by the physician. The physician is responsible for obtaining informed consent; the nurse validates that the consent is obtained. 22. 1. Aphakia means without lens, a keyhole pupil results from iridectomy. Loss of accommodation is a normal response to aging. A retinal detachment is usually associated with retinal holes created by vitreous traction. 23. 4. Open-angle glaucoma causes a painless increase in intraocular pressure (IOP) with loss of peripheral vision. A variety of miotics and agents to decrease IOP and occasional surgery are used to treat glaucoma. Blacks have a threefold greater chance of developing with an increased chance of blindness than other groups. Individuals older than 40 should be screened. 24. 1. Acetazolamide, a carbonic anhydrase inhibitor, decreases intraocular pressure (IOP) by decreasing the secretion of aqueous humor. Atropine dilates the pupil and decreases outflow of aqueous humor, causing further increase in IOP. Lasix is a loop diuretic, and Urokinase is a thrombolytic agent; they aren’t used for the treatment of glaucoma. (Remember surgical nursing and PVD? Ha!) 25. 1. Signs and symptoms of retinal detachment include abrupt flashing lights, floaters, loss of peripheral vision, or a sudden shadow or curtain in the vision. Occasionally visual loss is gradual. 26. 4. Without a lens, the eye cannot accommodate. It is difficult to judge distance and climb stairs when the eyes cannot accommodate. Therefore, the client should walk up and down stairs only with assistance.