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Terms in this set (72)The nurse is providing health promotion teaching to a group of older adults. Which information will the nurse include when teaching about routine glaucoma testing? a. A Tono-pen will be applied to the surface of the eye. Glaucoma is caused by an increase in intraocular pressure, which would be measured using the Tono-pen. The other techniques are used in testing for other eye disorders. The nurse is performing an eye examination on a 76-year-old patient. The nurse should refer
the patient for a more extensive assessment based on which finding? b. The patient reports persistent photophobia. Photophobia is not a normally occurring change with aging, and would require further assessment. The other assessment data are common gerontologic differences and would not be unusual in a 76-year-old patient. The nurse performing an eye examination will document normal findings for accommodation when d. the pupils constrict while fixating on an object being moved closer to the patients eyes. Accommodation is defined as the ability of the lens to adjust to various distances. The pupils constrict while fixating on an object being moved far away to near the eyes. The other responses may also be elicited as part of the eye examination, but they do not indicate accommodation. Which assessment finding alerts the nurse to provide patient teaching about cataract development? c. Blurred vision and light sensitivity Classic signs of cataracts include blurred vision and light sensitivity. Thyroid problems are a major cause of exophthalmos. Unequal pupil is indicative of anisocoria, not cataracts. Loss of peripheral vision is a sign of glaucoma. Assessment of a patients visual acuity reveals that the left eye can see at 20 feet what a person with normal vision can see at 50 feet and the right eye can see at 20 feet what a person with normal vision can see at 40 feet. The nurse records which finding? a. OS 20/50; OD 20/40 When documenting visual acuity, the first number indicates the standard (for normal vision) of 20 feet and the second number indicates the line that the patient is able to read when standing 20 feet from the Snellen chart. OS is the abbreviation for left eye and OD is the abbreviation for right eye. The remaining three answers do not correctly describe the patients visual acuity. When assessing a patients consensual pupil response, the nurse should d. shine a light into one pupil and observe the response of both pupils. The consensual pupil response is tested by shining a light into one pupil and observing for both pupils to constrict. Observe the corneal light reflex to evaluate for weakness or imbalance of the extraocular muscles. In a darkened room, ask the patient to look straight ahead while a penlight is shone directly on the cornea. The light reflection should be located in the center of both corneas as the patient faces the light source. To perform confrontation visual field testing, the patient faces the examiner and covers one eye, then counts the number of fingers that the examiner brings into the visual field. Instructing the patient to follow a moving object only with the eyes is testing for visual fields and extraocular movements. The nurse is observing a student who is preparing to perform an ear examination for a 30-year-old patient. The nurse will need to intervene if the student b. chooses a speculum larger than the ear canal. The speculum should be smaller than the ear canal so it can be inserted without damage to the external ear canal. The other actions are appropriate when performing an ear examination. When obtaining a health history from a 49-year-old patient, which patient statement is most important to communicate to the primary health care provider? d. I cant see as far over to the side. The decrease in peripheral vision may indicate glaucoma, which is not a normal visual change associated with aging and requires rapid treatment. The other patient statements indicate visual problems (presbyopia, dryness, and lens opacity) that are considered a normal part of aging. A 65-year-old patient is being evaluated for glaucoma. Which information given by the patient has implications for the patients treatment? c. I take metoprolol (Lopressor) daily for angina. It is important to note whether the patient takes any b-adrenergic blockers because this classification of medications is also used to treat glaucoma, and there may be an increase in adverse effects. The use of aspirin does not increase intraocular pressure and is safe for patients with glaucoma. Although older patients should have yearly eye examinations, the treatment for this patient will not be affected by the 10-year gap in eye care. Conjunctivitis does not increase the risk for glaucoma. The nurse is testing the visual acuity of a patient in the outpatient clinic. The nurses instructions for this test include asking the patient to a. stand 20 feet from the wall chart. When the Snellen chart is used to check visual acuity, the patient should stand 20 feet away. Accommodation is tested by looking at an object at both near and far distances. Shining a pen light into the eyes tests for pupil response. Following the examiners fingers with the eyes tests extraocular movements. A patient who underwent eye surgery is required to wear an eye patch until the scheduled postoperative clinic visit. Which nursing diagnosis will the nurse include in the plan of care? b. Risk for falls related to temporary decrease in stereoscopic vision The loss of stereoscopic vision created by the eye patch impairs the patients ability to see in three dimensions and to judge distances. It also increases the risk for falls. There is no evidence in the assessment data for ineffective health maintenance, disturbed body image, or ineffective denial. Which information will the nurse provide to the patient scheduled for refractometry? a. You will need to wear sunglasses for a few hours after the exam. The pupils are dilated using cycloplegic medications during refractometry. This effect will last several hours and cause photophobia. The other teaching would not be appropriate for a patient who was having refractometry. The nurse is assessing a 65-year-old patient for presbyopia. Which instruction will the nurse give the patient before the test? a. Hold this card and read the print out loud. The Jaeger card is used to assess near vision problems and presbyopia in persons over 40 years of age. The card should be held 14 inches away from eyes while the patient reads words in various print sizes. Using a penlight to determine pupil change is testing pupil response. A short burst of air may be used to test intraocular pressure but is not used for testing presbyopia. Covering one eye at a time while reading a wall chart at 20 feet describes the Snellen test. . A patient arrives in the emergency department complaining of eye itching and pain after sleeping with contact lenses in place. To facilitate further examination of the eye, fluorescein angiography is ordered. The nurse will
teach the patient to b. report any burning or pain at the IV site. Fluorescein angiography involves injecting IV dye. If extravasation occurs, fluorescein is toxic to the tissues. The patient should be instructed to report any signs of extravasation such as pain or burning. The nurse should closely monitor the IV site as well. The cornea is anesthetized during ultrasonography. Refractometry involves measuring visual acuity and asking the patient to choose lenses that are the sharpest; it is a painless test. The Amsler grid test involves using a hand held card with grid lines. The patient fixates on the center dot and records any abnormalities of the grid lines A patient complains of
dizziness when bending over and of nausea and dizziness associated with physical activities. The nurse will plan to teach the patient about b. rotary chair testing. The patients clinical manifestations of dizziness and nausea suggest a disorder of the labyrinth, which controls balance and contains three semicircular canals and the vestibule. Rotary chair testing is used to test vestibular function. The other tests are used to test for problems with hearing. When the nurse is taking a health history of a new patient at the ear clinic, the patient states, I have to sleep with the television on. Which follow-up question is most appropriate to obtain more information about possible hearing problems? c. Have you noticed ringing in your ears? Patients with tinnitus may use masking techniques, such as playing a radio, to block out the ringing in the ears. The responses Do you grind your teeth at night? and Are you ever dizzy when you are lying down? would be used to obtain information about other ear problems, such as vestibular disorders and referred temporomandibular joint (TMJ) pain. The response What time do you usually fall asleep? would not be helpful in assessing problems with the patients ears. When the patient turns his head quickly during the admission assessment, the nurse observes nystagmus. What is theindicated nursing action? b. Place a fall-risk bracelet on the patient. Problems with balance related to vestibular function may present as nystagmus or vertigo and indicate an increased risk for falls. The Rinne test is used to check hearing. Reading lips and louder speech are compensatory behaviors for decreased hearing. The nurse recording
health histories in the outpatient clinic would plan a focused hearing assessment for adult patients taking which medication? c. Ibuprofen (Advil) taken for 20 years to treat osteoarthritis Nonsteroidal antiinflammatory drugs (NSAIDs) are potentially ototoxic. Acetaminophen, atenolol, and albuterol are not associated with hearing loss. The charge nurse must intervene immediately if observing a nurse who is caring for a patient with vestibular disease c. encouraging the patient to ambulate independently. Vestibular disease affects balance, so the nurse should monitor the patient during activities that require balance. The other actions might be used for patients with hearing disorders. The nurse in the eye clinic is examining a 67-year-old patient who says I see small spots that move around in front of my eyes. Which action will the nurse take
first? d. Use an ophthalmoscope to examine the posterior eye chambers. Although floaters are usually caused by vitreous liquefaction and are common in aging patients, they can be caused by hemorrhage into the vitreous humor or by retinal tears, so the nurses first action will be to examine the retina and posterior chamber. Although the ophthalmologist will examine the patient, the presence of spots or floaters in a 65-year-old is not an emergency. The spots may indicate retinal damage, but the nurse should assess the eye further before discussing this with the patient. The nurse should report which assessment finding immediately
to the health care provider? a. The tympanum is blue-tinged. A bluish-tinged tympanum can occur with acute otitis media, which requires immediate care to prevent perforation of the tympanum. Cerumen in the ear canal may need to be removed before proceeding with the examination but is not unusual or pathologic. The presence of a cone of light on the eardrum is normal. Dry and scaly skin in the ear canal may need further assessment but does not require urgent care. Which equipment will the nurse obtain to perform a Rinne test? b. Tuning fork Rinne testing is done using a tuning fork. The other equipment is used for other types of ear examinations. Which action should the nurse take when providing patient teaching to a 76-year-old with mild presbycusis? c. Ask for permission to turn off the television before teaching Normal changes with aging make it more difficult for older patients to filter out unwanted sounds, so a quiet environment should be used for teaching. Loss of sensitivity for high-pitched tones is lost with presbycusis. Because the patient has mild presbycusis, the nurse should use both discussion and handouts. There is no need to wait until family members have left to provide patient teaching. Which
action can the nurse working in the emergency department delegate to experienced unlicensed assistive personnel (UAP)? b. Perform Snellen testing of visual acuity for a patient with a history of cataracts. The Snellen test does not require nursing judgment and is appropriate to delegate to UAP who have been trained to perform it. History taking about infection or medications and assessment are actions that require critical thinking and should be done by the RN. The nurse working in the vision and hearing clinic receives telephone calls from several patients who
want appointments in the clinic as soon as possible. Which patient should be seen first? a. 71-year-old who has noticed increasing loss of peripheral vision Increasing loss of peripheral vision is characteristic of glaucoma and the patient should be scheduled for an examination as soon as possible. The other patients have symptoms commonly associated with aging: presbycusis, possible cerumen impaction, and impaired night vision. The nurse evaluates that wearing bifocals improved the patients myopia and presbyopia by assessing for b. both near and distant vision. The lenses are prescribed to correct the patients near and distant vision. The nurse may also assess for cloudiness of the lenses, increased intraocular pressure, and eye movement, but these data do not evaluate whether the patients bifocals are effective. A nurse should instruct a patient with recurrent
staphylococcal and seborrheic blepharitis to c. use a gentle baby shampoo to clean the lids as needed. Baby shampoo is used to soften and remove crusts associated with blepharitis. The other interventions are not used in treating this disorder. When assisting a blind patient in ambulating to the bathroom, the nurse should d. walk slightly ahead of the patient and allow the patient to hold the nurses elbow. When using the sighted-guide technique, the nurse walks slightly in front and to the side of the patient and has the patient hold the nurses elbow. The other techniques are not as safe in assisting a blind patient. A nurse should include which instructions when teaching a patient with repeated hordeolum how to prevent further
infection? b. Discard all open or used cosmetics applied near the eyes. Hordeolum (styes) are commonly caused by Staphylococcus aureus, which may be present in cosmetics that the patient is using. Warm compresses are recommended to treat hordeolum. Antiseborrheic shampoos are recommended for seborrheic blepharitis. Patients with adult inclusion conjunctivitis, which is caused by Chlamydia trachomatis, should be referred for sexually transmitted infection (STI) testing. The nurse developing a teaching plan for a patient with herpes simplex keratitis should include which instruction? b. Wash hands frequently and avoid touching the eyes. The best way to avoid the spread of infection from one eye to another is to avoid rubbing or touching the eyes and to use careful hand washing when touching the eyes is unavoidable. Occlusive dressings are not used for herpes keratitis. Herpes simplex is a virus and antibiotic drops will not be prescribed. Topical corticosteroids are immunosuppressive and typically are not ordered because they can contribute to a longer course of infection and more complications. Which teaching point should the nurse plan to include when caring for a patient whose vision is corrected to 20/200? d. Where to obtain specialized magnifiers Various types of magnifiers can enhance the remaining vision enough to allow the performance of many tasks and activities of daily living (ADLs). Audio books, Braille instruction, and canes usually are reserved for patients with no functional vision. The nurse is
developing a plan of care for an adult patient diagnosed with adult inclusion conjunctivitis (AIC) caused byChlamydia trachomatis. Which action should be included in the plan of care?
a. Discussing the need for sexually transmitted infection testing Patients with AIC have a high risk for concurrent genital Chlamydia infection and should be referred for sexually transmitted infection (STI) testing. AIC is treated with antibiotics. Antiviral and corticosteroid medications are not appropriate therapies. Although some types of Chlamydia infection do cause blindness, AIC does not lead to blindness, so referral for visual rehabilitation is not appropriate. Which topic will the nurse teach after a patient has had outpatient cataract surgery and lens implantation? b. Administration of corticosteroid eye drops Antibiotic and corticosteroid eye drops are commonly prescribed after cataract surgery. The patient should be able to administer them using safe technique. Pain is not expected after cataract surgery and opioids will not be needed. Coughing and deep breathing exercises are not needed because a general anesthetic agent is not used. There is no bed rest restriction after cataract surgery. In reviewing a 55-year-old patients medical record, the nurse notes that the last eye examination revealed an
intraocular pressure of 28 mm Hg. The nurse will plan to assess d. peripheral vision. The patients increased intraocular pressure indicates glaucoma, which decreases peripheral vision. Because central visual acuity is unchanged by glaucoma, assessment of visual acuity could be normal even if the patient has worsening glaucoma. Color perception and pupil reaction to light are not affected by glaucoma A patient with a right retinal detachment had a pneumatic retinopexy procedure. Which information will be included in the discharge teaching plan? a. The purpose of maintaining the head in a prescribed position Following pneumatic retinopexy, the patient will need to position the head so the air bubble remains in contact with the retinal tear. The dark lenses and bilateral eye patches are not required after this procedure. Saturation of any eye dressings would not be expected following this procedure. A 72-year-old patient with
age-related macular degeneration (AMD) has just had photodynamic therapy. Which statement by the patient indicates that the discharge teaching has been effective? d. I will cover up with long-sleeved shirts and pants for the next 5 days. The photosensitizing drug used for photodynamic therapy is activated by exposure to bright light and can cause burns in areas exposed to light for 5 days after the treatment. There are no restrictions on the use of facial lotions, medications to keep the pupils dilated would not be appropriate, and bright lights would increase the risk for damage caused by the treatment. To
determine whether treatment is effective for a patient with primary open-angle glaucoma (POAG), the nurse can evaluate the patient for improvement by b. noting any changes in the patients visual field. POAG develops slowly and without symptoms except for a gradual loss of visual fields. Acute closed-angle glaucoma may present with excruciating pain, colored halos, and blurred vision. Problems with depth perception are not associated with POAG. A patient with glaucoma who has been using timolol (Timoptic) drops for several days tells the nurse that the eye drops cause eye burning and visual blurriness for a short time after administration. The best response
to the patients statement is b. The drops are uncomfortable, but it is important to use them to retain your vision. Patients should be instructed that eye discomfort and visual blurring are expected side effects of the ophthalmic drops but that the drops must be used to prevent further visual-field loss. The temporary burning and visual blurriness might not lessen with ongoing use, are not relieved by avoiding systemic absorption, and are not symptoms of glaucoma. The nurse is completing the admission database for a patient admitted with
abdominal pain and notes a history of hypertension and glaucoma. Which prescribed medications should the nurse question? d. Scopolamine patch (Transderm Scop) 1.5 mg Scopolamine is a parasympathetic blocker and will relax the iris, causing blockage of aqueous humor outflow and an increase in intraocular pressure. The other medications are appropriate for this patient. A patient who has bacterial endophthalmitis in the left eye is restless, frequently asking whether the eye is healing, and whether removal of the eye will be necessary. Based on the assessment data, which nursing diagnosis ismost appropriate at this time? b. Anxiety related to the possibility of permanent vision loss The patients restlessness and questioning of the nurse indicate anxiety about the future possible loss of vision. Because the patient can see with the right eye, functional vision is relatively intact. There is no indication of impaired self-esteem at this time. To decrease the risk for future hearing loss, which action should the nurse who is working with college students at the on-campus health clinic implement? c. Discuss the importance of limiting exposure to amplified music. The nurse should discuss the impact of amplified music on hearing with young adults and discourage listening to very amplified music, especially for prolonged periods. Tympanometry measures the ability of the eardrum to vibrate and would not help prevent future hearing loss. Although students are at risk for the influenza virus, being vaccinated does not help prevent future hearing loss. Otoscopic examinations are not necessary for all patients. A patient diagnosed with external otitis is being discharged from the emergency department with an ear wick in place. Which statement by the patient indicates a need for further teaching? c. I will clean the ear canal daily with a cotton-tipped applicator. Insertion of instruments such as cotton-tipped applicators into the ear should be avoided. The other patient statements indicate that the teaching has been successful. A patient who has undergone a left tympanoplasty should be instructed to c. avoid blowing the nose. Coughing or blowing the nose increases pressure in the eustachian tube and middle ear cavity and disrupts postoperative healing. There is no postoperative need for prolonged bed rest, elevation of the head, or continuous antibiotic irrigation. The nurse is assessing a patient
who has recently been treated with amoxicillin for acute otitis media of the right ear. Which finding is a priority to report to the health care provider? a. The patient has a temperature of 100.6 F. The fever indicates that the infection may not be resolved and the patient might need further antibiotic therapy. A feeling of fullness, popping of the ear, and decreased hearing are symptoms of otitis media with effusion. These symptoms are normal for weeks to months after an episode of acute otitis media and usually resolve without treatment. A 42-year-old woman with Mnires disease is admitted with vertigo, nausea, and vomiting. Which nursing intervention will be
included in the care plan? a. Dim the lights in the patients room. A darkened, quiet room will decrease the symptoms of the acute attack of Mnires disease. Because the patient will be nauseated during an acute attack, fluids are administered IV. Position changes will cause vertigo and nausea. The head of the bed can be positioned for patient comfort. Which statement by the patient to the home health nurse indicates a need for more teaching about self-administering eardrops? d. I should keep the medication refrigerated until I am ready to administer the drops. Administration of cold eardrops can cause dizziness because of stimulation of the semicircular canals. The other patient actions are appropriate. . An 82-year-old patient who is being admitted to the hospital repeatedly asks
the nurse to speak up so that I can hear you. Which action should the nurse take? b. Speak normally but more slowly. Patient understanding of the nurses speech will be enhanced by speaking at a normal tone, but more slowly. Increasing the volume, overenunciating, and exaggerating facial expressions will not improve the patients ability to comprehend the nurse. A 75-year-old patient with presbycusis is fitted with binaural hearing aids. Which information will the nurse include when teaching the patient how to use the hearing aids? a. Experiment with volume and hearing ability in a quiet environment initially. Initially the patient should use the hearing aids in a quiet environment like the home, experimenting with increasing and decreasing the volume as needed. There is no need to gradually increase the time of wear. The patient should experiment with the level of volume to find what works well in various situations. Both hearing aids should be used. Which information will the nurse include for a patient contemplating a cochlear implant? a. Cochlear implants require training in order to receive the full benefit. Extensive rehabilitation is required after cochlear implants in order for patients to receive the maximum benefit. Hearing aids, rather than cochlear implants, are used initially for presbycusis. Cochlear implants are used for sensorineural hearing loss and would not be helpful for conductive loss. They are appropriate for some patients with congenital deafness. Which statement by a patient with bacterial conjunctivitis indicates a need for further teaching? b. I will remove my contact lenses at bedtime. Contact lenses should not be used when patients have conjunctivitis because they can further irritate the conjunctiva. Hand washing is the major means to prevent the spread of conjunctivitis. Infection may be spread by sharing towels or other contact. It is common for bacterial conjunctivitis to spread through a family or other group in close contact. Which information will the nurse include when teaching
a patient with keratitis caused by herpes simplex type 1? d. Importance of taking all of the ordered oral acyclovir (Zovirax) Oral acyclovir may be ordered for herpes simplex infections. Corticosteroid ointments are usually contraindicated because they prolong the course of the infection. Herpes simplex I is viral, not parasitic, or fungal. Natamycin may be used forAcanthamoeba keratitis caused by a parasite. NSAIDs can be used to treat the pain associated with keratitis The nurse at the outpatient surgery unit obtains the following information about a patient who is scheduled for cataract extraction and implantation of an
intraocular lens. Which information is most important to report to the health care provider at this time? c. The patient takes 2 antihypertensive medications. Mydriatic medications used for pupil dilation are sympathetic nervous system stimulants and may increase heart rate and blood pressure. Using punctal occlusion when administering the mydriatic and monitoring of blood pressure are indicated for this patient. Blurred vision is an expected finding with cataracts. Patients are expected to be NPO for 6 to 8 hours before the surgical procedure. Cataract extraction and intraocular lens implantation are done using local anesthesia. During the preoperative assessment of the
patient scheduled for a right cataract extraction and intraocular lens implantation, it is most important for the nurse to assess a. the visual acuity of the patients left eye. Because it can take several weeks before the maximum improvement in vision occurs in the right eye, patient safety and independence are determined by the vision in the left eye. A white pupil in the operative eye would not be unusual for a patient scheduled for cataract removal and lens implantation. The length of time that the patient has had the cataract will not affect the perioperative care. Cataract surgery is done using local anesthetics rather than general anesthetics. The nurse learns that a newly admitted
patient has functional blindness and that the spouse has cared for the patient for many years. During the initial assessment of the patient, it is most important for the nurse to c. make eye contact with the patient and ask about any need for assistance. Making eye contact with a partially sighted patient allows the patient to hear the nurse more easily and allows the nurse to assess the patients facial expressions. The patient (rather than the spouse) should be asked about any need for assistance. The information about the cause of the vision loss and assessment of the patients visual acuity are not priorities during the initial assessment. Which action could the registered nurse (RN) who is working in the eye and ear clinic delegate to a licensed practical/vocational nurse (LPN/LVN)? b. Use a Snellen chart to check a patients visual acuity. Using standardized screening tests such as a Snellen chart to test visual acuity is included in LPN education and scope of practice. Evaluation, assessment, and patient teaching are higher level skills that require RN education and scope of practice. The occupational health nurse is caring for an employee who is complaining of bilateral eye pain after a
cleaning solution splashed into the employees eyes. Which action will the nurse take first? b. Flush the eyes with sterile saline. Flushing of the eyes immediately is indicated for chemical exposure. Emergency treatment of a burn or foreign-body injury to the eyes includes protecting the eyes from further injury by covering them with dry sterile dressings and protective shields. Flushing of the eyes immediately is indicated only for chemical exposure. In the case of chemical exposure, the nurse should begin treatment by flushing the eyes until the patient has been assessed by a health care provider and orders are available. Unlicensed assistive personnel (UAP) perform all the following actions when
caring for a patient with Mnires disease who is experiencing an acute attack. Which action by UAP indicates that the nurse should interveneimmediately? b. UAP turn on the patients television. Watching television may exacerbate the symptoms of an acute attack of Mnires disease. The other actions are appropriate because the patient will be at high fall risk and may suffer from nausea during the acute attack. The nurse at the eye clinic made a follow-up telephone call to a patient who underwent cataract extraction and intraocular lens implantation the previous day. Which information is the priority to communicate to the health care provider? b. The patient has eye pain rated at a 5 (on a 0 to 10 scale). Postoperative cataract surgery patients usually experience little or no pain, so pain at a level 5 on a 10-point pain scale may indicate complications such as hemorrhage, infection, or increased intraocular pressure. The other information given by the patient indicates a need for patient teaching but does not indicate that complications of the surgery may be occurring. Which finding in an emergency department patient who reports being struck in the right eye with a fist is a priority for the nurse to communicate to the health care provider? d. The patient complains of a curtain over part of the visual field. The patients sensation that a curtain is coming across the field of vision suggests retinal detachment and the need for rapid action to prevent blindness. The other findings would be expected with the patients history of being hit in the eye. The charge nurse observes a newly hired nurse performing all the following interventions for a patient who has just undergone right cataract removal and an intraocular lens implant. Which one requires that the charge nurse intervene? b. The nurse encourages the patient to cough. Because coughing will increase intraocular pressure, patients are generally taught to avoid coughing during the acute postoperative time. The other actions are appropriate for a patient after having this surgery. Which nursing activity is appropriate for the registered nurse (RN) working in the eye clinic to delegate to experienced unlicensed
assistive personnel (UAP)? b. Application of a warm compress to a patients hordeolum Application of cold and warm packs is included in UAP education and the ability to accomplish this safely would be expected for UAP working in an eye clinic. Medication administration, patient teaching, and assessment are high-level skills appropriate for the education and legal practice level of the RN. A patient with a head injury after a motorcycle crash arrives in the emergency department (ED) complaining of shortness of breath and severe eye pain. Which action will the nurse take first? b. Check the patients oxygen saturation. The priority action for a patient after a head injury is to assess and maintain airway and breathing. Because the patient is complaining of shortness of breath, it is essential that the nurse assess the oxygen saturation. The other actions are also appropriate but are not the first action the nurse will take. Which prescribed medication should the nurse give first to a patient who has just been admitted to a hospital with acute angle-closure glaucoma? b. Mannitol (Osmitrol) 100 mg IV The most immediate concern for the patient is to lower intraocular pressure, which will occur most rapidly with IV administration of a hyperosmolar diuretic such as mannitol. The other medications are also appropriate for a patient with glaucoma but would not be the first medication administered. The priority nursing diagnosis for a patient experiencing an acute attack with Menieres disease is a. risk for falls related to dizziness. All the nursing diagnoses are appropriate, but because sudden attacks of vertigo can lead to drop attacks, the major focus of nursing care is to prevent injuries associated with dizziness. Which information about a
patient who had a stapedotomy yesterday is most important for the nurse to communicate to the health care provider? b. The patients oral temperature is 100.8 F (38.1 C). An elevated temperature may indicate a postoperative infection. Although the nurse would report all the data, a temporary decrease in hearing, bloody drainage on the dressing, and a feeling of congestion (because of the accumulation of blood and drainage in the ear) are common after this surgery. A 75-year-old patient who lives alone at home tells the nurse, I am afraid of losing my independence because my eyes dont work as well they used to. Which action
should the nurse take first? d. Ask the patient more about what type of vision problems are being experienced. The nurses initial action should be further assessment of the patients concerns and visual problems. The other actions may be appropriate, depending on what the nurse finds with further assessment. A patient who received a corneal transplant 2 weeks ago calls the ophthalmology clinic to report that his vision has not improved with the transplant. Which action should the nurse take? c. Remind the patient it may take months to restore vision after transplant. Vision may not be restored for up to a year after corneal transplant. Because the patient is not experiencing complications of the surgery, an emergency clinic visit is not needed. Because floaters are not associated with complications of corneal transplant, the nurse will not need to ask the patient about their presence. Corticosteroid drops, not mydriatic drops, are used after corneal transplant surgery. Which action will the nurse take when performing ear irrigation for a patient with cerumen impaction? b. Fill the irrigation syringe with body-temperature solution. Solution at body temperature is used for ear irrigation. The patient should be sitting for the procedure. Use of cotton-tipped applicators to clear the ear may result in forcing the cerumen deeper into the ear canal. The ear should not be completely occluded with the syringe. Which action will the nurse include in the plan of care for a patient with benign paroxysmal positional vertigo (BPPV)? c. Teach the patient that canalith repositioning may be used to reduce dizziness. The Epley maneuver is used to reposition ear rocks in BPPV. Medications and placement in a dark room may be used to treat Mnires disease, but are not necessary for BPPV. There is no hearing loss with BPPV. When teaching a patient about the treatment of acoustic neuroma, the nurse will include information about a. a low sodium diet. b. ways to avoid falls. Intermittent vertigo occurs with acoustic neuroma, so the nurse should include information about how to prevent falls. Diet is not a risk factor for acoustic neuroma and no dietary changes are needed. Sunscreen would be used to prevent skin cancers on the external ear. Acoustic neuromas are benign and do not require chemotherapy. Which patient arriving at the urgent care center will the nurse assess first? a. Patient with acute right eye pain that occurred while using home power tools The history and symptoms suggest eye trauma with a possible penetrating injury. Blindness may occur unless the patient is assessed and treated rapidly. The other patients should be treated as soon as possible, but do not have clinical manifestations that indicate any acute risk for vision or hearing loss. The nurse is working in an urgent care clinic that has standardized treatment protocols for implementation by nursing staff. After reviewing the history, physical assessment, and vital signs for a 60-year-old patient as shown in the accompanying figure, which action should the nurse take first? d. Report the vision change to the health care provider. The sudden change in peripheral vision may indicate an acute problem, such as retinal detachment, that should be treated quickly to preserve vision. The other data about the patient are not indicative of any acute problem. The other actions are also appropriate, but the highest priority for this patient is prevention of blindness. Students also viewedTest Bank Eyes and Ears25 terms phillips32415 Health Assessment Jarvis Ch 15: Eyes40 terms Thaa2003Plus health assessment test bank 153 terms rearearichmond Health Assessment Jarvis: Ch 16: Ears40 terms Thaa2003Plus Sets found in the same folderMed Surge Exam 2169 terms Cecillia_CarterPlus NUR 2440C - MCN Exam 3201 terms Clodia_Frazil Head-to-Toe Assessment Script19 terms mr11787 Med Surg Final132 terms ekreto22 Other sets by this creatorRest of mark k149 terms nunyabiz1 ati quiz23 terms nunyabiz1 ati quiz91 terms nunyabiz1 Ch. 28 Hematologic or Immunologic Dysfunction65 terms nunyabiz1 Verified questionsbiology Describe one hypothesis that explains how habituation benefits animals. Verified answer
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