Deck 11: Care of the Eye and Ear

Question 1

The nurse admits a patient who wears a hearing aid for surgery.Which method should the nurse use to assess the patient's hearing acuity with the hearing aid in place?

A) Whisper very softly behind the patient.
B) Cover the patient's unaffected ear before talking.
C) Send the hearing aid to the audiologist for analysis.
D) Check patient response using a normal voice level.

Answer 1

Check patient response using a normal voice level.

Question 2

The nurse and the patient discuss the patient's need for a hearing aid.What information does the nurse include in patient teaching?

A) An in-the-ear hearing aid is easy to manipulate.
B) The patient's specific needs and abilities are determining factors.
C) The choice of a hearing aid is basically a financial matter.
D) Behind-the-ear models are inferior to the other types.

Answer 2

The patient's specific needs and abilities are determining factors.

Question 3

The patient asks the nurse to irrigate both ear canals to improve hearing and comfort.The patient has bilateral brown ear drainage and a history of a right mastoidectomy and perforation of the left tympanic membrane.Which intervention should the nurse implement first?

A) Inform the patient that the ears are infected.
B) Perform an otoscopic examination of the canals.
C) Collaborate with the audiologist about a hearing aid.
D) Irrigate the ear canals with warm saline solution.

Answer 3

Perform an otoscopic examination of the canals.

Question 4

The nurse is establishing a discharge teaching plan for a diabetic patient with visual impairment who is seen in urgent care for an ankle sprain.Which self-care tasks will need additional adjustments to accommodate for the visual impairment? (Select all that apply.)

A) Taking medications
B) Testing blood glucose
C) Applying ice pack to ankle injury
D) Applying Ace wrap to ankle
E) Taking insulin

Question 5

The nurse is instructing a patient on the procedure to remove a rigid contact lens.Instruction by the nurse is correct if the patient uses which technique?

A) Slides lens onto the sclera and pinches off the lens
B) Draws periorbital skin taut and asks the patient to blink
C) Uses a bulb syringe and applies suction to the lens
D) Squeezes the upper and lower lids together to pinch the lens

Question 6

The nurse prepares to remove the patient's soft contact lenses.Which intervention should the nurse implement to remove the lenses without traumatizing the cornea?

A) Irrigate the eye with 50 mL of a sterile saline solution.
B) Pull the lid down and instruct the patient to blink.
C) Pinch the sides of the lens together and pop it out.
D) Move the lens to the sclera and compress the lens gently.

Question 7

After removing a soft contact lens,the nurse observes that the sides of the lens are sticking together.Which intervention should the nurse implement before storing or reinserting the lens?

A) Thoroughly soak the lens in saline solution.
B) Rub the contact lens briskly to remove the debris.
C) Pry the lens apart gently with a fingertip.
D) Use the cleaning solution on the lens; then replace or store it.

Question 8

The nurse is assessing an elderly patient's ability to understand how to properly care for his hearing aid.Which of the following statements indicate further education is needed? (Select all that apply.)

A) "I can wear my hearing aid in the shower."
B) "I should take it out when I go to the pool to swim."
C) "I can wear my hearing aid when I get my hair done."
D) "I need to make sure I don't leave them in a hot car."
E) "I should store the batteries in a dry, safe place."

Question 9

The family of an older adult brings the patient to the healthcare provider because the patient seems to be confused or depressed at times.What approach by the nurse can best obtain valuable information about the underlying problem?

A) Talk to the patient in a normal voice while standing away from him or her.
B) Whisper questions to the patient to determine if the questions can be understood.
C) Ask the family to explain the activity patterns of the patient.
D) Ask the family for a list of what the patient usually eats.

Question 10

The nurse is performing eye care for a comatose patient.Which interventions indicate the nurse has a good understanding of the appropriate care needed? (Select all that apply.)

A) The nurse cleans the eye with water or saline.
B) The nurse uses an eyedropper to instill the prescribed lubricant.
C) The nurse wipes away excess lubricant moving from outer canthus to inner canthus.
D) The nurse applies eye patches when the blink reflex is absent.
E) The nurse changes the eye patches every 8 hours.

Question 11

The nurse is preparing to remove cerumen from an older adult's ear.Nursing care is appropriate if the nurse uses which procedure?

A) Applies slight negative pressure to the ear canal
B) Asks the patient not to move while the ear is being irrigated
C) Cleans the ear canal with a soft cotton swab to remove any remaining cerumen
D) Instills cool irrigating fluid to break down the cerumen in the ear canal

Question 12

The nurse plans care for a patient who has a hearing deficit.What actions when taken by the nurse indicate a good understanding of appropriate care? (Select all that apply.)

A) Face the patient before beginning to speak.
B) Keep the lights dimmed low.
C) Speak in a slow, clear, and loud voice.
D) Eliminate external voices.
E) Do not talk over the patient.

Question 13

The nurse plans care for a newly admitted female Muslim patient who is blind.Which is the priority nursing action for this patient?

A) Touch the patient before talking to her.
B) Talk with the patient before touching her.
C) Assign only female caregivers to this patient.
D) Obtain a history of what the patient can eat.

Question 14

The nurse assesses a 3-year-old patient with a dried bean in the left ear canal.Which action should the nurse implement?

A) Wait for the bean to fall out.
B) Examine the ears with an otoscope.
C) Collaborate with the healthcare provider.
D) Irrigate the ear to flush out the bean.

Question 15

The nurse irrigates the patient's right ear with saline solution to improve hearing.Which unexpected outcome of ear canal irrigation does the nurse prevent by preparing the irrigation solution properly?

A) Patient hearing acuity remains stable.
B) Patient senses that irrigant is slightly warm.
C) Patient complains of nausea and vertigo.
D) Patient drainage contains brown particles.

Question 16

The nurse is orienting a new graduate nurse about eye irrigation.Which statement indicates a good level of understanding of the procedure? (Select all that apply.)

A) "I should irrigate from inner to outer canthus."
B) "I should tell the patient not to blink."
C) "I should always remove the contact lenses first."
D) "I should hold the lids open by putting gentle pressure to the lower bony orbit."
E) "I should irrigate until clear or prescribed amount of time is reached."

Question 17

The nurse plans care for the patient in acute care.Which is the priority nursing diagnosis for a patient with altered sensory perception?

A) At risk for injury
B) Deficient knowledge
C) Impaired communication
D) Impaired social interaction

Question 18

The nurse instructs the patient on how to care for the hearing aid at home.What information should the nurse include in patient teaching to prevent damage to the hearing aid?

A) Store the hearing aid with a desiccant.
B) Wash the hearing aid in hot soapy water.
C) Keep the hearing aid in the bathroom.
D) Clean the hearing aid with a pipe cleaner.

Question 19

The nurse irrigates the patient's eye after the patient splashes an irritating liquid into it.Which intervention does the nurse implement to prevent injury during eye irrigation?

A) Positions the patient in high-Fowler's position during the procedure
B) Prevents the tip of the irrigating system from contacting the eyeball
C) Reassures the patient that the eye cannot be closed during irrigation
D) Allows the irrigating solution to run from the outer to the inner canthus

Question 20

The nursing assistive personnel (NAP)reports that the hearing-impaired patient is usually alert and oriented with the hearing aid in place,but the patient is not responding to verbal communication this morning.What action should the nurse implement first?

A) Document that the patient's neurological status is poor.
B) Assess the patient for clinical indicators of a stroke.
C) Remove the hearing aid and clean it with a stiff brush.
D) Instruct NAP to check the hearing aid battery.