Nursing Care of Patients With Sensory Disorders: Vision and Hearing

Multiple Choice
Identify the choice that best completes the statement or answers the question.

____ 1. The nurse is collecting data from a patient with cataracts. Which symptom should the nurse expect because of this health problem?
a. Visual fatigue
b. Loss of visual acuity
c. Loss of central vision
d. Floating filaments in vision
____ 2. A patient diagnosed with cataracts asks how they develop. What should the nurse respond to this patient?
a. “Cataracts usually result from chronic systemic diseases.”
b. “Cataracts usually result from the prolonged use of toxic substances.”
c. “Cataracts are believed to result from eye injuries sustained early in life.”
d. “Cataracts may form as a result of exposure to ultraviolet light over time.”
____ 3. A patient with acute angle glaucoma and a fractured femur that is scheduled for surgery is prescribed the preoperative medications morphine 10 mg intramuscularly (IM), and atropine 0.4 mg IM. Which action should the nurse take?
a. Hold the morphine.
b. Contact the physician.
c. Give medications as ordered.
d. Collect data on patient’s pain.
____ 4. The nurse is reinforcing teaching provided to a patient with open-angle glaucoma. What is most important for the nurse to include in the patient teaching?
a. Regardless of treatment, peripheral vision will be eventually lost.
b. Compliance with drug therapy is essential to prevent loss of vision.
c. Damage to the eye caused by glaucoma is reversible in early stages.
d. Eye pain is experienced until the optic nerve atrophies, causing blindness.
____ 5. A patient with glaucoma is prescribed pilocarpine 1% eye drops every 6 hours. What outcome should the nurse expect from this medication?
a. Reduction of inflammation of the iris and choroids
b. Prevention of dryness of the cornea and conjunctiva
c. Dilation of the pupil by paralyzing the ciliary muscle
d. Promotion of drainage of aqueous humor from the anterior chamber of the eye
____ 6. The nurse is teaching a patient with glaucoma how to instill eyedrops. Which action should the nurse instruct the patient to take?
a. Look up while pulling lower lid outward.
b. Squeeze the eyelids shut for 2 minutes after instillation.
c. Look straight ahead while pulling down the lower eyelid.
d. If the eye waters, wipe from the outer canthus to the inner canthus.
____ 7. The caregiver of a patient with macular degeneration. The patient’s caregiver becomes increasingly is frustrated because of food spills on the patient’s clothing. Which explanation should help the caregiver understand what the patient is experiencing?
a. “The patient’s vision is blurred.”
b. “There is total blindness in one eye occurring.”
c. “The central vision is gone and only peripheral vision remains.”
d. “There are black dots in the field of vision that cause confusion.”
____ 8. The nurse is caring for a patient recovering from a stapedectomy. What is the priority nursing action to maintain safety?
a. Check for drainage.
b. Put the side rails up.
c. Test hearing capability.
d. Have patient cough and deep breathe.
____ 9. A patient being sent home from a clinic after evaluation for a perforated eardrum is advised not to shower. Which statement indicates that the patient understands why showering should not be performed?
a. Water should not enter the ear.
b. Motion of the ear would cause pain.
c. Showering would disturb equilibrium.
d. The patient should move as little as possible.
____ 10. The nurse is contributing to the plan of care for a patient recovering from a myringoplasty. Which intervention should be included in this patient’s plan of care?
a. Restricting fluids
b. Coughing each hour
c. Avoiding excessive movement
d. Encouraging visitors to speak loudly
____ 11. The nurse is assisting with the auditory assessment phase of the physical examination for a high school swimming team. The nurse identifies a student who has pain and itching of the ear. For which disorder should the nurse anticipate treatment is needed?
a. Otitis media
b. Furunculosis
c. External otitis
d. Chronic mastoiditis
____ 12. The nurse is collecting data from aa patient who has Ménière’s disease. Which finding should the nurse expect?
a. Nystagmus, nausea, and edema
b. Syncope, headache, and diplopia
c. Hearing loss, vertigo, and tinnitus
d. Blurred vision, vomiting, and arthralgia
____ 13. The nurse is caring for a patient who has an acute attack of Ménière’s disease. What action should the nurse take first?
a. Administer prescribed diuretics.
b. Administer an antianxiety medication.
c. Help the patient into bed with side rails up.
d. Ensure that the patient is on fluid restriction.
____ 14. The nurse is caring for a patient with chronic otitis media. For which complication should the nurse observe in the patient?
a. Tonsillitis
b. Sore throat
c. Hearing loss
d. Cerebral edema
____ 15. The nurse is collecting data from a patient who has a bulging eardrum. For which health problem should the nurse anticipate providing care to this patient?
a. Otitis media
b. External ear infection
c. Hematoma in the middle ear
d. Normal tympanic membrane
____ 16. The nurse is collecting data from a patient with an inner ear disorder. Which findings should be the most concerning to the nurse?
a. Otalgia
b. Vertigo
c. Nausea
d. Headache
____ 17. The nurse is caring for a patient after a left stapedectomy. In which position should the nurse place the patient?
a. Flat
b. Prone
c. Left ear upward
d. Right ear upward
____ 18. A family member of an 85-year-old patient explains that the patient sits about 2 feet away from the television and is not interested in going out anymore. Which additional information should the nurse use to support visual impairment?
a. The patient watches television.
b. The patient does not go out anymore.
c. The patient visits with a relative occasionally.
d. The patient has not moved to a new home in 45 years.
____ 19. During a home visit the nurse identifies signs of visual impairment in a 74-year-old patient. Which action should the nurse recommend?
a. Avoid travel.
b. Make adjustments in lifestyle.
c. Schedule an eye examination.
d. Accept visual impairment as part of aging.
____ 20. A patient diagnosed with myopia asks the nurse to explain the condition. How should the nurse respond?
a. “It is blindness.”
b. “It is farsightedness.”
c. “It is nearsightedness.”
d. “It is cataract development.”
____ 21. The nurse is reinforcing teaching provided to a patient being treated for myopia. Which patient statement indicates a correct understanding of the teaching?
a. Cataract surgery must occur
b. Corrective convex lenses are needed
c. Mydriatic ophthalmic drops are used
d. Corrective concave lenses are needed
____ 22. The nurse is teaching a patient about conjunctivitis. Which statement indicates that the patient understands the most important means to prevent the spread of this infection?
a. “Wash hands.”
b. “Patch the eyes.”
c. “Irrigate the eyes.”
d. “Keep the eyes moist.”
____ 23. A patient with diabetic retinopathy is being discharged home. Which patient statement indicates understanding of the discharge plan to maintain vision?
a. “I should avoid being in the sun.”
b. “I should reduce my insulin dosage.”
c. “I should keep my diabetes under control.”
d. “I will need to schedule routine eye examinations every 3 years.”
____ 24. The nurse is reinforcing teaching provided to a patient with primary open-angle glaucoma (POAG) about symptoms to report. Which patient statement indicates a correct understanding of the teaching?
a. “Hypotension and bradycardia.”
b. “Fever and reddened conjunctiva.”
c. “Loss of central vision and dizziness.”
d. “Headache and seeing halos around lights.”
____ 25. A patient scheduled for cataract surgery asks if the surgery is safe. What should the nurse do?
a. Ask the surgeon to talk to the patient.
b. Encourage visitors to distract the patient.
c. Give the patient a sedative for relaxation.
d. Reassure the patient that everything will be all right.
____ 26. The nurse is having difficulty communicating with a hearing-impaired patient. Which action should the nurse take to improve communication?
a. Speak softly
b. Speak rapidly
c. Avoid verbal communication
d. Face the patient when speaking
____ 27. The nurse is reinforcing teaching provided to a patient recovering from a stapedectomy. Which patient statement indicates teaching has been effective?
a. “I will avoid airplane travel for 6 months.”
b. “I will cough or sneeze with my mouth open.”
c. “I will gently blow my nose with both sides open.”
d. “I will keep the ear moist by packing it with cotton balls.”
____ 28. The nurse is planning to perform an ear irrigation to remove a patient’s cerumen. Which patient condition would contraindicate this procedure?
a. Previous hearing loss
b. Chronic, severe earache
c. Previous perforated eardrum
d. Previous external ear infection
____ 29. The nurse is reinforcing teaching provided to a patient with Ménière’s disease. Which patient statement indicates understanding of how to manage the vertigo?
a. “Listen to soft music.”
b. “Increase fluid intake.”
c. “Increase sodium intake.”
d. “Avoid sudden movement.”
____ 30. A patient with Ménière’s disease is crying and wants to know why this disease is occurring. Which outcome should the nurse recommend for this patient’s care?
a. Prevent injury.
b. Decrease anxiety.
c. Prevent ear infection.
d. Maintain fluid volume.
____ 31. The nurse is reinforcing teaching provided to a patient with Ménière’s disease. Which discharge order should the nurse question?
a. Return if symptoms worsen.
b. Increase daily sodium intake to 4 g.
c. Ask for assistance when ambulating.
d. During an attack, lie down and keep head still.
____ 32. The nurse notes that a patient has astigmatism. What should the nurse expect when collecting data from this patient?
a. Blind spots
b. Blurred vision
c. Distorted near vision
d. Distorted distance vision
Multiple Response
Identify one or more choices that best complete the statement or answer the question.

____ 33. The nurse is caring for a patient with a sensorineural hearing loss. Which prescribed medications should the nurse question before providing to this patient? (Select all that apply.)
a. Gentamicin
b. Furosemide
c. Indomethacin
d. Acetaminophen
e. Warfarin sodium
____ 34. The nurse is collecting data from a patient with a detached retina. Which findings should the nurse expect in this patient? (Select all that apply.)
a. Severe pain
b. Blurred vision
c. Flashing lights
d. Loss of peripheral vision
e. Loss of acuity in the affected eye
____ 35. A patient with acute ear pain and drainage comes into the community clinic. Which diagnostic tests should the nurse prepare to collect prior to beginning treatment for this patient? (Select all that apply.)
a. Biopsy
b. Audiometric testing
c. Complete blood count
d. Rinne and Weber tests
e. Culture of ear discharge
____ 36. A patient with otitis media is experiencing severe ear pain. Which nonpharmacologic measures should the nurse use to help this patient? (Select all that apply.)
a. Offer a massage.
b. Apply heat to the area.
c. Offer liquid or soft diet.
d. Apply an ice pack to the area.
e. Dim the lights and reduce environmental noise.
Completion
Complete each statement.

37. After surgery for a detached retina, a patient is experiencing nausea and is prescribed prochlorperazine (Compazine), 10 mg IM prn every 6 hours. Compazine is available as 5 mg/mL. The nurse should administer ____________________ mL in each dose.

Chapter 52. Nursing Care of Patients With Sensory Disorders: Vision and Hearing
Answer Section

MULTIPLE CHOICE

1. ANS: B
Symptoms of cataract formation may include halos around lights, difficulty reading fine print or seeing in bright light, increased sensitivity to glare such as when driving at night, double or hazy vision, and decreased color vision. D. Floaters are associated with detached retina. C. Loss of central vision is associated with retinopathy and macular degeneration. A. Eye strain or visual fatigue is associated with refractive errors.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Physiological Adaptation | Cognitive Level: Application

2. ANS: D
Factors that contribute to cataract development may include age, ultraviolet radiation (sunlight), diabetes, smoking, steroids, nutritional deficiencies, alcohol consumption, intraocular infections, trauma, and congenital defects. A. Chronic systemic diseases do not cause cataracts. B. Toxic substances do not cause cataracts. C. Cataracts do not form because of eye injuries.

PTS: 1 DIF: Moderate
KEY: Client Need: Health Promotion and Maintenance | Cognitive Level: Application

3. ANS: B
Atropine is contraindicated for patients with acute angle glaucoma. It can cause blindness if given so the physician must be notified. A. There is no reason to hold the morphine. C. Giving the medications could cause blindness in the patient. D. The morphine is not being given for pain but rather for preoperative preparation.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Pharmacological and Parenteral Therapies | Cognitive Level: Analysis

4. ANS: B
Lifelong compliance with drug therapy is essential to prevent loss of vision. A. It is not definite that the patient will lose peripheral or any vision. C. Vision changes cannot be corrected with eyeglasses. D. Eye pain and optic nerve damage is associated with acute angle glaucoma.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Reduction of Risk Potential | Cognitive Level: Application

5. ANS: D
This medication promotions drainage of aqueous humor from the anterior chamber of the eye and reduces pressure in the eye as the fluid does not build up. A. B. C. This medication does not perform these actions.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Pharmacological and Parenteral Therapies | Cognitive Level: Analysis

6. ANS: A
The nurse should instruct the patient to tilt the head backward and look up toward the ceiling. Gently pull the lower lid down and out. This forms a pocket to catch the eyedrop. B. There is no need for the patient to squeeze the eyelids shut for 2 minutes. C. Looking straight ahead will not create a pocket for the eye drop. D. Cleansing should be done from the inner canthus to the outer canthus.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Pharmacological and Parenteral Therapies | Cognitive Level: Application

7. ANS: C
In macular degeneration, central vision is gone, and only peripheral vision remains, so it is hard to see things in front of oneself. A. B. D. These statements do not correctly describe macular degeneration.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Physiological Adaptation | Cognitive Level: Application

8. ANS: B
Activity orders may vary after stapedectomy. The patient may be dizzy and a fall risk, so use of safety rails can protect the patient. A. C. D. These actions will not maintain the patient’s safety.

PTS: 1 DIF: Moderate
KEY: Client Need: Safe and Effective Care Environment—Safety and Infection Control | Cognitive Level: Analysis

9. ANS: A
With a perforated eardrum, water should not enter the ear. B. C. D. These are not reasons why the patient with a perforated ear drum should not shower.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Reduction of Risk Potential | Cognitive Level: Analysis

10. ANS: C
The patient should be instructed to avoid excessive movement to prevent dislodging the graft after myringoplasty. A. There is no reason to restrict fluids. B. Coughing could dislodge the graft. D. The patient does not have a hearing deficit.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Reduction of Risk Potential | Cognitive Level: Analysis

11. ANS: C
The most common sign of external otitis is pain along with pruritus (itching). A. B. D. Itching and pain are not common signs of these disorders.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Physiological Adaptation | Cognitive Level: Application

12. ANS: C
A triad of symptoms of vertigo, hearing loss, and tinnitus characterizes Ménière’s disease. A. B. D. These are not symptoms characteristic of Meniere’s disease.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Physiological Adaptation | Cognitive Level: Application

13. ANS: C
Because extreme dizziness occurs with this disease the nurse should help the patient into bed with side rails up so that a fall does not occur due to vertigo. A. B. These actions can occur after the patient’s safety is addressed. D. The patient would be placed on a salt-restricted diet.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Reduction of Risk Potential | Cognitive Level: Application

14. ANS: C
If the infection continues longer than 3 months, chronic otitis media results and can lead to hearing loss. A. B. D. These are not complications from chronic otitis media.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Physiological Adaptation | Cognitive Level: Application

15. ANS: A
In otitis media otoscopic examination reveals a reddened, bulging tympanic membrane. B. C. D. These findings are not consistent with otitis media.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Physiological Adaptation | Cognitive Level: Application

16. ANS: B
Vertigo should be concerning because of the patient’s increased risk for falls. A. C. D. These are typically findings associated with an ear disorder and should not increase the nurse’s concern.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Reduction of Risk Potential | Cognitive Level: Analysis

17. ANS: C
After a stapedectomy the operative ear is placed upward when lying in bed to prevent pressure or drainage on the site. A. B. D. These positions are not appropriate for the patient after a stapedectomy.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Reduction of Risk Potential | Cognitive Level: Application

18. ANS: B
The patient does not go out anymore due to safety concerns and the reduced ability to see. A. C. D. These statements do not necessarily indicate that the patient has impaired vision.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Physiological Adaptation | Cognitive Level: Analysis

19. ANS: C
The patient should be encouraged to have an eye examination so that interventions if necessary can be made. A. B. D. There is no reason for the patient to avoid travel, adjust lifestyle, or accept visual impairment as a part of aging.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Reduction of Risk Potential | Cognitive Level: Application

20. ANS: C
Myopia is nearsightedness or the ability to see things close up but not far away. A. B. D. Myopia does not mean blindness, farsightedness, or that cataracts are developing.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Physiological Adaptation | Cognitive Level: Application

21. ANS: D
Myopia is corrected with concave lenses. A. Cataract surgery is used to remove cataracts. B. Hyperopia is corrected with convex lenses. C. Mydriatics dilate pupils for examination or surgical procedures.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Reduction of Risk Potential | Cognitive Level: Analysis

22. ANS: A
Conjunctivitis is very contagious and hand washing is essential to prevent the transmission of this infection. B. C. D. Patching, irrigating, and keeping the eye moist will not prevent the spread of this infection.

PTS: 1 DIF: Moderate
KEY: Client Need: Safe and Effective Care Environment—Safety and Infection Control | Cognitive Level: Analysis

23. ANS: C
Controlling diabetes is the best way to maintain vision in the patient with diabetic retinopathy. A. Avoiding the sun will not prevent the development this disorder. B. Reducing insulin dosage could cause this disorder to develop quicker. D. Eve examinations should be completed every year.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Reduction of Risk Potential | Cognitive Level: Analysis

24. ANS: D
POAG develops bilaterally. The onset is usually gradual and painless, so the patient may not experience noticeable symptoms or, after time, may experience mild aching in the eyes, headache, halos around lights, or frequent visual changes that are not corrected with eyeglasses. A. B. C. These are not symptoms of POAG.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Reduction of Risk Potential | Cognitive Level: Analysis

25. ANS: A
The surgeon needs to talk with the patient to ensure understanding and informed consent. It is not the nurse’s role to do so. B. C. D. These actions would not be appropriate or address the patient’s concern.

PTS: 1 DIF: Moderate
KEY: Client Need: Safe and Effective Care Environment—Management of Care | Cognitive Level: Application

26. ANS: D
For a patient who is hearing impaired, facing the patient when speaking allows the patient to read lips. A. B. The voice volume should not be altered. C. It is not realistic to expect the nurse and patient avoid verbal communication.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Basic Care and Comfort | Cognitive Level: Application

27. ANS: B
It is important to prevent increased pressure to protect the graft site, so the mouth should be open when coughing or sneezing. A. There is no need for the patient to avoid airplane travel for 6 months. C. The nose should be gently blown one side at a time. D. Nothing should be placed into the ears.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Reduction of Risk Potential | Cognitive Level: Analysis

28. ANS: C
Ear irrigations are contraindicated in a patient with a previous perforated eardrum. Irrigations could cause ear damage. A. B. D. These are not reasons to avoid irrigating the patient’s ears.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Reduction of Risk Potential | Cognitive Level: Analysis

29. ANS: D
The patient should avoid turning the head quickly to help alleviate the vertigo. A. B. C. These actions will not necessarily help manage the vertigo associated with this disorder.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Reduction of Risk Potential | Cognitive Level: Analysis

30. ANS: B
The patient is anxious due to the uncertainty of the disorder. The goal is to reduce the anxiety through education. A. C. D. These outcomes do not address the patient’s anxiety about the disorder.

PTS: 1 DIF: Moderate
KEY: Client Need: Psychosocial Integrity | Cognitive Level: Analysis

31. ANS: B
A salt-restricted diet should be ordered to reduce fluid retention in the inner ear. A. C. D. These orders would be appropriate for the patient with Meniere’s disease.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Reduction of Risk Potential | Cognitive Level: Analysis

32. ANS: B
Astigmatism results from unequal curvatures in the shape of the cornea. The person with astigmatism has blurred vision with distortion. A. Central vision blind spots are associated with macular degeneration. C. Distorted near vision occurs with myopia. D. Distorted distance vision occurs with hyperopia.

PTS: 1 DIF: Moderate
KEY: Client Need: Health Promotion and Maintenance | Cognitive Level: Application

MULTIPLE RESPONSE

33. ANS: A, B, C
Gentamicin, furosemide, and indomethacin are all ototoxic medications. For the patient with sensorineural hearing loss, the nurse should question these medications before providing. D. E. These medications are not considered ototoxic.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Pharmacological and Parenteral Therapies | Cognitive Level: Application

34. ANS: E
Patients experiencing a retinal detachment report a sudden change in vision. Initially, as the retina is pulled, patients report seeing flashing lights and then floaters. The flashing lights are caused by vitreous traction on the retina, and the floaters are caused by hemorrhage of vitreous fluid or blood. On visual examination, the patient typically has a loss of peripheral vision when the visual fields are tested and a loss of acuity in the affected eye. A. There is no pain because the retina does not contain sensory nerves. B. Blurred vision does not occur with a detached retina.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Reduction of Risk Potential | Cognitive Level: Application

35. ANS: C, D, E
For an external ear infection diagnostic tests include a complete blood cell count (CBC), specifically WBC counts, and cultures of discharge. This will help diagnose the infection. Culture and sensitivity tests isolate the specific infective organism and determine which antibiotics would be most effective to treat the infection. The Rinne and Weber tests can indicate conductive hearing impairment. A. A biopsy would be indicated for an ear mass. B. Audiometric testing would be appropriate for the patient with impacted cerumen.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Reduction of Risk Potential | Cognitive Level: Application

36. ANS: A, B, C
Nonpharmacological methods, such as relaxation, massage, music, guided imagery, or distraction techniques help to relieve ear pain. Apply heat as ordered to the area to promote comfort. Offer liquid or soft foods to relieve pain when chewing. D. Ice to the area could cause additional pain. E. Dimming the lights and reducing environmental noise would be helpful for a patient with an eye injury or condition.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Basic Care and Comfort | Cognitive Level: Application

COMPLETION

37. ANS:
2, two

10 mg 1 mL = 2 mL
5 mg
PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Pharmacological and Parenteral Therapies | Cognitive Level: Application