A nurse practitioner is assessing a patient who is experiencing changes in her vision. The nurse performs the following steps. Place them in the order in which the nurse would complete them. Use all options.
1. Examine the external eye
2.Perform direct ophthalmoscopy
3.Obtain an ocular history
4. Test visual acuity
3. Obtain an ocular history
4. Test visual acuity
1. Examine the external eye
2. Perform direct
ophthalmoscopy
When completing an assessment for a patient with visual complaints, the nurse would first obtain an ocular history and then test the patient's visual acuity. Next the nurse would examine the external eye and then perform direct ophthalmoscopy to examine the internal eye.
Which action by the nurse has the highest priority when caring for a client diagnosed with vertigo?
A. Encourage the client to keep his or her eyes open.
B. Administer antivertiginous medication as ordered.
C. Encourage the client to stare straight ahead, focusing on one object.
D. Educate the client on using the call light for assistance with ambulation.
D. Educate the client on using the call light for assistance with ambulation.
The client should restrict movement and change positions slowly to prevent an injury related to the vertigo. The prevention of injury related to the vertigo should be the highest priority nursing intervention; therefore, the nurse needs to teach the client about using the call light for assistance with ambulation. All other interventions are appropriate but do not address safety. The client should keep his or her eyes open and focus on one spot to reduce vertigo.
Which of the following classification of medications is the most common cause of ototoxicity?
A. Aminoglycosides
B. Cephalosporins
C. Sulfonamides
D. Penicillins
A. Aminoglycosides
IV medications, especially the aminoglycosides, are the most common cause of ototoxicity, and they destroy the hair cells in the organ of Corti. Cephalosporins, sulfonamides, and penicillins are not among the most common causes of ototoxicity.
During a pharmacology class, the students are told that some drugs need to be closely monitored. What aspect should the nurse closely monitor for in clients who have been administered salicylates, loop diuretics, quinidine, quinine, or aminoglycosides?
A. Signs of hypotension
B. Reduced urinary output
C. Tinnitus and sensorineural hearing loss
D. Impaired facial movement
C. Tinnitus and sensorineural hearing loss
It is important that nurses are knowledgeable about the ototoxic effects of certain medications such as salicylates, loop diuretics, quinidine, quinine, and aminoglycosides. Signs and symptoms of ototoxicity include tinnitus and sensorineural hearing loss. Hypotension, reduced urinary output, and impaired facial movement are not signs of ototoxicity.
A client has undergone enucleation. What complication of enucleation should be addressed by the nurse?
A. Hypotension
B. Nausea and vomiting
C. Hemorrhage
D. Pneumonia
C. Hemorrhage
The nurse should take measures to prevent hemorrhage, a complication of enucleation, by applying a pressure dressing. Nausea and vomiting may be common side effects of surgery. Enucleation does not increase risk of developing hypotension or pneumonia.
The nurse is assisting the eye surgeon in completing an examination of the eye. Which piece of equipment would the nurse provide to the physician to examine the optic disc under magnification?
A. Retinoscope
B. Ophthalmoscope
C. Tonometer
D. Amsler grid
B. Ophthalmoscope
The nurse is correct to provide an ophthalmoscope to the surgeon for examination of theoptic disc. A retinoscope is used to determine errors in refraction. A tonometer measures intraocular pressure. An Amsler grid tests for problems with the macula.
A patient has had cataract extractions and the nurse is providing discharge instructions. What should the nurse encourage the patient to do at home?
A. Maintain bed rest for 1 week.
B. Lie on the stomach while sleeping.
C. Avoid bending the head below the waist.
D. Lift weights to increase muscle strength.
C. Avoid bending the head below the waist.
The nurse should encourage the patient to avoid bending or stooping for an extended period. Keep activity light. Avoid lying on the side of the affected eye the night after surgery. Avoid lifting, pushing, or pulling objects heavier than 15 pounds.
When the client tells the nurse that his vision is 20/200 and then asks what that means, the nurse informs the client that a person with 20/200 vision
A. sees an object from 200 feet away that a person with normal vision sees from 20 feet away.
B. sees an object from 20 feet away just like a person with normal vision.
C. sees an object from 200 feet away just like a person with normal vision.
D. sees an object from 20 feet away that a person with normal vision sees from 200 feet away.
D. sees an object from 20 feet away that a person with normal vision sees from 200 feet away.
The fraction 20/20 is considered the standard of normal vision. Most people can see the letters on an eye chart designated as 20/20 from a distance of 20 feet.
The nurse is teaching a parent how to instill drops in their 12-year-old son's eyes. Which action would the nurse teach is accomplished first?
A. Close the eye gently.
B. Tilt the head slightly backward.
C. Instill the prescribed number of drops into the conjunctival pocket.
D. Do not allow the tip of the container to touch the eye.
B. Tilt the head slightly backward.
To instill eye drops: Tilt the head slightly backward and toward the eye in which the medication is to be instilled; Do not allow the tip of the container to touch the eye; Instill the prescribed number of drops into the conjunctival pocket, or apply a thin ribbon of ointment directly into the conjunctival pocket, beginning at the inner corner and moving outward; Close the eye gently. Options A, C, and D are not the first action in instilling eye drops.
The nurse should monitor for which manifestation in a client who has had LASIK surgery?
A. Excessive tearing
B. Cataract formation
C. Halos and glare
D. Stye formation
C. Halos and glare
After LASIK surgery, symptoms of central islands and decentered ablations can occur that include monocular diplopia or ghost images, halos, glare, and decreased visual acuity. These procedures do not cause excessive tearing or result in cataract or stye formation.
Following cataract removal, discharge instructions will be provided to the client. Which of the following instructions is most important?
A. Apply protective patch to both eyes at bedtime.
B. Only sleep on back.
C. Avoid washing face and eyes for first 24 hours.
D. Avoid any activity that can increase intraocular pressure.
D. Avoid any activity that can increase intraocular pressure.
For approximately 1 week, the client should avoid any activity that can cause an increase in intraocular pressure. Clients may sleep on back or unaffected side. Clients may use a clean damp cloth to remove eye discharge and wash face. An eye shield is often ordered for the first 24 hours and during the night to prevent rubbing or trauma to the operative eye.
Which client being treated for anorexia displays assessment values that warrant hospitalization?
A. A 25-year-old whose weight is 70% of ideal and who has a serum glucose of 58mg/dL
B. A 32-year-old with a temperature of 98° F and a pulse rate of 54 bpm
C. A 16-year-old with serum potassium of 3.8 mEq/L and a blood pressure of 98/66 mmHg
D. A 10-year-old whose weight has remained unchanged in spite of a 3-inch growth spurt
A. A 25-year-old whose weight is 70% of ideal and who has a serum glucose of 58mg/dL
A 25-year-old whose weight is 70% of ideal and who has a serum glucose of 58mg/dL should be hospitalized because both values are troublesome. The values of the other clients do not meet the criteria for hospitalization.