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EYE/EAR
NUR 237
| Question | Answer |
|---|---|
| Pupil | Central opening allowing light into interior |
| Ciliary Body | Connect the iris to the choroid. Secrete aqueous humor |
| Iris | Colored portion of eye |
| Anterior Chamber | Between the lens and the cornea |
| Posterior Chamber | Sits between lens and retina and contains vitreous humor |
| Eyelashes | Help trap foreign particles, keeping the out of the eye |
| Lacrimal Gland | Secretes tears that moisten, lubricate, and cleanse the eye |
| Tears | Contains an enzyme that kills bacteria |
| Suspensory Ligaments | Connect the ciliary body and lens |
| Ectropion | Eversion of the lower lid that may occur with aging |
| Farsightedness (hyperopia) | Cannot see items close up |
| Nearsightedness (Myopia) | Cannot see items far away |
| Accommodation | Eyes make an adjustment to the difference in the light rays entering the eye |
| Presbyopia | Hardening of the ciliary muscles occurs in people over 40. May affect accommodation |
| Astigmatism | Visual defect that results from warped lens or an irregular curvature |
| Uveitis S/S | Tearing Blurred vision Photophobia Blood shot sclera |
| Uveitis | Inflammation of the uveal tract (iris, ciliary body & choroid) Results from other medical conditions EX: Herpes, syphilis, cytomegalovirus, TB, West Nile Virus |
| Keratitis | Inflammation of the cornea. Often due to decreased moisture Eye becomes reddened and tearing Feeling grittiness or pain |
| The nurse is preparing to administer eye drops. Which interventions should the nurse take to administer the drops? (SATA) | Wash hands Put gloves on Place drop in conjunctival sac Pull the lower lid down against the cheekbone Make sure to put in the right eye Make sure to use right color eye drops |
| A client is prescribed an eye drop and eye ointment for the right eye. How should the nurse BEST administer the medications? | Administer the eye drop first, followed by the eye ointment. |
| A client w/ Meniere's disease is experiencing severe vertigo. Which instructions should the nurse give to the client to assist in controlling the vertigo? | Avoid sudden head movements |
| A pt vision is tested with the snellen chart. The results of the test are documented as 20/60. What action should the nurse implement based on this finding? | Instruct the client that he/she may need glasses while driving |
| Why is the optic disc considered to be a blind spot? | This area does not contain photoreceptors (Rods & Cones) |
| Which technique will the nurse use to assess the blink reflex in a client who is blind? | Expelling a syringe of air toward the client's eye |
| A nurse is assessing the eye changes in an older adult. Which acute changes suggest the need for physician consultation? (SATA) | Increasing redness in eyes Acute pain in the eyes Sudden change in acuity |
| The nurse is evaluating the client's technique for instilling eye drops. Which behavior indicates that the client needs more teaching? | The client touches his eye with the tip of the dropper |
| An adult client asks why she needs to get her intraocular pressure tested every year. What will the nurse tell the client? | Loss of vision can occur if the pressure is too high or too low |
| Which finding confirms normal accommodation during visual assessment? | Both of the client's pupils constrict when focusing on an object being moved in toward the nose. |
| When a person enters a dimly lit room, which type of vision is most keen? | Peripheral black and white vision |
| A client is scheduled for a fluorescein angiography. Place the nurse's activities in order, from highest to lowest priority | Have the consent form signed Instill the mydriatic eyedrops Start the IV access Inject fluorescein dye Have the client drink fluids Have the client wear dark glasses Teach about color changes |
| The nurse is assessing extraocular eye movements (EOM's) in an older adult client and finds that the client is unable to sustain an upward gaze for more than 2 seconds. What will the nurse do next? | Document the finding and continue assessing |
| Which client is at greatest risk for developing vision problems? | A young man who has DM |
| Which finding leads the nurse to conclude that hearing aids would be helpful for a client with hearing loss? | The client had chronic middle ear infections during childhood |
| The nurse is caring for a newly deaf client who is learning to read lips. Which client statement indicates that additional teaching is needed? | After I practice lip reading for a while, I won't need to worry about using sign language any more. |
| The nurse teaches a client's wife how to administer eardrops to the client. Which statement by the client's wife indicates that additional teaching is needed? | I will have my husband lay on his back with his chin up when I give him the eardrops. |
| The nurse is caring for a client with otitis media. The client reports that the pain was severe during the night but was gone when he woke up in the morning. Which finding will the nurse expect to find during the client's physical assessment? | Purulent fluid is present in the ear canal. |
| The nurse is caring for a client with otitis media and notes purulent drainage in the ear canal during the physical assessment . Which is the nurse's priority intervention? | Gently examining the client's ear with an otoscope. |
| The nurse is caring for a client with Meniere's disease. The client asks the nurse how to prevent another acute episode from occurring again. Which is the nurse's best response? | Stop or reduce smoking |
| The nurse has given a community group a presentation on eye health. Which statement by the participant indicates a need for more instruction? | I always lose my sunglasses, so I don't wear them. |
| The nurse reads on a client's chart that the client has exophthalmos. What assessment finding is consistent with this diagnosis? | Bulging eyes |
| A client's chart indicates anisocoria. For what should the nurse assess? | Difference in pupil size. |
| A client presents to the emergency department reporting a foreign body in the eye. For what diagnostic testing should the nurse prepare the client? | Corneal staining |
| A nurse who is applying eyedrops to a client holds pressure against the corner of the eye nearest the nose after instilling the drops. The client asks what the nurse is doing. What response by the nurse is best? | This prevents systemic absorption |
| The nurse is administering eyedrops to a client with infection in right eye. The drops go in both eyes, & two different bottles are used to administer the drops. The nurse uses the left eye bottle for the right eye. What action by the nurse is best? | Obtain a new bottle of eye drops |
| What is the provider assessing when using Ishihara chart? | Color vision |
| The student learning about vision should remember which facts related to the eyes? | Aqueous humor controls intraocular pressure. Glaucoma occurs due to increased pressure in the eye. Muscles of the iris control light entering the eye. Rods work in low light conditions. |
| The nursing student studying the eye learns that which cranial nerves control its functions? | II, III, VI |
| The nursing student learns that age-related changes affect the eyes and vision. Which changes does this include? (SATA) | Decreased eye muscle tone Development of arcus senilis Decrease in general color perception Increase in point of near vision |
| A nurse is teaching a client about ear hygiene and health. What client statement indicates a need for further teaching? | A soft cotton swab is alright to clean my ears with. |
| The student nurse is performing a weber tuning fork test. What technique is most important? | Placing the vibrating fork in the middle of the client's head. |
| The client's chart indicates a sensorineural hearing loss. What assessment question does the nurse ask to determine the possible cause? | Have you been exposed to loud noises? |
| The nurse works with clients who have hearing problems. Which action by a client best indicates goals for an important diagnosis have been met? | Being active in community events and volunteer work. |
| A client has external otitis. On what comfort measure does the nurse instruct the client? | Use of a heating pad to the ear. |
| An older adult in the family practice clinic reports a decrease in hearing over a week, What action by the nurse is most appropriate? | Assess for cerumen buildup. |
| A client had myringotomy. The nurse provides which discharge teaching? | Buy dry shampoo to use for a week. |
| A client is going on a cruise but has had motion sickness in the past. What suggestion does the nurse make to this client? | Try scopolamine (transdermal) |
| A nurse is teaching a community group about noise-induced hearing loss. Which client who does not use ear protection should the nurse refer to an audiologist as the priority? | Client who is a tree-trimmer and uses a chainsaw 6 to 7 hours a day. |
| A nursing student is instructed to remove a client's ear packing and instill eardrops. What action by the student requires intervention by the registered nurse? | Washing hands and removing packing. |
| A nurse is irrigating a client's ear when the client becomes nauseated. What action by the nurse is most appropriate for the client comfort? | Stop the irrigation immediately |
| A client hospitalized for a wound infection has a blood urea nitrogen of 45mg/dl and creatinine of 4.2 mg/dl. What action by the nurse is best? | Assess the ordered antibiotics for ototoxicity. |
| A nurse is teaching a community group about preventing hearing loss. What instruction is best? | Always wear a bicycle helmet. |
| A client has severe tinnitus that cannot be treated adequately. What action by the nurse is best? | Refer the client to online or local support groups. |
| A client has labyrinthitis and is prescribed antibiotics. What instruction by the nurse is most important for this client? | Immediately report headache or stiff neck. |
| A client with Meniere's disease is in the hospital when the client has an attack of this disorder. What action by the nurse takes priority? | Place the client in bed with the upper side rails up. |
| A client is scheduled to have a tumor of the middle ear removed. What teaching topic is most important for the nurse to cover? | Expecting hearing loss in the affected ear. |
| What would you do for a chemical injury to eye. | Test for pH using litmus paper. |
| Presbycusis | Sensorineural hearing loss that occurs with aging. |
| What is the diet for clients with Meniere's disease? | Low-sodium diet |
| Mastoiditis S/S | Headache Swelling directly behind the ear red and immobile tympanic membrane |
Created by:
latarshamiller