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Saunders NCLEX-PN Comprehensive Review Leave the first rating Students also studied Terms in this set (8) Science MedicineNursing Save Saunders Quiz Ch 56 Eye and Ear Pr...12 terms ppruchaPreview Eye Nclex review 106 terms Jazzma_Jemison Preview Saunder's Comprehensive NCLEX R...214 terms CaseyWard123 Preview Exam 3 47 terms jess A client arrives in the emergency department after an automobile crash. The client's forehead hit the steering wheel, and a hyphema has been diagnosed. Which position should the nurse prepare to position the client?
- Flat on bed rest
- On bed rest in a semi-Fowler's position
- In lateral position on the unaffected side
- In the lateral position on the affected side
- Speak loudly.
- Speak frequently.
- Speak in a normal tone.
- Speak directly into the impaired ear.
- Irrigation of the ear
- Instillation of antibiotic eardrops
- Instillation of corticosteroid ointment
- Instillation of mineral oil or diluted alcohol
2; A hyphema is the presence of blood in the anterior chamber. It is produced when a force is sufficient to break the integrity of the blood vessels in the eye. It can be caused by direct injury, such as penetrating injury from a BB pellet, or indirectly, such as from striking the forehead on a steering wheel during an accident. The client is treated by bed rest in a semi-Fowler's position to assist gravity in keeping the hyphema away from the optical center of the cornea.The nurse is caring for a client who is hearing-impaired and should take which approach to facilitate communication?
3; It is important to speak in a normal tone to the client with impaired hearing and avoid shouting. The nurse should talk directly to the client while facing the client and should speak clearly. If the client does not seem to understand what is said, the nurse should express it differently. Moving closer to the client and toward the better ear may facilitate communication, but it is important to avoid talking directly into the impaired ear.A client arrives at the emergency department with a foreign body in the left ear that has been determined to be an insect. Which initial intervention should the nurse anticipate to be prescribed?
4; Insects are killed before removal unless they can be coaxed out by a flashlight or a humming noise. Mineral oil or diluted alcohol is instilled into the ear to suffocate the insect, which is then removed by using ear forceps. When the foreign object is vegetable matter, irrigation is not used because this material expands with hydration and the impaction becomes worse. Options 1, 2, and 3 may be prescribed after the initial treatment if necessary and if inflammation or infection is a concern.
The nurse notes that the health care provider has documented a diagnosis of presbycusis on the client's chart. The nurse understands that this condition is accurately described as which?
- Tinnitus that occurs with aging
- Nystagmus that occurs with aging
- A conductive hearing loss that occurs with aging
- A sensorineural hearing loss that occurs with aging
- Low-fat diet
- Low-sodium diet
- Low-cholesterol diet
- Low-carbohydrate diet
- Cardiovascular disease
- A history of migraine headaches
- Frequent urinary tract infections
- Frequent upper respiratory infections
- Monitoring temperature
- Monitoring blood pressure
- Checking peripheral pulses
- Checking the blood glucose level
- Warm the irrigating solution to 98° F.
- Direct a slow, steady stream of irrigation solution
- Assist the client to turn his or her head so that the ear
4; Presbycusis is a type of hearing loss that occurs with aging. It is a gradual sensorineural loss caused by nerve degeneration in the inner ear or auditory nerve. Options 1, 2, and 3 are not accurate descriptions.The nurse is assigned to care for a client hospitalized with Ménière's disease. The nurse expects that which would most likely be prescribed for the client?
2; Dietary changes such as salt and fluid restrictions that reduce the amount of endolymphatic fluid are sometimes prescribed. Options 1, 3, and 4 are not specific dietary prescriptions for this condition.A client is diagnosed with glaucoma. Which data gathered by the nurse indicate a risk factor associated with glaucoma?
1; Hypertension, cardiovascular disease, diabetes mellitus, and obesity are associated with the development of glaucoma. Smoking, ingestion of caffeine or large amounts of alcohol, illicit drugs, corticosteroids, altered hormone levels, posture, and eye movements may cause varying transient increases in intraocular pressure.Betaxolol hydrochloride (Betoptic) eyedrops have been prescribed for the client with glaucoma. Which nursing action is most appropriate related to monitoring for the side/adverse effects of this medication?
2; Hypotension, dizziness, nausea, diaphoresis, headache, fatigue, constipation, and diarrhea are systemic effects of the medication. Nursing interventions include monitoring the blood pressure for hypotension and assessing the pulse for strength, weakness, irregular rate, and bradycardia. Options 1, 3, and 4 are not specifically associated with this medication.The nurse assists to prepare the client for ear irrigation as prescribed by the health care provider. Which action should the nurse plan to take?
2.Position the client with the affected side up after the irrigation.
toward the eardrum.
to be irrigated is facing upward.1; Irrigation solutions that are not close to the client's body temperature can be uncomfortable and may cause injury, nausea, and vertigo. The client is positioned so that the ear to be irrigated is facing downward, because this allows gravity to assist in the removal of the ear wax and solution. After the irrigation, the client is to lie on the affected side to finish draining the irrigating solution. A slow, steady stream of solution should be directed toward the upper wall of the ear canal and not toward the eardrum. Too much force could cause the tympanic membrane to rupture.
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