Day 2 Senses

1.
During the early postoperative period, a client who has undergone a cataract
extraction complains of nausea and severe eye pain over the operative site.
What should be the initial nursing action?
1. Call the health care provider (HCP).

2. Reassure the client that this is normal.
3. Turn the client onto his or her operative side.
4. Administer the prescribed pain medication and antiemetic.
2. a patient is brought to the recovery room after having cataract surgery. which
action should the nurse immediately perform for this patient?
1. place the patient in a private room
2. position the patient on the affected side
3. place the patient in semi Fowler's position
4. ensure the patient is in proximity to the nurses station
3. a patient is experiencing bright flashing lights throughout the field of vision .

what is the most appropriate response by the nurse?
1. initiate immediate referral to an ophthalmologist
2. advise to make an appointment to have blood pressure checked
3. recommend the patient lie down until the sensation has passed
4. reassure that this is not unusual and should resolve without treatment.
4. An adult male client had undergone surgery for detached retina. Which of the
following nursing interventions should be included in the client’s nursing care
plan?
A. Up in the bed all the time to prevent stasis.
b. Notify the physician for severe pain that does not respond to pain
medication.
c. Bed rest prone with one pillow under the chest.
d. Notify physician if there is feeling of something in the eyes.
5. A 67 years old patient has a detached retina. He asks Nurse what may have
contributed to the development of his detached retina. The nurse’s MOST
appropriate reply is:
A. “Those with cranial terrors are predisposed to retinal detachment.”
B. The most predisposing factor in the development of retinal tear is
nearsightedness.”
C. Sinusitis predisposes a person to retinal detachment.”
D. Persons with hypertension are prone to develop retinal tear.”
6. The nurse is performing an admission assessment on a client with a diagnosis

of detached retina. Which sign or symptom is associated with this eye
disorder?
1. Total loss of vision
2. Pain in the affected eye
3. A yellow discoloration of the sclera
4. A sense of a curtain falling across the field of vision
7. the nurse is instructing a patient with Meniere's disease on ways to prevent

attacks of vertigo and tinnitus. what should the nruse include in this teaching.
select all that apply
1. stop smoking
2. follow a low sodium diet
3. avoid caffeine and alcohol
4. sit down when an attack develops
5. take prescribed anti-emetic medications
8. During a hearing assessment, the nurse notes that the sound lateralizes to the
clients left ear with the Weber test. The nurse analyzes this result as:
1. A normal finding
2. A conductive hearing loss in the right ear
3. A sensorineural or conductive loss
4. The presence of nystagmus
9. The nurse is caring for a client that is hearing impaired. Which of the following
approaches will facilitate communication?
1. Speak frequently
2. Speak loudly
3. Speak directly into the impaired ear
4. Speak in a normal tone
10. The nurse has conducted discharge teaching for a client who had a
fenestration procedure for the treatment of otosclerosis. Which of the following,
if stated by the client, would indicate that teaching was effective?
1. “I should drink liquids through a straw for the next 2-3 weeks.”
2. “It’s ok to take a shower and wash my hair.”
3. “I will take stool softeners as prescribed by my doctor.”
4. “I can resume my tennis lessons starting next week.”
11. A client arrives at the emergency room with a foreign body in the left ear that
has been determined to be an insect. Which intervention would the nurse
anticipate to be prescribed initially?
1. Irrigation of the ear
2. Instillation of diluted alcohol
3. Instillation of antibiotic ear drops
4. Instillation of corticosteroids ear drops
12. The nurse has notes that the physician has a diagnosis of presbycusis on the
client’s chart. The nurse plans care knowing the condition is:
1. A sensorineural hearing loss that occurs with aging

2. A conductive hearing loss that occurs with aging.
3. Tinnitus that occurs with aging
4. Nystagmus that occurs with aging
13. A client with Meniere’s disease is experiencing severe vertigo. Which

instruction would the nurse give to the client to assist in controlling the vertigo?
1. Increase fluid intake to 3000 ml a day

2. Avoid sudden head movements
3. Lie still and watch the television
4. Increase sodium in the diet
14. The nurse is reviewing the physician’s orders for a client with Meniere’s
disease. Which diet will most likely be prescribed?
1. Low-cholesterol diet
2. Low-sodium diet
3. Low-carbohydrate diet
4. Low-fat diet
15. A client is diagnosed with a disorder involving the inner ear. Which of the
following is the most common client complaint associated with a disorder in this
part of the ear?
1. Hearing loss
2. Pruritus
3. Tinnitus
4. Burning of the ear
16. A nurse would question an order to irrigate the ear canal in which of the
following circumstances?
1. Ear pain
2. Hearing loss
3. Otitis externa
4. Perforated tympanic membrane
17. When teaching the client about Meniere’s disease, which of the following
instructions would a nurse give about vertigo?
1. Report dizziness at once

2. Drive in daylight hours only
3. Get up slowly, turning the entire body
4. Change your position using the logroll method
18. Nerve deafness would most likely result from an injury or infection that
damaged the:
1. Vagus nerve
2. Cochlear nerve
3. Vestibular nerve
4. Trigeminal nerve
19. A labyrinthectomy can be performed to treat Meniere’s syndrome. This

procedure results in:
1. Anosmia
2. Absence of pain
3. Reduction in cerumen
4. Permanent irreversible deafness
20. Otosclerosis is a common cause of conductive hearing loss. Which such a

partial hearing loss:
1. Stapedectomy is the procedure of choice

2. Hearing aids usually restore some hearing
3. The client is usually unable to hear bass tones
4. Air conduction is more effective than bone conduction
21. The physician determines that a client's chronic, progressive hearing loss
results from excess bone formation around the oval window, which impedes
normal stapes movement and prevents sound transmission. What is the clinical
term for this correctable middle ear disorder?
A. Stapes immobilization C. Otosclerosis

B. Myringotomy D. Otitis media
22. A client is admitted to the facility for investigation of balance and coordination
problems, including possible Ménière's disease. When assessing this client,
the nurse expects to note:
A. Vertigo, tinnitus, and hearing loss.
B. Vertigo, vomiting, and nystagmus.
C. Vertigo, pain, and hearing impairment.
D. Vertigo, blurred vision, and fever.
23. Which nursing diagnosis takes highest priority for a client admitted for
evaluation for Ménière's disease?
A. Pain related to vertigo
B. Imbalanced nutrition: Less than body requirements related to nausea and
vomiting
C. Risk for deficient fluid volume related to vomiting
D. Risk for injury related to vertigo

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1.

1. Call the health care provider (HCP).

3. a patient is experiencing bright flashing lights throughout the field of vision .

6. The nurse is performing an admission assessment on a client with a diagnosis

7. the nurse is instructing a patient with Meniere's disease on ways to prevent

1. A sensorineural hearing loss that occurs with aging

13. A client with Meniere’s disease is experiencing severe vertigo. Which

1. Increase fluid intake to 3000 ml a day

1. Report dizziness at once

19. A labyrinthectomy can be performed to treat Meniere’s syndrome. This

20. Otosclerosis is a common cause of conductive hearing loss. Which such a

1. Stapedectomy is the procedure of choice

A. Stapes immobilization C. Otosclerosis

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