Saunders – Adult Health
Section 1: Eye and Ear (106 questions)
1. A client is diagnosed with glaucoma. Which piece of nursing assessment
data identifies a risk factor associated with this eye disorder?
a. Cardiovascular disease - Hypertension, cardiovascular disease,
diabetes mellitus, and obesity are associated with the development of
glaucoma.
b. Frequent urinary tract infections
c. A history of migraine headaches
d. Frequent upper respiratory infections
2. The nurse is performing an otoscopic examination on a client with
mastoiditis. On examination of the tympanic membrane, which finding
would the nurse expect to observe?
a. A pink-colored tympanic membrane
b. A pearly colored tympanic membrane
c. A transparent and clear tympanic membrane
d. A red, dull, thick, and immobile tympanic membrane - Otoscopic
examination in a client with mastoiditis reveals a red, dull, thick, and
immobile tympanic membrane, with or without perforation.
Postauricular lymph nodes are tender and enlarged. Clients also have
a low-grade fever, malaise, anorexia, swelling behind the ear, and
pain with minimal movement of the head. A normal tympanic
membrane is pearly gray, intact, with a positive cone of light reflex.
3. A client is diagnosed with a disorder involving the inner ear. Which is
the most common client complaint associated with a disorder involving
this part of the ear?
a. Pruritus
b. Tinnitus - Tinnitus is the most common complaint of clients with
otological disorders, especially disorders involving the inner ear.
Symptoms of tinnitus range from mild ringing in the ear, which can
go unnoticed during the day, to a loud roaring in the ear, which can
interfere with the client's thinking process and attention span.
c. Hearing loss
d. Burning in the ear
,4. The nurse notes that the primary health care provider has documented a
diagnosis of presbycusis on a client's chart. Based on this information,
what action would the nurse take?
a. Speak loudly, but mumble or slur the words.
b. Speak loudly and clearly while facing the client.
c. Speak loudly and directly into the client's affected ear.
d. Speak at normal tone and pitch, slowly and clearly. - Presbycusis is a
type of hearing loss that occurs with aging. Presbycusis is a gradual
sensorineural loss caused by nerve degeneration in the inner ear or
auditory nerve. When communicating with a client with this
condition, the nurse would speak at a normal tone and pitch, slowly
and clearly.
5. A client with Ménière's disease is experiencing severe vertigo. Which
instruction would the nurse give to the client to assist in controlling the
vertigo?
a. Increase sodium in the diet.
b. Avoid sudden head movements. - The nurse instructs the client to
make slow head movements to prevent worsening of the vertigo.
Dietary changes such as salt and fluid restrictions that reduce the
amount of endolymphatic fluid are sometimes prescribed. Lying still
and watching television will not control vertigo.
c. Lie still and watch the television.
d. Increase fluid intake to 3000 mL a day.
6. The nurse is caring for a hearing-impaired client. Which approach will
facilitate communication?
a. Speak loudly.
b. Speak frequently.
c. Speak at a normal volume. - Speaking in a normal tone to the client
with impaired hearing and not shouting are important. The nurse
would talk directly to the client while facing the client and speak
clearly. If the client does not seem to understand what is said, the
nurse would express it differently. Moving closer to the client and
toward the better ear may facilitate communication, but the nurse
would avoid talking directly into the impaired ear.
d. Speak directly into the impaired ear.
7. The nurse is developing a teaching plan for a client with glaucoma.
Which instruction would the nurse include in the plan of care?
, a. Avoid overuse of the eyes.
b. Decrease the amount of salt in the diet.
c. Eye medications will need to be administered for life. - The
administration of eye drops is a critical component of the treatment
plan for the client with glaucoma. The client needs to be instructed
that medications will need to be taken for the rest of their life.
d. Decrease fluid intake to control the intraocular pressure.
8. The nurse is performing an assessment on a client with a suspected
diagnosis of cataract. Which clinical manifestation would the nurse
expect to note in the early stages of cataract formation?
a. Diplopia
b. Eye pain
c. Floating spots
d. Blurred vision - A gradual, painless blurring of central vision is the
chief clinical manifestation of a cataract. Early symptoms include
slightly blurred vision and a decrease in color perception.
9. The nurse is preparing a teaching plan for a client who had a cataract
extraction with intraocular implantation. Which home care measures
would the nurse include in the plan? Select all that apply.
a. Avoid activities that require bending over.
b. Contact the surgeon if eye scratchiness occurs.
c. Take acetaminophen for minor eye discomfort.
d. Expect episodes of sudden severe pain in the eye.
e. Place an eye shield on the surgical eye at bedtime.
f. Contact the surgeon if a decrease in visual acuity occurs.
Following eye surgery, some scratchiness and mild eye discomfort may
occur in the operative eye; these are usually relieved by mild analgesics. If
the eye pain becomes severe, the client needs to notify the surgeon because
this may indicate hemorrhage, infection, or increased intraocular pressure
(IOP). The nurse also would instruct the client to notify the surgeon of
increased purulent drainage, increased redness, or any decrease in visual
acuity. The client is instructed to place an eye shield over the operative eye
at bedtime to protect the eye from injury during sleep and to avoid activities
that increase IOP, such as bending over.
, 10. A client's vision is tested with a Snellen chart. The results of the tests are
documented as 20/60. What action would the nurse implement based on
this finding?
a. Provide the client with materials on legal blindness. – this is not
considered to be legal blindness
b. Instruct the client about the need glasses when driving. - A client
with a visual acuity of 20/60 can only read at a distance of 20 feet (6
meters) what a person with normal vision can read at 60 feet (18
meters). With this vision, the client may need glasses while driving in
order to read signs and to see far ahead.
c. Inform the client of where a white cane with a red tip can be
purchased.
d. Inform the client that it is best to sit near the back of the room when
attending conferences and lectures.
11. A client with retinal detachment is admitted to the nursing unit in
preparation for a repair procedure. Which prescription would the nurse
anticipate?
a. Allowing bathroom privileges only
b. Elevating the head of the bed to 45 degrees
c. Wearing dark glasses to read or watch television
d. Placing an eye patch over the client's affected eye – remember that
the eye needs to be protected and rested
The nurse places an eye patch over the client's affected eye to reduce eye
movement. Some clients may need bilateral patching. Depending on the
location and size of the retinal break, activity restrictions may be needed
immediately. These restrictions are necessary to prevent further tearing or
detachment and to promote drainage of any subretinal fluid. Therefore,
reading and watching television are not allowed. The client's position is
prescribed by the primary health care provider; normally, the prescription is
to lie flat.
12. The nurse is caring for a client who was recently diagnosed with
primary open-angle glaucoma (POAG). Which assessment finding is
specific to this type of glaucoma?
a. Client report of blurred vision – this is from primary angle-CLOSURE
glaucoma
b. Client report of "tunnel vision"
Section 1: Eye and Ear (106 questions)
1. A client is diagnosed with glaucoma. Which piece of nursing assessment
data identifies a risk factor associated with this eye disorder?
a. Cardiovascular disease - Hypertension, cardiovascular disease,
diabetes mellitus, and obesity are associated with the development of
glaucoma.
b. Frequent urinary tract infections
c. A history of migraine headaches
d. Frequent upper respiratory infections
2. The nurse is performing an otoscopic examination on a client with
mastoiditis. On examination of the tympanic membrane, which finding
would the nurse expect to observe?
a. A pink-colored tympanic membrane
b. A pearly colored tympanic membrane
c. A transparent and clear tympanic membrane
d. A red, dull, thick, and immobile tympanic membrane - Otoscopic
examination in a client with mastoiditis reveals a red, dull, thick, and
immobile tympanic membrane, with or without perforation.
Postauricular lymph nodes are tender and enlarged. Clients also have
a low-grade fever, malaise, anorexia, swelling behind the ear, and
pain with minimal movement of the head. A normal tympanic
membrane is pearly gray, intact, with a positive cone of light reflex.
3. A client is diagnosed with a disorder involving the inner ear. Which is
the most common client complaint associated with a disorder involving
this part of the ear?
a. Pruritus
b. Tinnitus - Tinnitus is the most common complaint of clients with
otological disorders, especially disorders involving the inner ear.
Symptoms of tinnitus range from mild ringing in the ear, which can
go unnoticed during the day, to a loud roaring in the ear, which can
interfere with the client's thinking process and attention span.
c. Hearing loss
d. Burning in the ear
,4. The nurse notes that the primary health care provider has documented a
diagnosis of presbycusis on a client's chart. Based on this information,
what action would the nurse take?
a. Speak loudly, but mumble or slur the words.
b. Speak loudly and clearly while facing the client.
c. Speak loudly and directly into the client's affected ear.
d. Speak at normal tone and pitch, slowly and clearly. - Presbycusis is a
type of hearing loss that occurs with aging. Presbycusis is a gradual
sensorineural loss caused by nerve degeneration in the inner ear or
auditory nerve. When communicating with a client with this
condition, the nurse would speak at a normal tone and pitch, slowly
and clearly.
5. A client with Ménière's disease is experiencing severe vertigo. Which
instruction would the nurse give to the client to assist in controlling the
vertigo?
a. Increase sodium in the diet.
b. Avoid sudden head movements. - The nurse instructs the client to
make slow head movements to prevent worsening of the vertigo.
Dietary changes such as salt and fluid restrictions that reduce the
amount of endolymphatic fluid are sometimes prescribed. Lying still
and watching television will not control vertigo.
c. Lie still and watch the television.
d. Increase fluid intake to 3000 mL a day.
6. The nurse is caring for a hearing-impaired client. Which approach will
facilitate communication?
a. Speak loudly.
b. Speak frequently.
c. Speak at a normal volume. - Speaking in a normal tone to the client
with impaired hearing and not shouting are important. The nurse
would talk directly to the client while facing the client and speak
clearly. If the client does not seem to understand what is said, the
nurse would express it differently. Moving closer to the client and
toward the better ear may facilitate communication, but the nurse
would avoid talking directly into the impaired ear.
d. Speak directly into the impaired ear.
7. The nurse is developing a teaching plan for a client with glaucoma.
Which instruction would the nurse include in the plan of care?
, a. Avoid overuse of the eyes.
b. Decrease the amount of salt in the diet.
c. Eye medications will need to be administered for life. - The
administration of eye drops is a critical component of the treatment
plan for the client with glaucoma. The client needs to be instructed
that medications will need to be taken for the rest of their life.
d. Decrease fluid intake to control the intraocular pressure.
8. The nurse is performing an assessment on a client with a suspected
diagnosis of cataract. Which clinical manifestation would the nurse
expect to note in the early stages of cataract formation?
a. Diplopia
b. Eye pain
c. Floating spots
d. Blurred vision - A gradual, painless blurring of central vision is the
chief clinical manifestation of a cataract. Early symptoms include
slightly blurred vision and a decrease in color perception.
9. The nurse is preparing a teaching plan for a client who had a cataract
extraction with intraocular implantation. Which home care measures
would the nurse include in the plan? Select all that apply.
a. Avoid activities that require bending over.
b. Contact the surgeon if eye scratchiness occurs.
c. Take acetaminophen for minor eye discomfort.
d. Expect episodes of sudden severe pain in the eye.
e. Place an eye shield on the surgical eye at bedtime.
f. Contact the surgeon if a decrease in visual acuity occurs.
Following eye surgery, some scratchiness and mild eye discomfort may
occur in the operative eye; these are usually relieved by mild analgesics. If
the eye pain becomes severe, the client needs to notify the surgeon because
this may indicate hemorrhage, infection, or increased intraocular pressure
(IOP). The nurse also would instruct the client to notify the surgeon of
increased purulent drainage, increased redness, or any decrease in visual
acuity. The client is instructed to place an eye shield over the operative eye
at bedtime to protect the eye from injury during sleep and to avoid activities
that increase IOP, such as bending over.
, 10. A client's vision is tested with a Snellen chart. The results of the tests are
documented as 20/60. What action would the nurse implement based on
this finding?
a. Provide the client with materials on legal blindness. – this is not
considered to be legal blindness
b. Instruct the client about the need glasses when driving. - A client
with a visual acuity of 20/60 can only read at a distance of 20 feet (6
meters) what a person with normal vision can read at 60 feet (18
meters). With this vision, the client may need glasses while driving in
order to read signs and to see far ahead.
c. Inform the client of where a white cane with a red tip can be
purchased.
d. Inform the client that it is best to sit near the back of the room when
attending conferences and lectures.
11. A client with retinal detachment is admitted to the nursing unit in
preparation for a repair procedure. Which prescription would the nurse
anticipate?
a. Allowing bathroom privileges only
b. Elevating the head of the bed to 45 degrees
c. Wearing dark glasses to read or watch television
d. Placing an eye patch over the client's affected eye – remember that
the eye needs to be protected and rested
The nurse places an eye patch over the client's affected eye to reduce eye
movement. Some clients may need bilateral patching. Depending on the
location and size of the retinal break, activity restrictions may be needed
immediately. These restrictions are necessary to prevent further tearing or
detachment and to promote drainage of any subretinal fluid. Therefore,
reading and watching television are not allowed. The client's position is
prescribed by the primary health care provider; normally, the prescription is
to lie flat.
12. The nurse is caring for a client who was recently diagnosed with
primary open-angle glaucoma (POAG). Which assessment finding is
specific to this type of glaucoma?
a. Client report of blurred vision – this is from primary angle-CLOSURE
glaucoma
b. Client report of "tunnel vision"
