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Medical Surgical Nursing - CH 46 Test 2

A spry 77-year-old female patient has been diagnosed with simple glaucoma. She lives alone, takes medications for asthma, is on a fixed income, and walks to Catholic Mass on Sunday mornings. The nurse must be certain that the ophthalmologist is aware of which of the aforementioned facts about the patient?

Lives alone.
Takes medications for asthma.
Lives on a fixed income.
Walks to Catholic Mass on Sundays.

Takes medications for asthma.

Rationale: Living alone and a fixed income should be concerns addressed through a Social Services consultation. The patient could be listed on a clergy visit list if hospitalized. Most importantly, the nurse wants to be certain that the patient takes medications for asthma because beta-adrenergic blockers are used topically to treat glaucoma. In asthmatic patients, beta-adrenergic blockers can cause bronchospasm, and are contraindicated

The patient is in the preoperative holding area, having been brought to surgery from the Emergency Department because of a detached retina. The tear has occurred in the right posterior aspect of the retina. The nurse places the patient in which of the following positions?

At a 45-degree angle (semi-Fowler's position)
At a 90-degree angle (high Fowler's position)


Rationale: The patient's head is positioned so that gravity pulls the detached portion of the retina into closer contact with the choroid. In this example, the patient's head should be flat and turned slightly to the right.

Which of the following aspects for health teaching regarding acute and chronic conjunctivitis is the most important information to be emphasized to a group of preschool parents?

Preventable cause of blindness
Importance of early medical diagnosis
Mode of transmission
Pain management

Mode of transmission

Rationale: The nurse should emphasize to the group ways to prevent the transmission of the infection. Conjunctivitis is highly contagious, and can be transmitted by direct contact with contaminated fomites (e.g., hands, tissues, towels, pillow cases), and some forms can be transmitted to an infant during vaginal delivery. Prevention is the most important aspect of conjunctivitis to be communicated to the group. Pain with acute conjunctivitis is not common.

Which of the following statements by a patient with newly prescribed contact lenses indicates a need for additional teaching?

"I think it is so cool that my best friend, Taylor, and I have the same prescription. She has blue lenses and I have brown lenses, so we'll be able to trade to see what we would look like with different eyes."

"If I run out of cleaning and wetting solution, I'll have to wait until I get a new supply before I'll be able to wear my lenses again."

"I'll follow the manufacturer's guide to tell me when I need to take them out."

"If I have eye redness or pain in my eyes, I'll take out my lenses and call the ophthalmologist first thing."

"I think it is so cool that my best friend, Taylor, and I have the same prescription. She has blue lenses and I have brown lenses, so we'll be able to trade to see what we would look like with different eyes."

Rationale: Manufacturer's recommendations indicate to the wearer proper length of time for wear, cleaning, and storing. Patients are instructed to use cleaning and wetting solutions recommended by the optometrist, ophthalmologist, or lens manufacturer. Patients are instructed not to use water or homemade solutions for wetting or cleaning lenses. If eye redness, tearing, vision loss, or pain occurs, the patient should remove the lenses and contact the eye care professional as soon as possible. Lenses should not be shared or "tried on" by another person.

The nurse providing postoperative teaching for a patient who has undergone LASIK surgery advises the patient to contact the office if he experiences:

Dry eyes.
Undercorrection of visual acuity.
Decreased night vision with halos.
Drainage from the eye.

Drainage from the eye.

Rationale: Following surgery, patients can experience a temporary loss of sharpness, over- or undercorrection of visual acuity, dry eyes, or temporarily decreased night vision with halos, glare, and starbursts. Bleeding or drainage could indicate a surgical complication, and should be reported immediately.

The nurse's first action for a patient who presents to the Emergency Department with manifestations of corneal perforation is to:

Contact the patient's ophthalmologist.
Place the patient in a supine position.
Cover the eye with gauze.
Administer tears for dry eyes.

Place the patient in a supine position.

Rationale: If corneal perforation is suspected, the nurse should first place the patient in the supine position, then close the eye, and cover it with a dry, sterile dressing. Thereafter, the nurse should notify either the patient's ophthalmologist or an on-call ophthalmologist to see the patient. The complications of corneal perforation include infection of deep eye structures and loss of ocular contents. Nothing should be placed in the eye.

The 77-year-old male smoker has developed cataracts on both eyes, and is awaiting surgery. The cataracts have prevented the patient from driving, reading, and seeing television. Which of the following statements would be appropriate for the nurse in the preoperative holding area to communicate to the patient?

"Did your eye doctor explain to you that you could choose to use eye drops six times a day to dissolve the cataract?"
"You are wise to have both eyes done at the same time."
"If you were a non-smoker, you would never have developed cataracts."
"Most patients undergoing cataract surgery do well and enjoy the improved vision."

"Most patients undergoing cataract surgery do well and enjoy the improved vision."

Rationale: Surgical removal is the only treatment used at this time for cataracts; no medical treatment is available to prevent or treat them. Surgical removal of the cataract and lens is indicated when the cataract has developed to the point that vision and activities of daily living are affected. If the patient presents with bilateral cataracts, surgery is only performed on one eye at a time. Complications from cataract surgery are unusual, and occur in less than 1% of the surgeries.

The patient with glaucoma has been prescribed travoprost (Travatan), a prostaglandin analog, to improve the outflow of aqueous humor and reduce ocular pressure. Of the following signs or symptoms, which will the nurse teach the patient to report immediately to the eye doctor?

Burning in the eye when the eye drops are used
Tearing in the eye when the eye drops are used
Changes in the color of the eyes
Intolerable pain in the eyes after the drops are used

Intolerable pain in the eyes after the drops are used

Rationale: Prostaglandin analogs have some adverse effects, such as blurred vision and stinging, and, when used long-term, cause permanent darkening of the iris of the eye and eyebrows, increased growth of eyelashes, and conjunctival redness.

Which of the following physical assessment maneuvers will allow the nurse to differentiate the ear pain of a patient with otitis externa from the ear pain of a patient with otitis media?

Manipulation of the auricle
Irrigating the ear canal with cool water
Rinne and Weber tests
Whisper test

Manipulation of the auricle

Rationale: The pain of otitis externa can be differentiated from that associated with otitis media by the manipulation of the auricle. In external otitis, this maneuver increases pain, whereas the patient with otitis media experiences no change in pain perception. Rinne and Weber tests are used to diagnose sensorineural hearing loss. The caloric test (irrigation with cool water) evaluates vestibulo-ocular reflex. The whisper test evaluates hearing loss.

Which of the following nursing diagnoses is the priority diagnosis for a patient with Ménière's disease?

Disturbed Sensory Perception: Auditory
Disturbed Sleep Pattern
Risk for Trauma
Social Isolation

Risk for Trauma

Rationale: The risk for trauma in patients with inner ear disorders, such as Ménière's disease, is great. Disturbed Sensory Perception: Auditory is a priority nursing diagnosis for patients with hearing loss. Sleep Pattern Disturbance is a priority nursing diagnosis for patients with tinnitus. Risk for Trauma is the priority nursing diagnosis for patients with inner ear disturbances causing balance disorders. Social Isolation is a priority diagnosis for patients with otosclerosis or presbycusis.

Which of the following suggestions should be taught by the nurse to the patient with tinnitus to assist the patient with coping with the symptom to promote concentration and sleep?

Sleeping medication
Hearing aid that produces a tone to mask tinnitus
Bedtime use of nasal decongestant spray

Hearing aid that produces a tone to mask tinnitus

Rationale: Options for masking tinnitus to promote concentrate and sleep include ambient noise from a radio or sound system; masking device or white noise machine; hearing aid that produces a tone to mask the tinnitus; and hearing aid that amplifies ambient sound. Earplugs will focus the patient's attention on the sound. The patient's issue is the noise, not a sleeping disorder; hence, sleeping medications are not indicated. The tinnitus is a result of neurosensory damage, not of congestion.

The public health nurse is preparing to teach the members of the local swim club about care of the ears. Which of the following statements would be appropriate for the nurse to include?

Use a clean cotton swab to dry the ear canal after swimming.
A tight-fitting swim cap is preferred to earplugs for keeping water out of the ear.
If there is debris in the ear canal, irrigate the ear with cold water.
After an episode of acute inflammation, the swimmer should wait 7-10 days before returning to the water.

After an episode of acute inflammation, the swimmer should wait 7-10 days before returning to the water.

Rationale: Guidelines include: Stay out of the water until the acute inflammatory process is completely resolved-ideally, 7-10 days before resuming water activities; and use silicone earplugs, and dry the outer ear with a towel, then use a hair dryer on the lowest setting several inches from the ear to dry the canal. Do not insert cotton swabs or other objects into the ear canal to dry it. A tight-fitting swim cap does not keep water out of the ear. Repeated exposure to cold water encourages the growth of exostoses in the ear canal.

A preschool-age child is undergoing bilateral myringotomy with tubes for the treatment of recurrent otitis media. The mother asks the nurse what the tubes will do. The nurse's best response is that the tubes will:

Provide for drainage.
Prevent future episodes of otitis media.
Equalize pressures between the middle ear and the environment.
Prevent the spread of infection to the mastoid bone.

Equalize pressures between the middle ear and the environment.

Rationale: Myringotomy (an incision of the tympanic membrane) is performed to relieve pressure caused by the edema and swelling of otitis media, which impairs the eustachian tubes' ability to equalize pressures between the middle ear and the environment. Without relief of pressure, the tympanic membrane can rupture, the delicate structures of the middle ear can be damaged, and infection can spread to adjoining tissues and structures. Infection can still occur and spread despite myringotomy.

When the patient who has undergone cataract extraction is preparing to go home, the nurse reinforces which of the following instructions?

Remove the dressing at bedtime.

A headache for the first few days after surgery should be expected.

Avoid sleeping on the operative side.

Set a new appointment with the surgeon for 1 month from today.

Avoid sleeping on the operative side.

Rationale: The nurse should reinforce any limitation, such as avoiding reading, lifting, and strenuous activity, and sleeping on the operative side. The patient also needs to understand the importance of not disturbing the eye dressing, of follow-up appointments, and of manifestations of complications such as eye pain, change in vision, headache, or nausea.

When the visiting nurse is teaching the family of a patient with acute conjunctivitis regarding the disease process, the nurse emphasizes which of the following statements as most important?

Wash hands before and after instilling eye drops.
Cleanse the patient's contact lenses twice each day.
Ask patient to gently rub eyes to circulate the eye drops after instillation.
Use a cotton-tipped swab to cleanse the right eye and then the left eye.

Wash hands before and after instilling eye drops.

Rationale: Acute conjunctivitis is highly contagious. Teach the family to wash hands thoroughly before and after instilling eye medication. Contact lens use should be avoided until the infection has cleared. Rubbing the eyes increases the risk of corneal trauma. Using a new swab between eyes prevents cross-contamination.

The nurse is caring for a patient who has a hearing deficit. Which of the following techniques should be implemented by the nurse to improve communication? (Select all that apply.)

Keep the patient's face in full light.
Use a low voice pitch with normal loudness.
Speak at a slower rate than usual.
Use short sentences.

Use a low voice pitch with normal loudness.

Use short sentences.

Rationale: Techniques to improve communication with a patient with a hearing loss include keeping one's face in full light-placing light in the patient's face will prevent patient from seeing the speaker; using a low voice pitch with normal loudness; speaking at a normal rate, and not overarticulating; and using short sentences, and pausing at the end of each sentence.

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