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NCLEX RN Chapter 60 Eye and Ear
Terms in this set (61)
The internal layer of the eye consists of the _____, a thin, delicate structure in which the fibers of the optic nerve are distributed.
The optic disk is a creamy pink to white depressed area in the retina. The optic nerve enters and exits the eyeball at this area. This area is called the ____ _____ because it contains only _____ fibers, lacks photoreceptor cells, and is insensitive to light.
The macula lutea is a small, oval, yellowish-pink area located lateral and temporal to the optic disc. The central depressed part of the macula is the ______ ____, the area of sharpest and keenest vision, where most acute vision occurs.
________ is the thin, transparent mucous membrane of the eye that lines the posterior surface of each eyelid and is lkocated over the sclera.
Which four nerves help with sight and which nerve is the "nerve of sight"
II: Optic (nerve of sight)
Before doing diagnostic tests for the eye, you should check the client for allergies and previous reactions to ______.
Corneal ______: a topical dye is instilled into the conjunctival sac to outline irregularities of the corneal surface that are not easily visible.
This test is used primarily to assess for an increase of intraocular pressure and potential glaucoma.
NOrmal intraocular pressure is ____ to ___mmHg. Intraocular pressure varies throught the day is is normally higher in the _____. Always document the time of intraocular measurement.
Patients who are legally blind: when speaking to the client who has limited sight or is blind, the nurse uses a _______ tone of voice.
Data collection for cataracts: ______ vision and decreased _____ perception are early signs.
Postoperative interventions for cataract surgery: should side rails be used?
-yes, for safety following agency policies
Glaucoma: ______ pressure is the fluid (aqueous humor) pressure within the eye. (Normal pressure is 10-21 mmHg)
Primary open-angle glaucoma: is it painful or painless? vision changes occur rapidly or slowly? This results in _______ vision.
-(chronic) Open angle glaucoma: caused by partial blockage of the drainage canal. The angle between the cornea and iris is open meaning the entrance to the drain is clear but the flow of aqueous humor is somewhat slowed. The pressure builds up slowly over a long period. Peripheral vision is lost first and progresses to central vision loss.
Acute angle-closure glaucoma is a medical emergency that causes sudden eye ____ and possible ______ and _____.
(acute) Angle Closure Glaucoma: is caused by a sudden and complete blockage of aqueous humor drainage. The pressure within the eye rises rapidly and may lead to total vision loss quickly. Angle between the iris and cornea is blocked completely
Chronic glaucoma: reinforce instructions to the client on the need for lifelong ________ use.
The following is data collection for what?:
flashes of light, floaters or black spots, increase in blurred vision, sense of curtain being drawn over the eye, loss of a portion of the visual field
Immediate inerventions for retinal detachment: provide ____ _____ (where patient is placed). Cover both eyes with _____ as prescribed to prevent further detachment.
Postoperative interventions for retinal detachment surgery: maintain eye ____(object) as prescribed. Monitor for ______.
Macular _______ is a deterioration of the macula, the area of ______ vision.
Occular ________: most common malignant eye tumor in adults. Tumor usually found in the uveal tract and can spread easily because of rich blood supply.
Enucleation is the removal of the entire _____. Exenteration is the removal of the ____ and surrounding tissues and bone.
Postoperative interventions for patient who has undergone enucleation and/or exenteration: report changes in ______ _____ or the presence of _______ _______ drainage on the pressure patch or dressing.
Hyphema is the presence of _______ in the anterior chamber that occurs as a result of an injury.
Interventions for hyphema: encourage rest with the client in ______ ______ position
For contusions (bleeding into the soft tissue as a result of an injury) place ______ on the eye immediately. Reinforce instructions to the client to receive a thorough eye ________.
Foreign bodies (dust or dirt in the eye): have the client look upward, expose the ______ lid, wet a cotton-tipped applicator with sterile _____ ____, and gently twist the swab over the particle, and remove it.
When an object has penetrated the eye, should you remove it? why or why not?
no, it may be holding ocular structures in place. The object must be removed by the HCP.
When an object has penetrated the eye, you should cover the object with what?
Steps for when someone has a chemical injury to the eye(s), _______ the eye, check the ____ of the eye, assess visual _____, document the event, actions taken, and the ________ response.
If a chemical splash to the eye occurs, treatment should begin immediately. Immediately flush the eyes at the scene of the injury with water for at least _____-____ minutes.
Preoperative care to the reipient of the cornea: recipient may be told of the tissue (cornea) availability only _____ hours to ____ day(s) before the surgery.
Postoperative care to the recipient of an eye: the eye is covered with a ______ _____ and protective shield that is left in place for ____ day(s) as prescribed.
Graft rejection of eyeball: the acronym to remember signs for a graft rejection are RSVP. What does each letter stand for?
The ear: the _____ cranial nerve: the _____ branch of the nerve transmits neuroimpulses from the cochlea to the brain, where they are interpreted as sound.
The middle ear is filled with _____, which is kept at atmospheric pressure by the opening of the auditory _____.
________ measures hearing acuity. It uses two types: pure tone and speech.
___________ hearing loss occurs when sound waves are blocked to the inner ear fibers because of external ear or middle ear disorders.
_____ _____ are used for sensorineural hearing loss. A small computer converts sound waves into electrical impulses.
_____ _____ are used for clients with conductive hearing loss. They have limited value for the client with sensorineural hearing loss, because they only make sounds louder, not clearer.
________ is sensorineural hearing loss associated with aging.
Presbicusis: hearing loss is gradual and _______ (happens in one ear at a time or both?). The client states that he or she has no problem with ______ but cannot understand what the _____ are.
Chronic ____ _____ is a chronic infective, inflammatory, or allergic response involving the structure of the middle ear.
Monitor the client with otitis media closely for response to treatment. Otic and systemic ______ may be used to treat the infection, but often the organism is resistant.
Postoperative interventions for ear surgery: inform the client that initial hearing after surgery is diminished because of the _____ in the ear canal and that hearing improvement will occur after this is removed.
The following is data collection for what?: feelings of fullness in the ear. Tinnitus, as a continuous low-pitched roar or humming sound, that is present much of the time but worsens just before and during severe attacks. Hearing loss that is worse during an attack. Vertigo, as periods of whirling, that might cause the client to fall to the ground.
________ may be acute or chronic and results from untreated or inadequately treated chronic or acute otitis media.
Swelling behind the ear and pain with minimal movement of the head. Cellulitis on the skin or external scalp over the mastoid process. A reddened, dull, thick, immobile tympanic membrane with or without perforation are all data collection for what?
_______ is a disease of the labyrinthine capsule of the middle ear that results in a bony overgrowth of the tissue surrounding the ossicles. This causes development of irregular areas of new bone formation and causes the fixation of the bones. Stapes fixation leads to a conductive hearing loss.
Fenestration is removal of the _____, with a small hole drilled in the footplate; a prosthesis is connected between the incus and footplate.
Fenestration postoperative interventions: inform the client that hearing is initially worse after the surgical procedure because of ________ and that no noticeable improvement in hearing may occur for as long as ____ weeks.
______ syndrome is also called endolymphatic hydrops and refers to dilation of the endolymphatic system by overproduction or decreased reabsorption of endolymphatic fluid. This syndrome is characterized by tinnitus, unilateral sensorineural hearing loss, and vertigo.
A priority nursing intervention in the care of a client with Meniere's syndrome is instituting ______ measures.
Acoustic neuroma is a benign tumor of the vestibular or acoustic nerve. Symptoms usually begin with _____ and progress to gradual ______ hearing loss.
Trauma: the tympanic membrane has a limited ______ ability and gives way under high _____.
Tympanic membrane perforations usually heal within _____ hours.
Cerumen and foreign bodies: the maximal amount of solution that should be used for irrigation is ___ to ____ mL.
Inform the client that ear candles should never be used to remove cerumen. Their use can cause ____ and a ____ effect, causing a perforation in the tympanic membrane.
With a foreign object of vegetable matter, irrigation is used with care because this material _______ with hydration.
pg. 780 Qs: 573, 575, 580, 581, 585
Diagnostic test for the eye: fluorescein angiography: preprocedure interventions: inform the client that the skin and urine may be what color for how long?
the dye may cause the skin to appear yellow for several hours after the test and is eliminated gradually through the urine which will be bright green or orange for up to 2 days following the procedure
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