Chapter 11: Care of the Eye and Ear

Chapter 11: Care of the Eye and Ear

 

Complete Chapter Questions With Answers

 

Sample Questions Are Posted Below

 

MULTIPLE CHOICE

 

1. The nurse prepares to remove the patient’s soft contact lenses. Which intervention should the nurse implement to remove the lenses without traumatizing the cornea?

a.	Irrigate the eye with 50 mL of a sterile saline solution.
b.	Pull the lid down and instruct the patient to blink.
c.	Pinch the sides of the lens together and pop it out.
d.	Move the lens to the sclera and compress the lens gently.

 

 

ANS:  D

To remove a soft contact lens from a patient’s eye, the nurse moves the lens to the sclera and gently compresses it. This maneuver disrupts the surface tension holding the lens to the eye, allowing the nurse to lift the lens off the eye without traumatizing the cornea. The nurse avoids flooding the eye with irrigation solution because it increases the risk of losing the lens. The nurse asks the patient to blink to eject a hard lens. The nurse avoids pinching the lens since that would risk corneal trauma.

 

DIF:    Cognitive Level: Comprehend          REF:   Page 274, Box 11-1

OBJ:   NCLEX: Physiological Integrity      TOP:   Nursing Process: Planning

 

2. The nurse irrigates the patient’s eye after the patient splashes an irritating liquid into it. Which intervention does the nurse implement to prevent injury during eye irrigation?

a.	Positions the patient in high-Fowler’s position during the procedure
b.	Prevents the tip of the irrigating system from contacting the eyeball
c.	Reassures the patient that the eye cannot be closed during irrigation
d.	Allows the irrigating solution to run from the outer to the inner canthus

 

 

ANS:  B

The nurse prevents additional injury to the patient’s eye during the eye irrigation by maintaining the irrigation system tip away from the eye. The nurse positions the patient in the side-lying position on the side of the affected eye to control the flow of irrigation solution. The patient is allowed to blink periodically during the irrigation. The nurse directs the irrigation solution to flow from the inner to the outer canthus to prevent contamination of the eye from a contaminated area.

 

DIF:    Cognitive Level: Remember            REF:   Page 273

OBJ:   NCLEX: Physiological Integrity      TOP:   Nursing Process: Implementation

 

3. The nurse and the patient discuss the patient’s need for a hearing aid. What information does the nurse include in patient teaching?

a.	An in-the-ear hearing aid is easy to manipulate.
b.	The patient’s specific needs and abilities are determining factors.
c.	The choice of a hearing aid is basically a financial matter.
d.	Behind-the-ear models are inferior to the other types.

 

 

ANS:  B

The patient’s specific needs and abilities are the determining factors in selecting a model of hearing aid for use. Hearing aids are available in many styles to suit a patient’s individual needs. In-the-ear hearing aids are a poor choice for a patient with impaired manual dexterity because they are small. Behind-the-ear hearing aids are suitable for mild-to-profound hearing loss. Choosing a hearing aid is partially a financial decision, but not all models suit a patient’s needs effectively.

 

DIF:    Cognitive Level: Comprehend          REF:   Page 280, Table 11-1

OBJ:   NCLEX: Physiological Integrity      TOP:   Nursing Process: Implementation

 

4. The nursing assistive personnel (NAP) reports that the hearing-impaired patient is usually alert and oriented with the hearing aid in place, but the patient is not responding to verbal communication this morning. What action should the nurse implement first?

a.	Document that the patient’s neurological status is poor.
b.	Assess the patient for clinical indicators of a stroke.
c.	Remove the hearing aid and clean it with a stiff brush.
d.	Instruct NAP to check the hearing aid battery.

 

 

ANS:  D

Because the patient is usually alert and oriented, the nurse realizes that the most likely cause of the patient’s change in hearing is a defective hearing aid battery. The nurse directs the NAP to check the battery first because this is also a simple factor to eliminate. After checking the batteries, the nurse instructs the NAP to clean the hearing aid with the brush supplied by the manufacturer, which is the brush that the patient uses regularly. The nurse does not know yet whether the patient’s neurological status is poor. The NAP reports clinical indicators of normal neurological function, making a stroke unlikely.

 

DIF:    Cognitive Level: Analyze                REF:   Page 282

OBJ:   NCLEX: Physiological Integrity      TOP:   Nursing Process: Assessment

 

5. The nurse instructs the patient on how to care for the hearing aid at home. What information should the nurse include in patient teaching to prevent damage to the hearing aid?

a.	Store the hearing aid with a desiccant.
b.	Wash the hearing aid in hot soapy water.
c.	Keep the hearing aid in the bathroom.
d.	Clean the hearing aid with a pipe cleaner.

 

 

ANS:  A

The nurse instructs the patient to store the hearing aid in a dry container with a desiccant to keep moisture and heat away from the device because moisture and heat can destroy the delicate electronic components of the hearing aid. The nurse instructs the patient to avoid immersing the hearing aid and inserting objects into it. The nurse also instructs the patient to avoid storing the hearing aid in the kitchen or bathroom to prevent exposure to moisture and heat.

 

DIF:    Cognitive Level: Comprehend          REF:   Page 282

OBJ:   NCLEX: Physiological Integrity      TOP:   Nursing Process: Implementation