Medical Surgical Nursing Assessment and Management of Clinical Problems, 10th Edition by Sharon L. Lewis
Medical Surgical Nursing Assessment and Management of Clinical Problems, 10th Edition by Sharon L. Lewis
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Chapter 21: Visual and Auditory Problems
Complete Chapter Questions With Answers
Sample Questions Are Posted Below
MULTIPLE CHOICE
| a. | strength of the eye muscles. | c. | cloudiness in the eye lenses. |
| b. | both near and distant vision. | d. | intraocular pressure changes. |
ANS: B
The lenses are prescribed to correct the patient’s near and distant vision. The nurse may also assess for cloudiness of the lenses, increased intraocular pressure, and eye movement, but these data do not evaluate whether the patient’s bifocals are effective.
DIF: Cognitive Level: Understand (comprehension) REF: 368
TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity
| a. | irrigate the eyes with saline solution. |
| b. | schedule an appointment for eye surgery. |
| c. | use a gentle baby shampoo to clean the eyelids. |
| d. | apply cool compresses to the eyes three times daily. |
ANS: C
Baby shampoo is used to soften and remove crusts associated with blepharitis. The other interventions are not used in treating this disorder.
DIF: Cognitive Level: Apply (application) REF: 371
TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity
| a. | have the patient place a hand on the nurse’s shoulder and guide the patient. |
| b. | lead the patient slowly to the bathroom, holding on to the patient by the arm. |
| c. | stay beside the patient and describe any obstacles on the path to the bathroom. |
| d. | walk slightly ahead of the patient, allowing the patient to hold the nurse’s elbow. |
ANS: D
When using the sighted-guide technique, the nurse walks slightly in front and to the side of the patient and has the patient hold the nurse’s elbow. The other techniques are not as safe in assisting a blind patient.
DIF: Cognitive Level: Apply (application) REF: 369
TOP: Nursing Process: Implementation MSC: NCLEX: Safe and Effective Care Environment
| a. | Apply cold compresses. |
| b. | Discard used eye cosmetics. |
| c. | Wash the scalp and eyebrows with an antiseborrheic shampoo. |
| d. | Be examined for recurrent sexually transmitted infections (STIs). |
ANS: B
Hordeolum (styes) are commonly caused by Staphylococcus aureus, which may be present in cosmetics that the patient is using. Warm compresses are recommended to treat hordeolum. Antiseborrheic shampoos are recommended for seborrheic blepharitis. Patients with adult inclusion conjunctivitis, which is caused by Chlamydia trachomatis, should be referred for STI testing.
DIF: Cognitive Level: Apply (application) REF: 370
TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity
| a. | Wash hands frequently and avoid touching the eyes. |
| b. | Apply antibiotic drops to the eye several times daily. |
| c. | Apply a new occlusive dressing to the affected eye at bedtime. |
| d. | Use corticosteroid ophthalmic ointment to decrease inflammation. |
ANS: A
The best way to avoid the spread of infection from one eye to another is to avoid rubbing or touching the eyes and to use careful hand washing when touching the eyes is unavoidable. Occlusive dressings are not used for herpes keratitis. Herpes simplex is a virus, and antibiotic drops will not be prescribed. Topical corticosteroids are immunosuppressive and typically are not ordered because they can contribute to a longer course of infection and more complications.
DIF: Cognitive Level: Apply (application) REF: 372
TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity
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