The nurse has given a community group a presentation on eye health. Which statement by a participant
indicates a need for more instruction?
a. I always lose my sunglasses, so I dont wear them.
b. I have diabetes and get an annual eye exam.
c. I will not share my contact solution with others.
d. I will wear safety glasses when I mow the lawn.
The nurse reads on a clients chart that the client has exophthalmos. What assessment finding is consistent
with this diagnosis?
a. Bulging eyes
b. Drooping eyelids
c. Sunken-in eyes
d. Yellow sclera
A clients chart indicates anisocoria. For what should the nurse assess?
client presents to the emergency department reporting a foreign body in the eye. For what diagnostic
testing should the nurse prepare the client?
A nurse who is applying eyedrops to a client holds pressure against the corner of the eye nearest the nose
after instilling the drops. The client asks what the nurse is doing. What response by the nurse is best?
The nurse is administering eyedrops to a client with an infection in the right eye. The drops go in both eyes,
and two different bottles are used to administer the drops. The nurse accidentally uses the left eye bottle for the
right eye. What action by the nurse is best?
The nurse enters an examination room to help with an eye examination. The client is directed toward the
assessment chart shown below:
What is the provider assessing?
a. Color vision
b. Depth perception
c. Spatial perception
d. Visual acuity
The student learning about vision should remember which facts related to the eyes? (Select all that apply.)
Aqueous humor controls intraocular pressure.
b. Cones work in low light conditions.
c. Glaucoma occurs due to increased pressure in the eye.
d. Muscles of the iris control light entering the eye.
e. Rods work in low light conditions.
The nursing student studying the eye learns that which cranial nerves control its functions? (Select all that apply.)
The nursing student studying the eye learns that which cranial nerves control its functions? (Select all thatapply.)
a. Decreased eye muscle tone
b. Development of arcus senilis
c. Increase in far point of near vision
d. Decrease in general color perception
e. Increase in point of near vision
1. A client has a corneal ulcer. What information provided by the client most indicates a potential barrier to
a. Chronic use of sleeping pills
b. Impaired near vision
c. Slightly shaking hands
d. Use of contact lenses
An older client has decided to give up driving due to cataracts. What assessment information is most
important to collect?
a. Family history of visual problems
b. Feelings related to loss of driving
c. Knowledge about surgical options
d. Presence of family support
A client is in the preoperative holding area waiting for cataract surgery. The client says Oh, yeah, I forgot to
tell you that I take clopidogrel, or Plavix. What action by the nurse is most important?
a. Ask the client when the last dose was.
b. Check results of the prothrombin time (PT) and international normalized ratio (INR).
c. Document the information in the chart.
d. Notify the surgeon immediately.
A client does not understand why vision loss due to glaucoma is irreversible. What explanation by the nurse is best?
a. Because eye pressure was too high, the tissue died.
b. Glaucoma always leads to permanent blindness.
c. The traumatic damage to your eye was too great.
d. The infection occurs so quickly it cant be treated.
A clients intraocular pressure (IOP) is 28 mm Hg. What action by the nurse is best?
a. Educate the client on corneal transplantation.
b. Facilitate scheduling the eye surgery.
c. Plan to teach about drugs for glaucoma.
d. Refer the client to local Braille classes.
A client had a retinal detachment and has undergone surgical correction. What discharge instruction is most
a. Avoid reading, writing, or close work such as sewing.
b. Dim the lights in your house for at least a week.
c. Keep the follow-up appointment with the ophthalmologist.
d. Remove your eye patch every hour for eyedr
A client has been taught about retinitis pigmentosa (RP). What statement by the client indicates a need for
a. Beta carotene, lutein, and zeaxanthin are good supplements.
b. I might qualify for a retinal transplant one day soon.
c. Since Im going blind, sunglasses are not needed anymore.
d. Vitamin A has been shown to slow progression of RP.
A client has a foreign body in the eye. What action by the nurse takes priority?
a. Administering ordered antibiotics
b. Assessing the clients visual acuity
c. Obtaining consent for enucleation
d. Removing the object immediately
A client who is near blind is admitted to the hospital. What action by the nurse is most important?
a. Allow the client to feel his or her way around.
b. Let the client arrange objects on the bedside table.
c. Orient the client to the room using a focal point.
d. Speak loudly and slowing when talking to the client
A client had proxymetacaine (Ocu-Caine) instilled in one eye in the emergency department. What
discharge instruction is most important?
a. Do not touch or rub the eye until it is no longer numb.
b. Monitor the eye for any bleeding for the next day.
c. Rinse the eye with warm saline solution at home.
d. Use all the eyedrops as prescribed until they are gone
A client is taking timolol (Timoptic) eyedrops. The nurse assesses the clients pulse at 48 beats/min. What
action by the nurse is the priority?
a. Ask the client about excessive salivation.
b. Assess the client for shortness of breath.
c. Give the drops using punctal occlusion.
d. Hold the eyedriops and notify the provider.
A client has been prescribed brinzolamide (Azopt). What assessment by the nurse requires consultation
with the provider?
a. Allergy to eggs
b. Allergy to sulfonamides
c. Use of contact lenses
d. Use of beta blockers
A client is brought to the emergency department after a car crash. The client has a large piece of glass in
the left eye. What action by the nurse takes priority?
a. Administer a tetanus booster shot.
b. Ensure the client has a patent airway.
c. Prepare to irrigate the clients eye.
d. Turn the client on the unaffected side.
A nurse is seeing clients in the ophthalmology clinic. Which client should the nurse see first?
a. Client with intraocular pressure reading of 24 mm Hg
b. Client who has had cataract surgery and has worsening vision
c. Client whose red reflex is absent on ophthalmologic examination
d. Client with a tearing, reddened eye with exudate
The nurse working in the ophthalmology clinic sees clients with eyelid and eye problems. What information
should the nurse understand about these disorders? (Select all that apply.)
a. A chalazion is an inflammation of an eyelid sebaceous gland.
b. An ectropion is the eyelid turning inward.
c. An entropion is the eyelid turning outward.
d. A hordeolum is an infection of the eyelid sweat gland.
e. Keratoconjunctivitis sicca is caused by drugs or diseases
A client is seen in the ophthalmology clinic with bacterial conjunctivitis. Which statements by the client
indicate a good understanding of home management of this condition? (Select all that apply.)
a. As long as I dont wipe my eyes, I can share my towel.
b. Eye irrigations should be done with warm saline or water.
c. I will throw away all my eye makeup when I get home.
d. I wont touch the tip of the eyedrop bottle to my eye.
e. When the infection is gone, I can use my contacts again
A client had cataract surgery. What instructions should the nurse provide? (Select all that apply.)
a. Call the doctor for increased pain.
b. Do not bend over from the waist.
c. Do not lift more than 10 pounds.
d. Sexual intercourse is allowed.
e. Use stool softeners to avoid constipation
A nurse has delegated applying a warm compress to a clients eye. What actions by the unlicensed assistive personnel (UAP) warrant intervention by the nurse? (Select all that apply.)
a. Heating the wet washcloth in the microwave
b. Holding the cloth on the client using an Ace wrap
c. Turning the cloth so it remains warm on the client
d. Using a clean washcloth for the compress
e. Washing the hands on entering the clients room
A nurse is teaching a client about ear hygiene and health. What client statement indicates a need for further
a. A soft cotton swab is alright to clean my ears with.
b. I make sure my ears are dry after I go swimming.
c. I use good earplugs when I practice with the band.
d. Keeping my diabetes under control helps my ears
The student nurse is performing a Weber tuning fork test. What technique is most appropriate?
a. Holding the vibrating tuning fork 10 to 12 inches from the clients ear
b. Placing the vibrating fork in the middle of the clients head
c. Starting by placing the vibrating fork on the mastoid process
d. Tapping the vibrating tuning fork against the bridge of the nose
The clients chart indicates a sensorineural hearing loss. What assessment question does the nurse ask to
determine the possible cause?
a. Do you feel like something is in your ear?
b. Do you have frequent ear infections?
c. Have you been exposed to loud noises?
d. Have you been told your ear bones dont move?
The nurse works with clients who have hearing problems. Which action by a client best indicates goals for
an important diagnosis have been met?
a. Babysitting the grandchildren several times a week
b. Having an adaptive hearing device for the television
c. Being active in community events and volunteer work
d. Responding agreeably to suggestions for adaptive devices
A client has external otitis. On what comfort measure does the nurse instruct the client?
a. Applying ice four times a day
b. Instilling vinegar-and-water drops
c. Use of a heating pad to the ear
d. Using a home humidifier
An older adult in the family practice clinic reports a decrease in hearing over a week. What action by the
nurse is most appropriate?
a. Assess for cerumen buildup.
b. Facilitate audiological testing.
c. Perform tuning fork tests.
d. Review the medication list.
A client had a myringotomy. The nurse provides which discharge teaching?
a. Buy dry shampoo to use for a week.
b. Drink liquids through a straw.
c. Flying is not allowed for 1 month.
d. Hot water showers will help the pain.
A client is going on a cruise but has had motion sickness in the past. What suggestion does the nurse make
to this client?
a. Avoid alcohol on the cruise ship.
b. Change positions slowly on the ship.
c. Change your travel plans.
d. Try scopolamine (Transderm Scop).
A nurse is teaching a community group about noise-induced hearing loss. Which client who does not use ear
protection should the nurse refer to an audiologist as the priority?
a. Client with an hour car commute on the freeway each day
b. Client who rides a motorcycle to work 20 minutes each way
c. Client who sat in the back row at a rock concert recently
d. Client who is a tree-trimmer and uses a chainsaw 6 to 7 hours a day
A nursing student is instructed to remove a clients ear packing and instill eardrops. What action by the
student requires intervention by the registered nurse?
a. Assessing the eardrum with an otoscope
b. Inserting a cotton ball in the ear after the drops
c. Warming the eardrops in water for 5 minutes
d. Washing the hands and removing the packing
A nurse is irrigating a clients ear when the client becomes nauseated. What action by the nurse is most
appropriate for client comfort?
a. Have the client tilt the head back.
b. Re-position the client on the other side.
c. Slow the rate of the irrigation.
d. Stop the irrigation immediately.
client hospitalized for a wound infection has a blood urea nitrogen of 45 mg/dL and creatinine of 4.2
mg/dL. What action by the nurse is best?
a. Assess the ordered antibiotics for ototoxicity.
b. Explain how kidney damage causes hearing loss.
c. Use ibuprofen (Motrin) for pain control.
d. Teach that hearing loss is temporary.
A nurse is teaching a community group about preventing hearing loss. What instruction is best?
a. Always wear a bicycle helmet.
b. Avoid swimming in ponds or lakes.
c. Dont go to fireworks displays.
d. Use a soft cotton swab to clean ears.
A client has severe tinnitus that cannot be treated adequately. What action by the nurse is best?
a. Advise the client to take antianxiety medication.
b. Educate the client on nerve cutting procedures.
c. Refer the client to online or local support groups.
d. Teach the client side effects of furosemide (Lasix).
A client has labyrinthitis and is prescribed antibiotics. What instruction by the nurse is most important for
a. Immediately report headache or stiff neck.
b. Keep all follow-up appointments.
c. Take the antibiotics with a full glass of water.
d. Take the antibiotic on an empty stomach.
A client with Mnires disease is in the hospital when the client has an attack of this disorder. What action by
the nurse takes priority?
a. Assess vital signs every 15 minutes.
b. Dim or turn off lights in the clients room.
c. Place the client in bed with the upper siderails up.
d. Provide a cool, wet cloth for the clients face.
A client is scheduled to have a tumor of the middle ear removed. What teaching topic is most important for
the nurse to cover?
a. Expecting hearing loss in the affected ear
b. Managing postoperative pain
c. Maintaining NPO status prior to surgery
d. Understanding which medications are allowed the day of surgery
A nursing student studying the auditory system learns about the structures of the inner ear. What structures
does this include? (Select all that apply.)
c. Organ of Corti
d. Semicircular canals
A client has Mnires disease with frequent attacks. About what drugs does the nurse plan to teach the client?
(Select all that apply.)
a. Broad-spectrum antibiotics
b. Chlorpromazine hydrochloride (Thorazine)
c. Diphenhydramine (Benadryl)
d. Meclizine (Antivert)
e. Nonsteroidal anti-inflammatory drugs (NSAIDs)
A client is scheduled for a tympanoplasty. What actions by the nurse are most appropriate? (Select all that
a. Administer preoperative antibiotics.
b. Assess for allergies to local anesthetics.
c. Ensure that informed consent is on the chart.
d. Give ordered antivertigo medications.
e. Teach that hearing improves immediately.
A client has a hearing aid. What care instructions does the nurse provide the unlicensed assistive personnel
(UAP) in the care of this client? (Select all that apply.)
a. Be careful not to drop the hearing aid when handling.
b. Soak the hearing aid in hot water for 20 minutes.
c. Turn the hearing aid off when the client goes to bed.
d. Use a toothpick to clean debris from the device.
e. Wash the device with soap and a small amount of warm water
A hospitalized client has Mnires disease. What menu selections demonstrate good knowledge of the
recommended diet for this disorder? (Select all that apply.)
a. Chinese stir fry with vegetables
b. Broiled chicken breast
c. Chocolate espresso cookies
d. Deli turkey sandwich and chips
A client is scheduled for a stapedectomy in 2 weeks. What teaching instructions are most appropriate?
(Select all that apply.)
a. Avoid alcohol use before surgery.
b. Blow the nose gently if needed.
c. Clean the telephone often.
d. Sneeze with the mouth open.
e. Wash the external ear daily.
A client is admitted to the nursing unit after having a tympanoplasty. What activities does the nurse delegate
to the unlicensed assistive personnel (UAP)? (Select all that apply.)
a. Administer prescribed antibiotics.
b. Keep the head of the clients bed flat.
c. Remind the client to lie on the operative side.
d. Remove the iodoform gauze in 8 hours.
e. Take and record postoperative vital signs.
A client is having a myelography. What action by the nurse is most important?
a. Assess serum aspartate aminotransferase (AST) levels.
b. Ensure that informed consent is on the chart.
c. Position the client flat after the procedure.
d. Reinforce the dressing if it becomes saturated.
A client is undergoing computed tomography (CT) of a joint. What action by the nurse is most important
before the test?
a. Administer sedation as prescribed.
b. Assess for seafood or iodine allergy.
c. Ensure that the client has no metal on the body.
d. Provide preprocedure pain medication.
A client had an arthroscopy 1 hour ago on the left knee. The nurse finds the left lower leg to be pale and
cool, with 1+/4+ pedal pulses. What action by the nurse is best?
a. Assess the neurovascular status of the right leg.
b. Document the findings in the clients chart.
c. Elevate the left leg on at least two pillows.
d. Notify the provider of the findings immediately.
A hospitalized clients strength of the upper extremities is rated at 3. What does the nurse understand about
this clients ability to perform activities of daily living (ADLs)?
a. The client is able to perform ADLs but not lift some items.
b. No difficulties are expected with ADLs.
c. The client is unable to perform ADLs alone.
d. The client would need near-total assistance with ADls.
A client is distressed at body changes related to kyphosis. What response by the nurse is best?
a. Ask the client to explain more about these feelings.
b. Explain that these changes are irreversible.
c. Offer to help select clothes to hide the deformity.
d. Tell the client safety is more important than looks.
The nurse knows that hematopoiesis occurs in what part of the musculoskeletal system?
a. Cancellous tissue
b. Collagen matrix
c. Red marrow
d. Yellow marrow
A nurse is providing community education about preventing traumatic musculoskeletal injuries related to car
crashes. Which group does the nurse target as the priority for this education?
a. High school football team
b. High school homeroom class
c. Middle-aged men
d. Older adult women
A school nurse is conducting scoliosis screening. In screening the client, what technique is most
a. Bending forward from the hips
b. Sitting upright with arms outstretched
c. Walking across the room and back
d. Walking with both eyes closed
The clients chart indicates genu varum. What does the nurse understand this to mean?
b. Fluid accumulation
d. Spinal curvature
The nurse is assessing four clients with musculoskeletal disorders. The nurse should assess the client with
which laboratory result first?
a. Serum alkaline phosphatase (ALP): 108 units/L
b. Serum aspartate aminotransferase (AST): 26 units/L
c. Serum calcium: 10.2 mg/dL
d. Serum phosphorus: 2 mg/dL
A nursing student studying the musculoskeletal system learns about important related hormones. What
information does the student learn? (Select all that apply.)
a. A lack of vitamin D can lead to rickets.
b. Calcitonin increases serum calcium levels.
c. Estrogens stimulate osteoblastic activity.
d. Parathyroid hormone stimulates osteoclastic activity.
e. Thyroxine stimulates estrogen release.
A student nurse learns about changes that occur to the musculoskeletal system due to aging. Which changes
does this include? (Select all that apply.)
a. Bone changes lead to potential safety risks.
b. Increased bone density leads to stiffness.
c. Osteoarthritis occurs due to cartilage degeneration.
d. Osteoporosis is a universal occurrence.
e. Some muscle tissue atrophy occurs with aging.
3. An older clients serum calcium level is 8.7 mg/dL. What possible etiologies does the nurse consider for this
result? (Select all that apply.)
a. Good dietary intake of calcium and vitamin D
b. Normal age-related decrease in serum calcium
c. Possible occurrence of osteoporosis or osteomalacia
d. Potential for metastatic cancer or Pagets disease
e. Recent bone fracture in a healing stage
When assessing gait, what features does the nurse inspect? (Select all that apply.)
b. Ease of stride
c. Goniometer readings
d. Length of stride