Name:

TEST DRILL IN PROBLEMS OF THE SENSORY FUNCTION

1. The nurse is performing a voice test to assess hearing. Which describes accurate procedure in performing the test?
A. Stand 4 feet away from the client to ensure that the client can hear at this distance.
B. Whisper a statement and ask the client to repeat it.
C. Whisper a statement with the examiners back facing the client
D. Whisper a statement while the client blocks both ears.

2. During a hearing assessment, the nurse notes that the sound lateralizes to the clients left ear with the Weber test. The
nurse analyzes this result as:
A. A normal finding C. A sensorineural or conductive loss
B. A conductive hearing loss in the right ear D. The presence of nystagmus

3. The nurse is caring for a client that is hearing impaired. Which approach will facilitate communication?
A. Speak frequently C. Speak directly into the impaired ear
B. Speak loudly D. Speak in a normal tone

4. The nurse has conducted discharge teaching for a client who had a fenestration procedure for the treatment of
otosclerosis. Which of the following, if stated by the client, would indicate that teaching was effective?
A. “I should drink liquids through a straw for the next 2-3 weeks.”
B. “It’s ok to take a shower and wash my hair.”
C. “I will take stool softeners as prescribed by my doctor.”
D. “I can resume my tennis lessons starting next week.”

5. A client arrives at the emergency room with a foreign body in the left ear that has been determined to be an insect.
Which intervention would the nurse anticipate to be prescribed initially?
A. Irrigation of the ear C. Instillation of antibiotic ear drops
B. Instillation of diluted alcohol D. Instillation of corticosteroids ear drops

6. The nurse has notes that the physician has a diagnosis of presbycusis on the client’s chart. The nurse plans care
knowing the condition is:
A. A sensorineural hearing loss that occurs with aging C. Tinnitus that occurs with aging
B. A conductive hearing loss that occurs with aging. D. Nystagmus that occurs with aging

7. A client with Meniere’s disease is experiencing severe vertigo. Which instruction would the nurse give to the client to
assist in controlling the vertigo?
A. Increase fluid intake to 3000 ml a day C. Lie still and watch the television
B. Avoid sudden head movements D. Increase sodium in the diet

8. The nurse is reviewing the physician’s orders for a client with Meniere’s disease. Which diet will most likely be
prescribed?
A. Low-cholesterol diet B. Low-sodium diet C. Low-carb diet D. Low-fat diet

9. A client is diagnosed with a disorder involving the inner ear. Which of the following is the most common client
complaint associated with a disorder in this part of the ear?
A. Hearing loss B. Pruritus C. Tinnitus D. Burning of the ear

10. A nurse would question an order to irrigate the ear canal in which of the following circumstances?
A. Ear pain C. Otitis externa
B. Hearing loss D. Perforated tympanic membrane

11. Which of the following interventions is essential when instilling Cortisporin suspension, 2 gtt right ear?
A. Verifying the proper client and route C. Holding an emesis basin under the client’s ear
B. Warming the solution to prevent dizziness D. Positioning the client in the semi-fowlers position

12. When teaching about Meniere’s disease, which of the following instructions would a nurse give about vertigo?
A. Report dizziness at once C. Get up slowly, turning the entire body
B. Drive in daylight hours only D. Change your position using the logroll method

13. The part of the ear that contains the receptors for hearing is the:
A. Utricle B. Cochlea C. Middle ear D. Tympanic cavity
14. The ear bones that transmit vibrations to the oval window of the cochlea are found in the:
A. Inner ear B. Outer ear C. Middle ear D. Eustachian tube

15. Nerve deafness would most likely result from an injury or infection that damaged the:
A. Vagus nerve B. Cochlear nerve C. Vestibular nerve D. Trigeminal nerve

16. A labyrinthectomy can be performed to treat Meniere’s syndrome. This procedure results in:
A. Anosmia C. Reduction in cerumen
B. Absence of pain D. Permanent irreversible deafness

17. Otosclerosis is a common cause of conductive hearing loss. Which such a partial hearing loss:
A. Stapedectomy is the procedure of choice C. The client is usually unable to hear bass tones
B. Hearing aids usually restore some hearing D. Air conduction is more effective than bone conduction

18. A client who is complaining of tinnitus is describing a symptom that is:

A. Objective B. Subjective C. Functional D. Prodromal

19. Physiologically, the middle ear, containing the three ossicles, serves primarily to:
A. Maintain balance C. Amplify the energy of sound waves entering the ear
B. Translate sound waves into nerve impulses D. Communicate w/ the throat via the Eustachian tube.

20. A nurse is caring for a hospitalized client with an acute attack of Meniere's disease. The client verbalizes concern
because the client has experienced a hearing loss as a result of the attack. Which of the following responses would the
nurse make to the client regarding the hearing loss?
A. it will take several weeks before the hearing returns C. the attack leaves a hearing loss in the involved ear
B. the hearing loss will fluctuate for a period of 1 week D. the hearing will return to normal
21. A nurse is reviewing the physician's orders on a client admitted to the hospital with a diagnosis of an acute attack of
Meniere's disease. Which of the following orders, if noted on the client's chart, would the nurse question?
A. the administration of a sedative C. the administration of vasoconstrictor
B. the administration of an antihistamine D. bedrest
22. A nurse is providing discharge instructions to the client who was hospitalized for an acute attack of Meniere's
disease. Which of the following statements, if made by the client, indicates a need for further instructions?
A. I need to take the diuretics to decrease the fluid in the ear
B. I need to take antihistamine as prescribed
C. I need to take a vasodilator
D. it is not necessary to restrict salt in my diet

23. A client with a diagnosis of otosclerosis is admitted to the ambulatory care unit for stapedectomy, and the nurse
prepares instructions for the client regarding home care after the procedure. Which statement by the client indicates a
need for further instructions?
A. I need water out of the ear canal for at least 3 weeks
B. I need to avoid air travel for at least 1 year
C. I need to notify the physician if I experience any persistent dizziness
D. I need to avoid bending and lifting heavy objects for at least 3 weeks

24. The nurse is providing instructions to a nursing assistant regarding care of an older client with hearing loss. The nurse
tells the assistant that clients with a hearing loss:
a) are often distracted c) respond to low-pitched tones
b) have middle ear changes d) develop moist cerumen production
25. The nurse is performing an otoscopic examination on a client with mastoiditis. On examination of the tympanic
membrane, which of the following would the nurse expect to observe?
a) a pink-colored tympanic membrane c) a transparent and clear tympanic membrane
b) a pearly colored tympanic membrane d) a red, dull, thick and immobile tympanic membrane

26. A nurse is assigned to care for a client after a mastoidectomy. Which nursing intervention would be appropriate in
the care of this client?
a) maintain a supine position c) change the ear dressing daily
b) position on the affected side to promote drainage d) monitor for signs of facial nerve injury
27. A nurse is performing an assessment on a client with a diagnosis of Meniere's disease. The nurse anticipates that the
client is most likely to report which of the following symptoms during an acute attack?
a) tinnitus c) fatigue
b) headache d) insomnia
28. A nurse has admitted a client with a diagnosis of an acute attack of Meniere's disease to the hospital. The nurse
reviews the physician's orders for the client. Which order should the nurse question?
a) diphenhydramine (Benadryl) c) atropine sulfate
b) diazepam (Valium) d) ambulation 4 times daily
29. A nurse in the health care clinic is preparing to perform an otoscopic examination on adult client. In performing the
examination, the nurse should:
a) position the client lying flat on the side of the ear be examined
b) pull the ear lobe down and back before inserting the speculum
c) tilt the client's head forward before inserting the speculum
d) pull the pinna up and back before inserting the speculum

30. A nurse is preparing to perform a Weber test on a client. The nurse obtains which item needed to perform this test?
a) a tongue blade c) a tuning fork
b) a stethoscope d) a reflex hammer
31. The home care nurse is visiting a client who was recently diagnosed with a hearing impairment. The nurse prepares
to instruct the client's spouse in which measure that will facilitate communication?
a) speak frequently to the client to provide sensory stimulation
b) speak loudly to the client to facilitate hearing
c) speak in a normal tone and face the client when speaking
d) speak directly into the impaired ear to facilitate hearing

32. A nurse is providing discharge instructions to a client who had a fenestration procedure for the treatment of
otosclerosis. The nurse instructs the client to:
a) drink liquids through a straw for the next 2-3 weeks c) avoid air travel
b) shower daily to prevent infection d) resume all normal activities in 1 week
33. A clinic nurse is preparing to perform a Romberg test on a client being seen in the clinic. The nurse performs this test
for the purpose of determining:
a) the client's ability to ambulate
b) the functional status of the vestibular apparatus in the inner ear
c) the intactness of the retinal structure of the eye
d) the intactness of the tympanic membrane

34. A clinic nurse is performing an otoscopic examination on an adolescent who was hit in the ear with a basketball
during a neighborhood game. A perforated eardrum is suspected. Which of the following would the nurse expect to
observe if the eardrum is perforated?
a) a colony of black dots on the eardrum c) a red bulging eardrum
b) dense white patches on the eardrum d) a round or oval darkened area on the eardrum
35. A caloric test is ordered for a client suspected of having disease of the labyrinth. The nurse would obtain which of
the following essential items in preparation for this test?
a) an otoscope c) a tongue blade
b) an opthalmoscope d) an emesis basin
36. A nurse educator is conducting an in-service education session to the nurses employed in the eye and ear surgical
unit of a large trauma center. In discussing the topic of cochlear implants, the educator notes that this surgical
procedure is contraindicated in which of the following clients?
a) a client who became deaf before learning to speak
b) a client with bilateral profound hearing loss
c) a client who communicates primarily by speech
d) a client who received no benefit from conventional hearing aids

37. A nurse is observing a nursing assistant communicating with a client who is deaf. The nurse will intervene if which of
the following behaviors is observed?
a) the nursing assistant is speaking directly to the client
b) the nursing assistant touches the client's arm to gain his or her attention
c) the nursing assistant faces the client when speaking to the client
d) the nursing assistant overenunciates words when speaking

38. A nurse is planning a presentation on noise prevention and ear protection for a display booth at a local health fair.
The nurse plans to incorporate which important concept regarding hearing loss in the presentation?
a) sitting near loud music is not harmful
b) ear plugs or other protectors are necessary only when use of power tools
c) prolonged ringing in the ears after loud noises is normal
d) cup the hands over the ears if loud noise is expected suddenly

39. A nurse instructs a client in the use of a hearing aid. The nurse includes the following in the instructions:
a) check the battery to ensure that it is working before use
b) leave the hearing aid in place while showering
c) hearing aids do not require any care
d) a water-soluble lubricant is used on the hearing aid before insertion

40. A nurse has given a client at risk for motion sickness suggestions about medications that can prevent an occurrence.
The nurse determines that the client has correctly learned the information if the client states to take medication at what
time before the triggering event?
a) at least 1/2 day before c) at least the day before
b) at least 1 hour before d) at least 2 days before
41. An adult client makes an appointment with an ear specialist because of the frequent recurrence of middle ear
infections. In performing an intake assessment of the client, the nurse would ask about which of the following as a risk
factor related to infection of the ears?
a) exposure to loud noise c) congenital abnormalities
b) use of drilling and other power tools d) occupational noise
42. A nurse is planning to instruct a client with chronic vertigo about safety measures to prevent exacerbation of
symptoms or injury. Teaching for this client will include which of the following statements?
a) drive only when feelings of dizziness have not been experienced for several hours
b) go to the bedroom and lie down when vertigo is experienced
c) remove throw rugs and clutter in the home
d) turn the head slowly when spoken to

43. A nurse is preparing a plan of care for a client being admitted to the hospital with exacerbation of Meniere's disease.
Which of the following would the nurse include in the plan of care?
a) increase fluid intake to 3000 ml a day
b) tell the client to avoid moving the head suddenly
c) maintain a quiet environment, and allow the client to read and watch TV
d) increase foods high in sodium in the diet
44. A nurse is performing an admission assessment of a client with a disorder involving the inner ear. Which
question will the nurse ask the client to determine if the common symptom of this type of ear disorder is present?
a) do you have any hearing loss? c) do you have any ringing in the ears?
b) do you have any itching around your ear? d) do you have any pain in the ear?
45. A new nursing graduate has been hired by the health care clinic to assist in conducting hearing tests in a local
neighborhood. The clinic nurse is observing the nursing graduate perform a voice test to assess hearing in a
client. Which of the following observations indicates that the graduate is performing the procedure correctly?
a) start 10 feet away from the client to determine if the client can hear clearly
b) asks the client to block one ear, quietly whispers a statement, and asks the client to repeat it
c) whispers a statement with the back facing the client
d) asks the client to block the ears, faces the client, verbalizes a statement, and asks the client to repeat the statement

46. A clinic nurse receives a telephone call form a client who states that an insect has somehow flown into her ear and
that a buzzing sound can be heard. The client asks the nurse how to remove the insect. Which of the following
instructions should the nurse initially provide to the client?
a) have her spouse irrigate ear to kill the insect
b) use a flashlight to try to coax the insect out of the ear
c) instill antibiotic eardrops if they are available
d) get into the shower and allow the ear to run into the ear to flush out the insect
47. The nurse notes that the physician has documented a diagnosis of presbycusis on the client's chart. The nurse plans
care knowing that the condition is:
a) tinnitus that occurs with aging c) a conductive hearing loss that occurs with aging
b) nystagmus that occurs with aging d) a sensorineural hearing loss that occurs with aging
48. The nurse is preparing to perform an otoscopic examination on an adult client. The nurse does which of the following
to perform this examination?
a) pulls the pinna up and back before inserting the speculum
b) pulls the earlobe down and back before inserting the speculum
c) uses the smallest speculum available to decrease the discomfort of the exam
d) tilts the clients head forward and down before inserting the speculum

49. A nurse is providing diet instructions to a client with Meniere's disease who is being discharged from the hospital
after admission for an acute attack. Which statement if made by the client indicates an understanding of the dietary
measures to take to prevent further attacks?
a) I need to drink at least 3 liters of fluid per day c) I need to maintain a low-fat, low-cholesterol diet
b) I need to restrict my carbohydrates intake d) I need to be sure to consume foods low in sodium
50. A nurse in the health care clinic is providing instructions to a client regarding the use of a hearing aid. Which of the
following statements would be appropriate for the nurse to include?
a) the ear mold for the hearing aid should be washed with mild soap and water once a month
b) the hearing aid should be removed from the ear at the end of the day then turned off after removal
c) the hearing aid contains a lifelong battery so you will not need to be concerned about changing batteries
d) the hearing aid should not be worn if an ear infection is present

51. A nurse is caring for a client with acute otitis media. In order to reduce pressure and allow fluid to drain, the nurse
anticipates that which of the following would most likely be recommended to the client?
a) the administration of diphenhydramine capsules c) strict bedrest
b) a myringotomy d) a mastoidectomy
52. A nurse is developing a plan of care for a client with a diagnosis of Meniere's disease who is being admitted to the
hospital. The priority nursing intervention in the plan of care should focus on:
a) safety measures c) knowledge about medication therapy
b) self-care measures d) food items to avoid
53. The nurse is caring for a client following craniotomy for removal of an acoustic neuroma. Assessment of which of the
following cranial nerves would identify a complication specifically associated with this surgery?
a) cranial nerve I, olfactory c) cranial nerve III, oculomotor
b) cranial nerve IV, trochlear d) cranial nerve VII, facial nerve
54. The nurse assesses the client with a blunt injury sustained from a motor vehicle accident. Which assessment sign
would indicate a basal skull fracture as a result of the injury?
a) epistaxis c) purulent drainage from the auditory canal
b) periorbital edema d) bloody or clear drainage from the auditory canal
55. A client was just admitted to the hospital to rule out a gastrointestinal (GI) bleed. The client has brought several
bottles of medications prescribed by different specialists. During the admission assessment, the client states, "Lately, I
have been hearing some roaring sounds in my ears, especially when I am alone." Which medication would the nurse
determine could be the cause of the client's complaint?
a) doxycycline (Vibramycin) c) acetylsalicylic acid (aspirin)
b) acetazolamide (Diamox) d) diltiazem hydrochloride (Cardizem)
56. The nurse prepares the client for an ear irrigation as prescribed by the physician. In performing the procedure, the
nurse:
a) warms the irrigating solution to 98F
b) position the client with the affected side up following the irrigation
c) directs a slow steady stream of irrigation solution toward the eardrum
d) assists the client to turn his or her head so that the ear to be irrigated is facing upward

57. Ear drops are prescribed for an infant with otitis media. The most appropriate method to administer the ear drops to
the infant is to:

a) pull up and back on the pinna and direct the solution onto the eardrum
b) pull down and back on the pinna and direct the solution onto the eardrum
c) pull down and back on the pinna and direct he solution toward the wall of the canal
d) pull up and back on the ear lobe and direct the solution toward the wall of the canal

58. A nurse receives a telephone call from a neighbor, who tells the nurse that the spouse accidentally broke a mirror,
and a piece of glass flew into the eye. The nurse arrives at the home and finds that a piece of glass is protruding from the
victim's eye. The nurse should:
a) remove the piece of glass using a tweezers that was boiled for sterilization purposes
b) apply an eye patch and instruct the victim and spouse to report to the emergency department
c) accompany the victim and spouse to the emergency department
d) flush the eye thoroughly with tap water

59. A client arrives at the emergency department after an eye injury in which an acid used to clean the bricks on a
fireplace splashed into his eye. The initial assessment question by the nurse is which of the following?
a) did you bring the container of acid with you? c) did you flush the eye following the injury?
b) what time did the injury occur? d) what type of acid caused the injury?
60. A nurse is caring for a client following enucleation. Which of the following assessment findings would indicate the
need to notify the physician?
a) bright red drainage on the dressing c) complaints of pain in the affected eye
b) a respiratory rate of 22 breaths per minute d) a blood pressure of 138/88 mm Hg
61. A client is being discharged from the ambulatory care unit after cataract removal, and the nurse provides
instructions regarding home care. Which of the following should the nurse tell the client?
a) take acetaminophen if any discomfort occurs c) avoid wearing glasses
b) sleep on the operated side to promote drainage d) do not lift anything that weighs more than 20 pounds

62. An ambulatory care nurse provides instructions to a client after a cataract extraction. Which statement by the client
indicates a need for further instructions?
a) I need to avoid bending over to pick up items c) I need to wear an eye shield all the time
b) I will sleep on the unoperative side d) There is no reason to stay on a special diet
63. A nursing student is caring for a client in the health care clinic who has been diagnosed with glaucoma. The nursing
instructor asks the student to describe the type of medication that will likely be prescribed for the client to treat the eye
disorder. Which statement by the student indicates an accurate understanding of the treatment for glaucoma?
a) a miotic agent will lower the pressure in the eye and increase the blood flow to the retina
b) a dilating agent will help dilate the eye to prevent pressure from occurring
c) a cycloplegic will relax the muscles of the eyes and prevent blurred vision
d) a mydriatic agent will help block the responses that are sent to muscles in the eye

64. A clinic nurse has provided instructions to a client with a diagnosis of glaucoma. Which statement by the client
indicates an understanding of the treatment plan for glaucoma?
a) I need to restrict my fluid intake to four glasses daily c) I can uses salt only for cooking
b) I need to take my eye drops for the rest of my life d) I need to limit my amount of reading to 2 hours a day
65. A nurse is caring for a client with a diagnosis of retinal detachment. The client suddenly complains of a burst of black
spots or floaters. The nurse interpret this symptom as:
a) hemorrhage as a result of the detachment c) the need to restrict fluids
b) an expected finding d) the need to patch the affected eye
66. A nurse is preparing a plan of care for a client being admitted to the hospital with a diagnosis of retinal detachment.
Which of the following will the nurse include in the plan of care?
a) out of bed to ambulate with assistance c) maintain high-fowler's position
b) place an eye patch over the affected eye d) restrict visitors
67. A client arrives at the emergency department after a blow to the eye from a softball. The initial nursing action would
be to:
a) call a physician to perform a thorough eye exam c) place the client in a supine position on a stretcher
b) irrigate the eye with sterile cool water d) apply ice to the affected eye
68. A client has undergone surgery to treat glaucoma. The nurse reinforces which home care instruction with the client?
a) wound healing usually takes 16 weeks
b) expect that vision will be permanently impaired to a small degree
c) a shield or eye patch should be worn to protect the eye
d) the sutures are removed after 1 week

69. A client has undergone surgery for cataracts. The nurse instructs the client to call the physician if which of the
following occurs?
a) a sudden decrease in vision c) small amounts of dried matter on lashes after sleep
b) eye pain relieved by acetaminophen (Tylenol) d) gradual resolution of eye redness
70. A nurse is caring for a client with arthritis. The client complains of difficulty instilling glaucoma eye drops because of
shaking hands caused by the arthritis. Which instruction would the nurse provide to the client to alleviate this problem?
a) keep drops in the ref to thicken and be easier to instill c) tilt the head straight back to instill the eye drops
b) lie down on a bed to instill the eye drops d) talk to the physician about the need for eye drops
71. Corrective glasses are prescribed for the client with bilateral aphakia, and the nurse provides instructions to the
client regarding the use of the glasses. Which statement by the client indicates the need for further instructions?
a) the glasses will correct my peripheral visual field of sight c) objects that I look at may be distorted
b) the glasses will magnify my central vision by 30% d) it may be difficult to judge distances when I drive a car

72. A client is brought to the ambulatory care department by her spouse one day following a cataract extraction
procedure and is diagnosed with hyphema that occurred as a result of the surgical procedure. The nurse provides which
instruction to the client and spouse regarding treatment for the hyphema?
a) resume normal activities because the hyphema will resolve on its own
b) obtain assistance when ambulating
c) return to the ambulatory care department for removal of the intraocular lens implant
d) maintain bedrest and place an eye shield or patch over both eyes

73. A scleral buckling procedure is performed on a client with retinal detachment, and the nurse provides home-care
instructions to the client. Which statement by the client indicates a need for further instructions?
a) I need to avoid heavy lifting
b) I need to avoid vigorous activity
c) I need to wear an eye shield during naps and at night
d) I need to clean the eye daily with sterile water ad a clean washcloth

74. The nurse is providing instructions to a client and family regarding home care after left-eye cataract removal. The
nurse tells the client and family which of the following about positioning during the postoperative period?
a) sleep only on the left side c) bend below the waist as often as you are able
b) sleep on the right side or the back d) lower the head between the knees three times a day
75. A client has undergone surgery for glaucoma. The nurse provides which discharge instructions to the client?
a) the sutures are removed after 1 week c) expect that vision will be permanently impaired
b) wound healing usually takes 12 weeks d) shield/eye patch should be worn to protect the eye
76. A client is seen in the health care clinic, and a diagnosis of conjunctivitis is made. The nurse provides instructions to
the client regarding the care of the disorder while at home. Which statement by the client indicates the need for further
instruction?
a) I can use an ophthalmic analgesic ointment at night if I have eye discomfort
b) I do not need to be concerned about spreading this infection to others in my family
c) I should apply warm compresses before instilling antibiotic drops if purulent discharge is present in my eye
d) I should perform a saline eye irrigation before instilling the antibiotic drops into my eye if purulent discharge is
present

77. The nurse has an order to administer two opthalmic medications to the client who has undergone eye surgery. The
nurse waits how many minutes after administering the first medication before giving the second?
a) 1 to 2
b) 3 to 5
c) 8 to 10
d) it is not necessary to wait; the second medication can be administered immediately

78. The nurse is assigned to care for a client who has just undergone cataract surgery. The nurse plans to instruct the
client that which of the following activities is permitted in the postoperative period?
a) bending over b) lifting objects c) coughing exercises d) watching television

79. During a routine visit to the physician's office for monitoring of diabetic control, an older client with diabetes mellitus
complains to the nurse of vision changes. The client describes blurring of vision with difficulty in reading and with driving
at night. Given the history, the nurse interprets that the client is probably developing:
a) cataracts b) glaucoma c) papilledema d) detached retina

80. A client arrives at the emergency room with a chemical burn of the left eye. The nurse immediately:
a) applies a light bandage to the eye c) applies a cold compress to the injured eye
b) performs an assessment on the client d) flushes the eye continuously with a sterile solution
81. Pilocarpine hydrochloride (Isopto Carpine) is prescribed for the client with glaucoma. Which of the following
medications does the nurse plan to have available in case of systemic toxicity?
a) atropine sulfate c) protamine sulfate
b) pindolol (Visken) d) naloxone hydrochloride (Narcan)
82. Betaxolol hydrochloride (Betoptic) eye drops have been prescribed for the client with glaucoma. Which of the
following nursing actions is most appropriate related to monitoring for the side effects of this medication?
a) monitoring temperature c) assessing peripheral pulses
b) monitoring blood pressure d) assessing blood glucose level

83. Tonometry is performed on the client with a suspected diagnosis of glaucoma. The nurse analyzes the test results as
documented in the client's chart and understands that the normal intraocular pressure is:
a) 2 to 7 mm Hg b) 10 to 21 mm Hg c) 22 to 30 mm Hg d) 31 to 35 mm Hg

84. The nurse is preparing a teaching plan for a client who is undergoing cataract extraction with intraocular
implantation. Which home care measures will the nurse include in the plan? Select all that apply
a) avoid activities that require bending over d) episodes of sudden severe eye pain is expected
b) contact the surgeon if eye scratchiness occurs e) contact surgeon if a decrease in visual acuity occurs
c) place an eye shield on the surgical eye at bedtime f) take acetaminophen for minor eye discomfort

85. The nurse is caring for a client following enucleation. The nurse notes the presence of bright red drainage on the
dressing. Which nursing action is appropriate?
a) notify the physician
b) document the finding
c) continue to monitor the drainage
d) mark the drainage on the dressing and monitor for any increase in bleeding

86. A 55-year old woman was working in her garden. She accidentally sprayed insecticide into her right eye. She calls the
emergency room frantic and screaming for help. The nurse should instruct the woman to take which immediate action?
a) call the physician c) come to the emergency room
b) irrigate the eyes with water d) irrigate the eyes with diluted hydrogen peroxide
87. The nurse is caring for a client with a diagnosis of detached retina. Which assessment sign would indicate that
bleeding has occurred as a result of the retinal detachment?
a) total loss of vision c) a sudden sharp pain in the eye
b) a reddened conjunctiva d) complaints of a burst of black spots or floaters
88. The client arrives in the emergency room following an automobile accident. The client's forehead hit the steering
wheel and a hyphema is diagnosed. The nurse places the client in which position?
a) flat on bed rest c) lateral on the affected side
b) semi-fowler's on bed rest d) lateral on the unaffected side

89. During the early postoperative period, the client who has had a cataract extraction complains of nausea and severe
eye pain over the operative site. The initial nursing action is to:
a) call the physician c) turn the client on his or her operative side
b) reassure the client that this is normal d) administer ordered pain meds and anti-emetic
90. The client is being discharged from the ambulatory care unit following cataract removal. The nurse provides
instructions regarding home care. Which of the following, if stated by the client, indicates an understanding of the
instructions?
a) I will take aspirin if I have any discomfort
b) I will sleep on the side that I was operated on
c) I will not lift anything if weighs more than 10 pounds
d) I will wear my eye shield at night and my glasses during the day

91. Shortly after a neonate is delivered, erythromycin is instilled into the neonate’s eyes. This drug is given to prevent:
a. Ophthalmia neonatorum c. Corneal keratitis
b. Retrolental fibroplasias d. Acute uveitis
92. An older female client confides to the visiting nurse that she is afraid she will fall while going to the bathroom at
night. Which suggestion, if made by the nurse, indicates that the nurse understands the visual changes affecting the
older client?
a) limit your fluid intake during the day c) keep a red light on the bathroom at night
b) use a commode in your bedroom at night d) use a bell to call daughter if you need to get up

93. A nurse is providing instructions to a client and the family regarding home care after right eye cataract removal.
Which statement by the client would indicate an understanding of the instructions?
a) I will not sleep on my left side c) I will not sleep with my head elevated
b) I will not sleep on my right side d) I won’t wear my glasses til my physician says it’s okay
94. A day care nurse is observing a 2-year old child and suspects that the child may have strabismus. Which observation
made by the nurse might indicate this condition?
a) the child has difficulty c) the child consistently turns the head to see
b) the child consistently tills the head to see d) the child does not respond when spoken to
95. The mother of a 6-year old child arrives at a clinic because the child has been experiencing scratchy, red, and swollen
eyes. The nurse notes a discharge from the eyes and sends a culture to the laboratory for analysis. Chlamydial
conjunctivitis is diagnosed. Based on this diagnosis, the nurse determines that which of the following requires further
investigation?
a) possible trauma c) presence of an allergy
b) possible sexual abuse d) presence of a respiratory infection
96. A nurse prepares a teaching plan for a mother of a child diagnosed with bacterial conjunctivitis. Which of the
following, if stated by the mother, indicates a need for further teaching?
a) I need to wash my hands frequently c) it is okay to share towels and washcloths
b) I need to clean the eye as prescribed d) I need to give the eye drops as prescribed
97. A nurse provides discharge instructions to the mother of a child after myringotomy with insertion of tympanostomy
tubes. The nurse determines that the mother needs additional instructions if the mother states that:
a) swimming in deep water is prohibited c) she will place earplugs in the child's ears during baths
b) swimming in lake water needs to be avoided d) she will give her child soft tissues to blow his nose

98. Which of the following is an effective technique of communicating with a hearing impaired client?
a) speak slowly in a low tone of voice c) speak slowly and try to overemphasize words
b) speak slowly in a loud voice d) speak slowly and directly in front of the client
99. Which of the following client statements indicates the need to postpone cataract surgery in the morning?
a) this seasonal allergy should no be a problem c) I feel nervous with my operation tomorrow
b) the meds instilled to my eyes make my vision blurred d) I have allergy to certain medications

100. Which of the following is done when performing Weber test?

a) place vibrating tuning fork in front of the ear opening c) place vibrating tuning fork behind the ear
b) place vibrating tuning fork in the middle of the head d) irrigate ear w/ cold water and observe eye movement
101. The client has been diagnosed to have Meniere's disease. Which of the following should be included when giving
health teachings?
a) limit carbohydrates and proteins in the diet c) limit fats in the diet
b) limit salt intake d) drink a lot of fluids
102. The nurse plans care for a client with acute glaucoma who reports severe pain in the eyes and rainbow colors
(halos) around lights. Which action should the nurse take first?
a) administer pain medication
b) explain to the client that with reduction in intraocular pressure, pain and other symptoms will subside
c) provide preoperative teachings to the client
d) assess the client's visual status

103. A physician prescribes "patching" for a child with strabismus of the right eye. A nurse instructs the mother
regarding this procedure. Which of the following statements when made by the mother indicates that she understands
the instruction?
a) I will place the patch on the right eye c) I will place the patch on the left eye
b) I will place the patch on both eyes d) I will alternate patch from right to left eye hourly
104. The client comments, "I frequently change my eye glasses, none of which is satisfactory and I have difficulty
focusing on my work." Which of the following disorders may the client be experiencing?
a) cataract b) glaucoma c) detached retina d) myopia

105. An 85-yr old complains of pain in her operated eye after cataract removal surgery. This symptoms is:
a) expected, and she should offer analgesic c) unexpected and may indicate hemorrhage
b) unexpected and may signify a detached retina d) expected and should advise client to be on bed rest
106. The client had just undergone repair of detached retina. Which should be included in the NCP of the client?
a) encourage self-care activities c) restrict excessive talking
b) limit movement of his eyes d) limit fluid intake
Situation: Mang Tomas is a 60 year old man who has just had cataract surgery performed on his right eye.

107. The physician has prescribed Cyclogel preoperatively to:

a) prevent dryness of the cornea and conjunctiva
b) reduce the inflammation of the iris and choroids
c) paralyze the ciliary muscle
d) promote drainage of aqueous humor from the chamber of the eye

108. After discharge, Mang Tomas attends the eye clinic for follow-up visits. When he receives his cataract glasses, it is
important that the nurse advise him that:
a) his peripheral vision will be increased c) magnification by the lens is only about 10%
b) objects will appear closer than they really are d) daily eye drops are required with these lenses
109. The nurse should instruct a client preparing for eye surgery that which of these activities will be restricted post-
operatively?
a) bending with the knees flexed c) keeping the head in a neutral position
b) bending from the waist d) lying flat
110. Nursing care for Mang Tomas during the first 48 hours after surgery will include:
a) maintain bed rest c) encouraging coughing and deep breathing
b) changing the dressing daily d) lie on the unoperated side