TEST
The Client with Health Problems of the Eyes,
15 Ears, Nose, and Throat
■ The Client with Cataracts
■ The Client with a Retinal Detachment
■ The Client with Glaucoma
■ The Client with Adult Macular Degeneration
■ The Client Undergoing Nasal Surgery
■ The Client with a Hearing Disorder
■ The Client with Ménière’s Disease
■ The Client with Cancer of the Larynx
■ Managing Care Quality and Safety
■ Answers, Rationales, and Test Taking Strategies
The Client with Cataracts
1. The nurse is observing a student nurse
administer eyedrops, as shown in the figure. What
should the nurse instruct the student to do?
■ 1. Move the dropper to the inner canthus.
■ 2. Have the client raise her eyebrows.
■ 3. Administer the drops in the center of the
lower lid.
■ 4. Have the client squeeze both eyes after
administering the drops.
2. A client is having a cataract removed and
will use eyeglasses after the surgery. The nurse
should develop a teaching plan that includes which
of the following? Select all that apply.
■ 1. Images will appear to be one-third larger.
■ 2. Look through the center of the glasses.
■ 3. The changes will be immediate.
■ 4. Use handrails when climbing stairs.
■ 5. Stay out of the sun for 2 weeks.
onlywearsunglasses
3. The client has had a cataract removed. The
nurse’s discharge instructions should include which
of the following? side
r sideto
■ 1. Keep the head aligned straight.
■ 2. Utilize bright lights in the home.m medscansephoto
■ 3. Use an eye shield at night.
r 2ndptoday
sensitivity
■ 4. Change the eye patch as needed.
4. The client with a cataract tells the nurse that
she is afraid of being awake during eye surgery.
Which of the following responses by the nurse
would be the most appropriate?
■ 1. “Have you ever had any reactions to local
anesthetics in the past?”
■ 2. “What is it that disturbs you about the idea of
being awake?”
■ 3. “By using a local anesthetic, you won’t have
nausea and vomiting after the surgery.”
■ 4. “There’s really nothing to fear about being
awake. You’ll be given a medication that will
help you relax.”
5. A client tells the nurse his vision is blurred
and hazy throughout the entire day. The nurse
should recommend that the client do which of the
following?
■ 1. Purchase a pair of magnifying glasses.
■ 2. Wear glasses with tinted lenses.
■ 3. Schedule an appointment with an optician.
■ 4. Schedule an appointment with an
I ophthalmologist.
hairatoried
I turn as
667
 668 The Nursing Care of Adults with Medical and Surgical Health Problems
6. The nurse is to instill drops of phenylephrine
hydrochloride (Neo-Synephrine) into the client’s
eye prior to cataract surgery. Which of the following
is the expected outcome?
■ 1. Dilation of the pupil and blood vessels.
■ 2. Dilation of the pupil and constriction of blood
vessels.
■ 3. Constriction of the pupil and constriction of
blood vessels.
■ 4. Constriction of the pupil and dilation of
blood vessels.
7. A short time after cataract surgery, the client
complains of nausea. The nurse should first:
■ 1. Instruct the client to take a few deep breaths
until the nausea subsides.
■ 2. Explain that this is a common feeling that
antiemetic will pass quickly.
■ 3. Tell the client to call the nurse promptly if
to XNN vomiting occurs.
Vomiting ■ 4. Medicate the client with an antiemetic, as
ordered.
TTIP
8. Which of the following is a potential
complication following cataract surgery? Select all
that apply.
s aureus
■ 1. Acute bacterial endophthalmitis.
■ 2. Retrobulbar hemorrhage.BEFORE
■ 3. Rupture of the posterior capsule.
■ 4. Suprachoroidal hemorrhage. JDURING
■ 5. Vision loss.
9. The nurse is instructing the client about
postoperative care following cataract removal. What
position should the nurse teach the client to use?
■ 1. Remain in a semi–Fowler’s position. or NONop
■ 2. Position the feet higher than the body. side ■ 3. Protect the injured eye from infection.
■ 3. Lie on the operative side.x x ■ 4. Rest the eyes to promote healing.
x
■ 4. Place the head in a dependent position. Hop
10. After returning home, a client who has had
cataract surgery will need to continue to instill eye
drops in the affected eye. The client is instructed to
apply slight pressure against the nose at the inner
canthus of the eye after instilling the eyedrops. The
punctate rationale that supports applying pressure is that it:
■ 1. Prevents the medication from entering the
occlusion
tear duct.
■ 2. Prevents the drug from running down the
client’s face.
■ 3. Allows the sensitive cornea to adjust to the
medication.
■ 4. Facilitates distribution of the medication over
the eye surface.
11. To decrease intraocular pressure following
cataract surgery, the nurse should instruct the client
to avoid:
■ 1. Lying supine.
■ 2. Coughing. opera.adtive
sneezing crying straining
■ 3. Deep breathing.
■ 4. Ambulation.
12. After cataract removal surgery, the client is
instructed to report sharp pain in the operative eye
because this could indicate which of the following
postoperative complications?
■ 1. Detached retina. painless
■ 2. Prolapse of the iris.
sundoffynshfgrpppain
■ 3. Extracapsular erosion.
■ 4. Intraocular hemorrhage. r
The Client with a Retinal
Detachment
13. The client is diagnosed in the emergency
department with a detached retina in the right eye.
The nurse should do which of the following first?
■ 1. Apply compresses to the eye.
■ 2. Instruct the client to lie prone.
■ 3. Remove all bed pillows.
■ 4. Promote measures that limit mobility.
14. A client with detachment of the retina is to
patch both eyes. The expected outcome of patching
is to:
■ 1. Reduce rapid eye movements.
■ 2. Decrease the irritation caused by light enter-
ing the damaged eye.
15. The client with retinal detachment in the
right eye is extremely apprehensive. He states, “I’m
afraid of going blind. It would be so hard to live that
way.” What factor should the nurse consider before
responding to his statement?
■ 1. Repeat surgery is impossible, so if this proce-
dure fails, vision loss is inevitable.
■ 2. The surgery will only delay blindness in the
right eye, but vision is preserved in the left
eye.
■ 3. More and more services are available to help
newly blind people adapt to daily living.
■ 4. Optimism is justified because surgical treat-
ment has a 90% to 95% success rate.
 The Client with Health Problems of the Eyes, Ears, Nose, and Throat
16. Which of the following statements would
provide the best guide for activity during the reha-
bilitation period for a client who has been treated
for retinal detachment?
■ 1. Activity is resumed gradually, and the cli-
ent can resume her usual activities in 5 to 6
weeks.
■ 2. Activity level is determined by the client’s
tolerance; she can be as active as she wishes.
■ 3. Activity level will be restricted for several
months, so she should plan on being seden-
tary.
■ 4. Activity level can return to normal and may
include regular aerobic exercises.
17. Which of the following goals is a priority
for a client who has undergone surgery for retinal
detachment?
■ 1. Control pain.
■ 2. Prevent an increase in intraocular pressure.
■ 3. Promote a low-sodium diet.
■ 4. Maintain a darkened environment.
The Client with Glaucoma
18. A client with glaucoma is to receive 3 gtt of
acetazolamide (Diamox) in the left eye. What should
the nurse do?
■ 1. Ask the client to close his right eye while
administering the drug in the left eye.
■ 2. Have the client look up while the nurse
administers the eyedrops.
■ 3. Have the client lift his eyebrows while the
nurse positions the hand with the dropper on
the client’s forehead.
■ 4. Wipe the eyes with a tissue following admin-
istration of the drops.
19. A client who has been treated for chronic
open-angle glaucoma (COAG) for 5 years asks the
nurse, “How does glaucoma damage my eyesight?”
The nurse’s reply should be based on the knowledge
that COAG:
■ 1. Results from chronic eye inflammation.
■ 2. Causes increased intraocular pressure.
■ 3. Leads to detachment of the retina.
■ 4. Is caused by decreased blood flow to the
retina.
20. The nurse should assess clients with chronic
open-angle glaucoma (COAG) for:
■ 1. Eye pain.
■ 2. Excessive lacrimation.
■ 3. Colored light flashes.
■ 4. Decreasing peripheral vision.
669
21. The expected outcome of using miotics to
treat glaucoma is:
MYDRIATIC
■ 1. Paralyzing ciliary muscles. S
i intraocular vessels.
■ 2. Constricting
■ 3. Constricting the pupil.
■ 4. Relaxing ciliary muscles.
Intros
22. Which of the following should the nurse pro-
vide as part of the information to prepare the client
for tonometry?
■ 1. Oral pain medication will be given before the
procedure.
measuresIOP
■ 2. It is a painless procedure with no adverse
effects. 1021
■ 3. Blurred or double vision may occur after the
procedure.
■ 4. Medication will be given to dilate the pupils
before the procedure.
23. A client uses timolol maleate (Timoptic) eye-
drops. The expected outcome of this beta-adrenergic
blocker is to control glaucoma by:
■ 1. Constricting the pupils.
■ 2. Dilating the canals of Schlemm.
■ 3. Reducing aqueous humor formation.
■ 4. Improving the ability of the ciliary muscle to
contract.
24. The nurse observes the client instill eye-
drops. The client says, “I just try to hit the middle
of my eyeball so the drops don’t run out of my eye.”
The nurse explains to the client that this method
may cause:
■ 1. Scleral staining.
■ 2. Corneal injury.
■ 3. Excessive lacrimation.
■ 4. Systemic drug absorption.
25. Which of the following clinical manifesta-
tions should the nurse asessess when a client has
acute angle-closure glaucoma?
■ 1. Gradual loss of central vision.
■ 2. Acute light sensitivity.
■ 3. Loss of color vision.
■ 4. Sudden eye pain.
26. A client has been diagnosed with an acute
episode of angle-closure glaucoma. The nurse plans
the client’s nursing care with the understanding that
acute angle-closure glaucoma:
■ 1. Frequently resolves without treatment.
■ 2. Is typically treated with sustained bed rest.
■ 3. Is a medical emergency that can rapidly lead
to blindness.
■ 4. Is most commonly treated with steroid
therapy.
670 The Nursing Care of Adults with Medical and Surgical Health Problems
The Client with Adult Macular
Degeneration
27. The nurse should assess an older adult with
macular degeneration for:
■ 1. Loss of central vision.
■ 2. Loss of peripheral vision.
■ 3. Total blindness.
■ 4. Blurring of vision.
28. A 75-year-old male client has a history of
macular degeneration. While he is in the hospital,
the priority nursing goal will be:
■ 1. To provide education regarding community
services for clients with adult macular degen-
eration (AMD).
■ 2. To provide health care related to monitoring
his eye condition.
■ 3. To promote a safe, effective care environment.
■ 4. To improve vision.
29. Although all of the following measures might
be useful in reducing the visual disability of a cli-
ent with adult macular degeneration (AMD), which
measure should the nurse teach the client primarily
as a safety precaution?
■ 1. Wear a patch over one eye.
■ 2. Place personal items on the sighted side.
■ 3. Lie in bed with the unaffected side toward
the door.
■ 4. Turn the head from side to side when
walking.
30. The nurse is assessing a client with macu-
lar degeneration. Identify the illustration that best
depicts what clients with this disorder typically see.
31. When the nurse enters the client’s room, the
nurse perceives that the client is staring straight
ahead. Which of the following is the best course of
action for the nurse to take next?
■ 1. Hold an interdisciplinary meeting on the
client’s behalf promptly.
■ 2. Consult with psychiatry.
■ 3. Listen to the client and observe the body
language.
■ 4. Address the client by first name upon enter-
ing the room.
The Client Undergoing Nasal Surgery
32. A 27-year-old female is admitted for elective
nasal surgery for a deviated septum. Which of the
following would be an important initial clue that
bleeding was occurring even if the nasal drip pad
remained dry and intact?
■ 1. Complaints of nausea.
■ 2. Repeated swallowing.
■ 3. Rapid respiratory rate.
■ 4. Feelings of anxiety.
33. The client is ready for discharge after sur-
gery for a deviated septum. Which of the following
discharge instructions would be appropriate?
■ 1. Avoid activities that elicit Valsalva’s maneuver.
■ 2. Take aspirin to control nasal discomfort.
■ 3. Avoid brushing the teeth until the nasal pack-
ing is removed.
■ 4. Apply heat to the nasal area to control swelling.
34. Which of the following statements would
indicate to the nurse that the client who has under-
gone repair of her nasal septum has understood the
discharge instructions?
■ 1. “I should not shower until my packing is
removed.”
■ 2. “I will take stool softeners and modify my
diet to prevent constipation.”
■ 3. “Coughing every 2 hours is important to pre-
vent respiratory complications.”
■ 4. “It is important to blow my nose each day to
remove the dried secretions.”
The Client with a Hearing Disorder
35. To approach a deaf client, the nurse should
do which of the following first?
■ 1. Knock on the room’s door loudly.
■ 2. Close and open the vertical blinds rapidly.
■ 3. Talk while walking into the room.
■ 4. Get the client’s attention.
 The Client with Health Problems of the Eyes, Ears, Nose, and Throat
36. A 75-year-old client who has been taking
furosemide (Lasix) regularly for 4 months tells the
nurse that he is having trouble hearing. What would
be the nurse’s best response to this statement?
■ 1. Tell the client that because he is 75 years old,
it is inevitable that his hearing should begin
to deteriorate.
■ 2. Have the client immediately report the hear-
ing loss to his physician.
■ 3. Schedule the client for audiometric testing
and a hearing aid.
■ 4. Tell the client that the hearing loss is only
temporary; when his system adjusts to the
furosemide, his hearing will improve.
37. The nurse has been assigned to a client who
is hearing impaired and reads speech. Which of the
following strategies should the nurse incorporate
when communicating with the client? Select all that
apply.
■ 1. Avoiding being silhouetted against strong
light.
■ 2. Not blocking out the person’s view of the
speaker’s mouth.
■ 3. Facing the client when talking.
■ 4. Having bright light behind so the individual
can see.
■ 5. Ensuring the client is familiar with the sub-
ject material before discussing.
■ 6. Talking to the client while doing other nurs-
ing procedures.
38. The client with a hearing aid does not seem
to be able to hear the nurse. The nurse should do
which of the following?
■ 1. Contact the client’s audiologist.
■ 2. Cleanse the hearing aid ear mold in normal
saline.
■ 3. Irrigate the ear canal.
■ 4. Check the hearing aid’s placement.
39. Sensorineural hearing loss results from
which of the following conditions?
■ 1. Presence of fluid and cerumen in the external
canal.
■ 2. Sclerosis of the bones of the middle ear.
■ 3. Damage to the cochlear or vestibulocochlear
nerve.
■ 4. Emotional disturbance resulting in a func-
tional hearing loss.
40. A 65-year-old male has hearing loss and a
sensation of fullness in both ears. The nurse exam-
ines his ears with the understanding that a common
cause of hearing loss in older adults is related to:
■ 1. Accumulation of cerumen in the external
canal.
■ 2. Accumulation of cerumen in the internal
canal.
■ 3. External otitis.
■ 4. Exostosis.
671
41. The best method to remove cerumen from a
client’s ear involves:
■ 1. Inserting a cotton-tipped applicator into the
external canal.
■ 2. Irrigating the ear gently.
■ 3. Using aural suction.
■ 4. Using a cerumen curette.
42. To prepare the irrigation solution used for
removal of cerumen, the nurse should use:
■ 1. Normal saline.
■ 2. Sterile water. causetissue dmg
■ 3. Antiseptic solution.
■ 4. Warm tap water.
43. A client is about to have a tympanoplasty,
and asks the nurse what the surgical procedure
involves. The nurse begins the conversation by:
■ 1. Assessing the client’s understanding of what
the physician has explained.
■ 2. Describing the surgical procedure.
■ 3. Educating the client that the procedure will
close the perforation and prevent recurrent
infection.
■ 4. Informing the client that the procedure will
improve hearing.
44. An older adult takes two 81 mg aspirin tab-
lets daily to prevent a heart attack. The client reports
having a constant “ringing” in both ears. How
should the nurse respond to the client’s comment?
■ 1. Tell the client that “ringing” in the ears is
associated with the aging process.
■ 2. Refer the client to have a Weber test.
■ 3. Schedule the client for audiometric testing.
■ 4. Explain to the client that the “ringing” may
be related to the aspirin.
The Client with Ménière’s Disease
45. A client has vertigo. Which of the following
actions would be most appropriate for the nursing
diagnosis of Risk for injury related to altered immo-
bility and gait disturbances? Select all that apply.
■ 1. The client assumes safe position when dizzy.
■ 2. The client experiences no falls.
■ 3. The client performs vestibular/balance
exercises.
■ 4. The client demonstrates family involvement.
■ 5. The client keeps head still when dizzy.
46. The client with Ménière’s disease is
instructed to modify his diet. The nurse should
explain that the most frequently recommended diet
modification for Ménière’s disease is:
■ 1. Low sodium.
■ 2. High protein.
■ 3. Low carbohydrate.
■ 4. Low fat.
672 The Nursing Care of Adults with Medical and Surgical Health Problems
47. Which of the following statements indicates
the client understands the expected course of
Ménière’s disease?
■ 1. “The disease process will gradually extend to
the eyes.”
■ 2. “Control of the episodes is usually possible,
but a cure is not yet available.”
■ 3. “Continued medication therapy will cure the
disease.”
■ 4. “Bilateral deafness is an inevitable outcome
of the disease.”
48. The risk for injury during an attack of
Ménière’s disease is high. The nurse should instruct
the client to take which immediate action when
experiencing vertigo?
■ 1. “Place your head between your knees.”
■ 2. “Concentrate on rhythmic deep breathing.”
■ 3. “Close your eyes tightly.”
■ 4. “Assume a reclining or flat position.”
49. The nurse should assess the client with
Ménière’s disease for the intended outcomes of
which of the following medications that are com-
monly used to manage the disease? Select all that
apply.
■ 1. Antihistamines.
■ 2. Antiemetics.
■ 3. Diuretics.
■ 4. Non-steroidal anti-inflammatory drugs
(NSAIDs).
■ 5. Antipyretics.
50. A client with Ménière’s disease continues to
have disabling attacks of vertigo and elects to have
a labyrinthectomy. A priority nursing diagnosis for
the client before surgery is:
■ 1. Deficient diversional activity related to inabil-
ity to participate secondary to vertigo.
■ 2. Risk for injury related to vertigo.
■ 3. Powerlessness related to inability to influence
effects of disease process
■ 4. Social isolation related to hearing loss.
The Client with Cancer of the Larynx
51. Following a laryngectomy, the nurse notices
that the client has saliva collecting beneath the skin
flaps. This finding is indicative of which of the fol-
lowing?
■ 1. Skin necrosis.
■ 2. Carotid artery rupture.
■ 3. Stomal stenosis.
■ 4. Development of a fistula.
52. The nurse is developing a care plan with
a client who had a laryngectomy 3 days ago. The
nurse should instruct the client to do which of the
following to assure adequate nutrition. Select all
that apply.
■ 1. Weigh weekly and report weight loss.
■ 2. When eating, sit and lean slightly forward.
■ 3. Have serum albumin level checked regularly.
■ 4. Administer enteral tube feedings as ordered.
■ 5. Manipulate the nasogastric tube daily.
53. The client with a laryngectomy is being dis-
charged. The nurse should determine that the client
understands to do which of the following self-care
measures? Select all that apply.
■ 1. Provide humidification in the home.
■ 2. Use a protective shield over the stoma for
bathing.
■ 3. Consume a liberal intake of fluids (2 to
3 L/day).
■ 4. Limit spicy seasonings on food.
■ 5. Follow a low-fiber diet.
54. After a total laryngectomy, the client has a
feeding tube. The feeding tube is effective if the tube
feedings:
■ 1. Meet the fluid and nutritional needs of the
client.
■ 2. Prevent aspiration.
■ 3. Prevent fistula formation.
■ 4. Maintain an open airway.
55. Complications associated with a tracheos-
tomy tube include:
■ 1. Decreased cardiac output.
■ 2. Damage to the laryngeal nerve.
■ 3. Pneumothorax.
■ 4. Acute respiratory distress syndrome (ARDS).
56. A priority goal for the hospitalized client
who 2 days earlier had a total laryngectomy with
creation of a new tracheostomy would be to:
■ 1. Decrease secretions.
■ 2. Instruct the client in caring for the tracheos-
tomy.
■ 3. Relieve anxiety related to the tracheostomy.
■ 4. Maintain a patent airway.
Managing Care Quality and Safety
57. The client with glaucoma is scheduled for
a hip replacement. Which of the following orders
would require clarification before the nurse carries
it out?
■ 1. Administer morphine sulfate.
■ 2. Administer atropine sulfate.
■ 3. Teach deep-breathing exercises.
■ 4. Teach leg lifts and muscle-setting exercises.
 The Client with Health Problems of the Eyes, Ears, Nose, and Throat
58. To ensure safety for a hospitalized blind client,
the nurse should:
■ 1. Require that the client has a sitter for each
shift.
■ 2. Require that the client stays in bed until the
nurse can assist.
■ 3. Orient the client to the room environment.
■ 4. Keep the side rails up when the client is
alone.
59. The nurse is taking care of a client who had a
laryngectomy yesterday. To assure client safety, the
nurse should give “hand-off reports” at which of the
following times? Select all that apply.
■ 1. Change of shift.
■ 2. Change of nurses.
■ 3. When nurse goes to lunch.
■ 4. When unit clerk goes to a staff meeting.
■ 5. When new medication orders are written.
60. The nurse is admitting a client with glau-
coma. The client brings prescribed eye drops from
home and insists on using them in the hospital. The
nurse should:
■ 1. Allow the client to keep the eye drops at the
bedside and use as prescribed on the bottle.
■ 2. Place the eye drops in the hospital medica-
tion drawer and administer as labeled on the
bottle.
■ 3. Explain to the client that the physician will
write an order for the eye drops to be used at
the hospital.
■ 4. Ask the client’s wife to assist the client in
administering the eye drops while the client
is in the hospital.
Answers, Rationales, and Test
Taking Strategies
The answers and rationales for each question follow
below, along with keys ( ) to the client need
(CN) and cognitive level (CL) for each question. Use
these keys to further develop your test-taking skills.
For additional information about test-taking skills
and strategies for answering questions, refer to pages
10–21, and pages 25–26 in Part 1 of this book.
The Client with Cataracts
1. 3. The student has positioned the dropper
and the client correctly to prevent injury to the cli-
ent’s eye. The student should administer the drops
in the center of the lower lid. Following administra-
tion of the eyedrops, the client should blink her eyes
673
to distribute the medication; squeezing or rubbing
her eyes might cause the medication to drip out of
the eye.
CN: Safety and infection control;
CL: Apply
2. 1, 2, 4. The use of glasses following cataract
surgery does not totally restore binocular vision.
Glasses will cause images to appear larger and
peripheral vision will be distorted; the client should
look through the center of the glasses and turn his or
her head to view objects in the periphery. The client
should also use caution when walking or climbing
stairs until he or she has adjusted to the change in
vision. Changes in vision following cataract surgery
are not immediate and the nurse can instruct the
client to be patient while adjusting to the changes.
The client does not need to stay out of the sun, but
should wear dark glasses to prevent discomfort from
photophobia.
CN: Physiological adaptation;
CL: Create
3. 3. Using an eye shield at night prevents rub-
bing the eye. The head should be turned to the side
to scan the entire visual field to compensate for
impaired peripheral vision. Eye medications may
initially cause sensitivity to bright light. The sur-
geon changes the eye patch on the second postop-
erative day.
CN: Reduction of risk potential;
CL: Synthesize
4. 2. The nurse should give a client who seems
fearful of surgery an opportunity to express her feel-
ings. Only after identifying the client’s concerns can
the nurse intervene appropriately. Asking the client
about previous reactions to local anesthetics may
be warranted, but it does not address the client’s
concerns in this instance. Telling the client that she
will not have nausea or vomiting ignores the client’s
feelings of fear and does not provide any data about
the client’s feelings. More data would help the nurse
plan care. Telling the client that there is nothing
to be afraid of minimizes her feelings and does not
address her concerns. Premature explanations and
clichés do not provide needed assessment data and
ignore the client’s feelings.
CN: Psychosocial adaptation;
CL: Synthesize
5. 4. An ophthalmologist is a physician who
specializes in the treatment of disorders of the eye,
and the nurse should advise the client to see a
physician. An optician makes glasses and it is not
known at this point what the best treatment for the
client is. Magnifying glasses, or glasses with tinted
lenses, do not correct hazy or blurred vision. If
674 The Nursing Care of Adults with Medical and Surgical Health Problems
glasses are needed to correct refractive errors, they
should be prescription glasses.
CN: Health promotion and maintenance;
CL: Synthesize
6. 2. Instilled in the eye, phenylephrine hydro-
chloride (Neo-Synephrine) acts as a mydriatic, caus-
ing the pupil to dilate. It also constricts small blood
vessels in the eye.
CN: Pharmacological and parenteral
therapies; CL: Evaluate
7. 4. A prescribed antiemetic should be admin-
istered as soon as the client complains of nausea fol-
lowing a cataract extraction. Vomiting can increase
intraocular pressure, which should be avoided after
eye surgery because it can cause complications.
Deep breathing is unlikely to relieve nausea. Postop-
erative nausea may be common; however, it doesn’t
necessarily pass quickly and can lead to vomiting.
Telling the client to call only if vomiting occurs
ignores the client’s need for comfort and interven-
tion to prevent complications.
CN: Pharmacological and parenteral
therapies; CL: Synthesize
8. 1, 5. Acute bacterial endophthalmitis can
occur in about 1 out of 1,000 cases. Organisms that
are typically involved include Staphylococcus epi-
dermidis, S. aureus, and Pseudomonas and Proteus
species. Vision loss is one result of acute bacterial
infection. In addition, vision loss can be the result
of malposition of the intraocular lens implant or
opacification of the posterior capsule. Retrobulbar
hemorrhage is a complication that may occur right
before surgery and is a result of retrobulbar infiltra-
tion of anesthetic agents. Rupture of the posterior
capsule and suprachoroidal hemorrhage are both
complications that can result during surgery.
CN: Physiological adaptation;
CL: Analyze
9. 1. The nurse should instruct the client to
remain in a semi-Fowler’s position or on the non-
operative side. Positioning the feet higher than the
body does not affect the operative eye; placing the
head in a dependent position could increase pres-
sure within the eyes.
CN: Reduction of risk potential;
CL: Synthesize
10. 1. Applying pressure against the nose at the
inner canthus of the closed eye after administering
eyedrops prevents the medication from entering
the lacrimal (tear) duct. If the medication enters
the tear duct, it can enter the nose and pharynx,
where it may be absorbed and cause toxic symp-
toms. Eyedrops should be placed in the eye’s lower
conjunctival sac. Applying pressure will not prevent
the drug from running down the face as long as the
drops are instilled in the eye. Pressure does not
affect the cornea or facilitate distribution of the
medication over the eye surface.
CN: Pharmacological and parenteral
therapies; CL: Apply
11. 2. Coughing is contraindicated after cataract
extraction because it increases intraocular pressure.
Other activities that are contraindicated because
they increase intraocular pressure include: turning
to the operative side, sneezing, crying, and strain-
ing. Lying supine, ambulating, and deep breathing
do not affect intraocular pressure.
CN: Physiological adaptation;
CL: Synthesize
12. 4. Sudden, sharp pain after eye surgery
should suggest to the nurse that the client may be
experiencing intraocular hemorrhage. The physician
should be notified promptly. Detached retina and
prolapse of the iris are usually painless. Extracapsu-
lar erosion is not characterized by sharp pain.
CN: Physiological adaptation;
CL: Analyze
The Client with a Retinal
Detachment
13. 4. Promoting measures that limit mobil-
ity may prevent further injury. Following surgical
repair of a detached retina, cool or warm com-
presses are applied to edematous eyelids, if ordered.
The client should avoid lying face down, stooping,
or bending pre-operatively. It is not necessary to
remove all pillows.
CN: Physiological adaptation;
CL: Synthesize
14. 1. Patching the eyes helps decrease random
eye movements that could enlarge and worsen reti-
nal detachment. Although clients with eye injuries
frequently are light-sensitive, and preventing infec-
tion is important, the specific goal is to reduce rapid
eye movements. Resting the eye is an indirect way
of stating the objective.
CN: Physiological adaptation;
CL: Evaluate
15. 4. Untreated retinal detachment results in
increasing detachment and eventual blindness, but
90% to 95% of clients can be successfully treated
with surgery. If necessary, the surgical procedure
can be repeated about 10 to 14 days after the first
procedure. Many more services are available for
 The Client with Health Problems of the Eyes, Ears, Nose, and Throat
newly blind people, but ideally this client will not
need them. Surgery does not delay blindness.
CN: Physiological adaptation;
CL: Synthesize
16. 1. The scarring of the retinal tear needs time
to heal completely. Therefore, resumption of activity
should be gradual; the client may resume her usual
activities in 5 to 6 weeks. Successful healing should
allow the client to return to her previous level of
functioning.
CN: Basic care and comfort;
CL: Synthesize
17. 2. After surgery to correct a detached retina,
prevention of increased intraocular pressure is the
priority goal. Control of pain with analgesics is the
second goal. Following a low-sodium diet or main-
taining a darkened environment is not a goal for this
client.
CN: Physiological adaptation;
CL: Synthesize
The Client with Glaucoma
18. 2. The client should look up while the nurse
instills the eyedrops. The client will need to keep
both eyes open while the nurse administers the drug.
If the client raises his eyebrows while the nurse’s
hand is positioned on the eyebrows, the movement
of the forehead may cause the dropper to move and
injure the eye. The client should gently blink his
eyes after the eyedrops have been instilled. Using
a tissue to wipe the eyes could remove some of the
medication; excess fluid can be removed with a cot-
ton ball.
CN: Pharmacological and parenteral
therapies; CL: Apply
19. 2. In COAG, there is an obstruction to the
outflow of aqueous humor, leading to increased
intraocular pressure. The increased intraocu-
lar pressure eventually causes destruction of the
retina’s nerve fibers. This nerve destruction causes
painless vision loss. The exact cause of glaucoma
is unknown. Glaucoma does not lead to retinal
detachment.
CN: Physiological adaptation;
CL: Analyze
20. 4. Although COAG is usually asymptom-
atic in the early stages, peripheral vision gradually
decreases as the disorder progresses. Eye pain is not
a feature of COAG but is common in clients with
angle-closure glaucoma. Excessive lacrimation is
not a symptom of COAG; it may indicate a blocked
675
tear duct. Flashes of light is a common symptom of
retinal detachment.
CN: Physiological adaptation;
CL: Analyze
21. 3. A miotic agent constricts the pupil and
contracts ciliary musculature. These effects widen
the filtration angle and permit increased outflow
of aqueous humor. Miotics also cause vasodilation
of the intraocular vessels, where intraocular fluids
leave the eye, also increasing aqueous humor out-
flow. Mydriatics cause cycloplegia, or paralysis of
the ciliary muscle.
CN: Pharmacological and parenteral
therapies; CL: Evaluate
22. 2. Tonometry, which measures intraocular
pressure, is a simple, noninvasive, and painless
procedure that requires no particular preparation or
postprocedure care and carries no adverse effects. It
is not necessary to dilate the pupils for tonometry.
CN: Reduction of risk potential;
CL: Synthesize
23. 3. Timolol maleate (Timoptic) is commonly
administered to control glaucoma. The drug’s action
is not completely understood, but it is believed to
reduce aqueous humor formation, thereby reducing
intraocular pressure. Timolol does not constrict the
pupils; miotics are used for pupillary constriction
and contraction of the ciliary muscle. Timolol does
not dilate the canal of Schlemm.
CN: Pharmacological and parenteral
therapies; CL: Evaluate
24. 2. The cornea is sensitive and can be injured
by eyedrops falling onto it. Therefore, eyedrops
should be instilled into the lower conjunctival sac
of the eye to avoid the risk of corneal damage. The
drops do not cause scleral staining or excessive
lacrimation. Systemic absorption occurs when eye-
drops enter the tear ducts.
CN: Pharmacological and parenteral
therapies; CL: Evaluate
25. 4. Acute angle-closure glaucoma produces
abrupt changes in the angle of the iris. Clinical man-
ifestations include severe eye pain, colored halos
around lights, and rapid vision loss. Gradual loss of
central vision is associated with macular degenera-
tion. The loss of color vision, or achromatopsia, is
a rare symptom that occurs when a stroke damages
the fusiform gyrus. It most often affects only half of
the visual field.
CN: Physiological adaptation;
CL: Analyze
676 The Nursing Care of Adults with Medical and Surgical Health Problems

26. 3. Acute angle-closure glaucoma is a medical 30. In macular degeneration the center vision is
emergency that rapidly leads to blindness if left blackened out and only the outer visual fields are
untreated. Treatment typically involves miotic drugs clear.
and surgery, usually iridectomy or laser therapy.
CN: Physiological adaptation;
Both procedures create a hole in the periphery of
CL: Analyze
the iris, which allows the aqueous humor to flow
into the anterior chamber. Bed rest does not affect
the progression of acute angle-closure glaucoma.
Steroids are not a treatment for acute angle-closure
glaucoma; in fact, they are associated with the
development of glaucoma.
CN: Physiological adaptation; CL: Apply

The Client with Adult Macular

Degeneration
27. 1. Macular degeneration generally involves
loss of central vision. Gradual blurring of vision can
occur as the disease progresses and may result in
blindness; however, loss of central vision is the most
common finding. Tiny yellowish spots, known as
drusen, develop beneath the retina. Loss of periph-
eral vision is characteristic of glaucoma.
CN: Physiological adaptation;
CL: Analyze
28. 3. AMD generally affects central vision.
Confusion may result related to the changes in the
environment and the inability to see the environ-
ment clearly. Therefore, providing safety is the
priority goal in the care of this client. Educating
him regarding community resources or monitoring
his AMD may have been done at an earlier date or
can be done after assessing his knowledge base and
experience with the disease process. Improving his
vision may not be possible.
CN: Safety and infection control;
CL: Synthesize
29. 4. To expand the visual field, the partially
sighted client should be taught to turn the head from
side to side when walking. Neglecting to do so may
result in accidents. This technique helps maximize
the use of remaining sight. A patch does not address
the problem of hemianopsia. Appropriate client
positioning and placement of personal items will
increase the client’s ability to cope with the problem
but will not affect safety.
CN: Safety and infection control;
CL: Synthesize
31. 3. By listening to the client should they
speak and by noting body language, the nurse may
be better able to ascertain the client’s physical and
cognitive status. The nurse should not utilize the
first name of a client unless a client provides per-
mission to do so. To consult with psychiatry would
not be appropriate unless ordered by the primary
care physician. An interdisciplinary meeting would
not enable the nurse to understand why the client
is staring straight ahead. Perhaps the client is only
deep in thought.
CN: Reduction of risk potential;
CL: Synthesize
The Client Undergoing Nasal Surgery
32. 2. Because of the dense packing, it is rela-
tively unusual for bleeding to be apparent through
the nasal drip pad. Instead, the blood runs down the
throat, causing the client to swallow frequently. The
back of the throat can be assessed with a flashlight.
An accumulation of blood in the stomach may cause
nausea and vomiting, but is not an initial sign of
bleeding. Increased respiratory rate occurs in shock
and is not an early sign of bleeding in the client after
nasal surgery. Feelings of anxiety are not indicative
of nasal bleeding.
CN: Physiological adaptation;
CL: Synthesize
 The Client with Health Problems of the Eyes, Ears, Nose, and Throat
33. 1. The client should be instructed to avoid
any activities that cause Valsalva’s maneuver (e.g.,
straining at stool, vigorous coughing, exercise) to
reduce stress on suture lines and bleeding. The
client should not take aspirin because of its anti-
platelet properties, which may cause bleeding. Oral
hygiene is important to rid the mouth of old dried
blood and to enhance the client’s appetite. Cool
compresses, not heat, should be applied to decrease
swelling and control discoloration of the area.
CN: Reduction of risk potential;
CL: Synthesize
34. 2. Constipation can cause straining during
defecation, which can induce bleeding. Showering
is not contraindicated. The client should take mea-
sures to prevent coughing. The client should avoid
blowing her nose for 48 hours after the packing
is removed. Thereafter, she should blow her nose
gently using the open-mouth technique to minimize
bleeding in the surgical area.
CN: Physiological adaptation;
CL: Evaluate
The Client with a Hearing Disorder
35. 4. The nurse should avoid startling the cli-
ent who is deaf and should obtain the attention of
the client before speaking. The client who is deaf
cannot hear knocking on the door or talking. Open-
ing the blinds is not a helpful way to get the client’s
attention.
CN: Psychosocial adaptation;
CL: Syntheisze
36. 2. Furosemide may cause ototoxicity. The
nurse should tell the client to promptly report the
hearing loss, dizziness, or tinnitus, to help prevent
permanent ear damage. Hearing loss is not inevi-
table, and it is inappropriate to make assumptions
about the cause of symptoms without a thorough
evaluation. The client’s system will not “adjust,”
and hearing loss will not resolve.
CN: Pharmacological and parenteral
therapies; CL: Synthesize
37. 1, 2, 3, 5. When working with a client who
is hearing impaired and speech reads, the presenter
must face the person directly and devote full atten-
tion to the communication process. In addition,
it will be useful for the client that the speaker not
be too silhouetted against strong light, that the
speaker’s mouth not be blocked from the client’s
view, and that there are no objects in the mouth
of the speaker. Finally, it is recommended that the
presenter provide the client with the needed infor-
mation to study before reviewing. This will provide
677
the client with the ability to use contextual clues in
speech reading.
CN: Basic care and comfort;
CL: Synthesize
38. 4. Inadequate amplification can occur when
a hearing aid is not placed properly. The certified
audiologist is licensed to dispense hearing aids. The
ear mold is the only part of the hearing aid that may
be washed frequently; it should be washed daily
with soap and water. Irrigation of the ear canal is
done to remove impacted cerumen or a foreign body.
CN: Physiological adaptation;
CL: Synthesize
39. 3. A sensorineural hearing loss results from
damage to the cochlear or vestibulocochlear nerve.
Presence of fluid and cerumen in the external canal
or sclerosis of the bones of the middle ear results
in a conductive hearing loss. Hearing loss resulting
from an emotional disturbance is called a psycho-
genic hearing loss.
CN: Physiological adaptation; CL: Apply
40. 1. Cerumen (ear wax) commonly gets
impacted in older clients in the external canal. Otal-
gia is the “fullness” sensation or pain that an older
client may experience when the cerumen becomes
impacted. External otitis is an inflammation of the
outer ear and would not explain the symptoms the
client is experiencing. Exostosis is a bony growth
that arises from the surface of a bone and would not
explain the symptoms the client is experiencing.
CN: Health promotion and maintenance;
CL: Analyze
41. 2. Irrigation is the first strategy to loosen
cerumen. Successful removal of the cerumen
involves gentle irrigation behind the impacted
cerumen. The flow of the water must be behind the
impaction to remove the cerumen from the canal.
A cotton-tipped applicator or other device is not
appropriate because it can cause damage to the ear-
drum. Use of aural suction or a cerumen curette is
appropriate only if the impacted cerumen cannot be
removed by irrigation.
CN: Reduction of risk potential;
CL: Apply
42. 1. Normal saline is the solution that is gener-
ally used to irrigate the ear. Sterile water will cause
tissue damage. An antiseptic solution is not typi-
cally used unless an infection is present. Warm tap
water may cause tissue damage.
CN: Pharmacological and parenteral
therapies; CL: Apply
43. 1. The nurse should first assess the client’s
knowledge base. Working within the framework
678 The Nursing Care of Adults with Medical and Surgical Health Problems
of the client’s knowledge and educational level,
the nurse then can describe the procedure and its
benefits.
CN: Reduction of risk potential;
CL: Synthesize
44. 4. Tinnitus (ringing in the ears) is an adverse
effect of aspirin. Aspirin contains salicylate, which
is an ototoxic drug that can induce reversible hear-
ing loss and tinnitus. The nurse should encourage
the client to inform the physician of the symptom.
Tinnitus is not a function of aging. The Weber test
and audiometric testing are useful for determining
hearing loss but are not necessarily helpful in the
management or diagnosis of drug-induced tinnitus.
CN: Pharmacological and parenteral
therapies; CL: Synthesize
The Client with Ménière’s Disease
45. 1, 2, 3, 5. Assessment of vertigo, includ-
ing history, onset, description of attacks, duration,
frequency, and associated ear symptoms, is impor-
tant. Vestibular/balance therapy or exercises should
be taught and practiced. The client needs to be
instructed to sit down when dizzy and decrease the
amount of head movement. The client will benefit
from recognizing whether he or she experiences an
“aura” before an attack so appropriate action can
be taken. Finally, it is recommended that the client
keep the eyes open and look straight ahead when
lying down. These expected outcomes will prevent
the problem of injury. Family involvement is essen-
tial when dealing with a client experiencing vertigo
but is not applicable for this particular nursing
diagnosis.
CN: Reduction of risk potential;
CL: Synthesize
46. 1. A low-sodium diet is frequently an effec-
tive mechanism for reducing the frequency and
severity of the disease episodes. About three-quar-
ters of clients with Ménière’s disease respond to
treatment with a low-salt diet. A diuretic may also
be ordered. Other dietary changes, such as high
protein, low carbohydrate, and low fat, do not have
an effect on Ménière’s disease.
CN: Basic care and comfort; CL: Apply
47. 2. There is no cure for Ménière’s disease, but
the wide range of medical and surgical treatments
allows for adequate control in many clients. The
disease often worsens, but it does not spread to the
eyes. The hearing loss is usually unilateral.
CN: Physiological adaptation;
CL: Evaluate
48. 4. The client needs to assume a safe and
comfortable position during an attack, which may
last several hours. The client’s location when the
attack occurs may dictate the most reasonable posi-
tion. Ideally, the client should lie down immediately
in a reclining or flat position to control the vertigo.
The danger of a serious fall is real. Placing the head
between the knees will not help prevent a fall and
is not practical because the attack may last several
hours. Concentrating on breathing may be a useful
distraction, but it will not help prevent a fall. Clos-
ing the eyes does not help prevent a fall.
CN: Safety and infection control;
CL: Synthesize
49. 1, 2, 3. Since the symptoms of Ménière’s
disease are associated with a change in the fluid
volume of the inner ear, a wide variety of medi-
cations may be used in an attempt to control the
signs/symptoms of Ménière’s disease, including
antihistamines, antiemetics, tranquilizers, and
diuretics. NSAIDs and antipyretics play no signifi-
cant role in Ménière’s disease management.
CN: Pharmacological and parenteral
therapies; CL: Analyze
50. 2. The client’s Risk for injury related to
vertigo is the highest priority nursing diagnosis
preoperatively. The client should be instructed
how to manage attacks of vertigo safely. Deficient
diversional activity related to inability to participate
secondary to vertigo is an appropriate nursing diag-
nosis, but it is not a priority. Powerlessness related
to inability to influence effects of the disease process
is a possible diagnosis, but more data are required
before making such a diagnosis. Social isolation
related to hearing loss is a possible diagnosis for the
client after surgery. The client retains the ability to
hear with Ménière’s disease; however, total hearing
loss is a possible complication of labyrinthectomy.
CN: Physiological adaptation;
CL: Analyze
The Client with Cancer of the Larynx
51. 4. A salivary fistula is suspected when there
is saliva collecting beneath skin flaps or leaking
through the suture line or drain site. Salivary fistula
or skin necrosis usually precedes carotid artery rup-
ture. Stomal stenosis may be present when there is
suprasternal and intercostal retractions and difficult
breathing.
CN: Physiological adaptation;
CL: Analyze
 The Client with Health Problems of the Eyes, Ears, Nose, and Throat
52. 1, 2, 3, 4. The nurse should monitor nutritional
status through frequent weighing and checking the
serum albumin level. The nurse also should admin-
ister enteral tube feedings until there is sufficient
healing of pharynx, and the client can consume suf-
ficient oral feedings to meet body needs. The nurse
should avoid manipulation of the nasogastric tube
during this time so it does not disrupt the suture
line. The nurse should place the client in sitting
position, leaning slightly forward, which allows
the larynx to move forward and the hypopharynx
to partially open; the epiglottis normally prevents
fluid and food from entering the larynx during
swallowing.
CN: Physiological adaptation; CL: Create
53. 1, 2, 3. The nurse should advise the client to
provide humidification at home. Instruct the client
to use a protective shield for bathing, showering,
or shampooing or cutting hair to prevent aspira-
tion. The nurse can also encourage the client to
obtain a fluid intake of 2 to 3 L daily to help liquefy
secretions. To counteract any loss of smell and
impairment of taste sensation, the client can add
additional seasoning to food. The client should fol-
low a high-fiber diet and use stool softeners because
the client may not be able to hold the breath and
bear down for bowel movements.
CN: Health promotion and maintenance;
CL: Evaluate
54. 1. The goal of postoperative care is to main-
tain physiologic integrity. Therefore, inserting a
feeding tube is a strategy to ensure the fluid and
nutritional needs of the client as the surgical site is
healing. The feeding tube does help prevent aspi-
ration by preventing ingested fluid from leaking
through the wound into the trachea before healing
occurs; however, the primary rationale is to meet
the client’s nutritional and fluid needs. A trache-
oesophageal fistula is a rare complication of total
laryngectomy and may occur if radiation therapy
has compromised wound healing. A feeding tube
does not help maintain an open airway.
CN: Reduction of risk potential;
CL: Evaluate
55. 2. Tracheostomy tubes carry several potential
complications, including laryngeal nerve damage,
bleeding, and infection. Tracheostomy tubes alone
do not affect cardiac output or cause acute respira-
tory distress. The tube is inserted in the trachea, not
the lung, so there is no risk of pneumothorax.
CN: Physiological adaptation;
CL: Apply
56. 4. The main goal for a client with a new
tracheostomy is to maintain a patent airway. A fresh
tracheostomy frequently causes bleeding and excess
679
secretions, and clients may require frequent suction-
ing to maintain patency. Decreasing secretions may
be a component of a client’s care after laryngectomy
and tracheostomy, and relieving anxiety is always
an important goal; however, the primary goal is to
maintain a patent airway. Instruction in care of a tra-
cheostomy is a priority later in the client’s recovery.
CN: Physiological adaptation;
CL: Synthesize
Managing Care Quality and Safety
57. 2. Atropine sulfate causes pupil dilation.
This action is contraindicated for the client with
glaucoma because it increases intraocular pressure.
The drug does not have this effect on intraocular
pressure in people who do not have glaucoma.
Morphine causes pupil constriction. Deep-breathing
exercises will not affect glaucoma. The client should
resume taking all medications for glaucoma immedi-
ately after surgery.
CN: Pharmacological and parenteral
therapies; CL: Synthesize
58. 3. The priority goal of care for a client who
is blind is safety and preventing injury. The initial
action is to orient the client to a new environment.
Taking time to identify the objects and where they
are located in the room can achieve this goal. It is
unrealistic to have someone stay with the client at
all times or for the client to stay in bed until the
nurse can assist. Using side rails creates unneces-
sary barriers and may be a safety hazard.
CN: Safety and infection control;
CL: Synthesize
59. 1, 2, 3. Effective communication is essential
when managing client safety and preventing errors.
“Handoff reports” should be made at shift change,
when there is a change of nurses or when the nurse
leaves the unit, and when the client is discharged or
transfers to another unit. There does not need to be
a handoff report when the unit clerk leaves the unit
or when new medication orders are written.
CN: Safety and infection control;
CL: Apply
60. 3. In order to prevent medication errors, cli-
ents may not use medications they bring from home;
the physician will order the eye drops as required.
It is not safe to place the eye drops in the client’s
medication box or to permit the client to use them
at the bedside. The nurse should ask the wife to take
the eye drops home.
CN: Safety and infection control;
CL: Synthesize