Chapter 12: Care of the Eye and Ear Perry et al.: Nursing Interventions & Clinical Skills, 7th Edition

Multiple Choice

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

a. Irrigate the eye with 50 mL of a sterile saline solution.

b. Pull the lid down and instruct the patient to blink.

c. Pinch the sides of the lens together and pop it out.

d. Move the lens to the sclera and compress the lens gently.

ANS: D

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

DIF: Cognitive Level: Remembering OBJ: NCLEX: Physiological Integrity

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

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

ANS: B

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

DIF: Cognitive Level: Remembering OBJ: NCLEX: Safe and Effective Care Environment

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

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

ANS: B

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

DIF: Cognitive Level: Understanding OBJ: NCLEX: Physiological Integrity

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

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

ANS: D

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

DIF: Cognitive Level: Applying OBJ: NCLEX: Physiological Integrity

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

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

ANS: A

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

DIF: Cognitive Level: Understanding OBJ: NCLEX: Physiological Integrity

TOP: Integrated Process: Teaching-Learning a. Applies slight negative pressure to the ear canal. b. Asks the patient not to move while the ear is being irrigated. c. Cleans the ear canal with a soft cotton swab to remove any remaining cerumen. d. Instills cool irrigating fluid to break down the cerumen in the ear canal.

6. The nurse is preparing to remove cerumen from an older adult’s ear. Nursing care is appropriate if the nurse uses which procedure?

ANS: B

The nurse prepares the patient by explaining the procedure, including the need to remain still while the ear is being irrigated. To prevent damage to the tympanic membrane, negative pressure is never applied to the ear canal. The nurse avoids inserting a cotton swab into the ear canal because it is likely to push cerumen further into the ear. Cool irrigating fluid is contraindicated because it can cause nausea and vertigo.

DIF: Cognitive Level: Applying OBJ: NCLEX: Physiological Integrity

TOP: Integrated Process: Teaching-Learning a. Inform the patient that the ears are infected. b. Perform an otoscopic examination of the canals. c. Collaborate with the audiologist about a hearing aid. d. Irrigate the ear canals with warm saline solution.

7. The patient asks the nurse to irrigate both ear canals to improve hearing and comfort. The patient has bilateral brown ear drainage and a history of a right mastoidectomy and perforation of the left tympanic membrane. Which intervention by the nurse takes priority?

ANS: B

The nurse completes the ear assessment with an otoscopic examination of the ear canals to provide comprehensive patient data to the health care provider. The nurse wants to observe cerumen, the tympanic membrane, and origin of the drainage in both ears. He or she avoids irrigating an ear with drainage because the drainage implies that the tympanic membrane is impaired. The nurse avoids sharing a diagnostic conclusion with the patient because he or she does not know that the ears are infected. The nurse’s scope of practice does not provide for collaboration with the audiologist about the need for a hearing aid. This is done by the health care provider after a thorough assessment to determine the patient’s plan of care and therapeutic regimen.

DIF: Cognitive Level: Applying OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Planning a. Wait for the bean to fall out. b. Examine the ears with an otoscope. c. Collaborate with the health care provider. d. Irrigate the ear to flush out the bean.

8. The nurse assesses a 3-year-old patient with a dried bean in the left ear canal. Which action does the nurse implement?

ANS: C

The nurse inspects the ears visually without the aid of an otoscope to complete the nursing assessment and then collaborates with the health care provider to remove the bean. The bean is not likely to fall out because it is more likely to increase in size by being in the moist environment of the ear canal. The nurse avoids an otoscopic examination because inserting the otoscope into the ear canal is likely to affect the bean and make it harder to remove. The nurse avoids irrigating the patient’s ear canal because the positive pressure from the irrigation solution is likely to affect the bean and make it harder to remove. In addition, a dried bean will absorb water, and its size will increase, further aggravating its removal.

DIF: Cognitive Level: Applying OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Implementation a. Patient hearing acuity remains stable. b. Patient senses that irrigant is slightly warm. c. Patient complains of nausea and vertigo. d. Patient drainage contains brown particles.

9. The nurse irrigates the patient’s right ear with saline solution to improve hearing. Which patient symptom requires immediate nursing intervention?

ANS: C

The nurse expects to irrigate the patient’s ear canal without causing patient discomfort, pain, nausea, or vertigo by warming the irrigation solution before instilling it. The nurse expects the patient to sense the warmth of the irrigation solution; this is an expected outcome. Irrigation drainage from the ear containing brown particles is consistent with clinical indicators for effective ear irrigation because this is evidence of cerumen removal; this is an expected finding if cerumen was in the ear canal before the procedure. Failure of patient hearing to improve after irrigation is a possible unexpected outcome, but it is not influenced by warming of solution.

DIF: Cognitive Level: Applying OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Implementation a. Slides lens onto the sclera and pinches off the lens. b. Draws periorbital skin taut and asks the patient to blink. c. Uses a bulb syringe and applies suction to the lens. d. Squeezes the upper and lower lids together to pinch the lens.

10. The nurse is instructing a patient on the procedure to remove a hard contact lens. Instruction by the nurse is correct if the patient uses which technique?

ANS: B

To remove a hard lens from a patient’s eye, the nurse draws the skin surrounding the eye tightly and instructs the patient to blink. Pulling the skin creates mild tension, which the eyelid uses to dislodge the lens from the cornea. Sliding a contact lens onto the sclera and pinching off the lens is the procedure to remove a soft contact lens. To prevent a corneal abrasion, the nurse avoids using suction to remove a contact lens. He or she avoids squeezing the eyelids together to prevent eye and conjunctival trauma from the hard lens.

DIF: Cognitive Level: Applying OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Evaluation a. Thoroughly soak the lens in saline solution. b. Rub the contact lens briskly to remove the debris. c. Pry the lens apart gently with a fingertip. d. Use the cleaning solution on the lens; then replace or store it.

11. After removing a soft contact lens, the nurse observes that the sides of the lens are sticking together. Which intervention will the nurse implement before storing or reinserting the lens?

ANS: A

A soft contact lens sticks together because it is dry. The nurse rehydrates the lens with saline solution; and the lens becomes soft, supple, less sticky, and suitable for the patient to wear or to store. Hard and soft contact lenses should never be rubbed because rubbing is likely to damage the lens. The nurse avoids prying apart the lens to prevent lens damage. Cleaning solution for lenses is intended to remove residue and debris from the lens but is not intended as a source of lens hydration. After using the cleaning solution, the nurse rinses the lens in saline solution before storage or reinsertion.

DIF: Cognitive Level: Understanding OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Planning a. Whisper very softly behind the patient. b. Cover the patient’s unaffected ear before talking. c. Send the hearing aid to the audiologist for analysis. d. Check patient response using a normal voice level.

12. The nurse admits a patient who wears a hearing aid for surgery. Which method does the nurse use to assess the patient’s hearing acuity with the hearing aid in place?

ANS: D

The nurse needs to determine the patient’s hearing ability with the hearing aid in place and both ears available to hear. The nurse speaks with the patient in a normal tone of voice, assesses the patient’s ability to respond properly, and asks the patient whether this is baseline hearing acuity. If the patient has difficulty hearing the nurse with normal conversation, the nurse conducts a more detailed assessment and ensures that the hearing aid battery is good. The nurse performs the assessment before surgery to alert the surgical team to the patient with a sensory impairment so an alternative method of communication may be identified. Whispering is a hearing acuity test used to evaluate a patient without hearing aids. The nurse avoids sending the hearing aid to an audiologist because the nurse is able to determine whether the patient can hear.

DIF: Cognitive Level: Applying OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Assessment a. At risk for injury b. Deficient knowledge c. Impaired communication d. Impaired social interaction

13. Which is the priority nursing diagnosis for a patient with altered sensory perception?

ANS: A

The patient with a sensory impairment is at high risk for injury because many methods of communication with the patient cannot be used or need alteration to accommodate the impairment. The sensory impairment may render the patient unable to follow important directions, visualize hazards, or provide information to the health care team. However, the nurse’s priority is to maintain safety first and then to manage the communication impairment to prevent injury effectively. Deficient knowledge is a suitable nursing diagnosis for the patient who has a sensory impairment in acute care because the patient is likely to miss important information and is unaware of potential solutions to the problem. The patient with a sensory impairment frequently has impaired social interaction, so this is a reasonable nursing diagnosis. However, safety is always more important than psychosocial issues.

DIF: Cognitive Level: Analyzing OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Diagnosis a. Talk to the patient in a normal voice while standing away from him or her. b. Whisper questions to the patient to determine if the questions can be understood. c. Ask the family to explain the activity patterns of the patient. d. Ask the family for a list of what the patient usually eats.

14. The family of an older adult brings the patient to the health care provider because the patient seems to be confused or depressed at times. What approach by the nurse can best obtain valuable information about the underlying problem?

ANS: A

The nurse can determine if the patient has a hearing impairment by standing a distance from him or her and speaking in a normal tone of voice. Hearing loss can cause the patient to be depressed or seem to be confused. The focus of the assessment needs to be on the patient, not the family. Whispering is inappropriate because this is not a level at which communication usually occurs. The patient’s activity level can be affected by many things other than hearing. The dietary pattern of the patient is not important at this time.

DIF: Cognitive Level: Applying OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Assessment

Multiple Response

1. The nurse plans care for a patient who has a hearing deficit. What actions when taken by the nurse indicate a good understanding of appropriate care? (Select all that apply.)

a. Face the patient before beginning to speak.

b. Keep the lights dimmed low.

c. Speak in a slow, clear, and loud voice.

d. Eliminate external voices.

e. Do not talk over the patient.

ANS: A, D, E

When patients have a hearing deficit, be sure they understand what you communicate to them. Always face the patient before beginning to speak and make sure there is enough light for the patient to see your lips. Eliminate external noises; speak in a slow, clear, normal tone of voice. Do not speak in a loud voice. Ask patients what communication styles they prefer. Never talk over or exclude a patient from conversation or decisions.

DIF: Cognitive Level: Applying OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Planning a. “I should irrigate from inner to outer canthus.” b. “I should tell the patient not to blink.” c. “I should always remove the contact lenses first.” d. “I should hold the lids open by putting gentle pressure to the lower bony orbit.” e. “I should irrigate until clear or prescribed amount of time is reached.”

2. The nurse is orienting a new graduate nurse about eye irrigation. Which statement indicates a good level of understanding of the procedure? (Select all that apply.)

ANS: A, D, E

The eye is irrigated from the inner to outer canthus. The patient is allowed to blink periodically, which can help move secretions from the upper conjunctival sac. You should determine if the patient is wearing contact lenses. Do not remove contact lenses unless there is a rapid swelling, there is a chemical injury, or you cannot get rapid medical attention. You can remove them later if they do not flush out during irrigation. Continue irrigation with prescribed solution, volume, or time or until secretions are cleared.

DIF: Cognitive Level: Evaluating OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Evaluation a. The nurse cleans the eye with water or saline. b. The nurse uses an eyedropper to instill the prescribed lubricant. c. The nurse wipes away excess lubricant moving from outer canthus to inner canthus. d. The nurse applies eye patches when the blink reflex is absent. e. The nurse changes the eye patches every 8 hours.

3. The nurse is performing eye care for a comatose patient. Which interventions indicate the nurse has a good understanding of the appropriate care needed? (Select all that apply.)

ANS: A, B, D

To prevent damage to corneas in a comatose patient, eye care is performed. The nurse cleans the eyes with water or saline, wiping from inner canthus to outer canthus, using a separate washcloth or cotton ball for each eye. Lubricant is applied using an eyedropper, wiping excess from inner canthus to outer canthus. Eye patches are used when there is no blink reflex and are changed every 4 hours.

DIF: Cognitive Level: Applying OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Implementation a. “I can wear my hearing aid in the shower.” b. “I should take it out when I go to the pool to swim.” c. “I can wear my hearing aid when I get my hair done.” d. “I need to make sure I don’t leave them in a hot car.” e. “I should store the batteries in a dry, safe place.”

4. The nurse is assessing an elderly patient’s ability to understand how to properly care for a new hearing aid. Which of the following statements indicate further education is needed? (Select all that apply.)

ANS: A, C

Patients should be instructed to avoid exposure of hearing aids to extreme heat, cold, or moisture. Do not leave in case near stove, heater, or sunny window. Do not use with hair dryer on hot settings or with sunlamp. Do not wear when bathing, during excess sweating, or when shampooing at a hair stylist. Do not use hair spray or other hair-care products while wearing hearing aids. Store batteries in a dry, safe place away from pets and children. Always keep a set of unused batteries in the home.

DIF: Cognitive Level: Evaluating OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Evaluation