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Which statement best describes the scientific rationale for the nurse holding the otoscope with the hand in a pencil-hold position when examining the client's ear?
- A. It is usually the most comfortable position to hold the otoscope.
- B. This allows the best visualization of the tympanic membrane.
- C. This prevents inserting the otoscope too far into the external ear.
- D. It ensures the nurse will not cause pain when examining the ear.
Correct Answer: C
Rationale: The pencil-hold prevents deep insertion, protecting the ear canal and tympanic membrane. Comfort, visualization, and pain avoidance are secondary.
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The client tells the nurse about being diagnosed with 'wet type' macular degeneration. Which finding should the nurse expect to observe when examining the client's eyes using an ophthalmoscope?
- A. Growth of abnormal blood vessels in the macula has occurred.
- B. Structures in the macula have atrophied.
- C. The lens of the eye has become cloudy.
- D. The edge of the cornea has a thin grayish arc.
Correct Answer: A
Rationale: The 'wet type' of macular degeneration results from the growth of abnormal blood vessels in the macula. The blood vessels often leak fluid and blood. Atrophy occurs in dry macular degeneration, cloudy lens indicates cataract, and corneal arcus is a normal finding in older clients.
The 65-year-old male client who is complaining of blurred vision reports he thinks his glasses need to be cleaned all the time, and he denies any type of eye pain. Which eye disorder should the nurse suspect the client has?
- A. Corneal dystrophy.
- B. Conjunctivitis.
- C. Diabetic retinopathy.
- D. Cataracts.
Correct Answer: D
Rationale: Blurred vision and a sense of dirty glasses without pain suggest cataracts, common in older adults. Corneal dystrophy is rarer, conjunctivitis causes redness, and diabetic retinopathy involves floaters or spots.
The client receives a prescription for sodium fluoride for otosclerosis and asks the nurse, 'What will this medication do for my ears?' Which response by the nurse is correct?
- A. Sodium fluoride prevents the breakdown of bone cells and hardens the bone in the ear.
- B. Sodium fluoride causes the breakdown of bone cells and softens the bone in the ear.
- C. Sodium fluoride blocks the effect of histamine and dries the fluid in the ear.
- D. Sodium fluoride causes the production of histamine and increases the fluid in the ear.
Correct Answer: A
Rationale: The medication, sodium fluoride, retards bone reabsorption (prevents the breakdown of bone cells) and promotes calcification (hardening) of the bony lesions in the ear.
The nurse reviews the chart of the client diagnosed with closed-angle glaucoma. Which documented finding should the nurse question with the HCP?
- A. Sudden onset of eye pain
- B. Reduced central visual acuity
- C. Normal intraocular pressure
- D. Nausea and vomiting
Correct Answer: C
Rationale: Closed-angle glaucoma causes an increased, not normal, intraocular pressure. This documentation finding should be questioned. Sudden eye pain, reduced central visual acuity, and nausea and vomiting are consistent with closed-angle glaucoma.
The client has an hordeolum of the left eye, which is painful. Which intervention, if prescribed, should the nurse implement?
- A. Apply an eye patch on the left eye.
- B. Insert miotic eye drops twice daily.
- C. Apply a warm compress four times daily.
- D. Administer an antibiotic intravenously.
Correct Answer: C
Rationale: Warm compresses are applied to promote drainage of the hordeolum. Patching is not indicated, miotic drops treat glaucoma, and IV antibiotics are unnecessary as topical antibiotics are used.