Tiêu đề WORKBOOK - SPECIAL SENSES (KEY) ✅

COMPREHENSIVE PHASE WORKBOOK SPECIAL SENSES NOVEMBER 2024 Philippine Nurse Licensure Examination Review SITUATION: Lara X is a farmer in Cabanatuan. She was diagnosed with cataract. 1. Cataract manifestations include all but one: I. Blurring of vision II. Absence of red reflex III. Appearance of milky white in the eye IV. Decreased sensitivity to light A. 1, 2 and 3 B. 2 only C. 4 only D. None of the above 2. The following nursing interventions are non-conformance after cataract extraction except: I. Place the client in supine or towards the un-operated side II. Advise to avoid bending stooping, bending, or lifting heavy objects III. Instruct to limit fluid intake to prevent increase in IOP IV. Instruct to protect eye with pads or eye shield A. 1 and 4 B. 3 only C. 1, 2 and 4 D. 2 and 3 3. A client underwent cataract removal with an intraocular lens implant. The nurse is giving the client discharge instructions. These instructions should include which of the following? I. Avoid lifting objects weighing more than 5 lb (2.27 kg) II. Lie on your abdomen when in bed III. Keep rooms brightly lit IV. Avoid straining during bowel movement or bending at the waist A. 2 and 3 B. 1, 3 and 4 C. 4 D. 1 and 4 4. Marina D was admitted for severe boring eye pain. A suspicion of glaucoma was made however further diagnostics is needed to identify if this is an open-angle, from close-angle glaucoma. You know that: A. Open-angle glaucoma occurs less frequently than closed-angle glaucoma B. Open-angle glaucoma's symptoms include pain, severe headache, nausea, and vomiting; whereas closed-angle glaucoma has a slow, silent, and generally painless onset C. The obstruction of aqueous flow in open-angle glaucoma generally occur somewhere in Schlemm's canal. It does not narrow or close the angle of the anterior chamber, as in closed-angle glaucoma D. Open-angle glaucoma rarely occurs in families; however, there is a heredity predisposition for closed-angle glaucoma. 5. Pilocarpine is the drug of choice in the treatment of open-angle glaucoma. The expected outcome following administration would be: A. Blocked action of cholinesterase at the cholinergic nerve endings, and therefore increased pupil size B. Constricted pupil and therefore widened outflow channels and increased flow of aqueous fluid C. Impaired vision from decreased aqueous humor production D. Constriction of aqueous veins and therefore decreased venous pooling in the eye 6. You expect that the initial symptom that brought the client to the ophthalmologist is what? A. Seeing colored flashes of light B. Extreme pain in the eye C. Decreasing vision D. Redness and tearing of the eye 7. Acetazolamide are sometimes used in the treatment of glaucoma because they A. Dilate the pupil B. Paralyze the power of accommodation C. Increase the power of accommodation D. Depress secretion of aqueous humor 8. Jordan X reported that he sees“floaters” prior to admission. The nurse should explain to the client that these spots were caused by. A. Blood cells released into the eye by the detachment B. Spasms of the retinal blood vessels traumatized by the detachment C. Pieces of retina floating in the eye D. Contamination of the aqueous humor 9. Which of the following symptoms would not occur in a client with a detached retina? I. Floaters II. Photopsia III. Eye pain IV. Curtain vision A. 2 only B. 1, 2 and 4 C. 1 and 4 D. 3 only 10. Scleral buckling, a procedure used to treat retinal detachment, involves: A. Creating a splint to hold the retina together until a scar can form and seal off the tear. B. Removing the torn segment of the retina and stitching down the remaining segment. C. Stitching the retina firmly to the optic nerve to give it support. D. Replacing the torn segment of the retina with a strip of retina from a donor. 11. The nurse would expect the client to complain of: I. Discharge from the ear II. Ear pain III. Neurosensory deafness IV. Conductive deafness V. Vertigo VI. Tinnitus VII.Fever A. 3, 5 and 6 B. 3, 4 and 6 C. 2, 3, 5 and 6 D. 1, 3, 5 and 7 12. The correct nursing management of Meniere’s disease is: I. Take diuretic to excrete excess fluids from the body II. Encourage a decrease sodium intake III. Use of bonamine during vertigo episodes IV. Take acetazolamide as prescribed TOP RANK REVIEW ACADEMY, INC. Page 1 | 4
A. 1, 2 and 4 B. 1, 2 and 3 C. 2 only D. All are correct 13. Which of the following patient statements would require follow-up by the nurse? A. “I smoke one pack of cigarette per day.” B. “When I have vertigo, I usually lie down.” C. “I have a continuous, low-pitched roar in my left ear.” D. “I continue to feel dizzy after the vertigo goes away.” 14. Mayang C was diagnosed with Meniere’s disease. While the nurse was doing her rounds, she found her leaning over the table in the room and clutching it with both hands. After determining that the patient is having an acute attack, which of the following actions should the nurse take FIRST? A. Help the patient back to bed and place a pillow on either side of the patient’s head. B. Have the patient lie down where he is and check the patient’s vital signs and pupil’s response to light. C. Give the patient an emesis basin and massage the neck over the area of the carotid arteries. D. Notify the physician and prepare to administer atropine sulfate subcutaneously. 15. Which signs and symptoms are associated with an acoustic neuroma? A. Profuse ear discharge, fever, erythema B. Otalgia, sense of fullness in the ear, no hearing loss C. Ataxia and intention tremor D. Unilateral hearing loss and tinnitus 16. The following are considered incorrect about myopia: I. This is otherwise known as farsightedness II. The bending of light is in front of the retina III. Corrected by using a concave lens IV. 20/10 is the result on Snellen’s chart A. 1, 2 B. 1, 4 C. 2, 3 D. 3, 4 17. A client’s vision is tested with a Snellen’s Chart. The results of the test are documented as 20/60. The nurse interprets this as: A. The client can read at a distance of 60 feet what a client with normal vision can read at 20 feet B. The client is legally blind C. The client’s vision is normal D. The client can read at a distance of 20 feet what a client with normal vision can read at 60 feet 18. Which of the following is the best way for the nurse to communicate with the hearing impaired client? A. Talked directly into the impaired ear B. Shout into the good ear C. Speak directly and clearly facing the person D. Write out all communications 19. A 33-year old client was assessed due to hearing loss. In order to determine what type of hearing loss the client is experiencing, Rinne's test was performeD. The nurse observes that the client heard the sound louder when the fork was placed at the mastoid than beside the impaired ear. What type of hearing loss is present with the client? A. Sensorineural hearing loss B. Neuro-sensory-conductive hearing loss C. Conductive hearing loss D. Normal ear 20. Sandra Z underwent stapedectomy with fenestration. Which findings show a possible complication of the procedure> A. A bitter metallic state B. Dryness of the lips and mouth C. A sensation of pain behind the ear D. An inability to wrinkle the forehead 21. Cara D was admitted to the ward due to a ruptured tympanic membrane. She complains of persistent pain at 3rd hospital day. How should the nurse interpret this finding? A. Expected since drainage takes 24–48 hours to occur B. Expected because of the trauma of the perforation C. Disease is progressing since pain should decrease immediately with rupture D. Secondary infection has occurred as a result of the break in the membrane 22. Clients with ear trauma must be assessed for which of the following problems? (Select all that apply.) I. Facial nerve damage II. Sensorineural hearing loss III. Dizziness IV. Nystagmus A. I,II only B. I,II,III C. II,III D. All of the above 23. Nurse Yana administered prochlorperazine to a Myrna, a patient with Meniere’s disease. Which data is the most important for the nurse to obtain? A. the number of attacks per week B. the length of time between attacks C. the duration of an attack D. the perceived severity of an attack 24. Vienna is 1 7 year old child with chronic otitis mediA. Myringotomy tubes were put in place. Which of the following patient statements indicate proper understanding on the care of myringotomy tubes? A. “I will make sure to let the tubes will remain in place until removed by the physician” B. “It is normal to see small amounts of drainage from the tubes will occur, especially in the morning” C. “I expect to feel periodic discomfort due to the tubes but I will treat it with acetaminophen” D. “I need to take prophylactic antibiotics while the tubes are in place 25. Which is the best indicator that an acute middle ear infection is resolving? A. Tinnitus disappears B. Drainage thins C. Hearing improves D. Pain dulls 26. Sherry came to the clinic to seek consult for her 4 month old child who has been screaming at night and tossing his head back and forth on the pillow for the last few nights. Which type of examination would the nurse suggest for the infant? A. Dental examination B. Ear examination C. Throat examination D. Neurological examination 27. Lola Berlina went to the Eye Center due to blurring of vision. She asks the nurse how can they known if a cataract is blurring her vision. Which is an accurate reply? A. “Cataracts are seen with an ophthalmoscope.” B. “Decreased central vision is diagnostic of cataracts.” C. “Cataracts are visualized using fluorescein dye.” D. “MRIs of the head are used to make the diagnosis.” 28. An Amsler grid was requested by the physician to be present during an examination of the patient. Which of the following eye diseases is being considered? A. Glaucoma B. Macular degeneration C. Retinal detachment D. Uveitis 29. Which finding indicates a risk for AMD? A. Decreased visual fields B. Sluggish pupillary response to light C. Presence of drusen TOP RANK REVIEW ACADEMY, INC. Page 2 | 4
D. IOP measurement of 22 30. Wilma D tells the nurse that the eye doctor said the pressure in her right eye was 19 and asks if this is normal. Which is the most appropriate answer? A. “19 is within the normal range of 10–21.” B. “19 is low but not dangerously so.” C. “19 is borderline high and needs monitoring.” D. “19 is high and treatment is needeD.” 31. Lola Paulina was diagnosed with cataract of the left eye. She asks when is it appropriate to undergo surgical removal. You reply: A. “When they reach a diameter of 3 mm or more.” B. “When they have turned from light gray to milky white in color.” C. “When they have a distinct capsule around them.” D. “When they interfere with daily activities.” 32. Vivian A sought consult at the eye clinic due to reports of floating spots before the eyes, flashes of light, and loss of an area of vision. Which of the following should be the primary consideration? A. acute glaucoma B. wet macular degeneration C. corneal abrasion D. retinal detachment 33. Jober A has been diagnosed with an inner ear infection. He complains of frequent tinnitus. What advice is appropriate for the nurse to give to the client? A. “You can block it with a white noise machine.” B. “A radio set at low volume will help.” C. “Wearing ear plugs is a very effective solution.” D. “Obtaining a hearing aid can help.” 34. Emily just had a cataract surgery and she has been advised to avoid too bright lights. Which measure would the nurse recommend for a client who needs to reduce glare? A. Use of fluorescent lighting in the home B. Use of 60-watt bulb in a lamp directly aimed at the reading surface C. Use of a hand-held magnifier D. Use of a yellow plastic overlay for reading 35. Terry H underwent laser surgery for retinal tears. Post-operatively, she complained about sensitivity to light. Which is an appropriate response by the nurse? A. “This sometimes occurs. If it continues over the next 8 hours you will need to be checked.” B. “This is normal. Let me review some things you can do to avoid exposure to direct light.” C. “Apply cool compresses; if you do not have relief in 2 hours, call me back.” D. “You need to come in right away to check for abnormal swelling in your eye.” 36. Nurse Gela is taking care of a client with macular degeneration. Which of the following is the most appropriate nursing diagnosis in the plan of care? A. Self-Care Deficit B. Imbalanced Nutrition C. Disturbed Sensory Perception D. Anxiety 37. Miranda was diagnosed with a cataract of both eyes. You would expect in her health history which chief clinical manifestation during the early stages of cataract formation? A. Eye pain B. Floating spots C. Blurred vision D. Diplopia 38. Terry G was scheduled for a cataract surgery. In preparation for cataract surgery, you are aware that an eye drops medication will be administereD. Which type of eye drops is indicated for the patient? A. An osmotic diuretic B. A miotic agent C. A mydriatic medication D. A thiazide diuretic 39. During the early postoperative period, the client who 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 B. Administer the ordered pain medication and anti emetic C. Reassure the client that this is normal D. Turn the client on his or her operative side 40. Terry G was being discharged from the ambulatory care unit for following cataract removal. The nurse provides instruction regarding home care. Which of the following, if stated by the client, indicates of 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 wear my eye shield at night and my glasses during the day.” D. “I will not lift anything if it weighs more than 10 pounds.” 41. Kelly complained of boring eye pain of the right eye until vision loss in some areas was experienced. She was diagnosed with glaucomA. She asks the nurse if complete vision will return. The most appropriate response is A. “Although some vision has been lost and cannot be restored, further lost may be prevented by adhering to the treatment plan.” B. “Your vision will return soon as the medication begins to work.” C. “Your vision will never return to normal.” D. “Your vision loss is temporary and will return in about 3 to 4 weeks.” 42. The nurse is caring for a hearing-impaired client. Which of the following approaches will facilitate communication? A. Speak loudly. B. Speak frequently. C. Speak at a normal volume. D. Speak directly into the impaired ear 43. Hannah B was diagnosed with Menière's disease. Which diet most likely would be prescribed for the client? A. Low-fat diet B. Low-sodium diet C. Low-cholesterol diet D. Low-carbohydrate diet 44. Rosanna H was diagnosed with presbycusis by the physician. She asked the home care nurse on what it means. The accurate reply is: A. Tinnitus that occurs with aging B. Nystagmus that occurs with aging C. A conductive hearing loss that occurs with aging D. A sensorineural hearing loss that occurs with aging 45. Gerry G is a 9 year old child complaining of pain behind the ear, fever, and chills. There is a suspicion of mastoiditis. Upon otoscopic examination, you would expect: A. A pink-colored tympanic membrane B. A pearly colored tympanic membrane C. A transparent and clear tympanic membrane D. A red, dull, thick and immobile tympanic membrane 46. Lou Y was diagnosed with a disorder involving the inner ear. Which of the following is the most common client complaint associated with a disorder involving this part of the ear? A. Pruritus B. Tinnitus C. Hearing loss D. Burning in the ear TOP RANK REVIEW ACADEMY, INC. Page 3 | 4
47. Marky D was diagnosed with glaucoma and was prescribed with eye drops. Which of the following instructions would the nurse include in the plan of care? A. Avoid overuse of the eyes. B. Decrease the amount of salt in the diet. C. Eye medications will need to be administered for the client's entire life. D. Decrease fluid intake to control the intraocular pressure. 48. A patient came to the ER and the physician is currently suspecting retinal detachment. Which of the following is associated with this eye disorder? A. Total loss of vision B. Pain in the affected eye C. A yellow discoloration of the sclera D. A sense of a curtain falling across the field of vision 49. Ailla D was about to undergo cryosurgery, to treat retinal detachment. You explain to the client that the goal of the treatment is to A. Creates a splint B. Stimulate an inflammatory response C. Attached the separated layer of the choroid D. Prevent increased IOP 50. True of the Optic nerve I. mediates general sensation of the auricle II. responsible for pupil constriction III. mediates vision IV. functions for corneal blink reflex A. 1, 2, 3, 4 B. 1,2,3 C. 2 only D. 3 only TOP RANK REVIEW ACADEMY, INC. Page 4 | 4