APO Review Center c.

The client’s intraocular pressure is 30 mm Hg

Competency Appraisal 2 d. The client’s eye exhibited the presence of protein
DMC-College Foundation Inc flare.
SPECIAL SENSES POST TEST
Prepared by: Elijah C. Legaspi, RN, MD 6. Patient Naveen recently had a consultation with his
Ophthalmologist. He has multiple risk factors for primary
1. Nurse Taylor is preparing to test the visual acuity of open-angle glaucoma (POAG). Which sign or symptom
client Joe, using a Snellen chart. Which identifies the should be investigated by Nurse Tiana as an EARLY
accurate procedure for this visual acuity test? SIGN of POAG?

a. Both eyes are assessed together, followed by an a. Loss of central visual field
assessment of the right eye and then the left eye. b. Seeing halos around lights
b. The right eye is tested, followed by the left eye, and c. Mild eye aching
then both eyes are tested. d. Loss of peripheral vision
c. The client is asked to stand at a distance of 40 feet
(12 meters) from the chart and to read the largest line on 7. Nurse Tiana is developing a teaching plan for Client
the chart. Naveen who was recently diagnosed with glaucoma.
d. The client is asked to stand at a distance of 40 feet Which instruction would Nurse Tiana include in the plan
(12 meters) from the chart and to read the line that can of care?
be read 200 feet (60 meters) away by an individual with
unimpaired vision. a. Eye medications will need to be administered for life.
b. Decrease fluid intake to control the intraocular
2. Client Joe’s vision was tested with a Snellen chart. pressure.
The results of the tests are documented as 20/60. What c. Avoid overuse of the eyes.
action would Nurse Taylor implement based on this d. Decrease the amount of salt in the diet.
finding?
8. Tonometry is performed on client Eric with a
a. Provide David with materials on legal blindness. suspected diagnosis of glaucoma. Nurse Ariel looks at
b. Tell David that it is best to sit near the back of the the documented test results and notes an intraocular
room when attending lectures. pressure (IOP) value of 23. What would be Nurse Ariel’s
c. Inform David where to purchase a white cane with a initial action?
red tip. a. Apply normal saline drops.
d. Instruct David that glasses may be needed when b. Note the time of day the test was done.
driving. c. Contact the primary health care provider.
d. Instruct Eric to sleep with the head of the bed flat.
3. The family of Mr. Alwyn is concerned that he will
eventually be blind due to the course of an illness. Nurse 9. A miotic medication has been prescribed for patient
Taylor should include the following in the family teaching Weng, who was previously diagnosed with glaucoma,
to help Mr. Alwyn cope with the possibility of blindness and the patient asks Nurse Vanna about the purpose of
EXCEPT: the medication. Which response would the nurse provide
to the client?
a. Marking medication bottles with textured paints. a. “The medication will help dilate the eye to prevent
b. Repositioning articles and furniture every week. pressure from occurring.”
c. Helping the client familiarize herself with spatial b. “The medication will relax the muscles of the eyes and
orientation. prevent blurred vision.”
d. Using the clock system to describe the location of c. “The medication causes the pupil to constrict and will
food on the plate. lower the pressure in the eye.”
d. “The medication will help block the responses that are
4. Glaucoma is a group of ocular conditions sent to the muscles in the eye.”
characterized by optic nerve damage. The optic nerve
damage is related to the IOP caused by congestion of 10. Nurse Remzy is preparing to administer a beta-
aqueous humor in the eye. Mr. Roxas has been adrenergic blocking glaucoma agent. Which statement
diagnosed as having chronic open-angle glaucoma. He made by Patient Marian warrants additional assessment
has been admitted to the hospital for treatment. The and a notification to the health care provider?
nurse identified a nursing problem of disturbed sensory
perception, visual impairment characterized by: a. “My blood pressure runs a little high if I gain too much
a. Loss of night vision weight.”
b. Loss of central vision b. “Occasionally, I have palpitations, but they pass very
c. Sudden loss of eyesight quickly.”
d. Loss of peripheral vision c. “My joints feel stiff today, but that’s just my arthritis.”
d. “My pulse rate is a little low today because I take
5. A tonometry test was undertaken by Mr. Roxas. digoxin.”
Which of the following results should the nurse expect?
a. The client’s visual acuity is 20/250.
b. The client has decreased peripheral vision
11. Pedro was diagnosed with chronic-open angle 16. Nurse Patrick calls patient David who underwent
glaucoma. He is scheduled for eye surgery. The nurse cataract surgery yesterday to assess patient David’s
assigned to Pedro should: current condition. Which client statement necessitates
a. Not administer acetazolamide (Diamox) before the further evaluation by an ophthalmologist?
surgery
b. Stay alert for any mydriatic medications ordered for a. “My eye begins to hurt again about 4 hours after I take
the client the pain pills the doctor ordered.”
c. Give pre-operatively ordered meperidine and atropine b. “The redness in my eye is much less than yesterday.”
on time c. “I cannot see nearly as well as I could yesterday after
d. Instill cycloplegic eye drops every 15 minutes for 1 the surgery.”
hour d. “There is no swelling around my eye to speak of.”

12. Nurse Aurora is performing an assessment on client 17. Nurse Mulan is performing an admission assessment
Phillip with a suspected diagnosis of cataract. Which to client Shang with a diagnosis of detached retina.
clinical manifestation would Nurse Aurora expect to note Which sign or symptom is associated with this eye
in the early stages of cataract formation? problem?
a. Double Vision a. Total loss of vision
b. Eye pain b. Pain in the affected eye
c. Floating spots c. A yellow discoloration of the sclera
d. Blurred vision d. A sense of a curtain falling across the field of vision

13. The nurse is preparing a teaching plan for a client 18. Nurse Mulan reiterates that scleral buckling, one of
who had a cataract extraction with intraocular the procedures used to treat retinal detachment,
implantation. Which home care measures would the involves:
nurse include in the plan? Select all that apply. a. Removing the torn segment of the retina and stitching
down the remaining segment
1.. Avoid activities that require bending over. b. Replacing the torn segment of the retina with a strip of
2.Contact the surgeon if eye scratchiness occurs. retina from a donor
3. Take acetaminophen for minor eye discomfort. c. Stitching the retina firmly to the optic nerve to give it
4.Expect episodes of sudden severe pain in the eye. support
5lPlace an eye shield on the surgical eye at bedtime. d. Creating a splint to hold the retina together until a scar
6. Contact the surgeon if a decrease in visual acuity forms and seal off the tear
occurs.
19. The nurse would assess which of the following types
a. 1, 4, 5, 6 of vision loss in a client with age-related macular
b. 2, 3, 4, 5 degeneration?
c. 1, 3, 5, 6 a. Total blindness
d. 3, 4, 5, 6 b. Central vision loss only
c. Peripheral vision loss only
14. During the early postoperative period, client Phillip, d. Seeing “halos” and “cobwebs”
who has undergone a cataract extraction complains of
nausea and severe eye pain over the operative site. 20. According to evidence-based guidelines from the
What would be the initial nursing action of Nurse American Optometric Association, which modifiable risk
Aurora? factor is the most important to emphasize during patient
a. Call the surgeon. teaching to reduce the risk for age-related macular
b. Reassure the client that this is normal. degeneration?
c. Turn the client onto their operative side. a. Initiate smoking cessation.
d. Administer the prescribed pain medication and b. Take vitamin D and E supplements.
antiemetic. c. Eat dark green, leafy vegetables.
d. Wear protective eyewear as needed.
15. In preparation for cataract surgery, Nurse Hope is to
administer cyclopentolate eye drops at 10:00 am for 21. Client Joseph tells Nurse Priscilla that he has been
surgery that is scheduled for 10:15 am. What initial diagnosed with macular degeneration, “wet type.” Based
action would Nurse Hope take in relation to the on the her knowledge of his diagnosis, Nurse Priscilla
characteristics of the medication action? examines client Joseph’s eyes using an
a. Provide lubrication to the operative eye prior to giving ophthalmoscope, she should expect to observe:
the eye drops. a. Growth of abnormal blood vessels in the macula.
b. Call the surgeon, as this medication will further b. Atrophy of structures in the macula.
constrict the operative pupil. c. Clouding of the lens of the eye.
c. Consult the surgeon, as there is not sufficient time for d. A thin, grayish-white area on the edge of the cornea.
the dilative effects to occur.
d. Give the medication as prescribed; the surgeon needs 22. Patient Glinda calls the eye clinic and reports the
optimal constriction of the pupil. presence of redness of the sclera, itching of the eyes,
and increased lacrimation for several hours. What
should Nurse Elphaba instruct client Glinda to do first?
a. “Please call your healthcare provider”
b. “Apply a cool compress to your eyes for 30 minutes to 29.Patient Brian has a hordeolum (sty) on his right upper
reduce inflammation.” eyelid. Which intervention would Nurse Lara recommend
c. “If you are wearing contact lenses, remove them.” first?
d. “Take an over-the-counter antihistamine, such as a. Apply warm compresses four times per day.
loratadine.” b. Gently perform hygienic eyelid scrubs.
c. Obtain a prescription for antibiotic drops.
23. Client Gaston arrives in the emergency department d. Contact the ophthalmologist.
with a penetrating eye injury from wood chips that
occurred while cutting wood. Nurse Belle assesses the 30. What should nurse Carla do first for a child
eye and notes a piece of wood protruding from Gaston’s diagnosed with conjunctivitis and was ordered to have
eye. What is the initial nursing action of Nurse Belle? eye ointment applied three times a day?
a. Remove the piece of wood using a sterile eye clamp. a. Remove any discharge from the affected eye.
b. Apply an eye patch. b. Ensure the ointment is at room temperature.
c. Perform visual acuity tests. c. Hold the tip of the eye ointment tube parallel to the
d. Irrigate the eye with sterile saline. eye.
d. Wash hands with soap and water.
24. Gaston sustains a contusion of the eyeball following
a traumatic injury with a baseball bat. Which intervention 31. A resident of a long-term care facility tells Nurse
would be initiated immediately by Nurse Belle? Stevie that he is having increased difficulty hearing
a. Apply ice to the affected eye. during conversations and while watching television.
b. Irrigate the eye with cool water. Nurse Stevie should:
c. Notify the primary health care provider (PHCP). a. Teach the client to eliminate background noises.
d. Accompany the client to the emergency department. b. Assess the client’s hearing and examine the client’s
ears using an otoscope.
25. Patient Cinderella arrives in the emergency c. Contact the primary care provider and schedule the
department following a vehicular accident. The client’s client for bilateral ear irrigations.
forehead hits the steering wheel, and a hyphema is d. Teach the client to look directly at the speaker’s face
diagnosed. The Nurse Anastasia would place the client in conversations or while watching a
in which position? television program.
a. Flat in bed
b. A semi-Fowler’s position 32. Nurse Stevie is assigned at an elderly care home
c. Lateral on the affected side and is caring for a hearing-impaired client Johnny Rose.
d. Lateral on the unaffected side Which approach will facilitate communication between
the nurse and the client?
26. Joshua was working in the garden when insecticide a. Speak frequently to client Johnny.
accidentally sprayed into his right eye. He calls the b. Shout whenever talking to client Johnny.
emergency department, frantic and screaming for help. c. Speak at a normal volume whenever communicating
Nurse Jane would instruct the client to take which to client Johnny.
immediate action? d. Speak directly to the impaired ear of client Johnny.
a. Irrigate the eyes with water.
b. Come to the emergency department. 33. Nurse Stevie notes that the primary health care
c. Call the primary health care provider. provider has documented a diagnosis of presbycusis on
d. Irrigate the eyes with diluted hydrogen peroxide. client Roland’s chart. Based on this information, what
actton would the nurse take?
27. Nurse Narda is providing instructions to client Regina a. Speak loudly but mumble or slur the words.
who will be self-administering eye drops. To minimize b. Speak loudly and clearly while facing the client.
systemic absorption of the eye drops, the nurse would c. Speak at normal tone and pitch, slowly and clearly.
instruct the client to take which action? d. Speak loudly and directly into the client’s affected ear.
a. Eat before instilling the drops.
b. Swallow several times after instilling the drops.
c. Blink vigorously to encourage tearing after instilling 34. A cheerful older widow Mrs. Moira Rose comes to
the drops. the community clinic for her annual checkup. She is in
d. Occlude the nasolacrimal duct with a finger after reasonably good health, but she has a hearing loss of 40
instilling the drops. dB. She confides, “I don’t get out much. I used to be
really active, but the older I get, the more trouble I have
28. Nurse Ariel is caring for client Ursula following hearing. It can be really embarrassing.” What is the
enucleation due to a workplace accident and notes the priority nursing concept to consider in planning care for
presence of bright red drainage on the dressing. Which this patient?
action should Nurse Ariel take at this time? a. Safety
a. Continue to monitor the drainage. b. Sensory perception
b. Document the finding. c. Mood and affect
c. Notify the primary health care provider (PHCP). d. Functional ability
d. Mark the drainage on the dressing and monitor for any
increase in bleeding.
35. A client’s daughter tells Nurse Caloy his frustration 41. Which physical assessment findings, when observed
while communicating with her elderly mother who wears by the nurse, should be reported to the health care
hearing aids. A Nurse Caloy suggests that the daughter provider?
should: a. Pearly gray or pink tympanic membrane
a. Minimize oral communication to essential matters. b. Dense whitish ring at the circumference of the
b. Speak directly into the client’s better ear. tympanum
c. Use exaggerated mouth expressions while speaking. c. Bulging red or blue tympanic membrane
d. Attract the client’s attention before speaking. d. Cone of light at the innermost part of the tympanum

36. Sensorineural hearing loss results from which of the 42. Which information is most important for patients to
following conditions? inform their health care provider before he/she
prescribes amoxicillin, which is the first-line antibiotic for
a. Presence of fluid and cerumen in the external canal. acute otitis media in children?
b. Sclerosis of the bones of the middle ear. a. Child took amoxicillin several months ago for a similar
c. Damage to the cochlear or vestibulocochlear nerve. problem
d. Emotional disturbance resulting in a functional hearing b. Child has a personal and family history of penicillin
loss. allergies
c. Child has concurrent allergic rhinitis with sneezing and
37. The best method to remove cerumen from a client’s congestion
ear involves: d. Child is 18 months old and goes to daycare and his
a. Inserting a cotton-tipped applicator into the external parents smoke
canal.
b. Irrigating the ear gently. 43. Which statement by the parents of Clarisse, a 3 y/o
c. Using aural suction. toddler with repeated otitis media, indicates they need
d. Using a cerumen curette. additional teaching?
a. “If I quit smoking, my child may have a decreased
38. The nurse prepares a client for ear irrigation as chance of getting an ear infection.”
prescribed by the primary health care provider. Which b. “As my child gets older, he should have fewer ear
action would the nurse take when performing the infections, because his immune system will be more
procedure? developed.”
a. Warm the irrigating solution to 37.0° C. c. “My child will have fewer ear infections if he has his
b. Position the client with the affected side up following tonsils removed.”
the irrigation. d. “My child may need a speech evaluation.”
c. Direct a slow, steady stream of irrigation solution
toward the eardrum.
d. Assist the client to turn their head so that the ear to be 44. When determining the parents’ compliance with
irrigated is facing upward. treatment for their toddler who has recurrent otitis media,
which of the following measures would the nurse expect
39. Nurse Mico is caring for several patients who are the parents to describe?
having problems with their ears. Which patient condition a. Cleaning the child’s ear canal with hydrogen peroxide
is cause for greatest concern? b. Administering continuous, small-dose antibiotic
a. Has discomfort of the ear preceded by a viral therapy
infection; the tympanic membrane is erythematous c. Instilling ear drops regularly to prevent cerumen
b. Has been treated with antibiotics for recurrent acute accumulation.
otitis media four times within the past 6 months d. Holding the child upright when feeding with a bottle.
c. Reports rapid onset ear pain with pruritus and a
sensation of fullness that started after cleaning the ear 45. Nurse Stevie is taking care of a 25 year old female
canal with a finger patient diagnosed with Mastoiditis. She knows that the
d. Reports progressive severe otic pain with purulent most common cause of mastoiditis is:
discharge and is positive for human immunodeficiency a. Picking of ears with hairpin
virus b. Recurrent Otitis Media
c. Tonsillitis
40. Which should be included in instructions to the d. Sinusitis
parent of a child prescribed amoxicillin to treat an ear
infection? 46. Nurse Stevie is performing an otoscopic examination
a. “Continue the amoxicillin until the child’s symptoms on client Alexis Rose who was suffering from mastoiditis.
subside.” On examination of the tympanic membrane, which
b. “Administer an over-the-counter antihistamine with the finding would the nurse expect to observe?
antibiotic.” a. A pink-colored tympanic membrane
c. “Administer the amoxicillin until all the medication is b. A pearly colored tympanic membrane
gone.” c. A transparent and clear tympanic membrane
d. “Allow your child to administer his own dose of d. A red, dull, thick, and immobile tympanic membrane
amoxicillin.”
47. Treatment of choice for Mastoiditis is:
a. Mastoidectomy
b. Oral Antibiotics for 14 days Which medication is most likely prescribed for treating
c. Irrigation of ear drainage the vertigo?
d. Ear packing a. Meclizine
b. Megestrol
48. Patient Millie receives a prescription for sodium c. Meropenem
fluoride for otosclerosis and asks Nurse Hannah what d. Metoprolol
the medication will do for her ears. Which response by
the nurse is correct? 54. Nurse Stevie is working in a clinic that specializes in
the care of patients with ear disorders. Patient Moira tells
a. “The medication prevents the breakdown of bone cells the nurse that she has been taking meclizine. Which
and hardens the bone in the ear.” question is the nurse most likely to ask to evaluate the
b. “The medication causes the breakdown of bone cells effectiveness of the medication?
and softens the bone in the ear.”
c. “The medication blocks the effect of histamine and a. Has the medication helped to relieve the pain in the
dries the fluid in the ear.” ear canal?
d. “The medication causes the production of histamine b. Are you still experiencing the whirling and turning
and increases the fluid in the ear.” sensations?
c. Have you been able to hear better since you started
49. Nurse Hannah performed postoperative the medication?
stapedectomy teaching to patient Millie several days d. Are you still having itching and discomfort in the outer
ago. Which comment by patient Delita is a cause for ear?
greatest concern?
55. Which description by a patient reporting vertigo is
a. “I’m going to take swimming lessons in a couple of cause for greatest concern?
months.” a. Dizziness with hearing loss
b. “I have to take a long overseas flight in several b. Episodic vertigo
weeks.” c. Vertigo without hearing loss
c. “I can’t wait to get back to my regular weightlifting d. “Merry-go-round” vertigo
class.” 56. Patient Joshua has hearing loss from a suspected
d. “I have been coughing a lot with my mouth open.” acoustic neuroma. Which diagnostic test should Nurse
Raf plan to prepare the client to confirm the presence of
50. Former television actress Mrs. Moira Rose, a client a tumor?
with Ménière’s disease, is currently experiencing severe
vertigo as told by her son David. Which instruction would a. Tympanometry
Nurse Stevie give to the client to assist her in controlling b. Arteriogram of the cranial vessels
the vertigi? c. Magnetic resonance imaging (MRI)
a. Lie still and watch the television. d. Auditory canal biopsy
b. Increase sodium in the diet. 57. Nurse Leslie is caring for client Andy following
c. Increase fluid intake to 3000 mL a day. craniotomy for removal of an acoustic neuroma.
d. Avoid sudden head movements. Assessment of which cranial nerve would identify a
complication specifically associated with this surgery?
51. Meniere’s disease is an abnormal inner ear fluid a. Cranial nerve I, olfactory
balance caused by malabsorption in the endolymphatic b. Cranial nerve IV, trochlear
sac, or a blockage in the endolymphatic duct. Nurse c. Cranial nerve III, oculomotor
Stevie is giving dietary instructions to the client. Which d. Cranial nerve VII, facial nerve
statement, if made by the client indicates that the
teaching has been SUCCESSFUL? 58. Jocelyn Schitt was diagnosed with a problem
a. “I will not eat chocolates, and yogurt.” involving the inner ear. Which is the most common client
b. “I must drink at least 3,000 ml of fluids per day.” complaint associated with a problem involving this part
c. “I will try to eat foods that are low in sodium and limit of the ear?
my fluid intake.” a. Itchiness
d. “I will try to follow a 50% carbohydrate, 30% fat, and b. Tinnitus
20% protein diet.” c. Hearing loss
d. Burning sensation
52. A client is diagnosed with Meniere’s disease. The
PRIORITY nursing diagnosis for Mrs. Moira Rose is: 59. Which combination of drugs is cause for greatest
a. Risk for injury concern if the patient reports tinnitus or other problems
b. Impaired social interaction with hearing?
c. Altered cerebral tissue perfusion a. Gentamycin and ethacrynic acid
d. Altered nutrition more than body requirements b. Furosemide and metoprolol
c. Vancomycin and nitroglycerin patch
53. Moira Rose was recently diagnosed with Ménière’s d. Aspirin and calcium supplement
disease. She tells Nurse Stevie that medication
treatment for vertigo has been prescribed and provides 60. Patient Xavier was just admitted to the hospital to
the nurse with a list of medications recently received. rule out a possible GI bleeding. Xavier has brought
several bottles of medications prescribed by different
specialists. During the admission assessment, the client
states, “Lately, I have been hearing some noisy sounds
in my ears, especially when I am alone.” Which
medication should Nurse Mico identify as the cause of
the client’s complaint?

a. Doxycycline
b. Atropine sulfate
c. Acetylsalicylic acid
d. Diltiazem hydrochloride