6. The nurse is performing an assessment on a client with a suspected diagnosis of cataract. What is the chief clinical manifestation that the nurse expects to note in the early stages of cataract formation?
a) Diplopia
b) Eye pain
c) Floating spots
d) Blurred vision
7. A client arrives in the emergency department following an automobile crash. The client’s forehead hit the steering wheel and a hyphema is diagnosed. The nurse should place the client in which position?
a) Flat in bed
b) A semi-Fowler’s position
c) Lateral on the affected side
d) Lateral on the unaffected side
8. Eye and Ear NCLEX Questions about the client who sustains a contusion of the eyeball following a traumatic injury with a blunt object. Which intervention should be initiated immediately?
a) Apply ice to the affected eye.
b) Irrigate the eye with cool water.
c) Notify the health care provider (HCP).
d) Accompany the client to the emergency department.
9. A client arrives in the emergency department with a penetrating eye injury from wood chips that occurred while cutting wood. The nurse assesses the eye and notes a piece of wood protruding from the eye. What is the initial nursing action?
a) Apply an eye patch.
b) Perform visual acuity tests.
c) Irrigate the eye with sterile saline.
d) Remove the piece of wood using a sterile eye clamp.
10. The nurse is caring for a client following enucleation and notes the presence of bright red drainage on the dressing. Which nursing action is most appropriate?
a) Document the finding.
b) Continue to monitor the drainage.
c) Notify the health care provider (HCP).
d) Mark the drainage on the dressing and monitor for any increase in bleeding.
Eye and Ear NCLEX Questions
Answers and Rationale
6) D
- Rationale: A gradual, painless blurring of central vision is the chief clinical manifestation of a cataract. Early symptoms include slightly blurred vision and a decrease in color perception. Options A, B, and C are not characteristics of a cataract.
- Test-Taking Strategy: Note the strategic word early. Remember the pathophysiology related to cataract development. As a cataract develops, the lens of the eye becomes opaque. This description will assist in directing you to the correct option.
7) B
- Rationale: A hyphema is the presence of blood in the anterior chamber. Hyphema is produced when a force is sufficient to break the integrity of the blood vessels in the eye and can be caused by direct injury, such as a penetrating injury from a BB or pellet, or indirectly, such as from striking the forehead on a steering wheel during an accident. The client is treated by bed rest in a semi-Fowler’s position to assist gravity in keeping the hyphema away from the optical center of the cornea.
- Test-Taking Strategy: Focus on the subject, care of the client who has sustained a hyphema. Remember that placing the client flat will produce an increase in pressure at the injured site. Also, note that the correct option is the one that identifies a position different from the other options.
8) A
- Rationale: Treatment for a contusion begins at the time of injury. Ice is applied immediately. The client then should be seen by an HCP and receive a thorough eye examination to rule out the presence of other eye injuries.
- Test-Taking Strategy: Focus on the strategic word immediately. Recalling the principles related to initial treatment of injuries and noting the type of injury sustained will direct you to the correct option.
9) B
- Rationale: If the eye injury is the result of a penetrating object, the object may be noted protruding from the eye. This object must never be removed except by the ophthalmologist because it may be holding ocular structures in place. Application of an eye patch or irrigation of the eye may disrupt the foreign body and cause further tearing of the cornea.
- Test-Taking Strategy: Note the strategic word initial and note the word penetrating. This should indicate that a laceration has occurred and that interventions are directed at preventing further disruption of the integrity of the eye. The only option that will prevent further disruption is to assess visual acuity.
10) C
- Rationale: If the nurse notes the presence of bright red drainage on the dressing, it must be reported to the HCP, because this indicates hemorrhage. Options A, B, and D are inappropriate.
- Test-Taking Strategy: Note the strategic words most appropriate and the words bright red. Remember that bright red drainage indicates active bleeding.
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Eye and Ear NCLEX Questions 11-15
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