Nokea
A client has had a cataract extraction performed. Which statement would indicate that the client needs more teaching?
- A. I will take a stool softener daily.'
- B. I'm going to start doing calisthenic exercises as soon as I get home.'
- C. I'm going to my daughter's for a few weeks until I am recovered.'
- D. I am looking forward to watching television during my recovery period.'
Correct Answer: B
Rationale: Calisthenic exercises involving bending or lifting should be avoided post-cataract extraction to prevent increased intraocular pressure.
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The nurse is preparing to administer otic drops into an adult client's right ear. Which intervention should the nurse implement?
- A. Grasp the earlobe and pull back and out when putting drops in the ear.
- B. Insert the eardrops without touching the outside of the ear.
- C. Instruct the client to close the mouth and blow prior to instilling drops.
- D. Pull the auricle down and back prior to instilling drops.
Correct Answer: B
Rationale: Inserting drops without touching the ear prevents contamination. Pulling the auricle up and back (not down) is correct for adults, and blowing is unnecessary.
A 10-year-old boy comes to the school clinic holding his broken pair of glasses. He says that he got hit in the face playing ball and his eye hurts and feels like there's something in it. What should the nurse do before taking him to the emergency room?
- A. Thoroughly examine his eyes
- B. Put a pressure dressing on his right eye.
- C. Cover both eyes lightly with gauze
- D. Flush his right eye with water for 20 minutes
Correct Answer: C
Rationale: Covering both eyes lightly with gauze prevents tracking and further injury, suitable for a suspected foreign body until emergency evaluation.
The client recovering at home following a stapedectomy for otosclerosis reports having dizziness. To decrease symptoms, which interventions should the nurse recommend? Select all that apply.
- A. Refrain from sudden movements.
- B. Avoid chewing on the affected side.
- C. Avoid lifting objects that are heavy.
- D. Minimize bending over at the waist.
- E. Restrict the intake of oral fluids.
Correct Answer: A,C,D
Rationale: Refraining from sudden movements, avoiding heavy lifting, and minimizing bending decrease dizziness by reducing fluid shifts in the inner ear. Chewing and fluid restriction do not affect dizziness.
Which signs/symptoms should the nurse expect to find when assessing the client with an acoustic neuroma?
- A. Incapacitating vertigo and otorrhea.
- B. Nystagmus and complaints of dizziness.
- C. Nausea and vomiting.
- D. Unilateral hearing loss and tinnitus.
Correct Answer: D
Rationale: Acoustic neuroma (vestibular schwannoma) causes unilateral hearing loss and tinnitus due to cranial nerve VIII compression. Vertigo, nystagmus, and nausea are less prominent; otorrhea is unrelated.
The nurse is using a tuning fork to perform the Rinne test for air and bone conduction hearing. Place an X on the location where the nurse should place the stem of the tuning fork.
- A. For the Rinne test the stem of the tuning fork is placed on the mastoid process, located posterior to the ear lobule.
Correct Answer: A
Rationale: For the Rinne test, the stem of the tuning fork is placed on the mastoid process, posterior to the ear lobule, to assess bone conduction compared to air conduction.