A client is scheduled for a tympanoplasty. What actions by the nurse are most appropriate? (Select all that apply.)
- A. Administer preoperative antibiotics
- B. Assess for allergies to local anesthetics
- C. Ensure that informed consent is on the chart
- D. Teach that hearing improves immediately
- E. Administer antivertigo medications
Correct Answer: A,B,C
Rationale: Preoperatively, the nurse administers antibiotics, assesses for allergies to anesthetics, and ensures that informed consent is on the chart. Antivertigo medications are not used, and hearing improvement is not immediate until the ear packing is removed.
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A hospitalized client has Ménière's disease. What menu selections demonstrate good knowledge of the recommended diet for this disorder? (Select all that apply.)
- A. Chinese stir fry with vegetables.
- B. Broiled chicken breast.
- C. Chocolate espresso cookies.
- D. Chili with tortilla chips.
- E. Green herbal tea with meals.
Correct Answer: B,E
Rationale: The diet recommendations for Ménière's disease include low-sodium, caffeine-free foods and fluids distributed evenly throughout the day. Plenty of water is also needed. The broiled chicken breast and herbal tea are the best selections. The stir fry is high in sodium and possibly monosodium glutamate (MSG, also not recommended). The cookies and chili with tortilla chips are high in sodium.
During ear irrigation, what action should the nurse take if the client becomes nauseated?
- A. Continue the procedure slowly.
- B. Stop the procedure immediately.
- C. Administer an antiemetic medication.
- D. Encourage the client to breathe deeply.
Correct Answer: B
Rationale: During ear irrigation, if the client becomes nauseated, the nurse should stop the procedure immediately to prevent further discomfort or complications. The other options are not appropriate in this context.
A nursing student studying the auditory system learns about the structures of the inner ear. What structures does this include? (Select all that apply.)
- A. Cochlea
- B. Epitympanum
- C. Organ of Corti
- D. Semicircular canals
- E. Vestibule
Correct Answer: A,C,D,E
Rationale: The cochlea, organ of Corti, semicircular canals, and vestibule are all part of the inner ear. The epitympanum is in the middle ear.
A client with labyrinthitis is prescribed antibiotics. What instruction is most important for the nurse to include?
- A. Immediately report headache or stiff neck.
- B. Keep all follow-up appointments.
- C. Take the antibiotics with a full glass of water.
- D. Take the antibiotic on an empty stomach.
Correct Answer: A
Rationale: Meningitis is a complication of labyrinthitis. The client should be taught to take all antibiotics as prescribed and to report manifestations of meningitis such as fever, headache, or stiff neck. Keeping follow-up appointments is important for all clients. Without knowing what antibiotic was prescribed, the nurse cannot instruct the client on how to take it.
A nurse is teaching a community group about noise-induced hearing loss. Which client who does not use ear protection should the nurse refer to an audiologist as the priority?
- A. Client with an hour car commute on the freeway each day.
- B. Client who rides a motorcycle daily.
- C. Client who sat in the back at a rock concert recently.
- D. Client who uses a chainsaw for 6 to 7 hours a day.
Correct Answer: D
Rationale: A chainsaw becomes dangerous to hearing after 2 hours of exposure without hearing protection. This client needs to be referred as the priority. Normal car traffic is safe for longer than 2 hours. Motorcycle noise is safe for about 8 hours. The safe exposure time for a front-row rock concert seat is 3 minutes, but this client was in the back, and so had less exposure. In addition, a one-time exposure is less damaging than chronic exposure.
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