Nokea
A nurse is teaching a group of clients about the specific types of fluids that protect the structures of the inner ear. Which of the following statements should the nurse include in the teaching?
- A. Endolymph fluid provides protection to the structures of the inner ear.
- B. Sanguineous fluid provides protection to the structures of the inner ear.
- C. Aqueous humor provides protection to the structures of the inner ear.
- D. Vitreous humor provides protection to the structures of the inner ear.
Correct Answer: A
Rationale: Endolymph is found within the inner ear, specifically in the membranous labyrinth, and plays a crucial role in hearing and balance. Sanguineous fluid refers to blood or fluid containing blood and is not present in the inner ear. Aqueous humor and vitreous humor are fluids found in the eye, not the ear.
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After radiation treatment, a client reports dryness, redness, and scaling of his skin occurring within the designated radiation treatment markings. The nurse should instruct the client to take which of the following actions?
- A. Wash with plain soap and water.
- B. sit in the sun for 10 min per day.
- C. Apply moist heat.
- D. Apply hydrating lotions.
Correct Answer: D
Rationale: Hydrating lotions soothe and moisturize skin, alleviating dryness and scaling from radiation. Other options risk further irritation or damage.
A nurse educator is working with the staff to decrease skin tissue injuries to clients on the medical surgical unit. Which of the following practices will decrease friction injuries?
- A. instruct the client to dig their heels into the bed to push themselves upwards.
- B. Assist the client with a trapeze to raise their body while staff assists with repositioning
- C. Have two to three staff members pull the client up in bed when needed.
- D. Elevate the head of the bed 90° for bedridden clients.
Correct Answer: B
Rationale: Using a trapeze reduces friction and shear forces during repositioning, preventing skin injuries. Other options increase friction or shear risks.
A nurse is caring for an adolescent who has hemophilia A and is scheduled for wisdom teeth extractions. Prior to the procedure, the nurse should anticipate that the client will receive which of the following products?
- A. Packed RBCS
- B. Fresh frozen plasma
- C. Recombinant
- D. Prophylactic antibiotics
Correct Answer: C
Rationale: Recombinant factor VIII is a synthetic form of the clotting factor deficient in hemophilia A, used to increase factor VIII levels before procedures to prevent excessive bleeding. Packed RBCs treat anemia, not clotting deficiencies. Fresh frozen plasma contains all clotting factors but is less targeted than recombinant factor VIII. Prophylactic antibiotics prevent infection, not bleeding.
A nurse is developing a plan of care to prevent skin breakdown for a client with a spinal cord injury and paralysis. Which of the following nursing actions are appropriate?
- A. Massage over erythematous bony prominences.
- B. Implement a turning schedule every 4 hr.
- C. Keep the client's skin dry with powder.
- D. Minimize skin exposure to moisture.
- E. Use pillows to keep heels off the bed surface
Correct Answer: B,E
Rationale: Using pillows to elevate heels and minimizing moisture exposure prevent pressure ulcers and skin breakdown. Massaging erythematous areas, 4-hour turning, and powder use increase skin breakdown risk.
A nurse is caring for a client who has Meniere's disease. The nurse identifies which of the following manifestations is caused by an excessive accumulation of endolymph fluid?
- A. Myopia
- B. Vertigo
- C. Photophobia
- D. Presbycusis
Correct Answer: B
Rationale: Vertigo is a primary symptom of Meniere's disease, caused by excessive endolymph fluid in the inner ear affecting balance and spatial orientation. Myopia, photophobia, and presbycusis are unrelated to endolymph accumulation.