Nokea
A nursing student is instructed to remove a clients ear packing and instill eardrops. What action by the student requires intervention by the registered nurse?
- A. Assessing the eardrum with an otoscope.
- B. Warming the eardrops in water for 5 minutes.
- C. Using a cotton swab to clean the ear canal.
- D. Instilling eardrops at room temperature.
Correct Answer: A
Rationale: Assessing the eardrum with an otoscope requires specialized training and is not within the scope of a nursing student. Warming eardrops and instilling them at room temperature are appropriate. Using a cotton swab is not ideal but does not require immediate intervention.
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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 had a myringotomy. The nurse provides which discharge teaching?
- A. Buy dry shampoo to use for a week.
- B. Drink liquids through a straw.
- C. Flying is not allowed for 1 month.
- D. Hot water showers will help the pain.
Correct Answer: A
Rationale: The client cannot shower or get the head wet for 1 week after surgery, so using dry shampoo is a good suggestion. The other instructions are incorrect: straws are not allowed for 2 to 3 weeks, flying is not allowed for 2 to 3 weeks, and the client should not shower.
A nurse is teaching a client about ear hygiene and health. What client statement indicates a need for further teaching?
- A. A soft cotton swab is alright to clean my ears with.
- B. I make sure my ears are dry after I go swimming.
- C. I stop good ear plugs when I practice with the band.
- D. Keeping my diabetes under control helps my ears.
Correct Answer: A
Rationale: Clients should be taught not to put anything larger than their fingertip into their ears. Using a cotton swab, although soft, can cause damage to the ears and cerumen buildup. The other statements are accurate.
A client is scheduled to have a tumor of the middle ear removed. What teaching topic is most important for the nurse to cover?
- A. Expecting hearing loss in the affected ear
- B. Managing postoperative pain
- C. Ensuring proper wound care
- D. Understanding which medications are allowed the day of surgery
Correct Answer: A
Rationale: Removal of an inner ear tumor will likely destroy hearing in the affected ear. The other teaching topics are appropriate for any surgical client but are not the most critical in this case.
A client with Ménière's disease is in the hospital when the client has an attack of this disorder. What action by the nurse takes priority?
- A. Assess vital signs every 15 minutes.
- B. Dim or turn off lights in the client's room.
- C. Place the client in bed with the upper siderails up.
- D. Provide a cool, wet cloth for the client's face.
Correct Answer: C
Rationale: Clients with Ménière's disease can have vertigo so severe that they can fall. The nurse should assist the client into bed and raise the upper siderails to prevent falls due to the intense whirling feeling. The other actions are not warranted for clients with Ménière's disease.