Nokea
A patient who had an enucleation of the right eye has been admitted postoperatively to the nursing unit. Which aspect does the nurse expect to see in the plan of care?
- A. Turn, cough, and deep breathe every 3 hours.
- B. Apply a pressure dressing over the right eye socket.
- C. Document dressing Data Collection every 2 hours.
- D. Turn on the affected side.
Correct Answer: B
Rationale: A pressure dressing will be applied to the right eye socket and the dressing should be checked every hour for the first 24 hours.
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For which reason is otitis media found more frequently in children 6 to 36 months?
- A. Eustachian tubes in children are shorter and straighter.
- B. Infection descends via the eustachian tube to the throat.
- C. Children's eustachian tubes are more vertical and longer.
- D. Otitis media is seen equally in both children and adults.
Correct Answer: A
Rationale: Children's shorter and straighter eustachian tubes provide easier access of the organisms from the nasopharynx to travel to the middle ear.
The nurse will provide which advise for a patient who has severe vertigo from labyrinthitis?
- A. Lean against a wall and not move the head forward until vertigo lessens.
- B. Bend at the waist and take several deep breaths.
- C. Drink an iced drink slowly.
- D. Lie immobile and hold the head in one position until the vertigo lessens.
Correct Answer: D
Rationale: Lying immobile and holding the head in one position will lessen vertigo.
A patient reports that the entire right side of the head hurts and being unable to chew without pain. The nurse recognizes the patient has symptoms of which disorder?
- A. mumps
- B. external otitis
- C. otitis media
- D. labyrinthitis
Correct Answer: B
Rationale: The symptoms of painful head, painful chewing, and pain when the auricle is moved all indicate external otitis, frequently caused by compacted cerumen.
When the patient in the emergency room reports seeing flashing lights and a curtain down over the right eye, the nurse recognizes this as a symptom of which condition?
- A. Detached retina
- B. Macular degeneration
- C. Early sign of cataract
- D. Diabetic retinopathy
Correct Answer: A
Rationale: The standard symptom of a detached retina is the report of seeing flashing lights and having a curtain being drawn over the eyes.
Which anatomical change is associated with diabetes retinopathy?
- A. Capillaries in retina hemorrhage
- B. Long-term overdosing of insulin
- C. Retinal detachment
- D. Aging
Correct Answer: A
Rationale: Retinopathy is caused when the capillaries in the retina have aneurysms or hemorrhage.