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An adult man fell off a ladder and hit his head and lost consciousness. After regaining consciousness several minutes later, he was drowsy and had trouble staying awake. He is admitted to the hospital for evaluation. The nursing care plan will most likely include which of the following?
- A. Elevate head of bed 15 to 30 degrees
- B. Encourage fluids to 1000 mL every eight hours
- C. Assist the client to cough and deep breathe every two hours
- D. Perform chest physical therapy every four hours while awake
Correct Answer: A
Rationale: Elevating the head of the bed 15 to 30 degrees promotes gravity drainage of fluid and reduces cerebral edema. Coughing, forcing fluids, and chest physical therapy may increase intracranial pressure and are contraindicated.
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Which referral is most important for the nurse to implement for the client with permanent hearing loss?
- A. Aural rehabilitation.
- B. Speech therapist.
- C. Social worker.
- D. Vocational rehabilitation.
Correct Answer: A
Rationale: Aural rehabilitation addresses communication strategies and hearing aids, critical for permanent hearing loss. Speech therapy, social work, and vocational rehab are secondary.
During an assessment, the nurse covers the client's right eye and then observes a shift in the client's gaze after the eye is uncovered. Which conclusion should the nurse make about the results of the test?
- A. The client has opacity of the lens.
- B. The client has absence of the blink reflex.
- C. The client has increased intraocular pressure.
- D. The client has weakness in the extraocular muscles.
Correct Answer: D
Rationale: Covering and then uncovering the client's eye and then observing for a shift in the client's gaze is the cover-uncover test used to detect weakness in the extraocular muscles. Lens opacity is detected by direct observation. Stroking the eyelashes will evoke the blink reflex. The intraocular pressure is measured by tonometry.
The nurse speaks with the client who recently learned that cataracts are developing in both of the client's eyes. Which statement made by the client should the nurse correct?
- A. It is important that I schedule my surgery as soon as possible.
- B. Usually surgery is performed on each eye at different times.
- C. My own lens will be removed when I have cataract surgery.
- D. An intraocular lens may be inserted with the surgical procedure.
Correct Answer: A
Rationale: Although there is reduced vision with beginning cataract development, a person can wait until vision worsens before having surgery. When vision is reduced to the extent that ADLs are affected, surgery should be performed as soon as possible. If both eyes have cataracts, usually the eyes are treated in separate procedures. Surgery for a cataract involves removal of the client's lens, and in most situations, the lens is replaced with an intraocular lens.
Which statement indicates to the nurse the client is experiencing some hearing loss?
- A. I clean my ears every day after I take a shower.
- B. I keep turning up the sound on my television.
- C. My ears hurt, especially when I yawn.
- D. I get dizzy when I get up from the chair.
Correct Answer: B
Rationale: Turning up the television volume suggests hearing loss. Ear cleaning is unrelated, ear pain suggests infection, and dizziness indicates vestibular issues.
The nurse writes the diagnosis 'risk for injury related to impaired balance' for the client diagnosed with vertigo. Which nursing intervention should be included in the plan of care?
- A. Provide information about vertigo and its treatment.
- B. Assess for level and type of diversional activity.
- C. Assess for visual acuity and proprioceptive deficits.
- D. Refer the client to a support group and counseling.
Correct Answer: C
Rationale: Assessing visual and proprioceptive deficits identifies factors contributing to vertigo-related falls, enhancing safety. Information, activities, and referrals are secondary.