Nokea
The client comes to the clinic and is diagnosed with otitis media. Which intervention should the clinic nurse include in the discharge teaching?
- A. Instruct the client not to take any over-the-counter pain medication.
- B. Encourage the client to apply cold packs to the affected ear.
- C. Tell the client to call the HCP if an abrupt relief of ear pain occurs.
- D. Wear a protective ear plug in the affected ear.
Correct Answer: C
Rationale: Abrupt pain relief in otitis media may indicate tympanic membrane rupture, requiring HCP notification. OTC pain meds are safe, cold packs are less effective, and ear plugs are unnecessary.
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A 10-year-old boy comes to the school clinic holding his broken pair of glasses. He says that he got hit in the face playing ball and his eye hurts and feels like there's something in it. What should the nurse do before taking him to the emergency room?
- A. Thoroughly examine his eyes
- B. Put a pressure dressing on his right eye.
- C. Cover both eyes lightly with gauze
- D. Flush his right eye with water for 20 minutes
Correct Answer: C
Rationale: Covering both eyes lightly with gauze prevents tracking and further injury, suitable for a suspected foreign body until emergency evaluation.
The day following a stapedectomy, the client tells the nurse that he cannot hear much in the operative ear and thinks the stapedectomy was a failure. What is the best response for the nurse to make?
- A. There is packing in your ear. You will not hear well for a few days.'
- B. The doctors have not yet turned on the stapes replacement.'
- C. You may not have hearing, but you will now be free of pain.'
- D. You seem upset that you aren't hearing well.'
Correct Answer: A
Rationale: Ear packing post-stapedectomy temporarily reduces hearing, which improves as packing is removed.
The nurse who is at a local park sees a young man on the ground who has fallen and has a stick lodged in his eye. Which intervention should the nurse implement at the scene?
- A. Carefully remove the stick from the eye.
- B. Stabilize the stick as best as possible.
- C. Flush the eye with water if available.
- D. Place the young man in a high-Fowler's position.
Correct Answer: B
Rationale: Stabilizing the stick prevents further damage until surgical removal. Removing it risks bleeding, flushing is contraindicated, and positioning is secondary.
Which risk factors should the nurse discuss with the client concerning reasons for hearing loss? Select all that apply.
- A. Perforation of the tympanic membrane.
- B. Chronic exposure to loud noises.
- C. Recurrent ear infections.
- D. Use of nephrotoxic medications.
- E. Multiple piercings in the auricle.
Correct Answer: A,B,C,D
Rationale: Tympanic perforation, loud noise, ear infections, and ototoxic medications (e.g., aminoglycosides) cause hearing loss. Auricle piercings are cosmetic and unrelated.
The nurse is assessing the client's cranial nerves. Which assessment data indicate cranial nerve I is intact?
- A. The client can identify cold and hot on the face.
- B. The client does not have any tongue tremor.
- C. The client has no ptosis of the eyelids.
- D. The client is able to identify a peppermint smell.
Correct Answer: D
Rationale: Cranial nerve I (olfactory) is assessed by identifying smells like peppermint. Temperature sensation (trigeminal), tongue movement (hypoglossal), and ptosis (oculomotor) involve other nerves.