Nokea
The client comes to the emergency department after splashing chemicals into the eyes. Which intervention should the nurse implement first?
- A. Have the client move the eyes in all directions.
- B. Administer a broad-spectrum antibiotic.
- C. Irrigate the eyes with normal saline solution.
- D. Determine when the client had a tetanus shot.
Correct Answer: C
Rationale: Immediate irrigation with normal saline removes chemicals, preventing corneal damage. Eye movement, antibiotics, and tetanus history are secondary.
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The client is complaining of ringing in the ears. Which data are most appropriate for the nurse to document in the client's chart?
- A. Complaints of vertigo.
- B. Complaints of otorrhea.
- C. Complaints of tinnitus.
- D. Complaints of presbycusis.
Correct Answer: C
Rationale: Ringing in the ears is tinnitus, the appropriate term to document. Vertigo, otorrhea, and presbycusis (age-related hearing loss) are distinct symptoms.
The client's eyes, tested with the use of a Snellen chart, show 20/40 vision in the right eye and 20/30 in the left eye. How should the nurse interpret these results?
- A. The client has elevated intraocular pressure in both eyes.
- B. The client needs testing for glaucoma with a tonometer.
- C. The left eye is closer to normal vision than the right eye.
- D. The client has errors of refraction indicating astigmatism.
Correct Answer: C
Rationale: The Snellen chart is used to test distance vision. The numbers recorded indicate that at 20 feet (the first number) the client is able to read what a person with normal vision can read at another distance (second number). The left eye's vision recorded as 20/30 has better vision than the right eye with vision recorded as 20/40. The Snellen chart is not used to measure intraocular pressure, suggest glaucoma testing, or determine astigmatism.
The elderly client is complaining of abdominal discomfort. Which scientific rationale should the nurse remember when addressing an elderly client's perception of pain?
- A. Elderly clients react to pain the same way any other age group does.
- B. The elderly client usually requires more pain medication.
- C. Reaction to painful stimuli may be decreased with age.
- D. The elderly client should use the Wong scale to assess pain.
Correct Answer: C
Rationale: Age-related sensory decline reduces pain perception in the elderly, affecting reporting. Pain reaction varies, more medication is not standard, and the Wong scale is pediatric.
The nurse is assessing the older adult client with otosclerosis. Which diagnostic characteristics should the nurse associate with otosclerosis?
- A. Bone conduction is greater than air conduction.
- B. Hearing aids are not effective in restoring hearing.
- C. Surgical restoration of hearing is not possible.
- D. Serial audiograms show progressive hearing loss.
Correct Answer: A
Rationale: Otosclerosis impairs the air conduction of sound waves; therefore, bone conduction is typically greater than air conduction. Hearing aids and surgical restoration (stapedectomy) are effective, and progressive hearing loss is detected by serial audiograms.
The nurse is teaching the client who has otitis media. To reduce the risk of recurrent otitis media, which vaccine should the nurse recommend?
- A. Varicella vaccine
- B. Pneumococcal vaccine
- C. Typhoid vaccine
- D. Zoster vaccine
Correct Answer: B
Rationale: Pneumococcal vaccine can reduce the risk of ear infections. Varicella, typhoid, and zoster vaccines prevent other conditions.