Nokea
The client following removal of a right-sided acoustic neuroma by a translabyrinthine approach calls the nurse to report pain. The nurse finds that the client has new-onset right-sided facial drooping and numbness. Place the nurse's actions in priority order.
- A. Close the client's right eye and place a patch over it.
- B. Assess the operative incision site and assess the arms for drift.
- C. Contact the stroke team and the HCP.
- D. Medicate the client for pain unless contraindicated.
Correct Answer: B,C,D,A
Rationale: Assess the incision and arms for drift first (B), then contact the stroke team and HCP for possible complications (C), medicate for pain (D), and finally patch the eye due to inability to close it (A).
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The nurse is caring for a client who has recently had a cerebrovascular accident (CVA). When positioning the client and supporting her extremities, the nurse must remember that when voluntary control of muscles is lost:
- A. the feet will maintain a position of eversion.
- B. the upper extremities will rotate externally.
- C. the hip joint will rotate internally.
- D. flexor muscles will become stronger than extensors.
Correct Answer: D
Rationale: After a CVA, flexor muscles become stronger than extensors, leading to flexion contractures, requiring careful positioning to prevent deformities.
Which teaching instruction should the nurse discuss with students who are on the high school swim team when discussing how to prevent external otitis?
- A. Do not wear tight-fitting swim caps.
- B. Avoid using silicone ear plugs while swimming.
- C. Use a drying agent in the ear after swimming.
- D. Insert a bulb syringe into each ear to remove excess water.
Correct Answer: C
Rationale: A drying agent (e.g., alcohol-based drops) prevents external otitis by removing moisture. Swim caps and ear plugs are protective, and bulb syringes risk trauma.
The student nurse asks the nurse, 'Which type of hearing loss involves damage to the cochlea or vestibulocochlear nerve?' Which statement is the best response of the nurse?
- A. It is called conductive hearing loss.
- B. It is called a functional hearing loss.
- C. It is called a mixed hearing loss.
- D. It is called sensorineural hearing loss.
Correct Answer: D
Rationale: Sensorineural hearing loss involves cochlear or vestibulocochlear nerve damage. Conductive loss affects the outer/middle ear, functional loss is psychological, and mixed involves both.
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.
Which intervention should the nurse include when conducting an in-service to the ancillary nursing staff on caring for elderly clients addressing normal developmental sensory changes?
- A. Ensure curtains are open when having the client read written material.
- B. Provide a variety of written material when discussing a procedure.
- C. Assist the client when getting out of the bed and sitting in the chair.
- D. Request a telephone for the hearing impaired for all elderly clients.
Correct Answer: A
Rationale: Open curtains maximize light, compensating for age-related vision decline. Varied materials, mobility assistance, and hearing-impaired phones are less universally applicable.