Nokea
The client has undergone a bilateral stapedectomy. Which action by the client warrants immediate intervention by the nurse?
- A. The client is ambulating without assistance.
- B. The client is sneezing with the mouth open.
- C. There is some slight serosanguineous drainage.
- D. The client reports hearing popping in the affected ear.
Correct Answer: A
Rationale: Ambulating without assistance post-stapedectomy risks vertigo and falls, requiring intervention. Open-mouth sneezing, slight drainage, and popping are expected.
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The nurse is examining the client's ear using an otoscope and sees the image illustrated. Which documentation by the nurse is best?
- A. Tympanic membrane ruptured, no excessive cerumen
- B. External ear canal showing no lesions or drainage
- C. Tympanic membrane cone of light reflex distorted
- D. Bony landmarks prominent on tympanic membrane
Correct Answer: C
Rationale: The tympanic membrane shown is reddened, and the cone of light is distorted, indicating increased pressure behind the tympanic membrane. The membrane is intact, the external canal is not shown, and bony landmarks are not prominent.
The client is one day post-surgical repair of a retinal detachment. Which assessment finding is most important for the nurse to report immediately to the HCP because it indicates a significant complication?
- A. Surgical eye pain rated 2 on a 10-point scale
- B. Increased tearing from the surgical eye
- C. Blurred vision and floaters in the surgical eye
- D. Dryness and injection of the sclera in the surgical eye
Correct Answer: C
Rationale: Blurred vision and floaters in the surgical eye may occur with redetachment of the retina and would warrant additional surgery. A low level of postoperative pain does not indicate a significant complication. Watery drainage is not a specific sign for concern and is less serious than changes in visual acuity. Dryness and injection of the sclera may or may not resolve without treatment, but loss of visual acuity is a more critical sign of complication.
The nurse is assessing a client and performs a whisper test. Which should the nurse implement? Rank in order of performance.
- A. Have the client cover the ear not being tested.
- B. Stand 12 to 24 inches to the side of the client.
- C. Explain to the client to repeat what the nurse says.
- D. Repeat the test for the opposite ear.
- E. Ask the client if he/she is willing to participate in the test.
Correct Answer: E,C,B,A,D
Rationale: 1) Ask for participation (consent); 2) Explain the procedure; 3) Position 12–24 inches away; 4) Cover the non-tested ear; 5) Repeat for the opposite ear.
A client complains of tinnitus and dizziness and has a diagnosis of Ménière's disease. She asks the nurse, 'What is the cause of Ménière's disease?' What is the nurse's best response?
- A. Ménière's disease is caused by a virus.'
- B. The cause of Ménière's disease is unknown.'
- C. Ménière's disease frequently follows a streptococcal infection.'
- D. It is hereditary. Both of your parents carried the gene for Ménière's disease.'
Correct Answer: B
Rationale: The exact cause of Ménière's disease is unknown, though it involves fluid imbalance in the inner ear.
The client with cataracts who has had intraocular lens implants is being discharged from the day surgery department. Which discharge instructions should the nurse discuss with the client?
- A. Do not push or pull objects heavier than 50 pounds.
- B. Lie on the affected eye with two pillows at night.
- C. Wear glasses or metal eye shields at all times.
- D. Bend and stoop carefully for the rest of your life.
Correct Answer: C
Rationale: Wearing eye shields protects the eye post-cataract surgery, especially at night. Heavy lifting is restricted lighter, lying on the affected eye is avoided, and lifelong bending restrictions are excessive.