Nokea
The client is a 60-year-old man who had a stapedectomy. He is to ambulate for the first time. Which nursing action should be taken?
- A. Encourage him to walk as far as he comfortably can
- B. Suggest that he practice bending and stretching exercises
- C. Walk with him, holding his arm
- D. Tell him to take deep breaths while he is ambulating
Correct Answer: C
Rationale: Walking with the client and holding his arm ensures safety and prevents falls post-stapedectomy.
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The client receives a prescription for sodium fluoride for otosclerosis and asks the nurse, 'What will this medication do for my ears?' Which response by the nurse is correct?
- A. Sodium fluoride prevents the breakdown of bone cells and hardens the bone in the ear.
- B. Sodium fluoride causes the breakdown of bone cells and softens the bone in the ear.
- C. Sodium fluoride blocks the effect of histamine and dries the fluid in the ear.
- D. Sodium fluoride causes the production of histamine and increases the fluid in the ear.
Correct Answer: A
Rationale: The medication, sodium fluoride, retards bone reabsorption (prevents the breakdown of bone cells) and promotes calcification (hardening) of the bony lesions in the ear.
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.
Which statement by the daughter of an 80-year-old female client who lives alone warrants immediate intervention by the nurse?
- A. I put a night-light in my mother’s bedroom.
- B. I got carbon monoxide detectors for my mother’s house.
- C. I changed my mother’s furniture around.
- D. I got my mother large-print books.
Correct Answer: C
Rationale: Changing furniture increases fall risk in an elderly client with potential sensory deficits, requiring intervention. Night-lights, CO detectors, and large-print books enhance safety.
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).
The nurse is administering eye drops to a client. Which action is correct?
- A. Ask the client to report any blurring of vision and difficulty focusing that occurs after the administration of eye drops.
- B. Apply gentle pressure to the nasolacrimal canal for one to two minutes after instillation to prevent systemic absorption.
- C. Have the client lie down with eyes closed for 45 minutes after giving drops.
- D. Gently pull the lower lid down and place medicine in the center of the eye.
Correct Answer: B
Rationale: Applying pressure to the nasolacrimal canal prevents systemic absorption of eye drops, enhancing safety and efficacy.