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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.
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The client with severely diminished vision has difficulty with visual discrimination. Which interventions should the nurse recommend to improve the client's sight in the home environment? Select all that apply.
- A. Ensure that all room walls are painted with colors that blend.
- B. Use a white board and a black marker when writing out lists.
- C. Place Velcro tabs on wall light switches to ease locating them.
- D. Ensure that doorknobs on the doors are a bright contrasting color.
- E. Match the color of dishes with the color of table-cloths or placemats.
Correct Answer: B,C,D
Rationale: Using black on white enhances readability. Velcro tabs on light switches aid location in low vision. Contrasting doorknob colors improve safety. Blending wall colors or matching dish and tablecloth colors worsens visual discrimination.
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.
The nurse is providing teaching on the home treatment of acute sinusitis. Which interventions should the nurse advise the client to implement? Select all that apply.
- A. Take over-the-counter ranitidine.
- B. Apply warm compresses to the face.
- C. Use saline nasal spray as directed.
- D. Take over-the-counter pseudoephedrine.
- E. Spend time outdoors in the sunlight.
Correct Answer: B,C,D
Rationale: Applying warm compresses, using saline nasal spray, and taking a decongestant like pseudoephedrine relieve nasal and sinus congestion. Ranitidine treats dyspepsia, and sunlight exposure is unrelated to sinusitis.
The client with a retinal detachment has just undergone a gas tamponade repair. Which discharge instruction should the nurse include in the teaching?
- A. The client must lie flat with the face down.
- B. The head of the bed must be elevated 45 degrees.
- C. The client should wear sunglasses when outside.
- D. The client should avoid reading for three (3) weeks.
Correct Answer: A
Rationale: Face-down positioning maintains gas tamponade pressure on the retina, aiding reattachment. Elevation, sunglasses, and reading restrictions are secondary or incorrect.
The client is receiving treatment with gentamicin ophthalmic solution for bacterial conjunctivitis. Which symptom, described by the client, indicates that the medication is ineffective?
- A. Eyes feel strained
- B. Yellowish eye drainage
- C. Twitching of the eye
- D. Unable to read small print
Correct Answer: B
Rationale: Mucopurulent eye drainage, especially yellowish or greenish, is associated with bacterial conjunctivitis; continuing with eye drainage indicates gentamicin is ineffective in treating the infection. Eyestrain, twitching, and inability to read small print are not associated with an infectious process.