Nokea
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 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.
The client is scheduled for ear surgery. Which statement indicates the client needs more preoperative teaching concerning the surgery?
- A. If I have to sneeze or blow my nose, I will do it with my mouth open.
- B. I may get dizzy after the surgery, so I must be careful when walking.
- C. I will probably have some hearing loss after surgery, but hearing will return.
- D. I can shampoo my hair the day after surgery as long as I am careful.
Correct Answer: D
Rationale: Shampooing the day after ear surgery risks water entry and infection; typically, hair washing is delayed. Open-mouth sneezing, dizziness, and temporary hearing loss are correct.
An adult is being treated with phenytoin (Dilantin) for a seizure disorder. Five days after starting the medication, he tells the nurse that his urine is reddish-brown in color. What action should the nurse take?
- A. Inform him that this is a common side effect of phenytoin (Dilantin) therapy
- B. Test the urine for occult blood
- C. Report it to the physician because it could indicate a clotting deficiency
- D. Send a urine specimen to the lab
Correct Answer: A
Rationale: Phenytoin commonly causes reddish-brown urine, a benign side effect, so informing the client is appropriate. Testing or reporting is unnecessary unless other symptoms suggest a problem.
The nurse is caring for the client with macular degeneration. Which illustration should the nurse associate with the field disturbance seen by the client?
- A. Limited peripheral vision is shown in illustration 1.
- B. Distorted central vision as seen in illustration 2.
- C. Illustration 3 shows a normal visual field.
- D. Illustration 4 shows a blurred visual field.
Correct Answer: B
Rationale: Distorted central vision as seen in illustration 2 is characteristic of macular degeneration. The macula is the area of the fundus responsible for central vision. When the cells in the macula have been damaged, central vision is impaired. Illustration 1 shows glaucoma, 3 shows normal vision, and 4 shows blurred vision from various conditions.
The nurse is concerned that the client in a long-term care facility is experiencing retinal detachment. Which intervention should the nurse implement first?
- A. Flush the eye thoroughly with saline solution and apply a pressure bandage.
- B. Apply an eye shield to the affected eye and give a prescribed oral analgesic.
- C. Notify the HCP; prepare for transport to a facility for ophthalmological care.
- D. Patch both eyes and place the client in a prone position until blurring stops.
Correct Answer: C
Rationale: The nurse should contact the HCP and secure an ophthalmological evaluation promptly. Flushing the eye and applying a pressure bandage may cause further injury and delay treatment. Applying an eye shield and analgesic or patching both eyes delays securing treatment.