Nokea
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.
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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.
A 50-year-old client is admitted with the diagnosis of open-angle glaucoma. Which of the following symptoms would the nurse expect the client to have?
- A. Severe eye pain
- B. Constant blurred vision
- C. Severe headaches, nausea, and vomiting
- D. Reports of seeing halos around objects
Correct Answer: D
Rationale: Open-angle glaucoma is characterized by halos around objects due to increased intraocular pressure, not severe pain or headaches.
What should the nurse include when teaching the client with Parkinson's disease?
- A. He should try to continue working as long as he can remain sitting most of the day.
- B. Drooling may be reduced somewhat if he remembers to swallow frequently.
- C. He should return monthly for lab tests, which will predict the progression of the disease.
- D. Emotional stress has no effect on voluntary muscle control in clients with Parkinson's disease.
Correct Answer: B
Rationale: Frequent swallowing can reduce drooling, a common symptom in Parkinson's disease, improving comfort and social interaction.
The client has a hearing loss from a possible acoustic neuroma. The nurse should prepare the client for which diagnostic test to confirm the presence of a tumor?
- A. Tympanometry
- B. Arteriogram of the cranial vessels
- C. Magnetic resonance imaging (MRI)
- D. Auditory canal biopsy
Correct Answer: C
Rationale: MRI with gadolinium enhancement is the most reliable test in determining size and anatomical location of an acoustic neuroma. Tympanometry, arteriogram, and biopsy are not used for this diagnosis.
The nurse is caring for a client admitted with Guillain-Barré syndrome. On day three of hospitalization, his muscle weakness worsens, and he is no longer able to stand with support. He is also having difficulty swallowing and talking. The priority in his nursing care plan should be to prevent which of the following?
- A. Aspiration pneumonia
- B. Decubitus ulcers
- C. Bladder distention
- D. Hypertensive crisis
Correct Answer: A
Rationale: Difficulty swallowing increases the risk of aspiration pneumonia, making it the priority in Guillain-Barré syndrome.