Nokea
The client is two (2) hours postoperative right-ear mastoidectomy. Which assessment data should be reported to the health-care provider?
- A. Complaints of aural fullness.
- B. Hearing loss in the affected ear.
- C. No vertigo.
- D. Facial drooping.
Correct Answer: D
Rationale: Facial drooping suggests cranial nerve VII injury, a serious complication post-mastoidectomy, requiring immediate reporting. Fullness and hearing loss are expected, and no vertigo is normal.
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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.
The female client tells the clinic nurse she is going on a seven (7)-day cruise and is worried about getting motion sickness. Which information should the nurse discuss with the client?
- A. Make an appointment for the client to see the health-care provider.
- B. Recommend getting an over-the-counter scopolamine patch.
- C. Discourage the client from taking the trip because she is worried.
- D. Instruct the client to lie down and the motion sickness will go away.
Correct Answer: B
Rationale: A scopolamine patch prevents motion sickness effectively. HCP appointments, trip discouragement, and lying down are less practical.
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.
A young man was swimming at the beach when an exceptionally large wave caused him to be drawn under the water. His family members found him in the water and pulled him ashore. He states that he heard something snap in his neck. When a nurse arrives, he is conscious and lying on his back. He states that he has no pain. He is unable to move his legs. How should he be transported?
- A. Position him in a prone position and place on a backboard.
- B. Apply a neck collar and position supine on a backboard.
- C. Log roll him to a rigid backboard.
- D. Position in an upright position with a firm neck collar.
Correct Answer: B
Rationale: A suspected neck injury requires immobilization with a neck collar and supine positioning on a backboard to prevent further spinal cord damage.
The nurse is caring for multiple older adult clients with age-related visual changes. Which intervention should the nurse implement?
- A. Provide reading materials with boldface, normal-sized font.
- B. Lower the intensity of reading lamps to prevent glare.
- C. Provide the clients with a magnifying device for reading.
- D. Give clients printed materials that use similar, blended colors.
Correct Answer: C
Rationale: The nurse should provide a magnifying device for reading to enlarge words, making them easier to read. Normal-sized fonts, low-intensity lamps, and blended colors are less effective for visual changes.