Nokea
The day following a stapedectomy, the client tells the nurse that he cannot hear much in the operative ear and thinks the stapedectomy was a failure. What is the best response for the nurse to make?
- A. There is packing in your ear. You will not hear well for a few days.'
- B. The doctors have not yet turned on the stapes replacement.'
- C. You may not have hearing, but you will now be free of pain.'
- D. You seem upset that you aren't hearing well.'
Correct Answer: A
Rationale: Ear packing post-stapedectomy temporarily reduces hearing, which improves as packing is removed.
You may also like to solve these questions
Which situation makes the nurse suspect the client has glaucoma?
- A. An automobile accident because the client did not see the car in the next lane.
- B. The cake tasted funny because the client could not read the recipe.
- C. The client has been wearing mismatched clothes and socks.
- D. The client ran a stoplight and hit a pedestrian walking in the crosswalk.
Correct Answer: A
Rationale: Not seeing a car in the next lane suggests peripheral vision loss, a hallmark of glaucoma. Taste, color perception, and stoplight issues are unrelated.
The nurse is preparing to administer otic drops into an adult client's right ear. Which intervention should the nurse implement?
- A. Grasp the earlobe and pull back and out when putting drops in the ear.
- B. Insert the eardrops without touching the outside of the ear.
- C. Instruct the client to close the mouth and blow prior to instilling drops.
- D. Pull the auricle down and back prior to instilling drops.
Correct Answer: B
Rationale: Inserting drops without touching the ear prevents contamination. Pulling the auricle up and back (not down) is correct for adults, and blowing is unnecessary.
A 17-year-old client had one generalized convulsion several hours prior to admission to the medical unit for a neurological workup. Physician's orders include Dilantin (phenytoin) 100 mg orally (PO) tid and phenobarbital 100 mg PO daily. He tells the nurse, 'I can't believe I really had a seizure. My mom says she was in the room when it happened, but I don't even remember it.' What is the best interpretation of his comments?
- A. They indicate an initial denial mechanism, but he will begin to remember the seizure later.
- B. Anoxia suffered during the seizure has damaged part of his cerebral cortex.
- C. Inability to remember the seizure is a normal response of a person who has had a seizure.
- D. They are an indication that he would rather not talk about his seizure at this time.
Correct Answer: C
Rationale: Amnesia for the seizure event is a normal response due to altered consciousness during a generalized seizure.
The client has undergone a bilateral stapedectomy. Which action by the client warrants immediate intervention by the nurse?
- A. The client is ambulating without assistance.
- B. The client is sneezing with the mouth open.
- C. There is some slight serosanguineous drainage.
- D. The client reports hearing popping in the affected ear.
Correct Answer: A
Rationale: Ambulating without assistance post-stapedectomy risks vertigo and falls, requiring intervention. Open-mouth sneezing, slight drainage, and popping are expected.
The client with glaucoma is prescribed pilocarpine hydrochloride 1% eye drops to both eyes four times per day. The nurse knows that this medication has which expected action?
- A. Increases the outflow of aqueous humor
- B. Improves vision in dimly lit environments
- C. Increases production of aqueous humor
- D. Increases ability of both pupils to dilate
Correct Answer: A
Rationale: Pilocarpine hydrochloride is a cholinergic agent used to treat glaucoma. It causes miosis (pupillary constriction), which then increases the angle of the channel in the anterior chamber of the eye. This improves the outflow of aqueous humor. It does not improve vision in dim light, increase aqueous humor production, or cause pupil dilation.