Nokea
The emergency department nurse is assessing a client who has a needle in the sclera of the right eyeball just below the iris. Which should the nurse implement first?
- A. Remove the needle with tweezers.
- B. Notify an ophthalmologist to care for the client.
- C. Stabilize the right eye and place a patch over the left eye.
- D. Irrigate the right eye to wash the needle out of the eye.
Correct Answer: C
Rationale: Stabilizing the eye and patching the unaffected eye prevents movement and further damage until surgical removal. Removing the needle, notifying later, or irrigating risks harm.
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Which risk factors should the nurse discuss with the client concerning reasons for hearing loss? Select all that apply.
- A. Perforation of the tympanic membrane.
- B. Chronic exposure to loud noises.
- C. Recurrent ear infections.
- D. Use of nephrotoxic medications.
- E. Multiple piercings in the auricle.
Correct Answer: A,B,C,D
Rationale: Tympanic perforation, loud noise, ear infections, and ototoxic medications (e.g., aminoglycosides) cause hearing loss. Auricle piercings are cosmetic and 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 client complains of tinnitus and dizziness and has a diagnosis of Ménière's disease. She asks the nurse, 'What is the cause of Ménière's disease?' What is the nurse's best response?
- A. Ménière's disease is caused by a virus.'
- B. The cause of Ménière's disease is unknown.'
- C. Ménière's disease frequently follows a streptococcal infection.'
- D. It is hereditary. Both of your parents carried the gene for Ménière's disease.'
Correct Answer: B
Rationale: The exact cause of Ménière's disease is unknown, though it involves fluid imbalance in the inner ear.
The nurse is reviewing the medication list of the client with Meniere's disease. Which medication was likely prescribed for treating the client's vertigo?
- A. Meclizine
- B. Megestrol
- C. Meropenem
- D. Metoprolol
Correct Answer: A
Rationale: The anticholinergic and antihistamine properties of meclizine (Antivert) treat the symptom of vertigo. Megestrol, meropenem, and metoprolol treat unrelated conditions.
A family member of the client undergoing cataract surgery asks the nurse if there are ways to prevent cataracts. Which recommendations should the nurse suggest? Select all that apply.
- A. Wear sunglasses that limit ultraviolet light penetration.
- B. Wear sunscreen with a high protection factor number.
- C. Wear eye protection if there is any risk for eye injury.
- D. Avoid activities and reading in dimly lit environments.
- E. Eat foods that are high in vitamin C, such as oranges.
Correct Answer: A,C
Rationale: Limiting eye exposure to UV light has been found to decrease the risk for cataracts. Avoiding trauma to the eye has been found to decrease the risk for cataracts. Sunscreen is applied to the skin, not the eyes. Straining the eyes to read does not lead to cataract formation. There is no evidence that nutrition prevents or delays progression of cataracts.