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The nurse is admitting a patient to the hospital who has an eye patch in place and tells the nurse 'I had a recent eye injury, so I need to wear this patch for a few weeks.' Which of the following nursing diagnoses will the nurse include in the plan of care?
- A. Risk for falls as evidenced by impaired vision (decrease in stereoscopic vision)
- B. Ineffective health maintenance related to impaired decision-making (inability to see surroundings)
- C. Disturbed body image related to alteration in self-perception
- D. Ineffective denial related to threat of unpleasant reality
Correct Answer: A
Rationale: The loss of stereoscopic vision created by the eye patch impairs the patient's ability to see in three dimensions and to judge distances. It also increases the risk for falls. There is no evidence in the assessment data for ineffective denial, disturbed body image, or ineffective health maintenance.
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The nurse is observing a student who is preparing to perform an ear examination of an adult patient. Which of the following actions by the student should cause the nurse to intervene in the assessment?
- A. Chooses a speculum smaller than the ear canal
- B. Pulls the auricle of the ear down and backward
- C. Stabilizes the hand holding the otoscope on the patient's head
- D. Stops inserting the otoscope after observing impacted cerumen
Correct Answer: B
Rationale: The auricle should be pulled up and back when assessing an adult. The other actions are appropriate when performing an ear examination.
The nurse is assessing a patient's auditory canal and tympanic membrane. Which of the following findings is a priority to report to the health care provider?
- A. There is a cone of light visible.
- B. The tympanum is bluish-tinged.
- C. Cerumen is present in the auditory canal.
- D. The skin in the ear canal is dry and scaly.
Correct Answer: B
Rationale: A bluish-tinged tympanum can occur with acute otitis media, which requires immediate care to prevent perforation of the tympanum. Cerumen in the ear canal may need to be removed before proceeding with the examination but is not unusual or pathological. The presence of a cone of light on the eardrum is normal. Dry and scaly skin in the ear canal may need further assessment but does not require urgent care.
The nurse is obtaining a nursing history from a patient when the patient indicates symptoms of dizziness when bending over and nausea and dizziness associated with physical activities. Which of the following topics should the nurse include in this patient's teaching plan?
- A. Tympanometry
- B. Rotary chair testing
- C. Pure-tone audiometry
- D. Bone-conduction testing
Correct Answer: B
Rationale: The patient's clinical manifestations of dizziness and nausea suggest a disorder of the labyrinth, which controls balance and contains three semicircular canals and the vestibule. Rotary chair testing is used to test vestibular function. The other tests are used to test for problems with hearing.
The nurse is conducting a health history with a new patient in the outpatient clinic. Which of the following medications in the health history may indicate the need to perform a focused hearing assessment?
- A. Salbutamol for acute asthma
- B. Atenolol to prevent angina
- C. Acetaminophen frequently for headaches
- D. Ibuprofen for 20 years to treat arthritis
Correct Answer: D
Rationale: Nonsteroidal anti-inflammatory drugs (NSAIDs) are potentially ototoxic. Acetaminophen, atenolol, and salbutamol are not associated with hearing loss. Other drugs that are potentially ototoxic include aminoglycosides, other antibiotics, salicylates, antimalarial agents, chemotherapeutic drugs, and diuretics.
The nurse is preparing to assess the visual acuity for a patient in the outpatient clinic. Which of the following supplies should the nurse obtain to prepare for this assessment?
- A. Penlight
- B. Amsler grid
- C. Snellen chart
- D. Ophthalmoscope
Correct Answer: C
Rationale: The Snellen chart is used to check visual acuity. An ophthalmoscope, penlight, and Amsler grid also may be used during an eye examination, but they are not helpful in assessing visual acuity.