Nokea
The nurse is assessing a patient who has recently been treated with amoxicillin for acute otitis media of the right ear. Which of the following assessment data obtained by the nurse is of most concern?
- A. The patient has a temperature of 38.1°C (100.6°F).
- B. The patient reports mild ear pain.
- C. The patient has slight redness in the ear canal.
- D. The patient reports decreased hearing in the right ear.
Correct Answer: A
Rationale: A temperature of 38.1°C (100.6°F) after treatment for acute otitis media may indicate a persistent or worsening infection, requiring immediate attention. Mild ear pain, slight redness, and decreased hearing may be residual symptoms but are less concerning unless persistent or severe.
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To decrease the risk for future hearing loss, which of the following actions should the nurse working with college students at the on-campus health clinic implement?
- A. Arrange to include otoscopic examinations for all patients.
- B. Administer rubella immunizations to all students at the clinic.
- C. Discuss the importance of limiting exposure to very high amplified music.
- D. Teach patients to regularly irrigate the ear to decrease cerumen impaction.
Correct Answer: C
Rationale: Exposure to high amplified music is a significant risk factor for hearing loss in young adults. Otoscopic exams and cerumen irrigation do not directly prevent hearing loss, and rubella immunization is unrelated to noise-induced hearing damage.
Which of the following topics should the nurse plan to include when teaching the patient with herpes simplex keratitis of the left eye about management of the infection?
- A. How to apply an occlusive dressing to the affected eye
- B. Need for frequent handwashing and avoiding touching the eyes
- C. Application of antibiotic drops to the left eye several times daily
- D. Use of corticosteroid ophthalmic ointment to decrease inflammation
Correct Answer: B
Rationale: The best way to avoid the spread of infection from one eye to another is to avoid rubbing or touching the eyes and to use careful handwashing when touching the eyes is unavoidable. Occlusive dressings are not used for herpes keratitis. Herpes simplex is a virus and antibiotic drops will not be prescribed. Topical corticosteroids typically are not ordered because they can contribute to a longer course of infection and more complications.
Which of the following actions should the nurse take when assisting a totally blind patient to walk to the bathroom?
- A. Take the patient by the arm and lead the patient slowly to the bathroom.
- B. Have the patient place a hand on the nurse's shoulder and guide the patient.
- C. Stay beside the patient and describe any obstacles on the path to the bathroom.
- D. Walk slightly ahead of the patient and allow the patient to hold the nurse's elbow.
Correct Answer: D
Rationale: When using the sighted-guide technique, the nurse walks slightly in front and to the side of the patient and has the patient hold the nurse's elbow. The other techniques are not as safe in assisting a blind patient.
A patient with hearing loss asks the nurse about the use of a cochlear implant. Which of the following information will the nurse include when replying to the patient?
- A. Cochlear implants require training in order to receive the full benefit.
- B. Cochlear implants are not useful for patients with congenital deafness.
- C. Cochlear implants are most helpful as an early intervention for presbycusis.
- D. Cochlear implants improve hearing in patients with conductive hearing loss.
Correct Answer: A
Rationale: Extensive rehabilitation is required after cochlear implants in order for patients to receive the maximum benefit. Hearing aids, rather than cochlear implants, are used initially for presbycusis. Cochlear implants are used for sensorineural hearing loss and would not be helpful for conductive loss. They are appropriate for some patients with congenital deafness.
The nurse is assessing a patient in the outpatient eye clinic who has myopia and presbyopia. Which of the following assessments should the nurse implement to evaluate the effectiveness of the prescribed bifocals?
- A. Strength of the eye muscles
- B. Both near and distant vision
- C. Cloudiness in the eye lenses
- D. Intraocular pressure changes
Correct Answer: B
Rationale: The lenses are prescribed to correct the patient's near and distant vision. The nurse also may assess for cloudiness of the lenses, increased intraocular pressure, and eye movement, but these data will not evaluate whether the patient's bifocals are effective.