Nokea
The nurse is caring for a child who has a perforated eardrum. Which of the following are possible causes?
- A. Persistent otitis media
- B. Mastoiditis
- C. Eustachian tube blockage
- D. Serous otitis media
- E. Acute otitis media
Correct Answer: A,B,E
Rationale: Perforation of the eardrum, central or marginal, can be caused by persistent otitis media, mastoiditis, and acute otitis media. Eustachian tube blockage could be the cause of a retracted eardrum. Serous otitis media presents as hairline fluid level, yellow-amber bubbles above the fluid line.
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The nurse is performing an eye examination on a patient and is assessing for accommodation. Which of the following actions should the nurse implement?
- A. Cover one eye for 1 minute and note the pupil reaction when the cover is removed.
- B. Shine a light into the patient's eye and assess the pupil response in the opposite eye.
- C. Observe the pupils when the patient focuses on a distant object and then on a close object.
- D. Touch the patient's pupil with a small piece of sterile cotton and watch for a blink reaction.
Correct Answer: C
Rationale: Accommodation is defined as the ability of the lens to adjust to various distances. The other nursing actions also may be part of the eye examination, but they do not test for accommodation.
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.
Which of the following actions should the nurse include in the plan of care for a patient who has vestibular disease?
- A. Check Rinne's and Weber's tests.
- B. Face the patient when speaking.
- C. Enunciate clearly when speaking.
- D. Monitor the patient's ability to ambulate safely.
Correct Answer: D
Rationale: Vestibular disease affects balance so the nurse should monitor the patient during activities that require balance. The other actions might be used for patients with hearing disorders.
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 obtaining a health history from an older-adult patient, who is new to the eye clinic and who has glaucoma. Which of the following information given by the patient will have the most implications for the patient's treatment?
- A. I use Aspirin when I have a sinus headache.'
- B. I have had frequent episodes of conjunctivitis.'
- C. I take metoprolol daily for angina.'
- D. I have not had an eye examination for 10 years.'
Correct Answer: C
Rationale: It is important to note whether the patient takes any β-adrenergic blockers because this category of medications also is used to treat glaucoma, and there may be an increase in adverse effects. The use of Aspirin does not increase intraocular pressure and is safe for patients with glaucoma. Although older patients should have yearly eye examinations, the treatment for this patient will not be affected by the 10-year gap in eye care. Conjunctivitis does not increase the risk for glaucoma.