Nokea
The nurse is caring for a client with Meniere's Disease. Which of the following assessment findings would be expected? Select all that apply.
- A. Presbyopia
- B. Tinnitus
- C. Vertigo
- D. Dyskinesia
- E. Hearing loss
Correct Answer: B,C,E
Rationale: Meniere's disease is characterized by tinnitus (ringing in the ears), vertigo (spinning sensation), and hearing loss due to inner ear dysfunction. Presbyopia (age-related vision loss) and dyskinesia (abnormal movements) are not associated with Meniere's disease.
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A nurse assesses a 40-year-old female client with vasospastic disorder (Raynaud's phenomenon) involving her right hand. The nurse notes the information in the progress notes, as shown below. From these findings, the nurse should formulate which priority nursing diagnosis?
- A. Acute pain related to hyperemic stage
- B. Disturbed sensory perception (tactile) related to vasospastic process
- C. Ineffective tissue perfusion (peripheral) related to vasospastic process
- D. Risk for impaired skin integrity related to vasospastic process
Correct Answer: C
Rationale: Ineffective tissue perfusion (peripheral) is the priority nursing diagnosis in Raynaud's phenomenon, as vasospasm reduces blood flow to the extremities, causing ischemia. This underlies symptoms like numbness or pallor. Pain, sensory changes, or skin integrity risks are secondary to perfusion deficits.
When performing postural drainage, which of the following factors promotes the movement of secretions from the lower to the upper respiratory tract?
- A. Friction between the cilia.
- B. E. Force of gravity.
- C. Sweeping motion of cilia.
- D. Involuntary muscle contractions.
Correct Answer: B
Rationale: The force of gravity in postural drainage positions the body to allow secretions to drain from lower to upper airways. Cilia and muscle contractions aid clearance but are not the primary mechanism.
The nurse anticipates that the client who has received epidural anesthesia is at decreased risk for a spinal headache because:
- A. A 17G needle is used.
- B. A subarachnoid injection is made.
- C. A noncutting needle is used.
- D. A faster onset occurs.
Correct Answer: C
Rationale: Epidural anesthesia uses a noncutting needle, reducing dural puncture risk and thus lowering the incidence of spinal headache compared to spinal anesthesia.
A pulmonary artery catheter is inserted in a client with severe mitral stenosis and regurgitation. The nurse administers furosemide (Lasix) to treat pulmonary congestion and begins a Nitroprusside (Nipride) drip for afterload reduction per physician orders. The nurse notices a sudden drop in the pulmonary artery diastolic pressure and pulmonary artery wedge pressure. Which of the following has the highest priority?
- A. Assess the 12-lead EKG.
- B. Assess the blood pressure.
- C. Assess the lung sounds.
- D. Assess the urine output.
Correct Answer: B
Rationale: A sudden drop in pulmonary pressures may indicate hypotension from nitroprusside. Assessing blood pressure is the priority to ensure adequate perfusion.
After surgery for head and neck cancer, a client has a permanent tracheostomy. The nurse should teach the client and family about the importance of:
- A. Providing tracheostomy site care.
- B. Addressing the psychosocial issues related to tracheostomy.
- C. Observing for early signs and symptoms of skin breakdown around the tracheostomy site.
- D. Using humidifiers to prevent thick, tenacious secretions.
Correct Answer: A,C,D
Rationale: Tracheostomy site care (A), monitoring for skin breakdown (C), and using humidifiers (D) are critical to prevent infection, maintain skin integrity, and keep secretions manageable.