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The nurse is caring for a client with recurrent ear infections. The nurse assesses the client for further infectious processes traveling deeper into the tissue and becoming more lethal. Which infection, originated in the ear, is of most concern?
- A. Mastoiditis
- B. Meningitis
- C. Sinusitis
- D. Labyrinthitis
Correct Answer: B
Rationale: The infection stemming from the ear may extend to the meninges, causing meningitis, or a brain abscess could occur. This could be life threatening. The other options are also potential complications of an ear infection but not as much of a concern as meningitis.
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The nurse is instructing a client's family members on the most incapacitating symptom of M?©ni?¨re disease. Which nursing instruction associated with the symptom is most helpful?
- A. Assist the client when ambulating.
- B. Keep a bucket beside the bed.
- C. Ensure low lighting in the room.
- D. Sit in front of the client when speaking.
Correct Answer: A
Rationale: The most incapacitating symptom of M?©ni?¨re disease is vertigo. When the client is experiencing vertigo or dizziness, gait becomes unsteady. Having a person assist the client when ambulating is most helpful in preventing falls. Keeping a bucket at the bedside is helpful if the client is experiencing nausea. Photophobia is not a main symptom of M?©ni?¨re disease. If the client experiences hearing loss, being able to see the nurse's lips may be helpful.
Which nursing goal is a priority when caring for a client newly diagnosed with vertigo?
- A. Client will maintain therapeutic medication schedule.
- B. Client will remain safe while ambulating in the home.
- C. Client will have a caretaker in the home.
- D. Client will close eyes as needed to reduce symptoms.
Correct Answer: B
Rationale: Safety is always a concern when a client is experiencing vertigo. The goal of the nurse's instruction and care is for the client to remain safe. Maintaining a therapeutic medication schedule and caretaker and establishing strategies to reduce symptoms are important but not of highest priority.
A nurse is caring for a 24-year-old female client diagnosed with otosclerosis. Which teaching by the nurse is most accurate?
- A. Symptoms may be accelerated by pregnancy.
- B. Medications can interfere with birth control pills.
- C. Menstrual periods may be longer and more severe.
- D. Females otosclerosis is linked with infertility.
Correct Answer: A
Rationale: The etiology of otosclerosis is unknown; however, it is more common in females than males and usually occurs in the second or third decade of life. It is accurate to instruct female that symptoms of otosclerosis seem to be accelerated during pregnancy.
Which nursing suggestion would be most helpful to the client with recurrent otitis externa?
- A. Use a cotton applicator to ensure that the ear canal is dry.
- B. Place ear plugs into the ears before swimming
- C. Flush the ear with hydrogen peroxide
- D. Avoid lying on the side of the affected ear
Correct Answer: B
Rationale: The nurse instructs the client to carry out the medical treatment and provides health teaching to prevent recurrence. For example, the nurse advises swimmers to wear soft plastic ear plugs to prevent trapping water in the ear. A cotton tip applicator should not be placed into the ear canal because it could perforate the eardrum. Above all, the nurse advises the client to avoid the use of nonprescription remedies unless they have been approved by the physician and to contact the physician if symptoms are not relieved in a few days.
The occupational nurse is advising a client on options to enhance workplace communication because the client has progressive hearing loss. The client works as a customer service representative. In discussing the options with the client, which type would be the last option offered by the nurse?
- A. Battery-operated hearing aid
- B. American sign language
- C. Headsets with amplifiers
- D. Text-based telecommunications
Correct Answer: B
Rationale: Although American sign language is an asset to use for communication, a client with an occupation of customer service representative needs accommodations to be able to understand the spoken word.