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The nurse is caring for a patient who had a stapedotomy yesterday. Which of the following findings is most important for the nurse to communicate to the health care provider?
- A. The patient complains of 'congestion' in the ear.
- B. The patient's oral temperature is 38°C (100.4°F).
- C. The patient reports mild dizziness when standing.
- D. The patient has slight redness at the surgical site.
Correct Answer: B
Rationale: An oral temperature of 38°C (100.4°F) after a stapedotomy may indicate a postoperative infection, which requires prompt reporting to the healthcare provider. Congestion, mild dizziness, and slight redness are less urgent, as they may be expected postoperative symptoms unless severe or persistent.
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The nurse is caring for a patient with neural presbycusis. Which of the following hearing changes should the nurse expect with this type of presbycusis?
- A. Loss of high-pitched sounds
- B. Loss of speech discrimination
- C. Uniform loss for all frequencies
- D. Range of hearing loss with low frequencies
Correct Answer: B
Rationale: The hearing change with a neural presbycusis is a loss of speech discrimination. Loss of high-pitched sounds accompanies a sensory presbycusis. A metabolic presbycusis has a hearing change that is uniform for all frequencies, accompanied by recruitment. A cochlear presbycusis has a hearing change that is a range of hearing loss that increases from low to high frequencies.
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.
The charge nurse observes a newly hired nurse caring for a patient who has just arrived in the postanesthesia care unit after having right cataract removal and an intraocular lens implant. Which of the following interventions requires that the charge nurse intervene?
- A. The nurse leaves the eye shield in place.
- B. The nurse encourages the patient to cough.
- C. The nurse elevates the patient's head to 45 degrees.
- D. The nurse applies corticosteroid drops to the right eye.
Correct Answer: B
Rationale: Because coughing will increase intraocular pressure, patients are generally taught to avoid coughing during the acute postoperative time. The other actions are appropriate for a patient after having this surgery.
A patient who had cataract extraction and intraocular lens implantation the previous day calls the eye clinic and gives the nurse all of this information. Which of the following information is the priority to communicate to the health care provider?
- A. The patient has eye pain rated at a 5 (on a 0-10 scale).
- B. The patient has questions about the ordered eye drops.
- C. The patient has poor depth perception when wearing an eye patch.
- D. The patient complains that the vision has 'not improved very much.'
Correct Answer: A
Rationale: Postoperative cataract surgery patients usually experience little or no pain, so pain at a 5 on a 10-point pain level may indicate complications such as hemorrhage, infection, or increased intraocular pressure. The other information given by the patient indicates a need for patient teaching but does not indicate that complications of the surgery may be occurring.
The nurse is reviewing a patient's medical record and notes that the last eye examination revealed an intraocular pressure of 28 mm Hg. Which of the following parameters should the nurse assess?
- A. Visual acuity
- B. Pupil reaction
- C. Colour perception
- D. Peripheral vision
Correct Answer: D
Rationale: The patient's increased intraocular pressure indicates glaucoma, which decreases peripheral vision. Because central visual acuity is unchanged by glaucoma, assessment of visual acuity could be normal even if the patient has worsening glaucoma. Colour perception and pupil reaction to light are not affected by glaucoma.