Nokea
The nurse is evaluating the independent care of a client recovering from a stapedectomy. Which action made by the client indicates a need for further teaching?
- A. The client turns head slowly when family approaches.
- B. The client uses clean technique to clean the wound.
- C. The client takes antibiotics on schedule
- D. The client asks for assistance upon ambulation.
Correct Answer: B
Rationale: The client needs further instructions on using aseptic technique when completing wound care. Using aseptic technique reduces the introduction and transmission of microorganisms and protects the client from introduction of pathogens. The other options are appropriate actions for the client recovering from a stapedectomy to take.
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The nurse is assisting the client in planning care during exacerbations of M?©ni?¨re disease. Which diet would the nurse identify as appropriate at this time?
- A. A high-protein diet
- B. A low-sodium diet
- C. A low-fat diet
- D. A calorie-controlled diet
Correct Answer: B
Rationale: Treatment for M?©ni?¨re disease is related to reducing fluid production in the inner ear, facilitating its drainage, and treating the symptoms that accompany the attack. A low-sodium and sodium-free diet lessens edema.
The nurse, employed in an ear, nose, and throat (ENT) physician's office, is obtaining a client history. The nurse documents the client's statements. Which symptom(s) may indicate a diagnosis of otosclerosis? Select all that apply.
- A. It seems that I increasingly could not hear my kids talk to me.'
- B. I woke up on Monday and had ear pain with a marked decrease in hearing.'
- C. I now notice a ringing in my ears especially when I lay down to sleep at night.'
- D. I can hear better when someone speaks in low tones.'
- E. I can hear best when you put the tuning fork behind my ear.'
Correct Answer: A,C,E
Rationale: Although the cause of otosclerosis is unknown, there are specific symptoms because of the interference of the vibrations in the ear. The symptoms of diagnosis of otosclerosis include a progressive, bilateral hearing loss; tinnitus especially noted at night; and the outcome of the Rinne test as being that sound is heard best with the tuning fork behind the ear. The nurse would not identify an abrupt onset of hearing loss or improvement of hearing in low tones.
What kind of otitis media is a pathogen-free fluid behind the tympanic membrane, resulting from irritation associated with respiratory allergies and enlarged adenoids?
- A. Purulent otitis media
- B. Infectious otitis media
- C. Serous otitis media
- D. Sterile otitis media
Correct Answer: C
Rationale: Serous otitis media, a collection of pathogen-free fluid behind the tympanic membrane, results from irritation associated with respiratory allergies and enlarged adenoids. The other options are distractors for this question. Purulent otitis media usually results from the spread of microorganisms from the eustachian tube to the middle ear during upper respiratory infections.
The nurse is caring for a client in the triage section of a walk-in clinic. Which triad of common symptoms suggests a diagnosis of M?©ni?¨re disease?
- A. Blurred vision, vertigo, nausea
- B. Syncope, vertigo, ear pain
- C. Disorientation, vertigo, nausea
- D. Hearing loss, vertigo, tinnitus
Correct Answer: D
Rationale: Hearing loss, vertigo, and tinnitus are common symptoms of many disease processes but, when placed together, indicate M?©ni?¨re disease. The other options do not include the accurate triad of symptoms.
The nurse is caring for a client who is post-stapedectomy. What would the nurse include in the nursing care?
- A. Place the client on the operative side.
- B. Keep the affected ear packed with cotton.
- C. Encourage the client to exercise within 24 hours.
- D. Assess the facial nerve.
Correct Answer: D
Rationale: After surgery, the nurse positions the client on the nonoperative side and takes care to prevent dislodgment of the prosthesis as a result of coughing, sneezing, or vomiting. Nausea and dizziness are common problems. The nurse assesses facial nerve function by checking symmetry when the client smiles or frowns. The nurse does not keep the ear packed with cotton or encourage the client to exercise.