Nokea
The nurse is planning the care of a patient with a diagnosis of vertigo. What nursing diagnosis risk should the nurse prioritize in this patients care?
- A. Risk for disturbed sensory perception
- B. Risk for unilateral neglect
- C. Risk for falls
- D. Risk for ineffective health maintenance
Correct Answer: C
Rationale: Vertigo increases fall risk due to impaired balance, making this the priority nursing diagnosis. Other risks are less immediate.
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The nurse is assessing a patient with multiple sclerosis who is demonstrating involuntary, rhythmic eye movements. What term will the nurse use when documenting these eye movements?
- A. Vertigo
- B. Tinnitus
- C. Nystagmus
- D. Astigmatism
Correct Answer: C
Rationale: Nystagmus is involuntary, rhythmic eye movement, common in multiple sclerosis. Vertigo is a sensation of movement, tinnitus is auditory, and astigmatism affects vision.
A patient has been diagnosed with hearing loss related to damage of the end organ for hearing or cranial nerve VIII. What term is used to describe this condition?
- A. Exostoses
- B. Otalgia
- C. Sensorineural hearing loss
- D. Presbycusis
Correct Answer: C
Rationale: Sensorineural hearing loss results from damage to the cochlea or cranial nerve VIII. Exostoses are bony growths, otalgia is ear pain, and presbycusis is age-related hearing loss.
On otoscopy, a red blemish behind the tympanic membrane is suggestive of what diagnosis?
- A. Acoustic tumor
- B. Cholesteatoma
- C. Facial nerve neuroma
- D. Glomus tympanicum
Correct Answer: D
Rationale: A red blemish behind the tympanic membrane is characteristic of glomus tympanicum, a vascular tumor. Acoustic tumors, cholesteatomas, and neuromas do not typically present this way.
A group of high school students is attending a concert, which will be at a volume of 80 to 90 dB. What is a health consequence of this sound level?
- A. Hearing will not be affected by a decibel level in this range.
- B. Hearing loss may occur with a decibel level in this range.
- C. Sounds in this decibel level are not perceived to be harsh to the ear.
- D. Ear plugs will have no effect on these decibel levels.
Correct Answer: B
Rationale: Sound levels above 80 dB can damage the inner ear, potentially causing hearing loss. These levels are perceived as harsh, and ear plugs can mitigate the risk.
A hearing-impaired patient is scheduled to have an MRI. What would be important for the nurse to remember when caring for this patient?
- A. Patient is likely unable to hear the nurse during test.
- B. A person adept in sign language must be present during test.
- C. Lip reading will be the method of communication that is necessary.
- D. The nurse should interact with the patient like any other patient.
Correct Answer: A
Rationale: During an MRI, a hearing-impaired patient cannot hear verbal communication due to the dark, noisy environment, requiring alternative communication methods. Sign language or lip reading may not be feasible.