Nokea
The nurse is preparing a staff in-service regarding sensorineural hearing loss. It would be appropriate for the nurse to identify which factors cause this type of hearing loss?
- A. Presbycusis
- B. Ototoxic substance
- C. Foreign body
- D. Exposure to loud noise
- E. Edema
Correct Answer: A,B,D
Rationale: Presbycusis, ototoxic substances, and loud noise exposure cause sensorineural hearing loss by damaging the inner ear or auditory nerve.
You may also like to solve these questions
The nurse is caring for a client with a spinal cord injury. Which actions should the nurse take if the client develops autonomic dysreflexia?
- A. Notify the rapid response team.
- B. Assess the client's bladder for distention.
- C. Place the client in a modified Trendelenburg position.
- D. Prepare the client for an emergency lumbar puncture (LP).
- E. Obtain and monitor the client's blood pressure.
- F. Obtain a prescription for a vasopressor.
Correct Answer: A,B,E
Rationale: Notifying RRT, assessing bladder distention, and monitoring blood pressure address autonomic dysreflexia.
The nurse in the emergency department (ED) is caring for a 26-year-old female client.
Item 6 of 6
• History and Physical
1702: The client reports a headache that has persisted for 48 hours. She describes the pain as constant, throbbing, and behind her left eye. She states that in the past six months, these headaches have occurred two to three times a month. The client reports visual disturbances, including flashes of light and blurred vision, often precede headaches. During the headache episodes, she experiences nausea, photophobia, and phonophobia. She notes that stress, lack of sleep, and certain foods such as chocolate seem to trigger the headaches. Over-the-counter pain relievers provide minimal relief. Her spouse reports new symptoms, stating that she became confused earlier in the day, had difficulty speaking, and had right arm weakness, all of which resolved before she arrived at the ED. Medical history of generalized anxiety and panic disorder for which she takes escitalopram 20 mg p.o. daily and buspirone 15 mg p.o. daily. Family history of ischemic stroke, hypertension, and diabetes mellitus.
Physical Examination
Neurological exam: Steady gait and cranial nerves grossly intact. Phonophobia.
Pupils: 3 mm and brisk with some tearing in both eyes. Sensitive to pen light.
Head and neck examination: Denies sinus pain and full cervical range of motion.
Integumentary: Skin warm to touch and pale pink in tone.
Cardiovascular: Peripheral pulses 2+ and no peripheral edema.
Respiratory: Clear lung sounds bilaterally.
Gastrointestinal: Reports persistent nausea. Normoactive bowel sounds in all quadrants. No distention.
Psych: Anxious and in moderate distress. Cooperative.
Vital Signs: Blood pressure: 120/80 mmHg Heart rate: 72 bpm Respiratory rate: 16 Temperature: 98.6°F (37°C) Oxygen saturation: 98% on room air
• Diagnostics Test Results
Head Computed Tomography (CT) scan
1739: No acute intracranial hemorrhage, mass effect, or midline shift identified. The ventricles and sulci are within normal limits. No evidence of acute ischemic changes.
• Nurses' Notes
1741: Client placed back in room following emergent CT scan of the head. The client is alert, fully oriented, cooperative, and slightly anxious. Reports 'throbbing' headache rated 7/10 on the Numerical Rating Scale. Endorses photophobia, requesting lights to be turned off. Glasgow coma scale is 15. Clear lung sounds bilaterally. Peripheral pulses 2+. Reports persistent nausea. Full range of motion in all extremities. A 20-gauge peripheral vascular access device was started in the left antecubital space.
1850: Pain reassessed. Client reports pain 7/10 on the Numerical Rating Scale. Reports persistent nausea.
1852: Physician notified of the findings.
• Orders
1800:
• ketorolac 30 mg intravenous push x 1 dose
• 500 mL of 0.9% sodium chloride (normal saline) over one hour
1900:
• metoclopramide 10 mg intravenous push x 1 dose
• diphenhydramine 25 mg intravenous push x 1 dose
• sumatriptan 6 mg subcutaneous x1 dose
Six hours later, the client recovers and is discharged home. The nurse is teaching the client about newly prescribed intranasal sumatriptan. Which of the following statements by the client would indicate a correct understanding of the teaching? Select all that apply.
- A. I should use this medication as soon as I notice migraine symptoms beginning.
- B. If my migraine does not improve after two hours, I can take a second dose, but no more than 40 mg in 24 hours.
- C. I should avoid using this medication if I experience chest pain or pressure after taking it.
- D. I can use this medication daily to prevent migraines from occurring.
- E. If I experience tingling or flushing after taking this medication, I should go to the emergency room.
- F. I should watch for signs of serotonin syndrome, such as confusion and muscle stiffness.
Correct Answer: A,B,C
Rationale: Using sumatriptan at migraine onset, redosing after 2 hours (with a 40 mg daily limit for intranasal form), and avoiding use with chest pain (due to possible coronary vasospasm) are correct. Daily use is incorrect (sumatriptan is for acute treatment), tingling/flushing are common side effects, and serotonin syndrome is unlikely with sumatriptan alone.
The nurse is discussing biological clocks with another nurse. What term is used to describe a human's innate biological clock relating to daytime and nighttime wakefulness and activity?
- A. REM sleep
- B. Circadian rhythm
- C. Diurnal rhythm
- D. Nocturnal activity
Correct Answer: B
Rationale: Circadian rhythm refers to the body's 24-hour cycle regulating sleep and wakefulness.
The nurse is caring for a client with a migraine headache. Which assessment findings should the nurse expect?
- A. Unilateral frontotemporal pain
- B. Nausea
- C. Photophobia
- D. Fever
- E. Nuchal rigidity
- F. Vomiting
Correct Answer: A,B,C,F
Rationale: Migraine headaches typically present with unilateral pain, nausea, photophobia, and vomiting.
The following scenario applies to the next 6 items
The nurse in the emergency department (ED) is caring for a 20-year-old female client
Item 4 of 6
ED Triage Note
History And Physical
0912: Client was brought to the ED by her two college roommates 'because she was not acting right.' The roommate reports that she went to bed the night before reporting stiffness in her neck and a headache. She attributed it to being under pressure with final exams and having poor sleep the previous several days. The client apparently took non-prescribed lorazepam from another roommate to assist her with sleep. The roommate reported recently having influenza and is unsure if she became infected. It is reported that she declined the influenza vaccination when it was offered on campus. The roommate reports waking her with physical stimuli and found her diaphoretic, hot to touch, and mumbling, saying she did not feel well.
Vital signs: T 103.4° F (39.7° C), P 112, RR 12, BP 116/86, pulse oximetry 95% on room air.
For each potential nursing intervention, click to specify whether the intervention is indicated or not indicated for the care of the client: A= Indicated, B= Not Indicated
- A. Keep the door to the client's room closed to maintain negative airflow
- B. Provide visitors with face shields upon entering the client's room
- C. Provide a quiet environment
- D. Perform frequent neurological assessments
- E. Obtain an order to start a peripheral vascular access device
- F. Prepare the client for an immediate electroencephalography (EEG)
Correct Answer: B,B,A,A,A,B
Rationale: Negative airflow is not typically required for bacterial meningitis unless airborne precautions are specified. Face shields are not standard for meningitis; droplet precautions are usually sufficient. A quiet environment reduces stimulation for a client with neurological symptoms. Frequent neurological assessments are critical for monitoring meningitis progression. IV access is necessary for administering antibiotics and fluids in suspected meningitis. EEG is not indicated unless seizures are suspected.