Nokea
The nurse is preparing to administer otic drops into an adult client's right ear. Which intervention should the nurse implement?
- A. Grasp the earlobe and pull back and out when putting drops in the ear.
- B. Insert the eardrops without touching the outside of the ear.
- C. Instruct the client to close the mouth and blow prior to instilling drops.
- D. Pull the auricle down and back prior to instilling drops.
Correct Answer: B
Rationale: Inserting drops without touching the ear prevents contamination. Pulling the auricle up and back (not down) is correct for adults, and blowing is unnecessary.
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The client has undergone a bilateral stapedectomy. Which action by the client warrants immediate intervention by the nurse?
- A. The client is ambulating without assistance.
- B. The client is sneezing with the mouth open.
- C. There is some slight serosanguineous drainage.
- D. The client reports hearing popping in the affected ear.
Correct Answer: A
Rationale: Ambulating without assistance post-stapedectomy risks vertigo and falls, requiring intervention. Open-mouth sneezing, slight drainage, and popping are expected.
The nurse is reviewing the medication list of the client with Meniere's disease. Which medication was likely prescribed for treating the client's vertigo?
- A. Meclizine
- B. Megestrol
- C. Meropenem
- D. Metoprolol
Correct Answer: A
Rationale: The anticholinergic and antihistamine properties of meclizine (Antivert) treat the symptom of vertigo. Megestrol, meropenem, and metoprolol treat unrelated conditions.
Which situation makes the nurse suspect the client has glaucoma?
- A. An automobile accident because the client did not see the car in the next lane.
- B. The cake tasted funny because the client could not read the recipe.
- C. The client has been wearing mismatched clothes and socks.
- D. The client ran a stoplight and hit a pedestrian walking in the crosswalk.
Correct Answer: A
Rationale: Not seeing a car in the next lane suggests peripheral vision loss, a hallmark of glaucoma. Taste, color perception, and stoplight issues are unrelated.
A 17-year-old client had one generalized convulsion several hours prior to admission to the medical unit for a neurological workup. Physician's orders include Dilantin (phenytoin) 100 mg orally (PO) tid and phenobarbital 100 mg PO daily. He tells the nurse, 'I can't believe I really had a seizure. My mom says she was in the room when it happened, but I don't even remember it.' What is the best interpretation of his comments?
- A. They indicate an initial denial mechanism, but he will begin to remember the seizure later.
- B. Anoxia suffered during the seizure has damaged part of his cerebral cortex.
- C. Inability to remember the seizure is a normal response of a person who has had a seizure.
- D. They are an indication that he would rather not talk about his seizure at this time.
Correct Answer: C
Rationale: Amnesia for the seizure event is a normal response due to altered consciousness during a generalized seizure.
The nurse is using a tuning fork to perform the Rinne test for air and bone conduction hearing. Place an X on the location where the nurse should place the stem of the tuning fork.
- A. For the Rinne test the stem of the tuning fork is placed on the mastoid process, located posterior to the ear lobule.
Correct Answer: A
Rationale: For the Rinne test, the stem of the tuning fork is placed on the mastoid process, posterior to the ear lobule, to assess bone conduction compared to air conduction.