Nokea
The nurse is preparing to assess cranial nerve VIII on a client. Which tests will the nurse perform? Select all that apply.
- A. Allen's test
- B. Phalen's test
- C. the Rinne test
- D. the Weber test
Correct Answer: C,D
Rationale: Cranial nerve VIII (vestibulocochlear) is assessed with the Rinne and Weber tests for hearing. Allen's and Phalen's tests assess circulation and carpal tunnel, respectively.
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A client has a new prescription for timolol and the nurse provides medication instructions to the client. Which statement by the client indicates a need for further teaching regarding the instructions?
- A. I should change positions slowly.
- B. I need to report shortness of breath to the doctor.
- C. I need to taper or discontinue the medication when I feel well.
- D. I have enough medication on hand to last through weekends and vacations.
Correct Answer: C
Rationale: Timolol is a beta-adrenergic blocking agent. The client should not discontinue or change the medication dose. Common client teaching points about beta-adrenergic blocking agents include taking the pulse daily, holding it if the rate is less than 60 beats/min (and notifying the primary health care provider); changing positions slowly; and reporting shortness of breath. The client is also instructed to keep enough medication on hand, not take over-the-counter medications (especially decongestants, cough, and cold preparations) without consulting the primary health care provider, and carry medical identification that states that a beta-blocker is being taken.
The nurse is discharging a female client from the hospital who has a diagnosis of a thoracic 11 (T11) fracture with cord transection. The nurse has provided home care instructions to the client. Which action indicates the need for further teaching before discharge?
- A. The client jokes about no longer needing to worry about birth control.
- B. The client states that she will be careful to not eat as many dairy products.
- C. The client verbalizes the need to eat her meals at the same time every day.
- D. The client states that she will wash her hands, her perineum, and the catheter with soap and water before performing self-catheterization.
Correct Answer: A
Rationale: Female spinal cord trauma clients remain fertile during their reproductive years, and contraception is necessary for those who are sexually active. However, oral contraceptives may increase the risk for thrombophlebitis. Clients with paralysis should avoid dairy products to control the formation of urinary calculi. Meals should be eaten at the same time every day, and they should include fiber and warm solid and liquid foods to promote and maintain the regular evacuation of the bowel. Clients who lack bladder control are taught to self-catheterize using clean technique.
A nurse working in the neonatal intensive care unit (NICU) teaches handwashing techniques to the parents of an infant who is receiving antibiotic treatment for a neonatal infection. The nurse determines that the parents understand the primary purpose of hand washing if which statement is made?
- A. It is primarily done to reduce their fears.
- B. It is primarily done to minimize the spread of infection to other siblings.
- C. It is primarily done to allow them an opportunity to communicate with each other and staff.
- D. It is primarily done to reduce the possibility of transmitting an environmental infection to the infant.
Correct Answer: D
Rationale: Appropriate hand washing by staff and parents has been effective for the prevention of nosocomial infections in nursery units. This action also promotes parents taking an active part in the care of their infant. Reducing fears and encouraging communication are not the primary reasons to perform hand washing. Because the infant already has an infection and is in the NICU, transference to siblings is not the best choice.
A client who is taking tranylcypromine sulfate requests information about foods that are acceptable to eat while taking the medication. Which foods are safe to consume while taking this medication?
- A. Yogurt
- B. Raisins
- C. Oranges
- D. Smoked fish
Correct Answer: C
Rationale: Tranylcypromine sulfate is classified as a monoamine oxidase inhibitor (MAOI); as such, tyramine-containing food should be avoided. Oranges are permissible. Types of food to be avoided include—but are not limited to—yogurt, raisins, and smoked fish. Additionally, beer, wine, caffeinated beverages, pickled meats, yeast preparations, avocados, bananas, and plums are to be avoided.
The home care nurse is evaluating a client's understanding of the self-management of trigeminal neuralgia. Which client statement indicates that there is a need for further teaching?
- A. I should chew on my good side.
- B. An analgesic will relieve my pain.
- C. I should use warm mouthwash for oral hygiene.
- D. Taking my carbamazepine will help control my pain.
Correct Answer: B
Rationale: Chronic irritation of cranial nerve V results in trigeminal neuralgia, and it is characterized by intermittent episodes of intense pain of sudden onset on the affected side of the face. The pain is rarely relieved by analgesics. It is recommended that clients chew on the unaffected side and use warm mouthwash for oral hygiene. Medications such as carbamazepine help control the pain of trigeminal neuralgia.