Nokea
The nurse is supervising a family member who is instilling ear drops into the client's ear. Which of the following statements, made by the family member, would prompt further nursing instruction?
- A. Turn your head to the side so I can put these drops in.
- B. These drops are cold from being on the windowsill.
- C. Let me put this cotton ball in your ear because I put the drop in.
- D. I squeeze the dropper to put a drop of medicine in the ear.
Correct Answer: B
Rationale: When the family member states that the drops are cold, the nurse would encourage the family member to place the bottle in a warm bath or warm the bottle in their hands. Cold or hot liquids, instilled in the ear, may cause dizziness and potential for injury.
You may also like to solve these questions
The nurse is instructing a client's family members on the most incapacitating symptom of M?©ni?¨re disease. Which nursing instruction associated with the symptom is most helpful?
- A. Assist the client when ambulating.
- B. Keep a bucket beside the bed.
- C. Ensure low lighting in the room.
- D. Sit in front of the client when speaking.
Correct Answer: A
Rationale: The most incapacitating symptom of M?©ni?¨re disease is vertigo. When the client is experiencing vertigo or dizziness, gait becomes unsteady. Having a person assist the client when ambulating is most helpful in preventing falls. Keeping a bucket at the bedside is helpful if the client is experiencing nausea. Photophobia is not a main symptom of M?©ni?¨re disease. If the client experiences hearing loss, being able to see the nurse's lips may be helpful.
The nurse is obtaining subjective data from a client with difficulty hearing. What should the nurse do to facilitate communication with the client? Select all that apply.
- A. Speak clearly at a normal pace.
- B. Avoid gesturing.
- C. Ensure there is adequate natural or artificial light.
- D. Exaggerate pronunciations.
- E. Promote a clear image of the nurse's mouth.
- F. Face the client when speaking.
Correct Answer: A,C,E,F
Rationale: In order to facilitate communication with the client with difficulty hearing, the nurse should speak clearly at a normal pace, ensure there is adequate natural or artificial light, promote a clear image of the nurse's mouth, and face the client when speaking. The nurse should use gestures and facial expressions to enhance what is being said orally. The nurse should not exaggerate pronunciations.
There are several types of hearing loss. Which type of hearing loss benefits from the use of a hearing aid?
- A. Sensorineural
- B. Conductive
- C. Genetic
- D. Acquired
Correct Answer: B
Rationale: Diminished hearing results from a conductive loss, sensorineural loss, or both. Clients with a conductive hearing loss benefit more from the use of a hearing aid because the structures that convert sound into energy and facilitate perception of sound in the brain continue to function. Genetic and acquired are not types of hearing loss.
The nurse is teaching a class on diseases of the ear. What would the nurse teach the class is the most characteristic symptom of otosclerosis?
- A. The client being distressed in the mornings
- B. A progressive, bilateral loss of hearing
- C. A red and swollen ear drum
- D. The client describing a recent upper respiratory infection
Correct Answer: B
Rationale: A progressive, bilateral loss of hearing is the characteristic symptom of otosclerosis. Tinnitus appears as the loss of hearing progresses; it is especially noticeable at night, when surroundings are quiet, and may be quite distressing to the client. The eardrum appears pinkish-orange from structural changes in the middle ear. The client often describes a history of having had a recent upper respiratory infection in case of otitis media, not otosclerosis.
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.