Nokea
The nurse is teaching the client with open-angle glaucoma. Which instruction should the nurse include?
- A. Limit oral fluid intake to 1000 mL daily.
- B. Eat foods that are high in omega-3 fatty acids.
- C. Have annual eye exams with an eye specialist.
- D. Use timolol maleate eye drops when feeling eye pressure.
Correct Answer: C
Rationale: Glaucoma is a chronic progressive disease; annual eye examinations should be completed by an eye specialist physician. Fluid restriction and omega-3 fatty acids do not affect intraocular pressure. Elevated intraocular pressure cannot be felt, and timolol maleate should be used as prescribed.
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Which signs/symptoms should the nurse expect to find when assessing the client with an acoustic neuroma?
- A. Incapacitating vertigo and otorrhea.
- B. Nystagmus and complaints of dizziness.
- C. Nausea and vomiting.
- D. Unilateral hearing loss and tinnitus.
Correct Answer: D
Rationale: Acoustic neuroma (vestibular schwannoma) causes unilateral hearing loss and tinnitus due to cranial nerve VIII compression. Vertigo, nystagmus, and nausea are less prominent; otorrhea is unrelated.
The client recovering at home following a stapedectomy for otosclerosis reports having dizziness. To decrease symptoms, which interventions should the nurse recommend? Select all that apply.
- A. Refrain from sudden movements.
- B. Avoid chewing on the affected side.
- C. Avoid lifting objects that are heavy.
- D. Minimize bending over at the waist.
- E. Restrict the intake of oral fluids.
Correct Answer: A,C,D
Rationale: Refraining from sudden movements, avoiding heavy lifting, and minimizing bending decrease dizziness by reducing fluid shifts in the inner ear. Chewing and fluid restriction do not affect dizziness.
The client comes to the clinic and is diagnosed with otitis media. Which intervention should the clinic nurse include in the discharge teaching?
- A. Instruct the client not to take any over-the-counter pain medication.
- B. Encourage the client to apply cold packs to the affected ear.
- C. Tell the client to call the HCP if an abrupt relief of ear pain occurs.
- D. Wear a protective ear plug in the affected ear.
Correct Answer: C
Rationale: Abrupt pain relief in otitis media may indicate tympanic membrane rupture, requiring HCP notification. OTC pain meds are safe, cold packs are less effective, and ear plugs are unnecessary.
The nurse is administering eyedrops to the client. Which guidelines should the nurse adhere to when instilling the drops into the eye? Select all that apply.
- A. Do not touch the tip of the medication container to the eye.
- B. Apply gentle pressure on the outer canthus of the eye.
- C. Apply sterile gloves prior to instilling eyedrops.
- D. Hold the lower lid down and instill drops into the conjunctiva.
- E. Gently pat the skin to absorb excess eyedrops on the cheek.
Correct Answer: A,D,E
Rationale: Avoiding container contact prevents contamination, instilling into the conjunctiva ensures absorption, and patting excess drops maintains hygiene. Pressure on the outer canthus is incorrect (nasolacrimal duct pressure prevents systemic absorption), and sterile gloves are unnecessary.
The client's daughter tells the nurse of frustration while communicating with her elderly mother who wears hearing aids. Which intervention should the nurse suggest to the client's daughter?
- A. Minimize oral communication to essential matters.
- B. Speak directly into her mother's better ear.
- C. Use exaggerated mouth expressions while speaking.
- D. Attract her mother's attention before speaking.
Correct Answer: D
Rationale: Attracting the client's attention improves communication by including the client fully from the start. Minimizing communication, speaking into the ear, or exaggerated expressions are less effective.