Nokea
The nurse on a cruise ship is assessing clients for motion sickness. Which is a common misconception regarding motion sickness?
- A. Repeated motion is the cause.
- B. Once symptoms occur, they will always be present.
- C. Medications help the symptoms.
- D. Pallor and diaphoresis is a first symptom.
Correct Answer: B
Rationale: When the client experiences motion sickness, the client will use that data to avoid further symptoms in the future. The client can use medication, change location or position, and recognize symptoms earlier for symptom management. The other options are correct and teachable statements.
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The nurse is evaluating the independent care of a client recovering from a stapedectomy. Which action made by the client indicates a need for further teaching?
- A. The client turns head slowly when family approaches.
- B. The client uses clean technique to clean the wound.
- C. The client takes antibiotics on schedule
- D. The client asks for assistance upon ambulation.
Correct Answer: B
Rationale: The client needs further instructions on using aseptic technique when completing wound care. Using aseptic technique reduces the introduction and transmission of microorganisms and protects the client from introduction of pathogens. The other options are appropriate actions for the client recovering from a stapedectomy to take.
The nurse is instructing a client on the benefits of a cochlear implant. The client asks, 'How am I able to interpret sound?' The nurse credits which of the following as significant in the production of hearing?
- A. External microphone
- B. Internal processor
- C. Amplifier
- D. Auditory nerve
Correct Answer: D
Rationale: The nurse credits stimulation of the auditory nerve in the transmission of the electrical signals to the brain for interpretation. The external processor and internal processor bring the sounds from the environment and send them to the internal processor, which converts to the electrical signal. An amplifier is used with typical hearing aids.
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.
The nurse is caring for a client being treated for M?©ni?¨re disease. Which medication is monitored closely due to its addictive properties?
- A. Meclizine
- B. Hydrochlorothiazide
- C. Diazepam
- D. Promethazine
Correct Answer: C
Rationale: Diazepam is used to treat the client with M?©ni?¨re disease to help control vertigo. Diazepam is a tranquilizer that has addictive properties. The other options, used in the treatment of M?©ni?¨re's disease, do not have any or significant addictive properties.
A nurse anticipates that an 8-year-old client has otitis externa from symptoms stated on the history. Which symptom(s), from the history and physical examination, would confirm the diagnosis? Select all that apply.
- A. Discomfort in the ear
- B. Redness of the ear canal
- C. Pus noted in the ear canal
- D. Conductive hearing loss
- E. Tympanic membrane may appear normal
Correct Answer: A,B,C,D,E
Rationale: The diagnosis of otitis externa (inflammation of the tissue of the outer ear) is confirmed by reports of pain, discharge from the external auditory canal, aural tenderness (usually not present in middle ear infections), and occasionally fever, cellulitis, and lymphadenopathy. Other symptoms may include pruritus and conductive hearing loss or a feeling of fullness in the ear. On otoscopic examination, the ear canal is erythematous and edematous. Discharge may be yellow or green and foul smelling. In fungal infections, hairlike black spores may be visible.