Nokea
The nurse works with clients who have hearing problems. Which action by a client best indicates goals for an important diagnosis have been met?
- A. Babysitting the grandchildren several times a week
- B. Having an adaptive hearing device for the television
- C. Being active in community groups and volunteer work
- D. Responding agreeably to suggestions for adaptive devices
Correct Answer: C
Rationale: Clients with hearing problems can become frustrated and withdrawn. The client who is actively engaged in the community shows the best evidence of psychosocial adjustment to hearing loss. Babysitting the grandchildren is a positive sign but does not indicate involvement outside the home. Having an adaptive device is not the same as being actively engaged outside the home. Responding agreeably does not indicate the client will actually follow through.
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The clients chart indicates a sensorineural hearing loss. What assessment question does the nurse ask to determine the possible cause?
- A. Do you feel like something is in your ear?
- B. Do you have frequent ear infections?
- C. Have you been exposed to loud noises?
- D. Have you been told your ear bones don't move?
Correct Answer: C
Rationale: Sensorineural hearing loss can occur from damage to the cochlea, the eighth cranial nerve, or the brain. Exposure to loud noises is one etiology. The other questions relate to conductive hearing loss.
A client has a hearing aid. What care instructions does the nurse provide the unlicensed assistive personnel (UAP) in the care of this client? (Select all that apply.)
- A. Be careful not to drop the hearing aid when handling.
- B. Soak the hearing aid in hot water for 20 minutes.
- C. Turn the hearing aid off when the client goes to bed.
- D. Use a toothpick to clean debris from the device.
- E. Wash the device with soap and a small amount of warm water.
Correct Answer: A,C,D,E
Rationale: All these actions except soaking the hearing aid in hot water are proper instructions for the nurse to give to the UAP. While some water is used to clean the hearing aid, excessive wetting should be avoided.
A client with labyrinthitis is prescribed antibiotics. What instruction is most important for the nurse to include?
- A. Immediately report headache or stiff neck.
- B. Keep all follow-up appointments.
- C. Take the antibiotics with a full glass of water.
- D. Take the antibiotic on an empty stomach.
Correct Answer: A
Rationale: Meningitis is a complication of labyrinthitis. The client should be taught to take all antibiotics as prescribed and to report manifestations of meningitis such as fever, headache, or stiff neck. Keeping follow-up appointments is important for all clients. Without knowing what antibiotic was prescribed, the nurse cannot instruct the client on how to take it.
A nursing student is instructed to remove a clients ear packing and instill eardrops. What action by the student requires intervention by the registered nurse?
- A. Assessing the eardrum with an otoscope.
- B. Warming the eardrops in water for 5 minutes.
- C. Using a cotton swab to clean the ear canal.
- D. Instilling eardrops at room temperature.
Correct Answer: A
Rationale: Assessing the eardrum with an otoscope requires specialized training and is not within the scope of a nursing student. Warming eardrops and instilling them at room temperature are appropriate. Using a cotton swab is not ideal but does not require immediate intervention.
A client had a myringotomy. The nurse provides which discharge teaching?
- A. Buy dry shampoo to use for a week.
- B. Drink liquids through a straw.
- C. Flying is not allowed for 1 month.
- D. Hot water showers will help the pain.
Correct Answer: A
Rationale: The client cannot shower or get the head wet for 1 week after surgery, so using dry shampoo is a good suggestion. The other instructions are incorrect: straws are not allowed for 2 to 3 weeks, flying is not allowed for 2 to 3 weeks, and the client should not shower.