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The student nurse asks the nurse, 'Which type of hearing loss involves damage to the cochlea or vestibulocochlear nerve?' Which statement is the best response of the nurse?
- A. It is called conductive hearing loss.
- B. It is called a functional hearing loss.
- C. It is called a mixed hearing loss.
- D. It is called sensorineural hearing loss.
Correct Answer: D
Rationale: Sensorineural hearing loss involves cochlear or vestibulocochlear nerve damage. Conductive loss affects the outer/middle ear, functional loss is psychological, and mixed involves both.
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An adult client is admitted for removal of a cataract from her right eye. Which of the following would the client likely have experienced as a result of the cataracts?
- A. Acute eye pain
- B. Redness and constant itching of the right eye
- C. Gradual blurring of vision
- D. Severe headaches and dizziness
Correct Answer: C
Rationale: Cataracts cause gradual blurring of vision due to lens opacity, not acute pain, itching, or headaches.
The client receives a prescription for sodium fluoride for otosclerosis and asks the nurse, 'What will this medication do for my ears?' Which response by the nurse is correct?
- A. Sodium fluoride prevents the breakdown of bone cells and hardens the bone in the ear.
- B. Sodium fluoride causes the breakdown of bone cells and softens the bone in the ear.
- C. Sodium fluoride blocks the effect of histamine and dries the fluid in the ear.
- D. Sodium fluoride causes the production of histamine and increases the fluid in the ear.
Correct Answer: A
Rationale: The medication, sodium fluoride, retards bone reabsorption (prevents the breakdown of bone cells) and promotes calcification (hardening) of the bony lesions in the ear.
Which instruction should the nurse discuss with the client when completing a sensory assessment regarding proprioception?
- A. Instruct the client to lie flat without a pillow during the assessment.
- B. Instruct the client to keep both eyes shut during the assessment.
- C. During the assessment the client must be in a treatment room.
- D. Keep the lights off during the client's sensory assessment.
Correct Answer: B
Rationale: Closing eyes during proprioception testing (e.g., Romberg test) isolates balance to proprioceptive input. Lying flat, treatment rooms, and lights off are irrelevant.
Which statement indicates to the nurse the client is experiencing some hearing loss?
- A. I clean my ears every day after I take a shower.
- B. I keep turning up the sound on my television.
- C. My ears hurt, especially when I yawn.
- D. I get dizzy when I get up from the chair.
Correct Answer: B
Rationale: Turning up the television volume suggests hearing loss. Ear cleaning is unrelated, ear pain suggests infection, and dizziness indicates vestibular issues.
An adult man fell off a ladder and hit his head and lost consciousness. After regaining consciousness several minutes later, he was drowsy and had trouble staying awake. He is admitted to the hospital for evaluation. The nursing care plan will most likely include which of the following?
- A. Elevate head of bed 15 to 30 degrees
- B. Encourage fluids to 1000 mL every eight hours
- C. Assist the client to cough and deep breathe every two hours
- D. Perform chest physical therapy every four hours while awake
Correct Answer: A
Rationale: Elevating the head of the bed 15 to 30 degrees promotes gravity drainage of fluid and reduces cerebral edema. Coughing, forcing fluids, and chest physical therapy may increase intracranial pressure and are contraindicated.