Nokea
The student nurse is performing a Weber tuning fork test. What technique is most appropriate?
- A. Holding the vibrating tuning fork 10 to 12 inches from the clients ear
- B. Placing the vibrating fork in the middle of the clients head
- C. Placing the vibrating fork in the middle of the clients head
- D. Tapping the vibrating tuning fork against the bridge of the nose
Correct Answer: B
Rationale: The Weber tuning fork test involves placing the vibrating tuning fork in the middle of the client's head and asking in which ear the client hears the vibrations loudest. The other techniques are incorrect.
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A nurse is teaching a community group about noise-induced hearing loss. Which client who does not use ear protection should the nurse refer to an audiologist as the priority?
- A. Client with an hour car commute on the freeway each day.
- B. Client who rides a motorcycle daily.
- C. Client who sat in the back at a rock concert recently.
- D. Client who uses a chainsaw for 6 to 7 hours a day.
Correct Answer: D
Rationale: A chainsaw becomes dangerous to hearing after 2 hours of exposure without hearing protection. This client needs to be referred as the priority. Normal car traffic is safe for longer than 2 hours. Motorcycle noise is safe for about 8 hours. The safe exposure time for a front-row rock concert seat is 3 minutes, but this client was in the back, and so had less exposure. In addition, a one-time exposure is less damaging than chronic exposure.
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.
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.
A nurse is teaching a client about ear hygiene and health. What client statement indicates a need for further teaching?
- A. A soft cotton swab is alright to clean my ears with.
- B. I make sure my ears are dry after I go swimming.
- C. I stop good ear plugs when I practice with the band.
- D. Keeping my diabetes under control helps my ears.
Correct Answer: A
Rationale: Clients should be taught not to put anything larger than their fingertip into their ears. Using a cotton swab, although soft, can cause damage to the ears and cerumen buildup. The other statements are accurate.
A client with Ménière's disease is in the hospital when the client has an attack of this disorder. What action by the nurse takes priority?
- A. Assess vital signs every 15 minutes.
- B. Dim or turn off lights in the client's room.
- C. Place the client in bed with the upper siderails up.
- D. Provide a cool, wet cloth for the client's face.
Correct Answer: C
Rationale: Clients with Ménière's disease can have vertigo so severe that they can fall. The nurse should assist the client into bed and raise the upper siderails to prevent falls due to the intense whirling feeling. The other actions are not warranted for clients with Ménière's disease.