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Which behavior by the male client should make the nurse suspect the client has a hearing loss? Select all that apply.
- A. The client reports hearing voices in his head.
- B. The client becomes irritable very easily.
- C. The client has difficulty making decisions.
- D. The client’s wife reports he ignores her.
- E. The client does not dominate a conversation.
Correct Answer: B,D,E
Rationale: Irritability, ignoring others, and not dominating conversations suggest hearing loss due to social withdrawal or misunderstanding. Hearing voices is psychiatric, and decision-making is unrelated.
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Which referral is most important for the nurse to implement for the client with permanent hearing loss?
- A. Aural rehabilitation.
- B. Speech therapist.
- C. Social worker.
- D. Vocational rehabilitation.
Correct Answer: A
Rationale: Aural rehabilitation addresses communication strategies and hearing aids, critical for permanent hearing loss. Speech therapy, social work, and vocational rehab are secondary.
The elderly client has undergone a right-eye cataract removal with an intraocular implant. Which discharge instructions should the nurse teach the client?
- A. Have the client demonstrate placing the otic drops in the ear.
- B. Teach the client to instill the eyedrops as prescribed.
- C. Remind the client to keep the lights in the home low at all times.
- D. Encourage the client to sleep on two pillows at night.
Correct Answer: B
Rationale: Instilling prescribed eyedrops (e.g., antibiotics, steroids) prevents infection and inflammation post-cataract surgery. Otic drops are irrelevant, low lights are unnecessary, and elevation is not standard.
When planning care for a woman with myasthenia gravis, the nurse asks her what time of day she feels strongest. The nurse would expect which of the following replies?
- A. I can wash up and comb my hair before breakfast because I feel best in the morning.'
- B. I only feel good for about an hour after I take my medication.'
- C. I feel strongest in the evening, so I would prefer to take a shower before bedtime.'
- D. I feel best after lunch after I've been moving around a little.'
Correct Answer: A
Rationale: Muscle strength in myasthenia gravis is typically best in the morning, with weakness worsening throughout the day.
The nurse is questioning the client about vision changes. Which symptom indicates that the client may be developing a cataract?
- A. Blurred vision, worsening at night
- B. Shooting pain in the back of one eye
- C. Increased frequency of headaches
- D. Seeing spots in the vision field of one eye
Correct Answer: A
Rationale: The lens opacity from a developing cataract diminishes vision. Blurriness and decreased night vision are early symptoms. Shooting eye pain is often associated with a subarachnoid hemorrhage, not a cataract. Headaches are not associated with cataract formation. Floating dark spots in the vision field are associated with bleeding within the eye that occurs with detached retina.
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.