Nokea
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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The nurse is planning the care of the client with Meniere's disease. With which member of the interdisciplinary team should the nurse expect a consultation?
- A. Rheumatologist
- B. Otolaryngologist
- C. Physical therapist
- D. Oncologist
Correct Answer: B
Rationale: Since Meniere's disease is a condition of the ear, the nurse would plan to include the otolaryngologist. Rheumatologists, physical therapists, and oncologists treat unrelated conditions.
A client who is recovering from a spinal cord injury complains of blurred vision and a severe headache. His blood pressure is 210/140. The most appropriate initial action for the nurse to take is to:
- A. check for bladder distention.
- B. place him in the Trendelenburg position.
- C. administer PRN pain medication.
- D. position him on his left side.
Correct Answer: A
Rationale: Symptoms suggest autonomic dysreflexia, often triggered by bladder distention, requiring immediate assessment and intervention.
The client is a 60-year-old man who had a stapedectomy. He is to ambulate for the first time. Which nursing action should be taken?
- A. Encourage him to walk as far as he comfortably can
- B. Suggest that he practice bending and stretching exercises
- C. Walk with him, holding his arm
- D. Tell him to take deep breaths while he is ambulating
Correct Answer: C
Rationale: Walking with the client and holding his arm ensures safety and prevents falls post-stapedectomy.
The client recently diagnosed with age-related macular degeneration (AMD) in both eyes returns to the clinic for a follow-up appointment. Which assessment will the nurse be certain to include during the visit?
- A. Stools for occult blood
- B. Blood glucose levels
- C. Screening for depression
- D. Screening for hearing loss
Correct Answer: C
Rationale: The nurse should assess for depression because loss of vision can affect functional ability, mood, and quality of life. Depression frequently develops within a few months after AMD is diagnosed in both eyes. GI bleeding, blood glucose, and hearing loss are not directly related to AMD.
The client has an hordeolum of the left eye, which is painful. Which intervention, if prescribed, should the nurse implement?
- A. Apply an eye patch on the left eye.
- B. Insert miotic eye drops twice daily.
- C. Apply a warm compress four times daily.
- D. Administer an antibiotic intravenously.
Correct Answer: C
Rationale: Warm compresses are applied to promote drainage of the hordeolum. Patching is not indicated, miotic drops treat glaucoma, and IV antibiotics are unnecessary as topical antibiotics are used.