Nokea
Which intervention should the nurse include when conducting an in-service to the ancillary nursing staff on caring for elderly clients addressing normal developmental sensory changes?
- A. Ensure curtains are open when having the client read written material.
- B. Provide a variety of written material when discussing a procedure.
- C. Assist the client when getting out of the bed and sitting in the chair.
- D. Request a telephone for the hearing impaired for all elderly clients.
Correct Answer: A
Rationale: Open curtains maximize light, compensating for age-related vision decline. Varied materials, mobility assistance, and hearing-impaired phones are less universally applicable.
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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 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.
The client following removal of a right-sided acoustic neuroma by a translabyrinthine approach calls the nurse to report pain. The nurse finds that the client has new-onset right-sided facial drooping and numbness. Place the nurse's actions in priority order.
- A. Close the client's right eye and place a patch over it.
- B. Assess the operative incision site and assess the arms for drift.
- C. Contact the stroke team and the HCP.
- D. Medicate the client for pain unless contraindicated.
Correct Answer: B,C,D,A
Rationale: Assess the incision and arms for drift first (B), then contact the stroke team and HCP for possible complications (C), medicate for pain (D), and finally patch the eye due to inability to close it (A).
The client with diminished sight has problems with the glare from light. Which recommendation should the nurse make?
- A. Install fluorescent lighting throughout the home.
- B. Wear sunglasses and hats with brims when outdoors.
- C. Avoid going outdoors on days that are sunny.
- D. Use direct sunlight from windows rather than lights.
Correct Answer: B
Rationale: Wearing sunglasses and hats with brims while outdoors blocks direct light, reducing glare. Fluorescent lighting and direct sunlight increase glare, and avoiding sunny days is unnecessary.