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Which nursing goal is a priority when caring for a client newly diagnosed with vertigo?
- A. Client will maintain therapeutic medication schedule.
- B. Client will remain safe while ambulating in the home.
- C. Client will have a caretaker in the home.
- D. Client will close eyes as needed to reduce symptoms.
Correct Answer: B
Rationale: Safety is always a concern when a client is experiencing vertigo. The goal of the nurse's instruction and care is for the client to remain safe. Maintaining a therapeutic medication schedule and caretaker and establishing strategies to reduce symptoms are important but not of highest priority.
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What aspect should the nurse closely monitor for in clients who have been administered salicylates, loop diuretics, quinidine, quinine, or aminoglycosides?
- A. Signs of hypotension
- B. Reduced urinary output
- C. Tinnitus and sensorineural hearing loss
- D. Impaired facial movement
Correct Answer: C
Rationale: It is important that nurses are knowledgeable about the ototoxic effects of certain medications such as salicylates, loop diuretics, quinidine, quinine, and aminoglycosides. Signs and symptoms of ototoxicity include tinnitus and sensorineural hearing loss. Hypotension, reduced urinary output, and impaired facial movement are not signs of ototoxicity.
The nurse is instructing a client on the benefits of a cochlear implant. The client asks, 'How am I able to interpret sound?' The nurse credits which of the following as significant in the production of hearing?
- A. External microphone
- B. Internal processor
- C. Amplifier
- D. Auditory nerve
Correct Answer: D
Rationale: The nurse credits stimulation of the auditory nerve in the transmission of the electrical signals to the brain for interpretation. The external processor and internal processor bring the sounds from the environment and send them to the internal processor, which converts to the electrical signal. An amplifier is used with typical hearing aids.
The nurse is supervising a family member who is instilling ear drops into the client's ear. Which of the following statements, made by the family member, would prompt further nursing instruction?
- A. Turn your head to the side so I can put these drops in.
- B. These drops are cold from being on the windowsill.
- C. Let me put this cotton ball in your ear because I put the drop in.
- D. I squeeze the dropper to put a drop of medicine in the ear.
Correct Answer: B
Rationale: When the family member states that the drops are cold, the nurse would encourage the family member to place the bottle in a warm bath or warm the bottle in their hands. Cold or hot liquids, instilled in the ear, may cause dizziness and potential for injury.
The nurse is teaching a class on diseases of the ear. What would the nurse teach the class is the most characteristic symptom of otosclerosis?
- A. The client being distressed in the mornings
- B. A progressive, bilateral loss of hearing
- C. A red and swollen ear drum
- D. The client describing a recent upper respiratory infection
Correct Answer: B
Rationale: A progressive, bilateral loss of hearing is the characteristic symptom of otosclerosis. Tinnitus appears as the loss of hearing progresses; it is especially noticeable at night, when surroundings are quiet, and may be quite distressing to the client. The eardrum appears pinkish-orange from structural changes in the middle ear. The client often describes a history of having had a recent upper respiratory infection in case of otitis media, not otosclerosis.
The occupational nurse is advising a client on options to enhance workplace communication because the client has progressive hearing loss. The client works as a customer service representative. In discussing the options with the client, which type would be the last option offered by the nurse?
- A. Battery-operated hearing aid
- B. American sign language
- C. Headsets with amplifiers
- D. Text-based telecommunications
Correct Answer: B
Rationale: Although American sign language is an asset to use for communication, a client with an occupation of customer service representative needs accommodations to be able to understand the spoken word.