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Which of the following nursing diagnoses is priority when caring for a patient who is experiencing an acute attack of Méni?¨re's disease?
- A. Risk for falls as evidenced by impaired balance
- B. Impaired verbal communication related to vulnerability (tinnitus)
- C. Bathing self-care deficit related to weakness (vertigo)
- D. Imbalanced nutrition: less than body requirements related to insufficient dietary intake (nausea)
Correct Answer: A
Rationale: All the nursing diagnoses are appropriate, but because sudden acute attacks of vertigo, the major focus of nursing care is to prevent injuries associated with impaired balance.
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Which of the following actions should the nurse take when communicating with a patient who has a moderate hearing loss?
- A. Overenunciate words.
- B. Speak normally but more slowly.
- C. Increase the volume when speaking.
- D. Use more facial expressions when talking.
Correct Answer: B
Rationale: Patient understanding of the nurse's speech will be enhanced by speaking at a normal tone, but more slowly. Increasing the volume, overenunciating, and exaggerating facial expressions will not improve the patient's ability to comprehend the nurse.
Which of the following actions is an example of an approach magnification?
- A. Using a telescopic lens
- B. Sitting closer to a television while watching it
- C. Using a black-tipped felt marker when writing
- D. Reading books with large-type print
Correct Answer: B
Rationale: Approach magnification is a simple but sometimes overlooked technique for enhancing the patient's residual vision. The nurse can recommend that the patient sit closer to the television or hold books closer to the eyes, which the patient may be reluctant to do unless encouraged. Using a telescopic lens is an optical device. Using a black-tipped marker to write is a contrast enhancement technique. Reading large-type print books may be helpful but is not an approach magnification action unless the book was brought close to the eyes, which is not indicated in the answer choice.
The nurse is caring for a patient with age-related macular degeneration who has just had photodynamic therapy. Which of the following statements by the patient indicates that the discharge teaching has been effective?
- A. I will need to use bright lights to read for at least the next week.
- B. I will use drops to keep my pupils dilated until my appointment.
- C. I will not use facial lotions near my eyes during the recovery period.
- D. I will keep covered with long-sleeve shirts and pants for the next 5 days.
Correct Answer: D
Rationale: The photosensitizing drug used for photodynamic therapy is activated by exposure to bright light and can cause burns in areas exposed to light for 5 days after the treatment. There are no restrictions on use of facial lotions, medications to keep the pupils dilated are not appropriate, and bright lights would increase the risk for damage caused by the treatment.
An older-adult patient with presbycusis is fitted with binaural hearing aids. Which of the following information should the nurse include when teaching the patient how to use the hearing aids?
- A. Experiment with volume and hearing ability in a quiet environment initially.
- B. Keep the volume low on the hearing aids for the first week while adjusting to them.
- C. Add the second hearing aid after making the initial adjustment to the first hearing aid.
- D. Wear the hearing aids for about an hour a day at first, gradually increasing the time of use.
Correct Answer: A
Rationale: Initially the patient should use the hearing aids in a quiet environment like the home, experimenting with increasing and decreasing the volume as needed. There is no need to gradually increase the time of wear. The patient should experiment with the level of volume to find what works well in various situations. Both hearing aids should be used.
The charge nurse observes a newly hired nurse caring for a patient who has just arrived in the postanesthesia care unit after having right cataract removal and an intraocular lens implant. Which of the following interventions requires that the charge nurse intervene?
- A. The nurse leaves the eye shield in place.
- B. The nurse encourages the patient to cough.
- C. The nurse elevates the patient's head to 45 degrees.
- D. The nurse applies corticosteroid drops to the right eye.
Correct Answer: B
Rationale: Because coughing will increase intraocular pressure, patients are generally taught to avoid coughing during the acute postoperative time. The other actions are appropriate for a patient after having this surgery.