Nokea
Which of the following types of hearing loss does the nurse understand is most improved with the use of a hearing aid?
- A. Conductive
- B. Mixed
- C. Sensorineural
- D. Central
Correct Answer: C
Rationale: The correct answer is C: Sensorineural hearing loss. Hearing aids are most effective for sensorineural hearing loss as they amplify sound signals to compensate for damage to the inner ear hair cells or auditory nerve. This type of hearing loss is due to problems in the inner ear or auditory nerve, which can be partially compensated for by using hearing aids. The other choices, A: Conductive, B: Mixed, and D: Central, are not as effectively improved by hearing aids. Conductive hearing loss is usually due to problems in the outer or middle ear, which can often be treated with medical or surgical interventions. Mixed hearing loss involves a combination of conductive and sensorineural components, and may require a combination of interventions. Central hearing loss is due to problems in the central auditory pathways in the brain, and is not typically improved by hearing aids.
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An adult has been stung by a bee and is in anaphylactic shock. An epinephrine (adrenaline) injection has been given. The nurse would expect which the following if the injection has been effective?
- A. The client’s breathing will become easier
- B. The client’s blood pressure will decrease
- C. There will be an increase in angiodema
- D. There will be a decrease in the client’s level of consciousness
Correct Answer: A
Rationale: The correct answer is A: The client’s breathing will become easier. Epinephrine is the first-line treatment for anaphylaxis as it helps to reverse the severe respiratory symptoms. By administering epinephrine, it causes bronchodilation, which helps improve breathing by opening up the airways. Choices B, C, and D are incorrect. B is incorrect because epinephrine typically causes an increase in blood pressure due to its vasoconstrictive effects. C is incorrect because angioedema is a potential side effect of anaphylaxis and would not be expected to increase after epinephrine administration. D is incorrect because epinephrine helps to improve alertness and consciousness by increasing blood flow to the brain.
A patient with a brain tumor is admitted to the medical unit to begin radiation treatments. Which nursing action should take priority?
- A. Pad the patient’s side rails
- B. Teach the patient what to expect during
- C. Assess the patient’s pain level radiation treatments
- D. Place the patient in isolation
Correct Answer: C
Rationale: The correct answer is C because assessing the patient's pain level is the priority when caring for a patient with a brain tumor about to begin radiation treatments. Pain management is crucial in providing comfort and ensuring the patient's well-being during treatment. Teaching the patient about what to expect and addressing any pain promptly are essential steps in delivering effective care.
Padding the side rails (choice A) is important for patient safety, but it is not the priority in this situation. Isolating the patient (choice D) is unnecessary unless there is a specific medical indication. Teaching the patient what to expect (choice B) is important but assessing and managing pain take precedence to ensure the patient's comfort and safety during treatment.
A college student goes to the college clinic and asks the best way to avoid contracting an STD. The nurse provides the clinic’s standard STD teaching. Which statement by the student indicates the need for additional instruction?
- A. “There is no guarantee that I won’t contract an STD if I choose to be sexually active.”
- B. “Abstinence is the only sure way to avoid an STD.”
- C. “If I use a condom with spermicide, I will be safer than if I don’t use one.”
- D. “If I question my partner about past sexual encounters, I can avoid STDs.”
Correct Answer: D
Rationale: The correct answer is D. This statement indicates a need for additional instruction because questioning a partner about past sexual encounters may not be a reliable method to avoid STDs. Here's the rationale:
1. A: Correct - Acknowledges the reality that engaging in sexual activity carries risks, even with precautions.
2. B: Correct - Emphasizes that abstinence is the most effective way to prevent STD transmission.
3. C: Correct - Using a condom with spermicide can reduce the risk of STD transmission, although it's not foolproof.
4. D: Incorrect - Relying solely on partner questioning is not a comprehensive or foolproof method to prevent STDs. It overlooks the potential for misinformation or lack of disclosure from the partner.
A client has an external fixation device on his leg due to a compound fracture. The client says that the device and swelling make his leg look ugly. Which nursing diagnosis should the nurse document in his care plan based on the client’s concern?
- A. Impaired physical mobility
- B. Disturbed body image
- C. Risk for infection
- D. Risk for social isolation
Correct Answer: B
Rationale: The correct answer is B: Disturbed body image. The client's concern about the external fixation device making his leg look ugly indicates a disturbance in his perception of his own body image. This diagnosis focuses on the client's feelings and emotions related to his appearance, which can impact his self-esteem and psychological well-being.
Rationale:
1. Impaired physical mobility (A) is not the most appropriate diagnosis in this scenario as the client's concern is related to the appearance of his leg, not his ability to move.
2. Risk for infection (C) is not the best choice because the client's concern is not directly related to the risk of infection but rather to the aesthetic aspect of his leg.
3. Risk for social isolation (D) is not the most suitable diagnosis as the client's concern is more about his own perception of his appearance rather than the potential impact on his social interactions.
While the patient’s lower extremity, which is in a cast, is assessed, the patient tells the nurse about an inability to rest at night. The nurse disregards this information, thinking that no correlation has been noted between having a leg cast and developing restless sleep. Which action would have been best for the nurse to take?
- A. Tell the patient to just focus on the leg and cast right now.
- B. Document the sleep patterns and information in the patient’s chart.
- C. Explain that a more thorough assessment will be needed next shift.
- D. Ask the patient about usual sleep patterns and the onset of having difficulty resting.
Correct Answer: D
Rationale: The correct answer is D because it involves a comprehensive approach to addressing the patient's concern. By asking the patient about usual sleep patterns and the onset of having difficulty resting, the nurse can gather important information to assess the potential correlation between the leg cast and restless sleep. This approach demonstrates active listening and shows concern for the patient's well-being.
Option A is incorrect because it dismisses the patient's concern and does not address the underlying issue. Option B is also incorrect as it focuses solely on documentation without actively addressing the patient's concern. Option C is not the best choice as it delays addressing the patient's immediate need for help with sleeping, which may impact their overall recovery.