Nokea
Which questions should the nurse ask when assessing a client for possible manifestations of Ménière's disease? Select all that apply.
- A. Do you experience ringing in your ears?
- B. Are you prone to vertigo that can last for days?
- C. Can you hear better out of one ear than the other?
- D. Is there a history of Ménière's disease in your family?
- E. Have you ever experienced a head injury in the area of your ears?
Correct Answer: A,B,C
Rationale: Ménière's disease is characterized by dilation of the endolymphatic system by overproduction or decreased reabsorption of endolymphatic fluid. Manifestations include tinnitus, vertigo that can last for days, and one-sided sensorineural hearing loss. Although the exact cause of the disease is unknown, there does not seem to be a connection with either genetics or head trauma.
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A client who experienced repeated pleural effusions from inoperable lung cancer is to undergo pleurodesis. What intervention should the nurse plan to implement after the primary health care provider injects the sclerosing agent through the chest tube to help assure the effectiveness of the procedure?
- A. Ambulate the client.
- B. Clamp the chest tube.
- C. Ask the client to cough and deep breathe.
- D. Ask the client to remain in a side-lying position.
Correct Answer: B
Rationale: After injection of the sclerosing agent, the chest tube is clamped to prevent the agent from draining back out of the pleural space. Depending on primary health care provider preference, a repositioning schedule is used to disperse the substance. Ambulation, coughing, and deep breathing have no specific purpose in the immediate period after injection.
A prenatal client has been diagnosed with a vaginal infection from the organism Candida albicans. What should the nurse expect to note on assessment of the client?
- A. Costovertebral angle pain
- B. Absence of any observable signs
- C. Pain, itching, and vaginal discharge
- D. Proteinuria, hematuria, and hypertension
Correct Answer: C
Rationale: Clinical manifestations of a Candida infection include pain; itching; and a thick, white vaginal discharge. Proteinuria and hypertension are signs of preeclampsia. Costovertebral angle pain, proteinuria, and hematuria are clinical manifestations associated with upper urinary tract infections.
A client receiving total parenteral nutrition (TPN) via a central venous catheter (CVC) is scheduled to receive an intravenous (IV) antibiotic. Which intervention should the nurse implement before administering the antibiotic?
- A. Turn off the TPN for 30 minutes.
- B. Ensure a separate IV access route.
- C. Flush the CVC with normal saline.
- D. Check for compatibility with TPN.
Correct Answer: B
Rationale: The TPN line is used only for the administration of the TPN solution to prevent crystallization in the CVC tubing and disruption of the TPN infusion. Any other IV medication must be administered through a separate IV access site, including a separate infusion port of the CVC catheter. Therefore, options 1, 3, and 4 are incorrect actions.
A magnetic resonance imaging (MRI) scan is prescribed for a client with a suspected brain tumor. Which prescription should the nurse anticipate will be prescribed for the client before the procedure?
- A. An opioid
- B. A sedative
- C. A corticosteroid
- D. An antihistamine
Correct Answer: B
Rationale: An MRI scan is a noninvasive diagnostic test that visualizes the body's tissues, structure, and blood flow. For an MRI, the client is positioned on a padded table and moved into a cylinder-shaped scanner. Relaxation techniques, an eye mask, and sedation are used before the procedure to reduce claustrophobic effects; however, because the client must remain very still during the scan, the nurse avoids oversedating the client to ensure client cooperation. There is no useful purpose for administering an opioid, corticosteroid, or antihistamine.
The nurse sends a sputum specimen to the laboratory for culture from a client with suspected active tuberculosis (TB). The results report that Mycobacterium tuberculosis is cultured. How should the nurse correctly analyze these results?
- A. The results are positive for active tuberculosis.
- B. The results indicate a less virulent strain of tuberculosis.
- C. The results are inconclusive until a repeat sputum specimen is sent.
- D. The results are unreliable unless the client has also had a positive tuberculin skin test (TST).
Correct Answer: A
Rationale: Culture of Mycobacterium tuberculosis from sputum or other body secretions or tissue confirms the diagnosis of active tuberculosis.