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Which referral is most important for the nurse to implement for the client with permanent hearing loss?
- A. Aural rehabilitation.
- B. Speech therapist.
- C. Social worker.
- D. Vocational rehabilitation.
Correct Answer: A
Rationale: Aural rehabilitation addresses communication strategies and hearing aids, critical for permanent hearing loss. Speech therapy, social work, and vocational rehab are secondary.
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The nurse writes the diagnosis 'risk for injury related to impaired balance' for the client diagnosed with vertigo. Which nursing intervention should be included in the plan of care?
- A. Provide information about vertigo and its treatment.
- B. Assess for level and type of diversional activity.
- C. Assess for visual acuity and proprioceptive deficits.
- D. Refer the client to a support group and counseling.
Correct Answer: C
Rationale: Assessing visual and proprioceptive deficits identifies factors contributing to vertigo-related falls, enhancing safety. Information, activities, and referrals are secondary.
The nurse reviews the chart of the client diagnosed with closed-angle glaucoma. Which documented finding should the nurse question with the HCP?
- A. Sudden onset of eye pain
- B. Reduced central visual acuity
- C. Normal intraocular pressure
- D. Nausea and vomiting
Correct Answer: C
Rationale: Closed-angle glaucoma causes an increased, not normal, intraocular pressure. This documentation finding should be questioned. Sudden eye pain, reduced central visual acuity, and nausea and vomiting are consistent with closed-angle glaucoma.
The physician has ordered mannitol IV for a client with a head injury. What should the nurse closely monitor because the client is receiving mannitol?
- A. Deep tendon reflexes
- B. Urine output
- C. Level of orientation
- D. Pulse rate
Correct Answer: B
Rationale: Mannitol is a diuretic, so monitoring urine output is critical to assess its effectiveness and prevent dehydration.
The nurse is concerned that the Caucasian client experiencing a stroke may have impaired hearing. Which observations of the client's behavior prompted this concern? Select all that apply.
- A. Nods and agrees to all statements made by the nurse
- B. Asks for more information about the therapy schedule
- C. Slow to respond verbally but answers questions appropriately
- D. Speaks in an excessively loud tone of voice
- E. Leans in toward the nurse when the nurse speaks
Correct Answer: A,D,E
Rationale: Nodding and agreeing to all statements, speaking loudly, and leaning toward the speaker suggest hearing impairment. Asking for schedule details and slow but appropriate responses do not indicate hearing issues.
During an assessment, the nurse covers the client's right eye and then observes a shift in the client's gaze after the eye is uncovered. Which conclusion should the nurse make about the results of the test?
- A. The client has opacity of the lens.
- B. The client has absence of the blink reflex.
- C. The client has increased intraocular pressure.
- D. The client has weakness in the extraocular muscles.
Correct Answer: D
Rationale: Covering and then uncovering the client's eye and then observing for a shift in the client's gaze is the cover-uncover test used to detect weakness in the extraocular muscles. Lens opacity is detected by direct observation. Stroking the eyelashes will evoke the blink reflex. The intraocular pressure is measured by tonometry.