Nokea
Which signs/symptoms should the nurse expect to find when assessing the client with an acoustic neuroma?
- A. Incapacitating vertigo and otorrhea.
- B. Nystagmus and complaints of dizziness.
- C. Nausea and vomiting.
- D. Unilateral hearing loss and tinnitus.
Correct Answer: D
Rationale: Acoustic neuroma (vestibular schwannoma) causes unilateral hearing loss and tinnitus due to cranial nerve VIII compression. Vertigo, nystagmus, and nausea are less prominent; otorrhea is unrelated.
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The nurse is teaching the client with open-angle glaucoma. Which instruction should the nurse include?
- A. Limit oral fluid intake to 1000 mL daily.
- B. Eat foods that are high in omega-3 fatty acids.
- C. Have annual eye exams with an eye specialist.
- D. Use timolol maleate eye drops when feeling eye pressure.
Correct Answer: C
Rationale: Glaucoma is a chronic progressive disease; annual eye examinations should be completed by an eye specialist physician. Fluid restriction and omega-3 fatty acids do not affect intraocular pressure. Elevated intraocular pressure cannot be felt, and timolol maleate should be used as prescribed.
The nurse is preparing to administer otic drops into an adult client's right ear. Which intervention should the nurse implement?
- A. Grasp the earlobe and pull back and out when putting drops in the ear.
- B. Insert the eardrops without touching the outside of the ear.
- C. Instruct the client to close the mouth and blow prior to instilling drops.
- D. Pull the auricle down and back prior to instilling drops.
Correct Answer: B
Rationale: Inserting drops without touching the ear prevents contamination. Pulling the auricle up and back (not down) is correct for adults, and blowing is unnecessary.
The nurse is examining the client's ear using an otoscope and sees the image illustrated. Which documentation by the nurse is best?
- A. Tympanic membrane ruptured, no excessive cerumen
- B. External ear canal showing no lesions or drainage
- C. Tympanic membrane cone of light reflex distorted
- D. Bony landmarks prominent on tympanic membrane
Correct Answer: C
Rationale: The tympanic membrane shown is reddened, and the cone of light is distorted, indicating increased pressure behind the tympanic membrane. The membrane is intact, the external canal is not shown, and bony landmarks are not prominent.
The client is scheduled for laser-assisted in situ keratomileusis (LASIK) surgery for severe myopia. Which instruction should the nurse discuss prior to the client's discharge from day surgery?
- A. Wear bilateral eye patches for three (3) days.
- B. Wear corrective lenses until the follow-up visit.
- C. Do not read any material for at least one (1) week.
- D. Teach the client how to instill corticosteroid ophthalmic drops.
Correct Answer: D
Rationale: Corticosteroid drops reduce inflammation post-LASIK, requiring teaching. Eye patches are not used, corrective lenses are unnecessary, and reading restrictions are shorter.
A 17-year-old client had one generalized convulsion several hours prior to admission to the medical unit for a neurological workup. Physician's orders include Dilantin (phenytoin) 100 mg orally (PO) tid and phenobarbital 100 mg PO daily. He tells the nurse, 'I can't believe I really had a seizure. My mom says she was in the room when it happened, but I don't even remember it.' What is the best interpretation of his comments?
- A. They indicate an initial denial mechanism, but he will begin to remember the seizure later.
- B. Anoxia suffered during the seizure has damaged part of his cerebral cortex.
- C. Inability to remember the seizure is a normal response of a person who has had a seizure.
- D. They are an indication that he would rather not talk about his seizure at this time.
Correct Answer: C
Rationale: Amnesia for the seizure event is a normal response due to altered consciousness during a generalized seizure.