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Which teaching instruction should the nurse discuss with students who are on the high school swim team when discussing how to prevent external otitis?
- A. Do not wear tight-fitting swim caps.
- B. Avoid using silicone ear plugs while swimming.
- C. Use a drying agent in the ear after swimming.
- D. Insert a bulb syringe into each ear to remove excess water.
Correct Answer: C
Rationale: A drying agent (e.g., alcohol-based drops) prevents external otitis by removing moisture. Swim caps and ear plugs are protective, and bulb syringes risk trauma.
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The nurse is caring for a client who is very hard of hearing. How should the nurse communicate with this person?
- A. Speak loudly and talk in his better ear
- B. Stand in front of him and speak clearly and distinctly
- C. Yell at him using a high-pitched voice
- D. Write all communication on a note pad or magic slate
Correct Answer: B
Rationale: Standing in front and speaking clearly aids lip-reading and communication for a hard-of-hearing client.
The client following removal of a right-sided acoustic neuroma by a translabyrinthine approach calls the nurse to report pain. The nurse finds that the client has new-onset right-sided facial drooping and numbness. Place the nurse's actions in priority order.
- A. Close the client's right eye and place a patch over it.
- B. Assess the operative incision site and assess the arms for drift.
- C. Contact the stroke team and the HCP.
- D. Medicate the client for pain unless contraindicated.
Correct Answer: B,C,D,A
Rationale: Assess the incision and arms for drift first (B), then contact the stroke team and HCP for possible complications (C), medicate for pain (D), and finally patch the eye due to inability to close it (A).
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.
Which statement by the daughter of an 80-year-old female client who lives alone warrants immediate intervention by the nurse?
- A. I put a night-light in my mother’s bedroom.
- B. I got carbon monoxide detectors for my mother’s house.
- C. I changed my mother’s furniture around.
- D. I got my mother large-print books.
Correct Answer: C
Rationale: Changing furniture increases fall risk in an elderly client with potential sensory deficits, requiring intervention. Night-lights, CO detectors, and large-print books enhance safety.
The student nurse asks the nurse, 'Which type of hearing loss involves damage to the cochlea or vestibulocochlear nerve?' Which statement is the best response of the nurse?
- A. It is called conductive hearing loss.
- B. It is called a functional hearing loss.
- C. It is called a mixed hearing loss.
- D. It is called sensorineural hearing loss.
Correct Answer: D
Rationale: Sensorineural hearing loss involves cochlear or vestibulocochlear nerve damage. Conductive loss affects the outer/middle ear, functional loss is psychological, and mixed involves both.