exam 10
Which one of the following patients is most likely to be experiencing a health problem that may be a result of vestibular dysfunction? A) A 78-year-old woman who requires open reduction and internal fixation of her left hip following a fall B) An 80-year-old man whose recent declines in cognition have prompted his move to a long-term care facility C) A woman whose progressive weakness and loss of coordination are attributable to multiple sclerosis D) A man who has been hospitalized with signs and symptoms of malnutrition and fluid volume deficit
A) A 78 year old women who requires open reduction and internal fixation of her left hip following a fall. The vestibular apparatus of the inner ear provides feedback regarding the movements and the position of the head and body in space. Disturbances in the function of this system are implicated in many falls, especially among older adults. Confusion, multiple sclerosis, and malnutrition are not affected by the vestibular system.
Which of the following classification of medications is the most common cause of ototoxicity? A) Aminoglycosides B) Cephalosporins C) Sulfonamides D) Penicillins
A) Aminoglycosides IV medications, especially the aminoglycosides, are the most common cause of ototoxicity, and they destroy the hair cells in the organ of Corti. Cephalosporins, sulfonamides, and penicillins are not among the most common causes of ototoxicity.
The nurse working on a neurological unit is mentoring a nursing student who asks about a client who has sustained primary and secondary brain injuries. The nurse correctly tells the student which of the following, related to the secondary injury? A) It results from inadequate delivery of nutrients and oxygen to the cells. B) It results from initial damage to the brain from the traumatic event. C) It refers to the permanent deficits seen after the rehabilitation process. D) It refers to the difficulties suffered by the client and family related to the changes in the client.
A) It results from inadequate delivery of nutrients and oxygen to the cells
Which set of symptoms characterize Korsakoff syndrome? A) Psychosis, disorientation, delirium, insomnia, and hallucinations B) Severe dementia and myoclonus C) Tremor, rigidity, and bradykinesia D) Choreiform movement and dementia
A) Psychosis, disorientation, delirium, insomnia, and hallucinations
The red reflex occurs when a normal orange glow is observed as light is applied to which of the following? A) Pupil B) Iris C) Optic disk D) Eye lid
A) Pupil
A client in the surgical intensive care unit has skeletal tongs in place to stabilize a cervical fracture. Protocol dictates that pin care should be performed each shift. When providing pin care for the client, which finding should the nurse report to the physician? A) Crust around the pin insertion site B) A small amount of yellow drainage at the left pin insertion site C)A slight reddening of the skin surrounding the insertion site D) Pain at the insertion site
B) A small amount of yellow drainage at the left pin insertion site
Which feature should a nurse observe during an ophthalmic assessment? A) Internal eye function B) Appearance of the external eye C) Visual acuity D) Intraocular pressure
B) Appearance of the external eye During an ophthalmic assessment, the nurse should examine the appearance of the external eye and the pupil responses in the client. A qualified examiner determines internal eye function, visual acuity, and intraocular pressure.
A client is being discharged home after surgery involving the middle ear. Which of the following client statements demonstrates understanding of the instructions? A) "I need to wait at least 1 week before washing my hair so that water doesn't enter my ear." B) "If I sneeze or cough during the first few weeks, I should keep my mouth open." C) "After the first 48 hours, I can bend over to pick things up if I need to." D) "I need to report any crackling sounds in my affected ear to the physician right away."
B) If I sneeze or cough during the first few weeks, I should keep my mouth open. After middle ear surgery, the client needs to sneeze or cough with an open mouth for a few weeks after surgery, wait 2 to 3 days to shampoo the hair (making sure that the ear is protected), and avoid bending at the waist, straining or lifting heavy objects for a few weeks. Poppling or crackling sounds or sensations in the operative ear are normal for the first 3 to 5 weeks after surgery.
A nurse is working with a student nurse who is caring for a client with an acute bleeding cerebral aneurysm. Which action by the student nurse requires further intervention? A) Positioning the client to prevent airway obstruction B) Keeping the client in one position to decrease bleeding C) Administering I.V. fluid as ordered and monitoring the client for signs of fluid volume excess D) Maintaining the client in a quiet environment
B) Keeping the client in one position to decrease bleeding. The student nurse shouldn't keep the client in one position. She should carefully reposition the client often (at least every hour). The client needs to be positioned so that a patent airway can be maintained. Fluid administration must be closely monitored to prevent complications such as increased intracranial pressure. The client must be maintained in a quiet environment to decrease the risk of rebleeding.
The nurse is instructing a nursing student when a new client comes to the eye clinic. The client explains that he thinks he has a corneal abrasion. The nurse should explain what to the student nurse? A) "To detect corneal abrasions, an ophthalmoscope is used." B) "To detect corneal abrasions, ultrasonography is used." C) "To detect corneal abrasions, a slit lamp is used." D) "To detect corneal abrasions, retinal angiography is used"
C) To detect corneal abrasions a sit lamp is used A slit lamp is a binocular microscope that magnifies the surface of the eye. A beam of light, narrowed to a slit, is directed at the cornea, facilitating an examination of structures and fluid in the anterior segment of the eye. This examination is used to identify disorders such as corneal abrasions, iritis, conjunctivitis, and cataracts. The other options are not used to detect corneal abrasions.
A patient's range of hearing loss is diagnosed as "mild-moderately severe." The nurse knows that the audiologist would recommend which of the following hearing aid sites? A) On the trunk of the body B) Behind the ear C) In the ear D) In the canal
D) In the canal
Which are accurate clinical manifestations of a retinal detachment? A) Sudden onset of a greater number of floaters B) Cobwebs C) Bright flashing lights D) Pain
A) Sudden onset of a greater number of floaters Clients may report the sensation of a shade or curtain coming across the vision of one eye, cobwebs, bright flashing lights, or the sudden onset of a great number of floaters. Clients with retinal detachment do not complain of pain.
The nurse is caring for a patient with Ménière's disease. The patient is scheduled to go home tomorrow, so the nurse is preparing the patient's discharge teaching. Dietary guidelines will be included. What foods should the patient be instructed to limit or avoid? A) Sweet pickles B) Frozen yogurt C) Citrus fruit D)Red meat
A) Sweet pickles The patient with Ménière's disease should avoid foods high in salt and/or sugar; sweet pickles are high in both. Milk products are not contraindicated for the patient with Ménière's. Fresh citrus fruit is permitted. Any type of meat, fish, or poultry is permitted, with the exception of canned or pickled varieties. In general, the patient with Ménière's should avoid or limit canned and processed foods.
A nursing instructor is preparing a class on air and bone conduction of sound. When describing the transmission of sounds by air conduction, which of the following would the instructor include? A) Vibrations bypass the tympanic membrane to reach the inner ear. B) Sounds travel through the external and middle ears. C) It is a less efficient pathway for sound. D) Vibration of the tympanic membrane diverts sound away from the ossicles.
B) Sounds travel through the external and middle ears. Sounds transmitted by air conduction travel over the air-filled external and middle ear through vibration of the tympanic membrane and ossicles. Sounds transmitted by bone conduction travel directly through bone to the inner ear, bypassing the tympanic membrane and ossicles. Normally, air conduction is the more efficient pathway.
When communicating with a client who has sensory (receptive) aphasia, the nurse should: A) allow time for the client to respond. B) speak loudly and articulate clearly. C) give the client a writing pad. D) use short, simple sentences.
D) Use short, simple sentences Although sensory aphasia allows the client to hear words, it impairs the ability to comprehend their meaning. The nurse should use short, simple sentences to promote comprehension. Allowing time for the client to respond might be helpful but is less important than simplifying the communication. Because the client's hearing isn't affected, speaking loudly isn't necessary. A writing pad is helpful for clients with expressive, not receptive, aphasia.
A nursing instructor is teaching pre-nursing students in a pathophysiology class. What would the instructor teach the students about Ménière's disease? A) It is referred to as endolymphatic hydrops. B) It originates in the middle ear. C) It is referred to as lymphatic hydrops. D) It originates in the outer ear.
A) it is referred to as endolymphatic hydrops When a person moves his or her head, the endolymph also moves, and nerve receptors within the membranous labyrinth send signals to the brain about the movement. In Ménière's disease, an increase in endolymph causes the membranous labyrinth to dilate like a balloon; this is referred to as endolymphatic hydrops. Ménière's disease does not originate in either the middle or the outer ear, and it is not referred to as lymphatic hydrops.