Med-Surge 1 Neuro PrepU

A nurse is asked to assess a patient's need for a hearing aid. The nurse knows that a general guideline to determine need would be a hearing loss of:

40 dB in the range of 500 to 2,000 Hz. A general guideline for assessing the patient's need for a hearing aid is a hearing loss exceeding 30 dB in the range of 500 to 2,000 Hz (units of cycles/second).

A patient has been diagnosed with a fungal infection causing external otitis. What is the most common fungal infection in the ear?

Aspergillus The most common bacterial pathogens associated with external otitis are Staphylococcus aureus and Pseudomonas species. The most common fungus isolated in both normal and infected ears is Aspergillus (Porth & Matfin, 2009).

A 45-year-old client presents to the ED reporting trouble speaking and numbness of the right arm and leg. The nurse suspects an ischemic stroke. Which insult or abnormality can cause an ischemic stroke?

Cocaine use Two classifications of ischemic strokes are cryptogenic strokes, which have no known cause, and strokes from other causes, such as illicit drug use, coagulopathies, migraine, and spontaneous dissection of the carotid or vertebral arteries. Cocaine is a potent vasoconstrictor and may result in a life-threatening reaction, even with the individual's first use of the drug. Arteriovenous malformations, trauma, and intracerebral aneurysm are associated with hemorrhagic strokes.

When providing teaching to a client who reports tension headaches, which of the following instructions would be most beneficial to prevent onset of symptoms?

Perform stretching exercises and frequent position change. Tension headaches are often associated with prolonged tensed muscles. Application of cool or warm cloths and avoidance of bright lights may help to reduce the headache after occurrence. Avoiding certain foods may prevent migraine headaches, but it is not likely to prevent tension headaches.

A diabetic patient is scheduled for surgery for repair of a detached retina that was caused by proliferative retinopathy. The nurse prepared the patient for surgery, aware that the type of detachment is most likely classified as which of the following?

Rhegmatogenous Rhegmatogenous detachment is the most common form of retinal detachment. In this condition, a hole or tear develops in the sensory retina, allowing some of the liquid vitreous to seep through the sensory retina and detach it from the retinal pigment epithelium.

A critical care nurse is documenting the assessment of a client. The client is status postresection of a brain tumor. The nurse documents that the client is flaccid on the left. This means that the client:

is not responding to stimuli. Flaccidity is when the client makes no motor response to stimuli. Flaccidity is a motor assessment.

A client is prescribed sumatriptan for the treatment of migraine headache. Which client statement would indicate a need for additional teaching from the nurse?

"I use this to prevent migraines." Sumatriptan is a serotonin receptor agonist that stimulates serotonin receptors in the brain and causes vasoconstriction of the cerebral arteries and reduce/eliminate headaches and other symptoms associated with migraines. Sumatriptan is used during an attack and is not indicated for preventative migraine therapy.

The nurse is teaching the client with Meniere's disease about controlling symptoms through diet. Which of the following would the nurse emphasize? Select all that apply.

Avoid foods high in sugar. Maintain hydration. Read labels carefully for sodium content. Limit intake of caffeinated beverages Most clients with Meniere's disease can be successfully treated through nutritional measures, such as adhering to a low-sodium diet to assist in regulating the delicate balance between the endolymph and perilymph in the inner ear. Therefore, the nurse should encourage the client to limit the amount of canned, frozen, and processed foods, substituting fresh fruits, fresh vegetables, and whole grains. Hydration is important, so the client should drink water, milk, and low-sugar fruit juices, avoiding caffeinated fluids because of the diuretic effect of caffeine. Clients also should limit foods high in sugar and read labels carefully to identify foods with hidden salts and sugars.

The nurse is caring for an older adult client who is frail in appearance. The client has been diagnosed with glaucoma and will be started on eye drops for the condition. Which medication would cause the nurse to call the health care provider before administering the first dose?

Brimonidine (Alphagan-P) Brimonidine should be used with caution in frail elderly clients because it may cause confusion.

The nurse is caring for a client with a traumatic brain injury and experiencing increased intracranial pressure. The nurse has administered mannitol, an osmotic diuretic, as ordered. This medication promotes the shift of fluid from the intracellular to the intravascular compartment. Therefore, it is necessary for the nurse to continually assess for which of the following?

Heart failure

The client in the ED has just had a diagnostic lumbar puncture. To reduce the incidence of a postlumbar puncture headache, what is the nurse's most appropriate action?

Position the client prone. The lumbar puncture headache may be avoided if a small-gauge needle is used and if the client remains prone after the procedure. Acetaminophen is not given as a preventative measure for postlumbar puncture headaches.

While reviewing the health history of an older adult experiencing hearing loss the nurse notes the client has had no trauma or loss of balance. What aspect of this client's health history is most likely to be linked to the client's hearing deficit?

Routine use of quinine for management of leg cramps Long-term, regular use of quinine for management of leg cramps is associated with loss of hearing acuity. Radiation therapy for cancer should not affect hearing; however, hearing can be significantly compromised by chemotherapy. Allergy to hair products may be associated with otitis externa; however, it is not linked to hearing loss. An ear drum that perforates spontaneously due to the sudden drop in altitude associated with a high dive usually heals well and is not likely to become infected. Recurrent otitis media with perforation can affect hearing as a result of chronic inflammation of the ossicles in the middle ear

The home health nurse is caring for a client with Parkinson's disease. The nurse understands that the purpose of adding selegiline with carbidopa-levodopa to the medication regime should result in which purpose?

Slows the progression of the disease Selegiline increases dopaminergic activity and slows the progression of the disease. Carbidopa-levodopa is a dopamine replacement drug. Anticholinergic drugs are used to reduce the symptoms of dyskinesia and other side effects.

As a member of the stroke team, the nurse knows that thrombolytic therapy carries the potential for benefit and for harm. The nurse should be cognizant of what contraindications for thrombolytic therapy? Select all that apply.

Symptom onset greater than 3 hours prior to admission Recent intracranial pathology Current anticoagulation therapy Some of the absolute contraindications for thrombolytic therapy include symptom onset greater than 3 hours before admission, a client who is anticoagulated (with an INR above 1.7), or a client who has recently had any type of intracranial pathology (e.g., previous stroke, head injury, trauma).

A client has impacted cerumen in the left ear. Which of the following would be appropriate to use to help dislodge the cerumen? Select all that apply.

Tap water Half-strength hydrogen peroxide Mineral oil To remove impacted cerumen, the external auditory ear canal can be irrigated gently with warmed tap water using the lowest effective pressure. Additionally, a few drops of warmed glycerin, mineral oil, or half-strength peroxide can be instilled into the canal for 30 minutes to soften cerumen before its removal. A moistened cotton-tipped applicator should not be used; it can push the cerumen further in the ear, become a foreign body, or cause trauma to the canal. Antibiotic solution is not necessary to remove impacted cerumen.

A nurse is preparing a client for a lumbar puncture and informs the client that the needle will be inserted into the subarachnoid space between L3 and L4 or L4 and L5. The client reports that she is worried about damage to her spinal cord. The appropriate response from the nurse is which of the following?

"The spinal cord ends at L1, so puncturing it is not possible." The needle is usually inserted into the subarachnoid space between the 3rd and 4th or 4th and 5th lumbar vertebrae. Because the spinal cord ends at the 1st lumbar vertebra, insertion of the needle below the level of the 3rd lumbar vertebra prevents puncture of the spinal cord.

You are admitting a client with an acoustic neuroma to your unit. What would you include during the assessment of this client?

Test for facial sensation. The assessment of a client with an acoustic neuroma includes evaluating hearing function, observing the client's facial movements, and testing for facial sensation. The client's urine output, height and weight, and ability to sustain balance, though important, are not as essential as testing for facial sensation.

The nurse is caring for a client with symptoms of ototoxicity from aminoglycoside administration. On which structure does the medication produce the ototoxic effect?

The eighth cranial nerve Ototoxicity describes the detrimental effect of aminoglycosides on the eighth cranial nerve. Signs and symptoms include tinnitus and sensorineural hearing. The other options are not related to the ototoxic effects.

What should the nurse recommend to a client with blepharitis?

frequent washing of the face and hair Frequent washing of the face and hair is recommended in a client with blepharitis because seborrhea or excessive oiliness of the skin of the face and scalp is associated with blepharitis. Warm soaks would be included for treatment of a sty. There is no benefit to sleeping with the face parallel to the floor.

Which type of hearing loss is most likely to be caused by frequent ear infections?

sensorineural Sensorineural hearing loss includes such etiologies as atherosclerosis, a tumor of the vestibulocochlear nerve, infections, and drug toxicity. Conductive hearing loss is more commonly caused by obstructions. Tinnitus is a symptom, not a cause of hearing loss.