Ch 48 medsurg question
A client has labyrinthitis and is prescribed antibiotics. What instruction by the nurse is most important for this client? a. Immediately report headache or stiff neck. b. Keep all follow-up appointments. c. Take the antibiotics with a full glass of water. d. Take the antibiotic on an empty stomach.
A; Meningitis is a complication of labyrinthitis. The client should be taught to take all antibiotics as prescribed and to report manifestations of meningitis such as fever, headache, or stiff neck. Keeping follow-up appointments is important for all clients. Without knowing what antibiotic was prescribed, the nurse cannot instruct the client on how to take it.
A client is scheduled to have a tumor of the middle ear removed. What teaching topic is most important for the nurse to cover? a. Expecting hearing loss in the affected ear b. Managing postoperative pain c. Maintaining NPO status prior to surgery d. Understanding which medications are allowed the day of surgery
A; Removal of an inner ear tumor will likely destroy hearing in the affected ear. The other teaching topics are appropriate for any surgical client.
The student nurse is performing a Weber tuning fork test. What technique is most appropriate? a. Holding the vibrating tuning fork 10 to 12 inches from the client's ear b. Placing the vibrating fork in the middle of the client's head c. Starting by placing the vibrating fork on the mastoid process d. Tapping the vibrating tuning fork against the bridge of the nose
B; The Weber tuning fork test includes placing the vibrating tuning fork in the middle of the client's head and asking in which ear the client hears the vibrations louder. The other techniques are incorrect.
What is the proper technique for assessing an adult client's ear with an otoscope? a. Hold the otoscope right side up when inserting it into the ear canal. b. Maintain distance between the otoscope and the client's head. c. Place the otoscope in the nondominant hand. d. Pull the pinna up and back with the nondominant hand.
d; Pull the pinna up and back with the non dominant hand
A client recently diagnosed with Ménière's disease is struggling with tinnitus. How does the nurse provide support to this client? a. Provide further assessment. b. Suggest a quiet environment. c. Suggest temporary removal of a hearing aid. d. Refer the client to the American Tinnitus Association.
d; Refer the client to the American Tinnitus Association
The nurse is teaching a client with vertigo about safety precautions for fall prevention. Which statement by the client indicates a need for further instruction? a. "I may need to use a cane." b. "I should keep my grandkids' toys out of the hallway." c. "Moving more slowly may help the vertigo subside." d. "Taking my medication will allow me to drive my car again."
d; Taking my medication will allow me to drive my car again
A client is having a stapedectomy. Which form of postoperative communication is most effective for the nurse to use? a. Gesturing b. Sign language c. Speaking d. Writing
d; Writing
An older adult in the family practice clinic reports a decrease in hearing over a week. What action by the nurse is most appropriate? a. Assess for cerumen buildup. b. Facilitate audiological testing. c. Perform tuning fork tests. d. Review the medication list.
A; All options are possible actions for the client with hearing loss. The first action the nurse should take is to look for cerumen buildup, which can decrease hearing in the older adult. If this is normal, medications should be assessed for ototoxicity. Further auditory testing may be needed for this client.
A nurse is teaching a community group about preventing hearing loss. What instruction is best? a. Always wear a bicycle helmet. b. Avoid swimming in ponds or lakes. c. Don't go to fireworks displays. d. Use a soft cotton swab to clean ears.
A; Avoiding head trauma is a practical way to help prevent hearing loss. Swimming can lead to hearing loss if the client has repeated infections. Fireworks displays are loud, but usually brief and only occasional. Nothing smaller than the client's fingertip should be placed in the ear canal.
A nurse is teaching a client about ear hygiene and health. What client statement indicates a need for further teaching? a. "A soft cotton swab is alright to clean my ears with." b. "I make sure my ears are dry after I go swimming." c. "I use good earplugs when I practice with the band." d. "Keeping my diabetes under control helps my ears."
A; Clients should be taught not to put anything larger than their fingertip into their ears. Using a cotton swab, although soft, can cause damage to the ears and cerumen buildup. The other statements are accurate.
A client is scheduled for a tympanoplasty. What actions by the nurse are most appropriate? (Select all that apply.) a. Administer preoperative antibiotics. b. Assess for allergies to local anesthetics. c. Ensure that informed consent is on the chart. d. Give ordered antivertigo medications. e. Teach that hearing improves immediately.
AC; Preoperatively, the nurse administers antibiotics and ensures that informed consent is on the chart. Local anesthetics can be used, but general anesthesia is used more often. Antivertigo medications are not used. Hearing will be decreased immediately after the operation until the ear packing is removed.
A client has severe tinnitus that cannot be treated adequately. What action by the nurse is best? a. Advise the client to take antianxiety medication. b. Educate the client on nerve cutting procedures. c. Refer the client to online or local support groups. d. Teach the client side effects of furosemide (Lasix).
C; If the client's tinnitus cannot be treated, he or she will have to learn to cope with it. Referring the client to tinnitus support groups can be helpful. The other options are not warranted.
The client's chart indicates a sensorineural hearing loss. What assessment question does the nurse ask to determine the possible cause? a. "Do you feel like something is in your ear?" b. "Do you have frequent ear infections?" c. "Have you been exposed to loud noises?" d. "Have you been told your ear bones don't move?"
C; Sensorineural hearing loss can occur from damage to the cochlea, the eighth cranial nerve, or the brain. Exposure to loud music is one etiology. The other questions relate to conductive hearing loss.
An older adult client reports ear pain. To differentiate the cause, which clinical manifestation is more indicative of otitis media? a. Dry, flaky cerumen b. Pain on movement of the tragus c. Ringing in the ears d. Dizziness
d; Dizziness
A client hospitalized for a wound infection has a blood urea nitrogen of 45 mg/dL and creatinine of 4.2 mg/dL. What action by the nurse is best? a. Assess the ordered antibiotics for ototoxicity. b. Explain how kidney damage causes hearing loss. c. Use ibuprofen (Motrin) for pain control. d. Teach that hearing loss is temporary.
A; Some medications are known to be ototoxic. Diminished kidney function slows the excretion of drugs from the body, worsening the ototoxic effects. The nurse should assess the antibiotics the client is receiving for ototoxicity. The other options are not warranted.
A client had a myringotomy. The nurse provides which discharge teaching? a. Buy dry shampoo to use for a week. b. Drink liquids through a straw. c. Flying is not allowed for 1 month. d. Hot water showers will help the pain.
A; The client cannot shower or get the head wet for 1 week after surgery, so using dry shampoo is a good suggestion. The other instructions are incorrect: straws are not allowed for 2 to 3 weeks, flying is not allowed for 2 to 3 weeks, and the client should not shower.
A client has a hearing aid. What care instructions does the nurse provide the unlicensed assistive personnel (UAP) in the care of this client? (Select all that apply.) a. Be careful not to drop the hearing aid when handling. b. Soak the hearing aid in hot water for 20 minutes. c. Turn the hearing aid off when the client goes to bed. d. Use a toothpick to clean debris from the device. e. Wash the device with soap and a small amount of warm water.
ACDE; All these actions except soaking the hearing aid are proper instructions for the nurse to give to the UAP. While some water is used to clean the hearing aid, excessive wetting should be avoided.
A nursing student studying the auditory system learns about the structures of the inner ear. What structures does this include? (Select all that apply.) a. Cochlea b. Epitympanum c. Organ of Corti d. Semicircular canals e. Vestibule
ACDE; The cochlea, organ of Corti, semicircular canals, and vestibule are all part of the inner ear. The epitympanum is in the middle ear.
An older adult client comes in for a routine visit. During the assessment he is irritable and says, "Speak up and quit mumbling!" How will the nurse respond? a. Apologizes and speaks louder and clearer b. Asks whether the client has a hearing loss c. Shout to ensure that the client can hear d. Suggests that the client move to a soundproof examination room to improve his hearing
a; Apologizes and speaks louder and clearer
Which test best determines hearing acuity? a. Audiometry b. Electronystagmography c. Otoscope d. Snellen test
a; Audiometry
Which type of hearing loss is most likely to be reversible when treated appropriately? a. Conductive hearing loss b. Sensorineural hearing loss c. Mixed conductive sensorineural hearing loss d. Central hearing loss
a; Conductive hearing loss
An older adult client reports ear pain. Otoscopic examination for otitis media by the nurse practitioner (NP) reveals a dull and retracted membrane. What does the NP do next? a. Continues further assessment b. Irrigates the ear c. Prescribes antibiotics for probable otitis media d. Tests hearing acuity
a; Continues further assessment
The nurse is performing an otoscopic examination of a client's ear and notes greenish white drainage. What does the nurse do next? a. Disposes of the otoscope tip and washes the hands before examining the other ear b. Reports the finding to the health care provider immediately c. Sends a specimen for culture d. Suctions out the drainage
a; Disposes of the otoscope tip and washes the hands before examining the other ear
The nurse is preparing a client for electronystagmography. Which statement by the client indicates that teaching was effective? a. "I can't drink caffeine 24 to 48 hours before the test." b. "I should drink more fluids 4 hours before the test." c. "I'll be placed in a soundproof booth for the test." d. "I'll be sedated for the test."
a; I can't drink caffeine 24-48 hours before the test
The nurse is teaching a client about ear protection. Which statement by the client indicates that teaching was effective? a. "I wear foam ear inserts at works where it is noisy." b. "I listen to music with foam ear inserts." c. "My ears ring after a rock concert, but it goes away." d. "The machinery is loud at work, but I get used to it."
a; I wear foam ear inserts at works where it is noisy
Which clients are at high risk for developing hearing problems? Select all that apply. a. Airline mechanic b. Client with Down syndrome c. Drummer in a rock band d. Teenager listening to music using ear buds e. Telephone operator
abcd;
Which technique is correct when instilling ear drops? a. Maintain the head in the same position for 2 minutes after instillation. b. Place the medication bottle in a bowl of warm water before instillation. c. Rinse the ear canal with hydrogen peroxide before instillation. d. Check to see whether the eardrum is intact before instillation.
b; Place the medication bottle of warm water before instillation
The nurse is teaching a client with impaired hearing about audiometric testing. Which statement by the nurse effectively communicates information about the procedure to the client? a. "Here is a picture of how the test is done. See how your bad ear will be tested first? You will be alone in the soundproof booth, so you will need to watch for lights flashing on and off as your cues." b. "Here is a video of the procedure. Please watch and feel free to ask me any questions." c. "I will sit right in front of you in the soundproof booth and give you instructions on what types of sounds you will hear and how you'll need to respond." d. "You will be in a soundproof booth and the sounds will be piped in. When you first hear the loudest sound, put your hand down. When you stop hearing the sound, put your hand up to stop."
c; "I will sit right in front of you in the soundproof booth and give you instructions on what types of sounds you will hear and how you'll need to respond."
The nurse is caring for a client who is admitted with mastoiditis. Which assessment data obtained by the nurse requires the most immediate action? a. The eardrum is red, thick appearing, and immobile. b. The lymph nodes are swollen and painful to touch. c. The client reports a headache and a stiff neck. d. The client's oral temperature is 100.1° F (37.8° C).
c; The client reports a headache and a stiff neck
The nurse has just received change of shift report about these clients. Which client needs to be assessed first? a. Client with Ménière's disease who is reporting severe nausea and is requesting an antiemetic b. Client who has had removal of an acoustic neuroma and has complete hearing loss on the surgical side c. Client with labyrinthitis who has a temperature of 102.4° F (39.1° C) and a headache d. Client who has acute otitis media and is reporting drainage from the affected ear
c; Client with labyrinthitis who has a temperature of 102.4° F (39.1° C) and a headache
Which type of drug therapy does the nurse anticipate giving to a client with Ménière's disease to decrease endolymph volume? a. Antihistamines b. Antipyretics c. Diuretics d. Nicotinic acid
c; Diuretics
An older adult client reports nausea during irrigation of the ear canal to remove impacted cerumen. What does the nurse do next? a. Administer an antiemetic. b. Call the health care provider. c. Stop irrigation immediately. d. Use less water to irrigate.
c; Stop the irrigation immediately
The nurse is assessing a client with recent changes in hearing. After taking a medication history, which drugs does the nurse identify as possible causes of the client's hearing change? Select all that apply. a. Acetaminophen (Tylenol) b. Beta blockers c. Erythromycin d. Ibuprofen (Advil) e. Insulin f. Furosemide (Lasix)
cdf;
The nurse is teaching a client who will soon be fitted for a hearing aid about proper care and use. Which statement by the client indicates that teaching was effective? a. "Background noises will be difficult for me to hear." b. "I should wear my hearing aid only to work at first." c. "I should just get a smaller hearing aid because I don't have much money." d. "Listening to the radio and television will help me get used to new sounds."
d; Listening to the radio and television will help me get use to new sounds
A client is in the immediate postoperative period after tympanoplasty. How does the nurse position the client? a. On the affected side b. Supine, with eyes toward the ceiling c. With the head elevated 60 degrees d. With the affected ear facing up
d; With the affected ear facing up
When preparing to examine an ear with drainage, what does the nurse do first? a. Begins testing at 1000 Hz b. Reassures the client that the ear drainage is normal c. Tilts the client's head away slightly d. Dons clean gloves
d; Dons clean gloves
The nurse is talking to a client about cerumen removal from the ear canal. Which statement by the client indicates a need for further teaching? a. "I dry my ears using my fingertip and a towel." b. "I may irrigate my ears with tap water." c. "I should not use an ear candle to soften the wax." d. "I use a cotton swab to remove earwax."
d; I use a cotton swab to remove earwax
The nurse is reviewing postoperative instructions with a client undergoing stapedectomy. Which statement by the client indicates a need for further teaching? a. "I may have problems with vertigo after the surgery." b. "I should not drink from a straw for several weeks." c. "I will have to take antibiotics after the surgery." d. "I will be able to hear as soon as my dressing is removed."
d; I will be able to hear as soon as my dressing is removed
A client has Ménière's disease with frequent attacks. About what drugs does the nurse plan to teach the client? (Select all that apply.) a. Broad-spectrum antibiotics b. Chlorpromazine hydrochloride (Thorazine) c. Diphenhydramine (Benadryl) d. Meclizine (Antivert) e. Nonsteroidal anti-inflammatory drugs (NSAIDs)
BCD; Drugs such as chlorpromazine, diphenhydramine, and meclizine can all be used to treat Ménière's disease. Antibiotics and NSAIDs are not used.
A client is scheduled for a stapedectomy in 2 weeks. What teaching instructions are most appropriate? (Select all that apply.) a. Avoid alcohol use before surgery. b. Blow the nose gently if needed. c. Clean the telephone often. d. Sneeze with the mouth open. e. Wash the external ear daily.
BCDE; It is imperative that the client having a stapedectomy is free from ear infection. Teaching includes ways to prevent such infections, such as blowing the nose gently, cleaning objects that come into contact with the ear, sneezing with the mouth open, and washing the external ear daily. Avoiding alcohol will not help prevent ear infections.
A client is admitted to the nursing unit after having a tympanoplasty. What activities does the nurse delegate to the unlicensed assistive personnel (UAP)? (Select all that apply.) a. Administer prescribed antibiotics. b. Keep the head of the client's bed flat. c. Remind the client to lie on the operative side. d. Remove the iodoform gauze in 8 hours. e. Take and record postoperative vital signs.
BE; The UAP can keep the head of the client's bed flat and take/record vital signs. The nurse administers medications. The client should lie flat with the head turned so the operative side is up. The nurse or surgeon removes the gauze packing.
A hospitalized client has Ménière's disease. What menu selections demonstrate good knowledge of the recommended diet for this disorder? (Select all that apply.) a. Chinese stir fry with vegetables b. Broiled chicken breast c. Chocolate espresso cookies d. Deli turkey sandwich and chips e. Green herbal tea with meals
BE; The diet recommendations for Ménière's disease include low-sodium, caffeine-free foods and fluids distributed evenly throughout the day. Plenty of water is also needed. The broiled chicken breast and herbal tea are the best selections. The stir fry is high in sodium and possibly monosodium glutamate (MSG, also not recommended). The cookies have caffeine, and the sandwich and chips are high in sodium.
A client has external otitis. On what comfort measure does the nurse instruct the client? a. Applying ice four times a day b. Instilling vinegar-and-water drops c. Use of a heating pad to the ear d. Using a home humidifier
C; A heating pad on low or a warm moist pack can provide comfort to the client with otitis externa. The other options are not warranted.
A client with Ménière's disease is in the hospital when the client has an attack of this disorder. What action by the nurse takes priority? a. Assess vital signs every 15 minutes. b. Dim or turn off lights in the client's room. c. Place the client in bed with the upper siderails up. d. Provide a cool, wet cloth for the client's face.
C; Clients with Ménière's disease can have vertigo so severe that they can fall. The nurse should assist the client into bed and put the siderails up to keep the client from falling out of bed due to the intense whirling feeling. The other actions are not warranted for clients with Ménière's disease.
The nurse works with clients who have hearing problems. Which action by a client best indicates goals for an important diagnosis have been met? a. Babysitting the grandchildren several times a week b. Having an adaptive hearing device for the television c. Being active in community events and volunteer work d. Responding agreeably to suggestions for adaptive devices
C; Clients with hearing problems can become frustrated and withdrawn. The client who is actively engaged in the community shows the best evidence of psychosocial adjustment to hearing loss. Babysitting the grandchildren is a positive sign but does not indicate involvement outside the home. Having an adaptive device is not the same as using it, and watching TV without evidence of other activities can also indicate social isolation. Responding agreeably does not indicate the client will actually follow through.
A nurse is teaching a community group about noise-induced hearing loss. Which client who does not use ear protection should the nurse refer to an audiologist as the priority? a. Client with an hour car commute on the freeway each day b. Client who rides a motorcycle to work 20 minutes each way c. Client who sat in the back row at a rock concert recently d. Client who is a tree-trimmer and uses a chainsaw 6 to 7 hours a day
D; A chainsaw becomes dangerous to hearing after 2 hours of exposure without hearing protection. This client needs to be referred as the priority. Normal car traffic is safe for more than 8 hours. Motorcycle noise is safe for about 8 hours. The safe exposure time for a front-row rock concert seat is 3 minutes, but this client was in the back, and so had less exposure. In addition, a one-time exposure is less damaging than chronic exposure.
A nurse is irrigating a client's ear when the client becomes nauseated. What action by the nurse is most appropriate for client comfort? a. Have the client tilt the head back. b. Re-position the client on the other side. c. Slow the rate of the irrigation. d. Stop the irrigation immediately.
D; During ear irrigation, if the client becomes nauseated, stop the procedure. The other options are not helpful.
A client is going on a cruise but has had motion sickness in the past. What suggestion does the nurse make to this client? a. Avoid alcohol on the cruise ship. b. Change positions slowly on the ship. c. Change your travel plans. d. Try scopolamine (Transderm Scop).
D; Scopolamine can successfully treat the vertigo and dizziness associated with motion sickness. Avoiding alcohol and changing positions slowly are not effective. Telling the client to change travel plans is not a caring suggestion.
A nursing student is instructed to remove a client's ear packing and instill eardrops. What action by the student requires intervention by the registered nurse? a. Assessing the eardrum with an otoscope b. Inserting a cotton ball in the ear after the drops c. Warming the eardrops in water for 5 minutes d. Washing the hands and removing the packing
D; The student should wash his or her hands, don gloves, and then remove the packing. The other actions are correct.