Adv. Med. Surg. Saunders Questions & Rationales:

The nurse is caring for a client diagnosed with trigeminal neuralgia. The client asks the nurse, "Why do I have so much pain?" Which is the appropriate response by the nurse?

"Pain is due to stimulation of the affected nerve by pressure and temperature." The paroxysms of pain that accompany this neuralgia are triggered by stimulation of the terminal branches of the trigeminal nerve. Symptoms can be triggered by pressure from washing the face, brushing the teeth, shaving, eating, or drinking. Symptoms also can be triggered by thermal stimuli, such as a draft of cold air.

A client with glaucoma is receiving acetazolamide. The nurse educator provides education to a group of nurses about the indications for and effect of this medication. Which statement by one of the nurses indicates that the teaching has been effective?

"This medication works to decrease intraocular pressure." Acetazolamide is a carbonic-anhydrase inhibitor used to treat glaucoma. The medication decreases the formation of aqueous humor. The statements in the remaining options are not indicative of the purpose of this medication.

The nurse educator is conducting an in-service education session for the nurses employed in the eye and ear surgical unit of a large trauma center. In discussing the topic of cochlear implants, the educator notes that this surgical procedure is contraindicated in which client?

A client who became deaf before learning to speak; Adults who were born deaf or became deaf before learning to speak usually are not candidates for this type of surgery. Criteria for a cochlear implant procedure are bilateral profound hearing loss, use of speech as the primary mode of communication, lack of benefit from conventional hearing aids, evidence of strong family and social support, and realistic client expectations for the outcome of the implant procedure.

The nurse instructs a client in the use of a hearing aid. The nurse should include which instruction?

Check the battery to ensure that it is working before use; The battery of the hearing aid should be checked before use. The hearing aid should be removed for showering because it should not get excessively wet. It also should be put away in its case at night. It should be cleaned according to the manufacturer's directions, which usually consist of cleaning the ear mold with mild soap and water (avoiding excessive wetness), followed by thorough drying. Lubricants or other solvents are not used on the hearing aid.

A client reports frequent use of acetaminophen for relief of headaches and other discomforts. The nurse should evaluate which diagnostic data to determine if the client is at risk for toxicity?

Liver function studies; In adults, overdose of acetaminophen causes liver damage. In addition, clients with liver disorders are at a higher risk of experiencing hepatotoxicity with chronic acetaminophen use.

When teaching a client with glaucoma about the effects of a miotic medication, the nurse should tell the client that the medication will produce which effect?

Lower intraocular pressure and improve blood flow to the retina; Miotics are used to lower the intraocular pressure, which then increases blood flow to the retina. This in turn decreases retinal damage and loss of vision. Miotics cause a contraction or constriction of the ciliary muscle and widen the trabecular meshwork.

The nurse is caring for a client with a head injury. The client's intracranial pressure reading is 8 mm Hg. Which condition should the nurse document?

The intracranial pressure reading is normal; The normal intracranial pressure is 5 to 15 mm Hg. A pressure of 8 mm Hg is within normal range.

A client is prescribed an eye drop and an eye ointment for the right eye. How should the nurse best administer the medications?

Administer the eye drop first, followed by the ointment; When an eye drop and an eye ointment are scheduled to be administered at the same time, the eye drop is administered first. The instillation of two medications is separated by 3 to 5 minutes.

A client has a neurological deficit involving the limbic system. On assessment, which finding is specific to this type of deficit?

Affect is flat, with periods of emotional lability; The limbic system is responsible for feelings (affect) and emotions. Calculation ability and knowledge of current events relate to function of the frontal lobe. The cerebral hemispheres, with specific regional functions, control orientation. Recall of recent events is controlled by the hippocampus.

A client is diagnosed with glaucoma. Which piece of nursing assessment data identifies a risk factor associated with this eye disorder?

Cardiovascular disease; Hypertension, cardiovascular disease, diabetes mellitus, and obesity are associated with the development of glaucoma.

The nurse is creating a plan of care for a client with a stroke (brain attack) who has global aphasia. The nurse should incorporate communication strategies into the plan of care because of which expected characteristic of the client's speech?

Associated with poor comprehension; Global aphasia is a condition in which the affected person has few language skills as a result of extensive damage to the left hemisphere. The speech is nonfluent and is associated with poor comprehension and limited ability to name objects or repeat words. The client with conduction aphasia has difficulty repeating words spoken by another, and speech is characterized by literal paraphasia with intact comprehension. The client with Wernicke's aphasia may exhibit a rambling type of speech.

A client recovering from a head injury is participating in care. The nurse determines that the client understands measures to prevent elevations in intracranial pressure if the nurse observes the client doing which activity?

Exhaling during repositioning; Activities that increase intrathoracic and intraabdominal pressures cause an indirect elevation of the intracranial pressure. Some of these activities include isometric exercises, Valsalva's maneuver, coughing, sneezing, and blowing the nose. Exhaling during activities such as repositioning or pulling up in bed opens the glottis, which prevents intrathoracic pressure from rising.

The nurse is developing a teaching plan for a client with glaucoma. Which instruction should the nurse include in the plan of care?

Eye medications will need to be administered for life; The administration of eye drops is a critical component of the treatment plan for the client with glaucoma. The client needs to understand that these medications will need to be taken for the rest of their lives.

The nurse in the neurological unit is caring for a client with a supratentorial lesion. The nurse assesses which measurement as the most critical index of central nervous system (CNS) dysfunction?

Level of consciousness; Level of consciousness is the most critical index of CNS dysfunction. Changes in level of consciousness can indicate clinical improvement or deterioration. Although blood pressure, temperature, and ability to speak may be components of the assessment, the client's level of consciousness is the most critical index of CNS dysfunction.

A client is about to undergo a lumbar puncture. The nurse describes to the client that which position will be used during the procedure?

Side-lying with the legs pulled up and the head bent down onto the chest; A client undergoing lumbar puncture is positioned lying on the side, with the legs pulled up to the abdomen and the head bent down onto the chest. This position helps to open the spaces between the vertebrae and allows for easier needle insertion by the health care provider. The nurse remains with the client during the procedure to help the client maintain this position.

A client is taking the prescribed dose of phenytoin to control seizures. Results of a phenytoin blood level study reveal a level of 35 mcg/mL (140 mcmol/L). Which finding would be expected as a result of this laboratory result?

Slurred speech; The therapeutic phenytoin level is 10 to 20 mcg/mL (40 to 79 mcmol/L). At a level higher than 20 mcg/mL, involuntary movements of the eyeballs (nystagmus) occur. At a level higher than 30 mcg/mL (120 mcmol/L), ataxia and slurred speech occur.

During routine nursing assessment after hypophysectomy, a client complains of thirst and frequent urination. Knowing the expected complications of this surgery, what should the nurse assess next?

urine specific gravity; After hypophysectomy, temporary diabetes insipidus can result from antidiuretic hormone deficiency. This deficiency is related to surgical manipulation. The nurse should assess urine specific gravity and notify the health care provider if the result is less than 1.005.

A preoperative client is scheduled for adrenalectomy to remove a pheochromocytoma. The nurse would most closely monitor which item in the preoperative period?

vital signs; Hypertension is the hallmark symptom of pheochromocytoma. Severe hypertension can precipitate a stroke (brain attack) or sudden blindness. Although all of the items are appropriate nursing assessments for the client with pheochromocytoma, the priority is to monitor the vital signs, especially the blood pressure.

The nurse is performing an assessment on a client with a diagnosis of thrombotic stroke (brain attack). Which assessment question would elicit data specific to this type of stroke?

"Have you had any numbness or tingling or paralysis-type feelings in any of your extremities recently?" Cerebral thrombosis (thrombotic stroke) does not occur suddenly. In the few days or hours preceding the thrombotic stroke, the client may experience a transient loss of speech, hemiparesis, or paresthesias on 1 side of the body. Signs and symptoms of this type of stroke vary but may also include dizziness, cognitive changes, or seizures. Headache is rare, but some clients with stroke experience signs and symptoms similar to those of cerebral embolism or intracranial hemorrhage. The client does not complain of difficulty with night vision as part of this clinical problem. In addition, most clients do not have repeated episodes of loss of consciousness.

A nurse is assessing a client who has had cranial surgery and is at risk for development of diabetes insipidus. The nurse would assess for which signs or symptoms that could indicate development of this complication?

Polydipsia; Polydipsia and polyuria are classic symptoms of diabetes insipidus. The urine is pale, and the specific gravity is low. Diarrhea is not indicative of the complication. Infection is not associated with diabetes insipidus. Anorexia and weight loss also may occur.

The nurse is caring for a client who has been taking hydrocodone for the last 3 months. For which side and adverse effects of this medication should the nurse assess the client?

Psychological and physical dependence; Hydrocodone is an opioid analgesic that also has antitussive properties. Side and adverse effects of this medication include physical and psychological dependence, bradycardia and hypotension, respiratory depression, nausea, vomiting, constipation, sedation, and confusion.

The nurse is teaching a mother to instill drops in her infant's ear. The nurse explains that to give the ear drops correctly, the mother needs to take which action?

Pull down and back on the earlobe and direct the solution toward the wall of the canal; The infant should be turned onto the side, with the affected ear uppermost. With the wrist of the nondominant hand resting on the infant's head, the mother pulls down and back on the earlobe and aims the solution at the wall of the canal, rather than directly onto the eardrum. In the adult, the auricle is pulled up and back to straighten the auditory canal.

The student nurse develops a plan of care for a client after a lumbar puncture. The nursing instructor corrects the student if the student documents which incorrect intervention in the plan?

Restrict fluid intake for a period of 2 hours; After the lumbar puncture the client remains flat in bed for at least 2 hours, depending on the health care provider's prescriptions. A liberal fluid intake is encouraged to replace the cerebrospinal fluid removed during the procedure, unless contraindicated by the client's condition. The nurse checks the puncture site for redness and drainage and assesses the client's ability to void and move the extremities.

The nurse is performing an assessment on a client with a suspected diagnosis of cataract. Which clinical manifestation should the nurse expect to note in the early stages of cataract formation?

Blurred vision; A gradual, painless blurring of central vision is the chief clinical manifestation of a cataract. Early symptoms include slightly blurred vision and a decrease in color perception.

A mother arrives at the emergency department with her 5-year-old child and states that the child fell off a bunk bed. A head injury is suspected. The nurse checks the child's airway status and assesses the child for early and late signs of increased intracranial pressure (ICP). Which is a late sign of increased ICP?

Bradycardia; Head injury is the pathological result of any mechanical force to the skull, scalp, meninges, or brain. A head injury can cause bleeding in the brain and result in increased ICP. In a child, early signs include a slight change in level of consciousness, headache, nausea, vomiting, visual disturbances (diplopia), and seizures. Late signs of increased ICP include a significant decrease in level of consciousness, bradycardia, decreased motor and sensory responses, alterations in pupil size and reactivity, posturing, Cheyne-Stokes respirations, and coma.

The nurse is planning to put aneurysm precautions in place for a client with a cerebral aneurysm. Which nursing measures would be implemented? Select all that apply.

-Provide physical aspects of care -Avoid pushing or straining activities -Maintain the head of the bed at 15 degrees Aneurysm precautions include placing the client on bed rest (as prescribed) in a quiet setting. Stimulants such as caffeine and nicotine are prohibited; decaffeinated coffee or tea may be used. Lights are kept dim to minimize environmental stimulation. Any activity that increases the blood pressure or impedes venous return from the brain is prohibited, such as pushing, pulling, sneezing, coughing, or straining. The nurse provides physical care to minimize increases in blood pressure. For the same reason, visitors, radio, television, and reading materials are prohibited or limited.

The nurse is assigned to care for a client with complete right-sided hemiparesis from a stroke (brain attack). Which characteristics are associated with this condition? Select all that apply.

-The client is aphasic -The client has weakness on the right side of the body -The client has weakness on the right side of the face and tongue Hemiparesis is a weakness of one side of the body that may occur after a stroke. It involves weakness of the face and tongue, arm, and leg on one side. These clients are also aphasic: unable to discriminate words and letters. They are generally very cautious and get anxious when attempting a new task. Complete bilateral paralysis does not occur in hemiparesis. The client with right-sided hemiparesis has weakness of the right arm and leg and needs assistance with feeding, bathing, and ambulating.

The nurse is assisting the neurologist in performing an assessment on a client who is unconscious after sustaining a head injury. The nurse understands that the neurologist would avoid performing the oculocephalic response (doll's eyes maneuver) if which condition is present in the client?

A cervical cord injury; In an unconscious client, eye movements are an indication of brainstem activity and are tested by the oculocephalic response. When the doll's eyes maneuver is intact, the eyes move in the opposite direction when the head is turned. Abnormal responses include movement of the eyes in the same direction as that for the head and maintenance of a midline position of the eyes when the head is turned. An abnormal response indicates a disruption in the processing of information through the brainstem. Contraindications to performing this test include cervical-level spinal cord injuries and severely increased intracranial pressure.

A client was just admitted to the hospital to rule out a gastrointestinal (GI) bleed. The client has brought several bottles of medications prescribed by different specialists. During the admission assessment, the client states, "Lately, I have been hearing some roaring sounds in my ears, especially when I am alone." Which medication would the nurse identify as the cause of the client's complaint?

Acetylsalicylic acid; Aspirin is contraindicated for GI bleeding and is potentially ototoxic. The client should be advised to notify the prescribing health care provider so the medication can be discontinued and/or a substitute that is less toxic to the ear can be taken instead.

The nurse caring for a client who underwent intracranial surgery is suspected of having diabetes insipidus. Which finding noted by the nurse is consistent with this complication of surgery?

Complaints of excessive thirst; Diabetes insipidus results from insufficient antidiuretic hormone (ADH) production, which in this case was caused by the intracranial surgery. Findings associated with diabetes insipidus include greatly increased urine output, low urine specific gravity (<1.005), hypotension, signs of dehydration, increased plasma osmolarity, increased thirst, and output that does not decrease when fluid intake decreases. A complaint of thirst is the only option consistent with diabetes insipidus.

The nurse is caring for a client who has undergone a craniotomy and has a supratentorial incision. The nurse should place the client in which position postoperatively?

Head of bed elevated 30 to 45 degrees, head and neck midline; After supratentorial surgery, the head is kept at a 30- to 45-degree angle. The head and neck should not be angled either anteriorly or laterally but rather should be kept in a neutral (midline) position. This promotes venous return through the jugular veins, which will help prevent a rise in intracranial pressure.

Members of the family of an unconscious client with increased intracranial pressure are talking at the client's bedside. They are discussing the client's condition and wondering whether the client will ever recover. The nurse intervenes on the basis of which interpretation?

It is possible the client can hear the family; Some clients who have awakened from an unconscious state have remembered hearing specific voices and conversations. Family and staff should assume that the client's sense of hearing is intact and act accordingly. In addition, positive outcomes are associated with coma stimulation-that is, speaking to and touching the client.

The nurse is preparing to care for a client after a lumbar puncture. The nurse should plan to place the client in which best position following the procedure?

Prone with a small pillow under the abdomen; After the procedure, the client assumes a flat position. If the client is able, a prone position with a pillow under the abdomen is the best position. This position helps reduce cerebrospinal fluid leakage and decreases the likelihood of post-lumbar puncture headache.

The nurse is reviewing a discharge teaching plan for a postcraniotomy client that was prepared by a nursing student. The nurse would intervene and provide teaching to the student if the student included which home care instruction?

Sounds will not be heard clearly unless they are loud; The postcraniotomy client typically is sensitive to loud noises and can find them excessively irritating. Control of environmental noise by others will be helpful for this client. Seizures are a potential complication that may occur for up to 1 year after surgery. For this reason, the client must diligently take anticonvulsant medications. The client and family are encouraged to keep track of the doses administered. The family should learn seizure precautions and should accompany the client during ambulation if dizziness or seizures tend to occur. The suture line is kept dry until sutures are removed to prevent infection.

The nurse is reviewing the medical records of a client admitted to the nursing unit with a diagnosis of a thrombotic brain attack (stroke). The nurse would expect to note that which is documented in the assessment data section of the record?

The client experienced paresthesias a few days before admission to the hospital; Cerebral thrombosis does not occur suddenly. In the few hours or days preceding a thrombotic brain attack (stroke), the client may experience a transient loss of speech, hemiplegia, or paresthesias on 1 side of the body. Signs and symptoms of thrombotic brain attack (stroke) vary but may include dizziness, cognitive changes, or seizures. Headache is rare, but some clients with stroke (brain attack) experience signs and symptoms similar to those of cerebral embolism or intracranial hemorrhage.

The nurse is creating a plan of care for a client with a diagnosis of stroke (brain attack). On reviewing the client's record, the nurse notes an assessment finding of anosognosia. The nursing care plan should address which manifestation related to this finding?

The client will exhibit neglect of the affected side; In anosognosia, the client neglects the affected side of the body. The client either may ignore the presence of the affected side (often creating a safety hazard as a result of potential injuries) or may state that the involved arm or leg belongs to someone else. The remaining options are not associated with anosognosia.

The nurse has instructed the family of a client with stroke (brain attack) who has homonymous hemianopsia about measures to help the client overcome the deficit. Which statement suggests that the family understands the measures to use when caring for the client?

"We need to remind him to turn his head to scan the lost visual field." Homonymous hemianopsia is loss of half of the visual field. The client with homonymous hemianopsia should have objects placed in the intact field of vision, and the nurse also should approach the client from the intact side. The nurse instructs the client to scan the environment to overcome the visual deficit and does client teaching from within the intact field of vision. The nurse encourages the use of personal eyeglasses, if they are available.

The nurse has just admitted to the nursing unit a client with a basilar skull fracture who is at risk for increased intracranial pressure. Pending specific health care provider prescriptions, the nurse should safely place the client in which positions? Select all that apply.

-Head midline -Neck in neutral position -Head of the bed elevated 30 to 45 degrees Use of proper positions promotes venous drainage from the cranium to keep intracranial pressure from elevating. The head of the client at risk for or with increased intracranial pressure should be positioned so that it is in a neutral, midline position. The head of the bed should be raised to 30 to 45 degrees. The nurse should avoid flexing or extending the client's neck or turning the client's head from side to side.

The nurse is caring for a client who begins to experience seizure activity while in bed. Which actions should the nurse take? Select all that apply.

-Loosening restrictive clothing -Removing the pillow and raising the padded side rails -Positioning the client to the side, if possible, with the head flexed forward Nursing actions during a seizure include providing for privacy, loosening restrictive clothing, removing the pillow and raising padded side rails in the bed, and placing the client on one side with the head flexed forward, if possible, to allow the tongue to fall forward and facilitate drainage. The limbs are never restrained because the strong muscle contractions could cause the client harm. If the client is not in bed when seizure activity begins, the nurse lowers the client to the floor, if possible; protects the head from injury; and moves furniture that may injure the client.

The nurse develops a plan of care for a client with a brain aneurysm who will be placed on aneurysm precautions. Which interventions should be included in the plan? Select all that apply.

-Place a blood pressure cuff at the patient's bedside -Close the shades in the client's room during the day Aneurysm precautions include placing the client on bed rest in a quiet setting. The use of lights is kept to a minimum to prevent environmental stimulation. The nurse should monitor the blood pressure and note any changes that could indicate rupture. Any activity, such as pushing, pulling, sneezing, or straining, that increases the blood pressure or impedes venous return from the brain is prohibited. The nurse provides physical care to minimize increases in blood pressure. Visitors, radio, television, and reading materials are restricted or limited. Stimulants, such as nicotine and coffee and other caffeine-containing products, are prohibited. Decaffeinated coffee or tea may be used.

Which findings should raise suspicion to the nurse that a head-injured client may be experiencing diabetes insipidus? Select all that apply.

-Urine specific gravity is 1.001 -Serum osmolality is 320 mOsm/kg (320 mmol/kg) of water. -Urine output has increased from 1000 mL in 24 hours to 4000 mL in 24 hours. Signs of diabetes insipidus include low urine specific gravity (<1.005), high serum osmolality (>300 mOsm/kg of water), and increased urine output from a deficiency of antidiuretic hormone (ADH). Options 2, 3, and 5 are not characteristic of diabetes insipidus.

The nurse is reviewing the postoperative prescriptions for a client who had a transsphenoidal hypophysectomy. Which health care provider's (HCP's) prescriptions, if noted on the record, would indicate the need for clarification?

Apply a loose dressing if any clear drainage is noted; The nurse should observe for clear nasal drainage; constant swallowing; and a severe, persistent, generalized, or frontal headache. These signs and symptoms indicate cerebrospinal fluid leak into the sinuses. If clear drainage is noted after this procedure, the HCP needs to be notified. Therefore, clarification is needed regarding application of a loose dressing.

The nurse in the neurological unit is monitoring a client for signs of increased intracranial pressure (ICP). The nurse reviews the assessment findings for the client and notes documentation of the presence of Cushing's reflex. The nurse determines that the presence of this reflex is obtained by assessing which item?

Blood pressure; Cushing's reflex is a late sign of increased ICP and consists of a widening pulse pressure (systolic pressure rises faster than diastolic pressure) and bradycardia.

A client is admitted to the hospital with a diagnosis of pheochromocytoma. The nurse would check which item to detect the primary manifestation of this disorder?

Blood pressure; Hypertension is the major symptom associated with pheochromocytoma and is assessed by taking the client's blood pressure. Glycosuria, weight loss, and diaphoresis are other clinical manifestations of pheochromocytoma; however, hypertension is the major symptom.

The nurse in the neurological unit is caring for a client who was in a motor vehicle crash and sustained a blunt head injury. On assessment of the client, the nurse notes the presence of bloody drainage from the nose. Which nursing action is most appropriate?

Contact the HCP; Bloody or clear drainage from either the nasal or the auditory canal after head trauma could indicate a cerebrospinal fluid leak. The appropriate nursing action is to notify the HCP, because this finding requires immediate intervention.

The nurse is caring for a client who sustained a spinal cord injury. During administration of morning care, the client begins to exhibit signs and symptoms of autonomic dysreflexia. Which initial nursing action should the nurse take?

Elevate the head of the bed; Autonomic dysreflexia is a serious complication that can occur in the spinal cord-injured client. Once the syndrome is identified, the nurse elevates the head of the client's bed and then examines the client for the source of noxious stimuli. The nurse also assesses the client's blood pressure, but the initial action would be to elevate the head of the bed. The client would not be placed in the prone position; lying flat will increase the client's blood pressure.

The nurse is evaluating the neurological signs of a client in spinal shock following spinal cord injury. Which observation indicates that spinal shock persists?

Flaccid paralysis; Resolution of spinal shock is occurring when there is return of reflexes (especially flexors to noxious cutaneous stimuli), a state of hyperreflexia rather than flaccidity, and reflex emptying of the bladder.

The nurse is assessing the nasal dressing on a client who had a transsphenoidal resection of the pituitary gland. The nurse notes a small amount of serosanguineous drainage that is surrounded by clear fluid on the nasal dressing. Which nursing action is most appropriate?

Notify the HCP; Cerebrospinal fluid (CSF) leakage after cranial surgery may be detected by noting drainage that is serosanguineous surrounded by an area of straw-colored or pale drainage. The physical appearance of CSF drainage is that of a halo. If the nurse notes the presence of this type of drainage, the HCP needs to be notified.

The nurse is documenting nursing observations in the record of a client who experienced a tonic-clonic seizure. Which clinical manifestation did the nurse most likely note in the clonic phase of the seizure?

Spasms of the entire body; The clonic phase of a seizure is characterized by alternating spasms and momentary muscular relaxation of the entire body, accompanied by strenuous hyperventilation. The face is contorted and the eyes roll. Excessive salivation results in frothing from the mouth. The tongue may be bitten, the client sweats profusely, and the pulse is rapid. The clonic jerking subsides by slowing in frequency and losing strength of contractions over a period of 30 seconds. Body stiffening, sudden loss of consciousness, and brief flexion of the extremities are associated with the tonic phase of a seizure.

A client arrives at the emergency department with a foreign body in the left ear and tells the nurse that an insect flew into the ear. Which intervention should the nurse implement initially?

Instillation of mineral oil; Insects are killed before removal unless they can be coaxed out by a flashlight or by a humming noise. Mineral oil or diluted alcohol may be instilled into the ear to suffocate the insect, which is then removed by using ear forceps. When the foreign object is vegetable matter, irrigation is not used because such material may expand with hydration, thereby worsening the impaction.

A client's vision is tested with a Snellen chart. The results of the tests are documented as 20/60. What action should the nurse implement based on this finding?

Instruct the client that he or she may need glasses when driving; Vision that is 20/20 is normal—that is, the client is able to read from 20 feet (6 meters) what a person with normal vision can read from 20 feet (6 meters). A client with a visual acuity of 20/60 can only read at a distance of 20 feet (6 meters) what a person with normal vision can read at 60 feet (18 meters). With this vision, the client may need glasses while driving in order to read signs and to see far ahead. The client should be instructed to sit in the front of the room for lectures to aid in visualization. This is not considered to be legal blindness.

The nurse has given instructions for taking codeine sulfate to a client with a severe headache. Which statement by the client indicates the teaching has been effective?

"I should increase fluid intake." Codeine sulfate can cause constipation, so the client is instructed to increase fluid intake to prevent this occurrence. A high-fiber diet and stool softeners may be prescribed to prevent constipation. All exercise is not avoided.

A client with a history of ear problems is going on vacation by aircraft. The nurse advises the client to include which activities to prevent barotrauma during ascent and descent of the airplane? Select all that apply.

Yawning, swallowing, chewing gum and sucking on hard candy; Clients who are prone to barotrauma should perform any of a variety of mouth movements to equalize pressure between the ear and the atmosphere, particularly during ascent and descent of an aircraft. These can include yawning, swallowing, drinking, chewing, and sucking on hard candy. Valsalva maneuver also may be helpful. The client should avoid sitting with the mouth motionless during this time because the resulting lack of pressure change in the ear will contribute to pressure buildup behind the tympanic membrane. Humming does not affect pressure.

The nurse is providing discharge instructions to the client being discharged after a fenestration procedure for the treatment of otosclerosis. Which statement made by the client indicates a need for further instruction?

"I should use a straw to drink liquids for the next 2 to 3 weeks." After ear surgery clients need to be instructed to avoid drinking with a straw for 2 to 3 weeks, to avoid air travel, and to avoid excessive coughing because these activities will increase pressure within the ear. The client should avoid getting the head wet, washing the hair, or showering for at least 1 week, and avoid rapidly moving the head, bouncing, and bending over for at least 3 weeks. The client also should be instructed to avoid straining when having a bowel movement and should be instructed to take stool softeners as prescribed.

The nurse is reviewing the instillation technique for both eye ointment and eye drops with the parent of a pediatric client diagnosed with bacterial conjunctivitis. Which statement made by the parent would indicate that learning has taken place?

"I will be careful not to touch the eye or eyelid during administration." Touching the eye or eyelid during medication administration can contaminate the dropper and cause eye injury. The child should be placed in a supine position with the neck slightly hyperextended for administration. Eye drops should be administered before eye ointment is administered. Blinking will increase the loss of medication.

The nurse is educating a client on how to eliminate whistling from a hearing aid. The nurse recognizes that further teaching is needed when the client makes which statement?

"I will raise the volume of my hearing aid." To reduce or eliminate whistling from a hearing aid, it should be reinserted, making certain that no hair is caught between the ear mold and canal. The ear mold or ear can be cleansed, and lowering the volume of the aid might help.

The preoperative medication sheet identifies that cyclopentolate is prescribed for a client before cataract surgery. The client asks the nurse what the medication is for, and the nurse provides education. Which statement by the client indicates that teaching has been effective?

"It paralyzes the muscles in my eyes." Cyclopentolate is used for preoperative mydriasis. It is a rapid-acting mydriatic and cycloplegic medication. Cycloplegics are medications that paralyze the ciliary muscle, and mydriatics are medications that dilate the pupil. Cyclopentolate becomes effective in 25 to 75 minutes, and the effects last for 6 to 24 hours. The statements in the remaining options are not actions of this medication.

The nursing student is caring for a client with a diagnosis of presbycusis. The nursing instructor determines that the student understands presbycusis when which statement is made?

"It's a sensorineural hearing loss that occurs with the aging process." Presbycusis is a type of hearing loss that occurs with aging. It is a gradual sensorineural loss caused by nerve degeneration in the inner ear or auditory nerve.

The nurse in the health care clinic is providing instructions to a client regarding the use of a hearing aid. Which statement is most appropriate for the nurse to include?

"The hearing aid should not be worn if an ear infection is present." The client should be instructed that the hearing aid should not be worn if an ear infection is present. The client should wash the ear mold frequently with mild soap and water and use a pipe cleaner to clean the cannula of the hearing aid. The client should be instructed to turn off the hearing aid before removing it from the ear to prevent any squealing feedback. The hearing aid should be turned off when not in use, and the client should keep extra batteries on hand at all times.

A miotic medication has been prescribed for the client with glaucoma and the client asks the nurse about the purpose of the medication. Which response should the nurse provide to the client?

"The medication causes the pupil to constrict and will lower the pressure in the eye." Miotics cause pupillary constriction and are used to treat glaucoma. They lower the intraocular pressure, thereby increasing blood flow to the retina and decreasing retinal damage and loss of vision. Miotics cause a contraction of the ciliary muscle and a widening of the trabecular meshwork.

A client who is scheduled for cataract surgery requires preoperative instillation of cyclopentolate eye drops as prescribed. The client asks the nurse why this medication is needed, and the nurse provides education. Which statement by the client indicates that teaching has been effective?

"The medication dilates the pupil of the operative eye." Cyclopentolate is a rapidly acting mydriatic and cycloplegic medication that is used preoperatively to dilate the eye. It is effective in 25 to 75 minutes, and accommodation returns in 6 to 24 hours.

The nursing student is assigned to care for a client with glaucoma for whom pilocarpine hydrochloride eye drops have been prescribed. The nursing instructor asks the student to describe the action of the eye medication. Which statement by the student indicates an understanding of the purpose of this medication?

"The medication increases the blood flow to the retina and also will lower the pressure in the eye." Pilocarpine hydrochloride is a miotic that is used to lower the intraocular pressure, thereby increasing blood flow to the retina and decreasing retinal damage and loss of vision. Miotics cause a contraction of the ciliary muscle and a widening of the trabecular meshwork.

A client being prepared for a myringotomy asks the nurse about the procedure. The nurse should respond by making which statement?

"This procedure will reduce the pressure you feel in your ear and allow fluid to drain." A myringotomy is a surgical procedure that allows fluid to drain from the middle ear. A small incision is created in the eardrum (tympanic membrane) to relieve pressure that may be caused by excessive buildup of fluid. A tympanostomy tube is inserted into the eardrum to keep the middle ear aerated and to prevent reaccumulation of fluid. A mastoidectomy, in which the mastoid bone is removed or partially removed, may be recommended to treat chronic otitis media that is resistant to other therapies. The tympanic membrane is a structure needed to transmit sound from the air to the ossicles inside the middle ear and then to the oval window in the fluid-filled cochlea. Thus, it ultimately converts and amplifies vibration in air to vibration in fluid.

The nurse is preparing a teaching plan for a client who had a cataract extraction with intraocular implantation. Which home care measures should the nurse include in the plan? Select all that apply.

-Avoid activities that require bending over. -Take acetaminophen for minor eye discomfort. -Place an eye shield on the surgical eye at bedtime. -Contact the surgeon if a decrease in visual acuity occurs. Following eye surgery, some scratchiness and mild eye discomfort may occur in the operative eye and usually is relieved by mild analgesics. If the eye pain becomes severe, the client should notify the surgeon because this may indicate hemorrhage, infection, or increased intraocular pressure (IOP). The nurse also would instruct the client to notify the surgeon of increased purulent drainage, increased redness, or any decrease in visual acuity. The client is instructed to place an eye shield over the operative eye at bedtime to protect the eye from injury during sleep and to avoid activities that increase IOP, such as bending over.

A client with a spinal cord injury is prone to experiencing autonomic dysreflexia. The nurse should include which measures in the plan of care to minimize the risk of occurrence? Select all that apply.

-Keeping the linens wrinkle-free under the client -Preventing unnecessary pressure on the lower limbs -Turning and repositioning the client at least every 2 hours The most frequent cause of autonomic dysreflexia is a distended bladder. Straight catheterization should be done every 4 to 6 hours (catheterization every 12 hours is too infrequent), and urinary catheters should be checked frequently to prevent kinks in the tubing. Constipation and fecal impaction are other causes, so maintaining bowel regularity is important. Ensuring a bowel movement once a week is much too infrequent. Other causes include stimulation of the skin from tactile, thermal, or painful stimuli. The nurse administers care to minimize risk in these areas.

The nurse is monitoring a client diagnosed with acromegaly who was treated with transsphenoidal hypophysectomy and is recovering in the intensive care unit. Which findings should alert the nurse to the presence of a possible postoperative complication? Select all that apply.

-Leukocytosis -Urinary output of 800ml/hr -Clear drainage on a nasal dripper pad Acromegaly results from excess secretion of growth hormone, usually caused by a benign tumor on the anterior pituitary gland. Treatment is surgical removal of the tumor, usually with a sublingual transsphenoidal complete or partial hypophysectomy. The sublingual transsphenoidal approach is often through an incision in the inner upper lip at the gum line. Transsphenoidal surgery is a type of brain surgery and infection is a primary concern. Leukocytosis, or an elevated white count, may indicate infection. Diabetes insipidus is a possible complication of transsphenoidal hypophysectomy. In diabetes insipidus there is decreased secretion of antidiuretic hormone and clients excrete large amounts of dilute urine. Following transsphenoidal surgery, the nasal passages are packed and a dripper pad is secured under the nares. Clear drainage on the dripper pad is suggestive of a cerebrospinal fluid leak. The surgeon should be notified and the drainage should be tested for glucose. A cerebrospinal fluid leak increases the postoperative risk of meningitis.

The nurse is preparing to provide care for a client who will need an ear irrigation to remove impacted cerumen. Which interventions should the nurse take when performing the irrigation? Select all that apply.

-Position the client with the affected side down after the irrigation. -Warm the irrigating solution to a temperature that is close to body temperature. -Direct a slow, steady stream of irrigation solution toward the upper wall of the ear canal. During the irrigation, the client is positioned so that the ear to be irrigated is facing downward because this allows gravity to assist in the removal of the earwax and solution. Delivery of irrigation solutions at temperatures that are not close to body temperature can cause discomfort for the client and may result in tissue injury, nausea, and vertigo. A slow, steady stream of solution should be directed toward the upper wall of the ear canal, not toward the tympanic membrane. After the irrigation, the client should lie on the affected side for a period of time that is necessary to allow the irrigating solution to finish draining (usually 10 to 15 minutes). Too much force could cause the tympanic membrane to rupture.

The nurse is creating a plan of care for a child who is at risk for seizures. Which interventions apply if the child has a seizure? Select all that apply.

-Time the seizure -Stay with the child -Move furniture away from the child A seizure is a disorder that occurs as a result of excessive and unorganized neuronal discharges in the brain that activate associated motor and sensory organs. During a seizure, the child is placed on his or her side in a lateral position. Positioning on the side prevents aspiration because saliva drains out the corner of the child's mouth. The child is not restrained because this could cause injury to the child. The nurse would loosen clothing around the child's neck and ensure a patent airway. Nothing is placed into the child's mouth during a seizure because this action may cause injury to the child's mouth, gums, or teeth. The nurse would stay with the child to reduce the risk of injury and allow for observation and timing of the seizure.

The nurse is preparing to administer eye drops. Which interventions should the nurse take to administer the drops? Select all that apply.

-Wash hands. -Put gloves on. -Place the drop in the conjunctival sac. -Pull the lower lid down against the cheekbone. To administer eye medications, the nurse should wash hands and put gloves on. The client is instructed to tilt the head backward, open the eyes, and look up. The nurse pulls the lower lid down against the cheekbone and holds the bottle like a pencil with the tip downward. Holding the bottle, the nurse gently rests the wrist of the hand on the client's cheek and squeezes the bottle gently to allow the drop to fall into the conjunctival sac. The client is instructed to close the eyes gently and not to squeeze the eyes shut to prevent the loss of medication.

The nurse is caring for a client following a craniotomy, in which a large tumor was removed from the left side. In which position can the nurse safely place the client?

30 degrees; Clients who have undergone crainotomy should have the head of the bed elevated 30 to 45 degrees to promote venous drainage from the head. The client is positioned to avoid extreme hip or neck flexion and the head is maintained in a midline neutral position. The client should not be positioned on the site that was operated on, especially if the bone flap was removed, because the brain has no bony covering on the affected site. A flat position (option 4) or Trendelenburg's position (option 2) would increase intracranial pressure. A reverse Trendelenburg's position (option 3) would not be helpful and may be uncomfortable for the client.

The parents of a child recently diagnosed with cerebral palsy ask the nurse about the limitations of the disorder. The nurse responds by explaining that the limitations occur as a result of which pathophysiological process?

A chronic disability characterized by impaired muscle movement and posture; Cerebral palsy is a chronic disability characterized by impaired movement and posture resulting from an abnormality in the extrapyramidal or pyramidal motor system. Meningitis is an infectious process of the central nervous system. Encephalitis is an inflammation of the brain that occurs as a result of viral illness or central nervous system infection. Down syndrome is an example of a congenital condition that results in moderate to severe intellectual disabilities.

The nurse is planning care for a client with acute otitis media. To reduce pressure and allow fluid to drain, the nurse anticipates that which measure would most likely be recommended to the client?

A myringotomy; A myringotomy is a surgical procedure that will allow fluid to drain from the middle ear and may be necessary to treat acute otitis media.

The nurse is performing an otoscopic examination on a client with mastoiditis. On examination of the tympanic membrane, which finding should the nurse expect to observe?

A red, dull, thick, immobile tympanic membrane; Otoscopic examination in a client with mastoiditis reveals a red, dull, thick, and immobile tympanic membrane, with or without perforation. Postauricular lymph nodes are tender and enlarged. Clients also have a low-grade fever, malaise, anorexia, swelling behind the ear, and pain with minimal movement of the head.

The clinic nurse is performing an otoscopic examination on an adolescent who was hit in the ear with a basketball during a neighborhood game. A perforated eardrum is suspected. Which finding should the nurse expect to observe if the eardrum is perforated?

A round or oval darkened area on the eardrum; A round or oval darkened area on the eardrum would be seen in a client with a perforated eardrum. A red and bulging eardrum is indicative of acute purulent otitis media. Dense white patches are seen on the eardrum of a client with sequelae of repeated ear infections. A colony of black dots on the eardrum suggests a yeast or fungal infection.

The nurse is performing an admission assessment on a client with a diagnosis of detached retina. Which sign or symptom is associated with this eye disorder?

A sense of a curtain falling across the field of vision; A characteristic manifestation of retinal detachment described by the client is the feeling that a shadow or curtain is falling across the field of vision. No pain is associated with detachment of the retina.

The nurse has admitted to the hospital a client with a diagnosis of an acute attack of Ménière's disease. The nurse reviews the health care provider's prescriptions for the client. Which prescription should the nurse question?

Ambulation four times daily; Medical interventions during the acute phase of Ménière's disease include using diazepam as prescribed to decrease the autonomic nervous system function. Diphenhydramine may be prescribed for its antihistamine effects, and a vasodilator (nicotinic acid) also will be prescribed. The client will remain on bed rest during the acute attack. When allowed out of bed, the client will need assistance with walking, sitting, or standing.

A caloric test is prescribed for a client suspected of having disease of the labyrinth. The nurse should obtain which essential item in preparation for this test?

An otoscope; A caloric test is contraindicated if the client has a perforated tympanic membrane (air may be used as a substitute) or if the client has an acute disease of the labyrinth. An otoscopic examination should be performed before the caloric test to rule out perforation and to determine whether the ear canal contains cerumen, which must be removed before the test.

A client with Ménière's disease is experiencing severe vertigo. Which instruction should the nurse give to the client to assist in controlling the vertigo?

Avoid sudden head movements; The nurse instructs the client to make slow head movements to prevent worsening of the vertigo. Dietary changes such as salt and fluid restrictions that reduce the amount of endolymphatic fluid are sometimes prescribed.

The nurse has given a client who is at risk for motion sickness suggestions about medications that can prevent an occurrence. The nurse determines that the client has correctly learned the information if the client states that the medication is taken at what time before the triggering event?

At least 1 hour before; To be maximally effective, medications to prevent motion sickness should be taken at least 1 hour before the triggering event. Medications that are commonly used for this purpose include dimenhydrinate, scopolamine, promethazine, and prochlorperazine.

Which medication, if prescribed for the client with glaucoma, should the nurse question?

Atropine sulfate; Options 1 and 2 (Betaxolol and Pilocarpine) are miotic agents used to treat glaucoma. Option 3 (Erythromycin) is an antiinfective medication used to treat bacterial conjunctivitis. Atropine sulfate is a mydriatic and cycloplegic (also anticholinergic) medication, and its use is contraindicated in clients with glaucoma. Mydriatic medications dilate the pupil and can cause an increase in intraocular pressure in the eye.

The nurse would question the health care provider if which medication were prescribed for a client with glaucoma?

Atropine sulfate; Pilocarpine and carbachol are examples of miotic agents used in the treatment of glaucoma. Atropine sulfate is a mydriatic and cycloplegic medication that is contraindicated for use in clients with glaucoma. Mydriatic medications dilate the pupil and can cause an increase in intraocular pressure in the eye.

The nurse working in a long-term care facility notes that several clients are taking pilocarpine hydrochloride eye drops. The nurse ensures that which medication is available on the nursing unit for use if a client should develop systemic toxicity from pilocarpine hydrochloride?

Atropine sulfate; Pilocarpine hydrochloride is a cholinergic agent. Atropine sulfate must be available in the event of systemic toxicity from pilocarpine hydrochloride. Pilocarpine toxicity is manifested by vertigo, bradycardia, tremors, hypotension, syncope, cardiac dysrhythmias, and seizures. Disulfiram is an alcohol deterrent used in the management of alcoholism in selected clients. Cyclopentolate is a rapidly acting mydriatic and cycloplegic medication used preoperatively for surgical procedures on the eye. Naloxone hydrochloride is an opioid antagonist used to reverse opioid-induced respiratory depression.

The nurse is caring for a postoperative client who is receiving demand-dose hydromorphone via a patient-controlled analgesia (PCA) pump for pain control. The nurse enters the client's room and finds the client drowsy and records the following vital signs: temperature 97.2°F (36.2°C) orally, pulse 52 beats per minute, blood pressure 101/58 mm Hg, respiratory rate 11 breaths per minute, and SpO2 of 93% on 3 liters of oxygen via nasal cannula. Which action should the nurse take next?

Attempt to arouse the client; The primary concern with opioid analgesics is respiratory depression and hypotension. Based on the assessment findings, the nurse should suspect opioid overdose. The nurse should first attempt to arouse the client and then reassess the vital signs. The vital signs may begin to normalize once the client is aroused because sleep can also cause decreased heart rate, blood pressure, respiratory rate, and oxygen saturation. The nurse should also check to see how much medication has been taken via the PCA pump, and should continue to monitor the client closely to determine if further action is needed. The nurse should contact the HCP and document the findings after all data are collected, after the client is stabilized, and if an abnormality still exists after arousing the client.

The nurse is providing discharge instructions to a client who had a fenestration procedure for the treatment of otosclerosis. The nurse should instruct the client to take which measure?

Avoid air travel; After ear surgery, the client needs to be instructed to avoid air travel, excessive coughing, and drinking through a straw for 2 to 3 weeks. In addition, the client should avoid straining when having a bowel movement and should avoid washing the hair, getting the head wet, or showering for 1 week. The client also needs to avoid rapidly moving the head, bouncing, and bending over for 3 weeks.

A client has been prescribed betaxolol eye drops for the treatment of glaucoma. The ambulatory care nurse determines that the client understands proper medication use if the client states the need to return to the office for monitoring of what item(s)?

Blood pressure and apical pulse; Betaxolol is an antiglaucoma medication and a β-adrenergic blocker. Systemic effects of this medication are hypotension, dizziness, nausea, diaphoresis, headache, fatigue, constipation, and diarrhea. The client should have the blood pressure monitored for hypotension and the pulse assessed for strength, weakness, irregular rate, and bradycardia. Bowel activity and evidence of heart failure also should be assessed.

Pilocarpine hydrochloride is prescribed for a client with glaucoma. The nurse checks the medication supply room to ensure that atropine sulfate is available for administration in the event that systemic toxicity occurs from the use of pilocarpine hydrochloride. The nurse also monitors for which sign of systemic toxicity?

Bradycardia; Systemic absorption of pilocarpine hydrochloride can produce toxicity, manifested as vertigo, bradycardia, tremors, hypotension, syncope, cardiac dysrhythmias, and seizures. Atropine sulfate is the antidote for systemic reactions that occur with pilocarpine.

The nurse is performing an admission assessment on a client who has a history of glaucoma and uses latanoprost eye drops. Which assessment finding would indicate a side/adverse effect of these eye drops?

Brown pigmentation of the iris; Latanoprost is a topical medication used to lower intraocular pressure in clients with open-angle glaucoma and ocular hypertension. The most significant side/adverse effect is heightened brown pigmentation of the iris. Other side effects include blurred vision, burning, stinging, conjunctival hyperemia, and punctate keratopathy. The heightened pigmentation does not progress further once the medication is discontinued but does not regress.

A client with glaucoma is given a prescription for a pilocarpine ocular system. The nurse plans to provide which instruction to the client on how to use the medication?

Check the eye each morning to make sure that the system is in place; The pilocarpine ocular system has a bilayered membrane surrounding a reservoir of pilocarpine solution. The tiny unit, which is placed in the conjunctival sac, slowly releases medication. The unit should be changed once a week. Because the unit may fall out during sleep, the client should check the eye each morning for its presence.

The home care nurse is reviewing the record of a client newly diagnosed with glaucoma who is scheduled for a home visit. The nurse notes that the health care provider (HCP) has prescribed atropine sulfate and pilocarpine hydrochloride eye drops. The nurse should contact the HCP before the home visit for which reason?

Clarify the prescription for atropine sulfate; Atropine sulfate is a mydriatic and cycloplegic medication that is contraindicated in clients with glaucoma. Mydriatic medications dilate the pupil and cause increased intraocular pressure in the eye. Pilocarpine hydrochloride is a miotic agent used in the treatment of glaucoma. It is unnecessary to contact the HCP regarding the date for follow-up treatment. In fact, the client may know this date, which the nurse can ask about during the home care visit. It is unnecessary to know the extent of the intraocular pressure caused by the glaucoma in planning care for the client.

The nurse is caring for a client who was recently diagnosed with primary open-angle glaucoma (POAG). Which assessment finding is specific to this type of glaucoma?

Client report of tunnel vision; POAG results from obstruction to outflow of aqueous humor and is the most common type. Assessment findings include painless vision changes and "tunnel vision." Primary angle-closure glaucoma (PACG) is another type of glaucoma that results from blocking the outflow of aqueous humor into the trabecular meshwork. Assessment findings include blurred vision, ocular erythema, and halos around lights.

A lumbar puncture is performed on a child suspected to have bacterial meningitis, and cerebrospinal fluid (CSF) is obtained for analysis. The nurse reviews the results of the CSF analysis and determines that which results would verify the diagnosis?

Cloudy CSF, elevated protein, and decreased glucose levels; Meningitis is an infectious process of the central nervous system caused by bacteria and viruses; it may be acquired as a primary disease or as a result of complications of neurosurgery, trauma, infection of the sinus or ears, or systemic infections. Meningitis is diagnosed by testing CSF obtained by lumbar puncture. In the case of bacterial meningitis, findings usually include an elevated pressure; turbid or cloudy CSF; and elevated leukocyte, elevated protein, and decreased glucose levels.

A client makes an appointment with an ear specialist because of the frequent recurrence of middle ear infections. In performing an intake assessment of the client, the nurse should ask about which risk factor related to infection of the ears?

Congenital abnormalities; Otitis media (middle ear infection) is associated with colds, allergies, sore throats, and blockage of the eustachian tube. Risk factors include young age (usually a childhood disease), congenital abnormalities, immune deficiencies, exposure to cigarette smoke, family history of otitis media, recent upper respiratory infections, and allergies. The remaining options are risk factors for hearing loss. Hearing loss can occur as a result of an acute loud noise (acoustic trauma) or as a result of chronic exposure to loud noise (noise-induced hearing loss).

In preparation for cataract surgery, the nurse is to administer cyclopentolate eye drops at 0900 for surgery that is scheduled for 0915. What initial action should the nurse take in relation to the characteristics of the medication action?

Consult the surgeon, as there is not sufficient time for the dilative effects to occur; Cyclopentolate is a rapidly acting mydriatic and cycloplegic medication. Cyclopentolate is effective in 25 to 75 minutes, and accommodation returns in 6 to 24 hours. Cyclopentolate is used for preoperative mydriasis, not pupil constriction. The nurse should consult with the surgeon about the time of administration of the eye drops since 15 minutes is not adequate time for dilation to occur.

The nurse is caring for a client in the postoperative period following enucleation. The nurse notes bloody staining on the surgical eye dressing. Which nursing action is most appropriate?

Contact the HCP; After enucleation, if the nurse notes any staining or bleeding on the surgical dressing, the HCP needs to be notified immediately.

The nurse is caring for a client following craniotomy for removal of an acoustic neuroma. Assessment of which cranial nerve would identify a complication specifically associated with this surgery?

Cranial nerve VII, facial nerve; An acoustic neuroma (or vestibular schwannoma) is a unilateral benign tumor that occurs where the vestibulocochlear or acoustic nerve (cranial nerve VIII) enters the internal auditory canal. It is important that an early diagnosis be made because the tumor can compress the trigeminal and facial nerves and arteries within the internal auditory canal. Treatment for acoustic neuroma is surgical removal via a craniotomy. Assessment of the trigeminal and facial nerves is important. Extreme care is taken to preserve remaining hearing and preserve the function of the facial nerve. Acoustic neuromas rarely recur following surgical removal.

A client with chronic glaucoma is being started on medication therapy with acetazolamide. The nurse teaches the client that which can occur early with the use of this medication?

Diuresis; Diuresis is an early side effect of acetazolamide that usually subsides with continued treatment. This is because the medication is also a weak diuretic, although it is no longer prescribed for that purpose. Fatigue, headache, and loss of libido are common side effects of therapy, but these may not subside spontaneously.

The nurse is caring for a client receiving morphine sulfate for pain. Because this medication has been prescribed for this client, which nursing action should be included in the plan of care?

Encourage the client to cough and deep breathe; Morphine sulfate suppresses the cough reflex. Clients need to be encouraged to cough and deep breathe to prevent pneumonia. The remaining options are not associated specifically with the use of this medication.

A client has clear fluid leaking from the nose following a basilar skull fracture. Which finding would alert the nurse that cerebrospinal fluid is present?

Fluid separates into concentric rings and tests positive for glucose; Leakage of cerebrospinal fluid (CSF) from the ears or nose may accompany basilar skull fracture. CSF can be distinguished from other body fluids because the drainage will separate into bloody and yellow concentric rings on dressing material, called a halo sign. The fluid also tests positive for glucose.

The client newly diagnosed with chronic kidney disease recently has begun hemodialysis. Knowing that the client is at risk for disequilibrium syndrome, the nurse should assess the client during dialysis for which associated manifestations?

Headache, deteriorating level of consciousness, and twitching; Disequilibrium syndrome is characterized by headache, mental confusion, decreasing level of consciousness, nausea, vomiting, twitching, and possible seizure activity. Disequilibrium syndrome is caused by rapid removal of solutes from the body during hemodialysis. At the same time, the blood-brain barrier interferes with the efficient removal of wastes from brain tissue. As a result, water goes into cerebral cells because of the osmotic gradient, causing increased intracranial pressure and onset of symptoms. The syndrome most often occurs in clients who are new to dialysis and is prevented by dialyzing for shorter times or at reduced blood flow rates.

The nurse is caring for the client with increased intracranial pressure. The nurse would note which trend in vital signs if the intracranial pressure is rising?

Increasing temperature, decreasing pulse, decreasing respirations, increasing blood pressure; A change in vital signs may be a late sign of increased intracranial pressure. Trends include increasing temperature and blood pressure and decreasing pulse and respirations. Respiratory irregularities also may occur.

The nurse is preparing to give a postcraniotomy client medication for incisional pain. The family asks the nurse why the client is receiving codeine sulfate and not "something stronger." In formulating a response, the nurse incorporates which information about codeine sulfate?

It does not alter respirations or mask neurological signs as do other opioids; Codeine sulfate is an opioid analgesic used for clients after craniotomy. It often is combined with a nonopioid analgesic such as acetaminophen for added effect. It does not alter the respiratory rate or mask neurological signs as do other opioids. Side effects of codeine sulfate include GI upset and constipation. Chronic use of the medication can lead to physical and psychological dependence.

A client being discharged to home with a prescription for eye drops to be given in the left eye has received instructions regarding self-administration of the drops. The nurse determines that the client needs further instruction if, on return demonstration, the client takes which action?

Lies supine, pulls up on the upper lid, and puts the drop in the upper lid; It is correct procedure for the client to lie down or sit with his or her head tilted back. The thumb or finger is used to pull down on the lower lid. The client holds the bottle like a pencil (tip facing downward) and squeezes the bottle so that one drop falls into the sac. The client then gently closes the eye. An alternative method for clients who blink very easily is to place the client in the supine position with the head turned to one side. The eye to be used is uppermost. With the eye closed, the client squeezes the drop onto the inner canthus of the eye. The client turns from this side to the other while blinking. Surface tension and gravity then cause the drop to move into the conjunctival sac.

A client arrives at the emergency department stating that a mosquito flew into his ear and that he is hearing a constant buzzing noise. Which intervention should the nurse take first?

Look into the ear canal using a flashlight; Insects are killed before removal unless they can be coaxed out by a flashlight or a humming noise. Therefore, the first action would be to look into the ear canal using a flashlight. Substances such as viscous lidocaine may be prescribed to be instilled into the ear to suffocate the insect, which then is removed with the use of ear forceps. Irrigation may be necessary to flush the ear canal once the mosquito is killed, but this would not be the first action.

The nurse notes documentation that a child is exhibiting an inability to flex the leg when the thigh is flexed anteriorly at the hip. Which condition does the nurse suspect?

Meningitis; Meningitis is an infectious process of the central nervous system caused by bacteria and viruses. The inability to extend the leg when the thigh is flexed anteriorly at the hip is a positive Kernig's sign, noted in meningitis. Kernig's sign is not seen specifically with spinal cord injury, intracranial bleeding, or decreased cerebral blood flow.

The nurse is assigned to care for a client after a mastoidectomy. Which nursing intervention would be a priority in the care of this client?

Monitor for signs of facial nerve injury; After mastoidectomy, the nurse should assess for signs of facial nerve injury (cranial nerve VII), such as facial drooping. The nurse should monitor vital signs and inspect the dressing for drainage or bleeding. The nurse also should monitor for signs of pain, dizziness, or nausea. The client should be instructed to lie on the unaffected side to prevent disruption of the surgical site. The head of the bed should be elevated at least 30 degrees. The client probably will have sutures, an outer ear packing, and a bulky dressing, which is removed on approximately the sixth day postoperatively.

Betaxolol hydrochloride eye drops have been prescribed for a client with glaucoma. Which nursing action is most appropriate related to monitoring for side and adverse effects of this medication?

Monitoring blood pressure; Hypotension, dizziness, nausea, diaphoresis, headache, fatigue, constipation, and diarrhea are side and adverse effects of the medication. Nursing interventions include monitoring the blood pressure for hypotension and assessing the pulse for strength, weakness, irregular rate, and bradycardia.

Betaxolol eye drops have been prescribed for a client with glaucoma. The home health nurse preparing to visit the client develops a plan of care that includes monitoring for the side/adverse effects of this medication by taking which assessment action?

Monitoring body weight; This medication is an antiglaucoma medication and a β-adrenergic blocker. The nurse assesses for evidence of heart failure manifested by dizziness, night cough, peripheral edema, and distended neck veins. Intake greater than output, weight gain, and decreased urine output also may indicate heart failure. Hypotension (manifested as dizziness), nausea, diaphoresis, headache, fatigue, and constipation or diarrhea also are potential systemic effects of the medication. Nursing interventions include monitoring body weight; periodically evaluating blood pressure for hypotension; and assessing the apical or radial pulse for strength, weakness, irregular heart rate, and bradycardia.

The nurse is assigned to care for an 8-year-old child with a diagnosis of a basilar skull fracture. The nurse reviews the health care provider's (HCP's) prescriptions and should contact the HCP to question which prescription?

Nasotracheal suction as needed; A basilar skull fracture is a type of head injury. Nasotracheal suctioning is contraindicated in a child with a basilar skull fracture: Because of the nature of the injury, there is a possibility that the catheter will enter the brain through the fracture, creating a high risk of secondary infection. Fluid balance is monitored closely by daily weight determination, intake and output measurement, and serum osmolality determination to detect early signs of water retention, excessive dehydration, and states of hypertonicity or hypotonicity. The child is maintained on NPO (nothing by mouth) status or restricted to clear liquids until it is determined that vomiting will not occur. An intravenous line is maintained to administer fluids or medications, if necessary.

The nurse is caring for a client receiving codeine sulfate for pain. The nurse determines that the client is experiencing a side or adverse effect of the medication based on which finding?

No bowel movement in 3 days; The client taking codeine sulfate is at risk for constipation. Thus, the nurse monitors the frequency of bowel movements. The nurse also would monitor the client for hypotension, decreased respirations, and urinary retention. The nurse would plan measures to counteract these expected effects, such as encouraging fluids, coughing and deep breathing, and increasing mobility to the extent tolerated by the client.

Tonometry is performed on a client with a suspected diagnosis of glaucoma. The nurse looks at the documented test results and notes an intraocular pressure (IOP) value of 23. What should be the nurse's initial action?

Note what time of day the test was done; Tonometry is a method of measuring intraocular fluid pressure. Pressures between 10 and 21 mm Hg are considered within the normal range. However, IOP is slightly higher in the morning. Therefore, the initial action is to check the time the test was performed. Flat positions may increase pressure*

The nurse is performing an assessment on a client who has returned from the dialysis unit following hemodialysis. The client is complaining of headache and nausea and is extremely restless. Which is the priority nursing action?

Notify the HCP; Disequilibrium syndrome may be caused by rapid removal of solutes from the body during hemodialysis. These changes can cause cerebral edema that leads to increased intracranial pressure. The client is exhibiting early signs and symptoms of disequilibrium syndrome and appropriate treatments with anticonvulsive medications and barbiturates may be necessary to prevent a life-threatening situation. The HCP must be notified.

The nurse is providing instructions to a client who will be self-administering eye drops. To minimize systemic absorption of the eye drops, the nurse should instruct the client to take which action?

Occlude the nasolacrimal duct with a finger after instilling the drops; Applying pressure on the nasolacrimal duct prevents systemic absorption of the medication.

The nurse is reviewing the record of a child with increased intracranial pressure and notes that the child has exhibited signs of decerebrate posturing. On assessment of the child, the nurse expects to note which characteristic of this type of posturing?

Rigid extension and pronation of the arms and legs; Decerebrate (extension) posturing is characterized by the rigid extension and pronation of the arms and legs.

A client with retinal detachment is admitted to the nursing unit in preparation for a repair procedure. Which prescription should the nurse anticipate?

Placing an eye patch over the client's affected eye; The nurse places an eye patch over the client's affected eye to reduce eye movement. Some clients may need bilateral patching. Depending on the location and size of the retinal break, activity restrictions may be needed immediately. These restrictions are necessary to prevent further tearing or detachment and to promote drainage of any subretinal fluid. Therefore, reading and watching television are not allowed. The client's position is prescribed by the health care provider; normally, the prescription is to lie flat.

An infant with a diagnosis of hydrocephalus is scheduled for surgery. Which is the priority nursing intervention in the preoperative period?

Position the infant frequently; Hydrocephalus occurs as a result of an imbalance of cerebrospinal fluid absorption or production that is caused by malformations, tumors, hemorrhage, infections, or trauma. It results in head enlargement and increased intracranial pressure (ICP). In infants with hydrocephalus, the head grows at an abnormal rate, and if the infant is not repositioned frequently, pressure ulcers can occur on the back and side of the head. An egg crate mattress under the head is also a nursing intervention that can help to prevent skin breakdown. Proteinuria is not specific to hydrocephalus. Stimulus should be kept at a minimum because of the increase in ICP. It is not necessary to check the blood pressure every 15 minutes.

A child is diagnosed with Reye's syndrome. The nurse creates a nursing care plan for the child and should include which intervention in the plan?

Providing a quiet atmosphere with dimmed lighting; Reye's syndrome is an acute encephalopathy that follows a viral illness and is characterized pathologically by cerebral edema and fatty changes in the liver. In Reye's syndrome, supportive care is directed toward monitoring and managing cerebral edema. Decreasing stimuli in the environment by providing a quiet environment with dimmed lighting would decrease the stress on the cerebral tissue and neuron responses. Hearing loss and urine output are not affected. Changing the body position every 2 hours would not affect the cerebral edema directly. The child should be positioned with the head elevated to decrease the progression of the cerebral edema and promote drainage of cerebrospinal fluid.

Ear drops are prescribed for an infant with otitis media. Which is the most appropriate method to administer ear drops to an infant?

Pull down and back on the pinna, and direct the solution toward the wall of the canal. In a child younger than 3 years of age, the pinna is pulled down and straight back. The infant should be turned on the side with the affected ear uppermost. Using the nondominant hand, the person administering the ear drops pulls the pinna down and back. The medication is administered by aiming it at the wall of the canal rather than directly onto the eardrum. The infant should remain with the affected ear uppermost for 10 to 15 minutes to retain the solution. In an adult or a child older than 3 years of age, the pinna is pulled up and back to straighten the auditory canal.

Betaxolol eye drops have been prescribed for a client with glaucoma. The nurse monitoring this client for side/adverse effects of the medication would place highest priority on which assessment?

Pulse rate; Betaxolol is a beta-blocking agent as well as an antiglaucoma medication. Nursing assessments include monitoring the blood pressure for hypotension and assessing the pulse for strength, weakness, irregular rate, and bradycardia. The nurse also assesses for evidence of heart failure as manifested by dizziness, night cough, peripheral edema, and distended neck veins.

The nurse is developing a plan of care for a client with a diagnosis of severe vertigo from Ménière's disease who is being admitted to the hospital. What is the priority nursing intervention in the plan of care?

Safety measures; Ménière's disease can cause severe vertigo in the client. The priority in the nursing care plan should focus on safety issues to prevent falls or injury to the client. Although self-care measures, dietary therapy, and medication therapy may be components of the plan of care, safety is the priority issue.

The nurse is caring for a client who underwent an open reduction internal fixation to the right hip. When administering opioid analgesics for pain, the nurse should instruct the client that which are side and adverse effects of opioid analgesics? Select all that apply.

Sedation, constipation and respiratory depression; Side and adverse effects of opioids include constipation, sedation, and respiratory depression. Diarrhea is not a side effect. The pain level should decrease, not increase.

The nurse develops a plan of care for a child at risk for tonic-clonic seizures. In the plan of care, the nurse identifies seizure precautions and documents that which item(s) need to be placed at the child's bedside?

Suctioning equipment and oxygen; A seizure results from the excessive and unorganized neuronal discharges in the brain that activate associated motor and sensory organs. A type of generalized seizure is a tonic-clonic seizure. This type of seizure causes rigidity of all body muscles, followed by intense jerking movements. Because increased oral secretions and apnea can occur during and after the seizure, oxygen and suctioning equipment are placed at the bedside. A tracheotomy is not performed during a seizure. No object, including a padded tongue blade, is placed into the child's mouth during a seizure.

The nurse provides dietary instructions to a client with Ménière's disease. The nurse should tell the client that which food or fluid item is acceptable to consume?

Sugar free jello; The underlying pathological changes of Ménière's disease include overproduction and defective absorption of endolymph. This increases the volume and pressure within the membranous labyrinth until distention results in rupture and mixing of the endolymph and perilymph fluids. Dietary therapy frequently is quite helpful in controlling the symptoms associated with Ménière's disease. The nurse encourages the client to follow a low-salt diet and to avoid caffeine, sugar, monosodium glutamate, and alcohol.

The nurse is caring for a client after hypophysectomy and notes clear nasal drainage from the client's nostril. The nurse should take which initial action?

Test the drainage for glucose; After hypophysectomy, the client should be monitored for rhinorrhea, which could indicate a cerebrospinal fluid leak. If this occurs, the drainage should be collected and tested for the presence of cerebrospinal fluid. Cerebrospinal fluid contains glucose, and if positive, this would indicate that the drainage is cerebrospinal fluid. The head of the bed should remain elevated to prevent increased intracranial pressure.

The nurse is assessing a client for meningeal irritation and elicits a positive Brudzinski's sign. Which finding did the nurse observe?

The client passively flexes the hip and knee in response to neck flexion and reports pain in the vertebral column; Brudzinski's sign is tested with the client in the supine position. The nurse flexes the client's head (gently moves the head to the chest) and there should be no reports of pain or resistance to the neck flexion. A positive Brudzinski's sign is observed if the client passively flexes the hip and knee in response to neck flexion and reports pain in the vertebral column. Kernig's sign also tests for meningeal irritation and is positive when the client flexes the legs at the hip and knee and complains of pain along the vertebral column when the leg is extended. Decorticate posturing is abnormal flexion and is noted when the client's upper arms are flexed and held tightly to the sides of the body and the legs are extended and internally rotated. Decerebrate posturing is abnormal extension and occurs when the arms are fully extended, forearms pronated, wrists and fingers flexed, jaws clenched, neck extended, and feet plantar-flexed.

A client with suspected opioid overdose has received a dose of naloxone hydrochloride. The client subsequently becomes restless, starts to vomit, and complains of abdominal cramping. The blood pressure increases from 110/72 mm Hg to 160/86 mm Hg. The nurse provides emotional support and reassurance while administering care to the client, knowing which piece of information?

These are signs of opioid withdrawal; Signs of opioid withdrawal include increased temperature and blood pressure, abdominal cramping, vomiting, and restlessness. Time of onset may be anywhere from a few minutes to a few hours after administration of naloxone hydrochloride, depending on the opioid involved, the degree of dependence, and the dose of naloxone. The remaining options are incorrect interpretations.

The nurse is performing an assessment on a client with a diagnosis of Ménière's disease. The nurse anticipates that the client is most likely to report which symptom during an acute attack?

Tinnitus; Ménière's disease results in a disturbance of the fluid of the endolymphatic system. The cause of the disturbance is not known. Attacks may be preceded by feelings of fullness in the ear or by tinnitus.

A client is diagnosed with a disorder involving the inner ear. Which is the most common client complaint associated with a disorder involving this part of the ear?

Tinnitus; Tinnitus is the most common complaint of clients with otological disorders, especially disorders involving the inner ear. Symptoms of tinnitus range from mild ringing in the ear, which can go unnoticed during the day, to a loud roaring in the ear, which can interfere with the client's thinking process and attention span.

Meperidine hydrochloride is prescribed for a client with pain. What should the nurse monitor for as a side or adverse effect of this medication?

Urinary retention; Side and adverse effects of meperidine include respiratory depression, orthostatic hypotension, tachycardia, drowsiness and mental clouding, constipation, and urinary retention.

Clients who have undergone crainotomy should have the head of the bed elevated 30 to 45 degrees to promote venous drainage from the head. The client is positioned to avoid extreme hip or neck flexion and the head is maintained in a midline neutral position. The client should not be positioned on the site that was operated on, especially if the bone flap was removed, because the brain has no bony covering on the affected site. A flat position (option 4) or Trendelenburg's position (option 2) would increase intracranial pressure. A reverse Trendelenburg's position (option 3) would not be helpful and may be uncomfortable for the client?

Vomiting; The brain, although well protected by the solid bony cranium, is highly susceptible to pressure that may accumulate within the enclosure. Volume and pressure must remain constant within the brain. A change in the size of the brain, such as occurs with edema or increased volume of intracranial blood or cerebrospinal fluid without a compensatory change, leads to an increase in ICP, which may be life-threatening. Vomiting, an early sign of increased ICP, can become excessive as pressure builds up and stimulates the medulla in the brainstem, which houses the vomiting center. Children with open fontanels (posterior fontanel closes at 2 to 3 months; anterior fontanel closes at 12 to 18 months) compensate for ICP changes by skull expansion and subsequent bulging fontanels. When the fontanels have closed, nausea, excessive vomiting, diplopia, and headaches become pronounced, with headaches becoming more prevalent in older children.

The nurse is caring for a client who takes ibuprofen for pain. The nurse is gathering information on the client's medication history, and determines it is necessary to contact the health care provider (HCP) if the client is also taking which medications, that are contraindicated for use with ibuprofen? Select all that apply.

Warfarin, Glimepiride and Amlodipine; Nonsteroidal antiinflammatory drugs (NSAIDs) such as ibuprofen can amplify the effects of anticoagulants such as warfarin; therefore, these medications should not be taken together. Hypoglycemia may result for the client taking ibuprofen if the client is concurrently taking an oral hypoglycemic agent such as glimepiride; these medications should not be combined. A high risk of toxicity exists if the client is taking ibuprofen concurrently with a calcium channel blocker such as amlodipine; therefore, this combination is contraindicated.

The nurse prepares a client for ear irrigation as prescribed by the health care provider. Which action should the nurse take when performing the procedure?

Warm the irrigation solution to 98.6 degrees; Before ear irrigation, the nurse should inspect the tympanic membrane to ensure that it is intact. The irrigating solution should be warmed to 98.6°F (37.0°C) because a solution temperature that is not close to the client's body temperature will cause ear injury, nausea, and vertigo. The affected side should be down following the irrigation to assist in drainage of the fluid. When irrigating, a direct and slow steady stream of irrigation solution is directed toward the wall of the canal, not toward the eardrum. The client is positioned sitting, facing forward with the head in a natural position; if the ear is faced upward, the nurse would not be able to visualize the canal.

The health care provider prescribes the instillation of mydriatic eye drops to both eyes of a client. The nurse administers the eye drops and monitors the client for an effective response from the medication, as indicated by which response? Click on the image to indicate your answer.

dilated eyes; The top figure identifies unequal pupil size. This finding may be normal in some individuals, but the client with unequal pupil size should be assessed for central nervous system disease. The figure that is second from the top identifies constricted pupils. The third figure from the top identifies a unilateral dilated pupil, indicating cranial nerve III damage.

In preparation for cataract surgery, the nurse is to administer prescribed eye drops. The nurse reviews the health care provider's prescriptions, expecting which type of eye drops to be prescribed?

mydriatic medication; A mydriatic medication produces mydriasis or dilation of the pupil. Mydriatic medications are used preoperatively in the client with a cataract. These medications act by dilating the pupils; they also constrict blood vessels. A miotic medication constricts the pupil. An osmotic diuretic may be used to decrease intraocular pressure. A thiazide diuretic is not likely to be prescribed for a client with a cataract.

The nurse is assessing the motor and sensory function of an unconscious client. The nurse should use which technique to test the client's peripheral response to pain?

nail bed pressure; Nail bed pressure tests a basic motor and sensory peripheral response. Cerebral responses to pain are tested using a sternal rub, placing upward pressure on the orbital rim, or squeezing the clavicle or sternocleidomastoid muscle.

A client with cancer is receiving a continuous intravenous infusion of morphine sulfate. The nurse monitoring the client for adverse effects would become most concerned about which vital sign?

respirations of 10 breaths/min; Before an opioid is administered, respiratory rate, blood pressure, and pulse rate should be assessed. Morphine sulfate should be withheld and the health care provider notified if the respiratory rate is at or below 12 breaths per minute, if the blood pressure is significantly below the pretreatment value, or if the pulse rate is significantly above or below pretreatment value. A temperature of 99.1°F (37.3°C) is not associated with the use of morphine sulfate.