ATI Fundamentals Ch 45
A nurse is caring for a client who has several risk factors for hearing loss. As the nurse reviews the client's medication history, which of the following medications the client takes should alert the nurse to a further risk for ototoxicity? (Select all that apply.) A. Furosemide (Lasix) B. Ibuprofen (Advil) C. Cimetidine (Tagamet) D. Simvastatin (Zocor) E. Amiodarone (Cordarone)
A. CORRECT: Furosemide, a loop diuretic, can cause hearing loss as well as blurred vision. B. CORRECT: Ibuprofen, a nonsteroidal anti-inflammatory agent, can cause hearing loss as well as vision loss. C. INCORRECT: Cimetidine, a medication that decreases gastric acid secretion, is unlikely to cause hearing loss. D. INCORRECT: Simvastatin, a medication that helps lower cholesterol, is unlikely to cause hearing loss. E. INCORRECT: Amiodarone, an antidysrhythmic medication, is more likely to cause blurred vision than hearing loss.
A nurse is caring for a client who recently had a cerebrovascular accident and has aphasia. Which of the following interventions should the nurse use to promote communication with this client? (Select all that apply.) A. Speak fast and loudly. B. Minimize background noise. C. Write down what the client does not understand. D. Allow plenty of time for the client to respond. E. Use brief sentences with simple words.
A. CORRECT: The client is not hearing impaired, so speaking loudly will not promote communication. B. CORRECT: Minimizing background noise provides a calming environment. C. INCORRECT: Writing down what the client does not understand provides the same information in a format the client can understand, provided he is literate. D. INCORRECT: Allowing ample time for the client to respond helps enhance communication. Rushing ahead to the next question would be demeaning and could cause frustration. E. INCORRECT: Brief sentences with simple words are generally easy to understand.
A nurse is caring for a client who reports difficulty hearing. Which of the following assessment findings indicate a sensorineural hearing loss in the left ear? (Select all that apply.) A. Weber test showing lateralization to the right ear B. Light reflex at 10 o'clock in the left ear C. No signs of obstruction in the left ear canal D. Rinne test showing length of time is decreased for air and bone conduction E. Rinne test showing air conduction less than bone conduction in the left ear
A. CORRECT: With sensorineural hearing loss, the Weber test demonstrates lateralization to the unaffected ear. D. CORRECT: With sensorineural hearing loss in the left ear, length of time is decreased for both air and bone conduction. B. INCORRECT: A light reflex at 10 o'clock in the left ear indicates that air or fluid has displaced the tympanic membrane, but it does not indicate sensorineural hearing loss. C. CORRECT: Signs of obstruction in the ear canal indicate conductive, not sensorineural, hearing loss. E. INCORRECT: With sensorineural hearing loss in the left ear, air conduction is greater than bone conduction in the left ear.
A nurse is caring for a client who had an amphetamine overdose and has sensory overload. Which of the following interventions should the nurse implement? A. Immediately complete a thorough assessment. B. Put the client in a room with a client who is hearing impaired. C. Provide a private room, and limit stimulation. D. Talk loudly to the client, and encourage ambulation.
C. CORRECT: Minimizing stimuli helps clients who have sensory overload. A. INCORRECT: Immediately completing a thorough assessment might overwhelm the client at this time. Therefore, brief assessments during the course of the shift are better. B. INCORRECT: Rooming with a client who is hearing impaired would increase environmental stimuli. D. INCORRECT: Talking loudly would increase environmental stimuli.
A nurse is reviewing instructions with a client who is hearing impaired and has just started wearing hearing aids. Which of the following statements by the client indicates understanding of the instructions? A. "I use a damp cloth to clean the outside part of my hearing aids." B. "I clean the ear molds of my hearing aids with rubbing alcohol." C. "I keep the volume of my hearing aids turned up so I can hear better." D. "I take the batteries out of my hearing aids when I take them off at night."
D. CORRECT: To conserve battery power, the client should turn off the hearing aids and remove the batteries when not in use. A. INCORRECT: The client should keep the hearing aids completely dry at all times. B. INCORRECT: The client should clean the ear molds with mild soap and water. C. INCORRECT: To avoid feedback noise, the client should keep the volume on the lowest setting that allows her to hear.
A nurse is teaching a group of nursing students how to intervene for clients who have sensory impairment. Use the ATI Active Learning Template: Systems Disorder to complete this item. Under Management of Client Care, list at least six interventions for clients who are hearing impaired and at least six interventions for clients who are visually impaired.
● Management of Client Care ◯ Hearing impairment Sit and face the client. Avoid covering the mouth while speaking. Encourage the use of hearing devices. Speak slowly and clearly. Do not shout. Try lowering vocal pitch before increasing volume. Use brief sentences with simple words. Write down what clients do not understand. Minimize background noises. Ask for a sign language interpreter if necessary. ◯ Vision impairment Call clients by name before approaching to avoid startling them. Identify yourself. Stay within the clients' visual field if they have a partial loss. Give specific information about the location of items or areas of the building. Explain interventions before touching clients. Before leaving, inform clients of your departure. Carefully appraise clothing and suggest changes if soiled or torn. Make a radio, television, compact disc (CD) player, or digital audio file player available. Describe the arrangement of the food on the tray before leaving the room