Unit S-Neurological/Sensory System

Question 1

The nurse teaches an 80-year-old client with diminished peripheral sensation. Which
statement would the nurse include in this client’s teaching?
a. “Place soft rugs in your bathroom to decrease pain in your feet.”
b. “Bathe in warm water to increase your circulation.”
c. “Look at the placement of your feet when walking.”
d. “Walk barefoot to decrease pressure injuries from your shoes.”

Answer 1

ANS: C
Older clients with decreased sensation are at risk of injury from the inability to sense changes
in terrain when walking. To compensate for this loss, the client is instructed to look at the
placement of his or her feet when walking. Throw rugs can slip and increase fall risk. Bath
water that is too warm places the client at risk for thermal injury.

Question 2

The nurse assesses a client’s recent memory. Which statement by the client confirms that
recent memory is intact?
a. “A young girl wrapped in a shroud fell asleep on a bed of clouds.”
b. “I was born on April 3, 1967, in Johnstown Community Hospital.”
c. “Apple, chair, and pencil are the words you just stated.”
d. “I ate oatmeal with wheat toast and orange juice for breakfast.”

Answer 2

ANS: D
Asking clients about recent events that can be verified, such as what the client ate for
breakfast, assesses recent memory. Asking clients about certain facts from the past that can be
verified assesses remote or long-term memory. Asking the client to repeat words assesses
immediate memory.

Question 3

A client is admitted to the emergency department with a probable traumatic brain injury.
Which assessment finding would be the priority for the nurse to report to the primary health
care provider?
a. Mild temporal headache
b. Pupils equal and react to light
c. Alert and oriented  3
d. Decreasing level of consciousness

Answer 3

ANS:D
A decreasing level of consciousness is the first sign of increasing intracranial pressure, a
potentially severe and possibly fatal complication of a traumatic brain injury (TBI). A mild
headache would be expected for a client having a TBI. Equal reactive pupils and being alert
and oriented are normal assessment findings.

Question 4

A nurse asks a client to take deep breaths during an electroencephalography. The client asks,
“Why are you asking me to do this?” How would the nurse respond?
a. “Hyperventilation causes vascular dilation of cerebral arteries, which decreases
electoral activity in the brain.”
b. “Deep breathing helps you to relax and allows the electroencephalograph to obtain
a better waveform.”
c. “Hyperventilation causes cerebral vasoconstriction and increases the likelihood of
seizure activity.”
d. “Deep breathing will help you to blow off carbon dioxide and decreases
intracranial pressures.”

Answer 4

ANS: C
Hyperventilation produces cerebral vasoconstriction and alkalosis, which increase the
likelihood of seizure activity. The client is asked to breathe deeply 20 times for 3 minutes.
The other responses are not accurate.

Question 5

A nurse assesses a client recovering from a cerebral angiography via the right femoral artery.
Which assessment would the nurse complete?
a. Palpate bilateral lower extremity pulses.
b. Obtain orthostatic blood pressure readings.
c. Perform a funduscopic examination.
d. Assess the gag reflex prior to eating.

Answer 5

ANS: A
Cerebral angiography is performed by threading a catheter through the femoral or brachial
artery. The extremity is kept immobilized after the procedure. The nurse checks the extremity
for adequate circulation by noting skin color and temperature, presence and quality of pulses
distal to the injection site, and capillary refill. Clients usually are on bedrest; therefore,
orthostatic blood pressure readings cannot be performed. The funduscopic (eye) examination
would not be affected by cerebral angiography. The client is not given general anesthesia;
therefore, the client’s gag reflex would not be compromised.

Question 6

When assessing a client who had a traumatic brain injury, the nurse notes that the client is
drowsy but easily aroused. What level of consciousness will the nurse document to describe
this client’s current level of consciousness?
a. Alert
b. Lethargic
c. Stuporous
d. Comatose

Answer 6

ANS: B
The client is categorized as being lethargic because he or she can be easily aroused even
though drowsy. The nurse would carefully monitor the client to determine any decrease in the
level of consciousness (LOC).

Question 7

The nurse is assessing a client diagnosed with trigeminal neuralgia affecting cranial nerve V.
What assessment findings will the nurse expect for this client?
a. Expressive aphasia
b. Ptosis (eyelid drooping)
c. Slurred speech
d. Severe facial pain

Answer 7

ANS: D
Cranial nerve (CN) V is the Trigeminal Nerve which has both a motor and sensory function in
the face. When affected by a health problem, the client experiences severely facial pain.
Expressive aphasia results from damage to the Broca speech area in the frontal lobe of the
brain. Ptosis can result from damage to CN III and slurred speech often occurs from either
damage to several cranial nerves or from damage to the motor strip in the frontal lobe of the
brain.

Question 8

The nurse is performing an assessment of cranial nerve III. Which testing is appropriate?

a. Pupil constriction
b. Deep tendon reflexes
c. Upper muscle strength
d. Speech and language

Answer 8

ANS: A
CN III is the oculomotor nerve which controls eye movement, pupil constriction, and eyelid
movement.

Question 9

A nurse cares for a client who is experiencing deteriorating neurologic functions. The client
states, “I am worried I will not be able to care for my young children.” How would the nurse
respond?
a. “Caring for your children is a priority. You may not want to ask for help, but you
really have to.”
b. “Our community has resources that may help you with some household tasks so
you have energy to care for your children.”
c. “You seem distressed. Would you like to talk to a psychologist about adjusting to
your changing status?”
d. “Can you tell me more about what worries you, so we can see if we can do
something to make adjustments?”

Answer 9

ANS: D
Investigate specific concerns about situational or role changes before providing additional
information. The nurse would not tell the client what is or is not a priority for him or her.
Although community resources may be available, they may not be appropriate for the patient.
Consulting a psychologist would not be appropriate without obtaining further information
from the client related to current concerns.

Question 10

A nurse plans care for a 77-year-old client who is experiencing age-related
peripheral sensory perception changes. Which intervention would the nurse include in this
client’s plan of care?
a. Provide a call button that requires only minimal pressure to activate.
b. Write the date on the client’s white board to promote orientation.
c. Ensure that the path to the bathroom is free from clutter.
d. Encourage the client to season food to stimulate nutritional intake.

Answer 10

ANS: C
Dementia and confusion are not common phenomena in older adults. However, physical
impairment related to illness can be expected. Providing opportunities for hazard-free
ambulation will maintain strength and mobility (and ensure safety). Providing a call button,
providing the date, and seasoning food do not address the client’s impaired sensory
perception.

Question 11

After teaching a patient who is scheduled for magnetic resonance imaging (MRI), the nurse
assesses the client’s understanding. Which statement indicates client understanding of the
teaching?
a. “I must increase my fluids because of the dye used for the MRI.”
b. “My urine will be radioactive so I should not share a bathroom.”
c. “My gag reflex will be tested before I can eat or drink anything.”
d. “I can return to my usual activities immediately after the MRI.”

Answer 11

ANS: D
No postprocedure restrictions are imposed after MRI. The client can return to normal
activities after the test is complete. There are no dyes or radioactive materials used for the
MRI; therefore, increased fluids are not needed and the client’s urine would not be
radioactive. The procedure does not impact the client’s gag reflex.

Question 12

A nurse performs an assessment of pain discrimination on an older adult. The client correctly
identifies, with eyes closed, a sharp sensation on the right hand when touched with a pin.
Which action would the nurse take next?
a. Touch the pin on the same area of the left hand.
b. Contact the primary health care provider with the assessment results.
c. Ask the client about current and past medications.
d. Continue the assessment on the client’s feet and legs.

Answer 12

ANS: A
If testing is begun on the right hand and the client correctly identifies the pain stimulus, the
nurse would continue the assessment on the left hand. This is a normal finding and does not
need to be reported to the provider, but instead documented in the client’s medical record.
Medications do not need to be assessed in response to this finding. The nurse would assess the
left hand prior to assessing the feet.

Question 13

A nurse is teaching a client with cerebellar function impairment. Which statement would the
nurse include in this client’s discharge teaching?
a. “Connect a light to flash when your door bell rings.”
b. “Label your faucet knobs with hot and cold signs.”
c. “Ask a friend to drive you to your follow-up appointments.”
d. “Use a natural gas detector with an audible alarm.”

Answer 13

ANS: C
Cerebellar function enables the client to predict distance or gauge the speed with which one is
approaching an object, control voluntary movement, maintain equilibrium, and shift from one
skilled movement to another in an orderly sequence. A client who has cerebellar function
impairment should not be driving. The client would not have difficulty hearing, distinguishing
between hot and cold, or smelling.

Question 14

Which statement would the nurse include when teaching the assistive personnel (AP) about
how to care for a client with cranial nerve II impairment?
a. “Tell the client where food items are on the breakfast tray.”
b. “Place the client in a high-Fowler position for all meals.”
c. “Make sure the client’s food is visually appetizing.”
d. “Assist the client by placing the fork in the left hand.”

Answer 14

ANS: A
Cranial nerve II, the optic nerve, provides central and peripheral vision. A patient who has
cranial nerve II impairment will have decreased visual acuity, so the AP would tell the client
where different food items are on the meal tray. The other options are not appropriate for
client with cranial nerve II impairment.

Question 15

A nurse prepares a client for lumbar puncture (LP). Which assessment finding would alert the
nurse to contact the primary health care provider?
a. Shingles infection on the client’s back
b. Client is claustrophobic
c. Absence of intravenous access
d. Paroxysmal nocturnal dyspnea

Answer 15

ANS: A
An LP would not be performed if the client has a skin infection at or near the puncture site
because of the risk of cerebrospinal fluid infection. A nurse would want to notify the primary
health care provider if shingles were identified on the client’s back. If a client has shortness of
breath when lying flat, the LP can be adapted to meet the client’s needs. Claustrophobia,
absence of IV access, and paroxysmal nocturnal dyspnea have no impact on whether an LP
can be performed.

Question 16

A nurse assesses a patient who is recovering from a lumbar puncture (LP). Which
complication of this procedure would alert the nurse to urgently contact the primary health
care provider?
a. Weak pedal pulses
b. Nausea and vomiting
c. Increased thirst
d. Hives on the chest

Answer 16

ANS: B
The nurse would immediately contact the provider if the client experiences a severe headache,
nausea, vomiting, photophobia, or a change in level of consciousness after an LP, which are
all signs of increased intracranial pressure. Weak pedal pulses, increased thirst, and hives are
not complications of an LP.

Question 17

A nurse assesses a client with an injury to the medulla. Which clinical manifestations would
the nurse expect to find? (Select all that apply.)
a. Decreased respiratory rate
b. Impaired swallowing
c. Visual changes
d. Inability to shrug shoulders
e. Loss of gag reflex

Answer 17

ANS: A, B, D, E
Cranial nerves IX (glossopharyngeal), X (vagus), XI (accessory), and XII (hypoglossal)
emerge from the medulla, as do portions of cranial nerves VII (facial) and VIII (acoustic).
Damage to these nerves causes decreased respirations, impaired swallowing, inability to shrug
shoulders, and loss of the gag reflex. The other manifestations are not associated with damage
to the medulla.

Question 18

An 84-year-old client who is usually alert and oriented experiences an acute cognitive decline.
Which of the following factors would the nurse anticipate as contributing to this neurologic
change? (Select all that apply.)
a. Chronic hearing loss
b. Infection
c. Drug toxicity
d. Dementia
e. Hypoxia
f. Aging

Answer 18

ANS: B, C, E
Acute client conditions that occur in older adults often cause acute confusion and associated
emotional behaviors. Infection, drug toxicity, and hypoxia are all acute health problems that
can contribute to the client’s cognitive decline. Aging does not cause changes in cognition. If
the client had dementia, he or she would not be alert and oriented. Having a chronic hearing
loss is not a change in the client’s condition.

Question 19

A nurse assesses a client with a brain tumor. Which newly identified assessment findings
would alert the nurse to urgently communicate with the primary health care provider? (Select
all that apply.)
a. Glasgow Coma Scale score of 8
b. Decerebrate posturing
c. Reactive pupils
d. Uninhibited speech
e. Decreasing level of consciousness

Answer 19

ANS: A, B, E
The nurse would urgently communicate changes in a patient’s neurologic status, including a
decrease in the Glasgow Coma Scale score; abnormal flexion or extension; changes in
cognition or level of consciousness; and pinpointed, dilated, and nonreactive pupils.

Question 20

A nurse assesses an older client. Which assessment findings would the nurse identify as
normal changes in the nervous system related to aging? (Select all that apply.)
a. Long-term memory loss
b. Slower processing time
c. Increased sensory perception
d. Decreased risk for infection
e. Change in sleep patterns

Answer 20

ANS: B, E
Normal changes in the nervous system related to aging include recent memory loss, slower
processing time, decreased sensory perception, an increased risk for infection, changes in
sleep patterns, changes in perception of pain, and altered balance and/or decreased
coordination.

Question 21

The nurse is teaching the daughter of a client who has middle-stage Alzheimer disease. The
daughter asks, “Will the sertraline my mother is taking improve her dementia?” How would
the nurse respond about the purpose of the drug?
a. “It will allow your mother to live independently for several more years.”
b. “It is used to halt the advancement of Alzheimer disease but will not cure it.”
c. “It will not improve her dementia but can help control emotional responses.”
d. “It is used to improve short-term memory but will not improve problem solving.”

Answer 21

ANS: C
Drug therapy is not effective for treating dementia or halting the advancement of Alzheimer
disease. However, certain psychoactive drugs may help suppress emotional disturbances and
manage depression, psychoses, or anxiety. Drug therapy will not allow the client with
middle-stage dementia to safely live independently.

Question 22

A client with early-stage Alzheimer disease is admitted to the hospital with chest pain. Which
nursing action is most appropriate to manage this client’s dementia?
a. Provide animal-assisted therapy as needed.
b. Ensure a structured and consistent environment.
c. Assist the client with activities of daily living (ADLs).
d. Use validation therapy when communicating with the client.

Answer 22

ANS: B
The client who has early Alzheimer disease (AD) does not require assistance with ADLs or
validation therapy. While animal-assisted therapy may be helpful, some health care agencies
do not allow this intervention. Therefore, the most appropriate action is to provide a structured
and consistent environment while the client is hospitalized to prevent worsening of the client’s
symptoms.

Question 23

The nurse observes a client with late-stage Alzheimer disease eat breakfast. Afterward the
client states, “I am hungry and want breakfast.” What is the nurse’s best response?
a. “I see you are still hungry. I will get you some toast.”
b. “You ate your breakfast 30 minutes ago.”
c. “It appears you are confused this morning.”
d. “Your family will be here soon. Let’s get you dressed.”

Answer 23

ANS: A
Use of validation therapy with clients who have late-stage Alzheimer disease involves
acknowledgment of the client’s feelings and concerns. This technique has proved more
effective in later stages of the disease because reality orientation only increases agitation. The
other statements do not validate the client’s concerns.

Question 24

The nurse cares for a client with middle-stage (moderate) Alzheimer disease. The client’s
caregiver states, “She is always wandering off. What can I do to manage this restless
behavior?” What is the nurse’s best response?
a. “This is a sign of fatigue. The client would benefit from a daily nap.”
b. “Engage the client in scheduled activities throughout the day.”
c. “It sounds like this is difficult for you. I will consult the social worker.”
d. “The provider can prescribe a mild sedative for restlessness.”

Answer 24

ANS: B
Several strategies may be used to cope with restlessness and wandering. One strategy is to
engage the client in structured activities. Another is to take the client for frequent walks. Daily
naps and a mild sedative will not be as effective in the management of restless behavior.
Consulting the social worker does not address the caregiver’s concern.

Question 25

The nurse prepares to discharge a client with early to moderate Alzheimer disease. Which statement to maintain client safety would the nurse include in the discharge teaching for the caregiver? a. “Provide periods of exercise and rest for the client.” b. “Place a padded throw rug at the bedside.” c. “Provide a highly stimulating environment.” d. “Install safety locks on all outside doors.”

Answer 25

ANS: D Clients with early to moderate Alzheimer disease have a tendency to wander, especially at night. If possible, alarms would be installed on all outside doors to alert family members if the client leaves. At a minimum, all outside doors should have safety locks installed to prevent the client from going outdoors unsupervised. The client would be allowed to exercise within his or her limits, but this action does not ensure his or her safety. Throw rugs are a slip and fall hazard and would be removed. A highly stimulating environment would likely increase the client’s confusion.

Question 26

The nurse is teaching a family caregiver about how best to communicate with the client who has been diagnosed with Alzheimer disease. Which statement by the caregiver indicates a need for further teaching? a. “I will avoid communicating with the client to prevent agitation.” b. “I should use simple, short sentences and one-step instructions.” c. “I can try to use gestures or pictures to communicate with the client.” d. “I will limit the number of choices I provide for the client.”

Answer 26

ANS: A Communication with the client is important to provide cognitive stimulation. Using short simple sentences, using gestures and pictures, and limiting choices provided for the client will help promote communication.

Question 27

The nurse teaches assistive personnel (AP) about how to care for a client with early-stage Alzheimer disease. Which statement would the nurse include? a. “If she is confused, play along and pretend that everything is okay.” b. “Remove the clock from her room so that she doesn’t get confused.” c. “Reorient the client to the day, time, and environment with each contact.” d. “Use validation therapy to recognize and acknowledge the client’s concerns.”

Answer 27

ANS: C Clients who have early-stage Alzheimer disease would be reoriented frequently to person, place, and time. The AP would reorient the client and not encourage the client’s delusions. The room would have a clock and white board with the current date written on it. Validation therapy is used with late-stage Alzheimer disease.

Question 28

The primary health care provider prescribes donepezil for a client diagnosed with early-stage Alzheimer disease. What teaching about this drug will the nurse provide for the client’s family caregiver? a. “Monitor the client’s temperature because the drug can cause a low grade fever.” b. “Observe the client for nausea and vomiting to determine drug tolerance.” c. “Donepezil will prevent the client’s dementia from progressing as usual.” d. “Report any client dizziness or falls because the drug can cause bradycardia.”

Answer 28

ANS: D Donepezil is a cholinesterase inhibitor that may temporarily slow cognitive decline for some clients but does not alter the course of the disease. The family caregiver would want to monitor the client’s heart rate and report any incidence of dizziness or falls because the drug can cause bradycardia. It does not typically cause fever or nausea/vomiting.

Question 29

After teaching the wife of a client who has Parkinson disease, the nurse assesses the wife’s understanding. Which statement by the client’s wife indicates that she correctly understands changes associated with this disease? a. “His masklike face makes it difficult to communicate, so I will use a white board.” b. “He should not socialize outside of the house due to uncontrollable drooling.” c. “This disease is associated with anxiety causing increased perspiration.” d. “He may have trouble chewing, so I will offer bite-sized portions.”

Answer 29

ANS: D Because chewing and swallowing can be problematic, small frequent meals and a supplement are better for meeting the client’s nutritional needs. A masklike face and drooling are common in clients with Parkinson disease. The client would be encouraged to continue to socialize and communicate as normally as possible. The wife should understand that the client’s masklike face can be misinterpreted and additional time may be needed for the client to communicate with her or others. Excessive perspiration is also common in clients with Parkinson disease and is associated with the autonomic nervous system’s response.

Question 30

The nurse plans care for a client with Parkinson disease. Which intervention would the nurse include in this client’s plan of care? a. Restrain the client to prevent falling. b. Ensure that the client uses incentive spirometry. c. Teach the client pursed-lip breathing techniques. d. Keep the head of the bed at 30 degrees or greater

Answer 30

ANS: D Elevation of the head of the bed will help prevent aspiration. The other options will not prevent aspiration, which is the greatest respiratory complication of Parkinson disease, nor do these interventions address any of the complications of Parkinson disease. Pursed-lip breathing increases exhalation of carbon dioxide; incentive spirometry expands the lungs. The client should not be restrained to prevent falls. Other less restrictive interventions should be used to maintain client safety.

Question 31

A nurse teaches assistive personnel (AP) about how to care for a client with Parkinson disease. Which statement would the nurse include as part of this teaching? a. “Allow the client to be as independent as possible with activities.” b. “Assist the client with frequent and meticulous oral care.” c. “Assess the client’s ability to eat and swallow before each meal.” d. “Schedule appointments early in the morning to ensure rest in the afternoon.”

Answer 31

ANS:A Clients with Parkinson disease do not move as quickly and can have functional problems. The client would be encouraged to be as independent as possible and provided time to perform activities without rushing. Although oral care is important for all clients, instructing the UAP to provide frequent and meticulous oral is not a priority for this client. This statement would be a priority if the client was immune-compromised or NPO. The nurse would assess the client’s ability to eat and swallow; this would not be delegated. Appointments and activities would not be scheduled early in the morning because this may cause the client to be rushed and discourage the client from wanting to participate in activities of daily living.

Question 32

A client diagnosed with Parkinson disease will be starting ropinirole for symptom control. Which statement by the client indicates a need for further teaching? a. “This drug should help decrease my tremors and help me move better.” b. “I need to change positions slowly to prevent dizziness or falls.” c. “I should take the drug at the same time each day for the best effect.” d. “I know the drug will probably make help me prevent constipation.”

Answer 32

ANS: D Although ropinirole is a dopamine agonist and mimics dopamine to promote movement, it does not work to prevent constipation. This class of drugs can cause orthostatic hypotension and should be taken at the same time every day.

Question 33

A nurse is teaching a client who experiences migraine headaches and is prescribed propranolol. Which statement would the nurse include in this client’s teaching? a. “Take this drug only when you have symptoms indicating the onset of a migraine headache.” b. “Take this drug as prescribed, even when feeling well, to prevent vascular changes associated with migraine headaches.” c. “This drug will relieve the pain during the aura phase soon after a headache has started.” d. “This drug will have no effect on your heart rate or blood pressure because you are taking it for migraines.”

Answer 33

ANS: B Propranolol is a beta-adrenergic blocker which is prescribed as prophylactic treatment to prevent the vascular changes that initiate migraine headaches. Heart rate and blood pressure will also be affected, and the client would monitor these side effects. The other responses do not discuss appropriate uses of this drug.

Question 34

The nurse assesses a client who has a history of migraines. Which symptom would the nurse identify as an early sign of a migraine with aura? a. Vertigo b. Lethargy c. Visual disturbances d. Numbness of the tongue

Answer 34

ANS: C Early warning of impending migraine with aura usually consists of visual changes, flashing lights, or diplopia. The other symptoms are not associated with an impending migraine with aura.

Question 35

The nurse assesses a client with a history of epilepsy who experiences stiffening of the muscles of the arms and legs, followed by an immediate loss of consciousness and jerking of all extremities. How would the nurse document this type of seizure? a. Atonic b. Myoclonic c. Absence d. Tonic-clonic

Answer 35

ANS: D Seizure activity that begins with stiffening of the arms and legs, followed by loss of consciousness and jerking of all extremities, is characteristic of a tonic-clonic seizure. An atonic seizure presents as a sudden loss of muscle tone followed by postictal confusion. A myoclonic seizure presents with a brief jerking or stiffening of extremities that may occur singly or in groups. Absence seizures present with automatisms, and the client is unaware of his or her environment.

Question 36

The nurse witnesses a client begin to experience a tonic-clonic seizure and loss of consciousness. What action would the nurse take first? a. Start fluids via a large-bore catheter. b. Administer IV push diazepam. c. Turn the client’s head to the side. d. Prepare to intubate the client.

Answer 36

ANS: C The nurse would turn the client’s head to the side to prevent aspiration and allow drainage of secretions. Anticonvulsants are administered on a routine basis if a seizure is sustained. If the seizure is sustained (status epilepticus), the client must be intubated and would be administered oxygen, 0.9% sodium chloride, and IV push lorazepam or diazepam.

Question 37

A nurse cares for a client who is experiencing status epilepticus. Which prescribed medication would the nurse anticipate to prepare for administration? a. Atenolol b. Lorazepam c. Phenytoin d. Lisinopril

Answer 37

ANS: B Initially, intravenous lorazepam or diazepam is administered to stop motor movements. This is followed by the administration of phenytoin. Atenolol, a beta blocker, and lisinopril, an angiotensin-converting enzyme inhibitor, are not administered for seizure activity. These drugs are typically administered for hypertension and heart failure.

Question 38

After teaching a client who is diagnosed with new-onset epilepsy and prescribed phenytoin, the nurse assesses the client’s understanding. Which statement by the client indicates a correct understanding of the teaching? a. “To prevent complications, I will drink at least 2 L of water daily.” b. “This medication will stop me from getting an aura before a seizure.” c. “I will not drive a motor vehicle while taking this medication.” d. “Even when my seizures stop, I will continue to take this drug.”

Answer 38

ANS: D Discontinuing antiepileptic drugs can lead to the recurrence of seizures or status epilepticus. The client does not need to drink more water and can drive while taking this medication. The drug will not stop an aura before a seizure.

Question 39

After teaching a client newly diagnosed with epilepsy, the nurse assesses the client’s understanding. Which statement by the client indicates a need for additional teaching? a. “I will wear my medical alert bracelet at all times.” b. “While taking my medications, I will not drink any alcoholic beverages.” c. “I will tell my doctor about my prescription and over-the-counter medications.” d. “If I am nauseated, I will not take my epilepsy medication.”

Answer 39

ANS: D The nurse must emphasize that antiepileptic drugs must be taken even if the client is nauseated. Discontinuing the medication can predispose the client to seizure activity and status epilepticus. The client should not drink alcohol while taking seizure medications. The client should wear a medical alert bracelet and should make the primary health care provider aware of all drugs he or she is taking to prevent complications of polypharmacy.

Question 40

The nurse is teaching a group of college students about the importance of preventing meningitis. Which health promotion activity is the most appropriate for preventing this disease? a. Eating a well-balanced diet that is high in protein b. Having an annual physical examination c. Obtaining the recommended meningitis vaccination and boosters d. Identifying signs and symptoms for early treatment

Answer 40

ANS: C CDC-recommended vaccinations and boosters are available for prevention of a number of diseases including meningococcal meningitis. While the other activities are appropriate for general health promotion, they are not specific to meningitis prevention.

Question 41

A nurse obtains a focused health history for a client who is suspected of having bacterial meningitis. Which question would the nurse ask? a. “Do you live in a crowded residence?” b. “When was your last tetanus vaccination?” c. “Have you had any viral infections recently?” d. “Have you traveled out of the country in the last month?”

Answer 41

ANS: A Bacterial meningitis tends to occur in multiple outbreaks. It is most likely to occur in areas of high-density population, such as college dormitories, prisons, and military barracks. A tetanus vaccination would not place the client at increased risk for meningitis or protect the client from meningitis. A viral infection would not lead to bacterial meningitis but could lead to viral meningitis. Simply knowing if the client traveled out of the country does not provide enough information.

Question 42

The nurse plans care for a client with epilepsy who is admitted to the hospital. Which interventions would the nurse include in this client’s plan of care? (Select all that apply.) a. Have suction equipment with an airway at the bedside. b. Place a padded tongue blade at the bedside. c. Permit only clear oral fluids. d. Have oxygen administration set at the bedside. e. Maintain the client on strict bedrest. f. Ensure that the client has IV access.

Answer 42

ANS: A, D, F Oxygen and suctioning equipment with an airway must be readily available. If the client does not have an IV access, insert a saline lock, especially for those clients who are at significant risk for generalized tonic-clonic seizures. The saline lock provides ready access if IV drug therapy must be given to stop the seizure. Padded tongue blades may pose a danger to the client or nurse during a seizure and would not be used. Dietary restrictions and strict bedrest are not interventions associated with epilepsy.

Question 43

``` The nurse assesses a client who is experiencing a common migraine without an aura. Which assessment finding(s) would the nurse expect? (Select all that apply.) a. Headache lasting up to 72 hours b. Unilateral and pulsating headache c. Abrupt loss of consciousness d. Acute confusion e. Pain worsens with physical activities f. Photophobia ```

Answer 43

ANS: A, B, E, F A common migraine with an aura is usually accompanied by photophobia, phonophobia, unilateral and pulsating pain, and nausea and/or vomiting. These migraines usually last 4 to 72 hours and are aggravated by physical activity. Loss of consciousness and acute confusion are not associated with a common migraine without an aura.

Question 44

A nurse prepares to provide perineal care to a client with meningococcal meningitis. Which personal protective equipment would the nurse wear? (Select all that apply.) a. Particulate respirator b. Isolation gown c. Shoe covers d. Surgical mask e. Gloves

Answer 44

ANS: D, E Meningococcal meningitis is spread via saliva and droplets, and Droplet Precautions are necessary. Caregivers would wear a surgical mask when within 6 feet (1.8 m) of the client and would continue to use Standard Precautions, including gloves. A particulate respirator, an isolation gown, and shoe covers are not necessary for Droplet Precautions.

Question 45

The nurse assesses clients on a medical-surgical unit. Which clients would the nurse identify as at risk for secondary seizures? (Select all that apply.) a. A 26-year-old woman with a left temporal brain tumor b. A 38-year-old male client in an alcohol withdrawal program c. A 42-year-old football player with a traumatic brain injury d. A 66-year-old female client with multiple sclerosis e. A 72-year-old man with chronic obstructive pulmonary disease

Answer 45

ANS: A, B, C Clients at risk for secondary seizures include those with a brain lesion from a tumor or trauma, and those who are experiencing a metabolic disorder, acute alcohol withdrawal, electrolyte disturbances, and high fever. Clients with a history of stroke, heart disease, and substance abuse are also at risk. Clients with multiple sclerosis or chronic obstructive pulmonary disease are not at risk for secondary seizures.

Question 46

``` A nurse assesses a client who is recovering from the implantation of a vagal nerve-stimulation device. For which signs and symptoms would the nurse assess as common complications of this procedure? (Select all that apply.) a. Bleeding b. Infection c. Hoarseness d. Dysphagia e. Seizures ```

Answer 46

ANS: C, D Complications of surgery to implant a vagal nerve-stimulation device include hoarseness (most common), dyspnea, neck pain, and dysphagia. The device is tunneled under the skin with an electrode connected to the vagus nerve to control simple or complex partial seizures. Bleeding is not a common complication of this procedure, and infection would not occur during the recovery period.

Question 47

The nurse assesses a client who has meningitis. Which sign(s) and symptom(s) would the nurse anticipate? (Select all that apply.) a. Photophobia b. Decreased level of consciousness c. Severe headache d. Fever and chills e. Bradycardia

Answer 47

ANS: A, B, C, D All of the choices except for bradycardia are key features of meningitis. Tachycardia is more likely than bradycardia due to the infectious process and fever.

Question 48

The nurse assesses a client who has Parkinson disease. Which signs and symptoms would the nurse recognize as a key feature of this disease? (Select all that apply.) a. Flexed trunk b. Long, extended steps c. Slow movements d. Uncontrolled drooling e. Tachycardia

Answer 48

ANS: A, C, D Key features of Parkinson disease include a flexed trunk, slow and hesitant steps, bradykinesia, and uncontrolled drooling. Tachycardia is not a key feature of this disease.

Question 49

A nurse teaches the spouse of a client who has Alzheimer disease. Which statements should the nurse include in this teaching related to caregiver stress reduction? (Select all that apply.) a. “Establish advanced directives early.” b. “Trust that family and friends will help.” c. “Set aside time each day to be away from the client.” d. “Use discipline to correct inappropriate behaviors.” e. “Seek respite care periodically for longer periods of time.”

Answer 49

ANS: A, C, D To reduce caregiver stress, the spouse should be encouraged to establish advanced directives early, set aside time each day for rest or recreation away from the client, seek respite care periodically for longer periods of time, use humor with the client, and explore alternative care settings and resources. Family and friends may not be available to help. A structured environment will assist the client with AD, but discipline will not correct inappropriate behaviors and not reduce caregiver stress.

Question 50

The nurse is caring for a client who has Alzheimer disease. The client’s wife states, “I am having trouble managing his behaviors at home.” Which questions would the nurse ask to assess potential causes of the client’s behavior problems? (Select all that apply.) a. “Does your husband bathe and dress himself independently?” b. “Do you weigh your husband each morning around the same time?” c. “Does his behavior become worse around large crowds?” d. “Does your husband eat healthy foods including fruits and vegetables?” e. “Do you have a clock and calendar in the bedroom and kitchen?”

Answer 50

ANS: A, C, E To minimize behavior problems, the nurse would encourage the patient to be as independent as possible with ADLs, minimize excessive simulation, and assist the patient to remain orientated. The nurse would assess these activities by asking if the patient is independent with bathing and dressing, if behavior worsens around crowds, and if a clock and single-date calendar are readily available. Diet and weight are not related to the management of behavior problems for a patient who has Alzheimer disease.

Question 51

``` The nurse is caring for a client in late-stage Alzheimer disease. Which assessment finding(s) will the nurse anticipate? (Select all that apply.) a. Immobile b. Has difficulty driving c. Wandering d. ADL dependent e. Incontinent f. Possible seizures ```

Answer 51

ANS: A, D, E, F The client in late-stage Alzheimer disease is totally bedridden and immobile, and therefore, cannot ambulate to wander or drive. The client is incontinent and ADL dependent.

Question 52

The nurse is teaching a group of older adults about basic eye examinations. What would the nurse recommend about the frequency for eye examinations for most people over 65 years of age? a. Every 1 to 2 years b. Every 2 to 4 years c. Every 3 to 5 years d. When the primary health care provider recommends

Answer 52

ANS: A Older adults need more frequent basic eye examinations due to the increased risk of glaucoma and cataracts associated with aging. Therefore, every 1 to 2 years for eye examination in the current best practice recommendation.

Question 53

A client with a family history of glaucoma asks the nurse how to prevent glaucoma? What statement by the nurse is appropriate? a. “You should check with your primary health care provider about eye examination.” b. “You should have genetic testing to determine your risk for glaucoma.” c. “You should have your intraocular pressure measured once or twice a year.” d. “You should check with your primary health care provider about preventive drug therapy.”

Answer 53

ANS: C Glaucoma tends to occur more often in clients who have a family history but cannot be prevented. Genetic testing is not the best response because the client’s family history is already known. Therefore, early detection by having intraocular pressure measured frequently.

Question 54

A client presents to the emergency department reporting a foreign body in the eye. For what diagnostic testing would the nurse prepare the client? a. Corneal staining b. Fluorescein angiography c. Ophthalmoscopy d. Tonometry

Answer 54

ANS:A Corneal staining is used when the possibility of eye trauma exists, including a foreign body. Fluorescein angiography is used to assess problems of retinal circulation. Ophthalmoscopy looks at both internal and external eye structures. Tonometry tests the intraocular pressure.

Question 55

The nurse assesses a client for factors that place the client at risk for cataracts. Which factor places the client at the highest risk for cataract development? a. Heart disease b. Glaucoma c. Diabetes mellitus d. Advanced age

Answer 55

ANS: D Advanced age is the major risk factor for developing cataracts because the lens loses water and lens fibers become more compact.

Question 56

The nurse is teaching about signs and symptoms of cataracts. Which change would the nurse emphasize as possibly indicating beginning cataract formation? a. Diplopia b. Cloudy pupil c. Loss of peripheral vision d. Blurred vision

Answer 56

ANS: D A cloudy pupil is a sign of late cataracts and loss of peripheral vision is more common in clients who have glaucoma. Diplopia occurs with a number of neurologic diseases. Blurred vision is the earliest sign that the lens of the eye is undergoing changes.

Question 57

The nurse is teaching a client about cataract surgery. Which statement would the nurse include as part of preoperative preparation? a. “You will receive general anesthesia for the surgical procedure.” b. “You will be in the hospital for only 1 to 2 days if everything goes as expected.” c. “You will need to put several types of eyedrops in your eyes before and after surgery.” d. “You will be on bedrest for about a week after the surgical procedure.”

Answer 57

ANS: C Cataract surgery is done as an ambulatory care procedure and the client is not hospitalized, does not receive general anesthesia, and does not need to be on bedrest postoperatively.

Question 58

A client’s intraocular pressure (IOP) is 28 mm Hg. What action would the nurse anticipate? a. Educate the client on corneal transplantation. b. Facilitate scheduling the eye surgery. c. Teach about drugs for glaucoma. d. Refer the patient to local Braille classes.

Answer 58

ANS: C This increased IOP indicates glaucoma. The nurse’s main responsibility is teaching the client about drug therapy. Corneal transplantation is not used in glaucoma. Eye surgery is not indicated at this time. Braille classes are also not indicated at this time.

Question 59

``` A client has a foreign body in one eye. What action by the nurse is appropriate for the client’s care? a. Administering ordered antibiotics b. Assessing the patient’s visual acuity c. Obtaining consent for enucleation d. Removing the object immediately ```

Answer 59

ANS: A To prevent infection, antibiotics are provided. Visual acuity in the affected eye cannot be assessed. The client may or may not need enucleation. The object is only removed by the ophthalmologist.

Question 60

A client who is nearly blind is admitted to the hospital. What action by the nurse is most important? a. Allow the client to feel his or her way around. b. Let the client arrange objects on the bedside table. c. Orient the client to the room using a focal point. d. Speak loudly and slowing when talking to the client.

Answer 60

ANS: C Using a focal point, orient the client to the room by giving descriptions of items as they relate to the focal point. Letting the client arrange the bedside table is appropriate, but not as important as orienting the client to the room for safety. Allowing the client to just feel around may cause injury. Unless the client is also hearing impaired, use a normal tone of voice.

Question 61

A client has been prescribed brinzolamide for glaucoma. What assessment by the nurse requires communication with the primary health care provider? a. Allergy to eggs b. Allergy to sulfonamides c. Use of contact lenses d. Use of beta blockers

Answer 61

ANS: B Brinzolamide is similar to sulfonamides, so an allergic reaction could occur. The other assessment findings are not related to brinzolamide.

Question 62

A client is brought to the emergency department after a car crash. The client has a large piece of glass in the left eye. What action by the nurse takes priority? a. Administer a tetanus booster shot. b. Ensure that the client has a patent airway. c. Prepare to irrigate the client’s eye. d. Turn the client on the unaffected side.

Answer 62

ANS: B Airway always comes first. After ensuring a patent airway and providing cervical spine precautions (do not turn the client to the side), the nurse provides other care that may include administering a tetanus shot. The client’s eye may or may not be irrigated.

Question 63

The nurse teaches assistive personnel about age-related changes that affect the eyes and vision. Which changes would the nurse include? (Select all that apply.) a. Decreased eye muscle tone b. Development of arcus senilis c. Increase in far point of near vision d. Decrease in general color perception e. Increase in point of near vision

Answer 63

ANS: A, B, D, E Normal age-related changes include decreased eye muscle tone, development of arcus senilis, decreased color perception, and increased point of near vision. The far point of near vision typically decreases.

Question 64

The nurse is teaching a group of adults about ways to prevent early cataract formation. What health teaching would the nurse include? (Select all that apply.) a. “Wear eye and head protection when playing sports.” b. “Be sure to get 7 to 8 hours of sleep each night.” c. “Drink less carbonated beverages, especially those with caffeine.” d. “Wear sunglasses when going outdoors or in ultraviolet light.” e. “Increase consumption of high-protein, low-carbohydrate foods.” f. “Avoid smoking or participate in a smoking cessation program.”

Answer 64

ANS: A, D, F Although all of these choices are strategies for overall health promotion. Wearing eye and head protection and sunglasses, and avoiding or quitting smoking are specific strategies to promote eye health. Cataracts may occur earlier in a client’s life if these recommendations are not followed.

Question 65

The nurse is teaching a client and family regarding symptoms to report to the primary health care provider after cataract surgery. Which symptoms would the nurse include in the teaching? (Select all that apply.) a. Sharp sudden pain in the surgical eye b. Green or yellow discharge from the surgical eye c. Eyelid swelling of the surgical eye d. Decreased vision in the surgical eye e. Blindness in the surgical eye f. Flashes or floaters seen in the surgical eye

Answer 65

ANS: A, B, C, D, E, F All of these symptoms are not normal and should be reported immediately to the surgeon or other appropriate primary health care provider.

Question 66

The nurse is assessing a client admitted to the emergency department with possible retinal detachment. What assessment findings would the nurse expect? (Select all that apply.) a. Presence of bright light flashes b. Decreased visual field in affected eye c. Feeling like a curtain is over one eye d. Gradual changes in visual acuity e. Painful throbbing in the affected eye

Answer 66

ANS: A, B, C Changes that occur in clients experiencing retinal detachment are usually sudden and painless. Typical changes that occur include bright light flashes, sudden decrease in visual filed, and a feeling like a curtain is over all or part of the affected eye.

Question 67

The nurse is teaching a client about care after surgery to repair a retinal detachment. What health teaching would the nurse include? (Select all that apply.) a. “Report sudden pain in the surgical eye.” b. “Report if the surgical eye remains dilated.” c. “Avoid close vision activities in the first week.” d. “Avoid activities that increase intraocular pressure.” e. “Report sudden reduced visual acuity.”

Answer 67

ANS: A, B, C, D, E | All of these instructions are important for the client who has a retinal detachment repair.

Question 68

``` The nurse is teaching a client about postoperative care after a LASIK procedure. Which common complications/adverse effects could occur either immediately or later after this type of surgery? (Select all that apply.) a. Halos around lights b. Blurred vision c. Blindness d. Infection e. Dry eyes ```

Answer 68

ANS: A, B, D, E All of these common problems can occur after LASIK surgery except for blindness. Some decrease in visual acuity can occur, however.

Question 69

A nurse is teaching a client about ear hygiene and health. Which statement by the client indicates a need for further teaching? a. “A soft cotton swab is alright to clean my ears with.” b. “I make sure my ears are dry after I go swimming.” c. “I use good earplugs when I practice with the band.” d. “Keeping my diabetes under control helps my hearing.”

Answer 69

ANS: A Clients should be taught not to put anything larger than their fingertip into their ears. Using a cotton swab, although soft, can cause damage to the ears and cerumen buildup. The other statements are accurate

Question 70

The nurse is teaching new assistive personnel (AP) about caring for older adults. Which statement would the nurse include about hearing ability of this client group? a. “You need to talk very loudly when communicating with these clients.” b. “You always need to check each client’s ears for excess ear wax.” c. “Remember to face the client when talking with him or her.” d. “Assess each client’s hearing ability using the voice or whisper test.”

Answer 70

ANS: C Losing one’s hearing is not a normal change of aging although high frequency sounds may be more difficult to hear. AP does not perform assessments and it is not necessary to talk loudly or shout unless a hearing impairment exists. Therefore, facing the client is the best strategy when communicating with most older adults.

Question 71

The client’s electronic health record indicates a sensorineural hearing loss. What assessment question does the nurse ask to determine the possible cause? a. “Do you feel like something is in your ear?” b. “Do you have frequent ear infections?” c. “Have you been exposed to loud noises?” d. “Have you been told your ear bones don’t move?”

Answer 71

ANS: C Sensorineural hearing loss can occur from damage to the cochlea, the eighth cranial nerve, or the brain. Exposure to loud music is one etiology. The other questions are related to conductive hearing loss.

Question 72

A client has external otitis. About what comfort measure would the nurse instruct the client? a. Applying ice four times a day b. Instilling vinegar-and-water drops c. Use of a heating pad to the ear d. Using a home humidifier

Answer 72

ANS: C A heating pad on low or a warm moist pack can provide comfort to the client with otitis externa. The other options are not appropriate.

Question 73

An older adult in the family practice clinic reports a decrease in hearing in one ear for over a week. What action by the nurse is most appropriate? a. Assess for cerumen buildup. b. Facilitate audiological testing. c. Perform tuning fork tests. d. Review the medication list.

Answer 73

ANS: A All options are possible actions for the client with hearing loss. The first action the nurse would take is to look for cerumen buildup, which can decrease hearing in the older adult. If this is normal, medications would be assessed for ototoxicity. Further auditory testing may be needed for this patient.

Question 74

A client had a myringotomy. What would the nurse include as part of discharge teaching? a. Buy dry shampoo to use for a week. b. Drink liquids through a straw. c. Flying is not allowed for 1 month. d. Hot water showers will help the pain.

Answer 74

ANS: A The client cannot shower or get the head wet for 1 week after surgery, so using dry shampoo is a good suggestion. The other instructions are incorrect: straws are not allowed for 2 to 3 weeks, flying is not allowed for 2 to 3 weeks, and the client should not shower.

Question 75

A client who has had cold symptoms for a week visits the local urgent care center with report of left ear discomfort, dizziness, and decreased hearing. What additional assessment findings would the nurse expect? a. High fever b. Nausea and vomiting c. Elevated blood pressure d. Purulent ear drainage

Answer 75

ANS: D The client presents with symptoms that indicate possible serous otitis or otitis media. In either case, the client would not have a high fever or blood pressure. Nausea and vomiting are not common with either diagnosis, but purulent ear drainage is likely to occur if the tympanic eardrum perforates. The client’s decreased hearing could indicate that perforation already occurred.

Question 76

The nurse is teaching a client about factors that can cause external otitis. Which of these factors would the nurse emphasize as the highest risk? a. Excess cerumen b. Swimming c. Sinus congestion d. Meniere disease

Answer 76

ANS: B External otitis is often called “swimmer’s ear” because it is most often caused by swimming in lakes, ponds, and untreated pools.

Question 77

``` A nurse is teaching a community group about preventing hearing loss. What instruction is appropriate? a. “Always wear a bicycle helmet.” b. “Avoid swimming in ponds or lakes.” c. “Don’t attend fireworks shows.” d. “Use a cerumen spoon to clean ears.” ```

Answer 77

ANS: A Avoiding head trauma is a practical way to help prevent hearing loss. Swimming can lead to hearing loss only if the client has repeated infections. Fireworks displays/shows are loud, but usually brief and only occasional. A cerumen spoon is only used by primary health care providers to remove ear wax from in the ear canal. DIF:

Question 78

A client has severe tinnitus that has not responded to treatment. What action by the nurse is appropriate? a. Advise the client to take antianxiety medication. b. Educate the client on nerve-cutting procedures. c. Refer the client to online or local support groups. d. Refer the client to a mental health professional.

Answer 78

ANS: C If the client’s tinnitus cannot be treated, he or she will need to learn how to cope with it. Referring the client to tinnitus support groups can be helpful. The other options are not warranted.

Question 79

A client has mastoiditis and is prescribed antibiotics. What health teaching by the nurse is most important for this client? a. “Immediately report headache or stiff neck.” b. “Keep all follow-up appointments.” c. “Take the antibiotics with a full glass of water.” d. “Take the antibiotic on an empty stomach.”

Answer 79

ANS: A Meningitis is a complication of mastoiditis. The client should be taught to take all antibiotics as prescribed and to report manifestations of meningitis such as fever, headache, or stiff neck. Keeping follow-up appointments is important for all clients. Without knowing what antibiotic was prescribed, the nurse cannot instruct the client on how to take it

Question 80

A client with Ménière disease is in the hospital when the client has an episode of this disorder. What action by the nurse is appropriate? a. Assess vital signs every 15 minutes. b. Dim or turn off lights in the client’s room. c. Place the client in bed with the upper side rails up. d. Provide a cool, wet cloth for the client’s face.

Answer 80

ANS: C Clients with Ménière disease can have vertigo so severe that they can fall. The nurse would assist the client into bed and put the side rails up to keep the client from falling out of bed due to the intense whirling feeling. The other actions are not warranted for clients with Ménière disease.

Question 81

A client is scheduled to have a tumor of the middle ear removed. Which perioperative health teaching is most important for the nurse to include? a. Expecting hearing loss in the affected ear b. Managing postoperative pain c. Maintaining NPO status prior to surgery d. Understanding which medications are allowed the day of surgery

Answer 81

ANS: A Removal of an inner ear tumor will likely destroy hearing in the affected ear. The other teaching topics are appropriate for any surgical client.

Question 82

The nurse is teaching an older adult how to prevent buildup of ear wax. Which statement by the nurse is most appropriate? a. “Visit your primary health care provider each month for wax removal.” b. “Drink plenty of water and other liquids to prevent hardening of the ear wax.” c. “Irrigate each ear once a month to remove wax and prevent was buildup.” d. “Put one drop of mineral oil in each ear once a week at bedtime.”

Answer 82

ANS: D Mineral oil provides lubrication to soften cerumen so that it flows out of the ears to prevent buildup. It is a safer method than irrigating the ears. If needed, the client would need to go to a primary health care provider for removal of impaction. Drinking water helps prevent hardening of wax but does not necessarily prevent wax buildup.

Question 83

The nurse is assessing a client’s medication profile to determine risk for tinnitus. Which drug classification is most likely to cause this health problem? a. Cephalosporins b. NSAIDs c. Beta-adrenergic blockers d. Osmotic diuretics

Answer 83

ANS: B None of these drug classifications except for NSAIDs pose a risk to clients for tinnitus as a side effect.

Question 84

A client is scheduled for a tympanoplasty. What action(s) by the nurse are (is) most appropriate? (Select all that apply.) a. Administer preoperative opioids. b. Assess for allergies to local anesthetics. c. Ensure that informed consent is on the health record. d. Give prescribed antivertigo medications. e. Teach that hearing improves immediately.

Answer 84

ANS: C Preoperatively, the nurse ensures that informed consent is in the health record. Local anesthetics can be used, but general anesthesia is used more often. Antivertigo medications are not used. Hearing will be decreased immediately after the operation until the ear packing is removed.

Question 85

A client has a hearing aid. What care instructions does the nurse provide the assistive personnel (AP) in the care of this client? (Select all that apply.) a. “Be careful not to drop the hearing aid when handling.” b. “Soak the hearing aid in hot water for 20 minutes.” c. “Turn the hearing aid off when the client goes to bed.” d. “Use a toothpick to clean debris from the device.” e. “Wash the device with soap and a small amount of warm water.” f. “Avoid using hair or cosmetic products near the hearing aid.”

Answer 85

ANS: A, C, D, F | All these actions except using water are proper instructions for the nurse to give to the AP.

Question 86

A hospitalized client has a new diagnosis of Ménière disease. What would the nurse include in health teaching to reduce symptoms for this disorder? (Select all that apply.) a. “Apply heat to the ear for 20 minutes three times a day.” b. “Move the head slowly to prevent worsening of the vertigo.” c. “Avoid food additives such as monosodium glutamate (MSG).” d. “Quit smoking to increase blood flow to the inner ear.” e. “Avoid caffeinated beverages.” f. “Avoid standing on chairs, step stools, or ladders.”

Answer 86

ANS: B, C, D, E, F Ménière disease is an excess of endolymphatic fluid that distorts the entire inner-canal system causing vertigo, tinnitus, and unilateral hearing loss. Applying heat or irrigating the ear canal will not alleviate symptoms. Moving the head slowly will prevent worsening of the vertigo. The diet recommendations for Ménière disease include avoiding caffeine and certain food additives. Smoking causes constriction of blood vessels and decreased blood flow to the inner ear. Clients should also avoid standing on high surfaces to prevent vertigo and falls.

Question 87

The nurse is caring for a client after ear surgery. What health teaching instruction(s) would the nurse provide for this client to promote healing? (Select all that apply.) a. “Avoid straining when having a bowel movement.” b. “Avoid drinking through a straw for 2 to 3 weeks.” c. “Avoid air travel for 2 to 3 weeks after surgery.” d. “Avoid crowds and people with infection, especially respiratory infection.” e. “Avoid moving your head quickly, jumping, or bending over for 2 to 3 weeks.” f. “Blow your nose very gently without blocking either nostril and keep your mouth open.”

Answer 87

ANS: A, B, C, D, E, F It is imperative that the patient having ear surgery is free from ear infection. The other precautions help to prevent increased intra-ear pressure which can affect the surgical procedure.

Question 88

The nurse is teaching a family member who is caring for a client who is hearing impaired. What health teaching would the nurse include about communicating with the client? (Select all that apply.) a. “Make sure that the room is well lighted.” b. “Speak slowly and clearly.” c. “Do not shout but you may need to speak loudly.” d. “Have conversations in a quiet room with minimal noise.” e. “Get the client’s attention before you begin to speak.” f. “Move closer to the better hearing ear if possible.”

Answer 88

ANS: A, B, C, D, E, F All of these recommendations are useful when communicating with clients who are hearing impaired.