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1. Monique is diagnosed with Ménière’s disease, which diet would be most appropriate to discuss with her?
2. Professor Mcgonagall had undergone nasal surgery with posterior packing in place, which assessment data would alert the nurse to the possibility of active bleeding?
A. Appearance of anxiety
B. Discoloration around the eyes
C. Frequent swallowing
D. Black, tarry stool
3. Chad, a 5-year-old preschooler, is brought to the clinic due to an ear problem. Which assessment data would cause the nurse to suspect serous otitis media?
A. Bright red, bulging or retracted tympanic membrane and fever
B. Inflammation of the external ear and crust formation on the auditory canal
C. Sensorineural hearing loss and complaints of tinnitus
D. Plugged feeling in the ear and reverberation of the client’s own voice.
4. As Nurse Ryan enters the room, he saw the client choking and unable to speak. Which intervention should the nurse implement first for the client?
A. Calling for help immediately
B. Leaving the client alone to clear his throat.
C. Telling the client to adequately humidify the room
D. Trying to determine what the client is choking on
5. Which statement by a client diagnosed with Ménière’s disease who has had a labyrinthectomy of the left ear indicates that he understands the discharge teaching concerning the surgery?
A. “I should be able to hear fairly well after the edema in my ear subsides.”
B. “I will be totally deaf in my left ear, but the dizziness will be gone.”
C. “I should remove the inner ear packing in exactly 3 days.”
D. “I should lubricate the skin around my stoma with petroleum jelly.”
6. For a client diagnosed with epistaxis, which intervention would be included in the care plan?
A. Performing several abdominal thrust (Heimlich) maneuvers
B. Compressing the nares
to the septum for 5 to 10 minutes
C. Applying an ice collar to the neck area
D. Encouraging warm saline throat gargles
7. Mang Isko, a 68-year-old widower, has been stricken with cataracts about year ago. Which assessment date would the nurse expect when collecting the nursing history from the client?
A. Blurred vision
B. Eye pain
D. Eye redness
8. Which intervention would be included in the care plan for the client with an acute exacerbation of Ménière’s disease?
A. Instructing the client on the correct way to remove impacted cerumen
B. Speaking slowly and distinctly in a low-pitched, clear voice without yelling
C. Providing a safe, quiet, dimly lit environment with enforced bed rest
D. Instructing the client to pull the top of the ear and back to instill eardrops
9. Which assessment data would the nurse expect as the chief complaint from a client who is experiencing an acute exacerbation of Ménière’s disease?
C. Severe ear pain
D. Sudden deafness
10. Nurse Errol is administering 2 drops of medication in OS prior to ophthalmic surgery. Which interventions should he implement? (Select all that apply.)
A. Instructing the client to look up prior to administering the medication
B. Administering the medication into the right eye
C. Administering the medication into the upper conjunctiva
D. Pulling the left ear up and back prior to administering the medication
E. Wiping the excess medication from the inner to the outer canthus
F. Pressing on the nasal-lacrimal canal
11. During eyedrop instillation, which intervention would the nurse perform to prevent systemic adverse effects from drug absorption?
A. Applying pressure on the eyelid rim
B. Having the client close his eyes tightly
C. Placing the client in the supine position for a few minutes
D. Applying pressure on the inner canthus
12. Ben is diagnosed with a retinal detachment at the inner aspect of the right eye. Into which position would the nurse place the client?
B. Supine with a small pillow
C. Right-side lying
D. Left-side lying
13. For a client complaining of periocular aching after a surgical repair of a detached retina, which medication would be the most appropriate analgesic?
14. Inigo is diagnosed with “strep throat.” Which clinical manifestation would the nurse expect to the client?
A. A fiery red pharyngeal membrane and fever
B. Pain over the sinus area and purulent nasal secretions
C. Foul-smelling breath and noisy respirations
D. Weak cough
and high-pitched noise on respirations
15. During the nursing history, which assessment data would the nurse expect the client scheduled for surgical correction of chronic open-angle glaucoma to report?
A. Seeing flashes of lights and floaters
B. Recent motor vehicle crash while changing lanes
C. Complaints of headaches, nausea
, and redness of the eyes
D. Increasingly frequent episodes of double vision
16. Aling Martha, a 73-year-old widow, tells to the nurse during the admission process that she was recently diagnosed with age-related hearing loss. Upon receiving such information, the nurse is correct if he suspects:
A. Ménière’s disease
C. Otitis media
17. Nurse Jairuz Roy is carrying out his preoperative teachings for an older client who will have cataract surgery on the right eye. The nurse concludes that the client needs further understanding about the teachings if he says:
A. “I will sleep
on my left side after the surgery.”
B. “I will wipe my nose gently if it is congested after surgery.”
C. “I will call my physician if I have sharp and sudden pain or a fever after surgery.”
D. “I will bend below my waist frequently to increase circulation after surgery.”
18. A 68-year-old client comes to the outpatient clinic and complains to the attending nurse his increased difficulty with “close-work” such as knitting. He indicates he does not have difficulty seeing objects on either side but does state that straight lines appear distorted or wavy. The nurse suspects which of the following disorders that is consistent with the client’s reported symptoms?
C. Macular degeneration
D. Subconjunctival hemorrhage
19. While inserting a nasogastric tube, the nurse should use which of the following protective measures?
A. Gloves, gown, goggles, and surgical cap
B. Sterile gloves, mask, plastic bags, and gown
C. Gloves, gown, mask, and goggles
D. Double gloves, goggles, mask, and surgical cap
20. An 8-year-old boy is returned to his room following a tonsillectomy. He remains sleepy from the anesthesia but is easily awakened. The nurse should place the child in which of the following positions?
Answers and Rationale
Here are the answers for this exam. Gauge your performance by counter checking your answers to those below. If you have any disputes or clarifications, please direct them to the comments section.
1. Answer: C. Low-sodium
It is taught that Ménière’s disease is caused by edema of the semicircular canals. A low-sodium diet is often prescribed in conjunction with diuretic therapy. Protein intake should have no relation to Ménière’s disease, but hypoproteinemia may aggravate edema. FIber and potassium have not been identified as instrumental in the development of Ménière’s disease.
2. Answer: C. Frequent swallowing
After nasal surgery, drainage tricking down the posterior pharynx (seen with a flashlight) accompanied by frequent swallowing, belching, or hematemesis indicate continued bleeding. Anxiety is common because of the necessity to breathe through the mouth
. Discoloration around the eyes occurs with surgical trauma and is to be expected. Tarry stools indicate previous, but not current bleeding.
3. Answer: D. Plugged feeling in the ear and reverberation of the client’s own voice.
Serous otitis media is manifested by a plugged feeling in the ear, reverberation of the client’s own voice, and hearing loss. A bright red, bulging or retracted tympanic membrane and fever suggest suppurative otitis media. Inflammation of the external ear and crust formation on the auditory canal suggest external otitis media. Sensorineural hearing loss and tinnitus indicate otosclerosis.
4. Answer: A. Calling for help immediately
Because the client cannot speak, a total airway obstruction has occurred. The client is in acute distress and requires emergency treatment. Leaving the client alone to clear the throat would be appropriate for a client with partial airway obstruction, as evidenced by choking but with an ability to speak. Adequate humidification is appropriate for the client with recurrent epistaxis or nasal congestion. It does not matter what the client is choking on.
5. Answer: B. “I will be totally deaf in my left ear, but the dizziness will be gone.”
A labyrinthectomy is the most radical procedure for Ménière’s disease. It involves resection of the vestibular nerve or total removal of the labyrinth by the transcanal route. Although this procedure controls the disorder, it results in deafness in the affected ear. With this procedure, inner ear packing is not used, and a stoma is not created.
6. Answer: B. Compressing the nares to the septum for 5 to 10 minutes
When a client experiences epistaxis, the nurse should compress the soft outer portion of the nares against the septum for approximately 5 to 10 minutes. the client should sit upright, breathe through the mouth, and refrain from talking. Performing abdominal thrusts is appropriate for the client with a foreign-body aspiration
. Applying an ice collar to the neck is commonly done for a client after a tonsillectomy. Warm saline throat gargles are appropriate for the client with pharyngitis.
7. Answer: A. Blurred vision
Cataracts lead to progressive worsening and blurring of vision. Eye pain and redness, common with glaucoma, are not present with cataracts. Floaters are characteristics of retinal detachment.
8. Answer: C. Providing a safe, quiet, dimly lit environment with enforced bed rest
Ménière’s disease is a chronic disorder of the inner ear involving sensorineural hearing loss, severe vertigo, and tinnitus. Typically, the client experiences sudden episodes of od severe whirling vertigo with an inability to stand or walk, buzzing tinnitus that worsens before and during an episode, nausea, vomiting
, and diaphoresis. The client’s safety must be ensured along with decreasing exposure to extraneous stimuli. This is accompanied by providing the client with a quiet, dimly lit environment and bed rest. Instructions about removing cerumen are appropriate for a client with cerumen impaction. Speaking slowly and distinctly in a low-pitched, clear voice without yelling is appropriate for clients experiencing a hearing loss. Clients with Ménière’s disease are not deaf during acute exacerbations. However, hearing loss may occur after repeated episodes. Ear drops are not the treatment of choice for an acute attack of Ménière’s disease.
9. Answer: A. Vertigo
Ménière’s disease is characterized by sudden, severe episodes of vertigo during which the client has a sensation of spinning. Dizziness is not vertigo and must be distinguished from true rotational vertigo. A feeling of pressure but not pain is also characteristic, and hearing loss os progressive, not sudden.
10. Answer: A, E, F
The nurse is administering medication into the left eye (OS) for ophthalmic surgery, which includes instructing the client to look up, administering the medication into the lower conjunctiva, pressing on the nasal-lacrimal canal to prevent systemic drug absorption, and wiping excess secretions with a sterile cotton ball from the inner to outer canthus. The abbreviation for the right eye is OD and both eyes is OU.
11. Answer: D. Applying pressure on the inner canthus
Systemic absorption and subsequent adverse effects may occur if the medication enters the nasolacrimal canal. The nurse therefore applies pressure to the inner canthus, causing occlusion of this canal and minimizing the risk for systemic adverse effects. Applying pressure on the eyelid rim would not occlude this canal. Having the client close his eyes tightly may cause some of the medication to be expelled. Positioning has no effect on the blood
flow of medication into the nasolacrimal canal and subsequent absorption.
12. Answer: D. Left-side lying
When retinal detachment occurs, the client is positioned so that the area of detachment is dependent. For this client, the left-side lying position is used. Positioning the client in the Fowler, supine, or right-side lying position would not place the detached area in a dependent position.
13. Answer: A. Acetaminophen
Because the discomfort is typically mild after surgery to repair a detached retina, a mild analgesic such as acetaminophen would be used. Codeine
is constipating and may lead to straining and increased intraocular pressure (IOP). Meperidine often causes nausea and vomiting, further adding to the client’s level of discomfort, and vomiting may lead to increased IOP. Morphine causes nausea, vomiting, and constipation
, which should be avoided after surgery.
14. Answer: A. A fiery red pharyngeal membrane and fever
Strep throat, or acute pharyngitis, results in a red throat, edematous lymphoid tissues, enlarged lymph
nodes, fever, and sore throat
. Pain over the sinus area and purulent nasal secretions would be evident with sinusitis. Foul-smelling breath and respirations indicate adenoiditis
. A weak cough and high-pitched noisy respirations are associated with foreign-body aspiration.
15. Answer: B. Recent motor vehicle crash while changing lanes
Typically, the client with chronic open-angle glaucoma experiences a gradual loss in peripheral vision leading to tunnel vision. Being involved in a motor vehicle crash while changing lanes suggests the disorder. The client may experience insidious blurring, decreased accommodation, mild aching eyes and, eventually, halos around the lights as intraocular pressure increases. Flashes of light and floaters are characteristic of retinal detachment. Nausea, headache, and eye redness are seen with an episode of acute (sudden) closed-angle closure. Double vision occurs when one eye has a lens and other is aphakic.
16. Answer: D. Presbycusis
The term presbycusis refers to sensorineural hearing impairment in elderly
17. Answer: D. I will bend below my waist frequently to increase circulation after surgery
Immediately after the procedure, the client should avoid bending over, to prevent putting extra pressure on the eye.
18. Answer: C. Macular degeneration
Macular degeneration, often age-related macular degeneration (AMD or ARMD), is a medical condition that usually affects older adults and results in a loss of vision in the center of the visual field (the macula) because of damage to the retina. It occurs in “dry” and “wet” forms. It is a major cause of blindness and visual impairment in older adults (>50 years). Macular degeneration can make it difficult or impossible to read or recognize faces, although enough peripheral vision remains to allow other activities of daily life.
19. Answer: C. Gloves, gown, mask, and goggles
Gloves, gown, mask, and goggles should be used as a universal precaution on all patients to prevent skin and mucous membrane exposure when contact with blood or other body fluids is anticipated. Surgical caps offer protection to hair
but aren’t required. Plastic bags provide no direct protection and are not part of universal precautions. It is also unnecessary to double glove.
20. Answer: B. Side-lying
Side-lying position is most effective to facilitate drainage of secretions from the mouth and pharynx; reduces possibility of airway obstruction. Sims’ position is on side with top knee flexed and thigh drawn up to chest and lower knee less sharply flexed: used for vaginal or rectal examination. Supine position increases risk for aspiration
, would not facilitate drainage of oral secretions. Prone position can develop airway obstruction and aspiration, unable to observe the child for signs of bleeding such as increased swallowing.