30.
In macular degeneration the center vision is blackened out and only the outer visual fi elds are clear.CN: Physiological adaptation;
CL: Analyze
31.
3. By listening to the client should they speak and by noting body language, the nurse may be better able to ascertain the client’s physical and cognitive status. The nurse should not utilize the fi rst name of a client unless a client provides per- mission to do so. To consult with psychiatry would not be appropriate unless ordered by the primary care physician. An interdisciplinary meeting would not enable the nurse to understand why the client is staring straight ahead. Perhaps the client is only deep in thought.CN: Reduction of risk potential;
CL: Synthesize
The Client Undergoing Nasal Surgery
32.
2. Because of the dense packing, it is rela- tively unusual for bleeding to be apparent through the nasal drip pad. Instead, the blood runs down the throat, causing the client to swallow frequently. The back of the throat can be assessed with a fl ashlight.An accumulation of blood in the stomach may cause nausea and vomiting, but is not an initial sign of bleeding. Increased respiratory rate occurs in shock and is not an early sign of bleeding in the client after nasal surgery. Feelings of anxiety are not indicative of nasal bleeding.
CN: Physiological adaptation;
CL: Synthesize
26.
3. Acute angle-closure glaucoma is a medical emergency that rapidly leads to blindness if left untreated. Treatment typically involves miotic drugs and surgery, usually iridectomy or laser therapy.Both procedures create a hole in the periphery of the iris, which allows the aqueous humor to fl ow into the anterior chamber. Bed rest does not affect the progression of acute angle-closure glaucoma.
Steroids are not a treatment for acute angle-closure glaucoma; in fact, they are associated with the development of glaucoma.
CN: Physiological adaptation; CL: Apply
The Client with Adult Macular
the client with the ability to use contextual clues in speech reading.
CN: Basic care and comfort;
CL: Synthesize
38.
4. Inadequate amplifi cation can occur when a hearing aid is not placed properly. The certifi ed audiologist is licensed to dispense hearing aids. The ear mold is the only part of the hearing aid that may be washed frequently; it should be washed daily with soap and water. Irrigation of the ear canal is done to remove impacted cerumen or a foreign body.CN: Physiological adaptation;
CL: Synthesize
39.
3. A sensorineural hearing loss results from damage to the cochlear or vestibulocochlear nerve.Presence of fl uid and cerumen in the external canal or sclerosis of the bones of the middle ear results in a conductive hearing loss. Hearing loss resulting from an emotional disturbance is called a psycho- genic hearing loss.
CN: Physiological adaptation; CL: Apply
40.
1. Cerumen (ear wax) commonly getsimpacted in older clients in the external canal. Otal- gia is the “fullness” sensation or pain that an older client may experience when the cerumen becomes impacted. External otitis is an infl ammation of the outer ear and would not explain the symptoms the client is experiencing. Exostosis is a bony growth that arises from the surface of a bone and would not explain the symptoms the client is experiencing.
CN: Health promotion and maintenance;
CL: Analyze
41.
2. Irrigation is the fi rst strategy to loosen cerumen. Successful removal of the cerumen involves gentle irrigation behind the impacted cerumen. The fl ow of the water must be behind the impaction to remove the cerumen from the canal.A cotton-tipped applicator or other device is not appropriate because it can cause damage to the ear- drum. Use of aural suction or a cerumen curette is appropriate only if the impacted cerumen cannot be removed by irrigation.
CN: Reduction of risk potential;
CL: Apply
42.
1. Normal saline is the solution that is gener- ally used to irrigate the ear. Sterile water will cause tissue damage. An antiseptic solution is not typi- cally used unless an infection is present. Warm tap water may cause tissue damage.CN: Pharmacological and parenteral therapies; CL: Apply
43.
1. The nurse should fi rst assess the client’s knowledge base. Working within the framework33.
1. The client should be instructed to avoid any activities that cause Valsalva’s maneuver (e.g., straining at stool, vigorous coughing, exercise) to reduce stress on suture lines and bleeding. The client should not take aspirin because of its anti- platelet properties, which may cause bleeding. Oral hygiene is important to rid the mouth of old dried blood and to enhance the client’s appetite. Cool compresses, not heat, should be applied to decrease swelling and control discoloration of the area.CN: Reduction of risk potential;
CL: Synthesize
34.
2. Constipation can cause straining during defecation, which can induce bleeding. Showering is not contraindicated. The client should take mea- sures to prevent coughing. The client should avoid blowing her nose for 48 hours after the packing is removed. Thereafter, she should blow her nose gently using the open-mouth technique to minimize bleeding in the surgical area.CN: Physiological adaptation;
CL: Evaluate
The Client with a Hearing Disorder
35.
4. The nurse should avoid startling the cli- ent who is deaf and should obtain the attention of the client before speaking. The client who is deaf cannot hear knocking on the door or talking. Open- ing the blinds is not a helpful way to get the client’s attention.CN: Psychosocial adaptation;
CL: Syntheisze
36.
2. Furosemide may cause ototoxicity. The nurse should tell the client to promptly report the hearing loss, dizziness, or tinnitus, to help prevent permanent ear damage. Hearing loss is not inevi- table, and it is inappropriate to make assumptions about the cause of symptoms without a thorough evaluation. The client’s system will not “adjust,”and hearing loss will not resolve.
CN: Pharmacological and parenteral therapies; CL: Synthesize
37.
1, 2, 3, 5. When working with a client who is hearing impaired and speech reads, the presenter must face the person directly and devote full atten- tion to the communication process. In addition, it will be useful for the client that the speaker not be too silhouetted against strong light, that the speaker’s mouth not be blocked from the client’s view, and that there are no objects in the mouth of the speaker. Finally, it is recommended that the presenter provide the client with the needed infor- mation to study before reviewing. This will provideBillings_Part 2_Chap 3_Test 15.indd 677
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48.
4. The client needs to assume a safe and comfortable position during an attack, which may last several hours. The client’s location when the attack occurs may dictate the most reasonable posi- tion. Ideally, the client should lie down immediately in a reclining or fl at position to control the vertigo.The danger of a serious fall is real. Placing the head between the knees will not help prevent a fall and is not practical because the attack may last several hours. Concentrating on breathing may be a useful distraction, but it will not help prevent a fall. Clos- ing the eyes does not help prevent a fall.
CN: Safety and infection control;
CL: Synthesize
49.
1, 2, 3. Since the symptoms of Ménière’s disease are associated with a change in the fl uid volume of the inner ear, a wide variety of medi- cations may be used in an attempt to control the signs/symptoms of Ménière’s disease, including antihistamines, antiemetics, tranquilizers, and diuretics. NSAIDs and antipyretics play no signifi - cant role in Ménière’s disease management.CN: Pharmacological and parenteral therapies; CL: Analyze
50.
2. The client’s Risk for injury related to vertigo is the highest priority nursing diagnosis preoperatively. The client should be instructed how to manage attacks of vertigo safely. Defi cient diversional activity related to inability to participate secondary to vertigo is an appropriate nursing diag- nosis, but it is not a priority. Powerlessness related to inability to infl uence effects of the disease process is a possible diagnosis, but more data are required before making such a diagnosis. Social isolation related to hearing loss is a possible diagnosis for the client after surgery. The client retains the ability to hear with Ménière’s disease; however, total hearing loss is a possible complication of labyrinthectomy.CN: Physiological adaptation;
CL: Analyze
The Client with Cancer of the Larynx
51.
4. A salivary fi stula is suspected when there is saliva collecting beneath skin fl aps or leaking through the suture line or drain site. Salivary fi stula or skin necrosis usually precedes carotid artery rup- ture. Stomal stenosis may be present when there is suprasternal and intercostal retractions and diffi cult breathing.CN: Physiological adaptation;
CL: Analyze of the client’s knowledge and educational level,
the nurse then can describe the procedure and its benefi ts.
CN: Reduction of risk potential;
CL: Synthesize
44.
4. Tinnitus (ringing in the ears) is an adverse effect of aspirin. Aspirin contains salicylate, which is an ototoxic drug that can induce reversible hear- ing loss and tinnitus. The nurse should encourage the client to inform the physician of the symptom.Tinnitus is not a function of aging. The Weber test and audiometric testing are useful for determining hearing loss but are not necessarily helpful in the management or diagnosis of drug-induced tinnitus.
CN: Pharmacological and parenteral therapies; CL: Synthesize
The Client with Ménière’s Disease
45.
1, 2, 3, 5. Assessment of vertigo, includ- ing history, onset, description of attacks, duration, frequency, and associated ear symptoms, is impor- tant. Vestibular/balance therapy or exercises should be taught and practiced. The client needs to be instructed to sit down when dizzy and decrease the amount of head movement. The client will benefi t from recognizing whether he or she experiences an“aura” before an attack so appropriate action can be taken. Finally, it is recommended that the client keep the eyes open and look straight ahead when lying down. These expected outcomes will prevent the problem of injury. Family involvement is essen- tial when dealing with a client experiencing vertigo but is not applicable for this particular nursing diagnosis.
CN: Reduction of risk potential;
CL: Synthesize
46.
1. A low-sodium diet is frequently an effec- tive mechanism for reducing the frequency and severity of the disease episodes. About three-quar- ters of clients with Ménière’s disease respond to treatment with a low-salt diet. A diuretic may also be ordered. Other dietary changes, such as high protein, low carbohydrate, and low fat, do not have an effect on Ménière’s disease.CN: Basic care and comfort; CL: Apply
47.
2. There is no cure for Ménière’s disease, but the wide range of medical and surgical treatments allows for adequate control in many clients. The disease often worsens, but it does not spread to the eyes. The hearing loss is usually unilateral.CN: Physiological adaptation;
CL: Evaluate
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secretions, and clients may require frequent suction- ing to maintain patency. Decreasing secretions may be a component of a client’s care after laryngectomy and tracheostomy, and relieving anxiety is always an important goal; however, the primary goal is to maintain a patent airway. Instruction in care of a tra- cheostomy is a priority later in the client’s recovery.
CN: Physiological adaptation;
CL: Synthesize
Managing Care Quality and Safety
57.
2. Atropine sulfate causes pupil dilation.This action is contraindicated for the client with glaucoma because it increases intraocular pressure.
The drug does not have this effect on intraocular pressure in people who do not have glaucoma.
Morphine causes pupil constriction. Deep-breathing exercises will not affect glaucoma. The client should resume taking all medications for glaucoma immedi- ately after surgery.
CN: Pharmacological and parenteral therapies; CL: Synthesize
58.
3. The priority goal of care for a client who is blind is safety and preventing injury. The initial action is to orient the client to a new environment.Taking time to identify the objects and where they are located in the room can achieve this goal. It is unrealistic to have someone stay with the client at all times or for the client to stay in bed until the nurse can assist. Using side rails creates unneces- sary barriers and may be a safety hazard.
CN: Safety and infection control;
CL: Synthesize
59.
1, 2, 3. Effective communication is essential when managing client safety and preventing errors.“Handoff reports” should be made at shift change, when there is a change of nurses or when the nurse leaves the unit, and when the client is discharged or transfers to another unit. There does not need to be a handoff report when the unit clerk leaves the unit or when new medication orders are written.
CN: Safety and infection control;
CL: Apply
60.
3. In order to prevent medication errors, cli- ents may not use medications they bring from home;the physician will order the eye drops as required.
It is not safe to place the eye drops in the client’s medication box or to permit the client to use them at the bedside. The nurse should ask the wife to take the eye drops home.
CN: Safety and infection control;
CL: Synthesize
52.
1, 2, 3, 4. The nurse should monitor nutritional status through frequent weighing and checking the serum albumin level. The nurse also should admin- ister enteral tube feedings until there is suffi cient healing of pharynx, and the client can consume suf- fi cient oral feedings to meet body needs. The nurse should avoid manipulation of the nasogastric tube during this time so it does not disrupt the suture line. The nurse should place the client in sitting position, leaning slightly forward, which allows the larynx to move forward and the hypopharynx to partially open; the epiglottis normally prevents fl uid and food from entering the larynx during swallowing.CN: Physiological adaptation; CL: Create
53.
1, 2, 3. The nurse should advise the client to provide humidifi cation at home. Instruct the client to use a protective shield for bathing, showering, or shampooing or cutting hair to prevent aspira- tion. The nurse can also encourage the client to obtain a fl uid intake of 2 to 3 L daily to help liquefy secretions. To counteract any loss of smell and impairment of taste sensation, the client can add additional seasoning to food. The client should fol- low a high-fi ber diet and use stool softeners because the client may not be able to hold the breath and bear down for bowel movements.CN: Health promotion and maintenance;
CL: Evaluate
54.
1. The goal of postoperative care is to main- tain physiologic integrity. Therefore, inserting a feeding tube is a strategy to ensure the fl uid and nutritional needs of the client as the surgical site is healing. The feeding tube does help prevent aspi- ration by preventing ingested fl uid from leaking through the wound into the trachea before healing occurs; however, the primary rationale is to meet the client’s nutritional and fl uid needs. A trache- oesophageal fi stula is a rare complication of total laryngectomy and may occur if radiation therapy has compromised wound healing. A feeding tube does not help maintain an open airway.CN: Reduction of risk potential;
CL: Evaluate
55.
2. Tracheostomy tubes carry several potential complications, including laryngeal nerve damage, bleeding, and infection. Tracheostomy tubes alone do not affect cardiac output or cause acute respira- tory distress. The tube is inserted in the trachea, not the lung, so there is no risk of pneumothorax.CN: Physiological adaptation;
CL: Apply
56.
4. The main goal for a client with a new tracheostomy is to maintain a patent airway. A fresh tracheostomy frequently causes bleeding and excessBillings_Part 2_Chap 3_Test 15.indd 679
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