NCLEX Review about Immune System Disorders (21-25)

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NCLEX Review about Immune System Disorders

21. The home care nurse is ordering dressing supplies for a client who has an allergy to latex. The nurse asks the medical supply personnel to deliver which of the following?

a) elastic bandages
b) adhesive bandages
c) brown ace bandages
d) cotton pads and silk tape

22. The camp nurse prepares to instruct a group of children about Lyme disease. Which of the following information would the nurse include in the instructions?

a) Lyme disease is caused by tick carried by deer
b) Lyme disease is caused by contamination from cat feces
c) Lyme disease can be contagious through skin contact with an infected individual
d) Lyme disease can be caused by the inhalation of spores from bird droppings

23. The client is diagnosed with stage I Lyme disease. The nurse assesses the client for which characteristic of this stage?

a) arthralgias
b) flu-like symptoms
c) enlarged and inflamed joints
d) signs of neurological disorders

24. Select the interventions that would apply in the care of a client at high risk for an allergic response to a latex allergy. Select all that apply

a) use non-latex gloves
b) use medications from glass ampules
c) place the client in a private room only
d) do not puncture rubber stoppers with needles
e) keep a latex-safe supply cart available in the client's area
f) use a blood pressure cuff from an electronic device only to measure the blood pressure

25. Amikacin (Amikin) is prescribed for a client with a bacterial infection. The nurse instructs the client to contact the physician immediately if which of the following occurs?

a) nausea
b) lethargy
c) hearing loss
d) muscle aches





NCLEX Review about Immune System Disorders:
ANSWERS AND RATIONALE

21) D
- Cotton pads and plastic or silk tape are latex-free products. The items identified in options A, B, and C are products that contain latex.

22) A
- Lyme disease is a multisystem infection that results from a bite by a tick carried by several species of deer. Persons bitten by the Ixodesscapularis or I. pacificus tick can become infected with the spirochete Borrelia burgdorferi. Lyme disease cannot be transmitted from one person to another. Histoplasmosis is caused by the inhalation of spores from bat or bird droppings. Toxoplasmosis is caused by the ingestion of cysts from contaminated cat feces.

23) B
- The hallmark of stage I Lyme disease is the development of a rash within 2 to 30 days of infection, generally at the site of the tick bite. The rash develops into a concentric ring, giving it a bull’s-eye appearance. The lesion enlarges up to 50 to 60 cm, and smaller lesions develop farther away from the original tick bite. In stage I, most infected persons develop flu-like symptoms that last 7 to 10 days; these symptoms may reoccur later. Neurological deficits occur in stage II. Arthralgias and joint enlargements are most likely to occur in stage III.

24) A, B, D, E
- If a client is allergic to latex and is at high risk for an allergic response, the nurse would use nonlatex gloves and latex-safe supplies, and would keep a latex-safe supply cart available in the client’s area. Any supplies or materials that contain latex would be avoided. These include blood pressure cuffs, medications with a rubber stopper that requires puncture with a needle, latex-safe syringes, and latex-safe intravenous tubing. It is not necessary to place the client in a private room.

25) C
Amikacin (Amikin) is an aminoglycoside. Adverse effects of aminoglycosides include ototoxicity (hearing problems) confusion, disorientation, gastrointestinal irritation, palpitations, blood pressure changes, nephrotoxicity, and hypersensitivity. The nurse instructs the client to report hearing loss to the physician immediately. Lethargy and muscle aches are not associated with the use of this medication. It is not necessary to contact the physician immediately if nausea occurs. If nausea persists or results in vomiting, the physician should be notified.



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    NCLEX Review about Immune System Disorders (16--20)

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    NCLEX Review about Immune System Disorders

    16. The nurse is assigned to care for a client with systemic lupus erythematosus. The nurse plans care, knowing that this disorder is a(n):

    a) local rash that occurs as a result of allergy
    b) disease caused by overexposure to sunlight
    c) inflammatory disease of collagen contained in connective tissue
    d) disease caused by the continuous release of histamine in the body

    17. The nurse is assigned to care for a client admitted to the hospital with a diagnosis of systemic lupus erythematosus. The nurse reviews the physician's orders, expecting to note that which type of medication is prescribed?

    a) antibiotic
    b) antidiarrheal
    c) corticosteroid
    d) opioid analgesic

    18. The community health nurse is conducting a research study and is identifying clients in the community at risk for latex allergy. Which client population is at most risk for developing this type of allergy?

    a) hairdressers
    b) the homeless
    c) children in day care centers
    d) individuals living in a group home

    19. The home care nurse is performing an assessment on a client who has been diagnosed with an allergy to latex. In determining the client's risk factors associated with the allergy, the nurse questions the client about an allergy to which food item?

    a) eggs
    b) milk
    c) yogurt
    d) bananas

    20. The home care nurse is assigned to visit a client who has returned home from the emergency room following treatment for a sprained ankle. The nurse notes that the client as sent home with crutches that have rubber axillary pads and needs instructions regarding crutch walking. On admission assessment, the nurse discovers that the client has an allergy to latex. Before providing instructions regarding crutch walking, the nurse should:

    a) contact the physician
    b) cover the crutch pads with cloth
    c) call the local medical supply store and ask for a cane to be delivered
    d) tell the client that the crutches must be removed from the house immediately






    NCLEX Review about Immune System Disorders:
    ANSWERS AND RATIONALE

    16) C
    - Systemic lupus erythematosus is an inflammatory disease of collagen in connective tissue. Options A, B, and D are not associated with this disease.

    17) C
    - Treatment of systemic lupus erythematosus is based on the systems involved and symptoms. Treatment normally consists of anti-inflammatory drugs, corticosteroids, and immunosuppressants. Options A, B, and D are not standard components of medication therapy.

    18) A
    - Individuals at risk for developing a latex allergy include health care workers, individuals who work in the rubber industry or those who have had multiple surgeries, have spina bifida, wear gloves frequently, such as food handlers, hairdressers, and auto mechanics, or are allergic to kiwis, bananas, pineapples, tropical fruits, grapes, avocados, potatoes, hazelnuts, and water chestnuts.

    19) D
    - Individuals who are allergic to kiwis, bananas, pineapples, tropical fruits, grapes, avocados, potatoes, hazelnuts, and water chestnuts are at risk for developing a latex allergy. This is thought to be to the result of a possible cross-reaction between the food and the latex allergen. Options A, B, and C are unrelated to latex allergy.

    20) B
    - The rubber pads used on crutches may contain latex. If the client requires the use of crutches, the nurse can cover the pads with a cloth to prevent cutaneous contact. Option 4 is inappropriate and may alarm the client. The nurse cannot order a cane for a client. Additionally, this type of assistive device may not be appropriate, considering this client’s injury. No reason exists to contact the physician at this time.




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      Linkbait - Magic Keyword "NCLEX Practice Test"

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      NCLEX Review about Immune System Disorders (11-15)

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      --> NCLEX Review about Immune System Disorders

      11. The client with acquired immunodeficiency syndrome has a respiratory infection from Pneumocystis jiroveci and a nursing diagnosis of Impaired Gas Exchange written in the plan of care. Which of the following indicates that the expected outcome of care has nor yet been achieved?

      a) client limits fluid intake
      b) client has clear breath sounds
      c) client expectorates secretions easily
      d) client is free of complaints of shortness of breath

      12. A client with pemphigus is being seen in the clinic regularly. The nurse plans care based on which of the following descriptions of this condition?

      a) the presence of tiny red vesicles
      b) an autoimmune disease that causes blistering in the epidermis
      c) the presence of skin vesicles found along the nerve caused by a virus
      d) the presence of red, raised papules and large plaques covered by silvery scales

      13. The nurse is providing dietary instructions to the client with systemic lupus erythematosus. Which of the following dietary items would the nurse instruct the client to avoid?

      a) steak
      b) turkey
      c) broccoli
      d) cantaloupe

      14. A client calls the nurse in the emergency room and tells the nurse that he was just stung by a bee while gardening. The client is afraid of a severe reaction because the client's neighbor experienced such a reaction just 1 week ago. The appropriate nursing action is to:

      a) advise the client to soak the site in hydrogen peroxide
      b) ask the client if ever sustained a bee sting in the past
      c) tell the client to call an ambulance for transport to the emergency room
      d) tell the client no to worry about the sting unless difficulty with breathing occurs

      15. The nurse is assisting in administering immunizations at a health care clinic. The nurse understands that an immunization will provide:

      a) protection from all disease
      b) innate immunity from disease
      c) natural immunity from disease
      d) acquired immunity from disease






      NCLEX Review about Immune System Disorders:
      ANSWERS AND RATIONALE

      11) A
      - The status of the client with a diagnosis of Impaired gas exchange would be evaluated against the standard outcome criteria for this nursing diagnosis. These would include the client stating that breathing is easier and is coughing up secretions effectively, and has clear breath sounds. The client should not limit fluid intake because fluids are needed to decrease the viscosity of secretions for expectoration.

      12) B
      - Pemphigus is an autoimmune disease that causes blistering in the epidermis. The client has large flaccid blisters (bullae). Because the blisters are in the epidermis, they have a thin covering of skin and break easily, leaving large denuded areas of skin. On initial examination, clients may have crusting areas instead of intact blisters. Option A describes eczema, option C describes herpes zoster, and option D describes psoriasis.

      13) A
      - The client with systemic lupus erythematosus (SLE) is at risk for cardiovascular disorders such as coronary artery disease and hypertension. The client is advised of lifestyle changes to reduce these risks, which include smoking cessation and prevention of obesity and hyperlipidemia. The client is advised to reduce salt, fat, and cholesterol intake.

      14) B
      - In some types of allergies, a reaction occurs only on second and subsequent contacts with the allergen. The appropriate action, therefore, would be to ask the client if he ever received a bee sting in the past. Option A is not appropriate advice. Option C is unnecessary. The client should not be told “not to worry.”

      15) D
      - Acquired immunity can occur by receiving an immunization that causes antibodies to a specific pathogen to form. Natural (innate) immunity is present at birth. No immunization protects the client from all diseases.




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        NCLEX Review about Immune System Disorders (6-10)

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        NCLEX Review about Immune System Disorders

        6. Which of the following individuals is least likely at risk for the development of Kaposis's sarcoma?

        a) A kidney transplant client
        b) a male with a history of same-gender partners
        c) a client receiving anti-neoplastic medications
        d) an individual working in an environment in which he or she is exposed to asbestos

        7. The nurse prepares to give a bath and change the bed linens on a client with cutaneous Kaposi's sarcoma lesions. The lesions are open and draining a scant amount of serous fluid. Which of the following would the nurse incorporate into the plan during the bathing of this client?

        a) wearing gloves
        b) wearing a gown and gloves
        c) wearing a gown, gloves, and a mask
        d) wear a gown and gloves to change the bed linens and gloves only for the bath

        8. A client is suspected of having systemic lupus erythematosus. The nurse monitors the client, knowing that which of the following is one of the initial characteristic signs of systemic lupus erythematosus?

        a) weight gain
        b) subnormal temperature
        c) elevated red blood cell count
        d) rash on the face across the bridge of the nose and on the cheeks

        9. The nurse provides home care instructions to a client with systemic lupus erythematosus and tells the client about methods to manage fatigue. Which statement by the client indicates a need for further instructions?

        a) I should take hot baths because they are relaxing
        b) I should sit whenever possible to conserve my energy
        c) I should avoid long periods of rest because it causes joint stiffness
        d) I should do some exercises, such as walking, when I am not fatigued

        10. The client with acquired immunodeficiency syndrome has raised, dark purplish-colored lesions on the trunk of the body. The nurse anticipates that which of the following procedures will be done to confirm whether these lesions are caused by Kaposi's sarcoma?

        a) skin biopsy
        b) lung biopsy
        c) western blot
        d) enzyme-linked immunosorbent assay






        NCLEX Review about Immune System Disorders:
        ANSWERS AND RATIONALE

        6) D
        - Kaposi’s sarcoma is a vascular malignancy that presents as a skin disorder and is a common acquired immunodeficiency syndrome indicator. Malignancy is seen most frequently in men with a history of same-gender partners. Although the cause of Kaposi’s sarcoma is not known, it is considered to be caused by an alteration or failure in the immune system. The renal transplantation client and the client receiving antineoplastic medications are at risk for immunosuppression. Exposure to asbestos is not related to the development of Kaposi’s sarcoma.

        7) B
        - Gowns and gloves are required if the nurse anticipates contact with soiled items such as those with wound drainage or is caring for a client who is incontinent with diarrhea or a client who has an ileostomy or colostomy. Masks are not required unless droplet or airborne precautions are necessary. Regardless of the amount of wound drainage, a gown and gloves must be worn.

        8) D
        - Skin lesions or rash on the face across the bridge of the nose and on the cheeks is an initial characteristic sign of systemic lupus erythematosus (SLE). Fever and weight loss may also occur. Anemia is most likely to occur later in SLE.

        9) A
        - To help reduce fatigue in the client with systemic lupus erythematosus, the nurse should instruct the client to sit whenever possible, avoid hot baths (because they exacerbate fatigue), schedule moderate low-impact exercises when not fatigued, and maintain a balanced diet. The client is instructed to avoid long periods of rest because it promotes joint stiffness.

        10) A
        - The skin biopsy is the procedure of choice to diagnose Kaposi’s sarcoma, which frequently complicates the clinical picture of the client with acquired immunodeficiency syndrome. Lung biopsy would confirm Pneumocystis jiroveci infection. The enzyme-linked immunosorbent assay and Western blot are tests to diagnose human immunodeficiency virus status.



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          Online Nursing Practice Test about Immune System Disorders (1-5)

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          NCLEX Review about Immune System Disorders

          1. An older adult with no known cognitive impairment residing in a long-term care facility suddenly becomes disoriented and confused. There are no signs of extremity weakness or other neurological changes. Based on these observations, the nurse would focus the assessment in which priority body systems?

          a) pulmonary and renal systems
          b) reproductive and endocrine system
          c) integumentary and neurological systems
          d) cardiovascular and gastrointestinal systems

          2. A female client arrives at the health care clinic and tells the nurse that she was just bitten by a tick and would like to be tested for Lyme disease. The client tells the nurse that she removed the tick and flushed it down the toilet. Which of the following nursing actions is most appropriate?

          a) refer the client for blood test immediately
          b) inform the client that there is no test available for Lyme disease
          c) tell the client that testing is not necessary unless arthralgia develops
          d) instruct the client to return in 4 to 6 weeks to be tested because testing before this time is not reliable

          3. Following diagnosis of stage I Lyme disease, the nurse would anticipate that which of the following will be part of the treatment plan for the client?

          a) no treatment unless symptoms develop
          b) a 3-week course of oral antibiotic therapy
          c) daily oatmeal baths for 2 weeks
          d) treatment with intravenously administered antibiotics

          4. A Cub Scout leader, who is a nurse preparing a group of Cub Scouts for an overnight camping trip, instructs the scouts about the methods to prevent Lyme disease. Which statement by one of the Cub Scouts indicates a need for further instructions?

          a) I need to bring a hat to wear during the trip
          b) I should wear long-sleeved tops and long pants
          c) I should not use insect repellents because it will attract the ticks
          d) I need to wear closed shoes and socks that can be pulled up over my pants

          5. The client with acquired immunodeficiency syndrome is diagnosed with cutaneous Kaposi's sarcoma. Based on this diagnosis, the nurse understands that this has been confirmed by which of the following?

          a) swelling in the genital area
          b) swelling in the lower extremities
          c) punch biopsy of the cutaneous lesions
          d) appearance of reddish-blue lesions noted on the skin






          NCLEX Review about Immune System Disorders:
          ANSWERS AND RATIONALE

          1) A
          - Changes in mental status and confusion are commonly associated with infections in the older adult. Assessments of the pulmonary and renal systems would be the priority. The older adult is at risk for pneumonia. The lungs should be auscultated for decreased breath sounds and other adventitious sounds. Urinary tract infections are also common in older adults, especially women. Flank pain with frequency and urgency are symptoms. The urine should be monitored for cloudiness, odor, and other changes indicating hematuria. Based on the data in the question, the body systems identified in options B, C, and D are not the priority.

          2) D
          A blood test is available to detect Lyme disease; however, the test is not reliable if performed before 4 to 6 weeks following the tick bite. Antibody formation takes place in the following manner. Immunoglobulin M is detected 3 to 4 weeks after Lyme disease onset, peaks at 6 to 8 weeks, and then gradually disappears; immunoglobulin G is detected 2 to 3 months after infection and may remain elevated for years. Options A, B, and C are incorrect.

          3) B
          - Prevention, public education, and early diagnosis are vital to the control and treatment of Lyme disease. A 3-week course of oral antibiotic therapy is recommended during stage I. Later stages of Lyme disease may require therapy with intravenously administered antibiotics, such as penicillin G. Options A and C are incorrect.

          4) C
          - In the prevention of Lyme disease, individuals need to be instructed to use an insect repellent on the skin and clothes when in an area where ticks are likely to be found. Long-sleeved tops and long pants, closed shoes, and a hat or cap should be worn. If possible, heavily wooded areas or areas with thick underbrush should be avoided. Socks can be pulled up and over the pant legs to the prevent ticks from entering under clothing.

          5) C
          - Kaposi’s sarcoma lesions begin as red, dark blue, or purple macules on the lower legs that change into plaques. These large plaques ulcerate or open and drain. The lesions spread by metastasis through the upper body and then to the face and oral mucosa. They can move to the lymphatic system, lungs, and gastrointestinal tract. Late disease results in swelling and pain in the lower extremities, penis, scrotum, or face. Diagnosis is made by punch biopsy of cutaneous lesions and biopsy of pulmonary and gastrointestinal lesions.


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            NCLEX Review about Ear Infection 36-40

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            NCLEX Review about Ear Infection

            36. A nurse is planning a presentation on noise prevention and ear protection for a display booth at a local health fair. The nurse plans to incorporate which important concept regarding hearing loss in the presentation?

            a) siting near loud music is not harmful
            b) ear plugs or other protectors are necessary only when use of power tools
            c) prolonged ringing in the ears after loud noises is normal
            d) cup the hands over the ears if loud noise is expected suddenly

            37. A nurse instructs a client in the use of a hearing aid. The nurse includes which of the following in the instructions?

            a) check the battery to ensure that it is working before use
            b) leave the hearing aid in place while showering
            c) hearing aids do not require any care
            d) a water-soluble lubricant is used on the hearing aid before insertion

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

            a) at least 1/2 day before
            b) at least 1 hour before
            c) at least the day before
            d) at least 2 days before

            39. An adult client makes an appointment with an ear specialist because of the frequent recurrence of middle ear infections. In performing an intake assessment of the client, the nurse would ask about which of the following as a risk factor related to infection of the ears?

            a) exposure to loud noise
            b) use of drilling and other power tools
            c) congenital abnormalities
            d) occupational noise

            40. A nurse is planning to instruct a client with chronic vertigo about safety measures to prevent exacerbation of symptoms or injury. Teaching for this client will include which of the following statements?

            a) drive only when feelings of dizziness have not been experienced for several hours
            b) go to the bedroom and lie down when vertigo is experienced
            c) remove throw rugs and clutter in the home
            d) turn the head slowly when spoken to





            NCLEX REVIEW ABOUT EAR INFECTION:
            ANSWERS AND RATIONALE

            36) D
            - A variety of ear protective devices are available commercially. These include disposable and reusable plugs, headbands, and foam-filled muffs. They should be used around any type of loud noise, such as from power tools, machinery, lawn mowers, chain saws, or other equipment. Sitting near loud music should be avoided whenever possible. If a loud noise is suddenly anticipated, the ears should be covered for protection. The client should see a physician for tinnitus or hearing loss after exposure to a loud noise.

            37) A
            - The battery of the hearing aid should be checked before use. The hearing aid should be removed for showering, because it should not get wet. It also should be put away in its case at night. It should be cleaned according to manufacturer’s directions, which usually consist of washing with warm soapy water, followed by thorough drying. Lubricants or other solvents are not used on the hearing aid.

            38) B
            - To be maximally effective, medications to prevent motion sickness should be taken at least 1 hour before the triggering event. Medications that are commonly used for this purpose include dimenhydrinate (Dramamine), scopolamine (Transderm-Scop), promethazine (Phenergan), and prochlorperazine (Compazine). Options A, C, and D are incorrect.

            39) C
            - Otitis media (middle ear infection) is associated with colds, allergies, sore throats, and blockage of the eustachian tube. Risk factors include a young age (usually a childhood disease), congenital abnormalities, immune deficiencies, exposure to cigarette smoke, family history of otitis media, recent upper respiratory infections, and allergies. Options A, B, and D can cause hearing loss. Hearing loss can occur as a result of an acute loud noise (acoustic trauma) or by the chronic exposure to loud noise (noise-induced hearing loss).

            40) C
            - The client with chronic vertigo should avoid driving and using public transportation. The sudden movements involved in each could precipitate an attack. To further prevent vertigo attacks, the client should change positions slowly and should turn the entire body, not just the head, when spoken to. If vertigo does occur, the client should immediately sit down or grasp the nearest piece of furniture. The client should maintain the home without throw rugs and in a state that is free of clutter, because the effort of trying to regain balance after slipping could trigger the onset of vertigo.



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            NCLEX Review about Ear Infection 1-5


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            NCLEX Review about Ear Infection 41-45

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              NCLEX Review about Ear Infection (31-35)

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              NCLEX Review about Ear Infection

              31. A clinic nurse is preparing to perform a Romberg test on a client being seen in the clinic. The nurse performs this test for the purpose of determining:

              a) the client's ability to ambulate
              b) the functional status of the vestibular apparatus in the inner ear
              c) the intactness of the retinal structure of the eye
              d) the intactness of the tympanic membrane

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

              a) a colony of black dots on the eardrum
              b) dense white patches on the eardrum
              c) a red bulging eardrum
              d) a round or oval darkened area on the eardrum

              33. A caloric test is ordered for a client suspected of having disease of the labyrinth. The nurse would obtain which of the following essential items in preparation for this test?

              a) an otoscope
              b) an opthalmoscope
              c) a tongue blade
              d) an emesis basin

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

              a) a client who became deaf before learning to speak
              b) a client with bilateral profound hearing loss
              c) a client who communicates primarily by speech
              d) a client who received no benefit from conventional hearing aids

              35. A nurse is observing a nursing assistant communicating with a client who is deaf. The nurse will intervene if which of the following behaviors is observed?

              a) the nursing assistant is speaking directly to the client
              b) the nursing assistant touches the client's arm to gain his or her attention
              c) the nursing assistant faces the client when speaking to the client
              d) the nursing assistant overenunciates words when speaking




              NCLEX Review about Ear Infection:
              ANSWERS AND RATIONALE

              31) B
              - The Romberg test assesses the ability of the vestibular apparatus in the inner ear to help maintain standing balance. The Romberg test also assesses intactness of the cerebellum and proprioception. Options A, C, and D are incorrect.

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

              33) A
              - A caloric test is contraindicated in a client with a perforated tympanic membrane (air may be used as a substitute) or if the client has an acute disease of the labyrinth. An otoscopic examination should be performed before the caloric test to rule out perforation and to determine if the ear canal contains cerumen, which must be removed before the test. An ophthalmoscope, a tongue blade, and an emesis basin are not essential items.

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

              35) D
              - Overenunciating words does not make lip reading easier and is demeaning to the deaf person. It is best to speak in a normal manner. Options A, B, and C are appropriate communication strategies for the client who is deaf.


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              NCLEX Review about Ear Infection (26-30)

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              NCLEX Review about Ear Infection

              26. The clinic nurse is preparing to provide care for a client who will need an ear irrigation to remove impacted cerumen. Which of the following will the nurse avoid when performing the irrigation?

              a) position the client to turn the head so that the ear be irrigated is facing upward
              b) warm the irrigating solution to a temperature that is close to body temperature
              c) direct a slow steady stream of irrigation solution toward the upper wall of the ear canal
              d) position the client with the affected side down after irrigation

              27. A nursing student is performing an otoscopic examination in an adult client. The nursing instructor observes the student perform this procedure. Which observation by the instructor indicates that the student is using correct technique for the procedure?

              a) pulling the pinna down and back before inserting the speculum
              b) pulling the earlobe down and back before inserting the speculum
              c) using the smallest speculum available
              d) tilting the client's head slightly away and holding the otoscope upside before inserting the speculum

              28. A nurse is preparing to perform a Weber test on a client. The nurse obtains which item needed to perform this test?

              a) a tongue blade
              b) a stethoscope
              c) a tuning fork
              d) a reflex hammer

              29. The home care nurse is visiting a client who was recently diagnosed with a hearing impairment. The nurse prepares to instruct the client's spouse in which measure that will facilitate communication?

              a) speak frequently to the client to provide sensory stimulation
              b) speak loudly to the client to facilitate hearing
              c) speak in a normal tone and face the client when speaking
              d) speak directly into the impaired ear to facilitate hearing

              30. A nurse is providing discharge instructions to a client who had a fenestration procedure for the treatment of otosclerosis. The nurse instructs the client to:

              a) drink liquids through a straw for the next 2 to 3 weeks
              b) shower daily to prevent infection
              c) avoid air travel
              d) resume all normal activities in 1 week





              NCLEX Review about Ear Infection:
              ANSWERS AND RATIONALE

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

              27) D
              - In the otoscopic examination, the nurse tilts the client’s head slightly away and holds the otoscope upside down as if it were a large pen. The pinna is pulled up and back and the nurse visualizes the external canal while slowly inserting the speculum. A small speculum is used in pediatric clients. The nurse may not be able to adequately visualize the ear canal if a small speculum is used in the adult client.

              28) C
              - A tuning fork is needed to perform the Weber test, during which the nurse places the vibrating tuning fork at the midline of the client’s forehead or above the upper lip over the teeth. Normally, the sound is heard equally in both ears by bone conduction. If the client has a sensorineural hearing loss in one ear, the sound is heard in the other ear. If the client has a conductive hearing loss in one ear, the sound is heard in that ear. The items identified in options A, B, and D are not needed to perform the Weber test.

              29) C
              - Measures that facilitate hearing in the client with a hearing impairment problem include speaking in a normal tone; avoiding shouting; talking directly to the client while facing the client; and speaking clearly. If the client does not seem to understand what is said, the statement should be expressed differently. Moving closer to the client and toward the better ear may facilitate communication, but talking directly into the impaired ear should be avoided.

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


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                NCLEX Review about Ear Infection (21-25)

                5:34 PM    No comments

                NCLEX Review about Ear Infection

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

                a) maintain a supine position
                b) position the client on the affected side to promote drainage
                c) change the ear dressing daily
                d) monitor for signs of facial nerve injury


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

                a) tinnitus
                b) headache
                c) fatigue
                insomnia


                23. A nurse has admitted a client with a diagnosis of an acute attack of Meniere's disease to the hospital. The nurse reviews the physician's orders for the client. Which order should the nurse question?

                a) diphenhydramine (Benadryl)
                b) diazepam (Valium)
                c) atropine sulfate
                d) ambulation 4 times daily

                24. A nurse in the health care clinic is preparing to perform an otoscopic examination on adult client. In performing the examination, the nurse should:

                a) position the client lying flat on the side of the ear be examined
                b) pull the ear lobe down and back before inserting the speculum
                c) tilt the client's head forward before inserting the speculum
                d) pull the pinna up and back before inserting the speculum

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

                a) I should take stool softeners to avoid straining when having a bowel movement
                b) I need to avoid washing my hair and showering for at least 1 week
                c) I should avoid movements requiring bending over for at least 3 weeks
                d) I should use a straw to drink liquids for the next 2 to 3 weeks





                NCLEX Review about Ear Infection:
                ANSWERS AND RATIONALE

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

                22) A
                - Ménière’s disease results in a disturbance of the fluid of the endolymphatic system. The cause of the disturbance is not known. Attacks may be preceded by feelings of fullness in the ear or by tinnitus. Headaches, fatigue, and insomnia are not associated with this disorder.

                23) D
                - Medical interventions during the acute phase of Ménière’s disease include using atropine sulfate or diazepam to decrease the autonomic nervous system function. Diphenhydramine may be prescribed for its antihistamine effects, and a vasodilator also will be prescribed. The client will remain on bedrest during the acute attack. When allowed out of bed, the client will need assistance with walking, sitting, or standing.

                24) D
                - The correct procedure for performing an otoscopic examination on an adult is to pull the pinna up and back to allow visualization of the external canal while slowly inserting the speculum. The nurse would tilt the client’s head slightly away and hold the otoscope upside down as if it were a large pen. The examination would be performed with the client in a sitting position. If the client were lying on the side to be examined, examination of the affected ear would not be possible.

                25) D
                - After ear surgery, clients need to be instructed to avoid drinking with a straw for 2 to 3 weeks, to avoid air travel, and to avoid coughing excessively. The client also should be instructed to avoid straining when having a bowel movement and should be instructed to take stool softeners as prescribed. The client should avoid getting the head wet, washing the hair, or showering for at least 1 week, and to avoid rapidly moving the head, bouncing, and bending over for at least 3 weeks.


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                  NCLEX Review about Ear Infection (16-20)

                  6:13 PM    1 comment

                  NCLEX Review about Ear Infection

                  16. The nurse is preparing to perform an otoscopic examination on an adult client. The nurse does which of the following to perform this examination?

                  a) pulls the pinna up and back before inserting the speculum
                  b) pulls the earlobe down and back before inserting the speculum
                  c) uses the smallest speculum available to decrease the discomfort of the exam
                  d) tilts the clients head forward and down before inserting the speculum

                  17. A nurse is providing diet instructions to a client with Meniere's disease who is being discharged from the hospital after admission for an acute attack. Which statement if made by the client indicates an understanding of the dietary measures to take to prevent further attacks?

                  a) I need to drink at least 3 liters of fluid per day
                  b) I need to restrict my carbohydrates intake
                  c) I need to maintain a low-fat and low-cholesterol diet
                  d) I need to be sure to consume foods that are low in sodium

                  18. A nurse in the health care clinic is providing instructions to a client regarding the use of a hearing aid. Which of the following statements would be appropriate for the nurse to include?

                  a) the ear mold for the hearing aid should be washed with mild soap and water once a month
                  b) the hearing aid should be removed from the ear at the end of the day then turned off after removal
                  c) the hearing aid contains a lifelong battery so you will not need to be concerned about changing batteries
                  d) the hearing aid should not be worn if an ear infection is present

                  19. A nurse is caring for a client with acute otitis media. In order to reduce pressure and allow fluid to drain, the nurse anticipates that which of the following would most likely be recommended to the client?

                  a) the administration of diphenhydramine (Benadryl) capsules
                  b) a myringotomy
                  c) strict bedrest
                  d) a mastoidectomy

                  20. A nurse is developing a plan of care for a client with a diagnosis of Meniere's disease who is being admitted to the hospital. The priority nursing intervention in the plan of care should focus on:

                  a) safety measures
                  b) self-care measures
                  c) knowledge about medication therapy
                  d) food items to avoid





                  NCLEX Review about Ear Infection:
                  ANSWERS AND RATIONALE

                  16) A
                  - The nurse tilts the client’s head slightly away and holds the otoscope upside down as if it were a large pen. The pinna is pulled up and back and the nurse visualizes the external canal while slowly inserting the speculum. Options B, C, and D are incorrect.

                  17) D
                  - Dietary changes such as salt and fluid restrictions that reduce the amount of endolymphatic fluid are sometimes prescribed for the client with Ménière’s disease. The client should be instructed to consume a low-sodium diet and restrict fluids as prescribed. Low-fat, low-carbohydrate, and low-cholesterol diets are not specifically prescribed for the client with Ménière’s disease.

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

                  19) B
                  - A myringotomy is a surgical procedure that will allow fluid to drain from the middle ear. Benadryl is an antihistamine with antiemetic properties. Strict bedrest is not necessary, although activity may be restricted. Additionally, bedrest would not assist in reducing pressure or allowing fluid to drain. In some cases, the mastoid bone is removed or partially removed for chronic otitis media.

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


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