NCLEX Review about Ear Infection (16-20)

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.

Go to the next page ---> NCLEX Review about Ear Infection (21-25)

Or go back toNCLEX Review about Ear Infection (1-5)


Related Topics:

• Fundamentals of Nursing  Concepts
• Medical-Surgical Concepts
• Maternal and Child Concepts