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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