A nurse is assessing a client who reports manifestations of tinnitus. Which of the following actions should the nurse perform to determine if movement is causing the clients manifestations to worsen?
Ask the client to move their eyes side to side while keeping their head still.
Ask the client to breathe in through pursed lips.
Ask the client to pull the pinna of their ears up and back.
Ask the client to open their mouth widely.
The Correct Answer is A
A. Ask the client to move their eyes side to side while keeping their head still: This action helps assess if movement exacerbates the client's tinnitus. Tinnitus that worsens with eye movement suggests a potential vascular cause, as the blood vessels surrounding the auditory nerve may be affected. This maneuver is known as the Valsalva maneuver and can help identify vascular issues contributing to tinnitus.
B. Ask the client to breathe in through pursed lips: Breathing through pursed lips is a technique used to help manage shortness of breath and is not directly related to assessing tinnitus or its exacerbating factors.
C. Ask the client to pull the pinna of their ears up and back: Pulling the pinna of the ears up and back is a maneuver commonly performed during otoscopic examination to straighten the ear canal for better visualization of the tympanic membrane. It is not directly relevant to assessing tinnitus or its exacerbating factors.
D. Ask the client to open their mouth widely: Opening the mouth widely is not typically associated with exacerbating tinnitus. This action is more relevant for assessing temporomandibular joint (TMJ) dysfunction or other oral conditions but is not specific to tinnitus assessment.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. "I can't see anything from the sides of my eyes." This statement suggests a visual field deficit, which may be indicative of conditions affecting peripheral vision, such as glaucoma, retinal detachment, or optic nerve disorders. It is not a typical symptom of cataracts.
B. "My vision is almost gone from the center part of my eye." This statement indicates a central visual impairment, which is a common symptom of cataracts. Cataracts cause clouding of the lens, leading to blurred or dimmed vision, especially in the center of the visual field. This symptom often progresses gradually over time.
C. "My contact lenses just don't fit like they used to." This statement suggests discomfort or fit issues with contact lenses and is not specifically indicative of cataracts. It may be related to changes in the shape or health of the cornea, conjunctiva, or tear film.
D. "I keep seeing flashes of lights moving around in my eye." Flashes of light in the visual field are not typical symptoms of cataracts. They may indicate other ocular conditions such as vitreous detachment, migraines with aura, or retinal disorders.
Correct Answer is B
Explanation
A. Dopamine: Dopamine is a catecholamine often used to increase blood pressure and cardiac output in hypotensive states. It does not directly reduce intracranial pressure (ICP).
B. Mannitol: Mannitol is an osmotic diuretic commonly used to reduce intracranial pressure in clients with conditions such as subarachnoid hemorrhage, traumatic brain injury, or cerebral edema. It works by drawing fluid from brain tissue into the bloodstream, thereby reducing cerebral edema and ICP.
C. Nicardipine: Nicardipine is a calcium channel blocker used primarily to lower blood pressure in hypertensive emergencies. While it can indirectly impact intracranial pressure by reducing cerebral perfusion pressure, its primary mechanism of action is not targeted at reducing ICP.
D. Phenytoin: Phenytoin is an antiepileptic medication used to prevent and control seizures. While it may be indicated in clients who have experienced a subarachnoid hemorrhage to prevent seizures, it does not directly reduce intracranial pressure.
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