A nurse is caring for a client diagnosed with an inner ear infection. Which of the following manifestations will the nurse expect the client to report?
Inability to recognize any words
Loss of balance
Twitching of the cheek
Lack of air sound
The Correct Answer is B
Choice A Reason: This is incorrect because inability to recognize any words may indicate a problem with the auditory cortex, which is the part of the brain that processes sound, not the inner ear. The inner ear consists of the cochlea, which converts sound waves into nerve impulses, and the vestibular system, which helps with balance and orientation.
Choice B Reason: This is correct because loss of balance is a common symptom of an inner ear infection. An inner ear infection can cause inflammation and fluid buildup in the vestibular system, which can disrupt the sense of equilibrium and cause vertigo, dizziness, or nausea.
Choice C Reason: This is incorrect because twitching of the cheek may indicate a problem with the facial nerve, which controls the muscles of facial expression, not the inner ear. The facial nerve runs close to the inner ear, but it is not part of it.
Choice D Reason: This is incorrect because lack of air sound may indicate a problem with the outer or middle ear, which transmit sound waves to the inner ear, not the inner ear itself. The outer ear consists of the pinna and the ear canal, and the middle ear consists of the eardrum and the ossicles.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C","D","E"]
Explanation
Choice A Reason: This is correct because clinical obesity is a risk factor for metabolic syndrome. Clinical obesity is defined by having a body mass index (BMI) of 30 or higher, or a waist circumference of more than 40 inches for men or 35 inches for women. Obesity can increase insulin resistance and inflammation, which can lead to metabolic syndrome.
Choice B Reason: This is correct because elevated blood pressure is a risk factor for metabolic syndrome. Elevated blood pressure is defined by having a systolic blood pressure of 130 mm Hg or higher, or a diastolic blood pressure of 85 mm Hg or higher. High blood pressure can damage the blood vessels and increase the risk of cardiovascular disease, which is associated with metabolic syndrome.
Choice C Reason: This is correct because high triglycerides are a risk factor for metabolic syndrome. Triglycerides are a type of fat that circulates in the blood and provides energy for the cells. High triglycerides are defined by having a level of 150 mg/dL or higher. High triglycerides can increase the risk of fatty liver disease and pancreatitis, which are related to metabolic syndrome.
Choice D Reason: This is correct because hypercholesterolemia is a risk factor for metabolic syndrome. Hypercholesterolemia is defined by having a total cholesterol level of 200 mg/dL or higher, or a low-density lipoprotein (LDL) cholesterol level of 100 mg/dL or higher. LDL cholesterol is also known as "bad" cholesterol because it can build up in the arteries and cause plaque formation and narrowing, which can lead to cardiovascular disease and metabolic syndrome.
Choice E Reason: This is correct because hyperglycemia is a risk factor for metabolic syndrome. Hyperglycemia is defined by having a fasting blood glucose level of 100 mg/dL or higher, or a hemoglobin A1c level of 5.7% or higher. Hemoglobin A1c is a measure of average blood glucose over three months. Hyperglycemia can indicate impaired glucose metabolism and insulin resistance, which are hallmarks of metabolic syndrome.
Correct Answer is D
Explanation
Choice A reason: This is incorrect because increasing her voice when speaking to the client may not prevent complications, but rather annoy or offend the client. The nurse should not assume that a client with a visual impairment has a hearing impairment as well unless it is confirmed by assessment or history. The nurse should speak in a normal tone and volume and identify herself by name and role.
Choice B reason: This is incorrect because lowering the bed rails before lowering the bed may increase the risk of complications, such as falls or injuries. The nurse should keep the bed rails up until the client is ready to get out of bed and lower them only when necessary. The nurse should also lock the wheels of the bed and adjust it to a comfortable height for the client.
Choice C reason: This is incorrect because using hand gestures to point to where the client will walk may not prevent complications, but rather confuse or frustrate the client. The nurse should not use visual cues or gestures that are meaningless to a client with a visual impairment. The nurse should use verbal directions and descriptions instead, such as "The restroom is on your left, about 10 steps away."
Choice D reason: This is correct because standing slightly in front and to one side of the client can prevent complications, such as collisions or falls. The nurse should guide the client by offering her arm or shoulder for support and walking slightly ahead of him or her. The nurse should also warn the client about any obstacles or changes in terrain, such as stairs, doors, or rugs.
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