A nurse is performing an ear irrigation for a client. Which of the following actions should the nurse take?

Point the tip of the syringe toward the top of the ear canal.

Use cool water for irrigation.

Insert the tip of the syringe 2.5 cm (1 in) into the ear canal.

Tilt the client’s head with the affected ear facing up.

Answer and Explanation

The Correct Answer is D

Choice A reason: Pointing the syringe toward the top of the ear canal risks directing water at the eardrum, potentially causing trauma or perforation. Irrigation should aim along the canal’s side to gently dislodge debris, ensuring safety and effectiveness without damaging delicate structures.

Choice B reason: Cool water can cause dizziness or discomfort by stimulating the vestibular system in the inner ear. Warm water (body temperature, ~37°C) is used to prevent vertigo and ensure client comfort during irrigation, making cool water an incorrect choice.

Choice C reason: Inserting the syringe 2.5 cm into the ear canal is unsafe, as it risks trauma to the canal or eardrum. The syringe tip should be placed just at the entrance to direct water safely, preventing injury during the irrigation procedure.

Choice D reason: Tilting the head with the affected ear up allows water to flow into the canal and debris to exit via gravity. This position ensures effective irrigation, prevents fluid pooling, and minimizes complications like infection or discomfort, aligning with safe practice standards.

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Correct Answer is D

Explanation

Choice A reason: Revenge-seeking behavior is not typical in dementia. It may occur in personality disorders or impulse control issues. Dementia primarily affects memory, language, and executive function due to neurodegeneration, leading to cognitive deficits rather than intentional aggressive behaviors aimed at retribution.

Choice B reason: Clang associations, where speech is driven by sound rather than meaning, are characteristic of schizophrenia or mania, not dementia. Dementia impairs language fluency and word retrieval due to cortical atrophy, particularly in Alzheimer’s disease, but does not typically produce clang associations.

Choice C reason: Traumatic flashbacks are specific to post-traumatic stress disorder (PTSD), not dementia. Dementia involves progressive memory loss and cognitive decline due to neuronal loss, not reliving past traumas. Flashbacks require intact memory processing, which is impaired in dementia’s neurodegenerative pathology.

Choice D reason: Difficulty finding words, or aphasia, is a common symptom in dementia, particularly Alzheimer’s, due to degeneration in language-processing areas like the temporal lobe. This leads to impaired word retrieval, hesitant speech, and reduced fluency, significantly affecting communication as the disease progresses.

A. Document the interventions used before applying restraints. B. Obtain a prescription to renew the restraint prescription every 48 hours. C. Secure the client in bed by tightly tucking in sheets. D. Delegate assistive personnel to check on the client regularly.

Correct Answer is A

Explanation

Choice A reason: Documenting interventions attempted before restraints is critical for legal and ethical compliance. Restraints are a last resort, and documentation demonstrates adherence to de-escalation protocols, ensuring patient safety and justifying restraint use in response to imminent danger, per regulatory standards.

Choice B reason: Restraint prescriptions typically require renewal every 24 hours, not 48, to ensure ongoing necessity and safety. Frequent reassessment prevents prolonged restraint use, which risks physical harm (e.g., pressure injuries) and psychological trauma, making this action incorrect and non-compliant with standards.

Choice C reason: Tightly tucking sheets can restrict movement, increasing risk of injury or discomfort, and is considered a form of restraint requiring a prescription. This action violates least-restraint principles and may exacerbate agitation or cause physical harm, making it unsafe and inappropriate.

Choice D reason: Delegating restraint monitoring to assistive personnel is inappropriate, as it requires clinical judgment to assess circulation, skin integrity, and behavior. Licensed nurses must perform regular checks (e.g., every 15 minutes) to ensure safety and compliance with restraint protocols, preventing complications.

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A nurse is performing an ear irrigation for a client. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

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