A nurse is teaching a group of clients about the specific types of fluids that protect the structures of the inner ear. Which of the following statements should the nurse include in the teaching?

"Endolymph fluid provides protection to the structures of the inner ear."

"Aqueous humor provides protection to the structures of the inner ear."

"Vitreous humor provides protection to the structures of the inner ear."

"Sanguineous fluid provides protection to the structures of the inner ear."

Answer and Explanation

The Correct Answer is A

A. "Endolymph fluid provides protection to the structures of the inner ear": Endolymph is a fluid found within the membranous labyrinth of the inner ear. It plays a crucial role in maintaining the balance of ions necessary for proper sensory function of the auditory and vestibular systems. Endolymph helps protect the delicate sensory structures of the inner ear, including the hair cells responsible for hearing and balance.

B. "Aqueous humor provides protection to the structures of the inner ear": Aqueous humor is a clear fluid that fills the anterior chamber of the eye, maintaining intraocular pressure and nourishing the cornea and lens. It is not involved in protecting the structures of the inner ear.

C. "Vitreous humor provides protection to the structures of the inner ear": Vitreous humor is a gel-like substance that fills the posterior chamber of the eye, providing structural support to the eyeball and maintaining its shape. It is not associated with protecting the structures of the inner ear.

D. "Sanguineous fluid provides protection to the structures of the inner ear": Sanguineous fluid refers to blood or a blood-like fluid, which does not directly provide protection to the structures of the inner ear. While the circulatory system supplies oxygen and nutrients to the inner ear structures, blood itself does not serve as a protective fluid within the inner ear.

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Correct Answer is C

Explanation

A. "Distributive shock occurs due to loss of myocardial contractility": This statement is incorrect. Distributive shock is not primarily caused by loss of myocardial contractility. Instead, distributive shock is characterized by widespread vasodilation, which leads to inadequate tissue perfusion despite normal or high cardiac output.

B. "Distributive shock occurs due to loss of blood volume": This statement is inaccurate. Distributive shock is not primarily caused by loss of blood volume. While hypovolemia (loss of blood volume) can lead to shock, distributive shock specifically involves excessive vasodilation, resulting in a relative hypovolemia due to pooling of blood in the expanded vascular bed.

C. "Distributive shock occurs due to systemic vasodilation": This statement is correct. Distributive shock, also known as vasodilatory shock, occurs due to widespread vasodilation of the systemic vasculature. This vasodilation leads to a decrease in systemic vascular resistance, which results in the redistribution of blood flow away from vital organs and tissues, leading to inadequate tissue perfusion and shock.

D. "Distributive shock occurs due to increased systemic vascular resistance": This statement is incorrect. Distributive shock is characterized by decreased systemic vascular resistance due to vasodilation, not increased systemic vascular resistance. Increased systemic vascular resistance is more commonly associated with conditions such as hypertension or obstructive shock.

A. "l need to walk slowly as I lose my balance often." B. "l don't go out much because of the pain in my legs." C. "It makes me sad that I can't keep up with my grandchildren." D. "l have a small-healed area on my spine that is painful."

Correct Answer is A

Explanation

A. "I need to walk slowly as I lose my balance often": This statement indicates a potential safety concern related to balance issues while walking. Loss of balance can increase the risk of falls, especially in individuals with peripheral artery disease (PAD) who may already have compromised circulation and reduced sensation in their legs. The nurse should report this statement to the provider for further evaluation and intervention to prevent falls and promote safety.

B. "I don't go out much because of the pain in my legs" : While this statement suggests that the client experiences pain in their legs, it does not directly indicate a safety concern that requires immediate reporting to the provider. Pain management strategies may be discussed with the provider to address this issue.

C. "It makes me sad that I can't keep up with my grandchildren" : While this statement reflects emotional distress related to the client's inability to participate fully in activities with their grandchildren, it does not indicate a specific safety concern that requires reporting to the provider. However, addressing the client's emotional well-being is important for overall holistic care.

D. "I have a small-healed area on my spine that is painful" : This statement describes a painful area on the client's spine but does not directly relate to potential safety concerns associated with PAD. The nurse may further assess this issue and include it in the client's overall assessment, but it does not require immediate reporting to the provider for safety concerns related to PAD.

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A nurse is teaching a group of clients about the specific types of fluids that protect the structures of the inner ear. Which of the following statements should the nurse include in the teaching?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse and a newly licensed nurse are providing care for a client who has distributive shock. How should the nurse explain the pathophysiology of distributive shock to the newly licensed nurse?

Correct Answer is C

Explanation

A nurse is assessing a client who has peripheral artery disease for potential safety concerns. Which of the following client statements should the nurse report to the provider?

Correct Answer is A

Explanation

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