When planning care for a client with an inner ear infection, the nurse will need to include interventions for which of the following potential problems?
Vertigo
Rhinorrhea
Fever
Headache
The Correct Answer is A
Choice A Reason:
Vertigo is a common complication associated with inner ear infections, such as labyrinthitis or vestibular neuritis. The inner ear is responsible for balance, and when it is infected, it can lead to a sensation of spinning or dizziness. Interventions may include medications like meclizine or dimenhydrinate to alleviate symptoms, as well as safety measures to prevent falls.
Choice B Reason:
Rhinorrhea, or a runny nose, is not typically a direct complication of an inner ear infection. It may be associated with upper respiratory infections that can precede or accompany an ear infection but is not a result of the inner ear infection itself.
Choice C Reason:
Fever may be present if the inner ear infection is part of a systemic infection, such as the flu or bacterial meningitis. However, fever is not a direct result of an isolated inner ear infection. If fever is present, the nurse should monitor the patient's temperature and may administer antipyretics as ordered.
Choice D Reason:
Headache can be a symptom experienced by individuals with inner ear infections due to the general discomfort and pressure changes in the ear. However, it is not as specific or as common as vertigo when it comes to inner ear infections. If headaches are present, pain management strategies can be included in the care plan.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A Reason:
The nasolacrimal sac is part of the tear drainage system. When a patient presents with excessive tearing, known as epiphora, it is important to assess for any obstruction in the lacrimal apparatus. The nasolacrimal sac can become blocked due to various reasons such as infection, inflammation, or structural abnormalities. Assessing this area can help determine if there is a blockage causing the tears to accumulate and overflow.
Choice B Reason:
Inspecting the palpebral conjunctiva is typically done if there is a complaint of eye pain or a sensation of a foreign body in the eye. While it is part of a comprehensive eye examination, it is not the first assessment to be performed for excessive tearing unless there are additional symptoms that suggest a problem with the conjunctiva.
Choice C Reason:
Testing the pupillary reaction to light is an assessment of the pupillary response and the function of the oculomotor nerve. This test is crucial when neurological issues are suspected or if there is a change in vision. However, it is not the primary assessment for excessive tearing without other associated symptoms.
Choice D Reason:
The eye positions test, which assesses eye muscle strength and cranial nerve function, is not necessary unless there are signs of problems with muscle strength, such as drooping. This test would not typically be the next step in assessing a patient with excessive tearing unless there are other indications of muscle or nerve impairment.
Correct Answer is ["A","B","C","D"]
Explanation
Choice a reason:
Wearing nonslip shoes in the house is a preventive measure against falls, which are a leading cause of traumatic brain injuries (TBIs) in adolescents. Nonslip shoes provide better grip and stability, especially on potentially slippery surfaces like tiles or polished wood, reducing the risk of slips and falls that can lead to head injuries.
Choice b reason:
The supervised use of guns by an adult is critical in preventing accidental shootings, which can result in TBIs. Adolescents may lack the maturity and experience to handle firearms safely, and adult supervision ensures that proper safety protocols are followed, reducing the risk of accidental discharge and potential injury.
Choice c reason:
The use of seat belts is one of the most effective ways to prevent TBIs in the event of a vehicle accident. Seat belts restrain the body and prevent individuals from being thrown around inside or ejected from the vehicle, significantly reducing the likelihood of head trauma.
Choice d reason:
Avoiding risky activities such as snowboarding without proper safety equipment is essential in preventing sports-related TBIs. Snowboarding, like other high-speed sports, carries a risk of falls and collisions, which can cause head injuries. Wearing helmets and other protective gear, and engaging in these activities with caution, can mitigate this risk.
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