with verified answers
A 23 year old man is admitted to the ambulatory surgery unit to undergo
removal of a cholesteatoma from the middle ear. Which of the following
post surgery nursing interventions takes priority?
Assessment of hearing
Treatment of nausea
Document decreased hearing acuity
Position client in supine on the affected side Ans✓✓✓Treatment of
nausea
Rationale: Clients who undergo ear surgery should be reassured that
decreased hearing acuity immediately after surgery is expected. The
client should be placed in a side-lying position on the unaffected side
with the head of the bed elevated. Antiemetics should be administered to
prevent vomiting since vomiting may increase the pressure in the middle
ear, disrupting the surgical site.
A preschool-age child is undergoing bilateral myringotomy with tubes
for the treatment of recurrent otitis media. The mother asks the nurse
what the tubes will do. The nurse's best response is that the tubes will:
Provide for drainage.
Prevent future episodes of otitis media.
Equalize pressures between the middle ear and the environment.
, Prevent the spread of infection to the mastoid bone. Ans✓✓✓Equalize
pressures between the middle ear and the environment.
Rationale: Myringotomy (an incision of the tympanic membrane) is
performed to relieve pressure caused by the edema and swelling of otitis
media, which impairs the eustachian tubes' ability to equalize pressures
between the middle ear and the environment. Without relief of pressure,
the tympanic membrane can rupture, the delicate structures of the middle
ear can be damaged, and infection can spread to adjoining tissues and
structures. Infection can still occur and spread despite myringotomy.
A spry 77-year-old female patient has been diagnosed with simple
glaucoma. She lives alone, takes medications for asthma, is on a fixed
income, and walks to Catholic Mass on Sunday mornings. The nurse
must be certain that the ophthalmologist is aware of which of the
aforementioned facts about the patient?
Lives alone.
Takes medications for asthma.
Lives on a fixed income.
Walks to Catholic Mass on Sundays. Ans✓✓✓Takes medications for
asthma.
Rationale: Living alone and a fixed income should be concerns
addressed through a Social Services consultation. The patient could be
listed on a clergy visit list if hospitalized. Most importantly, the nurse
wants to be certain that the patient takes medications for asthma because
beta-adrenergic blockers are used topically to treat glaucoma. In
, asthmatic patients, beta-adrenergic blockers can cause bronchospasm,
and are contraindicated
From the following list of signs and symptoms, identify those which are
associated with angle closure (also called narrow-angle or closed-angle)
glaucoma. (Select all that apply.)
painless, gradual loss of visual fields
nausea and vomiting
normal visual acuity
seeing halos around lights Ans✓✓✓nausea and vomiting
seeing halos around lights
Rationale: Open angle glaucoma is painless, with gradual loss of visual
fields. Visual acuity remains normal. Angle closure (also called narrow-
angle or closed-angle) glaucoma is a medical emergency characterized
by: nausea and vomiting, seeing colored halos around lights, a decrease
in visual acuity, general malaise, and eye and face pain.
The 77-year-old male smoker has developed cataracts on both eyes, and
is awaiting surgery. The cataracts have prevented the patient from
driving, reading, and seeing television. Which of the following
statements would be appropriate for the nurse in the preoperative
holding area to communicate to the patient?
"Did your eye doctor explain to you that you could choose to use eye
drops six times a day to dissolve the cataract?"