Medical surgical nursing, 10th Edition : assessment and management of clinical problems

When the patient turns his head quickly during the admission assessment, the nurse observes nystagmus. What is the indicated nursing action? a. Assess the patient with a Rinne test. b. Place a fall-risk bracelet on the patient. c. Ask the patient to watch the mouths of staff when they are speaking. d. Remind unlicensed assistive personnel to speak loudly to the patient. HTTPS://BIT.LY/3OTCF7O Problems with balance related to vestibular function may present as nystagmus or vertigo and i...

7. The nurse is observing a student who is preparing to perform an ear examination for a 30-yr-old patient. The nurse will need to intervene if the student a. pulls the auricle of the ear up and posterior. b. chooses a speculum larger than the ear canal. c. stabilizes the hand holding the otoscope on the patient’s head. d. stops inserting the otoscope after observing impacted cerumen. HTTPS://BIT.LY/3OTCF7O The speculum should be smaller than the ear canal so it can be inserted withou...

6. When assessing a patient’s consensual pupil response, the nurse should a. have the patient cover one eye while facing the nurse. b. observe for a light reflection in the center of both pupils. c. shine a light into one eye and observe responses of both pupils. d. instruct the patient to follow a moving object using only the eyes. HTTPS://BIT.LY/3OTCF7O The consensual pupil response is tested by shining a light into one pupil and observing for both pupils to constrict....