Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is caring for a client diagnosed with an inner ear infection. Which of the following manifestations will the nurse expect the client to report?
A. Inability to recognize any words
Reason: This is incorrect because inability to recognize any words may indicate a problem with the auditory cortex, which is the part of the brain that processes sound, not the inner ear. The inner ear consists of the cochlea, which converts sound waves into nerve impulses, and the vestibular system, which helps with balance and orientation.
B. Loss of balance
Reason: This is correct because loss of balance is a common symptom of an inner ear infection. An inner ear infection can cause inflammation and fluid buildup in the vestibular system, which can disrupt the sense of equilibrium and cause vertigo, dizziness, or nausea.
C. Twitching of the cheek
Reason: This is incorrect because twitching of the cheek may indicate a problem with the facial nerve, which controls the muscles of facial expression, not the inner ear. The facial nerve runs close to the inner ear, but it is not part of it.
D. Lack of air sound
Reason: This is incorrect because lack of air sound may indicate a problem with the outer or middle ear, which transmit sound waves to the inner ear, not the inner ear itself. The outer ear consists of the pinna and the ear canal, and the middle ear consists of the eardrum and the ossicles.
This question is an excerpt from Nurse Dive's nursing test bank - ATI Med Surg Proctored Exam 4. Take the full exam now
Full Explanation
Choice A Reason: This is incorrect because inability to recognize any words may indicate a problem with the auditory cortex, which is the part of the brain that processes sound, not the inner ear. The inner ear consists of the cochlea, which converts sound waves into nerve impulses, and the vestibular system, which helps with balance and orientation.
Choice B Reason: This is correct because loss of balance is a common symptom of an inner ear infection. An inner ear infection can cause inflammation and fluid buildup in the vestibular system, which can disrupt the sense of equilibrium and cause vertigo, dizziness, or nausea.
Choice C Reason: This is incorrect because twitching of the cheek may indicate a problem with the facial nerve, which controls the muscles of facial expression, not the inner ear. The facial nerve runs close to the inner ear, but it is not part of it.
Choice D Reason: This is incorrect because lack of air sound may indicate a problem with the outer or middle ear, which transmit sound waves to the inner ear, not the inner ear itself. The outer ear consists of the pinna and the ear canal, and the middle ear consists of the eardrum and the ossicles.
Similar Questions
A client diagnosed with cholecystitis reports right upper quadrant pain that radiates to the right shoulder. Which of the following interventions is the priority for the nurse to implement?
A. Administer IV ketorolac.
reason: This is incorrect because administering IV ketorolac is not a priority intervention for a client with cholecystitis. Ketorolac is a nonsteroidal anti-inflammatory drug (NSAID) that can cause gastrointestinal bleeding and kidney damage, which are contraindicated in cholecystitis. The nurse should administer analgesics as prescribed, but only after assessing the pain level and severity.
B. Report findings to healthcare provider.
reason: This is incorrect because reporting findings to healthcare provider is not a priority intervention for a client with cholecystitis. The nurse should communicate with the healthcare provider about the client's condition and treatment plan, but only after assessing the pain level and other vital signs.
C. Offer a high-calorie, high-fat meal.
reason: This is incorrect because offering a high-calorie, high-fat meal is not an intervention for a client with cholecystitis, but a potential trigger. High-fat foods can stimulate the gallbladder to contract and cause more pain and inflammation. The nurse should advise the client to avoid fatty foods and follow a low-fat diet.
D. Assess the pain level.
reason: This is the correct answer because assessing the pain level is a priority intervention for a client with cholecystitis. Pain is the most common symptom of cholecystitis and can indicate the severity and complications of the condition. The nurse should assess the pain level using a numeric or descriptive scale, and monitor for changes in location, intensity, and duration.
Full Explanation
Choice A reason: This is incorrect because administering IV ketorolac is not a priority intervention for a client with cholecystitis. Ketorolac is a nonsteroidal anti-inflammatory drug (NSAID) that can cause gastrointestinal bleeding and kidney damage, which are contraindicated in cholecystitis. The nurse should administer analgesics as prescribed, but only after assessing the pain level and severity.
Choice B reason: This is incorrect because reporting findings to healthcare provider is not a priority intervention for a client with cholecystitis. The nurse should communicate with the healthcare provider about the client's condition and treatment plan, but only after assessing the pain level and other vital signs.
Choice C reason: This is incorrect because offering a high-calorie, high-fat meal is not an intervention for a client with cholecystitis, but a potential trigger. High-fat foods can stimulate the gallbladder to contract and cause more pain and inflammation. The nurse should advise the client to avoid fatty foods and follow a low-fat diet.
Choice D reason: This is the correct answer because assessing the pain level is a priority intervention for a client with cholecystitis. Pain is the most common symptom of cholecystitis and can indicate the severity and complications of the condition. The nurse should assess the pain level using a numeric or descriptive scale, and monitor for changes in location, intensity, and duration.
A client has just had surgery to create an ileostomy. The nurse assesses the client in the immediate postoperative period for which most frequent complication of this type of surgery?
A. Intestinal obstruction
Reason: This is incorrect because intestinal obstruction is not a common complication of ileostomy surgery. An ileostomy is a surgical opening in the abdomen that connects the end of the small intestine (ileum) to a pouch or bag outside the body. This allows stool to bypass the colon and rectum. Intestinal obstruction can occur if there is a blockage or narrowing in any part of the digestive tract, but it is more likely to affect the colon than the ileum.
B. Folate deficiency
Reason: This is incorrect because folate deficiency is not a common complication of ileostomy surgery. Folate is a vitamin that is essential for DNA synthesis and cell division. Folate is mainly absorbed in the jejunum, which is the middle part of the small intestine. An ileostomy does not affect the jejunum, so it does not interfere with folate absorption.
C. Malabsorption of fat
Reason: This is incorrect because malabsorption of fat is not a common complication of ileostomy surgery. Fat is digested and absorbed in both the small and large intestine. An ileostomy does not affect fat digestion, but it may reduce fat absorption by decreasing the transit time and surface area of the intestine. However, this is usually not significant enough to cause malabsorption symptoms.
D. Fluid and electrolyte imbalance
Reason: This is correct because fluid and electrolyte imbalance is a common complication of ileostomy surgery. Fluid and electrolytes are mainly absorbed in the colon, which is bypassed by an ileostomy. This can result in increased fluid and electrolyte loss through stool, especially sodium and potassium. This can lead to dehydration, hypotension, weakness, cramps, or arrhythmias.
Full Explanation
Choice A Reason: This is incorrect because intestinal obstruction is not a common complication of ileostomy surgery. An ileostomy is a surgical opening in the abdomen that connects the end of the small intestine (ileum) to a pouch or bag outside the body. This allows stool to bypass the colon and rectum. Intestinal obstruction can occur if there is a blockage or narrowing in any part of the digestive tract, but it is more likely to affect the colon than the ileum.
Choice B Reason: This is incorrect because folate deficiency is not a common complication of ileostomy surgery. Folate is a vitamin that is essential for DNA synthesis and cell division. Folate is mainly absorbed in the jejunum, which is the middle part of the small intestine. An ileostomy does not affect the jejunum, so it does not interfere with folate absorption.
Choice C Reason: This is incorrect because malabsorption of fat is not a common complication of ileostomy surgery. Fat is digested and absorbed in both the small and large intestine. An ileostomy does not affect fat digestion, but it may reduce fat absorption by decreasing the transit time and surface area of the intestine. However, this is usually not significant enough to cause malabsorption symptoms.
Choice D Reason: This is correct because fluid and electrolyte imbalance is a common complication of ileostomy surgery. Fluid and electrolytes are mainly absorbed in the colon, which is bypassed by an ileostomy. This can result in increased fluid and electrolyte loss through stool, especially sodium and potassium. This can lead to dehydration, hypotension, weakness, cramps, or arrhythmias.
A client diagnosed with contact dermatitis is receiving education from the nurse. Which of the following therapies will the nurse recommend to the client?
A. Phototherapy
Reason: This is incorrect because phototherapy is not a recommended therapy for contact dermatitis. Phototherapy involves exposing the skin to artificial light sources that emit specific wavelengths of light that can have anti-inflammatory or immunomodulatory effects. Phototherapy can be used for some skin conditions, such as psoriasis or eczema, but not for contact dermatitis.
B. Antibiotics
Reason: This is incorrect because antibiotics are not a recommended therapy for contact dermatitis. Antibiotics are drugs that kill or inhibit bacteria that cause infections. Contact dermatitis is not an infection, but an allergic or irritant reaction to a substance that comes in contact with the skin. Antibiotics have no effect on contact dermatitis and may cause adverse effects or resistance.
C. UV light
Reason: This is incorrect because UV light is not a recommended therapy for contact dermatitis. UV light refers to ultraviolet radiation from sunlight or artificial sources that can damage DNA and cause skin cancer or aging. UV light can also worsen contact dermatitis by increasing inflammation and sensitivity to allergens or irritants.
D. Avoidance
Reason: This is correct because avoidance is the best therapy for contact dermatitis. Avoidance means identifying and avoiding the substance that causes the skin reaction. This can prevent further exposure and allow the skin to heal. The nurse can help the client by providing education on how to read labels, use protective clothing or gloves, or substitute safer products.
Full Explanation
Choice A Reason: This is incorrect because phototherapy is not a recommended therapy for contact dermatitis. Phototherapy involves exposing the skin to artificial light sources that emit specific wavelengths of light that can have anti-inflammatory or immunomodulatory effects. Phototherapy can be used for some skin conditions, such as psoriasis or eczema, but not for contact dermatitis.
Choice B Reason: This is incorrect because antibiotics are not a recommended therapy for contact dermatitis. Antibiotics are drugs that kill or inhibit bacteria that cause infections. Contact dermatitis is not an infection, but an allergic or irritant reaction to a substance that comes in contact with the skin. Antibiotics have no effect on contact dermatitis and may cause adverse effects or resistance.
Choice C Reason: This is incorrect because UV light is not a recommended therapy for contact dermatitis. UV light refers to ultraviolet radiation from sunlight or artificial sources that can damage DNA and cause skin cancer or aging. UV light can also worsen contact dermatitis by increasing inflammation and sensitivity to allergens or irritants.
Choice D Reason: This is correct because avoidance is the best therapy for contact dermatitis. Avoidance means identifying and avoiding the substance that causes the skin reaction. This can prevent further exposure and allow the skin to heal. The nurse can help the client by providing education on how to read labels, use protective clothing or gloves, or substitute safer products.