A nurse is assessing a client who reports manifestations of tinnitus. Which of the following actions should the nurse perform to determine if movement is causing the clients manifestations to worsen?

Ask the client to move their eyes side to side while keeping their head still.

Ask the client to breathe in through pursed lips.

Ask the client to pull the pinna of their ears up and back.

Ask the client to open their mouth widely.

Answer and Explanation

The Correct Answer is A

A. Ask the client to move their eyes side to side while keeping their head still: This action helps assess if movement exacerbates the client's tinnitus. Tinnitus that worsens with eye movement suggests a potential vascular cause, as the blood vessels surrounding the auditory nerve may be affected. This maneuver is known as the Valsalva maneuver and can help identify vascular issues contributing to tinnitus.

B. Ask the client to breathe in through pursed lips: Breathing through pursed lips is a technique used to help manage shortness of breath and is not directly related to assessing tinnitus or its exacerbating factors.

C. Ask the client to pull the pinna of their ears up and back: Pulling the pinna of the ears up and back is a maneuver commonly performed during otoscopic examination to straighten the ear canal for better visualization of the tympanic membrane. It is not directly relevant to assessing tinnitus or its exacerbating factors.

D. Ask the client to open their mouth widely: Opening the mouth widely is not typically associated with exacerbating tinnitus. This action is more relevant for assessing temporomandibular joint (TMJ) dysfunction or other oral conditions but is not specific to tinnitus assessment.

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Correct Answer is B

Explanation

A. Decrease sedation: Decreasing sedation may help reduce intracranial pressure (ICP) by allowing the client to have a more responsive level of consciousness. However, it is not a direct treatment for brain herniation. Sedation reduction should be done cautiously to prevent agitation and further increases in ICP.

B. Hyperventilate the client: Hyperventilation is a temporary intervention used to reduce intracranial pressure by inducing cerebral vasoconstriction, which decreases cerebral blood flow and intracranial volume. However, it is typically reserved for acute situations and is not considered a definitive treatment for brain herniation. Prolonged or excessive hyperventilation can lead to cerebral ischemia and should be used cautiously.

C. Lower blood pressure: Lowering blood pressure may help reduce cerebral perfusion pressure, which can mitigate the risk of further brain injury during herniation. However, lowering blood pressure alone is not a direct treatment for brain herniation. It may be part of the overall management strategy to prevent secondary injury.

D. Reduce the temperature in the room: Reducing the temperature in the room, or therapeutic hypothermia, is sometimes used in the management of elevated intracranial pressure and brain injury. Lowering body temperature can reduce metabolic demands and cerebral edema, thereby lowering intracranial pressure. However, it is not a direct treatment for brain herniation and should be implemented cautiously to prevent complications such as shivering and hypotension.

A. Encouraging increased mobility B. Dietary and fluid restrictions C. Cessation of intravenous (IV) drug use D. Cessation of hormonal supplements

Correct Answer is B

Explanation

A. Encouraging increased mobility: While mobility is important for overall health, it may not be the primary lifestyle modification emphasized in the discharge teaching for heart failure. The focus is typically on dietary and fluid restrictions, medication adherence, and symptom management.

B. Dietary and fluid restrictions: Dietary and fluid restrictions are essential lifestyle modifications for managing heart failure. Clients are often advised to follow a low-sodium diet and restrict fluid intake to prevent fluid retention and exacerbation of heart failure symptoms.

C. Cessation of intravenous (IV) drug use: While cessation of intravenous drug use is important for overall health and may be addressed if relevant to the client's situation, it may not be a primary focus of discharge teaching specifically related to heart failure.

D. Cessation of hormonal supplements: Cessation of hormonal supplements may be recommended if they contribute to heart failure or exacerbate its symptoms. However, this recommendation would be specific to individual client circumstances and may not apply to all clients with heart failure.

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A nurse is assessing a client who reports manifestations of tinnitus. Which of the following actions should the nurse perform to determine if movement is causing the clients manifestations to worsen?

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