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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Lower back or groin pain: Lower back or groin pain can be an early manifestation of an abdominal aortic aneurysm (AAA). This pain may result from pressure exerted by the enlarging aneurysm on surrounding structures or from irritation of nerves as the aneurysm expands. As the aneurysm enlarges, the pain may become more severe and persistent.
B. Hunger after eating: Hunger after eating is not typically associated with an abdominal aortic aneurysm. This symptom may be indicative of various gastrointestinal issues such as peptic ulcer disease or gastritis, but it is not a characteristic manifestation of AAA.
C. Pain in the chest: While AAA can lead to compression of nearby structures, resulting in referred pain, chest pain is not a common early manifestation of an abdominal aortic aneurysm. Chest pain is more commonly associated with cardiac issues such as angina or myocardial infarction.
D. Presence of Cullen's sign: Cullen's sign refers to periumbilical bruising, which can occur due to retroperitoneal hemorrhage from a ruptured AAA. However, Cullen's sign is not an early manifestation of an AAA; it is typically observed in more advanced cases or after rupture has occurred.
Correct Answer is A
Explanation
A. The aortic and mitral valves are the most commonly replaced valves: This statement is accurate. The aortic and mitral valves are indeed the most commonly replaced valves in cardiac valve replacement surgeries. Aortic valve replacement is commonly performed for conditions such as aortic stenosis or regurgitation, while mitral valve replacement is often indicated for mitral regurgitation or stenosis.
B. Mitral valve insufficiency occurs during the diastolic phase of the cardiac cycle: This statement is incorrect. Mitral valve insufficiency, also known as mitral regurgitation, occurs during the systolic phase of the cardiac cycle. It involves the backflow of blood from the left ventricle into the left atrium during ventricular systole, leading to volume overload of the left atrium and potentially causing symptoms such as dyspnea and fatigue.
C. Inadequate closure of the tricuspid valve causes overload in the left ventricle: This statement is incorrect. Inadequate closure of the tricuspid valve leads to regurgitation of blood from the right ventricle back into the right atrium during ventricular systole. This condition, known as tricuspid regurgitation, causes volume overload in the right atrium and ventricle, rather than overload in the left ventricle.
D. Aortic stenosis increases right ventricular systolic pressure and decreases afterload: This statement is partially correct. Aortic stenosis indeed increases left ventricular systolic pressure and decreases afterload, not right ventricular pressure. The increased afterload on the left ventricle can lead to left ventricular hypertrophy and eventually heart failure. However, aortic stenosis does not directly affect right ventricular systolic pressure.
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