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?

Inability to recognize any words

Loss of balance

Twitching of the cheek

Lack of air sound

Answer and Explanation

The Correct Answer is B

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.

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Correct Answer is D

Explanation

Choice A Reason: To administer medications and electrolytes is not the best reply for why the client will need the NG tube, because this is not the primary purpose of the NG tube in this case. The NG tube is mainly used to relieve gastric distension and prevent vomiting and aspiration. Medications and electrolytes can be given through the IV route.

Choice B Reason: To dilate the stomach as a presurgical preparation is not the best reply for why the client will need the NG tube, because this is not a valid indication for the NG tube in this case. The NG tube is mainly used to relieve gastric distension and prevent vomiting and aspiration. Dilation of the stomach is not a goal of presurgical preparation, but rather an adverse effect of gastric obstruction.

Choice C Reason: You will not be able to eat for several days is not the best reply for why the client will need the NG tube, because this is not a complete or accurate explanation of the NG tube in this case. The NG tube is mainly used to relieve gastric distension and prevent vomiting and aspiration. The client will not be able to eat for several days because of the NPO diet, which is necessary to rest the inflamed peritoneum and reduce the risk of complications.

Choice D Reason: To remove secretions and decompress your stomach is the best reply for why the client will need the NG tube, because this is a clear and correct explanation of the NG tube in this case. The NG tube is mainly used to relieve gastric distension and prevent vomiting and aspiration, which are common symptoms of acute peritonitis. By removing secretions and decompressing the stomach, the NG tube can reduce pain, inflammation, and infection in the abdominal cavity.

A. Insert a nasal swab to observe the fluid. B. Suction the nose gently with a bulb syringe. C. Allow the drainage to drip onto a sterile gauze pad. D. Insert sterile packing into the nares.

Correct Answer is C

Explanation

Choice A Reason: Inserting a nasal swab to observe the fluid is contraindicated, as it can introduce infection or increase intracranial pressure. The fluid can be tested for glucose or halo sign to confirm cerebrospinal fluid (CSF) leakage.

Choice B Reason: Suctioning the nose gently with a bulb syringe is also contraindicated, as it can create negative pressure and increase CSF leakage or cause meningitis.

Choice C Reason: This is the correct answer because allowing the drainage to drip onto a sterile gauze pad can prevent contamination and facilitate observation of the amount and characteristics of the fluid.

Choice D Reason: Inserting sterile packing into the nares is not recommended, as it can obstruct the drainage and increase intracranial pressure or infection risk.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse caring for a client with acute peritonitis reviews the physician's orders. The orders include an NPO diet, insertion of a nasogastric tube set to low intermittent suction, and IV fluids at 50 mL per hour. When asked why he will need the NG tube, what is the nurse's best reply?

Correct Answer is D

Explanation

Correct Answer is C

Explanation

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