When planning care for a client with an inner ear infection, the nurse will need to include interventions for which of the following potential problems?

Vertigo

Rhinorrhea

Fever

Headache

Answer and Explanation

The Correct Answer is A

Choice A Reason:
Vertigo is a common complication associated with inner ear infections, such as labyrinthitis or vestibular neuritis. The inner ear is responsible for balance, and when it is infected, it can lead to a sensation of spinning or dizziness. Interventions may include medications like meclizine or dimenhydrinate to alleviate symptoms, as well as safety measures to prevent falls.

Choice B Reason:
Rhinorrhea, or a runny nose, is not typically a direct complication of an inner ear infection. It may be associated with upper respiratory infections that can precede or accompany an ear infection but is not a result of the inner ear infection itself.

Choice C Reason:
Fever may be present if the inner ear infection is part of a systemic infection, such as the flu or bacterial meningitis. However, fever is not a direct result of an isolated inner ear infection. If fever is present, the nurse should monitor the patient's temperature and may administer antipyretics as ordered.

Choice D Reason:
Headache can be a symptom experienced by individuals with inner ear infections due to the general discomfort and pressure changes in the ear. However, it is not as specific or as common as vertigo when it comes to inner ear infections. If headaches are present, pain management strategies can be included in the care plan.

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Correct Answer is C

Explanation

Choice A Reason:
While falls are a common cause of injury in children, they are not the leading cause of TBI in adolescents. Falls tend to be more frequent in the younger population, particularly in children under the age of 4. In adolescents, sports-related injuries and motor vehicle accidents are more prevalent causes of TBI.

Choice B Reason:
The statement that females have twice the risk of TBI compared to males is incorrect. National data reveal that males are at increased risk of TBI compared to females, especially in the adolescent age group. This is likely due to higher engagement in risk-taking behaviors and contact sports.

Choice C Reason:
Concussions in sports and motor vehicle accidents are indeed the leading causes of TBI in adolescents. Engaging in contact sports such as football, hockey, and soccer can lead to concussions, which are a form of mild TBI. Motor vehicle accidents are also a significant risk factor due to high-impact collisions that can cause head injuries.

Choice D Reason:
Firearm incidents are a serious concern for TBI; however, they are not the most common cause of TBI in adolescents. While firearm-related injuries can be severe and are a leading cause of TBI-related deaths, concussions from sports and motor vehicle accidents account for a larger number of non-fatal TBIs in this age group.

A. Angular cheilitis B. Herpes simplex C. Angioedema

Correct Answer is B

Explanation

Choice A Reason:
Angular cheilitis is characterized by inflammation of one or both corners of the mouth. It often presents as red, swollen patches in the corners of the mouth and can be associated with fungal or bacterial infection. However, it does not typically cause vesicular eruptions, which are more indicative of viral infections like herpes simplex.

Choice B Reason:
Herpes simplex virus (HSV) is known for causing vesicular eruptions, commonly referred to as cold sores or fever blisters, around the lips and mouth area. These eruptions are fluid-filled blisters that can be painful and are highly indicative of an HSV infection, particularly HSV type 1, which commonly affects the oral region.

Choice C Reason:
Angioedema involves the rapid swelling of the deeper layers of the skin, often seen with hives. While it can affect the lips and surrounding areas, it does not cause vesicular eruptions. Angioedema is more associated with allergic reactions and can be part of anaphylaxis, a severe systemic reaction.

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When planning care for a client with an inner ear infection, the nurse will need to include interventions for which of the following potential problems?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which risk factor for traumatic brain injury (TBI) should a nurse include in a discussion about prevention for a group of adolescents?

Correct Answer is C

Explanation

During the physical examination of the mouth, the nurse identifies vesicular eruptions along the client's lips and surrounding skin. Which problem should the nurse document?

Correct Answer is B

Explanation

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