During a hearing assessment, the nurse notes that the sound lateralizes to the clients left ear with the Weber test. The nurse analyzes this result as: A normal finding. A conductive hearing loss in the right ear. A sensorineural or conductive loss. The presence of nystagmus.
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Hello,
Can you please help me with the next question?
- How would you have responded to engagement prompt #2 that occurred in the recorded webinar? Why?
NCLEX QUESTION 2
During a hearing assessment, the nurse notes that the sound lateralizes to the clients left ear with the Weber test. The nurse analyzes this result as:
- A normal finding.
- A conductive hearing loss in the right ear.
- A sensorineural or conductive loss.
- The presence of nystagmus.
Thank you in advance!
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- CLIENT PROFILE: Mr. Evans is a 73-year-old man who presents to the clinic with complaints of “foggy” vision, headaches, and aching in his eyes. He also reports seeing “rings around lights.” Since his wife’s death two months ago, he states things have not been going well at home. He has not been able to handle the bill payments because of his change in vision and his depression. He is upset and is worried that he will not be able to stay in his home. His children live in another state and have not been home to help him. CASE STUDY: Mr. Evans’s vital signs are temperature 98.18F, blood pressure 172/92, pulse 68, and respiratory rate of 24. Tonometry shows an elevated intraocular pressure of 26 mm Hg. He reports that his peripheral vision is decreased and it is noted in the visual exams by the physician that his optic disk appears pale and the depth and size of the optic cup appears increased. Mr. Evans’s history reveals that his mother also had glaucoma. His neighbor and good friend is…CLIENT PROFILE: Mr. Evans is a 73-year-old man who presents to the clinic with complaints of “foggy” vision, headaches, and aching in his eyes. He also reports seeing “rings around lights.” Since his wife’s death two months ago, he states things have not been going well at home. He has not been able to handle the bill payments because of his change in vision and his depression. He is upset and is worried that he will not be able to stay in his home. His children live in another state and have not been home to help him. CASE STUDY: Mr. Evans’s vital signs are temperature 98.18F, blood pressure 172/92, pulse 68, and respiratory rate of 24. Tonometry shows an elevated intraocular pressure of 26 mm Hg. He reports that his peripheral vision is decreased and it is noted in the visual exams by the physician that his optic disk appears pale and the depth and size of the optic cup appears increased. Mr. Evans’s history reveals that his mother also had glaucoma. His neighbor and good friend is…Minerva is given a propranolol (Inderal) 40 mg bid. What is the most important instruction the nurse should give to this client?a. Take this medication on an empty stomach, as food interferes with its absorption.b. Do not stop taking this medication abruptly; the dosage must be decreased gradually if it isdiscontinued.c. If the client experiences any disturbances in hearing, the client should notify the health care providerimmediately.d. The client may become very sleepy while taking this medication; do not drive.Is letter b the correct answer why or why not? Also explain why the other options are not the right answer (a,c and d)
- What activities will the nurse tell the client to avoid after cataract surgery? (Select all that apply.) Sleeping for greater than 1 hour Lifting items greater than 10 pounds Blowing one's nose Bearing down when one defecates UrinatingJJ Case Continued: [NEW INFORMATION]: JJ was started on an ophthalmic prostaglandin analog after her first visit and has been compliant with therapy. At her 3 month follow-up visit her IOP has not yet reached the desired goal in her right eye. She does not have any additional new medical conditions. She and her eye care provider agree the next step will be to try dual pharmacologic therapy by adding an agent with a different mechanism of action. Which is the most appropriate new ophthalmic therapy to add to her prior therapy at this time? a. netarsudil (Rhopressa) b. methazolamide oral C. timolol (Timoptic) d. dorzolamide (Trusopt) O e. brimonidine (Alphagan P)The nurse is performing neurologic assessment on patient with an arsficial eye. How would the nurse confirm identification of the natural eye? 1 Only the natural eye would produce tears and lubrication. 2 The arcificial eye would have more natural movement. 3 The arsificial eye would respond siightly to a light stmulus. 4 Accommadation would only be present n the natural eye.
- The nurse is assessing a client with macular degeneration. Identify the illustration that best depicts what dlients with this disorder typically see, Although all of the following measures might be useful n reducing the visual disability of a client with aduls macular degeneration (AMD), which measure should the nurse teach the client primarily as a safery precaution? 1. Wear a patch over one eye. 2. Place personal irems on the sighted side. 3. Lie in bed with the unaffected side toward the door. 4.Turn the head from side o side when walking i o ' ]A nurse is diagnosing an 11-year-old 6th grade studentfollowing a physical assessment. The nurse notes that the student’s grades have dropped, she has difficulty complet-ing her work on time, and she frequently rubs her eyes and squints. Her visual acuity on a Snellen’s eye chartis 160/20. Which nursing diagnosis would be mostappropriate?a. Deficient Knowledge related to visual impairmentb. Ineffective Role Performance (Student) related to visualimpairmentc. Disturbed Body Image related to visual impairmentd. Delayed Growth and Development related to visualimpairmentNursing Care Plan Knowledge deficit related to lack of information about cataract as evidenced by patient's verbalization of ignoring the symptoms of visual impairment Short term goal- Patient will verbalize an understanding of their disease condition after 12 hours of nursing intervention Long term goal - The patient will demonstrate adequate coping techniques to carry out activities of daily living within the liminations of visual impairment until the cataract surgery on both eyes are complete throughout hospitalization List 20 nursing interventions with rationales for the nursing diagnosis based on the scenario
- The nurse is educating a postoperative patient about their patient-controlled analgesia pump. Which instructions should the nurse include? Select all that apply. a. Inform the nurse about the pain level being experienced b. Push the button before the pain is unbearable c. Ask the family to push the button as needed d. Report the inability to void e. Report any nausea and vomitingQuestion: Can you explain these 3 nursing diagnoses. Thank you! Disturbed Sensory Perception: Auditory/Visual related to altered sensory perception, as evidenced by hallucinations, (auditory/visual distortions) and talking to self. Defensive coping RT suspiciousness and delusions AEB hostility and false beliefs about the intention of others Self-care deficit RT perceptual cognitive impairment AEB unwashed hair, foul body odor, and lack of proper dressingQuestion: Can you explain these 3 nursing diagnoses. Thank you! Disturbed Sensory Perception: Auditory related to altered sensory perception as evidenced by Hallucinations, Auditory distortions and Talking to self. Defensive coping RT perceived threat to self, suspicions of motives of others AEB difficulty in reality testing of perceptions, false beliefs about the intention of others. Self-care deficit RT cognitive impairment secondary to Schizophrenia AEB unwashed hair, foul body odor