Chapter 62 Medical Surgical Nursing Preparation For Practice 2nd Edition

Chapter 62  Medical Surgical Nursing Preparation For Practice 2nd Edition

Complete Chapter Questions And Answers
 

Sample Questions

Question 1
Type: MCSA
The nurse notes that the cerumen (earwax) in a patient’s ear may indicate an infection. The nurse makes that assessment because of which characteristic of the cerumen?
1. It is nearly absent.
2. It is hardened, dry, and foul-smelling.
3. It is brown, wet, and sticky.
4. It is dry, white, and flaky.
Correct Answer: 2
Rationale 1: Cerumen lubricates the ear and is always present.
Rationale 2: Hardened, dry, or foul-smelling cerumen may indicate an infection.
Rationale 3: Cerumen should be moist and may vary in color from brown to white.
Rationale 4: In a majority of Asians and Native Americans, cerumen is dry, white, and flaky.
Global Rationale:

Cognitive Level: Applying
Client Need: Physiological Integrity
Client Need Sub: Physiological Adaptation
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 62-1

Question 2
Type: MCSA
Which patient statement would the nurse evaluate as indicating that the patient has otalgia?
1. “I fainted when I saw blood on my hand.”
2. “My ears ring all of the time.”
3. “I feel dizzy most of the time.”
4. “When I got up this morning, my ear was hurting.”
Correct Answer: 4
Rationale 1: Fainting is recorded as syncope. It is not necessarily related to otalgia.
Rationale 2: Ringing in the ears is tinnitus. This symptom is not specifically related to otalgia.
Rationale 3: Dizziness may be a symptom of vertigo and is not specifically related to otalgia.
Rationale 4: Otalgia is ear pain.
Global Rationale:

Cognitive Level: Applying
Client Need: Physiological Integrity
Client Need Sub: Physiological Adaptation
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 62-1

Question 3
Type: MCSA
Which subjective symptom of the sensory system may also be an objective symptom?
1. Presyncope
2. Vertigo
3. Otalgia
4. Tinnitus
Correct Answer: 4
Rationale 1: Presyncope is a feeling of fainting. The observer may see signs that a patient is weak or dizzy but cannot directly observe the feeling of fainting.
Rationale 2: Vertigo is the illusion of rotational movement, tilting, or swaying, with feelings of imbalance during standing and walking. The patient has to report the sensation.
Rationale 3: Otalgia is ear pain that only the patient feels and must report.
Rationale 4: Tinnitus is primarily a localized, internal auditory perception usually not heard by others. However, objective tinnitus can be heard by others and is caused by vascular problems of the carotid arteries or jugular veins.
Global Rationale:

Cognitive Level: Applying
Client Need: Physiological Integrity
Client Need Sub: Physiological Adaptation
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 62-2

Question 4
Type: MCSA
A 45-year-old patient is admitted complaining of dizziness, hearing loss, and a “full” feeling in one ear. Based on the patient’s age and symptoms, the nurse would ask which additional assessment question?
1. “Do you have reduced feeling in your cheek on that side?”
2. “Have you noticed any impairment in your sense of smell?”
3. “Do you have a headache?”
4. “Do you have ringing in your ears?”
Correct Answer: 4
Rationale 1: The disorder suggested by these symptoms and the patient’s age does not cause paresthesia.
Rationale 2: The disorder suggested by these symptoms and the patient’s age does not impair the ability to smell.
Rationale 3: The disorder suggested by these symptoms and the patient’s age does not cause headache.
Rationale 4: Ménière’s disease is a dysfunction of the labyrinth of the ear, with symptoms of vertigo, hearing loss, unilateral aural fullness, and tinnitus. It is most common between the ages of 30 and 60.
Global Rationale:

Cognitive Level: Applying
Client Need: Physiological Integrity
Client Need Sub: Physiological Adaptation
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 62-5