which steps should the nurse take when administering ear drops to an adult client

NCLEX-RN

Psychosocial Integrity NCLEX Questions Quizlet

1. What step should be taken when administering ear drops to an adult client?

A. Place the client in a side-lying position.
B. Hold the dropper 1 cm above the ear canal.
C. Place a cotton ball into the outermost canal.
D. Pull the auricle down and back.

Correct answer: A

Rationale: The correct step when administering ear drops to an adult client is to place the client in a side-lying position (A). This position allows for easier administration of the drops and helps prevent spillage. The dropper should be held approximately 1 cm (� inch) above the ear canal (B) to ensure accurate delivery of the medication. Placing a cotton ball into the outermost canal (C) is unnecessary and may interfere with the absorption of the ear drops. Pulling the auricle down and back (D) is a technique used for children younger than 3 years old to straighten the ear canal, but it is not necessary for adults and may cause discomfort.

2. What initial response would the nurse give to a husband who is upset that his wife's alcohol withdrawal delirium has persisted for a second day?

A. "I see that you're worried. We're using medication to ease your wife's discomfort."?
B. "This is expected. I suggest that you go home because there's nothing you can do to help."?
C. "If you're afraid that she will die, I assure you, very few alcoholics die during detoxification."?
D. "If you are concerned that she is uncomfortable, I'm sure that she's not in pain."?

Correct answer: A

Rationale: The correct response is to acknowledge the husband's feelings and provide information on the treatment plan to alleviate his concerns. This approach validates his emotions and educates him on the steps being taken to help his wife, promoting understanding and reducing anxiety. Choice B is incorrect as it dismisses the husband's worries and implies helplessness, potentially increasing his distress. Choice C is inappropriate as it introduces the concept of death, which can heighten fear and anxiety in the husband. Choice D is not recommended as it provides reassurance about the wife's pain without accurate knowledge of her discomfort, which could undermine trust and communication between the nurse and the husband.

3. Which initial response would the nurse make to a 67-year-old man with type 2 diabetes who sadly confides in the nurse that he has been unable to have an erection for several years?

A. 'At your age, sex isn't that important.''
B. ''That is a natural occurrence at your age.''
C. ''You sound upset about not being able to have an erection.''
D. 'Maybe it's time for you to speak to your primary health care provider about this.''

Correct answer: C

Rationale: The correct response is, 'You sound upset about not being able to have an erection.' When a client discloses personal information, the nurse should respond in a non-judgmental manner to encourage further communication and gather more details. This response demonstrates empathy and understanding, opening the door for the patient to express his feelings and concerns. Choice A, 'At your age, sex isn't that important,' is dismissive and fails to address the client's emotions or concerns, potentially hindering open communication. Choice B, 'That is a natural occurrence at your age,' provides inaccurate information as the inability to have an erection is not considered a normal part of aging. Choice D, 'Maybe it's time for you to speak to your primary health care provider about this,' while important eventually, should not be the initial response as the nurse should first explore the client's feelings and concerns before discussing potential referrals or interventions.

4. After receiving written and verbal instructions from a clinic nurse about a newly prescribed medication, a client asks the nurse what to do if questions arise about the medication after getting home. How should the nurse respond?

A. Provide the client with a list of reliable internet sites that offer information on medications.
B. Advise the client to obtain a current edition of a drug reference book from a local bookstore or library.
C. Reassure the client that information about the medication is included in the written instructions.
D. Encourage the client to call the clinic nurse or healthcare provider if any questions arise.

Correct answer: D

Rationale: To ensure safe medication use, the nurse should encourage the client to call the clinic nurse or healthcare provider if any questions arise. This direct communication allows for personalized assistance and clarification tailored to the client's specific concerns. Providing Internet sites (Choice A) may lead to unreliable information, and a drug reference book (Choice B) may not address individualized questions. While the written instructions may contain information (Choice C), they may not cover all potential queries the client might have, making direct contact with the healthcare provider the most appropriate option.

5. What behavior is expected of members of Alcoholics Anonymous (AA)?

A. Speaking at and participating in weekly meetings
B. Promising to attend at least 12 meetings yearly
C. Maintaining controlled drinking after 6 months
D. Acknowledging an inability to control the drinking

Correct answer: D

Rationale: A fundamental aspect of Alcoholics Anonymous (AA) is the acceptance of one's inability to control their drinking behavior. This acknowledgment is crucial for individuals seeking recovery from alcohol abuse issues. While speaking at and participating in meetings is encouraged, it is not a strict requirement for AA members. Similarly, there is no specific mandate on the number of meetings to attend yearly, as long as the individual finds the support they need. Maintaining controlled drinking after 6 months is not aligned with AA principles, as the group emphasizes complete abstinence from alcohol to support long-term sobriety.