what are signs of hearing loss select all that apply

ATI RN

Multi Dimensional Care | Final Exam

1. What are signs of hearing loss? (Select all that apply)

A. Answering questions correctly
B. Presence of cerumen
C. Tinnitus
D. Frequent asking of others to repeat statements

Correct answer: C

Rationale: Signs of hearing loss include tinnitus, frequent asking to repeat statements, and shouting in conversations.

2. The nurse is caring for 4 clients. What client should the nurse see first?

A. A client with multiple children visiting
B. A client with lupus asking for dinner
C. A client on Methotrexate with a fever
D. A client with chronic rheumatic pain

Correct answer: C

Rationale: The correct answer is the client on Methotrexate with a fever. Fever in a client on Methotrexate, an immunosuppressant, could indicate a serious infection or adverse drug reaction requiring immediate attention to prevent complications. The other choices do not present immediate life-threatening concerns. A client with lupus asking for dinner can wait, a client with chronic rheumatic pain may need pain management but is not the priority over a fever in a client on Methotrexate, and a client with children visiting does not pose an urgent medical issue.

3. What nursing interventions increase the risk the pressure injuries?

A. Padding hard surfaces
B. Have client sit in wheelchair as much as possible
C. Place pillows between bony surfaces
D. Keep head of bed (HOB) at or less than 3

Correct answer: B

Rationale:

4. The nurse is caring for a client with rheumatoid arthritis one day after shoulder surgery. What would prompt the nurse to call the provider immediately?

A. The client refused her pain medication this morning and is doing physical therapy.
B. The client reports a minor headache and states she takes an over-the-counter pain pill at home.
C. The client reports intermittent flatus and minor abdominal discomfort.
D. The client has paresthesia in her fingers and intense increasing pain in her shoulder.

Correct answer: D

Rationale: In a client with rheumatoid arthritis one day after shoulder surgery, paresthesia in the fingers and intense increasing pain in the shoulder could indicate nerve compression or damage, which are serious post-operative complications. This situation requires immediate attention from the provider to prevent further complications and ensure appropriate management. The other options, such as refusing pain medication, reporting a minor headache, or experiencing minor abdominal discomfort, are important but not as urgent or indicative of potential serious complications as paresthesia in the fingers and intense increasing pain in the shoulder.