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A patient has been admitted after an accident at work. During the assessment, the patient is having trouble hearing and states, "I don't know what the matter is. All of a sudden, I can't hear you out of my left ear!" What should the nurse do next?

A.

Make note of this finding for the report to the next shift

B.

Prepare to remove cerumen from the patient's ear.

C.

Irrigate the ear with rubbing alcohol.

D.

Notify the patient's health care provider

Answer and Explanation

The Correct Answer is D

A. Make note of this finding: Delaying action by merely reporting the finding later may compromise patient care.

B. Prepare to remove cerumen: Sudden hearing loss is unlikely to be caused by cerumen buildup without further assessment.

C. Irrigate with rubbing alcohol: This is inappropriate and could harm the ear.

D. Notify the health care provider: Sudden sensorineural hearing loss can be a medical emergency and should be promptly evaluated by the healthcare provider.


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Related Questions

Correct Answer is D

Explanation

A. Change in cilia: This is not the cause of dry, flaky cerumen. It would not be typical to assess hearing loss based on this observation alone.

B. Poor hygiene: Dry, flaky cerumen is not indicative of poor hygiene. Hygiene-related cerumen would more likely be wet and impacted.

C. Lesions from eczema: While eczema can affect the ear canal, the dry cerumen itself is more likely to be a normal characteristic for some individuals, particularly in people of Asian descent.

D. Normal finding: The presence of dry, flaky cerumen is normal in certain ethnic groups, including East Asians, and usually requires no follow-up.

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"B"}}

Explanation

New Nurse Statement

Met

Not Met

I will confirm the patient's pupil size with the scale on the side of the penlight.

✅

When putting the penlight at the bridge of the nose, the eyes converge and constrict

✅

I will check the patient's pupillary reflex by shining a light into their eyes.

✅

When shining the penlight into the patient's eyes, their pupils should dilate

✅

Rationale:

"I will confirm the patient's pupil size with the scale on the side of the penlight" (Met):

This is a correct use of the penlight to assess pupil size and document findings accurately.

"When putting the penlight at the bridge of the nose, the eyes converge and constrict" (Met):

This statement describes the normal accommodation reflex, where the eyes converge and pupils constrict when focusing on a near object.

"I will check the patient's pupillary reflex by shining a light into their eyes" (Met):

This correctly describes testing for the pupillary light reflex, where the pupil constricts in response to light.

"When shining the penlight into the patient's eyes, their pupils should dilate" (Not Met):

This is incorrect. The pupils should constrict in response to light, not dilate. Dilation occurs in response to low light or sympathetic stimulation.

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