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?
Make note of this finding for the report to the next shift
Prepare to remove cerumen from the patient's ear.
Irrigate the ear with rubbing alcohol.
Notify the patient's health care provider
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is {"A":{"answers":"A"},"B":{"answers":"B"}}
Explanation
Each category must have at least 1 response option selected
|
Finding |
Normal |
Abnormal |
|
Tympany to percussion over the intestines |
✅ |
|
|
Loose, watery stool |
✅ |
|
|
Suprapubic tenderness |
✅ |
|
|
A non-palpable spleen |
✅ |
|
|
Aortic pulsation in the epigastric area |
✅ |
|
|
Decreased bowel sounds |
✅ |
Rationale:
Tympany to percussion over the intestines (Normal):
Tympany is expected due to the presence of gas in the intestines.
Loose, watery stool (Abnormal):
This is indicative of diarrhea, which may point to gastrointestinal upset or infection.
Suprapubic tenderness (Abnormal):
Tenderness in this area may indicate bladder infection, inflammation, or pelvic issues.
A non-palpable spleen (Normal):
The spleen is generally not palpable in healthy individuals unless it is enlarged (splenomegaly).
Aortic pulsation in the epigastric area (Normal):
Mild pulsations may be felt in thin or normal-weight individuals. However, a widened or strong pulsation could suggest an abdominal aortic aneurysm.
Decreased bowel sounds (Abnormal):
Hypoactive or absent bowel sounds may indicate decreased intestinal motility, such as in ileus or peritonitis.
Correct Answer is D
Explanation
A. Subjective vertigo: Subjective vertigo refers to the sensation of being dizzy but without the room spinning. The patient described the sensation of the room spinning.
B. Tinnitus: Tinnitus refers to a ringing or buzzing sound in the ears, not the sensation of the room spinning.
C. Dizziness: Dizziness can refer to a range of symptoms, but the description of the room spinning suggests vertigo, not just dizziness.
D. Objective vertigo: Objective vertigo refers to the sensation that the room is spinning, which the patient describes. This is typically a vestibular issue involving the inner ear.
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