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

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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Correct Answer is ["B","D","E","H","I"]

Explanation

A. Low-fat diet: This reduces the risk of arterial insufficiency, making it incorrect as a risk factor.

B. Diabetes mellitus: Diabetes is a significant risk factor due to its effects on vascular health.

C. Decreased lipid levels: Lower lipid levels reduce arterial risk, making it incorrect as a risk factor.

D. Smoking: Smoking damages blood vessels and increases arterial insufficiency risk.

E. Heavy alcohol use: Excessive alcohol consumption contributes to hypertension and cardiovascular disease.

F. Physical activity: Physical activity reduces arterial risk, making it incorrect as a risk factor.

G. Hypertension: High blood pressure increases arterial insufficiency risk.

H. Male: Males have a higher risk of developing arterial insufficiency than females.

I. Obesity: Obesity increases the risk of atherosclerosis and arterial insufficiency.

A. "We need to determine the areas of tenderness before using percussion and palpation." B. "Auscultation allows the patient more time to relax and therefore be more comfortable with the physical examination." C. "Auscultation prevents distortion of bowel sounds that might occur after percussion and palpation." D. "Auscultation prevents distortion of vascular sounds, such as bruits and hums, that might occur after percussion and palpation."

Correct Answer is C

Explanation

A. Determine areas of tenderness: While identifying tenderness is important, it is not the reason for auscultating first.

B. Allows the patient to relax: Relaxation is helpful but not the primary reason for the sequence.

C. Prevents distortion of bowel sounds: Percussion and palpation can stimulate or suppress bowel sounds, leading to inaccurate findings if performed before auscultation.

D. Prevents distortion of vascular sounds: Vascular sounds (bruits) are less likely to be affected by percussion or palpation.

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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?

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Naxlex Comprehensive Predictor Exams

A nurse is educating a patient regarding arterial insufficiency. The nurse knows the patient has a correct understanding of arterial risk factors by listing the following:

Correct Answer is ["B","D","E","H","I"]

Explanation

The nurse is watching a new graduate nurse perform auscultation of a patient's abdomen. Which statement by the new graduate shows a correct understanding of the reason auscultation precedes percussion and palpation of the abdomen?

Correct Answer is C

Explanation

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