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 C

Explanation

A. Begin with inspection to visually assess the abdomen for abnormalities. Auscultate before palpation and percussion to avoid altering bowel sounds. Determine areas of pain to avoid causing discomfort during palpation and percussion. Lightly palpate to assess for tenderness or masses. Percuss last to evaluate organ size and detect abnormal fluid or gas.
B. Begin with inspection to visually assess the abdomen for abnormalities. Auscultate before palpation and percussion to avoid altering bowel sounds. Determine areas of pain to avoid causing discomfort during palpation and percussion. Lightly palpate to assess for tenderness or masses. Percuss last to evaluate organ size and detect abnormal fluid or gas.
C. Begin with inspection to visually assess the abdomen for abnormalities. Auscultate before palpation and percussion to avoid altering bowel sounds. Determine areas of pain to avoid causing discomfort during palpation and percussion. Lightly palpate to assess for tenderness or masses. Percuss last to evaluate organ size and detect abnormal fluid or gas.
D. Begin with inspection to visually assess the abdomen for abnormalities. Auscultate before palpation and percussion to avoid altering bowel sounds. Determine areas of pain to avoid causing discomfort during palpation and percussion. Lightly palpate to assess for tenderness or masses. Percuss last to evaluate organ size and detect abnormal fluid or gas.

A. Using the smallest speculum to decrease the amount of discomfort B. Once the speculum is in the ear, releasing the traction C. Tilting the person's head forward during the examination D. Pulling the pinna up and back before inserting the speculum

Correct Answer is D

Explanation

A. Smallest speculum: The smallest speculum may not provide the best view of the ear canal and tympanic membrane, especially in adults. The correct size should be chosen for adequate visualization.

B. Releasing the traction: Traction should be maintained to stabilize the ear and allow a better view of the ear canal.

C. Tilting the person's head forward: This is not the ideal positioning for the ear examination. The head should be tilted slightly away to straighten the ear canal.

D. Pulling the pinna up and back: This helps straighten the ear canal, especially in adults, providing better visualization during the otoscopic examination.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is C

Explanation

The nurse is performing an otoscopic examination on an adult. Which of these actions is correct?

Correct Answer is D

Explanation

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