An advanced practice nurse has performed a Rinne test on a new patient. During the test, the patient reports that air-conducted sound is louder than bone-conducted sound. How should the nurse interpret this assessment finding?

The patient has sensorineural hearing loss

The patient is at risk for tinnitus

The patient’s hearing is likely normal

The patient likely has otosclerosis

Answer and Explanation

The Correct Answer is C

Choice A rationale
Sensorineural hearing loss is a type of hearing loss in which the root cause lies in the inner ear or sensory organ (cochlea and associated structures) or the vestibulocochlear nerve (cranial nerve VIII). Sensorineural hearing loss can be mild, moderate, severe, or profound, and it affects the ability to hear faint sounds or understand speech. However, in the Rinne test, if the air-conducted sound is louder than the bone-conducted sound, it indicates that the patient’s hearing is likely normal.
Choice B rationale
Tinnitus is the perception of noise or ringing in the ears. It is a common problem that affects about 15 to 20 percent of people and is especially common in older adults. However, the Rinne test is not used to diagnose tinnitus. It is used to compare air and bone conduction of sound.
Choice C rationale
In a normal Rinne test, air conduction (AC) is better than bone conduction (BC). This is referred to as a positive Rinne test. If a patient reports that air-conducted sound is louder than bone-conducted sound, it suggests that the patient’s hearing is likely normal.
Choice D rationale
Otosclerosis is a condition that affects the bones in the middle ear, causing hearing loss. It is a common cause of conductive hearing loss, particularly in young adults. However, in otosclerosis, bone conduction (BC) is better than air conduction (AC), which is referred to as a negative Rinne test.

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Correct Answer is A

Explanation

Choice A rationale
Speaking slowly and clearly using yes/no questions one at a time can help facilitate communication with a client diagnosed with aphasia.
Choice B rationale

Asking a family member if they know what the client wants may not always be effective, as the client may have difficulty expressing their needs even to family members.
Choice C rationale
Repeating the same question multiple times may not be effective and could potentially frustrate the client.
Choice D rationale
Putting a cell phone in their right hand to text their questions assumes that the client has the ability to text, which may not be the case for all clients diagnosed with aphasia.

A. Assessing the patient’s ability to follow complex commands B. Assessing the patient’s judgment C. Assessing the patient’s verbal response D. Assessing the patient’s response to pain

Correct Answer is D

Explanation

Choice D rationale
When assessing a patient with an altered level of consciousness, the nurse’s initial action should be to assess the patient’s response to pain. This is a fundamental part of the neurological examination and can provide valuable information about the patient’s level of consciousness and neurological function. Pain response can be assessed by applying a painful stimulus, such as a pinch, and observing the patient’s reaction.
Choice A rationale
Assessing the patient’s ability to follow complex commands is an important part of the neurological examination, but it is not typically the initial action when assessing a patient with an altered level of consciousness. This assessment requires a higher level of cognitive function and may not be possible in a patient with significantly altered consciousness.
Choice B rationale
Assessing the patient’s judgment is an important part of the mental status examination, but it is not typically the initial action when assessing a patient with an altered level of consciousness. Like the ability to follow complex commands, judgment requires a higher level of cognitive function and may not be assessable in a patient with significantly altered consciousness.

Choice C rationale
Assessing the patient’s verbal response is an important part of the neurological examination, but it is not typically the initial action when assessing a patient with an altered level of consciousness. The patient’s ability to speak and the content of their speech can provide important information about their neurological function, but this assessment may not be possible in a patient with significantly altered consciousness.

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An advanced practice nurse has performed a Rinne test on a new patient. During the test, the patient reports that air-conducted sound is louder than bone-conducted sound. How should the nurse interpret this assessment finding?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a client that has been diagnosed with aphasia. How can the nurse communicate effectively with the client?

Correct Answer is A

Explanation

The nurse is caring for a patient whose recent health history includes an altered level of consciousness. What should be the nurse’s initial action when assessing this patient?

Correct Answer is D

Explanation

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