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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
In the case of a major ischemic stroke, the medication that a nurse would anticipate the doctor to order is tissue plasminogen activator (tPA)8. This medication works by dissolving the clot that is blocking blood flow to the brain. It is most effective when given as soon as possible after the onset of stroke symptoms.
Choice B rationale
Ibuprofen is a nonsteroidal anti-inflammatory drug (NSAID) that is used to relieve pain and reduce inflammation. It is not typically used in the treatment of ischemic stroke.
Choice C rationale
Aspirin is an antiplatelet drug that is sometimes used in the prevention of stroke. However, it is not typically used as an immediate treatment for a major ischemic stroke.
Choice D rationale
Warfarin is an anticoagulant medication that is used to prevent blood clots from forming or growing larger. It is not typically used as an immediate treatment for a major ischemic stroke.
Correct Answer is D
Explanation
Choice D rationale
Teaching the patient to perform deep breathing and coughing exercises is a key intervention to address a potential complication after an ischemic stroke. These exercises can help prevent pneumonia, a common complication after stroke, by promoting lung expansion, improving oxygenation, and facilitating the clearance of secretions.
Choice A rationale
Keeping a urinary catheter in place for the entire duration of recovery is not typically recommended due to the increased risk of urinary tract infections. Catheters should be used sparingly and removed as soon as possible.
Choice B rationale
Providing three larger meals rather than frequent small meals does not specifically address a potential complication after an ischemic stroke. In fact, smaller, more frequent meals may be easier for some stroke patients to manage, particularly if they have difficulty swallowing.
Choice C rationale
Limiting the intake of insoluble fiber does not specifically address a potential complication after an ischemic stroke. A balanced diet with adequate fiber is generally recommended for stroke patients to promote bowel regularity and overall health.
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