The nurse is performing an otoscopic examination on an adult. Which of these actions is correct?
Using the smallest speculum to decrease the amount of discomfort
Once the speculum is in the ear, releasing the traction
Tilting the person's head forward during the examination
Pulling the pinna up and back before inserting the speculum
The Correct Answer is D
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.
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 B
Explanation
A. Stops any movement, and appears to listen for the sound: This does not relate to the corneal light reflex test.
B. Consider this a normal finding: Symmetric light reflection at the same clock position in both eyes indicates normal alignment of the eyes.
C. Shows no obvious response to the noise: This response is unrelated to the corneal light reflex test.
D. Shows a startle and acoustic blink reflex: This describes a normal response to a loud noise, not the corneal light reflex test.
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