Nokea
A 6-month-old infant is brought to the ED by his parents for inconsolable crying and pulling at his right ear. When assessing this infant, the advanced practice nurse is aware that the tympanic membrane should be what color in a healthy ear?
- A. Yellowish-white
- B. Pink
- C. Gray
- D. Bluish-white
Correct Answer: C
Rationale: A healthy tympanic membrane is pearly gray. Yellowish-white, pink, or bluish-white colors suggest inflammation or other pathology.
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Which of the following nursing interventions would most likely facilitate effective communication with a hearing-impaired patient?
- A. Ask the patient to repeat what was said in order to evaluate understanding.
- B. Stand directly in front of the patient to facilitate lip reading.
- C. Reduce environmental noise and distractions before communicating.
- D. Raise the voice to project sound at a higher frequency.
Correct Answer: C
Rationale: Reducing environmental noise enhances the patient's ability to hear and focus, improving communication. Asking to repeat may frustrate, raising the voice distorts sound, and not all patients lip-read effectively.
The nurse is providing discharge education for a patient with a new diagnosis of Mnires disease. What food should the patient be instructed to limit or avoid?
- A. Sweet pickles
- B. Frozen yogurt
- C. Shellfish
- D. Red meat
Correct Answer: A
Rationale: Mnires disease is exacerbated by high salt and sugar intake, which sweet pickles contain. Dairy, shellfish, and red meat are not contraindicated unless processed or canned.
The nurse is discharging a patient home after mastoid surgery. What should the nurse include in discharge teaching?
- A. Try to induce a sneeze every 4 hours to equalize pressure.
- B. Be sure to exercise to reduce fatigue.
- C. Avoid sleeping in a side-lying position.
- D. Dont blow your nose for 2 to 3 weeks.
Correct Answer: D
Rationale: Avoiding nose blowing for 2-3 weeks prevents pressure changes that could dislodge grafts or prostheses. Sneezing, exercise, or side-lying are not contraindicated.
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 best interpret this assessment finding?
- A. The patients hearing is likely normal.
- B. The patient is at risk for tinnitus.
- C. The patient likely has otosclerosis.
- D. The patient likely has sensorineural hearing loss.
Correct Answer: A
Rationale: A Rinne test showing louder air-conducted sound indicates normal hearing or sensorineural loss, but in context, normal hearing is most likely. Tinnitus and otosclerosis are not directly assessed by this test.
A group of high school students is attending a concert, which will be at a volume of 80 to 90 dB. What is a health consequence of this sound level?
- A. Hearing will not be affected by a decibel level in this range.
- B. Hearing loss may occur with a decibel level in this range.
- C. Sounds in this decibel level are not perceived to be harsh to the ear.
- D. Ear plugs will have no effect on these decibel levels.
Correct Answer: B
Rationale: Sound levels above 80 dB can damage the inner ear, potentially causing hearing loss. These levels are perceived as harsh, and ear plugs can mitigate the risk.