Nokea
Which of the ff. statements would the nurse understand is true when assessing normal auditory acuity using the Rinne test?
- A. The patient perceives sound equally in both ears.
- B. Air conduction is heard longer than bone conduction in both ears.
- C. Bone conduction is heard longer than air conduction in both ears.
- D. The patient's left ear will perceive the sound better than the right ear.
Correct Answer: B
Rationale: In the Rinne test, a tuning fork is placed first on the mastoid bone behind the ear to test bone conduction, and then beside the ear to test air conduction. A normal finding in the Rinne test is when air conduction (heard beside the ear) is longer than bone conduction (heard on the mastoid bone) in both ears. This indicates that sound waves travel through the air better than through bone. If air conduction is heard longer than bone conduction, it suggests normal auditory acuity.
You may also like to solve these questions
A young male client visits a nurse with a complaint of chronic tension headaches. Which of the ff is the most appropriate nursing instruction to manage the client?
- A. Instructing the client to monitor for signs of bruising or bleeding
- B. Suggesting eating and swallowing techniques that reduce the potential for aspiration
- C. Counselling on alternate therapies
- D. Advising the client to change sleeping positions frequently
Correct Answer: C
Rationale: The most appropriate nursing instruction to manage a young male client with chronic tension headaches is counseling on alternate therapies. Chronic tension headaches can be caused or exacerbated by various factors such as stress, poor posture, eyestrain, or muscular tension. Counseling on alternate therapies can include techniques such as relaxation exercises, stress management strategies, mindfulness practices, physical therapy, or massage therapy. These alternative therapies can help the client manage stress, improve posture, and reduce muscle tension, which may help alleviate the frequency or intensity of tension headaches. It is important to explore non-pharmacological approaches before considering medication, especially for chronic conditions like tension headaches.
A 3-year-old boy is hospitalized after falling down the stairs. His mother cries, 'This is all my fault.' Which is the nurse's best response?
- A. Accidents happen; you shouldn't blame yourself.
- B. Falls are one of the most common injuries in this age group.
- C. It might help to install a baby gate on the stairs.
- D. Your son should be proficient at walking down stairs by now.
Correct Answer: B
Rationale: Reassuring the parent that falls are common in young children can help reduce guilt and anxiety.
A client with idiopathic thrombocytopenic purpura (ITP), an autoimmune disorder, is admitted to an acute care facility. Concerned about hemorrhage, the nurse monitors the client's platelet count and observes closely for signs and symptoms of bleeding. The client is at greatest risk for cerebral hemorrhage when the platelet count falls below:
- A. 135,000/ul
- B. 20,000/ul
- C. 75,000/ul
- D. 500/ul
Correct Answer: B
Rationale: In a client with idiopathic thrombocytopenic purpura (ITP), a platelet count falling below 20,000/ul puts them at the greatest risk for cerebral hemorrhage. This is because the risk of spontaneous bleeding, especially in critical areas like the brain, significantly increases as platelet counts drop below this level. The brain is a sensitive organ, and even minor bleeds can have serious consequences. Therefore, it is crucial for healthcare providers to closely monitor platelet counts and promptly intervene to prevent life-threatening hemorrhage in clients with ITP.
A newborn begins to cough, choke, and becomes cyanotic while feeding. What is the nurse's immediate action?
- A. Inform the physician.
- B. Have the mother stop feeding and observe.
- C. Remove the infant from the mother, place the infant in the crib for assessment, obtain oxygen saturation, and administer blow-by oxygen immediately.
- D. Continue feeding while monitoring.
Correct Answer: C
Rationale: Immediate removal from the feeding situation and rapid assessment with oxygen support is critical for airway safety.
At the time of birth, what is the grayish white, cheeselike substance that normally covers the newborn's skin called?
- A. Miliaria
- B. Meconium
- C. Amniotic fluid
- D. Vernix caseosa
Correct Answer: D
Rationale: Vernix caseosa is the grayish white, cheeselike substance that normally covers a newborn's skin at the time of birth. It is a natural substance produced by the baby's skin glands while in the womb. Vernix caseosa helps protect the baby's delicate skin from the amniotic fluid in the uterus and acts as a moisturizer as well. It also has antimicrobial properties, providing a barrier against infection. After birth, healthcare providers typically wipe off or gently wash the vernix from the baby's skin during the first bath.