The nurse holds the tuning fork by the handle and gently strikes ...

[washai]

The nurse holds the tuning fork by the handle and gently strikes the fork on the palm of the hand. Then, the nurse places the base of the fork on the client's mastoid process.
 
  The nurse requests that the client indicate when the sound can no longer be heard. Which test is the nurse performing?
  1. Weber.
  2. Whisper.
  3. Rinne.
  4. Romberg.

Question 2

The student nurse is preparing to insert the otoscope into the adult client's ear. Which statement by the student nurse indicates the need for further education?
 
  1. I'm going to use the largest speculum that will fit easily into the ear canal.
  2. I'm going to prepare to insert the otoscope by pulling the pinna down and back.
  3. The tympanic membrane should look gray and translucent.
  4. I will ask the client to perform the Valsalva maneuver so that I can see how well the tympanic membrane moves.

[momo1250]

Answer to Question 1

Correct Answer: 3
The Rinne test is used to compare air and bone conduction of sound and is performed in the manner described. The Weber test uses bone conduction to evaluate hearing in a person who hears better in one ear than in the other. The nurse holds the tuning fork by the handle and strikes the fork on the palm of the hand. The nurse places the base of the vibrating fork against the client's skull. The midline of the anterior portion of the frontal bone is used. The whisper test is performed by standing to the side of the client at a distance of 1-2 feet and whispering information to the client. The client then repeats the information back to the nurse. The Romberg test is used to assess equilibrium. The client stands with feet together and arms at sides, first with eyes opened and then with eyes closed. The client's ability to maintain balance for 20 seconds with only mild swaying is documented as a negative Romberg test.

Answer to Question 2

Correct Answer: 2
In infants, the pinna is pulled down and back due to the shorter, straight external ear canal. In the adult client, pull the pinna up, back, and out to straighten the canal. For the best visualization, use the largest speculum that will fit into the auditory canal. The membrane should be flat, gray, and translucent with no scars. The Valsalva maneuver lets the nurse assess the mobility of the tympanic membrane.

[washai]

TYSM

[laurnthompson]

Excellent