The client admits to cleaning his ears with a cotton-tipped ...

[Haya94]

The client admits to cleaning his ears with a cotton-tipped applicator. As a consequence, the client has developed impacted cerumen and unilateral hearing loss. As the nurse prepares the client's plan of care, which nursing diagnosis is most applicable?
 
  1. Acute pain.
  2. Knowledge deficit.
  3. Acute confusion.
  4. Unilateral neglect.

Question 2

The nurse is explaining discussing the Rinne test to a group of student nurses. Which statement by the nurse is most appropriate?
 
  1. This test requires the use of an otoscope.
  2. The test is performed by whispering statements a few feet away from the client.
  3. The test is used to determine if a client hears sound in one ear better than the other.
  4. This test compares air and bone conduction of sound using a tuning fork.

[pami445]

Answer to Question 1

Correct Answer: 2
Of the choices, the best nursing diagnosis for this client is knowledge deficit regarding how to adequately care for his ears. Another possible nursing diagnosis that would be applicable for this client is disturbed sensory perception because he will be unable to hear well out of the ear that is impacted with cerumen. Acute pain would be appropriate if the client had perforated the tympanic membrane with the cotton-tipped applicator. However, there are no data to suggest this. Acute confusion is not an appropriate nursing diagnosis. This client will not develop confusion as a result of unilateral hearing loss. The client will not neglect one side as a result of unilateral hearing loss.

Answer to Question 2

Correct Answer: 4
The Rinne test compares air and bone conduction of sound with the use of a tuning fork. The Rinne test does not require the use of an otoscope. The whisper test is administered by whispering statements a few feet away from the client. The Weber test is performed to determine if during bone conduction, with the use of a tuning fork, the client hears the sound in one ear better than the other. If there is impaired conduction in one ear, the sound will lateralize to that ear during the Weber test.

[Haya94]

Gracias!

[matt95]

Excellent