The nurse is conducting a hearing assessment on an older adult ...

[appyboo]

The nurse is conducting a hearing assessment on an older adult client with impacted cerumen noted in the right ear canal. When performing the Weber test, which would the nurse expect to learn?
 
  1. Air conduction is longer than bone conduction.
  2. Bone conduction is longer than air conduction.
  3. Sound lateralized to the right ear.
  4. The client is unable to maintain balance while standing.

Question 2

During the focused interview, the client confides in the nurse issues with anxiety. During the physical assessment, which findings support the presence of anxiety? Select all that apply.
 
  1. The client complains of pain when the tragus is gently manipulated.
  2. The client has several small ulcers on her lip.
  3. Pale nasal mucosa
  4. Small sores are noted within the mouth.
  5. Perforated nasal septum

[upturnedfurball]

Answer to Question 1

Correct Answer: 3

The Weber test uses bone conduction to evaluate hearing in a person who hears better in one ear than in the other. With impacted cerumen, an ear infection, or a perforated tympanic membrane, the sound will lateralize to the affected ear during the Weber test. The Rinne test compares air and bone conduction. Normally, the sound is heard twice as long by air conduction than by bone conduction after bone conduction stops. The Romberg test is used to determine equilibrium and the client's ability to maintain balance while standing.

Answer to Question 2

Correct Answer: 1, 2, 4

Pain that occurs with manipulation of the tragus may accompany temporomandibular joint dysfunction that may be associated with jaw clenching. Jaw clenching can accompany psychological stress. Clients who are under a great deal of stress might bite their lips. Clients who are under a great deal of stress might present with ulcers in their mouth. Pale nasal mucosa is associated with cocaine use, infection, hypoxia, and allergies. A perforated nasal septum is associated with cocaine use.

[appyboo]

Excellent

[matt95]

TYSM