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38.A nurse examines a patient’s auditory canal and tympanic membrane with an otoscope and observes which finding as normal?a.Clear fluid lining the auditory canalb.A firm tympanic membrane without fluctuation with puffs of airc.A small hole within the cone of lightd.A shiny, translucent tympanic membraneANS: DTestBankWorld.org
A shiny, translucent tympanic membrane is an expected finding. Clear fluid or bloody drainage following a head injury may indicate a basilar skull fracture. An expected response isthat the tympanic membrane slightly fluctuates with puffs of air. A cone of light is expected, but a hole indicates perforation.DIF:Cognitive Level: ApplyREF:p. 159TOP:Nursing Process: AssessmentMSC:NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body Systems39.A nurse observes a student using the whisper test to screen a patient with hearing loss. Which behavior by the student requires a corrective comment from the nurse?DIF:Cognitive Level: ApplyREF:p. 160TOP:Nursing Process: AssessmentMSC:NCLEX Patient Needs: Health Promotion and Maintenance: Techniques of Physical Assessment40.A nurse reads in the history that a patient has a new onset of acute otitis media. Based on this information, how does the nurse expect this patient’s tympanic membrane to appear?DIF:Cognitive Level: ApplyREF:p. 175TOP:Nursing Process: AssessmentMSC:NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body Systems41.During the Rinne test, a nurse determines that the patient hears the tuning fork held on the mastoid process for 15 seconds and hears the tuning fork held in front of the ear for 30 seconds. The same results are found in both ears. Based on this finding, what is the most appropriate response of the nurse?TestBankWorld.org
b.Tell the patient that this represents an expected finding.c.Refer the patient for additional testing to detect hearing abnormality.d.Perform a Weber test to confirm the findings of the Rinne test.