A nurse is teaching a client about the Rinne test. Which of the following client statements indicates an understanding of the teaching?
"I will wear earphones during this test."
"Small electrodes are placed on my scalp."
"A small probe is placed inside my ear."
"A tuning fork is placed on my head."
The Correct Answer is D
Choice A Reason: This is incorrect because earphones are not used in the Rinne test. The Rinne test compares air conduction and bone conduction of sound using a tuning fork.
Choice B Reason: This is incorrect because electrodes are not used in the Rinne test. Electrodes are used in electroencephalography (EEG), which measures brain activity.
Choice C Reason: This is incorrect because a probe is not used in the Rinne test. A probe is used in tympanometry, which measures the pressure and mobility of the eardrum.
Choice D Reason: This is correct because a tuning fork is used in the Rinne test. The tuning fork is placed on the mastoid process behind the ear and then moved near the ear canal to compare the sound perception.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A Reason: Culture is not a diagnostic test that uses an ultraviolet light source, but a laboratory test that involves growing microorganisms from a sample of body fluid or tissue. Culture can help identify the type and sensitivity of the infection-causing agent.
Choice B Reason: KOH is not a diagnostic test that uses an ultraviolet light source, but a chemical test that involves applying potassium hydroxide to a sample of skin, hair, or nail. KOH can help diagnose fungal infections by dissolving the keratin and revealing the fungal elements under a microscope.
Choice C Reason: Diascopy is not a diagnostic test that uses an ultraviolet light source, but a physical test that involves applying pressure to a lesion with a glass slide or lens. Diascopy can help differentiate between blanchable and non-blanchable lesions, such as erythema or petechiae.
Choice D Reason: Wood's is a diagnostic test that uses an ultraviolet light source, also known as a Wood's lamp or black light. Wood's can help observe color changes to the skin that are not visible under normal light, such as fluorescence or hypopigmentation. Wood's can help diagnose conditions such as tinea capitis, vitiligo, or erythrasma.
Correct Answer is ["E","F"]
Explanation
Choice A Reason: This is incorrect because submerging the client in a cold bath can cause hypothermia, shock, or infection. Cold water can lower the body temperature and blood pressure, which can impair circulation and organ function. Cold water can also introduce bacteria or contaminants into the open wounds. The nurse should use cool water or saline to gently irrigate the burned areas and then cover them with sterile dressings.
Choice B Reason: This is correct because administering oxygen can help the client breathe better and prevent hypoxia. Burns to the face, neck, or chest can cause swelling or damage to the airway, which can impair gas exchange and oxygen delivery. Oxygen can also reduce the risk of carbon monoxide poisoning, which can occur from inhaling smoke or fumes.
Choice C Reason: This is incorrect because restricting fluids can worsen dehydration and shock. Burns can cause significant fluid and electrolyte loss through evaporation and leakage from damaged capillaries. This can lead to hypovolemia, which is low blood volume, and hypotension, which is low blood pressure. The nurse should monitor the client's vital signs, urine output, and weight, and administer intravenous fluids as ordered.
Choice D Reason: This is incorrect because providing a meal high in fiber can cause abdominal discomfort or diarrhea. Burns can cause paralytic ileus, which is a temporary loss of bowel function due to nerve damage or inflammation. This can impair digestion and absorption of food and cause nausea, vomiting, or constipation. The nurse should assess the client's bowel sounds and provide enteral or parenteral nutrition as ordered.
Choice E Reason: This is correct because assessing airway is a priority nursing action for a client with burns. As mentioned above, burns to the face, neck, or chest can compromise the airway and cause respiratory distress or failure. The nurse should assess the client's level of consciousness, breathing rate and pattern, oxygen saturation, and signs of inhalation injury, such as sooty sputum, singed nasal hairs, or hoarseness. The nurse should also be prepared to assist with intubation or tracheostomy if needed.
Choice F Reason: This is correct because applying ice to burned areas can help reduce pain and swelling. Ice can constrict blood vessels and numb nerve endings, which can decrease inflammation and sensation. However, ice should be applied for no more than 15 minutes at a time and wrapped in a cloth or towel to prevent frostbite or tissue damage. Ice should not be applied to large or deep burns.
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