A parent reports their preschool-aged child often asks others to repeat statements and does not articulate common words correctly. The parents think the child has a hearing impairment due to multiple episodes of ear infections and rupture tympanic membranes. The nurse inspects the outer ear canal using an otoscope and no obstruction, inflammation, or drainage is observed. Which action is most important for the nurse to implement?
Clap behind the child's ears to assess for a reflex response to sound.
Refer the child for further evaluation and screening with audiometric testing.
Explain that preschool-agers may not respond when engaged in a task at play.
Inspect the nasal canals and oropharynx for inflammation and drainage.
The Correct Answer is B
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Correct answer: D
D. Risk for infection related to impaired skin integrity: Bladder exstrophy exposes the bladder to the external environment, significantly increasing the risk of infection. This is a critical concern that requires immediate attention to prevent serious complications.
Incorrect:
A. Knowledge deficit related to caring for the infant: While educating the parents about caring for an infant with bladder exstrophy is important, it is not the highest priority compared to preventing infection.
B. Risk for impaired parenting related to appearance of the infant: While the appearance of the infant may be challenging for parents, addressing the immediate risk of infection is more critical.
C. Altered urinary elimination related to exposure of the bladder: This is a known consequence of bladder exstrophy and is addressed through surgical intervention and ongoing care. However, preventing infection is the most immediate priority.
Correct Answer is C
No explanation
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