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 C
Explanation
A.While non-pharmacologic strategies are important for pain management, they are typically introduced after initial assessment and understanding of the client's pain experience. In this case, the priority is to clarify the apparent discrepancy between the reported pain level and observed behavior.
B.Respecting the client's privacy and providing time for personal activities like phone calls is important but does not directly address the concern of incongruent pain assessment and behavior.
C.Incongruence between reported pain intensity (10/10) and observed behavior (laughing on the phone) suggests a potential discrepancy that needs to be documented and further investigated. This documentation is crucial for accurate assessment and communication among the healthcare team.
D.Administering pain medication immediately without further assessment may not be appropriate if there is uncertainty about the accuracy of the pain report. It's important to first clarify and validate the client's pain experience before proceeding with medication administration.
Correct Answer is A
No explanation
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