A patient is being evaluated for hearing loss. The doctor is unable to examine the tympanic membrane due to a blockage caused by cerumen. What actions can the nurse take to allow for an examination?
Instill mineral oil into the canal and immediately irrigate to remove the impacted wax.
Instill a small amount of mineral oil into the canal, then have the patient return in 30 minutes for wax removal.
Irrigate the ear with cold water until all the wax is removed.
Irrigate the ear with warm water and a high amount of otic pressure.
The Correct Answer is B
Choice A rationale
Instilling mineral oil into the canal and immediately irrigating to remove the impacted wax is not typically recommended. This approach may not allow enough time for the mineral oil to soften the cerumen, making it more difficult to remove and potentially causing discomfort or injury.
Choice B rationale
Instilling a small amount of mineral oil into the canal, then having the patient return in 30 minutes for wax removal is a common and effective method for managing cerumen impaction. The mineral oil helps to soften the cerumen, making it easier to remove through irrigation.
Choice C rationale
Irrigating the ear with cold water is not typically recommended. Cold water can cause discomfort and potentially lead to vertigo.
Choice D rationale
Irrigating the ear with warm water and a high amount of otic pressure is not typically recommended. High pressure can potentially damage the ear canal or tympanic membrane.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Assessing lung sounds is an important part of monitoring a patient’s respiratory status, but it may not be the most immediate action if the patient is finding it increasingly difficult to breathe.
Choice B rationale
While explaining the progression of the syndrome is important for patient education, it may not be the most immediate action if the patient is experiencing difficulty breathing.
Choice C rationale
Guillain-Barre syndrome can affect the muscles used for breathing, resulting in a weakened or paralyzed diaphragm, which can lead to an ineffective breathing pattern. Therefore, if a patient states that it is getting harder to take a deep breath, the nurse should call the physician and prepare for possible intubation.
Choice D rationale
Encouraging the client to cough may not be the most appropriate action if the patient is finding it increasingly difficult to breathe.
Correct Answer is C
Explanation
Choice A rationale
While assessing visual acuity may be part of a comprehensive eye examination, it would not specifically address distortions noted on the Amsler grid.
Choice B rationale
Tonometry testing is used to measure the pressure inside the eye and is typically used in the diagnosis of glaucoma. It would not specifically address distortions noted on the Amsler grid.
Choice C rationale
Distortions when looking at the Amsler grid can be a sign of macular degeneration16. Therefore, arranging for the client to be assessed for macular degeneration would be the appropriate action16.
Choice D rationale
While age-related changes in vision can occur, distortions when looking at the Amsler grid are not typically considered a normal age-related change16. Therefore, reassuring the client that this is an age-related change in vision would not be the appropriate action16.
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