An advanced practice nurse has performed a Rinne test on a new patient. During the test, the patient reports that air-conducted sound is louder than bone-conducted sound. How should the nurse interpret this assessment finding?

The patient has sensorineural hearing loss

The patient is at risk for tinnitus

The patient’s hearing is likely normal

The patient likely has otosclerosis

Answer and Explanation

The Correct Answer is C

Choice A rationale
Sensorineural hearing loss is a type of hearing loss in which the root cause lies in the inner ear or sensory organ (cochlea and associated structures) or the vestibulocochlear nerve (cranial nerve VIII). Sensorineural hearing loss can be mild, moderate, severe, or profound, and it affects the ability to hear faint sounds or understand speech. However, in the Rinne test, if the air-conducted sound is louder than the bone-conducted sound, it indicates that the patient’s hearing is likely normal.
Choice B rationale
Tinnitus is the perception of noise or ringing in the ears. It is a common problem that affects about 15 to 20 percent of people and is especially common in older adults. However, the Rinne test is not used to diagnose tinnitus. It is used to compare air and bone conduction of sound.
Choice C rationale
In a normal Rinne test, air conduction (AC) is better than bone conduction (BC). This is referred to as a positive Rinne test. If a patient reports that air-conducted sound is louder than bone-conducted sound, it suggests that the patient’s hearing is likely normal.
Choice D rationale
Otosclerosis is a condition that affects the bones in the middle ear, causing hearing loss. It is a common cause of conductive hearing loss, particularly in young adults. However, in otosclerosis, bone conduction (BC) is better than air conduction (AC), which is referred to as a negative Rinne test.

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Correct Answer is C

Explanation

Choice C rationale
Dimming the lights and reducing stimulation can be an effective nursing intervention for a patient with herpes simplex virus encephalitis who is complaining of a headache. Bright lights and excessive noise can exacerbate headaches, so creating a quiet, dimly lit environment can help to alleviate this symptom.
Choice A rationale

While administering hydromorphone as needed can help to manage the patient’s pain, it does not directly address the patient’s complaint of a headache. Moreover, opioids like hydromorphone can have side effects such as drowsiness and constipation, which may not be desirable in a patient with encephalitis.
Choice B rationale
Distracting the patient with activity may not be appropriate for a patient with herpes simplex virus encephalitis who is complaining of a headache. Rest and quiet are often more beneficial for these patients.
Choice D rationale
Initiating a patient-controlled analgesia (PCA) of morphine sulfate can provide effective pain relief for some patients, but it may not be the best first-line approach for a patient with a headache due to herpes simplex virus encephalitis. Like hydromorphone, morphine can have side effects such as drowsiness and constipation.

A. By using the Romberg test B. By assessing the patient’s sensitivity to temperature and touch C. By observing the patient’s response to painful stimuli D. By observing the reaction of pupils to light

Correct Answer is C

Explanation

Choice C rationale
When providing care for a comatose patient, a nurse should evaluate motor responses by observing the patient’s response to painful stimuli. This can be done by applying a painful stimulus, such as a trapezius pinch or nailbed pressure, and observing the patient’s motor response. Purposeful or semi-purposeful movements, such as localizing or withdrawing from pain, can provide valuable information about the patient’s level of consciousness and neurological function.
Choice A rationale
The Romberg test is used to evaluate balance and is not typically used to evaluate motor responses in a comatose patient.
Choice B rationale
Assessing the patient’s sensitivity to temperature and touch can provide information about sensory function, but it does not directly evaluate motor responses.
Choice D rationale

Observing the reaction of pupils to light can provide information about cranial nerve function, but it does not directly evaluate motor responses.

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An advanced practice nurse has performed a Rinne test on a new patient. During the test, the patient reports that air-conducted sound is louder than bone-conducted sound. How should the nurse interpret this assessment finding?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A patient is being admitted to the unit with suspected herpes simplex virus encephalitis. What nursing action best addresses the patient’s complaints of headache?

Correct Answer is C

Explanation

When providing care for a comatose patient, how should a nurse evaluate motor responses?

Correct Answer is C

Explanation

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