During an assessment of the ear structures, the nurse would expect to identify which structure as part of the middle ear?
Tympanic Membrane
Ear lobe
Cochlea
Pinna
The Correct Answer is A
Choice a reason:
The tympanic membrane, also known as the eardrum, is a critical component of the middle ear. It is a thin membrane that separates the external ear from the middle ear and vibrates in response to sound waves. These vibrations are then transmitted to the ossicles within the middle ear, which amplify and carry the sound to the inner ear.
Choice b reason:
The ear lobe is part of the external ear, not the middle ear. It is composed of soft skin and fatty tissue and does not play a role in hearing. The ear lobe serves primarily as a site for body decoration such as earrings.
Choice c reason:
The cochlea is a structure located in the inner ear. It is a spiral-shaped organ that contains the organ of Corti, the sensory organ of hearing. The cochlea converts the mechanical vibrations from the middle ear into nerve impulses that are sent to the brain.
Choice d reason:
The pinna, or auricle, is the visible part of the external ear. It is made of cartilage and skin and functions to capture sound waves and direct them into the ear canal towards the tympanic membrane.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice a reason:
Objective data refers to information that is observable and measurable by the healthcare provider, such as vital signs, physical examination findings, and laboratory results. The patient's statements about his feelings are not objective data because they cannot be directly measured or observed by the nurse.
Choice b reason:
Introspective data is not a commonly used term in healthcare. Introspection generally refers to the examination of one's own conscious thoughts and feelings, which in the context of healthcare, can be part of subjective data as it is reported by the patient.
Choice c reason:
Subjective data consists of information that is reported by the patient, including feelings, perceptions, and concerns. It is called 'subjective' because it is based on the patient's personal experience and cannot be independently verified by the nurse. In this case, the patient's report of feeling anxious, nauseated, and hot is considered subjective data.
Choice d reason:
Reflective data is not a standard term in healthcare documentation. Reflection is a process of personal thought and does not pertain to the clinical data gathered during a patient assessment.
Correct Answer is B
Explanation
Choice a reason:
Draping body areas that are not being assessed is important for maintaining the client's privacy and comfort, but it is not the highest priority when dealing with a client with generalized muscle weakness. The primary concern is to prevent further strain or injury during the examination.
Choice b reason:
Limiting position changes as much as possible is the priority when examining a client with generalized muscle weakness. Frequent or unnecessary movements can cause fatigue, discomfort, and may even be unsafe if the client has severely compromised muscle strength. The nurse should plan the examination to minimize the number of times the client needs to change positions.
Choice c reason:
Hand-washing throughout the exam is a standard practice to prevent the spread of infection. While it is crucial for both the client's and the nurse's safety, in the context of a client with generalized muscle weakness, the priority is to conduct the exam in a way that does not exacerbate the client's condition.
Choice d reason:
Using alcohol swabs to clean the stethoscope before and after the exam is also a standard infection control practice. However, it is not the most immediate concern when prioritizing the steps of a physical examination for a client with muscle weakness.
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