The nurse is assessing the patient's ear. The correct procedure for straightening the ear canal of an adult is to pull the pinna…
Down and back
Up and back
Down and forward
Straight back
None
None
The Correct Answer is B
A. This option is appropriate for children under the age of 3. Pulling the pinna down and back straightens the ear canal in young children, but it does not align the canal correctly in adults.
B. For an adult, the correct method to straighten the ear canal during examination is to pull the pinna (outer part of the ear) up and back. This maneuver aligns the ear canal for better visualization of the tympanic membrane (eardrum) and inner structures.
C. Pulling the pinna down and forward is incorrect for both adults and children. This action would not provide a clear view of the ear canal and could make examination difficult.
D. Pulling the pinna straight back does not fully straighten the ear canal in adults and may make the examination less effective. The correct technique is up and back for adults to fully straighten the canal and enhance visualization.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
When assessing the abdomen, the nurse would expect to auscultate bowel sounds, which are the sounds made by the movement of gas and fluid through the intestines. The normal bowel sounds are characterized as high-pitched, gurgling, and occurring at a rate of 5-30 sounds per minute.
Bruits are abnormal sounds indicating turbulent blood flow and are usually assessed in other areas of the body, such as the epigastric and renal arteries, as well as in the aorta.
Friction rubs are also abnormal sounds, but they are typically heard during auscultation of the heart and lungs.
Low-pitched sonorous sounds are not typical sounds that are expected to be heard during an abdominal assessment
Correct Answer is D
Explanation
This response demonstrates respect for the client's religious beliefs and a willingness to work with the client to meet their needs. It also opens up a dialogue between the nurse and the client to develop a plan of care that is consistent with the client's beliefs and values.
Option a, "Fasting is harmful to your body," is not an appropriate response as it does not respect the client's religious beliefs and may be perceived as insensitive or disrespectful.
Option b, "You must have food during times of illness," may be accurate in some situations, but it is not relevant to the client's request to fast during Ramadan.
Option c, "I will let your healthcare provider know that you need to be discharged," is not an appropriate response as it does not address the client's request to fast during Ramadan and may be perceived as dismissive or unhelpful.
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