The nursing student is asked by the preceptor what are the expected findings of the Rinne test. What statement by the nursing student is correct?
The client is able to repeat three whispered words without difficulty.
The client is able to tack the unlock on the left ear versus the right ear when placed on top of the head.
The client will display minimal swaying when standing with feet together and eyes closed.
The client will hear the tuning fork for a longer period when placed next to the ear than when placed behind the ear on the mastoid process.
The Correct Answer is D
Choice A reason: The ability to repeat three whispered words without difficulty is an assessment of auditory acuity, not a specific finding of the Rinne test. The Rinne test evaluates bone and air conduction of sound.
Choice B reason: Placing the tuning fork on top of the head is part of the Weber test, which assesses lateralization of sound. It is not part of the Rinne test.
Choice C reason: Minimal swaying when standing with feet together and eyes closed is an assessment of balance, known as the Romberg test. It is not related to the Rinne test.
Choice D reason: The Rinne test compares air conduction (next to the ear) with bone conduction (on the mastoid process). Normally, air conduction is heard longer than bone conduction, indicating normal hearing or sensorineural hearing loss. This is the correct expected finding for the Rinne test.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Telling the client it is too soon to expect to feel normal and to give it a few more years dismisses her feelings and provides an unrealistic timeline. It is not supportive or empathetic.
Choice B reason: Saying "Really, you look just fine to me. There's no need to feel undesirable" invalidates the client's feelings and does not address her concerns about her body image and sexual desire.
Choice C reason: Suggesting an afternoon at the spa and a facial to make her feel more attractive trivializes the client's emotional and physical experience post-surgery. It does not provide meaningful support or address the underlying issues.
Choice D reason: Expressing interest in how the client's body feels to her validates her feelings and opens up a dialogue for her to share her concerns. This approach is empathetic and allows the nurse to provide better support and address any issues the client might have.
Correct Answer is A
Explanation
Choice A reason: Defibrillation is the appropriate intervention for pulseless ventricular tachycardia (VT). It delivers an electrical shock to the heart to restore a normal rhythm. Immediate defibrillation is crucial for survival as it can terminate the arrhythmia and allow the heart to re-establish an effective rhythm.
Choice B reason: Vagal maneuvers, such as the Valsalva maneuver, are used to terminate supraventricular tachycardias but are ineffective for pulseless VT. These maneuvers stimulate the vagus nerve to slow the heart rate but do not provide the necessary intervention for life-threatening arrhythmias like pulseless VT.
Choice C reason: Radiofrequency catheter ablation is a procedure used to treat recurrent arrhythmias by destroying abnormal electrical pathways in the heart. It is not an emergency intervention for pulseless VT. Defibrillation is needed to address the immediate, life-threatening situation.
Choice D reason: Administration of atropine is not indicated for pulseless VT. Atropine is used to treat bradycardia by increasing heart rate, but it does not address the underlying cause of VT. Defibrillation is the correct immediate intervention for pulseless VT.
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