When conducting a physical examination, the nurse uses a tuning fork to assess for which condition?

Otitis media.

Neurological pathology.

Tinnitus.

Hearing loss.

Answer and Explanation

The Correct Answer is D

A.   Otitis media is an infection of the middle ear, and while it can affect hearing, it is not typically assessed using a tuning fork. Tuning forks are more useful for evaluating conductive hearing loss or bone conduction.
B.   A tuning fork is generally not used to assess neurological pathology directly. Neurological conditions often require other diagnostic tools or tests to evaluate nerve function or reflexes.
C.   Tinnitus is the perception of ringing in the ears and is usually assessed through patient reporting and audiometric testing. A tuning fork is not used to diagnose tinnitus, but it may be used to test hearing acuity.
D.   A tuning fork is commonly used to assess for hearing loss, specifically conductive hearing loss. The fork helps test the function of bone and air conduction, which are important for determining the type of hearing impairment.

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Correct Answer is D

Explanation

A. Observing pupillary response to a penlight helps assess the neurological function related to the eyes, such as reaction to light, but it does not directly assess the client's overall visual acuity or support the claim of being legally blind.
B. Examining the optic disc can help identify structural changes in the eye, such as damage to the retina or optic nerve, but it doesn't directly assess the client’s claim of being legally blind or the extent of visual impairment.
C. Assessing eye movements can help evaluate for conditions such as strabismus or cranial nerve abnormalities, but it doesn't provide a direct assessment of visual acuity or support the client’s statement of blindness.
D. The Snellen chart is a standard tool for assessing visual acuity and is the most appropriate method to objectively measure whether the client has the visual impairment consistent with being legally blind.

A. Borborygmi sounds. B. Hyperactive bowel sounds. C. Hypoactive bowel sounds. D. Normal bowel sounds.

Correct Answer is D

Explanation

A. Borborygmi refers to the audible rumbling sounds produced by the movement of gas through the intestines. While these sounds may be present in this case, they are more commonly described as prolonged, loud, or audible sounds, not as typical gurgles occurring at the interval described.
B. Hyperactive bowel sounds are frequent and loud, often heard in conditions like diarrhea or early bowel obstruction. The described pattern here, with sounds occurring every 5 to 10 seconds, doesn't necessarily suggest hyperactivity.
C. Hypoactive bowel sounds are reduced or absent, commonly seen in conditions like ileus or bowel obstruction. The sounds described here are not consistent with hypoactive sounds, which would be faint or absent.
D. The description provided aligns with normal bowel sounds, which are intermittent and occur every 5 to 30 seconds in a healthy individual. This pattern of gurgles with the stated frequency is typical of normal bowel function.

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When conducting a physical examination, the nurse uses a tuning fork to assess for which condition?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client states, "I am legally blind." Which assessment technique should the nurse use to obtain subjective data to support the client's statement?

Correct Answer is D

Explanation

While auscultating for bowel sounds in an adult client, the nurse notes a series of gurgles that last about 3 seconds and occur every 5 to 10 seconds in all quadrants. How should the nurse document this finding?

Correct Answer is D

Explanation

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