ATI RN
health assessment practice questions Questions
Question 1 of 5
Tests have shown that a patient has sensorineural hearing loss. During the assessment, it would be important for the nurse to:
Correct Answer: B
Rationale: The correct answer is B: assess for middle ear infection as a possible cause. Sensorineural hearing loss is usually caused by damage to the inner ear or the nerve pathway to the brain. Middle ear infection can sometimes lead to conductive hearing loss, but it's important to rule out this possibility during assessment. Speaking loudly (A) is not effective for sensorineural hearing loss. Asking about medications (C) may be relevant but not as crucial as assessing for a possible cause. Looking for external ear obstruction (D) is more relevant for conductive hearing loss, not sensorineural.
Question 2 of 5
A 31-year-old patient tells the nurse that he has noticed pain in his left ear when people speak loudly to him. The nurse knows that this finding:
Correct Answer: C
Rationale: The correct answer is C because pain in the ear when people speak loudly can be a sign of a middle ear infection. This is due to increased pressure in the middle ear caused by inflammation or fluid buildup. Recruitment (B) is a phenomenon related to hearing loss, not ear pain. Cerumen impaction (D) would not typically cause pain in response to loud sounds. It is not normal for a person of that age to experience ear pain when people speak loudly (A).
Question 3 of 5
A colleague is assessing an 80-year-old patient who has ear pain and asks him to hold his nose and swallow. Which of the following about this technique is true?
Correct Answer: D
Rationale: The correct answer is D because asking the patient to hold his nose and swallow causes the eustachian tube to open, equalizing pressure in the middle ear. This action will cause the eardrum to bulge slightly outward, making landmarks more visible. Choice A is incorrect as age alone does not preclude the use of this technique. Choice B is incorrect because this technique is not primarily used for assessing otitis media. Choice C is incorrect as it is not specific to upper respiratory infections.
Question 4 of 5
The nurse is assessing the hearing of a 7-month-old. What would be the expected response to clapping of hands?
Correct Answer: A
Rationale: The correct answer is A because at 7 months, infants typically have developed the ability to localize sounds. When clapping hands, the expected response is for the infant to turn their head towards the sound source, indicating their ability to detect and localize the sound. This behavior reflects the normal auditory development at this age. Choice B is incorrect because by 7 months, infants should show some response to noise, such as turning their head or showing some interest. Choice C is incorrect as the startle and acoustic blink reflex typically occur in response to sudden loud noises, but at 7 months, the infant should also be able to localize the source of the sound. Choice D is incorrect as stopping all movement and appearing to listen is not a typical response expected from a 7-month-old when hearing a sound. Infants at this age are more likely to actively turn towards the sound source to investigate.
Question 5 of 5
The mother of a 2-year-old is concerned about tympanostomy tubes that are going to be inserted in her son's ears. Which of the following would the nurse include in the teaching plan?
Correct Answer: D
Rationale: Rationale for Correct Answer D: Tympanostomy tubes are inserted into the eardrum to help drain fluid from the middle ear, relieve pressure, and prevent infections. This is important in children who have recurrent ear infections or fluid buildup. By allowing drainage, the tubes help improve hearing and reduce the risk of complications. Summary of Incorrect Choices: A) Incorrect - Tympanostomy tubes are placed in the middle ear, not the inner ear. B) Incorrect - Tympanostomy tubes are used for conductive hearing loss, not sensorineural loss. C) Incorrect - Tympanostomy tubes are not permanently inserted and are usually removed after a period of time once they are no longer needed.