ATI RN
foundations of nursing practice questions Questions
Question 1 of 5
While reviewing the health history of an older adult experiencing hearing loss the nurse notes the patient has had no trauma or loss of balance. What aspect of this patients health history is most likely to be linked to the patients hearing deficit?
Correct Answer: D
Rationale: The correct answer is D: Previous perforation of the eardrum. A perforated eardrum can lead to hearing loss as it affects the transmission of sound waves to the inner ear. This is the most likely link to the patient's hearing deficit as trauma or injury to the eardrum can directly impact hearing. Incorrect choices: A: Recent completion of radiation therapy for treatment of thyroid cancer - Radiation therapy for thyroid cancer typically does not directly affect hearing. B: Routine use of quinine for management of leg cramps - Quinine use is associated with tinnitus (ringing in the ears) but not typically with hearing loss. C: Allergy to hair coloring and hair spray - Allergy to hair products is not directly related to hearing loss. In summary, the most likely cause of the patient's hearing deficit based on the health history provided is the previous perforation of the eardrum, as it directly affects the transmission of sound waves to the inner ear.
Question 2 of 5
The nurse is discussing the results of a patients diagnostic testing with the nurse practitioner. What Weber test result would indicate the presence of a sensorineural loss?
Correct Answer: C
Rationale: The correct answer is C because in sensorineural hearing loss, the sound is heard better in the ear with poorer hearing due to damage to the inner ear or auditory nerve. This is because the brain perceives the sound as louder in the affected ear to compensate for the hearing loss. Choice A is incorrect as it describes the result for conductive hearing loss. Choice B is incorrect as it indicates normal hearing. Choice D is incorrect as it describes the result for a lateralizing conductive hearing loss.
Question 3 of 5
The nurse is planning the care of a patient with a diagnosis of vertigo. What nursing diagnosis risk should the nurse prioritize in this patients care?
Correct Answer: C
Rationale: The correct answer is C: Risk for falls. Patients with vertigo experience a false sensation of spinning or movement, which can lead to imbalance and increased risk of falls. Prioritizing the risk for falls is crucial to prevent injuries and ensure patient safety. Other choices are incorrect as they do not directly address the immediate safety concern of falls associated with vertigo. A: Risk for disturbed sensory perception may be present, but the priority is preventing falls. B: Risk for unilateral neglect is not typically associated with vertigo. D: Risk for ineffective health maintenance is important but falls take precedence due to the immediate risk of injury.
Question 4 of 5
A child goes to the school nurse and complains of not being able to hear the teacher. What test could the school nurse perform that would preliminarily indicate hearing loss?
Correct Answer: C
Rationale: The correct answer is C: Whisper test. The nurse can perform a whisper test by whispering a series of numbers or words at a distance from the child to see if they can repeat them accurately. If the child struggles to hear and repeat the whispered words, it could indicate hearing loss. Rationale: A: Audiometry is a comprehensive hearing test that measures the range and sensitivity of hearing, not suitable for a quick preliminary assessment. B: Rinne test and D: Weber test are both tuning fork tests used to assess conductive and sensorineural hearing loss, not ideal for a quick initial screening of hearing loss. Summary: The Whisper test is the most suitable choice as it provides a quick and simple way to preliminarily assess hearing loss by evaluating the child's ability to hear and repeat whispered sounds accurately.
Question 5 of 5
A hearing-impaired patient is scheduled to have an MRI. What would be important for the nurse to remember when caring for this patient?
Correct Answer: A
Rationale: Correct Answer: A Rationale: 1. Hearing-impaired patient is likely unable to hear during an MRI due to loud noises. 2. Nurse needs to use alternative communication methods like writing or gestures. 3. Sign language interpreter may not be necessary for an MRI. 4. Lip reading may be challenging due to the noisy MRI environment. 5. Interaction should be adapted to accommodate the patient's communication needs.