A client has dysfunction of the cochlear division of the vestibulocochlear nerve (cranial nerve VIII). The nurse should determine that the client is adequately adapting to this problem if he or she states a plan to obtain which item?
A pulse oximeter
A hearing aid
Eyeglasses
A bath thermometer
The Correct Answer is B
A. A pulse oximeter is used to measure oxygen saturation and is not relevant to cochlear dysfunction.
B. A hearing aid is appropriate for someone with cochlear dysfunction as it can help amplify sound and improve hearing, indicating the client is adapting to the hearing loss.
C. Eyeglasses are used for vision problems and do not relate to the function of the cochlear division of the vestibulocochlear nerve.
D. A bath thermometer is used to measure water temperature and is not relevant to auditory issues.
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Correct Answer is D
Explanation
A. In the anterior chest assessment, auscultation usually follows inspection and is typically done before percussion.
B. In the neck assessment, the nurse may inspect and then auscultate (e.g., carotid arteries) before palpation.
C. In the heart assessment, auscultation follows inspection but may not involve percussion.
D. In the abdomen, the correct order is to inspect, auscultate, and then percuss to assess bowel sounds effectively before creating additional disturbances with percussion.
Correct Answer is A
Explanation
A. The bell of the stethoscope is best used to listen for low-pitched sounds, including some types of murmurs, and can help assess the quality and intensity of a cardiac murmur.
B. While palpation can provide some information about the heart's function (such as thrills), it is not the primary method for assessing the quality of a murmur.
C. A Doppler ultrasound device is used for measuring blood flow and can help in assessing murmurs but does not provide the quality assessment needed for characterizing a murmur.
D. Percussion is not typically used to evaluate murmurs; it is more useful for assessing the size and borders of organs.