A nurse is assessing a client for conductive hearing loss. When using the Rinne test, which of the following results should the nurse identify as an indication that the client has conductive hearing loss of the left ear?
Sound is lateralizing to the right ear.
Sound is lateralizing to the left ear.
Air conduction is greater than bone conduction in the left ear.
Air conduction is less than bone conduction in the left ear.
The Correct Answer is D
Choice A rationale
Sound lateralizing to the right ear during the Rinne test does not indicate conductive hearing loss in the left ear. This result suggests that the right ear may have better hearing or that there is an issue with the left ear, but it does not specifically diagnose conductive hearing loss.
Choice B rationale
Sound lateralizing to the left ear during the Rinne test indicates that the left ear is perceiving the sound better, which could be due to conductive hearing loss in the left ear. However, this option does not provide a definitive result for conductive hearing loss.
Choice C rationale
Air conduction being greater than bone conduction in the left ear is a normal finding and does not indicate conductive hearing loss. In conductive hearing loss, bone conduction is typically better than air conduction.
Choice D rationale
Air conduction being less than bone conduction in the left ear is indicative of conductive hearing loss. This result means that the sound is being conducted through the bones of the skull more effectively than through the air, which is a hallmark of conductive hearing loss.
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Correct Answer is B
Explanation
Choice A rationale
Rephrasing statements the client does not hear is helpful but not the priority action. The priority is to determine if the client uses hearing aids to ensure they can hear instructions and communication effectively.
Choice B rationale
Determining if the client uses hearing aids is the priority action. Ensuring the client has and uses their hearing aids can significantly improve communication and care.
Choice C rationale
Speaking using the usual tone of voice and directly in front of the client is important but secondary to ensuring the client has their hearing aids.
Choice D rationale
Using hand gestures to communicate can be helpful but is not the priority action. The primary focus should be on ensuring the client has their hearing aids for optimal hearing.
Correct Answer is D
Explanation
Choice A rationale
Allowing the client to ambulate one day after a detached retinal repair is not recommended. Ambulation can increase intraocular pressure and disrupt the healing process of the retina. The client should be advised to limit physical activity to prevent any strain on the eye.
Choice B rationale
Removing the eye patch during the day is not advisable as it can expose the eye to potential injury or infection. The eye patch helps protect the eye and maintain the correct position for healing. It should be worn as directed by the healthcare provider.
Choice C rationale
Encouraging coughing and deep-breathing exercises is not appropriate for a client who has undergone retinal repair. These activities can increase intraocular pressure and risk detachment of the retina. The client should avoid activities that cause strain or pressure on the eyes.
Choice D rationale
Avoiding reading and writing is crucial for a client one day postoperative following a detached retinal repair. These activities can cause rapid eye movements and strain, which can interfere with the healing process and reattachment of the retina. The client should be advised to rest their eyes and avoid any activities that require intense focus or eye movement.