To assess the tympanic membrane mobility, which instrument is most appropriate for the nurse to use?
Audiometer
Ophthalmoscope
Pneumatic otoscope
Tuning fork
The Correct Answer is C
A. An audiometer is used to assess hearing ability and is not appropriate for examining the tympanic membrane.
B. An ophthalmoscope is used to examine the interior of the eye and cannot assess tympanic membrane mobility.
C. A pneumatic otoscope is specifically designed for examining the tympanic membrane and allows for assessment of its mobility by using air pressure.
D. A tuning fork is used to evaluate hearing and vibration sense, not tympanic membrane mobility.
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Correct Answer is D
Explanation
A. The severity of the condition may correlate with pain but is not a direct measure of the individual's pain experience.
B. Vital signs can change due to pain but are not specific indicators of pain intensity or presence.
C. Nonverbal behavior can provide clues about pain but is subjective and can vary greatly between individuals.
D. Self-rating of pain is considered the most reliable indicator of pain because it reflects the individual's personal experience and perception of their pain, making it the gold standard for assessing pain intensity.
Correct Answer is C
Explanation
A. This would show a regular rhythm with a consistent rate (60-100 bpm) and clear P waves before each QRS complex, which is not present in asystole.
B. This indicates a slow heart rate (below 60 bpm) but would still display P waves and QRS complexes; asystole shows no electrical activity.
C. This is the correct interpretation as it represents a flatline on the ECG, indicating no electrical activity in the heart.
D. This would show a rapid heart rate (above 100 bpm) with present P waves, which is not the case in asystole.