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 C
Explanation
A. Restlessness is an objective sign that may indicate pain, but it is not a subjective report from the client.
B. Pupil dilation is an objective physiological response often associated with pain or stress, not a subjective indicator.
C. A report of a burning sensation is a subjective indicator because it is based on the client’s own description of their pain experience.
D. Grimacing is an objective observation by the nurse, not a subjective report from the client.
Correct Answer is A
Explanation
A. Asking the client to identify scented aromas assesses cranial nerve I (olfactory nerve), which is responsible for the sense of smell.
B. Reading a Snellen chart assesses cranial nerve II (optic nerve), which is related to vision.
C. Listening to the client's speech evaluates the function of cranial nerves V (trigeminal) and XII (hypoglossal), which are related to mastication and tongue movement, respectively.
D. Asking the client to clench his teeth tests cranial nerve V, which innervates the muscles of mastication.