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ATI Medical Surgical Nursing, Assessment of the Ear and Hearing
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The nurse notes that a client’s tympanic membrane moves in response to air injected into the external canal. What is the nurse’s best action? a. Notify the health care provider. b. Document ... the finding. c. Prepare to wash the external ear canal. d. Immediately remove the otoscope. ANS: B The healthy ear should have a tympanic membrane that is mobile when air is injected into the external canal. This normal finding should be documented in the client’s chart. Because the mobile tympanic membrane is an expected finding, the nurse does not need to remove the otoscope immediately from the client’s ear canal. No cerumen is impacting the ear canal, so irrigation is not appropriate. The physician does not need to be notified about a normal finding. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—System-Specific Assessments) MSC: Integrated Process: Nursing Process (Assessment) [Show More]
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Mar 02, 2025
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