The student nurse is preparing to insert the otoscope into the adult client's ear. Which of the following statements indicates that the student nurse requires further education?
1. "I'm going to use the largest speculum that will fit easily into the ear canal.".
2. "I'm going to prepare to insert the otoscope by pulling the pinna down and back.".
3. "The tympanic membrane should look gray and translucent.".
4. "I will ask the client to perform the valsalva maneuver so that I can see how well the tympanic membrane moves.".
2
Rationale 1: For the best visualization, use the largest speculum that will fit into the auditory canal.
Rationale 2: In infants, the pinna is pulled down and back due to the shorter, straight external ear canal. In the adult client, pull the pinna up, back, and out to straighten the canal.
Rationale 3: The membrane should be flat, gray, and translucent with no scars.
Rationale 4: The valsalva maneuver lets the nurse assess the mobility of the tympanic membrane.
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