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.
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 mo-bile 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.
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a. "Sometimes it's best to disregard subjective perceptions like that and focus on the objective signs.". b. "Pay attention to your feelings. They can provide valuable clues about the patient's feelings.". c. "You should share your perceptions with the patient and seek an explanation.". d. "Confrontation can be a useful tool in situations like this.".
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1. Support optimal healing. 2. Be conducive to the shortest recovery period. 3. Prevent or reduce postoperative complications. 4. All of the above.
While developing a conference for adolescents, the nurse prepares a handout describing socioeconomic and cultural factors that contribute to adolescent pregnancy. Which information should the nurse include in the handout?
1. All cultures share an aversion to early pregnancy. 2. The younger the teen when she first gets pregnant, the less likely she is to have another pregnancy in her teens. 3. Poverty is a major risk factor for teen pregnancy. 4. A child born to a teenage mother is at a lower risk for teen pregnancy.