The nurse is assisting with a caloric test to determine if an alteration exists in the vestibular origin of the acoustic nerve. Which of the following accurately describes a step in this procedure?
A) Place the client in a prone position to perform the examination.
B) Instill cold and/or warm water into the external ear canal.
C) Test the affected side after testing the normal side.
D) Replace water with hot air for a client with a punctured eardrum.
B
Feedback:
During this procedure, the client is either seated or supine, and water is instilled into the external ear canal. Sometimes, warm and cold water are alternated. The affected side is tested first because less of a reaction is expected to occur there. The normal response to this test is nystagmus (rapid, rhythmic eye movements), nausea, vomiting, vertigo (a feeling of spinning), and a feeling of falling. Decreased or absence of these responses within 3 minutes indicates an abnormality. Water cannot be used for this test if the client's eardrum is punctured. Cold air may be substituted.
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