The nurse suspects that the client has a hearing disorder; however, th

The nurse suspects that the client has a hearing disorder; however, the client denies not being able to hear. What initial assessment technique should the nurse employ?

1. Schedule a Weber and Rinne test.
2. Observe the client’s interaction with significant others.
3. Use an otoscope to visualize the inner ear.
4. Confront the client with the nurse’s suspicion.

ANSWER

Correct Answer: 2
Rationale 1: The Weber and Rinne test may be a part of assessment, but will not yield as much information as the simple observation.
Rationale 2: The most telling of these options would be to observe the client’s interactions with significant others. The nurse should assess for frequent requests to repeat, inattention to conversation, turning one ear to the conversation, and lip-reading.
Rationale 3: Use of an otoscope may be a part of assessment, but will not yield as much information as the simple observation.
Rationale 4: The client has already denied a hearing problem, so confronting the client with the nurse’s suspicion will probably only serve to alienate the client from the nurse.