Audiometry is the most important diagnostic test for assessing hearing loss. This test measures a

person's ability to hear sounds, varying in pitch and loudness. It is a comprehensive evaluation that

helps determine the degree and type of hearing loss, whether it is conductive, sensorineural, or

mixed. Tympanogram, middle ear endoscopy, and auditory brain stem response are also valuable

diagnostic tools, but audiometry provides the primary assessment necessary for diagnosing hearing

loss and guiding subsequent treatment.

Purpose of Throat Culture: A throat culture is performed to detect the presence of pathogens (like

bacteria) that cause infections such as strep throat.

Correct Technique:

Uvula and Soft Palate: These are not the primary sites for collecting throat cultures.

Any site of Oral Cavity Mucosa: This is too broad and non-specific.

Tongue and Buccal Mucosa: These sites are not typically infected in throat infections and do not

provide accurate culture results.

Oropharynx and Tonsillar Region: The mucosa of the oropharynx and tonsillar region is the most

common site of infection in throat infections, making it the appropriate site for swabbing.

Procedure: The nurse should gently swab the oropharynx and tonsillar area, avoiding the tongue and

other parts of the oral cavity to avoid contamination and ensure accurate results.

Conclusion: The correct site for collecting a throat culture is the mucosa of the oropharynx and

tonsillar region, ensuring the detection of the causative pathogens.

Reference: Clinical nursing skills textbooks, NCLEX-RN review guides, guidelines for throat culture

collection.

For a client with brain cancer undergoing radiation therapy and exhibiting cachexia, the first nursing

measure should be to encourage a high protein and high-calorie diet.

High Protein and High Calorie Diet: Cachexia is a severe form of malnutrition often seen in cancer

patients, characterized by weight loss, muscle wasting, and decreased quality of life. Ensuring

adequate nutrition is crucial to improve strength, immune function, and overall well-being.

Frequent Oral Hygiene: This is important, especially if the patient has oral side effects from radiation,

but it does not address the primary issue of malnutrition.

Daily Physical Activity: Beneficial for maintaining muscle mass and overall health but should be

secondary to addressing severe nutritional deficits.

Small Cold Meals: These may be more palatable if the patient has nausea but should also be high in

calories and protein to combat cachexia.

Reference:

American Cancer Society: Managing Cancer Cachexia

Oncology Nursing Society (ONS): Nutrition and Cancer Care

The maximum duration for the therapeutic effects of a bath, especially for conditions like perineum

irritation, is generally 15 minutes. This duration is sufficient to provide relief and ensure the

therapeutic benefits without causing skin maceration or other complications. Shorter durations may

not provide adequate relief, and significantly longer baths can lead to issues like skin breakdown.

Applying Erikson's psychosocial development theory, the nurse should instruct the parents to

observe and respond to the newborn's signals of needs. According to Erikson, the first stage of

psychosocial development is "Trust vs. Mistrust," which occurs from birth to approximately 18

months.

Trust vs. Mistrust: In this stage, infants learn to trust their caregivers when their needs for food,

comfort, and affection are consistently met. If caregivers are responsive to the infant’s needs, the

infant develops a sense of trust and security.

Ignoring and Distracting the Newborn: This approach may lead to feelings of mistrust as the infant’s

needs are not being adequately addressed.

Anticipating and Planning for the Newborn's Demands: While planning is important, it is more crucial

to be responsive to the infant's immediate signals.

Providing a Comfortable Environment: This is beneficial but must be combined with responsive

caregiving to establish trust.

Reference:

Erikson,

E. H. (1963). Childhood and Society.

American Psychological Association (APA): Erikson's Stages of Psychosocial Development