Chapter 15 Health Assessment quiz

During an otoscopic examination, the nurse notices an area of black and white dots on the tympanic membrane and ear canal wall. What does this finding suggest?

ANS: Blood in the middle ear A colony of black or white dots on the drum or canal wall suggests a yeast or fungal infection (otomycosis).

The nurse is assessing a 16-year-old patient who has suffered head injuries from a recent motor vehicle accident. Which of these statements indicates the most important reason for assessing for any drainage from the ear canal?

ANS: Bloody or clear watery drainage can indicate a basal skull fracture. Frank blood or clear watery drainage (cerebrospinal leak) after trauma suggests a basal skull fracture and warrants immediate referral. Purulent drainage indicates otitis externa or otitis media.

The nurse is reviewing the function of the cranial nerves. Which of the cranial nerves is responsible for conducting nerve impulses to the brain from the organ of Corti?

ANS: CN VIII The nerve impulses are conducted by the auditory portion of CN VIII to the brain.

The nurse is conducting a child safety class for new mothers. Which of these is a risk factor for ear infections in young children?

ANS: Passive cigarette smoke Exposure to passive and gestational smoke is a risk factor for ear infections in infants and children.

In performing an examination of a 3 year old with a suspected ear infection, the nurse would:

ANS: perform the otoscopic examination at the end of the assessment In addition to its place in the complete examination, eardrum assessment is mandatory for any infant or child requiring care for illness or fever. For the infant or young child, the timing of the otoscopic examination is best toward the end of the complete examination.

During an interview, the patient states he has the sensation that "everything around him is spinning." The nurse recognizes that the portion of the ear responsible for this sensation is:

ANS: the labyrinth. If the labyrinth ever becomes inflamed, it feeds the wrong information to the brain, creating a staggering gait and a strong, spinning, whirling sensation called vertigo.

While discussing the history of a 6-month-old infant, the mother tells the nurse that she took a great deal of aspirin while she was pregnant. What question would the nurse want to include in the history?

ANS: "Does your baby seem to startle with loud noise?" Children at risk for hearing deficit include those exposed in utero to a variety of conditions, such as maternal rubella, or to maternal ototoxic drugs.

The nurse is taking the history of a patient who may have a perforated eardrum. What would be an important question in this situation?

ANS: "Was there any relationship between the ear pain and the discharge you mentioned?" Typically with perforation, ear pain occurs first, stopping with a popping sensation, and then drainage occurs

The mother of a 2-year-old is concerned because her son has had three ear infections in the past year. What would be an appropriate response by the nurse?

ANS: "Your son's eustachian tube is shorter and wider than yours because of his age, which allows for infections to develop more easily." The infant's eustachian tube is relatively shorter and wider, and its position is more horizontal than the adult's, so it is easier for pathogens from the nasopharynx to migrate through to the middle ear. The other responses are not appropriate.

The nurse is reviewing the structures of the ear. Which of these statements concerning the eustachian tube is true?

ANS: It helps equalize air pressure on both sides of the tympanic membrane. The eustachian tube allows equalization of air pressure on each side of the tympanic membrane so that the membrane does not rupture (e.g., during altitude changes in an airplane). The tube is normally closed, but it opens with swallowing or yawning.

The nurse is assessing a patient who may have hearing loss. Which of these statements is true concerning air conduction?

ANS: It is the normal pathway for hearing. The normal pathway of hearing is air conduction, which starts when sound waves produce vibrations on the tympanic membrane. Conductive hearing loss results from a mechanical dysfunction of the external or middle ear.

The nurse is performing an otoscopic examination on an adult. Which of these actions is correct?

ANS: Pull the pinna up and back before inserting the speculum. Pull the pinna up and back on an adult or older child. This helps straighten the S-shape of the canal. Traction should not be released on the ear until the examination is completed and the otoscope is removed.

The nurse assesses the hearing of a 7-month-old by clapping hands. What is the expected response?

ANS: The infant turns the head to localize sound. With a loud sudden noise, the nurse should notice the infant turning his or her head to localize sound and responding to his or her own name. A startle reflex and acoustic blink reflex is expected in newborns; at age 3 to 4 months, the infant stops movements and appears to listen.

The nurse is testing the hearing of a 78-year-old man and keeps in mind the changes in hearing that occur with aging include which of the following? Select all that apply.

ANS: The progression is slow. The aging person may find it harder to hear consonants than vowels Sounds may be garbled and difficult to localize Presbycusis is a type of hearing loss that occurs with aging and is found in 60% of those older than 65 years. It is a gradual sensorineural loss caused by nerve degeneration in the inner ear or auditory nerve, and it slowly progresses after age 50. The person first notices a high-frequency tone loss; it is harder to hear consonants (high-pitched components of speech) than vowels. This makes words sound garbled. The ability to localize sound is impaired also.

In performing a voice test to assess hearing, which of these actions would the nurse do? A) Shield the lips so that the sound is muffled.

ANS: Whisper a set of random numbers and letters and ask the patient to repeat them. With your head 30 to 60 cm (1 to 2 ft) from the person's ear, exhale and whisper slowly a set of random numbers and letters, such as "5, B, 6." Normally, the person repeats each number and letter correctly after you say it.

A patient with a middle ear infection asks the nurse, "What does the middle ear do?" The nurse responds by telling the patient that the middle ear functions to:

ANS: conduct vibrations of sounds to the inner ear. Among its other functions, the middle ear conducts sound vibrations from the outer ear to the central hearing apparatus in the inner ear. The other responses are not functions of the middle ear.

A patient has been shown to have a sensorineural hearing loss. During the assessment, it would be important for the nurse to:

ANS: ask the patient what medications he is currently taking. A simple increase in amplitude may not enable the person to understand words. Sensorineural hearing loss may be caused by presbycusis, which is a gradual nerve degeneration that occurs with aging and by ototoxic drugs, which affect the hair cells in the cochlea.

The nurse is examining a patient's ears and notices cerumen in the external canal. Which of these statements about cerumen is correct?

ANS: Cerumen is necessary for transmitting sound through the auditory canal. The ear is lined with glands that secrete cerumen, which is a yellow waxy material that lubricates and protects the ear.

The nurse suspects that a patient has otitis media. Early signs of otitis media include which of these findings of the tympanic membrane?

ANS: Hypomobility An early sign of otitis media is hypomobility of the tympanic membrane. As pressure increases, the tympanic membrane begins to bulge.

The nurse is performing an assessment on a 65-year-old male patient. He reports a crusty nodule behind the pinna. It bleeds intermittently and has not healed over the past 6 months. On physical assessment, the nurse finds an ulcerated crusted nodule with an indurated base. The preliminary analysis in this situation is that this:

ANS: could be a potential carcinoma and should be referred. An ulcerated crusted nodule with an indurated base that fails to heal is characteristic of a carcinoma. These lesions fail to heal and bleed intermittently. Individuals with such symptoms should be referred for a biopsy. The other responses are not correct. See Table 15-2.

A 31-year-old patient tells the nurse that he has noticed pain in his left ear when people speak loudly to him. The nurse knows that this finding:

ANS: is a characteristic of recruitment. Recruitment is a marked loss occurring when speech is at low intensity, but sound actually becomes painful when the speaker repeats at a louder volume. The other responses are not correct

When performing an otoscopic examination of a 5-year-old child with a history of chronic ear infections, the nurse sees that his right tympanic membrane is amber-yellow in color and that there are air bubbles behind the tympanic membrane. The child reports occasional hearing loss and a popping sound with swallowing. The preliminary analysis based on this information is that:

ANS: this is most likely a serous otitis media. An amber-yellow color to the tympanic membrane suggests serum or pus in the middle ear. Often air or fluid or bubbles behind the tympanic membrane are visible. The patient may have feelings of fullness, transient hearing loss, and a popping sound with swallowing. The other responses are not correct.

When examining the ear with an otoscope, the nurse notes that the tympanic membrane should appear:

ANS: pearly gray and slightly concave. The tympanic membrane is a translucent membrane with a pearly gray color and a prominent cone of light in the anteroinferior quadrant, which is the reflection of the otoscope light. The tympanic membrane is oval and slightly concave, pulled in at its center by the malleus, which is one of the middle ear ossicles.

The nurse is performing an ear examination of an 80-year-old patient. Which of these would be considered a normal finding?

ANS: A high-tone frequency loss A high-tone frequency hearing loss is apparent for those affected with presbycusis, the hearing loss that occurs with aging. The pinna loses elasticity, causing earlobes to be pendulous. The eardrum may be whiter in color and more opaque and duller than in the young adult.

An assessment of a 23-year-old patient reveals the following: an auricle that is tender and reddish-blue in color with small vesicles. Additional information the nurse would need to know includes which of these?

ANS: Any prolonged exposure to extreme cold Frostbite causes reddish-blue discoloration and swelling of the auricle after exposure to extreme cold. Vesicles or bullae may develop, and the person feels pain and tenderness.

In an individual with otitis externa, which of these signs would the nurse expect to find on assessment?

ANS: Enlarged superficial cervical nodes The lymphatic drainage of the external ear flows to the parotid, mastoid, and superficial cervical nodes. The signs are severe swelling of the canal, inflammation, and tenderness. Rhinorrhea, periorbital edema, and pain over the maxillary sinuses do not occur with otitis externa.

A 70-year-old patient tells the nurse that he has noticed that he is having trouble hearing, especially in large groups. He says he "can't always tell where the sound is coming from" and the words often sound "mixed up." What might the nurse suspect as the cause for this change?

ANS: Nerve degeneration in the inner ear Presbycusis is a type of hearing loss that occurs in 60% of those older than 65 years of age, even in people living in a quiet environment. It is a gradual sensorineural loss caused by nerve degeneration in the inner ear. Words sound garbled, and the ability to localize sound is impaired also. This communication dysfunction is accentuated when background noise is present.

A patient has been admitted after an accident at work. During the assessment, the patient is having trouble hearing and states, "I don't know what the matter is. All of a sudden, I can't hear you out of my left ear!" What should the nurse do next?

ANS: Notify the patient's health care provider. Any sudden loss of hearing in one or both ears, that is not associated with an upper respiratory infection, needs to be reported at once to the patient's health care provider. Hearing loss associated with trauma is often sudden. It is not appropriate to irrigate the ear or remove cerumen at this time.

The nurse is preparing to do an otoscopic examination on a 2-year-old child. Which of these reflects correct procedure?

ANS: Pull the pinna down. For an otoscopic examination, pull the pinna down on an infant and a child under 3 years of age. The other responses are not part of the correct procedure.

A patient in her first trimester of pregnancy is diagnosed with rubella. Which of these statements is correct regarding the significance of this in relation to the infant's hearing?

ANS: Rubella can damage the infant's organ of Corti, which will impair hearing. If maternal rubella infection occurs during the first trimester, then it can damage the organ of Corti and impair hearing

The nurse is preparing to perform an otoscopic examination of a newborn infant. Which statement is true regarding this examination?

ANS: The normal membrane may appear thick and opaque. During the first few days, the tympanic membrane often looks thickened and opaque. It may look "injected" and have a mild redness from increased vascularity. The other statements are not correct.

The mother of a 2-year-old is concerned about the upcoming placement of tympanostomy tubes in her son's ears. The nurse would include which of these statements in the teaching plan?

ANS: The purpose of the tubes is to decrease the pressure and allow for drainage. Polyethylene tubes are inserted surgically into the eardrum to relieve middle ear pressure and to promote drainage of chronic or recurrent middle ear infections. Tubes extrude spontaneously in 6 months to 1 year.

During an assessment of a 20-year-old Asian patient, the nurse notices that he has dry, flaky cerumen in his canal. What is the significance of this finding?

ANS: This is a normal finding and no further follow-up is necessary. Asians and Native Americans are more likely to have dry cerumen, whereas African Americans and Caucasians usually have wet cerumen.

A colleague is assessing an 80-year-old patient who has ear pain and asks him to hold his nose and swallow. The nurse knows that which of the following is true concerning this technique?

ANS: This should not be used in an 80-year-old patient. The eardrum is flat, slightly pulled in at the center, and flutters when the person performs the Valsalva maneuver or holds the nose and swallows (insufflation). One may elicit these maneuvers to assess drum mobility. However, these maneuvers should be avoided with an aging person because they may disrupt equilibrium.

While performing the otoscopic examination of a 3-year-old boy who has been pulling on his left ear, the nurse finds that his left tympanic membrane is bright red and that the light reflex is not visible. The nurse interprets these findings to indicate:

ANS: acute otitis media. Absent or distorted light reflex and a bright red color of the eardrum are indicative of acute otitis media. See Table 15-5 for descriptions of the other conditions.

The nurse needs to pull the portion of the ear that consists of movable cartilage and skin down and back when administering eardrops. This portion of the ear is called the:

ANS: auricle. The external ear is called the auricle or pinna and consists of movable cartilage and skin.

The nurse is performing a middle ear assessment on a 15-year-old patient who has a history of chronic ear infections. When examining the right tympanic membrane, the nurse sees the presence of dense white patches. The tympanic membrane is otherwise unremarkable. It is pearly, with the light reflex at 5 o'clock and landmarks visible. The nurse should:

ANS: know that these are scars caused from frequent ear infections. Dense white patches on the tympanic membrane are sequelae of repeated ear infections. They do not necessarily affect hearing.

During an examination, the nurse notices that the patient stumbles a bit while walking, and, when she sits down, she holds on to the sides of the chair. The patient states, "It feels like the room is spinning!" The nurse notices that the patient is experiencing:

ANS: objective vertigo. With objective vertigo, the patient feels like the room spins; with subjective vertigo, the person feels like he or she is spinning. Tinnitus is a sound that comes from within a person; it can be a ringing, crackling, or buzzing sound. It accompanies some hearing or ear disorders. Dizziness is not the same as true vertigo; the person who is dizzy may feel unsteady and lightheaded

A 31-year-old patient tells the nurse that he has noticed a progressive loss in his hearing. He says that it does seem to help when people speak louder or if he turns up the volume. The most likely cause of his hearing loss is:

ANS: otosclerosis. Otosclerosis is a common cause of conductive hearing loss in young adults between the ages of 20 and 40 years. Presbycusis is a type of hearing loss that occurs with aging. Trauma and frequent ear infections are not a likely cause of his hearing loss.

During an examination, the patient states he is hearing a buzzing sound and says that it is "driving me crazy!" The nurse recognizes that this symptom indicates:

ANS: tinnitus. Tinnitus is a sound that comes from within a person; it can be a ringing, crackling, or buzzing sound. It accompanies some hearing or ear disorders.

A 17-year-old student is a swimmer on her high school's swim team. She has had three bouts of otitis externa so far this season and wants to know what to do to prevent it. The nurse instructs her to:

ANS: use rubbing alcohol or 2% acetic acid eardrops after every swim. With otitis externa (swimmer's ear), swimming causes the external canal to become waterlogged and swell; skinfolds are set up for infection. Prevent by using rubbing alcohol or 2% acetic acid eardrops after every swim.