Health Assessment Perp U: Chapter 17- Assessment of the Ears

Which finding should a nurse recognize as normal when assessing the ears of an elderly client? A. Bulging tympanic membrane B. High-tone frequency loss C. Shortened earlobes D. Decrease in cerumen production

B. High-tone frequency loss

The client is having a Weber test. During a Weber test, where should the tuning fork be placed? A. On the mastoid process behind the ear. B. In the midline of the client's skull or in the center of the forehead. C. Near the external meatus of each ear. D. Under the bridge of the nose.

B. In the midline of the client's skull or in the center of the forehead.

Which of the following tests use a tuning fork between two positions to assess hearing? A. Weber's B. Rinne C. Whisper D. Watch tick

B. Rinne

Which of the following is a symptom related to vertigo? A. Syncope B. Spinning sensation C. Fainting D. Loss of consciousness

B. Spinning sensation

A client admitted to the health care facility is diagnosed with vertigo. Which test is appropriate for the nurse to perform to assess for equilibrium in the client? A. Rinne B. Whisper C. Romberg D. Weber

C. Romberg

Which of the following describes a condition characterized by abnormal spongy bone formation around the stapes? A. Chronic otitis media B. Middle ear infection C. Otitis externa D. Otosclerosis

D. Otosclerosis

A client visits a community clinic reporting severe allergies causing a "crackling sensation" in the ear. The physician diagnoses serous otitis media. Which of the following is a characteristic of this condition? A. Fluid collects in the middle ear causing an obstruction of the auditory tube. B. This condition develops if acute purulent otitis media is not treated promptly. C. An upper respiratory infection spreads through the auditory tube. D. This condition is usually associated with a puncture eardrum.

A. Fluid collects in the middle ear causing an obstruction of the auditory tube.

A client has been receiving intravenous antibiotics for several weeks. Which prevention strategy would be best for the nurse to recommend for this client? A. Formal hearing test B. Whisper hearing test C. Tuning fork test D. Rubbing fingers test

A. Formal hearing test

The nurse assesses a client with a bump covered in white patches on the ear lobe. What should the nurse suspect is occurring with this client? A. Gout B. Normal finding C. Buildup of cerumen D. Precancerous lesion

A. Gout

When teaching a class of school-age children about hygiene, the nurse should include which information about the ears? A. Never put anything smaller than your elbow in your ears. B. Ears should be cleaned with cotton applicators once a day at bedtime. C. Only allow your parents clean out your ears with cotton applicators. D. Producing less earwax can lead to a hearing loss.

A. Never put anything smaller than your elbow in your ears.

A client has been diagnosed with conductive hearing loss. The nurse understands that which of the following could be the cause of this type of hearing loss? A. Perforated eardrum B. Injury to the organ of Corti C. Damage to cranial nerve VIII D. Dysfunction of the temporal lobe of the brain

A. Perforated eardrum

During a physical examination the nurse places the turning fork behind the ear. What assessment is the nurse performing? A. Rinne test B. Vestibular function C. Auditory acuity D. Weber test

A. Rinne test

As a part of the ear examination for hearing loss, a nurse conducts a Weber test on a client. To accurately perform this test, the nurse should place the base of the tuning fork in which of the following locations? A. Behind the external auditory canal B. At the center of the client's forehead C. In front of the external auditory canal D. On the client's mastoid process

B. At the center of the client's forehead

In examining a client's external auditory canal with an otoscope, the nurse discovers impacted ear wax, known as cerumen. Which of the following is characteristic of cerumen? Select all that apply. A. Has bacteriostatic properties B. Serves as a defense against foreign bodies C. Has a sticky consistency D. Has a translucent, pearly gray appearance E. Serves as a partition stretched across the inner end of the auditory canal F. Keeps the tympanic membrane soft

A. Has bacteriostatic properties B. Serves as a defense against foreign bodies C. Has a sticky consistency F. Keeps the tympanic membrane soft

The eustachian tube is a passage between the middle ear and the nasopharynx. What is the function of the eustachian tube? A. Helps to regulate pressure in the middle ear B. Protects the middle ear C. Allows for drainage of fluid from the middle ear D. Maintains fluid in the middle ear

A. Helps to regulate pressure in the middle ear

The client is having a Weber test. During a Weber test, where should the tuning fork be placed? A. In the midline of the client's skull or in the center of the forehead. B. On the mastoid process behind the ear. C. Under the bridge of the nose. D. Near the external meatus of each ear.

A. In the midline of the client's skull or in the center of the forehead.

A client presents with otalgia and yellow-green discharge from the external ear canal. Which question should the nurse ask to determine the cause of this problem? A. "Have you had any recent trauma to the inside of your ear?" B. "Do you hear ringing in your ears?" C. "Are their times when you feel dizzy?" D. "Have you ever taken medication that is ototoxic?"

A. "Have you had any recent trauma to the inside of your ear?"

A client reports the onset of tinnitus. What question should the nurse ask the client to further assess this condition? A. "Have you taken any antibiotics in the past few weeks?" B. "Are you having trouble hearing the phone ring?" C. "Did you experience a lot of ear infections as a child?" D. "Do you clean your ears with cotton-tipped applicators?"

A. "Have you taken any antibiotics in the past few weeks?"

What components of sound does the cochlea interpret? (Select all that apply.) A. Amplitude B. Frequency C. Decibel D. Direction E. Tone

A. Amplitude B. Frequency

Upon inspection of an elderly client's ears using an otoscope, the nurse observes a cloudy appearance to the tympanic membranes with prominent landmarks. What action should the nurse perform first? A. Ask whether the client is experiencing ear pain or pressure B. Assess for balance using the Romberg test C. Perform hearing test to assess for conductive hearing loss D. Document these findings as normal changes in the older adult

A. Ask whether the client is experiencing ear pain or pressure

An alternate pathway that bypasses the external and middle ear is called what? A. Neuro conduction B. Bone conduction C. Air conduction D. Sensory conduction

B. Bone conduction

When providing client education on hearing, the nurse should remind clients to utilize ear plugs when they are what? (Select all that apply.) A. At concerts B. At train stations C. Working with children D. Cleaning their homes E. Using lawnmowers

A. At concerts B. At train stations E. Using lawnmowers

A client is diagnosed with otosclerosis, a condition in which the auditory ossicles develop a spongy consistency, which results in conductive hearing loss. It appears that the worst site is the inner most bone, which transmits sound waves through the oval window. Which bone is this? A. Umbo B. Incus C. Stapes D. Malleus

C. Stapes

During a pharmacology class the students are told that some drugs need to be closely monitored. What aspect should the nurse closely monitor for in clients who have been administered salicylates, loop diuretics, quinidine, quinine, or aminoglycosides? A. Reduced urinary output B. Signs of hypotension C. Tinnitus and sensorineural hearing loss D. Impaired facial movement

C. Tinnitus and sensorineural hearing loss

When assessing the client's risk for hearing loss, it is important to ask about the history of exposure to noise. What related client teaching would be important? (Select all that apply.) A. Types of noise to avoid B. Length of time to limit protective equipment C. Types of protective equipment used D. Effectiveness of protective equipment E. Instructions for the use of protective ear equipment

C. Types of protective equipment used D. Effectiveness of protective equipment E. Instructions for the use of protective ear equipment

A nurse performs an initial examination of a client brought to the emergency department after sustaining a head injury in an automobile accident. Which characteristic of discharge from the ears should alert the nurse that the client has a cerebrospinal fluid leak? A. Sticky or yellow B. Brown & odorless C. Watery or bloody D. Bloody & purulent

C. Watery or bloody

A nurse performs a hearing test on an elderly client. Which result should the nurse recognize as an indication that presbycusis is present? An inability to hear: A. the calling bell B. the tuning fork C. whispered sounds D. the sound of "th"

C. whispered sounds

You are a pediatric nurse caring for a child who has been brought to the clinic with otitis externa. What assessment finding is characteristic of otitis externa? A. Dark yellow cerumen in the external auditory canal B. Tophi on the pinna and ear lobe C. Air bubbles visible in the middle ear D. Pain on manipulation of the auricle

D. Pain on manipulation of the auricle

You are teaching a class on diseases of the ear. What would you teach the class is the most characteristic symptom of otosclerosis? A. The client being distressed in the mornings B. A red and swollen ear drum C. The client describing a history of having had a recent upper respiratory infection. D. A progressive, bilateral loss of hearing

D. A progressive, bilateral loss of hearing

An adult farm worker presents at the ED after falling out of a hay loft. The client states falling approximately 4 hours ago and did not lose consciousness. The client is experiencing only a mild headache. When asked why the client came to the ED, the client states that he had a clear discharge from the right ear ever since the accident. What should this finding indicate to the nurse? A. Possible otitis media B. Possible mass in the ear C. Possible otitis externa D. Possible basilar skull fracture

D. Possible basilar skull fracture

What action should the nurse implement using an otoscope when assessing the ear of an adult client? A. Insert the speculum gently down and backward B. Choose the smallest speculum for client comfort C. Hold the speculum in the nondominant hand D. Pull the auricle out, up, and back

D. Pull the auricle out, up, and back

The transmission of sound waves through the external ear and the middle ear is known as A. connective hearing. B. external hearing. C. perceptive hearing. D. conductive hearing.

D. conductive hearing.

A mother asks why her school-age child develops so many ear infections after having a head cold. When explaining the process, which structure on the diagram should the nurse identify that connects the throat to the ear?

Eustachian Tube (red small sac)

The nurse is assessing the hearing of an older adult. Which type of hearing problem might the nurse expect to find in the older adult?

Presbycusis

Which characteristic feature of the tympanic membrane should a nurse anticipate finding in a client with acute otitis media? A. Yellowish, bulging, with fluid bubbles B. Pearly, translucent, with no bulging C. Red, bulging, with an absent light reflex D. Gray, translucent, with no retraction

C. Red, bulging, with an absent light reflex

After conducting a health history, the nurse decides to perform the assessment where you place the turning fork on the top medial portion of ones head. What finding did the nurse use to make this clinical determination? A. Rigid tympanic membrane B. Edematous neck lymph nodes C. Reduced hearing in one ear D. Sore throat

C. Reduced hearing in one ear

The nurse has performed the Rinne test on an older adult client. After the test, the client reports that her bone conduction sound was heard longer than the air conduction sound. The nurse determines that the client is most likely experiencing A. central hearing loss. B. sensorineural hearing loss. C. conductive hearing loss. D. normal hearing.

C. conductive hearing loss.

A nurse is interviewing a client as part of a routine examination of his ears and hearing. The nurse notes that this client has high blood pressure. Which of the following questions regarding his hearing should the nurse ask that is associated with his high blood pressure? A. "Do you experience any ringing, roaring, or crackling in your ears?" B. "Do you have any ear drainage?" C. "Do you have any ear pain?" D. "Are you ever concerned that you may be losing your ability to hear well?"

A. "Do you experience any ringing, roaring, or crackling in your ears?"

Which question asked by the nurse is assessing problems with tinnitus? A. "Do you experience buzzing in your ears?" B. "Have you ever had drainage from your ears?" C. "In what situations is it hard for you to hear?" D. "Do you ever have problems with balance?"

A. "Do you experience buzzing in your ears?"

A 61-year-old man has visited the clinic at the prompting of his wife, who states that his hearing is becoming less acute. Which of the following assessment questions is most useful in determining whether the man's hearing loss is sensorineural or conductive? A. "Do you find that you have particular difficulty understanding people's speech?" B. "Have you noticed changes in any of your other senses?" C. "Have you noticed any change in your balance lately?" D. "Do you find it easier to discern low-pitched sounds?"

A. "Do you find that you have particular difficulty understanding people's speech?"

A nurse practitioner is assessing a client in the ED following a motor vehicle accident. The client complains of ear pain. The nurse practitioner is performing an otoscopic examination. What would demonstrate the correct technique for using the otoscope? A. Rotating the otoscope slightly B. Holding the client's ear at the helix C. Holding the otoscope so that the thumb is by the window D. Pulling the client's ear down and back E. Visualizing portions of the stapes

A. Rotating the otoscope slightly B. Holding the client's ear at the helix C. Holding the otoscope so that the thumb is by the window

Which action by the nurse is consistent with Weber's test? A. The nurse activates the tuning fork and places it on the midline of the parietal bone in line with both ears. B. The nurse strikes the tuning fork and places it on the client's mastoid process to measure bone conduction. C. The nurse uses a bulb insufflator attached to an otoscope to observe movement of the tympanic membrane. D. The nurse shields their mouth and whispers a simple sentence approximately 18 inches from the client's ear.

A. The nurse activates the tuning fork and places it on the midline of the parietal bone in line with both ears.

Which action by the nurse is consistent with the Rinne test? A. The nurse strikes the tuning fork and places it on the client's mastoid process to measure bone conduction. B. The nurse uses a bulb insufflator attached to an otoscope to observe movement of the tympanic membrane. C. The nurse shields their mouth and whispers a simple sentence approximately 18 inches from the client's ear. D. The nurse activates the tuning fork and places it on the midline of the parietal bone in line with both ears.

A. The nurse strikes the tuning fork and places it on the client's mastoid process to measure bone conduction.

A 52-year-old client fails the Romberg test. The nurse explains that this might indicate a dysfunction in what part of the ear? A. The vestibular portion of the inner ear B. The bones of the middle ear C. The eustachian tubes D. The pinna

A. The vestibular portion of the inner ear

Which portion of the middle ear equalizes pressure? A. Tympanic membrane B. Ossicles C. Auricle D. Cochlea

A. Tympanic membrane

In performing an otoscopic examination of a client's tympanic membrane, the nurse observes through the membrane the tip of a landmark at the center of the membrane. Which of the following landmarks is this? A. Umbo B. Pars tensa C. Handle and short process of the malleus D. Pars flaccida

A. Umbo

The nurse assessing for unilateral hearing loss by using a tuning fork. What test is the nurse performing? A. Weber's test B. Watch tick test C. Rinne test D. Whisper test

A. Weber's test

After examining the client's tympanic membranes, the nurse documents "Right tympanic membrane, red and bulging with no light reflex." The nurse recognizes that these are signs of A. acute otitis media. B. serous otitis media. C. skull trauma. D. trauma from infection.

A. acute otitis media.

A nurse is inspecting the ears of an Asian client and observes that her earlobes appear soldered, or tightly attached to adjacent skin with no apparent lobe. Which of the following should the nurse do next? A. Ask the client whether she has ever experienced an injury involving her ears B. Continue with the examination C. Record the finding and plan to follow-up at the client's next visit to note any changes D. Notify the physician of the finding

B. Continue with the examination

A nurse is admitting a client to the hospital. When reviewing the client's medical record, the nurse notes that this client had abnormal findings during the Weber test. What would the nurse know this means? A. The client has loss of high-frequency sounds B. The client has unilateral hearing loss C. The client has loss of low-frequency sounds D. The client has bilateral hearing loss

B. The client has unilateral hearing loss

Which action by the nurse is consistent with the Rinne test? A. The nurse activates the tuning fork and places it on the midline of the parietal bone in line with both ears. B. The nurse strikes the tuning fork and places it on the client's mastoid process to measure bone conduction. C. The nurse shields their mouth and whispers a simple sentence approximately 18 inches from the client's ear. D. The nurse uses a bulb insufflator attached to an otoscope to observe movement of the tympanic membrane.

B. The nurse strikes the tuning fork and places it on the client's mastoid process to measure bone conduction.

Which of the following findings from the health history of a 70-year-old woman with tinnitus is likely most significant to her diagnosis? A. The woman was diagnosed with oral cancer 12 years prior, which responded well to treatment. B. The woman takes aspirin 4 times daily to treat her rheumatoid arthritis. C. The woman takes a beta-blocker to treat hypertension. D. The woman has experienced transient ischemic attacks in recent years.

B. The woman takes aspirin 4 times daily to treat her rheumatoid arthritis.

A client diagnosed with arthritis has been taking aspirin and now reports experiencing adverse effects. What adverse effect indicates that a decrease in dose may be necessary? A. Nystagmus B. Tinnitus C. Vertigo D. Otalgia

B. Tinnitus

When planning care for a client with an inner ear infection, the nurse will need to include interventions for which of the following potential problems? A. Fever B. Vertigo C. Rhinorrhea D. Headache

B. Vertigo

The nurse is planning to perform an ear examination on an adult client. After explaining the procedures to the client, the nurse should A. ask the client to remove his contact lenses. B. observe the client's response to the explanations. C. ask the client to remain standing. D. show the client the otoscope.

B. observe the client's response to the explanations.

Upon examination, the Advanced Practice Nurse finds that a client has otitis media with effusion. What assessment finding is most clearly indicative of this diagnosis? A. A gray tympanic membrane B. Inflammation in the ear canal C. A diffuse cone of light D. A perforated tympanic membrane

C. A diffuse cone of light

The nurse notes a tophus of the ear of an older adult. Which assessment data is consistent with a tophus? A. A sac with a membranous lining filled with fluid B. Redness and bulging of the eardrum C. A hard nodule composed of uric acid crystals D. Scarring of the tympanic membrane

C. A hard nodule composed of uric acid crystals

A client has Darwin tubercle. What is this? A. A growth in the bony labyrinth B. A growth in the ear canal C. A small painless nodule on the helix D. A type of skin cancer found on the ear

C. A small painless nodule on the helix

A 55-year-old male client has just been diagnosed with presbycusis. In the interview with the client, the nurse should most expect the client to complain of having trouble hearing which of the following in the initial stages of this condition? A. The sound of his car engine starting B. The bass speakers of his stereo system C. A story his wife is telling him D. His son giving him directions to a restaurant

C. A story his wife is telling him

As a part of the ear examination for hearing loss, a nurse conducts a Weber test on a client. To accurately perform this test, the nurse should place the base of the tuning fork in which of the following locations? A. On the client's mastoid process B. In front of the external auditory canal C. At the center of the client's forehead D. Behind the external auditory canal

C. At the center of the client's forehead

A client exhibits purulent drainage in the right external ear canal. The client complains of pain that increases when the ear is touched. Which client teaching instructions should the nurse provide? A. Take over the counter common cold remedies to resolve the problem. B. Permanent deafness is common with this condition. C. Finish the entire course of antibiotic therapy. D. Tympanostomy tubes will usually fall out on their own over time.

C. Finish the entire course of antibiotic therapy.

A six-month old male infant is brought to the emergency department by his parents for inconsolable crying and pulling at his right ear. When assessing this infant the nurse is aware that the tympanic membrane should be what color in a healthy ear? A. Bluish-white B. Yellowish-white C. Gray D. Red

C. Gray

When inspecting the tympanic membrane, which of the following structures does the nurse expect to identify? A. Pars tensa, pars flaccida, vestibule, cone of light B. Pars tensa, umbo, handle of malleus, ossicles C. Handle of malleus, short process of malleus, cone of light D. Cone of light, incus, umbo, cochlea

C. Handle of malleus, short process of malleus, cone of light

The nurse is planning to conduct the Weber test on an adult male client. To perform this test, the nurse should plan to A. ask the client to close his eyes while standing with feet together. B. whisper a word with two distinct syllables to the client. C. strike a tuning fork and place it on the center of the client's head or forehead. D. strike a tuning fork and place it at the base of the client's mastoid process.

C. strike a tuning fork and place it on the center of the client's head or forehead.

The client asks the nurse why the nurse put the tuning fork on the bone behind the ear. Which is the best response by the nurse? A. "It determines hearing loss caused by degeneration of nerves in your inner ear." B. "It can determine if you have a problem with repeated ear infections." C. "It can identify if you have an inner ear problem causing disequilibrium." D. "It identifies a problem with the normal pathways for sound to travel to your inner ear."

D. "It identifies a problem with the normal pathways for sound to travel to your inner ear."

A client presents with otalgia and yellow-green discharge from the external ear canal. Which question should the nurse ask to determine the cause of this problem? A. "Are their times when you feel dizzy?" B. "Do you hear ringing in your ears?" C. "Have you ever taken medication that is ototoxic?" D. "Have you had any recent trauma to the inside of your ear?"

D. "Have you had any recent trauma to the inside of your ear?"

A client calls the clinic and tells the nurse that the doctor told her that she has "otalgia." The client cannot remember what the doctor explained this to be. How would the nurse most appropriately respond? A. "Otalgia is the beginning of hearing loss." B. "Otalgia is discoloration of the ear." C. "Otalgia is a disease of the inner ear." D. "Otalgia is pain in the ear."

D. "Otalgia is pain in the ear."

A mother of a small child calls the clinic and asks to schedule an appointment for ear tube removal. The call is transferred to the nurse. What is the nurse's best action? A. Schedule appointment at hospital for tubes to be removed surgically. B. Schedule first available office appointment. C. Ask healthcare provider about prescribing antibiotics before removal. D. Ask the mother how long the tubes have been in place.

D. Ask the mother how long the tubes have been in place.

A nurse is educating a client about the function of the parts of the auditory system. Which is the function of the eustachian tube? A. Separates the external from the middle ear. B. Transmits vibration to the fluid filled inner ear at the oval window. C. Sends sensory information to the cerebellum and midbrain. D. Equalizes the pressure in the middle ear with atmospheric pressure.

D. Equalizes the pressure in the middle ear with atmospheric pressure.

A client visits a community clinic reporting severe allergies causing a "crackling sensation" in the ear. The physician diagnoses serous otitis media. Which of the following is a characteristic of this condition? A. This condition is usually associated with a puncture eardrum. B. An upper respiratory infection spreads through the auditory tube. C. This condition develops if acute purulent otitis media is not treated promptly. D. Fluid collects in the middle ear causing an obstruction of the auditory tube.

D. Fluid collects in the middle ear causing an obstruction of the auditory tube.

A client has been receiving intravenous antibiotics for several weeks. Which prevention strategy would be best for the nurse to recommend for this client? A. Whisper hearing test B. Tuning fork test C. Rubbing fingers test D.Formal hearing test

D. Formal hearing test

The nurse is documenting an objective assessment of the client's ears. Which of the following would be the most appropriate documentation? A. Hearing intact on right and left with Rinne test B. No decrease in hearing evident on Weber test C. Client states experiencing no decrease in hearing D. Hearing intact bilaterally on whisper test

D. Hearing intact bilaterally on whisper test

A 55-year-old male presents to the health care clinic with reports of decreased hearing over the past year. Which subjective data in the client's review of systems should the nurse recognize as risk factors for hearing loss? Select all that apply. A. Use of antihypertensive medication B. Uses ear plugs at work because of the loud noises C. Drinks six cups of coffee daily D. History of measles at 3 years of age E. Chronic ear infections as a child F. Wax blocking the ear canal

D. History of measles at 3 years of age E. Chronic ear infections as a child F. Wax blocking the ear canal

The nurse palpates a client's auricles and notes an enlarged lymph node on one ear. No redness is observed, and the client denies pain or tenderness. What is the nurse's best action? A. Refer the client to an audiologist for an audiogram. B. Inform the client of the need for ear drops. C. Document the finding as an isolated benign node. D. Notify the healthcare provider about the finding.

D. Notify the healthcare provider about the finding.