NCLEX - EAR DISORDERS
A nurse would question an order to irrigate the ear canal in which of the following circumstances? A Ear pain B Hearing loss C Otitis externa D Perforated tympanic membrane
D. Irrigation of the ear canal is contraindicated with perforation of the tympanic membrane because the solution entering the inner ear may cause dizziness, nausea, vomiting, and infection.
The nurse has notes that the physician has a diagnosis of presbycusis on the client's chart. The nurse plans care knowing the condition is: A sensorineural hearing loss that occurs with aging B A conductive hearing loss that occurs with aging. C Tinnitus that occurs with aging D Nystagmus that occurs with aging
A. Presbycusis is a type of hearing loss that occurs with aging. Presbycusis is a gradual sensorineural loss caused by nerve degeneration in the inner ear or auditory nerve.
Mang Isko, a 68-year-old widower, has been stricken with cataracts about year ago. Which assessment date would the nurse expect when collecting the nursing history from the client? A Blurred vision B Eye pain C Floaters D Eye redness
A. Cataracts lead to progressive worsening and blurring of vision. Eye pain and redness, common with glaucoma, are not present with cataracts. Floaters are characteristics of retinal detachment.
Aling Martha, a 73-year-old widow, tells to the nurse during the admission process that she was recently diagnosed with age-related hearing loss. Upon receiving such information, the nurse is correct if he suspects: A Ménière's disease B Otalgia C Otitis media D Presbycusis
D. The term presbycusis refers to sensorineural hearing impairment in elderly individuals.
The nurse is performing a voice test to assess hearing. Which of the following describes the accurate procedure for performing this test? A Stand 4 feet away from the client to ensure that the client can hear at this distance. B Whisper a statement and ask the client to repeat it. C Whisper a statement with the examiners back facing the client. D Whisper a statement while the client blocks both ears.
B The examiner stands 1-2 feet away from the client and asks the client to block one external ear canal. The nurse whispers a statement and asks the client to repeat it. Each ear is tested separately.
Nerve deafness would most likely result from an injury or infection that damaged the: A Vagus nerve B Cochlear nerve C Vestibular nerve D Trigeminal nerve
B. Because the organ of hearing is the organ of Corti, located in the cochlea, nerve deafness would most likely accompany damage to the cochlear nerve.
A client arrives at the emergency room with a foreign body in the left ear that has been determined to be an insect. Which intervention would the nurse anticipate to be prescribed initially? A Irrigation of the ear B Instillation of diluted alcohol C Instillation of antibiotic ear drops D Instillation of corticosteroids ear drops
B. Insects are killed before removal unless they can be coaxed out by a flashlight or a humming noise. Mineral oil or diluted alcohol is instilled into the ear to suffocate the insect, which then is removed by using forceps. When the foreign object is vegetable matter, irrigation is not used because this material expands with hydration and the impaction becomes worse.
A client with Meniere's disease is experiencing severe vertigo. Which instruction would the nurse give to the client to assist in controlling the vertigo? A Increase fluid intake to 3000 ml a day B Avoid sudden head movements C Lie still and watch the television D Increase sodium in the diet
B. The nurse instructs the client to make slow head movements to prevent worsening of the vertigo. Dietary changes such as salt and fluid restrictions that reduce the amount of endolymphatic fluid sometimes are prescribed. Lying still and watching television will not control vertigo.
Otosclerosis is a common cause of conductive hearing loss. Which such a partial hearing loss: A Stapedectomy is the procedure of choice B Hearing aids usually restore some hearing C The client is usually unable to hear bass tones D Air conduction is more effective than bone conduction
B. With a partial hearing loss that auditory ossicles have not yet become fixed; as long as vibrations occur, a hearing aid may be beneficial.
A client who is complaining of tinnitus is describing a symptom that is: A Objective B Subjective C Functional D Prodromal
B. A subjective symptom such as ringing in the ears can be felt only by the client.
The part of the ear that contains the receptors for hearing is the: A Utricle B Cochlea C Middle ear D Tympanic cavity
B. The dendrites of the cochlear nerve terminate on the hair cells of the organ of Corti in the cochlea.
For a client diagnosed with epistaxis, which intervention would be included in the care plan? A Performing several abdominal thrust (Heimlich) maneuvers B Compressing the nares to the septum for 5 to 10 minutes C Applying an ice collar to the neck area D Encouraging warm saline throat gargles
B. When a client experiences epistaxis, the nurse should compress the soft outer portion of the nares against the septum for approximately 5 to 10 minutes. the client should sit upright, breathe through the mouth, and refrain from talking. Performing abdominal thrusts is appropriate for the client with a foreign-body aspiration. Applying an ice collar to the neck is commonly done for a client after a tonsillectomy. Warm saline throat gargles are appropriate for the client with pharyngitis.
During a hearing assessment, the nurse notes that the sound lateralizes to the clients left ear with the Weber test. The nurse analyzes this result as: A A normal finding B A conductive hearing loss in the right ear C A sensorineural or conductive loss D The presence of nystagmus
C. In the Weber tuning fork test the nurse places the vibrating tuning fork in the middle of the client's head, at the midline of the forehead, or above the upper lip over the teeth. Normally, the sound is heard in equally in both ears by bone conduction. If the client has a sensorineural hearing loss in one ear, the sound is heard in the other ear. If the client has a conductive hearing loss in one ear, the sound is heard in that ear.
The nurse has conducted discharge teaching for a client who had a fenestration procedure for the treatment of otosclerosis. Which of the following, if stated by the client, would indicate that teaching was effective? A "I should drink liquids through a straw for the next 2-3 weeks." B "It's ok to take a shower and wash my hair." C "I will take stool softeners as prescribed by my doctor." D "I can resume my tennis lessons starting next week."
C. Following ear surgery, the client needs to avoid straining while having a bowel movement. The client needs to be instructed to avoid drinking through a straw for 2-3 weeks, air travel, and coughing excessively. The client needs to avoid getting his or her hair wet, washing hair, showering for 1 week, and rapidly moving the head, bouncing, and bending over for 3 weeks.
The ear bones that transmit vibrations to the oval window of the cochlea are found in the: A Inner ear B Outer ear C Middle ear D Eustachian tube
C. The bones in the middle ear transmit and amplify air pressure waves from the tympanic membrane to the oval window of the cochlea, which is the inner ear. The tympanic membrane separates the other from the middle ear.
Physiologically, the middle ear, containing the three ossicles, serves primarily to: A Maintain balance B Translate sound waves into nerve impulses C Amplify the energy of sound waves entering the ear D Communicate with the throat via the Eustachian tube.
C. The middle ear contains the three ossicles—malleus, incus, and stapes—which, along with the tympanic membrane and oval window, form an amplifying system.
A client is diagnosed with a disorder involving the inner ear. Which of the following is the most common client complaint associated with a disorder in this part of the ear? A Hearing loss B Pruritus C Tinnitus D Burning of the ear
C. Tinnitus is the most common complaint of clients with otological disorders, especially disorders involving the inner ear. Symptoms of tinnitus range from mild ringing in the ear, which can go unnoticed during the day, to a loud roaring in the ear, which can interfere with the client's thinking process and attention span.
Chad, a 5-year-old preschooler, is brought to the clinic due to an ear problem. Which assessment data would cause the nurse to suspect serous otitis media? A Bright red, bulging or retracted tympanic membrane and fever. B Inflammation of the external ear and crust formation on the auditory canal C Sensorineural hearing loss and complaints of tinnitus D Plugged feeling in the ear and reverberation of the client's own voice.
D. Serous otitis media is manifested by a plugged feeling in the ear, reverberation of the client's own voice, and hearing loss. A bright red, bulging or retracted tympanic membrane and fever suggest suppurative otitis media. Inflammation of the external ear and crust formation on the auditory canal suggest external otitis media. Sensorineural hearing loss and tinnitus indicate otosclerosis.
The nurse is caring for a client that is hearing impaired. Which of the following approaches will facilitate communication? A Speak frequently B Speak loudly C Speak directly into the impaired ear D Speak in a normal tone
D. Speaking in a normal tone to the client with impaired hearing and not shouting are important. The nurse should talk directly to the client while facing the client and speak clearly. If the client does not seem to understand what is said, the nurse should express it differently. Moving closer to the client and toward the better ear may facilitate communication, but the nurse should avoid talking directly into the impaired ear.
