SENSORY-NCLEX

The nurse is assisting the primary health care provider in performing a caloric test on a client. Following instillation of cool water into the ear, the nurse observes the presence of nystagmus. The nurse should document the findings of this test as indicative of which result? 1. normal 2. positive 3. abnormal 4. inconclusive

1. normal

A client is experiencing blockage of the eustachian tubes. The nurse teaches the client that which activities by the client may forcibly open the eustachian tube? 1. performing the valsalva maneuver 2. tapping the side of the head lightly 3. using a cotton-tipped applicators in the ear 4. chewing food using exaggerated mouth movements

1. performing the valsalva maneuver

A client who frequently experiences hearing loss due to build up cerumen in the ears asks the nurse about ways to deal with the problem including irrigating the ears. Which information is correct for the nurse to include in the teaching plan?SELECT ALL THAT APPLY 1. decrease ear cerumen by avoiding foods high in sodium cintent 2. irrigate the ear canal with lukewarm tap water around 98 degrees 3. after a warm shower, cleanse ears canals gently with a cotton swab 4. the ear irrigation should be stopped if the client becomes dizzy nauseous 5. use an ear syringe ti direct the flow of water straight into the ear during the irrigation 6. instill drops of mineral oil and hydrogen peroxide for several days to soften dried cerumen before irrigation

2. irrigate the ear canal with lukewarm tap water around 98 degrees 4. the ear irrigation should be stopped if the client becomes dizzy nauseous 6. instill drops of mineral oil and hydrogen peroxide for several days to soften dried cerumen before irrigation

The nurse is assigned to care for a client hospitalized with Meniers's disease. The nurse expects that which would MOST LIKELY be prescribed for the client? 1. low-fat diet 2. low-sodium diet 3. low-cholesterol diet 4. low-carbohydrate diet

2. low-sodium diet

The nurse is caring for a client with acute otitis media. The nurse plans care knowing which treatment for this problem is likely to be included? 1. bed rest 2. myringotomy 3. mastoidectomy 4. diphenhydramine

2. myringotomy

The nurse is assisting a primary health care provider in performing a caloric test on a client. Following instillation of warm water into the ear, the nurse notes that nystagmus does not occur. The nurse should document the findings of this test as indicative of which result? 1. normal 2. positive 3. inconclusive 4. requiring a repeat test

2. positive

The nursing student is developing information for use in a clinical conference about hearing disorders. In the presentation, the student plans to include the statement that the ear is housed in which bones of the skull? 1. frontal 2. parietal 3. temporal 4. occipital

3. temporal

Which instruction is appropriate for the nurse to provide to a client who reports via telephone that he is certain an insect has flown into his ear because he can hear it " buzzing" 1. probe the ear with blunted tweezers 2. instill antibiotic eardrops if they are available 3. use a flashlight to coax the insect out of the ear 4. get into the shower and allow the water to run into the ear

3. use a flashlight to coax the insect out of the ear

A client has had same day surgery to insert a ventilating tube in the tympanic membrane. The nurse reinforces to the client to be sure to perform which action until the postoperative assessment by the primary health care provider? 1. avoid taking any medication for pain except aspirin 2. go swimming as long as the head is kept above water 3. use a shower cap to protect the ears if taking a shower 4. wash the hair 2 minutes or less to avoid water buildup in the ears

3. use a shower cap to protect the ears if taking a shower

A client with a diagnosis of otosclerosis is admitted ti the ambulatory care unit for stapedectomy, and the nurse reinforces instructions to the client regarding home care following the procedure. Which statement by the client indicates a need for FURTHER teaching? 1. I need to avoid air travel for at least 6 months 2. I need to keep water out of my ear canal for at least 3 weeks 3. I need to avoid bending and lifting heavy objects for a least 3 weeks 4. I need to notify the primary health care provider if I experience any persistent dizziness

1. I need to avoid air travel for at least 6 months

A caloric test is prescribed for a client suspected of having a disease of the labyrinth. The nurse obtains which essential item in preparation for this test? 1. an otoscope 2. a tongue blade 3. an emesis basin 4. an ophthalmoscope

1. an otoscope

The nurse is reviewing the record of a client with mastoiditis. The nurse should expect to note which signs and symptoms? SELECT ALL THAT APPLY 1. headache 2. swelling directly behind the ear 3. decreased white blood cell count 4. thin serous drainage from the ear 5. red and immobile tympanic membrane

1. headache 2. swelling directly behind the ear 5. red and immobile tympanic membrane

Which medications cause ototoxicity? SELECT ALL THAT APPLY 1. ibuprofen 2. metoprolol 3. furosemide 4. vancomycin 5. acetaminophen

1. ibuprofen 3. furosemide 4. vancomycin

A client has sought treatment in the ambulatory care clinic after an insect has become trapped in the external ear canal. The nurse prepares to assist the primary health care provider to instill which acceptable solutions into the ear to remove the insect? 1. lidocaine 2. mineral oil 3. ether solution 4. tepid tap water 5. warm, sterile water

1. lidocaine 2. mineral oil 3. ether solution

A nursing instructor asks a student about cochlear implants. The student understands that which clients are candidates for such a procedure? SELECT ALL THAT APPLY 1. a client who becomes deaf before learning to speak 2. a client who has a profound hearing loss in both ears 3. a client whose hearing loss is a result of a congenital defect 4. a client who has received no benefit from the conventional hearing 5. a client who experienced hearing loss because of a systemic infection as a child

2. a client who has a profound hearing loss in both ears 4. a client who has received no benefit from the conventional hearing

The nurse is reviewing the medication list for an assigned client. Which medication is the only one on the client's prescription sheet that does not have an ototoxic effect? 1. furosemide 2. acetaminophen 3. acetylsalicylic acid 4.vancomycin hydrochloride

2. acetaminophen

Which actions should be performed when communicating with a client with presbycusis? SELECT ALL THAT APPLY 1. speak in a very loud voice 2. speak slowly and distinctly 3. face client when speaking 4. sit with a strong light behind you 5. use short sentences and phrases 6. write out the complete conversation

2. speak slowly and distinctly 3. face client when speaking 5. use short sentences and phrases

A perforated eardrum is suspected in a client who was hit in the ear with a basketball. A tympanoplasty was performed. The nurse is giving the client discharge instructions. Which client statement indicates a need for FURTHER teaching? 1. I will cough or sneeze with my mouth open 2. I won't be able to fly to attend a wedding next week 3. I will keep my ear dry for the next 4 to 6 weeks't 4. I will drink from a plastic bottle mouth since I can't use drinking straws

4. I will drink from a plastic bottle mouth since I can't use drinking straws

The nurse notes that the primary health care provider has documented a diagnosis of presbycusis on the client's chart. Which explanation should the nurse give to the client to explain this condition? 1. tinnitus that occurs with aging 2. nystamus that occurs with aging 3. a conductive hearing loss that occurs with aging 4. a sensorineural hearing loss that occurs with aging

4. a sensorineural hearing loss that occurs with aging

A myringotomy is performed on a client in the ambulatory care center. The ambulatory care nurse calls the client 24 hours after the procedure to evaluate the status of the client. The client reports to the nurse that a small amount of brownish drainage has been coming from the ear. Which instruction should the nurse provide to the client? 1. contact the primary health care provider 2. place a cotton plug in the ear ti absorb the drainage 3. lie on the unaffected side to prevent the drainage from occurring 4. continue to monitor the drainage because this is normal and may occur for 24-48 hours following the surgery

4. continue to monitor the drainage because this is normal and may occur for 24-48 hours following the surgery

A client arrives to the ER with a foreign body in the left ear that has been determined to be an insect. Which INITIAL intervention should the nurse anticipate to be prescribed? 1. irrigation of the ear 2. instillation of antibiotic eardrops 3. instillation of cortiocosteroid ointment 4. instillation of mineral oil or diluted alcohol

4. instillation of mineral oil or diluted alcohol

The nurse is reviewing the health care record of a client with a diagnosis of otoscelerosis. Which signs and symptoms should the nurse note?SELECT ALL THAT APPLY 1. tinnitus 2. rapid hearing loss 3. raises own voice when speaking 4. difficulty hearing voices of others 5. bone conduction better than air conduction

1. tinnitus 4. difficulty hearing voices of others 5. bone conduction better than air conduction

The nurse assists with preparing the client for ear irrigation as prescribed by the primary health care provider. What action should the nurse plan to take? 1. warm the irrigation solution to 98 degrees 2. position the client with the affected side up after the irrigation 3. direct a slow, steady stream of irrigation solution toward the eardrum 4. assist the client with turning his or her head so that the ear to be irrigated is facing upward

1. warm the irrigation solution to 98 degrees

The nurse is reinforcing discharge instructions with a client who is being discharged following a fenestration procedure for the treatment of ostosclerosis. Which should be included on the list of instructions prepared for this client? 1. you need to avoid air travel 2. it is all right to take a shower daily 3. it is all right to begin your golf lessons 4. you need to avoid bending activities for 1 week

1. you need to avoid air travel

The nurse administers meclizine hydrochloride to a client diagnosed with an attack of Meniere's disease. Which observation demonstrate to the nurse that the medication is effective? SELECT ALL THAT APPLY 1. control seizures 2. decrease in nausea 3. decrease in vertigo 4. decrease in neck stiffness 5. decrease in mental alertness 6. decrease in severity of ear pain

2. decrease in nausea 3. decrease in vertigo

The nurse is reviewing the primary health care provider's prescription for a client admitted to the hospital with a diagnosis of an acute attack of Meniere's disease. Which prescription noted on the client's chart should the nurse question? 1. bed rest 2. the administration of a sedative 3. the administration of an antihistamine 4. the administration of a vasoconstrictor

4. the administration of a vasoconstrictor

The nurse is caring for a client who will e undergoing surgical treatment for Meniere's disease. The nurse plans care based on which expected outcome? 1. the surgery repairs the tympanic membrane 2. the surgery is performed to replace the stapes footplate 3. the surgery relieves fluid accumulation in the middle ear 4. the surgery relieves pressure from accumulation of inner ear fluid in the endolymphatic sac

4. the surgery relieves pressure from accumulation of inner ear fluid in the endolymphatic sac

An adult client with a history of ear infections reports a right earache accompanied by a sensation of fullness. The client also reports nausea and has a temperature of 100.6. The nurse questions the client about which aspect of the client's history? 1. whether any medications have relieved the pain 2. whether there is a history of recent head injury 3. whether the client hears a ringing in the affected ear 4. whether the client has had a recent upper respiratory infection

4. whether the client has had a recent upper respiratory infection