Chap 14 Ear assessment
A 55-year-old client is being evaluated for a hearing impairment. Which question would be most appropriate to provide the most useful information? "Are you having difficulty hearing high-frequency sounds?" "Do you notice any drainage from your ears?" "Are you experiencing any pain in your ears?" "Have you felt any popping sensations?"
"Are you having difficulty hearing high-frequency sounds?" Explanation: Asking the client about changes in hearing ability with different frequency sounds would be most appropriate because the client is over age 50 and may be experiencing presbycusis, a loss of ability to hear high-frequency sounds. Asking about drainage would provide information about a possible infection; asking about pain would provide information about possible ear infection, cerumen blockage, sinus infections, or teeth and gum problems. Asking about a popping sensation may be appropriate if otitis media and perforation are suspected. Reference: Jensen, S, Nursing Health Assessment, 3rd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 14: Ear Assessment for Advanced and Specialty Practice, p. 358.
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? "Do you have any ear pain?" "Do you experience any ringing, roaring, or crackling in your ears?" "Do you have any ear drainage?" "Are you ever concerned that you may be losing your ability to hear well?"
"Do you experience any ringing, roaring, or crackling in your ears?" Explanation: Ringing in the ears (tinnitus) may be associated with excessive ear wax buildup, high blood pressure, or certain ototoxic medications. None of the other questions pertains to conditions related to high blood pressure. Ear pain is associated with ear infections, cerumen blockage, sinus infections, teeth and gum problems, and swimmer's ear. Drainage usually indicates infection. Hearing loss may be related to any number of causes but is not associated with high blood pressure. Reference: Jensen, S, Nursing Health Assessment, 3rd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 14: Ear Assessment for Advanced and Specialty Practice.
A clinic client's primary complaint is earache (otalgia). What question should the nurse include in the health interview? "What do you do for a living?" "Do you know if your vaccinations are up to date?" "Do you take medications or supplements?" "Have you been swimming lately?"
"Have you been swimming lately?" Explanation: Otalgia can occur with ear infections, cerumen blockage, sinus infections, or teeth and gum problems; water entry during swimming ("swimmer's ear") is also a very plausible cause of the client's pain. Occupational hazards usually involve hearing loss, not ear infection. Immunizations are not relevant to the prevention or treatment of ear infections. Medications can cause tinnitus and/or hearing loss, but ear pain is atypical. Reference: Chapter 14: Ear Assessment for Advanced and Specialty Practice - Page 358
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? "Have you had any recent trauma to the inside of your ear?" "Do you hear ringing in your ears?" "Are their times when you feel dizzy?" "Have you ever taken medication that is ototoxic?"
"Have you had any recent trauma to the inside of your ear?" Explanation: Otalgia and yellow-green discharge from the external ear canal suggest a ruptured tympanic membrane. In order to identify the cause of the rupture, it would be most effective to ask the client about trauma to the inside of the ear. Asking the client about ringing in the ears would suggest the nurse suspects tinnitus. The yellow-green drainage and pain are not associated with this condition. Asking the client about feeling dizzy suggests the nurse suspects vertigo. Yellow-green drainage and pain are not associated with this condition. Asking the client if she has ever taken medication that is ototoxic suggests the nurse is focusing the assessment on sensorineural hearing loss. Discharge and pain are not associated with this condition. Vertigo is A sudden internal or external spinning sensation, often triggered by moving your head too quickly.
An adult client tells the nurse that his 80-year-old father is almost completely deaf. After an explanation to the client about risk factors for hearing loss, the nurse determines that the client needs further instruction when the client says "There is a genetic predisposition to hearing loss." "Certain cultural groups have a higher rate of hearing loss." "It is difficult to prevent hearing loss or worsening of hearing." "Chronic otitis media has been associated with hearing loss."
"It is difficult to prevent hearing loss or worsening of hearing." Explanation: Causes of hearing disorders are many and include genetics, infections, injuries to head or ear, ototoxic drugs, aging, and loud noises. Chapter 14: Ear Assessment for Advanced and Specialty Practice - Page 355
The mother of a small child with tubes in both eardrums asks the nurse if it is okay if the child travels by airplane. What is the nurse's best response? "He should avoid flying for 6 months after tube placement." "The child must wear ear plugs while flying." "It's safe to fly because the tubes will equalize pressure." "He shouldn't fly with anyone who is immunocompromised."
"It's safe to fly because the tubes will equalize pressure." Explanation: Pressure equalization tubes equalize pressure on either sides of the eardrum; so it's a great time to fly if one has tubes in the ears. The child should wear ear plugs to keep water out of the ears when swimming. Wearing ear plugs while flying may diminish the pressure equalization advantage of the tubes. Clients do not have to avoid flying for any period of time after tube placement. Ear tubes do not have an effect on immunocompromised clients. Chapter 14: Ear Assessment for Advanced and Specialty Practice - Page 356
An increased risk of falls is dangerous for any client. What client would be at an increased risk of falls? A client with a hearing loss of 45 dB. A client with acute otitis media. A client with vertigo. A client with damage to the VIIIth cranial nerve.
A client with vertigo. Explanation: Vertigo is defined as the misperception or illusion of motion either of the person or the surroundings. A client suffering from vertigo will be at an increased risk of falls. This makes options A, B and D incorrect. Chapter 14: Ear Assessment for Advanced and Specialty Practice - Page 357
conductive hearing loss. sensorineural hearing loss lateralization of sound
A conductive hearing loss happens when sounds cannot get through the outer and middle ear. It may be hard to hear soft sounds. Louder sounds may be muffled. Medicine or surgery can often fix this type of hearing loss. Sensorineural hearing loss (SNHL) is caused by damage to the structures in your inner ear or your auditory nerve. It is the cause of more than 90 percentof hearing loss in adults. Lateralization of sound: độ trễ của âm thanh
The nurse notes a tophus of the ear of an older adult. Which assessment data is consistent with a tophus? A hard nodule composed of uric acid crystals A sac with a membranous lining filled with fluid Scarring of the tympanic membrane Redness and bulging of the eardrum
A hard nodule composed of uric acid crystals Explanation: A tophus is a hard nodule composed of uric acid crystals. A cyst on the ear would present as a fluid-filled sac. Redness and bulging of the eardrum is characteristic of otitis media with effusion. Scarring of the tympanic membrane occurs with repeated ear infections with perforation of the tympanic membrane Chapter 14: Ear Assessment for Advanced and Specialty Practice - Page 371
A client has Darwin tubercle. What is this? A type of skin cancer found on the ear A growth in the ear canal A growth in the bony labyrinth A small painless nodule on the helix
A small painless nodule on the helix Explanation: Small painless nodules on the helix are a variation of normal anatomy known as darwinian tubercle. Reference: Chapter 14: Ear Assessment for Advanced and Specialty Practice - Page 360
Otoscopic examination of a 69-year-old client's tympanic membrane reveals that it is red, bulging, and distorted. The nurse also notes a diminished light reflex. To what should the nurse most likely attribute this assessment finding? Repeated ear infections Trauma Age-related changes Acute otitis media
Acute otitis media Explanation: A red, bulging eardrum coupled with distorted, diminished, or absent light reflex is associated with acute otitis media. Repeated ear infections usually cause the formation of white scar tissue. Trauma causes the accumulation of blood behind the eardrum, which appears blue or dark red. Chapter 14: Ear Assessment for Advanced and Specialty Practice - Page 361
While using an otoscope to assess the ears of an 8-year-old boy, the nurse observes white spots on the boy's tympanic membrane. The nurse also observes that no redness is present. Which action would be most appropriate? Assess the boy for previous trauma to his skull. Determine whether impacted cerumen is present. Ask the mother whether the child has had numerous ear infections. Assess the child for further symptoms of acute otitis media.
Ask the mother whether the child has had numerous ear infections. Explanation: White spots on the tympanic membrane indicate scarring from previous infections. Therefore the nurse would ask the mother about a history of previous ear infections. A bluish or dark red color to the membrane would suggest skull trauma. Impacted cerumen would prevent the nurse from viewing the tympanic membrane. A red, bulging eardrum and a distorted, diminished, or absent light reflex would suggest acute otitis media. Reference: Chapter 14: Ear Assessment for Advanced and Specialty Practice - Page 361
High doses of this medication can produce bilateral tinnitus? Antivert Aspirin Promethazine Dramamine
Aspirin Explanation: At high doses, aspirin toxicity can produce bilateral tinnitus. Antivert and Dramamine is used for nausea and vomiting related to motion sickness. Antiemetics such as promethazine (Phenergan) suppositories help control the nausea and vomiting and the vertigo because of the antihistamine effect. Chapter 14: Ear Assessment for Advanced and Specialty Practice - Page 356
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? At the center of the client's forehead On the client's mastoid process In front of the external auditory canal Behind the external auditory canal
At the center of the client's forehead Explanation: During a Weber test for assessment of hearing loss, the nurse should place the tuning fork at the center of the client's forehead. Placing the base of the tuning fork at the client's mastoid process and placing the prongs of the tuning fork in front of the external auditory canal are part of the Rinne test. Placing the base of the tuning fork in front of or behind the external auditory canal is an inappropriate technique. Chapter 14: Ear Assessment for Advanced and Specialty Practice - Page 365
When providing client education on hearing, the nurse should remind clients to utilize ear plugs when they are what? (Select all that apply.) At train stations Cleaning their homes Using lawnmowers Working with children At concerts
At train stations Using lawnmowers At concerts Explanation: As nurses, prevention is key, and clients should be reminded to utilize ear plugs when exposed to loud noises in their daily lives (e.g., lawnmowers, leaf blowers, chainsaws, concerts, train stations, battlefields, and sirens) and to limit exposure (iPod buds and cell phones). Chapter 14: Ear Assessment for Advanced and Specialty Practice - Page 355
Tragus of the ear
Cartilage projection anterior to the external opening of the ear
When assessing the tympanic membrane, a variation of normal is a tympanic membrane with what? Sclerosis Yellow areas Pink color Prominent stapes
Sclerosis Explanation: A variation of normal is a tympanic membrane with white areas (sclerosis). These white areas are visible scars from repeated ear infections. Yellow areas, pink color, or prominent stapes are not variations of normal assessment. Chapter 14: Ear Assessment for Advanced and Specialty Practice - Page 361
The nurse would suspect a problem at which area when pressure builds up on either side of the tympanic membrane? Cochlea Eustachian tube Vestibulocochlear nerve Organ of Corti
Eustachian tube Explanation: The eustachian tube equalizes the pressure on either side of the tympanic membrane, which separates the external ear from the middle ear. The cochlea, organ of Corti, and the vestibulocochlear nerve are part of the inner ear. Chapter 14: Ear Assessment for Advanced and Specialty Practice - Page 351
The nurse is providing client teaching to the mother of a 3-month-old with otitis media. What would the nurse explain is a risk factor for otitis media? Being outside in the spring Exposure to cigarette smoke Being taken out in crowds Being an only child
Exposure to cigarette smoke Explanation: Exposure to cigarette smoke, propping bottles for babies to feed, and bottle feeding in a supine position are all environmental factors that increase risk for otitis media. Otitis media: is An infection of the air-filled space behind the eardrum (the middle ear). An ear infection is usually caused by bacteria or viruses. Ear pain and fever are common symptoms. Less commonly, there may be drainage of fluid from the ear or hearing loss. Reference: Chapter 14: Ear Assessment for Advanced and Specialty Practice - Page 354
Which nursing action is most appropriate when caring for the client with decreased hearing acuity? Face the client when speaking Enhance background sounds Sit next to the client Overenunciate words
Face the client when speaking Explanation: The nurse should allow the client to see the nurse's face to facilitate the communication process. The nurse should sit directly in front of the client, avoid overenunciation of words, and minimize background sounds. Over enunciation (also over articulation and over pronunciation) is when a speaker puts far too much effort into saying every sound in a word Chapter 14: Ear Assessment for Advanced and Specialty Practice - Page 361
Which of the following, if obtained during the health history, would alert the nurse to a possible risk factor for ear-related problems? Frequent use of acetaminophen (Tylenol) Frequent use of cotton-tipped applicators Preference for showers rather than baths In adequate hygiene practices
Frequent use of cotton-tipped applicators Explanation: Use of cotton-tipped applicators inside the ear can cause earwax to become impacted and cause ear damage. Factors such as showering rather than bathing or having poor hygiene practices do not normally cause ear-related problems. Acetaminophen is not ototoxic. Chapter 14: Ear Assessment for Advanced and Specialty Practice - Page 356
When inspecting the tympanic membrane, which of the following structures does the nurse expect to identify? Cone of light, incus, umbo, cochlea Pars tensa, umbo, handle of malleus, ossicles Pars tensa, pars flaccida, vestibule, cone of light Handle of malleus, short process of malleus, cone of light
Handle of malleus, short process of malleus, cone of light Explanation: Visualization of the tympanic membrane using an otoscope includes inspection of the cone of light, the short process of the malleus, and the handle of the malleus. The cochlea, vestibule, and stapes (part of the ossicles) are not normally visualizable. Chapter 14: Ear Assessment for Advanced and Specialty Practice - Page 351
The nurse has completed a focused ear and hearing assessment and gathered the following data: the client speaks very softly, denies hearing loss, and has never had and cannot afford additional hearing tests; the client fails the whisper test. Which nursing diagnosis would be most appropriate? Ineffective health maintenance related to denial of hearing problem and inadequate resources for additional testing Impaired social interaction, related to decreased ability to maintain contact with friends and family Impaired verbal communication, related to a lack of understanding of hearing changes and deficit Readiness for enhanced communication related to auditory integrity and need for hearing therapy
Ineffective health maintenance related to denial of hearing problem and inadequate resources for additional testing Explanation: A nursing diagnosis of ineffective health maintenance would be most appropriate based on the data. There is nothing to suggest that the client is having difficulty with social interaction. A soft speaking voice does not indicate a problem with impaired verbal communication. The client has a problem, so a health promotion diagnosis of readiness for enhanced communication would be inappropriate.
A client's electronic health record states that he has been diagnosed with sensorineural hearing loss. Which condition should the nurse most likely identify as a cause? Perforated eardrum Otosclerosis Inner ear problem Otitis media
Inner ear problem Explanation: Sensorineural hearing loss is related to the dysfunction of the inner ear. A perforated eardrum, otosclerosis, or otitis media would most likely cause a conductive hearing loss, since these would affect structures in the external or middle ear. Chapter 14: Ear Assessment for Advanced and Specialty Practice - Page 352
Which of the following denotes the correct procedure for using an otoscope when examining the ears of a 32-year-old client? Keeping the dominant hand away from the client's head Inserting the speculum down and forward into the ear canal Using the smallest speculum on the otoscope head Holding the otoscope in the non-dominant hand
Inserting the speculum down and forward into the ear canal Explanation: The nurse should insert the speculum gently down and forward into the canal. Using the dominant hand, the nurse should position the hand holding the otoscope against the client's head or face. The largest speculum that fits comfortably into the client's ear canal is used. Jensen, S, Nursing Health Assessment, 3rd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 14: Ear Assessment for Advanced and Specialty Practice, p. 361.
While inspecting the tympanic membrane, the nurse notes a pearly gray and shiny appearance. The nurse would interpret this finding as which of the following? Scarring from previous infections Serous otitis media Normal tympanic membrane Acute otitis media
Normal tympanic membrane Explanation: The tympanic membrane is normally a pearly gray color with a shiny appearance. White spots would indicate scarring. <wbr />A yellowish bulging membrane would suggest serous otitis media; a red bulging membrane would suggest acute otitis media. Chapter 14: Ear Assessment for Advanced and Specialty Practice - Page 362
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? Document the finding as an isolated benign node. Inform the client of the need for ear drops. Refer the client to an audiologist for an audiogram. Notify the healthcare provider about the finding.
Notify the healthcare provider about the finding. Explanation: Lymph tissue should not be palpable on the ears. Enlarges lymph nodes indicate pathology or inflammation; and the healthcare provider should be notified. Ear drops are not indicated since the node is on the auricle, not in the canal. An audiogram is indicated for hearing loss. Chapter 14: Ear Assessment for Advanced and Specialty Practice - Page 361
The nurse is preparing to perform the Rinne test on a client. The nurse would place the tuning fork at which location first? Center of client's forehead On the mastoid process In front of the external auditory canal At the base of the skull
On the mastoid process Explanation: For the Rinne test, the tuning fork base is place on the client's mastoid process and then it is moved to the front of the external auditory canal when the client no longer hears the sound. The tuning fork is place in the center of the client's forehead or head for the Weber test. Chapter 14: Ear Assessment for Advanced and Specialty Practice - Page 363
A nurse obtains an objective assessment on a child who presents to the clinic with reports of right ear pain. The nurse observes the following: painful movement of the pinna and tragus; ear canal is red and swollen with presence of purulent discharge from the external canal; temperature 101.8°F. The mother states that the family was on vacation at the beach last week. The nurse recognizes these findings as an indication of what acute ear condition? Foreign body Acute otitis media Otitis externa Perforated tympanic membrane
Otitis externa Explanation: The key to this condition is that the child was at the beach. Otitis externa occurs as an infection of the external canal from swimming. It presents with a pain and swelling of the ear canal, fever, and purulent drainage. There was no data to support the presence of a foreign object. Acute otitis media is an infection behind the tympanic membrane that presents with many of the same symptoms but the pain is behind the ear and the tympanic membrane is red and swollen, with a loss of the cone of light. A perforated tympanic membrane will produce drainage in the ear canal, a perforation will be present in the tympanic membrane, and the pain most often subsides once the pressure is released from the ear. Chapter 14: Ear Assessment for Advanced and Specialty Practice - Page 358
A nurse palpates a client's ear and finds that the tragus is tender. The nurse suspects which of the following? Otitis media Otitis externa Ruptured tympanic membrane Mastoiditis
Otitis externa Explanation: A tender tragus is associated with otitis externa. Tenderness behind the ear would suggest otitis media. A ruptured tympanic membrane would be associated with ear pain and a popping sensation. Tenderness over the mastoid process would suggest mastoiditis. Chapter 14: Ear Assessment for Advanced and Specialty Practice - Page 352
A nurse palpates a client's ear and finds that the tragus is exquisitely tender. The nurse should suspect what health problem? Otitis media Otitis externa Ruptured tympanic membrane Mastoiditis
Otitis externa Explanation: A tender tragus is associated with otitis externa. Tenderness behind the ear would suggest otitis media. A ruptured tympanic membrane would be associated with ear pain and a popping sensation. Tenderness over the mastoid process would suggest mastoiditis. Chapter 14: Ear Assessment for Advanced and Specialty Practice - Page 361
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 Tinnitus Conductive hearing loss Sensorineural hearing loss
Presbycusis Explanation: Presbycusis results from gradual degeneration of nerves and sensory hair cells of the organ of Corti and may be related either aging or use of ototoxic drugs. Tinnitus is a perception of buzzing or ringing in the ear(s) that does not correspond to an external sound. Disruption of sound wave transmission through the external or middle ear results in conductive hearing loss. Sensorineural hearing loss results from a problem from the inner ear to the auditory cortex. Chapter 14: Ear Assessment for Advanced and Specialty Practice - Page 358
Some clients with acoustic neuromas have vertigo. What is a priority nursing action with clients with vertigo? Protect the client from injury Provide small meals of tepid food Mobilize the client at every opportunity Provide ice to the affected ear
Protect the client from injury Explanation: For clients with vertigo, the nurse takes measures to protect the client from injury. Nursing actions do not include providing small meals of tepid food; mobilizing the client at every opportunity; or providing ice to the affected ear. Reference: Chapter 14: Ear Assessment for Advanced and Specialty Practice - Page 365
What action should the nurse implement using an otoscope when assessing the ear of an adult client? Pull the auricle out, up, and back Choose the smallest speculum for client comfort Hold the speculum in the nondominant hand Insert the speculum gently down and backward
Pull the auricle out, up, and back Explanation: The nurse should pull the auricle out, up, and back to straighten the external auditory canal. This is because the external auditory canal is S-shaped in the adult. The outer part of the canal curves up and back, and the inner part of the canal curves down and forward. The nurse should choose the largest speculum that fits comfortably into the client's ear. The nurse should hold the speculum in the dominant hand and insert the speculum gently down and forward. Reference:. Chapter 14: Ear Assessment for Advanced and Specialty Practice - Page 361
Which characteristic feature of the tympanic membrane should a nurse anticipate finding in a client with otitis media? Pearly, translucent with no bulging Yellowish, bulging with fluid bubbles Gray, translucent with retraction Red, bulging with an absent light reflex
Red, bulging with an absent light reflex Explanation: A client with acute otitis media would have a red, bulging eardrum with absent light reflex. A pearly, translucent membrane with no bulging is a normal finding in the tympanic membrane. A yellowish, bulging membrane with bubbles is seen in serous otitis media. A gray, translucent membrane with retraction is a normal finding in the tympanic membrane. Chapter 14: Ear Assessment for Advanced and Specialty Practice - Page 365
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? Weber Rinne Romberg Whisper
Romberg Explanation: The nurse should perform the Romberg test to assess equilibrium in the client. The Weber test and the Rinne test are used to distinguish between sensorineural and conductive hearing loss. The whisper test is used to assess hearing loss in a client.
In which position should the nurse place the toddler when examining the ear? Sitting on the parent's lap with parent steadying the head Side-lying position on the examination table Supine on the examination table Sitting position on the examination table
Sitting on the parent's lap with parent steadying the head Explanation: The toddler should sit on the parent's lap with the parent steadying the head. Preschoolers often need to be held down on the examination table in a supine position with the head turned toward the parent. Older children can sit on the examination table. Chapter 14: Ear Assessment for Advanced and Specialty Practice - Page 359
bilateral tinnitus
Some people describe the noise as a high-pitched ringing, but it may also be heard as a buzzing, clicking, hissing, roaring, or rushing sound. Most people experience tinnitus in both ears, called bilateral tinnitus. Less commonly it develops in only one ear, called unilateral tinnitus.
The nurse assists and educates clients about the structure and function of the sensory system. The nurse is showing the client the path taken by sound waves to reach the brain. The nurse dropped the note cards with the correct sequence on the floor. The sequence of steps is scrambled and need to be placed in the correct order. Which is the correct order of the steps in the path taken by sound waves to the brain? Click an option, hold and drag it to the desired position, or click an option to highlight it and move it up or down in the order using the arrows to the left. 1Sound waves enter though the ear's external auditory canal and strike the tympanic membrane. 2The tympanic membrane vibrates at various speeds in response to various pitches of sounds. 3The ossicles within the middle ear act as a moveable bridge to transmit these vibrations to the oval window, which amplifies the sound waves. 4The stapes vibrates against the membrane, setting the fluid of the cochlea in motion, which in turn passes on to the hair like nerve ending in the organ of Corti.
Sound waves enter though the ear's external auditory canal and strike the tympanic membrane. The tympanic membrane vibrates at various speeds in response to various pitches of sounds. The ossicles within the middle ear act as a moveable bridge to transmit these vibrations to the oval window, which amplifies the sound waves. The stapes vibrates against the membrane, setting the fluid of the cochlea in motion, which in turn passes on to the hair like nerve ending in the organ of Corti. The stimuli in the organ of Corti are sent to the vestibulocochlear nerve and to the temporal lobe in the cerebral cortex, where the sounds are interpreted. Explanation: The correct order of the steps in the path taken by sound waves to the brain is that sound waves enter through the ear's external auditory canal and strike the tympanic membrane. The tympanic membrane vibrates at various speeds in response to various pitches of sounds. The ossicles within the middle ear act as a moveable bridge to transmit these vibrations to the oval window, which amplifies the sound waves. The stapes vibrates against the membrane, setting the fluid of the cochlea in motion, which in turn passes on to the hair like nerve ending in the organ of Corti. The stimuli in the organ of Corti are sent to the vestibulocochlear nerve and then to the temporal lobe in the cerebral cortex, where the sounds are interpreted. Reference: Chapter 14: Ear Assessment for Advanced and Specialty Practice - Page 351
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? Malleus Incus Stapes Umbo
Stapes Explanation: Sound waves are transmitted through auditory ossicles as the vibration of the eardrum causes the malleus, the incus, and then the stapes to vibrate. As the stapes vibrates at the oval window, the sound waves are passed to the fluid in the inner ear. The umbo is the base of the malleus. Chapter 14: Ear Assessment for Advanced and Specialty Practice - Page 351
The nurse is completing a client's ear assessment. What assessment finding would indicate the need to perform Weber's test? The client has unilateral hearing loss. The client has suspected otitis externa. The client is older than age 65. The client has a history of stroke.
The client has unilateral hearing loss. Explanation: Unilateral hearing loss is the major indication for Weber's test, which helps distinguish between conductive hearing and sensorineural hearing. Older age, infection, and a history of stroke are not specific indications for this test. Chapter 14: Ear Assessment for Advanced and Specialty Practice - Page 365
What structure in the inner ear senses the position and movements of the head and helps to maintain balance? The cochlea The labyrinth The umbo The ossicle
The labyrinth Explanation: The labyrinth within the inner ear senses the position and movements of the head and helps to maintain balance. Chapter 14: Ear Assessment for Advanced and Specialty Practice - Page 354
Which action by the nurse is consistent with the Rinne test? The nurse strikes the tuning fork and places it on the client's mastoid process to measure bone conduction. The nurse activates the tuning fork and places it on the midline of the parietal bone in line with both ears. The nurse uses a bulb insufflator attached to an otoscope to observe movement of the tympanic membrane. The nurse shields their mouth and whispers a simple sentence approximately 18 inches from the client's ear.
The nurse strikes the tuning fork and places it on the client's mastoid process to measure bone conduction. Explanation: In the Rinne test, the nurse strikes the tuning fork and places it on the client's mastoid process to measure bone conduction. Using Weber's test, the nurse activates the tuning fork and places it on the midline of the parietal bone in line with both ears to differentiate the cause of unilateral hearing loss. When examining the inner ear, the nurse uses a bulb insufflator attached to an otoscope to observe movement of the tympanic membrane. In the Whisper test, the nurse shields their mouth and whispers a simple sentence approximately 18 inches from the client's ear. Chapter 14: Ear Assessment for Advanced and Specialty Practice - Page 363-364
A nurse is preparing a teaching session for a group of new parents about ear infections and measures to prevent them. The nurse is planning to address the reasons why children are more susceptible to these infections than adults. Which information would the nurse describe? Young children have a tendency to stick objects into their ear canal. The size and shape of children's eustachian tubes makes them vulnerable. Children's immune systems lack the maturity to fight infections. Children generally have poorer hygiene than adults.
The size and shape of children's eustachian tubes makes them vulnerable. Explanation: The fact that children are more susceptible than adults to otitis media is due mostly to the shorter, straighter, narrower eustachian tubes of children. Otitis media in children is not normally associated with putting things in their ears, immature immune systems, or poor hygiene. Reference: Chapter 14: Ear Assessment for Advanced and Specialty Practice - Page 351
A 52-year-old client fails the Romberg test. The nurse explains that this might indicate a dysfunction in what part of the ear? The bones of the middle ear The eustachian tubes The pinna The vestibular portion of the inner ear
The vestibular portion of the inner ear Explanation: Failure of the Romberg test may indicate dysfunction in the vestibular portion of the inner ear, semicircular canals, and vestibule.
During a Weber test, the client reports lateralization of sound to the good ear. The nurse interprets this as which the following? The good ear cannot receive sound vibrations. There is a dysfunction of the middle ear. The poor ear is receiving sound vibrations by air. There is a sensorineural hearing impairment.
There is a sensorineural hearing impairment. Explanation: With the Weber test, lateralization of sound to the good ear suggests sensorineural hearing loss because of the limited perception of sound due to nerve damage in the affected ear, making sound seem louder in the unaffected ear. Lateralization to the poor ear suggests conductive hearing loss. Chapter 14: Ear Assessment for Advanced and Specialty Practice - Page 365
Which portion of the middle ear equalizes pressure? Tympanic membrane Ossicles Auricle Cochlea
Tympanic membrane Explanation: The tympanic membrane of the middle ear equalizes pressure. Ossicles, which are held in place by joints, muscles, and ligaments, assist in the transmission of sound. The auricle collects the sound waves and directs vibrations into the external auditory canal. The cochlea is a winding, snail-shaped bony tube that forms a portion of the inner ear and contains the organ of Corti; the transducer of hearing. Chapter 14: Ear Assessment for Advanced and Specialty Practice - Page 351
The nurse is using audiometry to screen the hearing of elementary school students. Which best describes audiometry? Uses headphones and a box that delivers tones to each ear at variable frequencies and volumes. Hearing is tested by placing the individual in a sound-proof booth to measure oto-acoustic emissions. Tests the conduction of sounds through the bones of the skull, using a fork-shaped instrument. A U-shaped instrument is used to assess sound perception through bone and air conduction.
Uses headphones and a box that delivers tones to each ear at variable frequencies and volumes. Explanation: Headphones and a box that delivers tones to each ear at variable frequencies and volumes are used in testing hearing by audiometry. A tuning fork, a U-shaped instrument, is used to assess sound perception through bone and air conduction. An audiologist assesses hearing with an audiogram by placing the individual in a sound-proof booth. An audiologist measures oto-acoustic emissions with a tympanogram. Chapter 14: Ear Assessment for Advanced and Specialty Practice - Page 366
The nurse assessing for unilateral hearing loss by using a tuning fork. What test is the nurse performing? Watch tick test Rinne test Whisper test Weber's test
Weber's test Explanation: The Weber's test uses bone conduction to test lateralization of sound and is useful in detecting unilateral hearing loss. In the Rinne test, the examiner shifts the stem of a vibrating tuning fork between two positions to test air conduction of sound and bone conduction of sound. The whisper test involves covering the untested ear and whispering from a distance of 2 or 3 feet from the unoccluded ear and determining the client's ability to repeat what was whispered. The watch tick test relies on the ability of the client to perceive the high-pitched sound made by a watch held at the client's auricle. Chapter 14: Ear Assessment for Advanced and Specialty Practice - Page 359
A child goes to the school nurse and complains of not being able to hear their teacher. What test could the school nurse perform that would indicate hearing loss? Chiming clock test Rinne test Whisper test Weber test
Whisper test Explanation: A general estimate of hearing can be made by assessing the client's ability to hear a whispered phrase or a ticking watch, testing one ear at a time. The Rinne and Weber tests distinguish sensorineural from conductive hearing loss. There is no chiming clock test. Reference: Jensen, S, Nursing Health Assessment, 3rd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 14: Ear Assessment for Advanced and Specialty Practice, p. 361. Chapter 14: Ear Assessment for Advanced and Specialty Practice - Page 361
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 normal hearing. sensorineural hearing loss. conductive hearing loss. central hearing loss.
conductive hearing loss. Explanation: With conductive hearing loss, bone conduction (BC) sound is heard longer than or equally as long as air conduction (AC) sound (BC ? AC). Chapter 14: Ear Assessment for Advanced and Specialty Practice - Page 364
Cone of light
is the light reflex
Presbycusis
is the loss of hearing that gradually occurs in most individuals as they grow older. Hearing loss is a common disorder associated with aging. About 30-35 percent of adults age 65 and older have a hearing loss. It is estimated that 40-50 percent of people 75 and older have a hearing loss.
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: whispered sounds the calling bell the tuning fork the sound of "th"
whispered sounds Explanation: The inability of the client to hear whispered sounds indicates presbycusis, which is a gradual sensorineural hearing loss due to degeneration of the cochlea or vestibulocochlear nerve, common in older clients. The inability to hear the calling bell may indicate deafness. The inability to hear the tuning fork may indicate sensorineural or conductive hearing loss. Chapter 14: Ear Assessment for Advanced and Specialty Practice - Page 353
