Chapter 64
A patient has undergone diagnostic testing and has been diagnosed with otosclerosis? 9. What ear structure is primarily affected by this diagnosis? A) Malleus B) Stapes C) Incus D) Tympanic membrane
Ans: B Feedback: Otosclerosis involves the stapes and is thought to result from the formation of new, abnormal bone, especially around the oval window, with resulting fixation of the stapes.
The nurse is admitting a patient to the unit who is scheduled to have an ossiculoplasty. What postoperative assessment will best determine whether the procedure has been successful? A) Otoscopy B) Audiometry C) Balance testing D) Culture and sensitivity testing of ear discharge
Ans: B Feedback: Ossiculoplasty is the surgical reconstruction of the middle ear bones to restore hearing. Consequently, results are assessed by testing hearing, not by visualizing the ear, testing balance, or culturing ear discharge.
The nurse is discussing the results of a patient's diagnostic testing with the nurse practitioner. What Weber test result would indicate the presence of a sensorineural loss? A) The sound is heard better in the ear in which hearing is better. B) The sound is heard equally in both ears. C) The sound is heard better in the ear in which hearing is poorer. D) The sound is heard longer in the ear in which hearing is better.
Ans: A Feedback: A patient with sensorineural hearing loss hears the sound better in the ear in which hearing is better. The Weber test assesses bone conduction of sound and is used for assessing unilateral hearing loss. A tuning fork is used. A patient with normal hearing hears the sound equally in both ears or describes the sound as centered in the middle of the head. A patient whose hearing loss is conductive hears the sound better in the affected ear.
A hearing-impaired patient is scheduled to have an MRI. What would be important for the nurse to remember when caring for this patient? A) Patient is likely unable to hear the nurse during test. B) A person adept in sign language must be present during test. C) Lip reading will be the method of communication that is necessary. D) The nurse should interact with the patient like any other patient.
Ans: A Feedback: During health care and screening procedures, the practitioner (e.g., dentist, physician, nurse) must be aware that patients who are deaf or hearing-impaired are unable to read lips, see a signer, or read written materials in the dark rooms required during some diagnostic tests. The same situation exists if the practitioner is wearing a mask or not in sight (e.g., x-ray studies, MRI, colonoscopy).
A patient is postoperative day 6 following tympanoplasty and mastoidectomy. The patient has phoned the surgical unit and states that she is experiencing occasional sharp, shooting pains in her affected ear. How should the nurse best interpret this patient's complaint? A) These pains are an expected finding during the first few weeks of recovery. B) The patient's complaints are suggestive of a postoperative infection. C) The patient may have experienced a spontaneous rupture of the tympanic membrane. D) The patient's surgery may have been unsuccessful.
Ans: A Feedback: For 2 to 3 weeks after surgery, the patient may experience sharp, shooting pains intermittently as the eustachian tube opens and allows air to enter the middle ear. Constant, throbbing pain accompanied by fever may indicate infection and should be reported to the primary care provider. The patient's pain does not suggest tympanic perforation or unsuccessful surgery.
The nurse in the ED is caring for a 4 year-old brought in by his parents who state that the child will not stop crying and pulling at his ear. Based on information collected by the nurse, which of the following statements applies to a diagnosis of external otitis? A) External otitis is characterized by aural tenderness. B) External otitis is usually accompanied by a high fever. C) External otitis is usually related to an upper respiratory infection. D) External otitis can be prevented by using cotton-tipped applicators to clean the ear.
Ans: A Feedback: Patients with otitis externa usually exhibit pain, discharge from the external auditory canal, and aural tenderness. Fever and accompanying upper respiratory infection occur more commonly in conjunction with otitis media (infection of the middle ear). Cottontipped applicators can actually cause external otitis so their use should be avoided.
A patient with otosclerosis has significant hearing loss. What should the nurse do to best facilitate communication with the patient? A) Sit or stand in front of the patient when speaking. B) Use exaggerated lip and mouth movements when talking. C) Stand in front of a light or window when speaking. D) Say the patient's name loudly before starting to talk.
Ans: A Feedback: Standing directly in front of a hearing-impaired patient allows him or her to lip-read and see facial expressions that offer clues to what is being said. Using exaggerated lip and mouth movements can make lip-reading more difficult by distorting words. Backlighting can create glare, making it difficult for the patient to lip-read. To get the attention of a hearing-impaired patient, gently touch the patient's shoulder or stand in front of the patient.
A patient with mastoiditis is admitted to the post-surgical unit after undergoing a radical mastoidectomy. The nurse should identify what priority of postoperative care? A) Assessing for mouth droop and decreased lateral eye gaze B) Assessing for increased middle ear pressure and perforated ear drum C) Assessing for gradual onset of conductive hearing loss and nystagmus D) Assessing for scar tissue and cerumen obstructing the auditory canal
Ans: A Feedback: The facial nerve runs through the middle ear and the mastoid; therefore, there is risk of injuring this nerve during a mastoidectomy. When injury occurs, the patient may display mouth droop and decreased lateral gaze on the operative side. Scar tissue is a long-term complication of tympanoplasty and therefore would not be evident during the immediate postoperative period. Tympanic perforation is not a common complication of this surgery.
The nurse is providing discharge education for a patient with a new diagnosis of Ménière's disease. What food should the patient be instructed to limit or avoid? A) Sweet pickles B) Frozen yogurt C) Shellfish D) Red meat
Ans: A Feedback: The patient with Ménière's disease should avoid foods high in salt and/or sugar; sweet pickles are high in both. Milk products are not contraindicated. Any type of meat, fish, or poultry is permitted, with the exception of canned or pickled varieties. In general, the patient with Ménière's disease should avoid or limit canned and processed foods.
A patient diagnosed with arthritis has been taking aspirin and now reports experiencing tinnitus and hearing loss. What should the nurse teach this patient? A) The hearing loss will likely resolve with time after the drug is discontinued. B) The patient's hearing loss and tinnitus are irreversible at this point. C) The patient's tinnitus is likely multifactorial, and not directly related to aspirin use. D) The patient's tinnitus will abate as tolerance to aspirin develops.
Ans: A Feedback: Tinnitus and hearing loss are signs of ototoxicity, which is associated with aspirin use. In most cases, this will resolve upon discontinuing the aspirin. Many other drugs cause irreversible ototoxicity.
The advanced practice nurse is attempting to examine the patient's ear with an otoscope. Because of impacted cerumen, the tympanic membrane cannot be visualized. The nurse irrigates the patient's ear with a solution of hydrogen peroxide and water to remove the impacted cerumen. What nursing intervention is most important to minimize nausea and vertigo during the procedure? A) Maintain the irrigation fluid at a warm temperature. B) Instill short, sharp bursts of fluid into the ear canal. C) Follow the procedure with insertion of a cerumen curette to extract missed ear wax. D) Have the patient stand during the procedure.
Ans: A Feedback: Warm water (never cold or hot) and gentle, not forceful, irrigation should be used to remove cerumen. Too forceful irrigation can cause perforation of the tympanic membrane, and ice water causes vomiting. Cerumen curettes should not be routinely used by the nurse. Special training is required to use a curette safely. It is unnecessary to have the patient stand during the procedure.
An advanced practice nurse has performed a Rinne test on a new patient. During the test, the patient reports that air-conducted sound is louder than bone-conducted sound. How should the nurse best interpret this assessment finding? A) The patient's hearing is likely normal. B) The patient is at risk for tinnitus. C) The patient likely has otosclerosis. D) The patient likely has sensorineural hearing loss.
Ans: A The Rinne test is useful for distinguishing between conductive and sensorineural hearing loss. A person with normal hearing reports that air-conducted sound is louder than bone conducted sound.
The nurse is providing care for a patient who has benefited from a cochlear implant. The nurse should understand that this patient's health history likely includes which of the following? Select all that apply. A) The patient was diagnosed with sensorineural hearing loss. B) The patient's hearing did not improve appreciably with the use of hearing aids. C) The patient has deficits in peripheral nervous function. D) The patient's hearing deficit is likely accompanied by a cognitive deficit. E) The patient is unable to lip-read.
Ans: A, B Feedback: A cochlear implant is an auditory prosthesis used for people with profound sensorineural hearing loss bilaterally who do not benefit from conventional hearing aids. The need for a cochlear implant is not associated with deficits in peripheral nervous function, cognitive deficits, or an inability to lip-read.
The nurse is planning the care of a patient who is adapting to the use of a hearing aid for the first time. What is the most significant challenge experienced by a patient with hearing loss who is adapting to using a hearing aid for the first time? A) Regulating the tone and volume B) Learning to cope with amplification of background noise C) Constant irritation of the external auditory canal D)Challenges in keeping the hearing aid clean while minimizing exposure to moisture
Ans: B Feedback: Each of the answers represents a common problem experienced by patients using a hearing aid for the first time. However, amplification of background noise is a difficult problem to manage and is the major reason why patients stop using their hearing aid. All patients learning to use a hearing aid require support and coaching by the nurse and other members of the health care team. Patients should be encouraged to discuss their adaptation to the hearing aid with their audiologist.
A patient is scheduled to have an electronystagmography as part of a diagnostic workup for Ménière's disease. What question is it most important for the nurse to ask the patient in preparation for this test? Have you ever experienced claustrophobia or feelings of anxiety while in enclosed A) spaces? B) Do you currently take any tranquilizers or stimulants on a regular basis? C) Do you have a history of falls or problems with loss of balance? D) Do you have a history of either high or low blood pressure?
Ans: B Feedback: Electronystagmography measures changes in electrical potentials created by eye movements during induced nystagmus. Medications such as tranquilizers, stimulants, or antivertigo agents are withheld for 5 days before the test. Claustrophobia is not a significant concern associated with this test; rather, it is most often a concern for patients undergoing magnetic resonance imaging (MRI). Balance is impaired by Ménière's disease; therefore, a patient history of balance problems is important, but is not relevant to test preparation. Hypertension or hypotension, while important health problems, should not be affected by this test.
While reviewing the health history of an older adult experiencing hearing loss the nurse notes the patient has had no trauma or loss of balance. What aspect of this patient's 2. health history is most likely to be linked to the patient's hearing deficit? A) Recent completion of radiation therapy for treatment of thyroid cancer B) Routine use of quinine for management of leg cramps C) Allergy to hair coloring and hair spray D) Previous perforation of the eardrum
Ans: B Feedback: Long-term, regular use of quinine for management of leg cramps is associated with loss of hearing acuity. Radiation therapy for cancer should not affect hearing; however, hearing can be significantly compromised by chemotherapy. Allergy to hair products may be associated with otitis externa; however, it is not linked to hearing loss. An ear drum that perforates spontaneously due to the sudden drop in altitude associated with a high dive usually heals well and is not likely to become infected. Recurrent otitis media with perforation can affect hearing as a result of chronic inflammation of the ossicles in the middle ear.
A group of high school students is attending a concert, which will be at a volume of 80 to 90 dB. What is a health consequence of this sound level? A) Hearing will not be affected by a decibel level in this range. B) Hearing loss may occur with a decibel level in this range. C) Sounds in this decibel level are not perceived to be harsh to the ear. D) Ear plugs will have no effect on these decibel levels.
Ans: B Feedback: Sound louder than 80 dB is perceived by the human ear to be harsh and can be damaging to the inner ear. Ear protection or plugs do help to minimize the effects of high decibel levels.
A nurse is planning preoperative teaching for a patient with hearing loss due to otosclerosis. The patient is scheduled for a stapedectomy with insertion of a prosthesis. What information is most crucial to include in the patient's preoperative teaching? A) The procedure is an effective, time-tested treatment for sensory hearing loss. B) The patient is likely to experience resolution of conductive hearing loss after the procedure. C) Several months of post-procedure rehabilitation will be needed to maximize benefits. D) The procedure is experimental, but early indications suggest great therapeutic benefits.
Ans: B Feedback: Stapedectomy is a very successful time-tested procedure, resulting in the restoration of conductive hearing loss. Lengthy rehabilitation is not normally required.
The nurse and a colleague are performing the Epley maneuver with a patient who has a diagnosis of benign paroxysmal positional vertigo. The nurses should begin this maneuver by performing what action? A) Placing the patient in a prone position B) Assisting the patient into a sitting position C) Instilling 15 mL of warm normal saline into one of the patient's ears D) Assessing the patient's baseline hearing by performing the whisper test
Ans: B Feedback: The Epley maneuver is performed by placing the patient in a sitting position, turning the head to a 45-degree angle on the affected side, and then quickly moving the patient to the supine position. Saline is not instilled into the ears and there is no need to assess hearing before the test.
The nurse is caring for a patient who has undergone a mastoidectomy. In an effort to prevent postoperative infection, what intervention should the nurse implement? A) Teach the patient about the risks of ototoxic medications. B) Instruct the patient to protect the ear from water for several weeks. C) Teach the patient to remove cerumen safely at least once per week. D) Instruct the patient to protect the ear from temperature extremes until healing is complete.
Ans: B Feedback: To prevent infection, the patient is instructed to prevent water from entering the external auditory canal for 6 weeks. Ototoxic medications and temperature extremes do not present a risk for infection. Removal of cerumen during the healing process should be avoided due to the possibility of trauma.
A patient has been diagnosed with serous otitis media for the third time in the past year. How should the nurse best interpret this patient's health status? A) For some patients, these recurrent infections constitute an age-related physiologic change. B) The patient would benefit from a temporary mobility restriction to facilitate healing. C) The patient needs to be assessed for nasopharyngeal cancer. D) Blood cultures should be drawn to rule out a systemic infection.
Ans: C Feedback: A carcinoma (e.g., nasopharyngeal cancer) obstructing the eustachian tube should be ruled out in adults with persistent unilateral serous otitis media. This phenomenon is not an age-related change and does not indicate a systemic infection. Mobility limitations are unnecessary.
A child goes to the school nurse and complains of not being able to hear the teacher. What test could the school nurse perform that would preliminarily indicate hearing loss? A) Audiometry B) Rinne test C) Whisper test D) Weber test
Ans: C Feedback: A general estimate of hearing can be made by assessing the patient'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. These tests, as well as audiometry, are not usually performed by a registered nurse in a general practice setting.
Which of the following nursing interventions would most likely facilitate effective communication with a hearing-impaired patient? A) Ask the patient to repeat what was said in order to evaluate understanding. B) Stand directly in front of the patient to facilitate lip reading. C) Reduce environmental noise and distractions before communicating. D) Raise the voice to project sound at a higher frequency.
Ans: C Feedback: Communication with the hearing impaired can be facilitated by talking in a quiet space free of competing noise stimuli and other distractions. Asking the patient to repeat what was said is likely to provoke frustration in the patient. A more effective strategy would be to repeat the question or statement, choosing different words. Raising the voice to project sound at higher frequency would make understanding more difficult. The nurse cannot assume that the patient reads lips. If the patient does read lips, on average he or she will understand only 50% of words accurately.
The clinic nurse is assessing a child who has been brought to the clinic with signs and symptoms that are suggestive of otitis externa. What assessment finding is characteristic 1. of otitis externa? A) Tophi on the pinna and ear lobe B) Dark yellow cerumen in the external auditory canal C) Pain on manipulation of the auricle D) Air bubbles visible in the middle ear
Ans: C Feedback: Pain when the nurse pulls gently on the auricle in preparation for an otoscopic examination of the ear canal is a characteristic finding in patients with otitis externa. Tophi are deposits of generally painless uric acid crystals; they are a common physical assessment finding in patients diagnosed with gout. Cerumen is a normal finding during assessment of the ear canal. Its presence does not necessarily indicate that inflammation is present. Air bubbles in the middle ear may be visualized with the otoscope; however, these do not indicate a problem involving the ear canal.
A patient is being discharged home after mastoid surgery. What topic should the nurse address in the patient's discharge education? A) Expected changes in facial nerve function B) The need for audiometry testing every 6 months following recovery C) Safe use of analgesics and antivertiginous agents D) Appropriate use of OTC ear drops
Ans: C Feedback: Patients require instruction about medication therapy, such as analgesics and antivertiginous agents (e.g., antihistamines) prescribed for balance disturbance. OTC ear drops are not recommended and changes in facial nerve function are signs of a complication that needs to be addressed promptly. There is no need for serial audiometry testing.
A patient has been diagnosed with hearing loss related to damage of the end organ for hearing or cranial nerve VIII. What term is used to describe this condition? A) Exostoses B) Otalgia C) Sensorineural hearing loss D) Presbycusis
Ans: C Feedback: Sensorineural hearing loss is loss of hearing related to damage of the end organ for hearing or cranial nerve VIII. Exostoses refer to small, hard, bony protrusions in the lower posterior bony portion of the ear canal. Otalgia refers to a sensation of fullness or pain in the ear. Presbycusis is the term used to refer to the progressive hearing loss associated with aging. Both middle and inner ear age-related changes result in hearing loss.
A 6-month-old infant is brought to the ED by his parents for inconsolable crying and pulling at his right ear. When assessing this infant, the advanced practice nurse is aware that the tympanic membrane should be what color in a healthy ear? A) Yellowish-white B) Pink C) Gray D) Bluish-white
Ans: C Feedback: The healthy tympanic membrane appears pearly gray and is positioned obliquely at the base of the ear canal. Any other color is suggestive of a pathological process.
The nurse is assessing a patient with multiple sclerosis who is demonstrating involuntary, rhythmic eye movements. What term will the nurse use when documenting these eye movements? A) Vertigo B) Tinnitus C) Nystagmus D) Astigmatism
Ans: C Feedback: Vertigo is an illusion of movement where the individual or the surroundings are sensed as moving. Tinnitus refers to a subjective perception of sound with internal origin. Nystagmus refers to involuntary rhythmic eye movement. Astigmatism is a defect is visual acuity.
The nurse is planning the care of a patient with a diagnosis of vertigo. What nursing diagnosis risk should the nurse prioritize in this patient's care? A) Risk for disturbed sensory perception B) Risk for unilateral neglect C) Risk for falls D) Risk for ineffective health maintenance
Ans: C Feedback: Vertigo is defined as the misperception or illusion of motion, either of the person or the surroundings. A patient suffering from vertigo will be at an increased risk of falls. For most patients, this is likely to exceed the patient's risk for neglect, ineffective health maintenance, or disturbed sensation.
An older adult with a recent history of mixed hearing loss has been diagnosed with a cholesteatoma. What should this patient be taught about this diagnosis? Select all that apply A) Cholesteatomas are benign and self-limiting, and hearing loss will resolve spontaneously. B) Cholesteatomas are usually the result of metastasis from a distant tumor site. C) Cholesteatomas are often the result of chronic otitis media. D) Cholesteatomas, if left untreated, result in intractable neuropathic pain. E) Cholesteatomas usually must be removed surgically.
Ans: C, E Feedback: Cholesteatoma is a tumor of the external layer of the eardrum into the middle ear, often resulting from chronic otitis media. They usually do not cause pain; however, if treatment or surgery is delayed, they may burst or destroy the mastoid bone. They are not normally the result of metastasis and are not self-limiting.
Which of the following nurse's actions carries the greatest potential to prevent hearing loss due to ototoxicity? A) Ensure that patients understand the differences between sensory hearing loss and conductive hearing loss. B) Educate patients about expected age-related changes in hearing perception. C) Educate patients about the risks associated with prolonged exposure to environmental noise. D) Be aware of patients' medication regimens and collaborate with other professionals accordingly.
Ans: D Feedback: A variety of medications may have adverse effects on the cochlea, vestibular apparatus, or cranial nerve VIII. All but a few, such as aspirin and quinine, cause irreversible hearing loss. Ototoxicity is not related to age-related changes, noise exposure, or the differences between types of hearing loss.
The nurse is reviewing the health history of a newly admitted patient and reads that the patient has been previously diagnosed with exostoses. How should the nurse accommodate this fact into the patient's plan of care? A) The nurse should perform the Rinne and Weber tests. B) The nurse should arrange for audiometry testing as soon as possible. C) The nurse should collaborate with the pharmacist to assess for potential ototoxic medications. D) No specific assessments or interventions are necessary to addressing exostoses.
Ans: D Feedback: Exostoses are small, hard, bony protrusions found in the lower posterior bony portion of the ear canal; they usually occur bilaterally. They do not normally impact hearing and no treatments or nursing actions are usually necessary.
Following a motorcycle accident, a 17-year-old man is brought to the ED. What physical assessment findings related to the ear should be reported by the nurse immediately? A) The malleus can be visualized during otoscopic examination. B) The tympanic membrane is pearly gray. C) Tenderness is reported by the patient when the mastoid area is palpated. D) Clear, watery fluid is draining from the patient's ear.
Ans: D Feedback: For the patient experiencing acute head trauma, immediately report the presence of clear, watery drainage from the ear. The fluid is likely to be cerebrospinal fluid associated with skull fracture. The ability to visualize the malleus is a normal physical assessment finding. The tympanic membrane is normally pearly gray in color. Tenderness of the mastoid area usually indicates inflammation. This should be reported, but is not a finding indicating urgent intervention.
A patient with a sudden onset of hearing loss tells the nurse that he would like to begin using hearing aids. The nurse understands that the health professional dispensing hearing aids would have what responsibility? A) Test the patient's hearing promptly. B) Perform an otoscopy. C) Measure the width of the patient's ear canal. D) Refer the patient to his primary care physician.
Ans: D Feedback: Health care professionals who dispense hearing aids are required to refer prospective users to a physician if the patient has sudden or rapidly progressive hearing loss. This would be a health priority over other forms of assessment, due to the possible presence of a pathologic process.
A child has been experiencing recurrent episodes of acute otitis media (AOM). The nurse should anticipate that what intervention is likely to be ordered? A) Ossiculoplasty B) Insertion of a cochlear implant C) Stapedectomy D) Insertion of a ventilation tube
Ans: D Feedback: If AOM recurs and there is no contraindication, a ventilating, or pressure-equalizing, tube may be inserted. The ventilating tube, which temporarily takes the place of the eustachian tube in equalizing pressure, is retained for 6 to 18 months. Ossiculoplasty is not used to treat AOM and stapedectomy is performed to treat otosclerosis. Cochlear implants are used to treat sensorineural hearing loss.
On otoscopy, a red blemish behind the tympanic membrane is suggestive of what diagnosis? A) Acoustic tumor B) Cholesteatoma C) Facial nerve neuroma D) Glomus tympanicum
Ans: D Feedback: In the case of glomus tympanicum, a red blemish on or behind the tympanic membrane is seen on otoscopy. This assessment finding is not associated with an acoustic tumor, facial nerve neuroma, or cholesteatoma.
A patient presents to the ED complaining of a sudden onset of incapacitating vertigo, with nausea and vomiting and tinnitus. The patient mentions to the nurse that she suddenly cannot hear very well. What would the nurse suspect the patient's diagnosis will be? A) Ossiculitis B) Ménière's disease C) Ototoxicity D) Labyrinthitis
Ans: D Feedback: Labyrinthitis is characterized by a sudden onset of incapacitating vertigo, usually with nausea and vomiting, various degrees of hearing loss, and possibly tinnitus. None of the other listed diagnosis is characterized by a rapid onset of symptoms.
A nurse is teaching preventative measures for otitis externa to a group of older adults. What action should the nurse encourage? A) Rinsing the ears with normal saline after swimming B) Avoiding loud environmental noises C) Instilling antibiotic ointments on a regular basis D) Avoiding the use of cotton swabs
Ans: D Feedback: Nurses should instruct patients not to clean the external auditory canal with cotton-tipped applicators and to avoid events that traumatize the external canal such as scratching the canal with the fingernail or other objects. Environmental noise should be avoided, but this does not address the risk for ear infection. Routine use of antibiotics is not encouraged and rinsing the ears after swimming is not recommended.
After mastoid surgery, an 81-year-old patient has been identified as needing assistance in her home. What would be a primary focus of this patient's home care? A) Preparation of nutritious meals and avoidance of contraindicated foods B) Ensuring the patient receives adequate rest each day C) Helping the patient adapt to temporary hearing loss D) Assisting the patient with ambulation as needed to avoid falling
Ans: D Feedback: The caregiver and patient are cautioned that the patient may experience some vertigo and will therefore require help with ambulation to avoid falling. The patient should not be expected to experience hearing loss and no foods are contraindicated. Adequate rest is needed, but this is not a primary focus of home care.
The nurse is discharging a patient home after mastoid surgery. What should the nurse include in discharge teaching? A) "Try to induce a sneeze every 4 hours to equalize pressure." B) "Be sure to exercise to reduce fatigue." C) "Avoid sleeping in a side-lying position." D) "Don't blow your nose for 2 to 3 weeks."
Ans: D Feedback: The patient is instructed to avoid heavy lifting, straining, exertion, and nose blowing for 2 to 3 weeks after surgery to prevent dislodging the tympanic membrane graft or ossicular prosthesis. Side-lying is not contraindicated; sneezing could cause trauma.
