Ch. 14 PrepU Practice Questions

A 12-year-old boy has been brought to the emergency department after being hit in the head with a pitch during a baseball game. The emergency department nurse's comprehensive assessment includes examination of the boy's ears with an otoscope. What assessment finding would suggest trauma to the middle ear or inner ear? a) Dark red or bluish tympanic membrane b) White spots on the tympanic membrane c) Yellowish, bulging tympanic membrane d) Clear tympanic membrane

Dark red or bluish tympanic membrane Explanation: A blue or dark red tympanic membrane indicates blood behind the eardrum due to trauma. A yellow appearance is suggestive of ear infection, and white spots or streaks are caused by recurrent infections.

The nurse is presenting an educational event for gardeners. When discussing the ears, what would be an important topic to cover? Sound control Otalgia Tinnitus Skin cancer prevention

Skin cancer prevention Explanation: Many melanomas develop near or on the helix of the ear. Teaching clients how to protect themselves from unnecessary sun exposure increases the likelihood of preventative behaviors. Otalgia is an earache. Tinnitus is ringing in the ears. Sound control would be related to environmental loud noises. None of the three would be a topic for gardeners.

A nurse health promotion teaching is focusing on hygiene and the prevention of illness. When instructing clients how to clean their ears, what action should the nurse recommend? a) Washing with a warm, moist washcloth b) Cleaning with cotton-tipped applicator c) Irrigating with mildly soapy water d) Gently irrigating with normal saline

Washing with a warm, moist washcloth Explanation: A warm, moist washcloth should be used to clean the outside of the ears, but nothing (including fluids) should be inserted into the ear canal.

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

"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.

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

"It identifies a problem with the normal pathways for sound to travel to your inner ear." Explanation: Placing the tuning fork on the mastoid bone is one part of the Rinne's test, which assesses the normal pathways for sound to travel to the inner ear. Equilibrium is assessed with the Romberg test. Multiple sources of assessment data are used to determine whether hearing loss is caused by degeneration of nerves in the inner ear or repeated ear infections.

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 a) "Certain cultural groups have a higher rate of hearing loss." b) "There is a genetic predisposition to hearing loss." c) "It is difficult to prevent hearing loss or worsening of hearing." d) "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.

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? a) "He should avoid flying for 6 months after tube placement." b) "The child must wear ear plugs while flying." c) "It's safe to fly because the tubes will equalize pressure." d) "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.

A patient calls the clinic and tells the nurse that the doctor told her that she has "otalgia." The patient cannot remember what the doctor explained this to be. How would the nurse most appropriately respond? a) "Otalgia is the beginning of hearing loss." b) "Otalgia is a disease of the inner ear." c) "Otalgia is pain in the ear." d) "Otalgia is a dysfunction of the ear."

"Otalgia is pain in the ear." Explanation: Otalgia usually indicates ear dysfunction, most commonly otitis media or otitis externa. Pain in the ear can be referred from the pharynx. It is not uncommon for a patient recovering from tonsil surgery to complain of ear pain. Severe pain followed by relief and drainage indicates a ruptured TM.

A client has sought care at the clinic, telling the nurse, "This ringing in my ears has gone on for weeks, and it's driving me crazy." The patient denies exposure to excessive noise levels. The nurse recognizes the likely presence of tinnitus and should follow up with which of the following questions? a) "How do you usually clean your ears?" b) "What medications are you currently taking?" c) "Did your parents even complain of something similar?" d) "How would you describe your overall level of health?"

"What medications are you currently taking?" Explanation: Tinnitus may be associated with certain ototoxic medications. There is not usually a family history of this problem. Cerumen buildup can contribute, but hygiene is not a common etiology of tinnitus. The client's overall perception of health is important but is less likely to explain why he is experiencing tinnitus.

Question: 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? 1. Sound waves enter though the ear's external auditory canal and strike the tympanic membrane. 2. The ossicles within the middle ear act as a moveable bridge to transmit these vibrations to the oval window, which amplifies the sound waves. 3. The tympanic membrane vibrates at various speeds in response to various pitches of sounds. 4. 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. 5. 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.

-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.

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

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

An increased risk of falls is dangerous for any patient. What patient would be at an increased risk of falls? a) A patient with a hearing loss of 45 dB. b) A patient with acute otitis media. c) A patient with vertigo. d) A patient with damage to the VIIIth cranial nerve.

A patient with vertigo. Explanation: 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. This makes options A, B and D incorrect.

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

A progressive, bilateral loss of hearing Explanation: A progressive, bilateral loss of hearing is the characteristic symptom of otosclerosis. Tinnitus appears as the loss of hearing progresses; it is especially noticeable at night, when surroundings are quiet, and may be quite distressing to the client. The eardrum appears pinkish-orange from structural changes in the middle ear. The client often describes a history of having had a recent upper respiratory infection in case of otitis media, not otosclerosis

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

A progressive, bilateral loss of hearing Explanation: A progressive, bilateral loss of hearing is the characteristic symptom of otosclerosis. Tinnitus appears as the loss of hearing progresses; it is especially noticeable at night, when surroundings are quiet, and may be quite distressing to the client. The eardrum appears pinkish-orange from structural changes in the middle ear. The client often describes a history of having had a recent upper respiratory infection in case of otitis media, not otosclerosis.

The nurse notes a cyst on the ear of an older adult. Which assessment data is consistent with a cyst? a) A sac with a membranous lining filled with fluid b) A hard nodule composed of uric acid crystals c) Redness and bulging of the eardrum d) Swelling of the external ear canal

A sac with a membranous lining filled with fluid Explanation: A cyst on the ear would present as a fluid-filled sac. A tophus is a hard nodule composed of uric acid crystals. Redness and bulging of the eardrum is characteristic of otitis media with effusion. Swelling of the external ear canal with inflammation or infection would be referred to as an edematous ear

A patient has Darwin tubercle. What is this? a) A type of skin cancer found on the ear b) A growth in the ear canal c) A small painless nodule on the helix d) A growth in the bony labyrinth

A small painless nodule on the helix Explanation: Small painless nodules on the helix are a variation of normal anatomy known as darwinian tubercle.

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

A story his wife is telling him Explanation: Presbycusis often begins with a loss of high-frequency sounds (woman's voice) followed later by the loss of low-frequency sounds. The bass speakers, his son's voice, and the engine starting would all have lower-frequency sounds than his wife's voice.

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? a) Trauma b) Repeated ear infections c) Acute otitis media d) Age-related changes

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

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

Ask the mother how long the tubes have been in place. Explanation: Ear tubes generally fall out spontaneously in 2-5 years after placement, and the membrane most often closes. The client does not need manual removal in the office or operating room unless the child is experiencing problems. Antibiotics are indicated for infection and are not necessary for removal.

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? a) Assess the boy for previous trauma to his skull. b) Assess the child for further symptoms of acute otitis media. c) Determine whether impacted cerumen is present. d) Ask the mother whether the child has had numerous ear infections.

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.

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

Ask whether the client is experiencing ear pain or pressure Explanation: The older client's eardrums may appear cloudy with prominent landmarks due to the atrophy of the tympanic membranes associated with normal aging. The nurse should ask the client about ear pain because prominent landmarks can also be a sign of negative pressure associated with obstructed eustachian tubes. An ear infection should be ruled out and problems with hearing and balance assessed before making a clinical judgment that this is a normal finding. All objective information should be documented by the nurse.

High doses of this medication can produce bilateral tinnitus? a) Aspirin b) Antivert c) Promethazine d) 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 (Phernergan) suppositories help control the nausea and vomiting and the vertigo because of the antihistamine effect.

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

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.

An alternate pathway that bypasses the external and middle ear is called what? a) Bone conduction b) Air conduction c) Neuro conduction d) Sensory conduction

Bone conduction Correct Explanation: An alternate pathway, known as bone conduction, bypasses the external and middle ear and is used for testing purposes.

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

Continue with the examination Earlobes may be free, attached, or soldered (tightly attached to adjacent skin with no apparent lobe). Most African Americans and Caucasians have free lobes, whereas most Asians have attached or soldered lobes, although any type is possible in all cultural groups. Thus, this finding is normal and does not need to be reported to the physician, followed up on with a question to the client about an ear injury, or recorded and followed up on at a later visit

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

Equalizes the pressure in the middle ear with atmospheric pressure. Explanation: The eustachian tube opens during swallowing or yawning. Its function is to equalize the pressure in the middle ear with atmospheric pressure so that there is equal pressure on both sides of the tympanic membrane to allow the drum to vibrate freely. The stapes transmits the vibration to the fluid-filled inner ear at the oval window. The vestibule sends information to the cerebellum and the midbrain. The tympanic membrane separates the external from the middle ear.

The nurse would suspect a problem at which area when pressure builds up on either side of the tympanic membrane? a) Organ of Corti b) Cochlea c) Vestibulocochlear nerve d) Eustachian tube

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 chochlea, organ of Corti, and the vestibulocochlear nerve are part of the inner ear.

The nursing student hopefuls are taking a pre-nursing anatomy and physiology class. What will they learn is the anatomical feature that equalizes air pressure in the middle ear? a) Eustachian tube b) The malleus c) The pinna d) The meatus

Eustachian tube Explanation: The eustachian tube extends from the floor of the middle ear to the pharynx and is lined with mucous membrane. It equalizes air pressure in the middle ear. Options B, C and D do not equalize pressure in the middle ear.

An avid swimmer presents with ear pain. Her history includes pain and drainage from the left ear. On examination, she has pain when the ear, including the tragus, is manipulated. The canal is narrowed and erythematous with some white debris in the canal. The rest of the examination is normal. What diagnosis would be most appropriate for this client? a) Perforation of the tympanum b) Cholesteatoma c) External otitis d) Otitis media

External otitis Explanation: This is a classic history and examination of a client suffering from external otitis. Otitis media would not usually include pain with movement of the external ear or drainage unless the eardrum was perforated. In this case, the examination of the eardrum is recorded as normal. Cholesteatoma is a growth behind the eardrum and would not account for these symptoms. Otitis media would classically be accompanied by a bulging, erythematous eardrum.

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

Fluid collects in the middle ear causing an obstruction of the auditory tube. Explanation: Serous otitis media results from fluid that collects in the middle ear, causing an obstruction of the auditory tube. This condition may stem from infection, allergy, tumors, or sudden changes in altitude. Symptoms include crackling sensations and fullness in the ear, with some hearing loss. Acute purulent otitis media is generally caused by an upper respiratory infection spreading through the auditory tube. Pus forms and collects in the middle ear to create pressure on the eardrum. Chronic otitis media can develop if acute purulent otitis media is not treated promptly. Chronic purulent otitis media is usually associated with a punctured eardrum or may be a complication of acute otitis media, mastoiditis, or a severe upper respiratory infection.

A client has been receiving intravenous antibiotics for several weeks. Which prevention strategy would be best for the nurse to recommend for this client? a) Whisper hearing test b) Formal hearing test c) Tuning fork test d) Rubbing fingers test

Formal hearing test Explanation: One group at risk for developing a hearing loss is those who are receiving intravenous antibiotics. The prevention strategy that would be applicable for this client would be a formal hearing test. Although the other tests including whisper hearing test, rubbing fingers test and tuning fork test can be used to test hearing, these are not considered the gold standard. These tests would not be the best prevention strategy to rule out hearing loss in this case.

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

Gray Explanation: The healthy tympanic membrane appears pearly gray and is positioned obliquely at the base of the ear canal. This makes options A, B and D incorrect.

The nurse caring for a client with Ménière's disease makes what assessments? a) Level of disability b) Ability to function c) Social support d) Gross hearing

Gross hearing Explanation: The nurse assesses gross hearing and performs the Weber and Rinne tests. It also is important to determine the extent and effect of the client's disability.

When inspecting the tympanic membrane, which of the following structures does the nurse expect to identify? a) Pars tensa, pars flaccida, vestibule, cone of light b) Handle of malleus, short process of malleus, cone of light c) Pars tensa, umbo, handle of malleus, ossicles d) Cone of light, incus, umbo, cochlea

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 maleus. The cochlea, vestibule, and stapes (part of the ossicles) are not normally visualizable

A nurse is preparing to perform a general assessment of an adult client who is new to the clinic. How would the nurse prepare to obtain objective data about the client's ears? (Select all that apply.) Make sure the client is comfortable in a quiet room Place the client's ears at the nurse's eye level Have the client sit on the examination table Place the client in semi-Fowler's position on the examination table Perform the whisper, Weber, and Rinne tests before inspection

Have the client sit on the examination table Explanation: To obtain objective data about the ears, it is best to make sure the client is comfortable and the room is quiet. It is ideal for the client's ears to be at the nurse's eye level to facilitate inspection that does not cause discomfort for the client. For adults and older children, nurses can perform the examination with the patient sitting on the examination table. The nurse would inspect before performing the whisper, Weber, and Rinne tests. The client would sit in the upright position, not semi-Fowler's position for the exam.

A clinic client's primary complaint is earache (otalgia). Consequently, the nurse's assessment is focusing on potential causes of the client's pain. What question should the nurse include in the health interview? a) "Have you been swimming lately?" b) "What do you do for a living?" c) "Do you know if your vaccinations are up to date?" d) "Do you take over-the-counter medications or supplements?"

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

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

Hearing intact bilaterally on whisper test Explanation: Documentation of the whisper test should be "hearing intact bilaterally on whisper test." Documentation of the Rinne and Weber test results usually validates normal findings (e.g., "No unexpected findings on Weber and Rinne tests."). The report from the client is a subjective assessment finding.

A nurse is preparing a community education session on hearing loss. Which information should the nurse include? Hearing loss can lead to mental health problems. All ethnic groups experience hearing loss in the same way. Hearing loss typically begins after the age of 40. In order to hold a driver's license, hearing must be tested regularly.

Hearing loss can lead to mental health problems. Explanation: Hearing is a critical sense with which one can experience the world. Loss of hearing is associated with social and emotional isolation which can lead to mental health problems. All ethnic groups do not experience hearing loss in the same way. African Americans experience less hearing loss due to higher amounts of melanin in the cochlea. Unlike vision prerequisites for driving, there is no mandate for widespread testing of hearing. Hearing loss can begin at any age, not just after 40.

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

Helps to regulate pressure in the middle ear Explanation: The eustachian tube, a conduit that connects the middle ear to the nasopharynx, allows for pressure regulation of the middle ear. The other options are distracters for the question.

Which finding should a nurse recognize as a normal when assessing the ears of an elderly client? a) Decrease in cerumen production b) Increased elasticity of the pinna c) Bulging tympanic membrane d) High tone frequency loss

High tone frequency loss Explanation: Presbycusis, a gradual hearing loss, is common after the age of 50 years. It begins with a loss of the ability to hear high frequency tones. Cerumen production may increase in older age or become direr and build up as t he cilia become more rigid. The pinna looses elasticity in older age. A bulging tympanic membrane is not a normal finding at any age.

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

In the midline of the client's skull or in the center of the forehead. Explanation: The Weber test is performed by striking the tuning fork and placing its stem in the midline of the client's skull or in the center of the forehead. In the Rinne test, the tuning fork is struck and placed on the mastoid process behind the ear. The tuning fork is not placed near the external meatus of each ear or under the bridge of the nose.

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? a) Otosclerosis b) Perforated eardrum c) Otitis media d) Inner ear problem

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.

A client presents to an ambulatory clinic with purulent, bloody drainage of the ear. Which of the following should the nurse assess first? a) Inspect the client's external ear canal. b) Assess the client's tympanic membrane. c) Perform hearing assessments. d) Palpate the client's tragus.

Inspect the client's external ear canal. Explanation: Purulent, bloody drainage suggests external otitis, an infection of the external ear canal. Therefore the nurse would need to inspect the external auditory canal. Assessing the tympanic membrane would be appropriate if the client has purulent drainage, pain, and complained of a popping sensation, which is associated with otitis media and tympanic perforation. Palpation of the tragus is not an immediate priority in cases of suspected external otitis. Hearing assessments may later be indicated, but these would not be performed at the beginning of the assessment

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

Never put anything smaller than your elbow in your ears. Explanation: The nurse should reinforce proper cleaning techniques such as cleaning the bowl of the helix and never introducing anything into the external auditory canal. An elbow will not fit into an ear canal; therefore stating not to put anything smaller than an elbow into the ears, eliminates putting anything into the external ear canal. It's also a fun way to educate school age children. Cotton tipped applicators can cause complications and should not be used to clean the ears. An increased amount of earwax, not decreased, can lead to conductive hearing loss.

While inspecting the client's tympanic membrane, the nurse notes a pearly gray and shiny appearance. The nurse would interpret this finding as which of the following? a) Normal tympanic membrane b) Scarring from previous infections c) Otitis media d) Otitis externa

Normal tympanic membrane Explanation: The tympanic membrane is normally a pearly gray color with a shiny appearance. White spots would indicate scarring. A yellowish bulging membrane would suggest serous otitis media; a red bulging membrane would suggest acute otitis media. Otitis externa does not directly affect the appearance of the tympanic membrane.

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

Notify the healthcare provider about the finding. 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.

What is located in the cochlea of the inner ear? a) Vestibulocochlear nerve b) Labyrinth c) Organ of Corti d) Semicircular canals

Organ of Corti Explanation: The fluid motion created by the vibrating stapes excites the nerve endings in the sensitive sound receptors of the organ of Corti located in the cochlea

A nurse palpates a client's ear and finds that the tragus is tender. The nurse suspects which of the following? a) Otitis media b) Otitis externa c) Ruptured tympanic membrane d) 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.

A nurse obtains an objective assessment on a child who presents to the clinic with reports of right ear pain. 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 the family was on vacation at the beach last week. The nurse recognizes these findings as an indication of what acute ear condition? a) Acute otitis media b) Otitis externa c) Perforated tympanic membrane d) Foreign body

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 resents with many of the same symptoms but the pain is behind the ear and the tympanic membrane is red, swollen, with 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.

While interviewing a client who complains of earache, the nurse asks, "Is there anything that makes it better or worse?" The client replies, "It hurts much worse when I wiggle my ear." Which of the following conditions should the nurse most suspect? a) Sinus infection b) Otitis externa c) Teeth problems d) Ear infection

Otitis externa Explanation: Pain caused by "swimmer's ear," or otitis externa, differs from pain felt in middle-ear infections. If you can wiggle the outer ear without pain, the condition is most likely not swimmer's ear. Earache (otalgia) can also occur with ear infections, cerumen blockage, sinus infections, or teeth and gum problems.

A patient comes to the clinic and reports pain when he touches his ear. With what is this finding most consistent? Otitis media Meniere disease Acoustic neuroma Otitis externa

Otitis externa Explanation: Pain with auricle movement or tragus palpation indicates otitis externa or furuncle.

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

Pain on manipulation of the auricle Explanation: Tophi are deposits of uric acid crystals and are generally painless; they are a common physical assessment finding in clients diagnosed with gout. Cerumen is a normal finding during assessment of the ear canal. Its presence does not necessarily indicate that inflammation is present. Pain when the nurse pulls gently on the auricle in preparation for an otoscopic examination of the ear canal is a characteristic finding in clients with otitis externa. Air bubbles in the middle ear may be visualized with the otoscope; however, these do not indicate a problem involving the ear canal. Aural tenderness or pain is not usually associated with middle ear disorders

Which statement reflects accurate documentation by the nurse of a normal, left tympanic membrane? a) Pearly gray, translucent, with cone of light at 7 o'clock position b) Light pink, opaque, with cone of light at 5 o'clock position c) Pearly gray, translucent, with cone of light at 5 o'clock position d) Light yellow, slightly protruding, with cone of light at 7 o'clock position

Pearly gray, translucent, with cone of light at 7 o'clock position Explanation: A normal tympanic membrane should be pearly gray, shiny, translucent. The cone of light in the left ear is located at the 7 o'clock position. The cone of light will be located at the 5 o'clock position in the right ear. A tympanic membrane that is pink or red may exhibit an absent light reflex and indicate acute otitis media. A yellow color to the tympanic membrane with bulging or protrusion indicates the presence of fluid

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

Perforated eardrum Explanation: The transmission of sound waves through the external and middle ear is referred to as "conductive hearing," and the transmission of sound waves in the inner ear is referred to as "perceptive" or "sensorineural hearing." Therefore, a conductive hearing loss would be related to a dysfunction of the external or middle ear (e.g., impacted ear wax, otitis media, foreign object, perforated eardrum, drainage in the middle ear, or otosclerosis). A "sensorineural loss" would be related to dysfunction of the inner ear (i.e., cranial nerve VIII, temporal lobe of brain, or organ of Corti)

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

Perforated eardrum Explanation: The transmission of sound waves through the external and middle ear is referred to as "conductive hearing," and the transmission of sound waves in the inner ear is referred to as "perceptive" or "sensorineural hearing." Therefore, a conductive hearing loss would be related to a dysfunction of the external or middle ear (e.g., impacted ear wax, otitis media, foreign object, perforated eardrum, drainage in the middle ear, or otosclerosis). A "sensorineural loss" would be related to dysfunction of the inner ear (i.e., cranial nerve VIII, temporal lobe of brain, or organ of Corti).

Which precaution should a nurse take to ensure the safety of a client when performing the Romberg test? Place arms around the client without touching Tell the client to keep the eyes open & focused ahead Instruct the client to hold on to a chair Offer assistance by holding the client's arm

Place arms around the client without touching Explanation: During the Romberg test, the nurse should put his or her arms around the client without touching to prevent the client from falling. The eyes are closed to assess the client's ability to maintain equilibrium without looking or holding onto something. The client should not be instructed to hold on to a chair during the test as it may interfere with the assessment of equilibrium. The nurse should not hold the client's arm as it would give support to the client and affect the result.

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

Possible basilar skull fracture Explanation: Hemotympanum, otorrhea, or tympanic membrane rupture may indicate barotrauma from pressure changes or a basilar skull fracture. Otitis externa is a outer ear infection. Otitis media is an inner ear infection. The drainage from the ear is a classic sign of a possible basilar skull fracture. Possible mass in the ear is a distracter to the question.

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? a) Tinnitus b) Conductive hearing loss c) Presbycusis d) 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

A 66-year-old client states that he has increasing difficulty hearing high-pitched sounds. The patient's statement most likely suggests that he has what diagnosis? a) Vertigo b) Otalgia c) Presbycusis d) Tinnitus

Presbycusis Explanation: Presbycusis, a gradual hearing loss that often begins with a loss of the ability to hear high-frequency sounds, is common after age 50. Vertigo refers to a true spinning motion. Otalgia refers to ear pain. Tinnitus refers to ringing in the ears.

Which terms refers to the progressive hearing loss associated with aging?

Presbycusis Explanation: Both middle and inner ear age-related changes result in hearing loss. Exostoses refers 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. Sensorineural hearing loss is loss of hearing related to damage of the end organ for hearing and/or cranial nerve VIII.

When moving a client's left auricle up and back, the client reports pain. What should the nurse do? Perform an otoscopic examination of the right ear before the left. Press on the left tragus to confirm the presence of discharge. Confine the otoscopic inspection to the right ear. Postpone the otoscopic examination.

Press on the left tragus to confirm the presence of discharge. Explanation: Pain on movement of the auricle suggests otitis externa; the presence of discharge would confirm an infectious process and should be assessed. It is not likely necessary to abandon or change the sequence of otoscopic examination.

Some clients with acoustic neuromas have vertigo. What is a priority nursing action with clients with vertigo? Protect the client from injury Mobilize the client at every opportunity Provide ice to the affected ear Provide small meals of tepid food

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.

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

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.

Which characteristic feature of the tympanic membrane should a nurse anticipate finding in a client with otitis media? a) Pearly, translucent with no bulging b) Yellowish, bulging with fluid bubbles c) Gray, translucent with retraction d) 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.

Which characteristic feature of the tympanic membrane should a nurse anticipate finding in a client with acute otitis media? You Selected: 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 no retraction is a normal finding in the tympanic membrane.

The nurse notes otitis media with effusion in the left ear of a 3-year-old child. Which assessment data is consistent with otitis media with effusion? a) Dense white patches on the tympanic membrane b) Clear discharge in the ear canal c) Bloody discharge in the ear canal d) Redness and bulging of the eardrum

Redness and bulging of the eardrum Explanation: Redness and bulging of the eardrum are characteristic of otitis media with effusion. Clear or bloody discharge occurs with rupture of the tympanic membrane. Dense white patches on the tympanic membrane are noted with scarring of the tympanic membrane

The nurse notes otitis media with effusion in the left ear of a 3-year-old child. Which assessment data is consistent with otitis media with effusion? a) Redness and bulging of the eardrum b) Dense white patches on the tympanic membrane c) Clear discharge in the ear canal d) Bloody discharge in the ear canal

Redness and bulging of the eardrum Explanation: Redness and bulging of the eardrum are characteristic of otitis media with effusion. Clear or bloody discharge occurs with rupture of the tympanic membrane. Dense white patches on the tympanic membrane are noted with scarring of the tympanic membrane. (

After conducting a health history, the nurse decides to perform the assessment shown. What finding did the nurse use to make this clinical determination?

Reduced hearing in one ear Explanation: The Weber test is used to determine unilateral hearing loss. With conductive hearing loss, the client reports hearing the tuning fork sound better in the poor ear. With sensorineural hearing loss, the client hears the sound better in the good ear. The Weber test is not used to assess a sore throat. There are many reasons for a rigid tympanic membrane. A Weber test is used to test for hearing only. This test will not help diagnose the reason for edematous neck lymph nodes.

The results of a client's Rinne test suggest that bone conduction and air conduction are both reduced. Which of the following would be most appropriate? a) Take a swab of the client's tympanic member. b) Repeat the test in 5 to 10 minutes. c) Perform a Romberg test. d) Refer the client for further evaluation.

Refer the client for further evaluation. Explanation: Bone conduction greater than air conduction suggest a conductive hearing loss. When data suggest signs and symptoms requiring diagnosis and treatment, the client should be referred to a physician for further evaluation. Taking a swab for culture testing is irrelevant; infection does not cause this change in hearing function. Repeat testing is unlikely to yield differing results.

The emergency department nurse notes a clear, watery discharge from the client's ear following a bicycle accident. Which of the following actions should the nurse do next? a) Assess for foreign body impaction. b) Position the patient to facilitate drainage. c) Examine for postauricular cysts. d) Refer the client immediately for further evaluation.

Refer the client immediately for further evaluation. Explanation: Watery drainage may suggest cerebrospinal fluid, for which the client should be referred immediately for further evaluation. Tophi and postauricular cysts would be visible on inspection and are not associated with drainage. Repositioning the patient is not a priority, due to the potential severity of the client's injury.

A nurse is caring for a client that was in a motor vehicle accident and suffered damage to the external ear. The client asks the nurse how hearing will be affected on a long-term basis. Based on this information, what is the best description the nurse can tell the client about the function of the external ear? a) Responsible for the transmitting sound waves. b) Responsible for the transmission of sound. c) Responsible for protecting internal structures of the ear from foreign substances. d) Responsible for providing information about body position to the brain.

Responsible for protecting internal structures of the ear from foreign substances. Explanation: The external ear is responsible for protecting the internal structures of the ear from foreign substances and for catching and carrying sound waves to the middle ear. The middle ear is responsible for the transmission of sound. The inner ear is responsible for transmitting sound waves and information about body position to the brain

A nurse performs a Rinne test on a client who relates a history of decreased hearing in the right ear. The test demonstrates that the client has conductive hearing loss in the right ear. What is the correct documentation of this test by the nurse? a) Right: AC> BC; left BC> AC b) Right: AC> BC; left AC= BC c) Right: BC> AC; left BC= AC d) Right: BC> AC; left AC> BC

Right: BC> AC; left AC> BC Explanation: With normal hearing, air conduction should be heard longer than bone conduction. With hearing loss, bone conduction becomes longer than or equal to air conduction. The correct documentation of this finding is Right: BC> AC; left AC> BC.

Which of the following tests use a tuning fork between two positions to assess hearing? a) Whisper b) Rinne c) Watch tick d) Weber's

Rinne Explanation: 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 1 or 2 feet from the unoccluded ear, and the ability of the patient to repeat what was whispered. The watch tick test relies on the ability of the patient to perceive the high-pitched sound made by a watch held at the patient's auricle. The Weber's test uses bone conduction to test lateralization of sound.

Which diagnostic test distinguishes between conductive and sensorineural hearing loss? a) Whisper test b) Audiometry c) Weber test d) Rinne test

Rinne test Explanation: The Rinne test is useful for distinguishing between conductive and sensorineural hearing loss. The whisper test, the patient with normal acuity can correctly repeat what was whispered. Audiometry is used to detect hearing loss. The Weber test uses bones conduction to test lateralization of sound

A client presents at the clinic complaining of a loss of balance. What test should the nurse expect the physician to carry out on a client with a loss of balance? a) Audiometric test b) Romberg test c) Weber test d) Rinne test

Romberg test Explanation: The Romberg test is used to evaluate a person's ability to sustain balance. The Audiometric test measures the hearing acuity precisely, while the Rinne test and the Weber test identify the types of hearing loss

A patient 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? Incus Stapes Umbo Malleus

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.

The nurse is completing a client's ear assessment. What assessment finding would indicate the need to perform Weber's test? a) The client is older than age 65. b) The client has suspected otitis externa. c) The client has a history of stroke. d) The client has unilateral hearing loss.

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

The nurse's assessment of an 81-year-old client's hearing has corroborated her recent history of hearing loss. The nurse questions the client about her use of hearing aids, to which the client responds, "I've got enough frustration in my life without having to fiddle with those." The nurse should suspect which of the following? a) The client may be unwilling to adhere to treatment regimens. b) The client may have had a negative experience with hearing aids in the past. c) The client may misunderstand the factors underlying her hearing loss. d) The client may be unable to afford the cost of hearing aids.

The client may have had a negative experience with hearing aids in the past. Explanation: The older client may have had a bad experience with certain hearing aids and may refuse to wear one. The client may also associate a negative self-image with a hearing aid. Financial concerns are a realistic possibility, but these are not strongly suggested by the client's statement. Similarly, a misunderstanding of hearing loss may exist, but this is unlikely to underlie the client's forceful statement.

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

The nurse activates the tuning fork and places it on the midline of the parietal bone in line with both ears. Explanation: 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. In Rinne's test, the nurse strikes the tuning fork and places it on the patient's mastoid process to measure bone conduction. 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 patient's ear.

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

The woman takes aspirin 4 times daily to treat her rheumatoid arthritis. Explanation: Excessive use of aspirin can cause tinnitus. A history of TIAs and cancer is not likely to be related, nor is the use of antihypertensives.

During a Weber test, the client reports lateralization of sound to the good ear. The nurse interprets this as which the following? a) The poor ear is receiving sound vibrations by air. b) There is a sensorineural hearing impairment. c) The good ear cannot receive sound vibrations. d) There is a dysfunction of the middle ear.

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.

A patient diagnosed with arthritis has been taking aspirin and now reports experiencing adverse effects. What adverse effect indicates that a decrease in dose may be necessary? a) Otalgia b) Nystagmus c) Vertigo d) Tinnitus

Tinnitus Explanation: Tinnitus is a sign of ototoxicity, which can occur when a patient's dose is too high

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

Tinnitus and sensorineural hearing loss Explanation: It is important that nurses are knowledgeable about the ototoxic effects of certain medications such as salicylates, loop diuretics, quinidine, quinine, and aminoglycosides. Signs and symptoms of ototoxicity include tinnitus and sensorineural hearing loss. Hypotension, reduced urinary output, and impaired facial movement are not signs of ototoxicity.

The nurse assists and educates client about the structure and function of the sensory system. When educating clients on the parts and functions of the ear, what is the nurse's best description of the function of the semicircular canal? a) Equalizes the pressure in the middle ear with atmospheric pressure b) Transmits information on the body's position to the brain c) Begins the transmission of nerve stimuli related to sound d) Send sensory information to the cerebellum and the midbrain

Transmits information on the body's position to the brain Explanation: The semicircular canal transmits information on the body's position to the brain. The vestibule sends sensory information to the cerebellum and midbrain, whereas the transmission of nerve stimuli begins in the cochlea, and the auditor tube equalizes the pressure in the middle ear with the atmospheric pressure. The semicircular canal does not send sensory information to the cerebellum and the midbrain, begin the transmission of nerve stimuli related to sound, or equalize the pressure in the middle ear with atmospheric pressure.

Which portion of the middle ear equalizes pressure? a) Cochlea b) Auricle c) Ossicles d) Tympanic membrane

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 forma a portio of the inner ear and containss the organ of Corti; the transducer of hearing

The nurse is using audiometry to screen the hearing of elementary school students. Which best describes audiometry? a) Uses headphones and a box that delivers tones to each ear at variable frequencies and volumes. b) A U-shaped instrument is used to assess sound perception through bone and air conduction. c) Hearing is tested by placing the individual in a sound-proof booth to measure oto-acoustic emissions. d) Tests the conduction of sounds through the bones of the skull, using a fork-shaped instrument.

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.

When planning care for a client with an inner ear infection, the nurse will need to include interventions for which of the following potential problems? a) Rhinorrhea b) Vertigo c) Headache d) Fever

Vertigo Explanation: The labyrinth within the inner ear senses the position and movements of the head and helps to maintain balance. If these structures are infected or inflamed, the patient could develop vertigo. Rhinorrhea, fever, and headache are not potential problems associated with an inner ear infection.

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

Watery or bloody Explanation: The presence of watery or bloody discharge in the external auditory canal indicates leakage of cerebrospinal fluid in the client with a head injury. Sticky, yellow discharge is found in cases of otitis externa. Bloody, purulent discharge is found in otitis media with ruptured tympanic membrane. Brown, odorless discharge is a normal finding in the external auditory canal.

A client tells the nurse that it is difficult to hear normal conversation when in a room with a lot of noise. Which test should the nurse perform to assess the hearing ability of the client? Rinne Weber Romberg Otoscopic

Weber Explanation: If a client reports the inability to hear normal conversation because of background noise, the client may be experiencing conduction hearing loss. This occurs be cause background noise in the room distracts the good ear from hearing sound by air which the poor ear cannot hear. The Weber test helps to differentiate conduction from sensorineural hearing loss. The Rinne test compares air and bone conduction. An otoscopic examination looks at the tympanic membrane for infection and swelling but not test hearing loss. Romberg is a test for equilibrium.

The nurse assessing for unilateral hearing loss by using a tuning fork. What test is the nurse performing? a) Watch tick test b) Rinne test c) Whisper test d) 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 patient's ability to repeat what was whispered. The watch tick test relies on the ability of the patient to perceive the high-pitched sound made by a watch held at the patient's auricle.

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? a) Chiming clock test b) Rinne test c) Whisper test d) Weber test

Whisper test Explanation: 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. There is no chiming clock test

The results of a client's Rinne test are as follows: bone condcution > air conduction. How should the nurse explain these findings to the client? "You have a unilateral hearing loss." "You have a high frequency hearing loss." "You have a conductive hearing loss." "You have nerve damage in your ears."

You have a conductive hearing loss." Explanation: The Rinne test tests for conductive hearing loss. The client's results indicate that bone conduction is greater than air conduction which indicates conductive hearing loss. Air conduction should be twice as long as bone conduction. The whisper test evaluates loss of high frequency sounds. An audiogram can reveal a nerve related or unilateral hearing loss.

A 53-year-old client with a sensorineural hearing loss asks the nurse how this occurred. Which of the following responses would be most appropriate? a) "Your work in the factory exposed you to loud noises over a long time." b) "You probably have a lot of wax buildup that is interfering with hearing sounds." c) "You have a history of fluid building up in your middle ear, which is responsible." d) "This is not uncommon in people your age because your eardrum is hardening."

Your work in the factory exposed you to loud noises over a long time." Explanation: Sensorineural hearing loss is most commonly associated with prolonged exposure to loud noises or the use of ototoxic medications. Conductive hearing loss is associated with cerumen buildup and fluid in the middle ear. Conductive hearing impairment is not uncommon in the older client due to a greater incidence of cerumen buildup or atrophy or sclerosis of the tympanic membrane.

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

acute otitis media. Explanation: In acute otitis media there is a bulging red membrane with decreased or absent light reflex.

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

acute otitis media. Explanation: In acute otitis media there is a bulging red membrane with decreased or absent light reflex.

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

he nurse is preparing to examine the ears of an adult client with an otoscope. The nurse should plan to a) release the auricle during the examination. b) use a speculum that measures 10 mm in diameter. c) firmly pull the auricle out, up, and back. d) ask the client to tilt the head slightly forward

firmly pull the auricle out, up, and back. Explanation: Use the thumb and fingers of your opposite hand to grasp the client's auricle firmly but gently. Pull out, up, and back to straighten the external auditory canal. Do not alter this positioning at any time during the otoscope examination.

In the hearing pathway, hair cells of the spiral organ of Corti are stimulated by movement of air. sound. bone. fluid.

fluid. Explanation: As the stapes vibrates at the oval window, the sound waves are passed to the fluid in the inner ear. The movement of this fluid stimulates the hair cells of the spiral organ of Corti and initiates the nerve impulses that travel to the brain by way of the acoustic nerve.

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

he nurse strikes the tuning fork and places it on the patient's mastoid process to measure bone conduction. Explanation: In the Rinne test, the nurse strikes the tuning fork and places it on the patient'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 patient's ear.

The nurse is planning to perform an ear examination on an adult client. After explaining the procedures to the client, the nurse should a) observe the client's response to the explanations. b) show the client the otoscope. c) ask the client to remove his contact lenses. d) ask the client to remain standing.

observe the client's response to the explanations. Explanation: As you prepare the client for the ear examination, carefully note how the client responds to your explanations

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

onductive hearing. Explanation: Conductive hearing is sound waves transmitted by the external and middle ear.

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

strike a tuning fork and place it on the center of the client's head or forehead. Explanation: Perform Weber's test if the client reports diminished or lost hearing in one ear. The test helps to evaluate the conduction of sound waves through bone to help distinguish between conductive hearing (sound waves transmitted by the external and middle ear) and sensorineural hearing (sound waves transmitted by the inner ear). Strike a tuning fork softly with the back of your hand and place it at the center of the client's head or forehead.

An adult client visits the clinic and complains of tinnitus. The nurse should ask the client if she has been a) hypotensive. b) experiencing ear drainage. c) dizzy. d) taking antibiotics.

taking antibiotics. Explanation: Ringing in the ears (tinnitus) may be associated with excessive earwax buildup, high blood pressure, or certain ototoxic medications (such as streptomycin, gentamicin, kanamycin, neomycin, ethacrynic acid, furosemide, indomethacin, or aspirin), loud noises, or other causes.

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

tosclerosis Explanation: Otosclerosis is more common in females than males and is frequently hereditary. A middle ear effusion is denoted by fluid in the middle ear without evidence of infection. Chronic otitis media is defined as repeated episodes of acute otitis media causing irreversible tissue damage and persistent tympanic membrane perforation. Otitis externa refers to inflammation of the external auditory canal.

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

umbo Explanation: The malleus is the nearest auditory ossicle that can be seen through the translucent membrane and includes a handle and short process, which are closer to the edge of the membrane, and the umbo, or base, which is a center point landmark of the tympanic membrane. Pars flaccida is the top portion of the membrane, which appears to be less taut than the bottom portion. Pars tensa is the bottom of the membrane, which appears to be taut.

A nurse performs a hearing test on an elderly client. Which result should the nurse recognize as an indication that presbycusis is present? An inability to hear: a) whispered sounds b) the calling bell c) the tuning fork d) 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.

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

• At train stations • Using lawnmowers • At concerts Explanation: As nurses, prevention is key, and patients 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)