Health Assessment Chapter 15 Ears

2 Otosclerosis

Which condition may cause conductive hearing loss in a patient? 1 Presbycusis 2 Otosclerosis 3 Inflammation of the labyrinth 4 Eighth cranial nerve damage

1 Infants

Which group of individuals has a higher risk of middle ear infections? 1 Infants 2 Adolescents 3 Adults 4 Geriatrics

2 Fluid behind the tympanic membrane

After an otoscopic examination, the nurse suspects otitis media in the patient. What observation would support this? 1 Perforated tympanic membrane 2 Fluid behind the tympanic membrane 3 Shiny and translucent tympanic membrane 4 Impacted cerumen blocks the tympanic membrane

4 Presence of pearly gray-colored tympanic membrane

After examining the tympanic membrane of a patient, the nurse concludes that the patient is normal and does not have hearing impairment. Which finding supports the nurse's conclusion? 1 Presence of slightly retracted tympanic membrane 2 Presence of white dots on the tympanic membrane 3 Presence of air bubbles on the tympanic membrane 4 Presence of pearly gray-colored tympanic membrane

3 Otitis externa

A patient feels pain when the nurse pulls the pinna during assessment. What might be the reason for this pain? 1 Frostbite 2 Keloid 3 Otitis externa 4 Branchial remnant

1 Cochlea

A patient is experiencing conductive hearing loss and is given an exam. What structure would not be examined because of its location and disassociation with conductive hearing loss? 1 Cochlea 2 Malleus 3 Tympanic membrane 4 External auditory canal

3 Romberg test

A patient reports having impaired balance and a tendency to fall down while walking. Which test would the nurse perform in the patient in order to identify the cause of these symptoms? 1 Rinne test 2 Weber test 3 Romberg test 4 Otoacoustic emission (OAE) test

3 The patient has frank blood and watery discharge from the ear.

After assessing a patient who has been in an accident, the nurse concludes that the patient has a basal skull fracture. Which findings support the nurse's conclusion? 1 The patient has redness in the ear with purulent discharge. 2 The patient has gray-colored, foul odor discharge from the ear. 3 The patient has frank blood and watery discharge from the ear. 4 The patient has reddish-blue discoloration from the ear with ear necrosis.

1 The patient has a staggering gait.

After assessing a patient, the nurse believes that the patient has labyrinthitis. Which finding is consistent with inflammation of the labyrinth? 1 The patient has a staggering gait. 2 The patient has cerumen impaction. 3 The patient has white watery discharge from the ear. 4 The patient feels uneasy while traveling in a flight.

1, 2, 4 1 Presence of ear necrosis 2 Presence of vesicular bullous rash 4 Presence of reddish-blue discoloration of the auricle

After assessing a patient, the nurse concludes that the patient has frostbite. Which findings are consistent with frostbite? Select all that apply. 1 Presence of ear necrosis 2 Presence of vesicular bullous rash 3 Presence of yellowish-amber tympanic membrane 4 Presence of reddish-blue discoloration of the auricle 5 Presence of painful, reddened hair follicles in the ear canal

4 The patient describes a sensation of the room revolving.

After completing the assessment, the nurse suspects that the patient has vertigo. What may be the cause of this finding? 1 The patient feels pain when the auricle is pulled. 2 The patient has dry cerumen in the auditory canal. 3 The patient reports a persistent ringing in the ears. 4 The patient describes a sensation of the room revolving.

3 The presence of yellow/amber-colored tympanic membrane

After performing the otoscopic examination of a patient, the nurse concludes that the patient has an infection. Which findings enabled the nurse to reach this conclusion? 1 The presence of pearl gray-colored tympanic membrane 2 The presence of whiter and denser annulus at the periphery 3 The presence of yellow/amber-colored tympanic membrane 4 The presence of the malleus visible behind the tympanic membrane

3 Cranial nerve VIII

After reviewing the medical records of a patient, the nurse finds that the patient has hearing impairment caused by damage to the cranial nerve. Which cranial nerve is damaged? 1 Cranial nerve II 2 Cranial nerve VII 3 Cranial nerve VIII 4 Cranial nerve X

2 Pull the patient's pinna up and back

The nurse is performing an otoscopic examination in an adult patient. What would the nurse do to straighten the patient's ear canal during the test? 1 Pull the patient's pinna straight out 2 Pull the patient's pinna up and back 3 Leave the patient's ear undisturbed 4 Pull the patient's pinna down and back

3 Cerumen is generally dry in Asians.

The nurse is preparing for a lecture on cerumen. Which information regarding cerumen would the nurse include in the lecture? 1 Cerumen is related to ear infections. 2 Cerumen is soft and red in color. 3 Cerumen is generally dry in Asians. 4 Cerumen is always dark brown in color.

1 Avoid irrigating the patient's ear

The nurse is preparing to perform otoscopy in a patient with an earache. The nurse finds that the patient's ear canal is filled with cerumen, along with discharge of yellow-colored fluid. What is an appropriate nursing action in this situation? 1 Avoid irrigating the patient's ear 2 Avoid instilling eardrops into the patient's ear 3 Irrigate the patient's ear canal with warm water 4 Clean the patient's ear with a cotton bud dipped in mineral oil

3 Bullous myringitis

The nurse performs an otoscopic examination on the ear of a patient with mycoplasma pneumonia infection. During the exam the nurse sees that the patient has small vesicles on the eardrum that are filled with blood. Which condition does the nurse expect to find in the patient? 1 Otomycosis 2 Otitis externa 3 Bullous myringitis 4 Cholesteatoma

1 "It is the sensorineural loss that occurs with aging."

The nursing instructor is teaching about presbycusis. Which statement by the student nurse indicates effective learning? 1 "It is the sensorineural loss that occurs with aging." 2 "It occurs due to logging of water in the ear after swimming." 3 "It is the inflammation in the ear that occurs with obstruction of the eustachian tube." 4 "It occurs in neonates who are fed by bottle during the first three months of age."

2, 3, 4 2 Improved ventilation in the middle ear 3 Increased outflow of fluid from the middle ear 4 Reduced risk of recurrent middle ear infection

The primary health care provider orders the insertion of tympanostomy tubes for a patient who has otitis media. What outcomes does the nurse expect in the patient after this procedure? Select all that apply. 1 Increased blood supply to the middle ear 2 Improved ventilation in the middle ear 3 Increased outflow of fluid from the middle ear 4 Reduced risk of recurrent middle ear infection 5 Increased pressure in the middle ear

4 It helps to funnel sound waves into the external auditory canal.

What is the function of the auricle? 1 It helps to amplify sound in the inner ear. 2 It helps to maintain the equilibrium of the body. 3 It helps to protect the inner ear from loud sounds. 4 It helps to funnel sound waves into the external auditory canal.

4 Equalization of air pressure on both sides of the eardrum

What is the function of the eustachian tube in the middle ear? 1 Promotes lubrication of the ear 2 Helps in maintaining balance 3 Prevents the entry of foreign bodies 4 Equalization of air pressure on both sides of the eardrum

3 It helps to maintain the balance of the body.

What is the function of the inner ear? 1 It promotes lubrication of the ear. 2 It acts as a barrier against foreign bodies. 3 It helps to maintain the balance of the body. 4 It equalizes air pressure on both the sides of the eardrum.

4 The newborn has serous otitis media

While performing an otoscopic examination in a two-week-old newborn, the nurse finds that the newborn has hypomobile tympanic membrane. What does the nurse suspect from this finding? 1 The newborn has a keloid. 2 The newborn has a furuncle. 3 The newborn has cholesteatoma. 4 The newborn has serous otitis media

1 The patient has tophi.

While performing otoscopic examination in a patient with gout, the nurse finds that the patient has small, whitish-yellow nodules and uric acid crystals in the ear helix. What information will the nurse document in the patient's chart? 1 The patient has tophi. 2 The patient has a keloid. 3 The patient has battle sign. 4 The patient has a sebaceous cyst.

4 Inserting tympanostomy tubes into the ear surgically

While performing the otoscopic examination of a patient, the nurse sees that the patient has a bright red-colored eardrum, distortion of light reflex, and drum hypomobility. Which treatment strategy would be most beneficial for this patient? 1 Providing hearing aids for the patient 2 Instilling 2% acetic acid solution into the ear 3 Irrigating the ear canal with warm solution 4 Inserting tympanostomy tubes into the ear surgically

4 Concave and pearl gray

How does the normal tympanic membrane appear during an otoscopic examination? 1 Straight and pink 2 Convex and white 3 Opaque and red 4 Concave and pearl gray

1, 2, 5 1 Umbo 2 Pars flaccida 5 Long process of the malleus

The nurse is examining the tympanic membrane of a patient. Which landmarks should the nurse explore? Select all that apply. 1 Umbo 2 Pars flaccida 3 Vestibule 4 Cochlea 5 Long process of the malleus

4 The newborn has serous otitis media.

While performing an otoscopic examination in a two-week-old newborn, the nurse finds that the newborn has hypomobile tympanic membrane. What does the nurse suspect from this finding? 1 The newborn has a keloid. 2 The newborn has a furuncle. 3 The newborn has cholesteatoma. 4 The newborn has serous otitis media.

2, 3, 4 2 Incus 3 Malleus 4 Stapes

Which are the bones of the middle ear? Select all that apply. 1 Cochlea 2 Incus 3 Malleus 4 Stapes 5 Vestibule

1, 2, 5 1 Parotid lymph node 2 Mastoid lymph node 5 Superficial cervical lymph node

Damage to which lymph nodes lead to the accumulation of lymph in the external ear? Select all that apply. 1 Parotid lymph node 2 Mastoid lymph node 3 Occipital lymph node 4 Axillary lymph node 5 Superficial cervical lymph node

2 The patient has acute otitis media.

During the otoscopic examination of a patient, the nurse sees that the superior part of the patient's eardrum is bright red and bulging. What does the nurse infer from this finding? 1 The patient has skull fracture. 2 The patient has acute otitis media. 3 The patient has chronic otitis media. 4 The patient has a fungal ear infection.

4 A 9-month-old who is more reactive to movement than to sound

The nurse is assessing a group of children in a health care setting. Which child does the nurse expect to have hearing impairment? 1 A newborn showing acoustic blink reflex 2 A 3-month-old child who cries when there is silence 3 A 1-year-old child who is able to speak in small sentences 4 A 9-month-old who is more reactive to movement than to sound

1 The patient has rubella infection.

The nurse is assessing a pregnant patient who is in the seventh week of gestation. After reviewing the patient's laboratory and diagnostic reports, the nurse suspects the fetus is at risk of hearing impairment. Which finding supports this assumption? 1 The patient has rubella infection. 2 The patient has vitamin A deficiency. 3 The patient has high estrogen levels. 4 The patient has high platelet count.

2 "These tubes usually fall out in about 12 to 18 months."

The nurse is caring for a patient who has undergone a tympanostomy. The patient asks the nurse, "What will happen to the tubes in my ear?" Which response by the nurse is best? 1 "These tubes will remain in place forever." 2 "These tubes usually fall out in about 12 to 18 months." 3 "These tubes usually dissolve on their own within a year." 4 "These tubes will be surgically removed after 24 months."

1 Otalgia

The nurse is caring for a patient who is scheduled for a root canal surgery. The patient complains of having ear pain. Which condition does the nurse expect to find in the patient? 1 Otalgia 2 Osteoma 3 Otorrhea 4 Cholesteatoma

3 Report to the primary health care provider about the patient

The nurse is caring for a patient who was in an accident. The nurse notices that the patient has clear, watery drainage from the ear. What is the priority nursing intervention in this situation? 1 Instill 2% acetic acid solution in the patient's ear 2 Instill antibiotic solution into the patient's ear 3 Report to the primary health care provider about the patient 4 Irrigate the patient's ear canal with a warm solution

3 Inner ear

The nurse is caring for a patient with impaired hearing and impaired balance. Which part of the ear is affected in this patient? 1 External ear 2 Middle ear 3 Inner ear 4 Auricle

4 Irrigating the ear canal with warm solution

The nurse is caring for an elderly patient diagnosed with conductive hearing loss due to impacted cerumen. Which nursing intervention would be the most beneficial for the patient? 1 Providing hearing aids to the patient 2 Inserting tympanostomy tubes into the ear 3 Leaving the ear undisturbed for four days 4 Irrigating the ear canal with warm solution

1 Providing hearing aids to the patient

The nurse is caring for an elderly patient diagnosed with presbycusis. Which intervention would be most beneficial for the patient? 1 Providing hearing aids to the patient 2 Instilling antibiotic solutions into the patient's ear 3 Inserting tympanostomy tubes into the patient's ear 4 Irrigating the patient's ear canal with a warm solution

3 Whisper a set of three random numbers and letters while standing 2 feet behind the patient.

The nurse is examining the hearing of an elderly patient using the whisper voice test. Which intervention would the nurse follow to properly administer this test? 1 Whisper a set of three random numbers and letters after the patient covers both ears. 2 Whisper a set of three random numbers and letters while standing in front of the patient. 3 Whisper a set of three random numbers and letters while standing 2 feet behind the patient. 4 Whisper a set of three random numbers and letters while standing 10 feet away from the patient.

1 Pull the auricle up and back.

What action should the nurse take during an otoscopic examination of an adult patient? 1 Pull the auricle up and back. 2 Pull the auricle downward. 3 Touch the speculum to the bony surface. 4 Tilt the head of the patient towards left.

1, 2, 3 1 It equalizes air pressure. 2 It protects the auditory apparatus. 3 It conducts the sound vibrations.

What are the functions of the middle ear? Select all that apply. 1 It equalizes air pressure. 2 It protects the auditory apparatus. 3 It conducts the sound vibrations. 4 It maintains a sense of equilibrium. 5 It transmits sound waves to the brain.

4 2.5 to 3 cm

What is the approximate length of the external auditory canal in an adult? 1 1 to 1.5 cm 2 1.5 to 2 cm 3 2 to 2.5 cm 4 2.5 to 3 cm

1 Chromosome 16

Which chromosome helps determine the presence of wet or dry cerumen in a newborn? 1 Chromosome 16 2 Chromosome 17 3 Chromosome 18 4 Chromosome 19

1 Eustachian tube

Which part of the ear connects the middle ear to the nasopharynx? 1 Eustachian tube 2 Semicircular canals 3 Tympanic membrane 4 External auditory canal

1 The external and the middle ear

Which part of the ear does the tympanic membrane separate? 1 The external and the middle ear 2 The middle and the inner ear 3 The auricle and the cochlea 4 The middle ear and the Eustachian tube

3 The patient has microtia and Darwin's tubercle.

While assessing a patient, the nurse finds that the patient's ears are 3 cm in length and have a small, painless nodule at the helix. What does the nurse infer from these findings? 1 The patient has microtia and swimmer's ear. 2 The patient has macrotia and swimmer's ear. 3 The patient has microtia and Darwin's tubercle. 4 The patient has macrotia and Darwin's tubercle.

4 Pulling the newborn's ear pinna up and back

While conducting the otoscopic examination in a newborn, the nurse tilts the newborn's head slightly toward the opposite side of the shoulder. Then, the nurse pulls the newborn's pinna up and backward and holds it gently but firmly. The nurse then holds the otoscope upside down and proceeds to perform further steps. Which action by the nurse needs correction? 1 Tilting the newborn's head slightly 2 Holding the otoscope upside-down 3 Holding the newborn's ear pinna firmly 4 Pulling the newborn's ear pinna up and back

3 The child has honey-colored cerumen.

While examining a child's ear, the nurse finds that the child has wet cerumen. Which finding would be consistent with the wet cerumen? 1 The child's cerumen appears flaky. 2 The child has grayish cerumen. 3 The child has honey-colored cerumen. 4 The child's ear canal has thin layer of cerumen.

1 The patient has normal hearing.

While examining the patient's ear, the nurse finds that the patient's ear canal is 70% blocked with cerumen. What does the nurse infer from this finding? 1 The patient has normal hearing. 2 The patient is at a risk of developing swimmer's ear. 3 The patient may have whirling sensation. 4 The patient may have disturbed equilibrium.