med surg my evolve practice questions chapter 21

Otoscopic examination of the patient's left ear indicates the presence of an exostosis. What does the nurse teach the patient about regarding the growth? Surgery Electrocochleography Monitoring of the growth Irrigation of the ear canal

Monitoring of the growth Rationale: An exostosis is a bony growth into the ear canal that normally does not require intervention or correction.

The nurse is examining a patient's ear in the clinic to determine if recent treatment for acute otitis media has been effective. Which assessment finding indicates improvement of the middle ear infection? Fenestrations are visible in the tympanic membrane. Tympanic membrane is gray, shiny, and translucent. Cone of light is not visible on the tympanic membrane. Tympanic membrane is blue and bulging with no landmarks.

Tympanic membrane is gray, shiny, and translucent. Rationale: The tympanic membrane (TM) is normally pearly gray, white or pink, shiny, and translucent. Perforation of the TM that has not healed will appear as open areas of the tympanic membrane. The absence of the cone of light indicates a retracted TM. A bulging red or blue eardrum and lack of landmarks indicates a fluid-filled middle ear. The fluid may be pus or blood.

The nurse is assessing an older adult patient who has just been transferred to the long-term care facility. Which assessment question will best allow the nurse to assess for the presence of presbycusis? "Do you ever experience any ringing in your ears?" "Have you ever fallen down because you became dizzy?" "Do you ever have pain in your ears when you're chewing or swallowing?" "Have you noticed any change in your hearing in recent months and years?"

"Have you noticed any change in your hearing in recent months and years?" Rationale: Presbycusis is an age-related change in auditory acuity. Whereas ringing in the ears is termed tinnitus, dizziness and falls are related to balance and the function of the vestibular system. Presbycusis is not associated with pain during chewing and swallowing.

The nurse is providing care for a patient with loss of hearing acuity over the past several years. Which statement by the nurse is most accurate? "This is often due to an infection that will resolve on its own." "Many people experience an age-related decline in their hearing." "This is likely an effect of your medications. Try stopping them for a few days." "You can accommodate for your hearing loss with a few small changes in your routine."

"Many people experience an age-related decline in their hearing." Rationale: Presbycusis is a loss of hearing that is both common and age-related. Infections are most often accompanied by different symptoms. It would be inappropriate to counsel the patient to stop his medications. It would be simplistic to advise the patient to accommodate the hearing loss rather than seek intervention.

When using the otoscope, the nurse is unable to see the landmarks or light reflex of the tympanic membrane. The tympanic membrane is bulging and red. What does the nurse determine is most likely occurring in the patient's ear? Swimmer's ear Acute otitis media Impacted cerumen Chronic otitis media

Acute otitis media Rationale: The inability to see the landmarks or light reflex of the tympanic membrane and the bulging and redness of the tympanic membrane are those of acute otitis media. With swimmer's ear and chronic otitis media, there is frequently drainage in the external auditory canal. Impacted cerumen would block the visualization of the tympanic membrane.

A patient with Ménière's disease had decompression of the endolymphatic sac to reduce the frequent and incapacitating attacks. What should the nurse include in the discharge teaching for this patient? Airplane travel will be more comfortable now. Avoid sudden head movements or position changes. Cough or blow the nose to keep the Eustachian tubes clear. Take antihistamines, antiemetics, and sedatives for recovery.

Avoid sudden head movements or position changes. Rationale: After ear surgery, the patient should avoid sudden head movements or position changes. The patient should not cough or blow the nose because this increases pressure in the Eustachian tube and middle ear cavity and may disrupt healing. Airplane travel should be avoided at first as increased pressure and ear popping is normally experienced, which will disrupt healing. Antihistamines, antiemetics, and sedatives are used to decrease the symptoms of acute attacks of Ménière's disease.

A patient working in a noisy factory reports being off balance when standing or walking but not while lying down. What term will the nurse use to document this patient's symptoms? Vertigo Syncope Dizziness Nystagmus

Dizziness Rationale: Dizziness is a sensation of being off balance that occurs when standing or walking; it does not occur when lying down. Nystagmus is an abnormal eye movement that may be observed as a twitching of the eyeball or described by the patient as a blurring of vision with head or eye movement. Vertigo is a sense that the person or objects around the person are moving or spinning and is usually stimulated by movement of the head. Syncope is a brief lapse in consciousness accompanied by a loss in postural tone (fainting).

After an acoustic neuroma is removed from a patient, the nurse teaches the patient about tumor recurrence. What should the nurse instruct the patient to monitor? (Select all that apply.) Lack of coordination Episodes of dizziness Worsening of hearing Inability to close the eye Clear drainage from the nose

Episodes of dizziness Worsening of hearing Inability to close the eye Rationale: An acoustic neuroma is a unilateral benign tumor that occurs where the vestibulocochlear nerve (cranial nerve [CN] VIII) enters the internal auditory canal. Clinical manifestations of tumor recurrence including facial nerve (CN VII) paralysis can be manifested by intermittent vertigo, hearing loss, and inability to close the eye. Lack of coordination and clear nasal drainage do not manifest with acoustic neuroma.

When assessing an adult patient's external ear canal and tympanum, what assessment techniques should the nurse use? Ask the patient to tip their head toward the nurse. Note a pearly gray tympanic membrane as a sign of infection. Gently pull the auricle up and backward to straighten the canal. Identify a normal light reflex by the appearance of irregular edges.

Gently pull the auricle up and backward to straighten the canal. Rationale: When examining a patient's external ear canal and tympanum, ask the patient to tilt the head toward the opposite shoulder. Grasp and gently pull the auricle up and backward to straighten the canal. A healthy, normal tympanic membrane will appear pearl gray, white, or pink and have a cone-shaped light reflex.

A patient is prescribed intravenous (IV) gentamicin after repair of an intestinal perforation. The nurse should assess for which adverse effect of this medication? Hearing loss Exophthalmos Conjunctivitis Recurrent fever

Hearing loss Rationale: Aminoglycosides such as gentamicin are drugs that are potentially ototoxic and may cause damage to the auditory nerve. When this drug is used, careful monitoring for hearing and balance problems (e.g., hearing loss, tinnitus, vertigo) is essential. Exophthalmos is related to a symptom of hyperthyroidism. Conjunctivitis is a bacterial or a viral infection of the conjunctiva. Recurrent fever can be related to many issues and is not related to the use of IV gentamicin.

An older adult patient states they do not seem to hear well and have to ask people to repeat themselves. What should the nurse do first to determine the cause of the hearing loss? Look for cerumen in the ear. Assess for increased hair growth in the ear. Tell the patient it is probably related to aging. Ask the patient if he has fallen because of dizziness.

Look for cerumen in the ear. Rationale: Gerontologic differences in the assessment of the auditory system include increased production of and drier cerumen, which can become impacted in the ear canal and contribute to hearing loss. Conductive hearing loss with impacted cerumen may lead to speaking softly as the patient's voice conducted through bone seems loud to the patient. Although increased hair growth occurs, it will not impact the hearing. Presbycusis may be occurring, but it should not be assumed. There is no reason to ask the patient if he has fallen because dizziness and vertigo are not a normal change of aging of the ear.

When examining the patient's ear with an otoscope, the nurse observes discharge in the canal and the patient reports pain with the examination. What should the nurse next assess the patient for? Sebaceous cyst Swimmer's ear Metabolic disorder Serous otitis media

Swimmer's ear Rationale: Swimmer's ear or an infection of the external ear is probably the cause of the discharge and pain. Asking the patient about swimming, ear protection, and exposure to types of water can identify contact with contaminated water. After clearing the discharge, the tympanic membrane can be assessed for otitis media. A sebaceous cyst and metabolic disorders would not cause drainage or discomfort in the external ear canal.

A patient with septic shock is receiving multiple medications. The nurse assesses which intravenous (IV) medication is the most likely to cause a hearing loss? Aspirin Dopamine Ampicillin Vancomycin

Vancomycin Rationale: The IV medication in use that is most likely to cause a hearing loss is vancomycin (Vancocin) because it is an ototoxic medication. For that reason, serum drug levels are monitored to maintain therapeutic levels and reduce the risk of ototoxicity. Aspirin can also cause hearing loss, but it is not administered IV. Neither dopamine nor ampicillin is likely to cause hearing loss.