Ch. 17 Health assessment - Assessing the ears

Which question asked by the nurse is assessing problems with vertigo?

"Do you ever have problems with balance"

A nurse is interviewing a client as part of a routine examination of his ears and hearing. The nurse notes that this client has high blood pressure. Which of the following questions regarding his hearing should the nurse ask that is associated with his high blood pressure?

"Do you experience any ringing, roaring, or crackling in your eyes."

Which question asked by the nurse is assessing problems with tinnitus?

"Do you experience buzzing in your ears?"

A 61-year-old man has visited the clinic at the prompting of his wife, who states that his hearing is becoming less acute. Which of the following assessment questions is most useful in determining whether the man's hearing loss is sensorineural or conductive?

"Do you find that you have particular difficulty understanding people's speech?"

A client reports the onset of tinnitus. What question should the nurse ask the client to further assess this condition?

"Have you taken any antibiotics in the past few weeks?"

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?

"It identifies a problem with the normal pathways for sound to travel to your inner ear."

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?

"It's safe to fly because the tubes will equalize pressure"

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?

"Otalgia is pain in the ear"

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 conductive hearing loss."

A registered nurse is working with a nurse practitioner at a local walk-in clinic. The nurse practitioner needs to perform an objective assessment of a client's left ear. What equipment would the RN make sure is in the room? Select all that apply.

- High-pitched tuning fork -Otoscope

An older adult client presents at the clinic, reporting otalgia in the right ear. Physical assessment reveals cerumen impacted in the client's ear. Removing this mechanical blockage may do what for this client? (Select all that apply.)

-Enhance socialization -Improve hearing -Prevent injury

In examining a client's external auditory canal with an otoscope, the nurse discovers impacted ear wax, known as cerumen. Which of the following is characteristic of cerumen? Select all that apply.

-Has a sticky consistency -Keeps the tympanic membrane soft -Has bacteriostatic properties -Serves as a defense against foreign bodies

A nurse practitioner is assessing a client in the ED following a motor vehicle accident. The client complains of ear pain. The nurse practitioner is performing an otoscopic examination. What would demonstrate the correct technique for using the otoscope?

-Holding the otoscope so that the thumb is by the window -Holding the clients ear at the helix -Rotating the otoscope slightly

A 55-year-old male presents to the health care clinic with reports of decrease hearing over the past year. Which subjective data in client's review of systems should the nurse recognize as risk factors for hearing loss? Select all that apply.

-Increased cerumen production -Repeated episodes of otitis media as a child -History of measles at age 3 years of age

When providing client education on hearing, the nurse should remind clients to utilize ear plugs when they are what? (Select all that apply.)

-Using lawnmowers -At train stations -At concerts

Functionally, the most important range for hearing is the range of human speech. What is the range of human speech?

500 Hz to 3000 Hz

The nurse notes a tophus of the ear of an older adult. Which assessment data is consistent with a tophus?

A hard nodule composed of uric acid crystals

An increased risk of falls is dangerous for any patient. What patient would be at an increased risk of falls?

A patient with vertigo

You are teaching a class on diseases of the ear. What would you teach the class is the most characteristic symptom of otosclerosis?

A progressive, bilateral loss of hearing

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

When reviewing ear assessment, a student nurse would learn that the cone of light should be visible where on the tympanic membrane?

Anterior inferior quadrant

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?

Ask the mother how long the tubes have been in place

As a part of the ear examination for hearing loss, a nurse conducts a Weber test on a client. To accurately perform this test, the nurse should place the base of the tuning fork in which of the following locations?

At the center of the client's forehead

Upon examination of the ear with an otoscope, the nurse documents the skin of the ear canal as thickened, red, and itchy. The nurse would expect this finding with a diagnosis of

Chronic otitis media

The transmission of sound waves through the external ear and the middle ear is known as

Conductive hearing

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?

Continue with the examination

A nurse is educating a client about the function of the parts of the auditory system. Which is the function of the eustachian tube

Equalizes the pressure in the middle ear with atmospheric pressure

A nurse is educating a client about the function of the parts of the auditory system. Which is the function of the eustachian tube?

Equalizes the pressure in the middle ear with atmospheric pressure

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?

Eustachian tube

A client exhibits purulent drainage in the right external ear canal. The client complains of pain that increases when the ear is touched. Which client teaching instructions should the nurse provide?

Finish the entire course of the antibiotic therapy

The nurse is preparing to examine the ears of an adult client with an otoscope. The nurse should plan to

Firmly pull the auricle out, up and back

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.

A client has been receiving intravenous antibiotics for several weeks. Which prevention strategy would be best for the nurse to recommend for this client?

Formal hearing test

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?

Gray

Which finding should a nurse recognize as normal when assessing the ears of an elderly client?

High-tone frequency loss

Which of the following is a priority patient teaching topic related to the ears?

How to prevent skin cancer

The client is having a Weber test. During a Weber test, where should the tuning fork be placed?

In the midline of the client's skull or in the center of the forehead

While assessing the ears of an adult client, the nurse observes that the tympanic membrane is completely immobile. The nurse should further assess the client for signs and symptoms of

Infection

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

A client with hearing loss by whisper test is further examined with a tuning fork, using the Weber and Rinne maneuvres. The abnormal results are as follows: bone conduction is greater than air on the left, and the client hears the tuning fork better on the left. Which of the following is most likely?

Ostesclerosis of the ear

A nurse obtains an objective assessment on a child who presents to the clinic with reports of right ear pain. The nurse observes the following: painful movement of the pinna and tragus; ear canal is red and swollen with presence of purulent discharge from the external canal; temperature 101.8°F. The mother states that the family was on vacation at the beach last week. The nurse recognizes these findings as an indication of what acute ear condition?

Otitis externa

A patient comes to the clinic and reports pain when he touches his ear. With what is this finding most consistent?

Otitis externa

While positioning the head to examine the ears the client expresses pain when the area behind the ears is touched. On which health problem should the nurse focus during the assessment of this client?

Otitis media

Which of the following describes a condition characterized by abnormal spongy bone formation around the stapes?

Otosclerosis

Which statement reflects accurate documentation by the nurse of a normal, left tympanic membrane?

Pearly gray, translucent, with cone of light at 7 o'clock position

Transmission of sound waves in the inner ear is known as

Perceptive hearing

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

Prebycusis

The nurse is assessing the hearing of an older adult. Which type of hearing problem might the nurse expect to find in the older adult?

Presbycusis

A nurse examines the ear of a client diagnosed with an obstructed eustachian tube. What finding should the nurse anticipate upon assessment?

Prominent landmarks on the tympatic membrane

Some clients with acoustic neuromas have vertigo. What is a priority nursing action with clients with vertigo?q

Protect the client from injury

What action should the nurse implement using an otoscope when assessing the ear of an adult client?

Pull the auricle out, up and back

What action should the nurse implement when assessing the ear of an adult client using an otoscope?

Pull the surgical out, up, and back.

Which characteristic feature of the tympanic membrane should a nurse anticipate finding in a client with acute otitis media?

Red, bulging, with an absent light reflex

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?

Redness and bulging of the eardrum

A client with advanced presbycusis admits to the nurse that he was nearly involved in a car accident because he could not hear the siren of an ambulance that was crossing an intersection through which he was driving. The client says that he lives alone and has no one else to drive him. Which of the following diagnoses can the nurse make at this time?

Risk for injury related to hearing impairment

A client admitted to the health care facility is diagnosed with vertigo. Which test is appropriate for the nurse to perform to assess for equilibrium in the client?

Romberg

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?

Romberg test

When assessing the tympanic membrane, a variation of normal is a tympanic membrane with what?

Sclerosis

The nurse is presenting an educational event for gardeners. When discussing the ears, what would be an important topic to cover?

Skin cancer prevention

Which of the following is a symptom related to vertigo?

Spinning sensation

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?

Stapes

The ossicles contained in the middle ear include the malleus, the incus, and the

Stapes

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 clients head or forehead

A nurse is admitting a client to the hospital. When reviewing the client's medical record, the nurse notes that this client had abnormal findings during the Weber test. What would the nurse know this means?

The client has unilateral hearing loss

What structure in the inner ear senses the position and movements of the head and helps to maintain balance?

The labyrinth

Which action by the nurse is consistent with Weber's test?

The nurse activates the tuning fork and places it on the midline of the parietal bone in line with both ears

Which action by the nurse is consistent with the Rinne test?

The nurse strikes the tuning fork and places it on the patient's mastoid process to measure bone conduction

An nurse practitioner is assessing the tympanic membrane of a client who has come to the clinic. What would the nurse practitioner expect to visualize if the client has a normal otoscopic evaluation?

The short process of the malleus

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?

Tinnitus

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?

Tinnitus and sensorineural hearing loss

A 30-year-old client arrives at the community healthcare center complaining of dizziness and a feeling of the room spinning. Based on the client's symptoms, which condition best describes what the client most likely experiencing?

Vertigo

A client complains, "I feel like the whole room is spinning around me, and it makes me nauseous sometimes." What term should the nurse use to document the client's symptom?

Vertigo

The clinic nurse is assessing an older adult client who fell. The nurse asks if the client ever feels dizzy or has problems with balance. For what is the nurse assessing?

Vertigo

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?

Vertigo

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?

Weber

The nurse assessing for unilateral hearing loss by using a tuning fork. What test is the nurse performing?

Webers test

A nurse performs a hearing test on an elderly client. Which result should the nurse recognize as an indication that presbycusis is present? An inability to hear:

Whispered sounds

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?

external otitis