Chapter 14

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." 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. (less)

A 55-year-old client is being evaluated for a hearing impairment. Which question would be most appropriate to provide the most useful information?

"Are you having difficulty hearing high-frequency sounds?" Asking the client about changes in hearing ability with different frequency sounds would be most appropriate because the client is over age 50 and may be experiencing presbycusis, a loss of ability to hear high-frequency sounds. Asking about drainage would provide information about a possible infection; asking about pain would provide information about possible ear infection, cerumen blockage, sinus infections, or teeth and gum problems. Asking about a popping sensation may be appropriate if otitis media and perforation are suspected. (less)

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 ears?" 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. (less)

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

"Do you experience buzzing in your ears?" The nurse assesses tinnitus by asking, "Do you experience buzzing in your ears?" Problems with balance occur with vertigo. Drainage from the ear(s) occurs with otalgia. The question, "In what situations is it hard for you to hear?" assesses for general hearing loss. (less)

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." 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. (less)

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 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 (less)

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

A sac with a membranous lining filled with fluid 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. (less)

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 story his wife is telling him 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. (less)

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?

Acute otitis media 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. (less)

Audiometry is testing that measures hearing acuity precisely. Who does the nurse know can perform audiometric testing?

Audiologist Audiometry is done by an audiologist. Audiometric testing measures hearing acuity precisely. Options A, B and D can screen hearing but they cannot do audiometric testing.

After having a client perform a Romberg test, which of the following would indicate to the nurse that the test is negative?

Client maintains the position during the exam A negative Romberg test is documented when the client maintains position for 20 seconds without swaying or with minimal swaying. The test is positive if the client moves the feet apart to prevent falls, or starts to fall from loss of balance. (less)

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 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. (less)

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 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. (less)

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. 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. (less)

The nurse has completed a focused ear and hearing assessment and gathered the following data: the client speaks very softly, denies hearing loss, and has never had and cannot afford additional hearing tests; the client fails the whisper test. Which nursing diagnosis would be most appropriate?

Ineffective health maintenance related to denial of hearing problem and inadequate resources for additional testing A nursing diagnosis of ineffective health maintenance would be most appropriate based on the data. There is nothing to suggest that the client is having difficulty with social interaction. A soft speaking voice does not indicate a problem with impaired verbal communication. The client has a problem, so a health promotion diagnosis of readiness for enhanced communication would be inappropriate. (less)

The following data are gathered: speaks very softly, denies hearing loss, has never had and cannot afford additional hearing tests, fails whisper test. Which nursing diagnosis would be most appropriate?

Ineffective health maintenance, related to denial of hearing problem and inadequate resources for additional testing A nursing diagnosis of ineffective health maintenance would be most appropriate based on the data. There is nothing to suggest that the client is having difficulty with social interaction. A soft-speaking voice does not indicate a problem with impaired verbal communication. The client has a problem, so a wellness diagnosis of readiness for enhanced communication would be inappropriate. (less)

The nurse is performing an ear assessment of an adult client. Which of the following actions constitutes the correct procedure for using an otoscope when examining the client's ears?

Inserting the speculum down and forward into the ear canal The nurse should insert the speculum gently down and forward into the canal. Using the dominant hand, the nurse should position the hand holding the otoscope against the client's head or face. The largest speculum that fits comfortably into the client's ear canal is used. (less)

Which of the following denotes the correct procedure for using an otoscope when examining the ears of a 32-year-old client?

Inserting the speculum down and forward into the ear canal The nurse should insert the speculum gently down and forward into the canal. Using the dominant hand, the nurse should position the hand holding the otoscope against the client's head or face. The largest speculum that fits comfortably into the client's ear canal is used. (less)

A client presents to an ambulatory clinic with purulent, bloody drainage of the ear. Which of the following should the nurse assess first?

Inspect the client's external ear canal. 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. (less)

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?

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. (less)

The nurse is preparing to perform the Rinne test on a client. The nurse should place the tuning fork at which location first?

On the client's mastoid process For the Rinne test, the tuning fork base is place on the client's mastoid process and then it is moved to the front of the external auditory canal when the client no longer hears the sound. The tuning fork is placed in the center of the client's forehead or head for the Weber test. (less)

The nurse is preparing to perform the Rinne test on a client. The nurse would place the tuning fork at which location first?

On the mastoid process For the Rinne test, the tuning fork base is place on the client's mastoid process and then it is moved to the front of the external auditory canal when the client no longer hears the sound. The tuning fork is place in the center of the client's forehead or head for the Weber test. (less)

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

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

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?

Presbycusis 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. (less)

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 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. (less)

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?

Refer the client for further evaluation. 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. (less)

In which position should the nurse place the toddler when examining the ear?

Sitting on the parent's lap with parent steadying the head The toddler should sit on the parent's lap with the parent steadying the head. Preschoolers often need to be held down on the examination table in a supine position with the head turned toward the parent. Older children can sit on the examination table. (less)

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

Skin cancer prevention 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. (less)

Which of the following is a symptom related to vertigo?

Spinning sensation Vertigo is defined as the misperception or illusion of motion of the person or the surroundings. Most people with vertigo describe a spinning sensation or say they feel although objects are moving around them. (less)

When assessing the client's ear, which finding should the nurse identify as indicating a need for further assessment and possible treatment?

Tender tragus A tender tragus is associated with otitis externa or a postauricular cyst. Darwin's tubercle is a clinically insignificant finding. Normally, cerumen may be yellow, orange, red, brown, gray, or black and soft, moist, dry, flaky, or even hard. A pearly gray tympanic membrane is a normal finding. (less)

The nurse is completing a client's ear assessment. What assessment finding would indicate the need to perform Weber's test?

The client has unilateral hearing loss. 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. (less)

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. 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. (less)

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. 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. (less)

A 52-year-old patient fails the Romberg test. The nurse explains that this might indicate a dysfunction in what part of the ear?

The vestibular portion of the inner ear Failure of the Romberg test may indicate dysfunction in the vestibular portion of the inner ear, semicircular canals, and vestibule.

A nurse is preparing a class for a group of parents about ear infections and measures to prevent them. The nurse is planning to address the reasons why children are more susceptible to this infection than adults. Which of the following would the nurse include?

Their eustachian tube is shorter, straighter, and narrower. The fact that children are more susceptible than adults to otitis media is due mostly to the shorter, straighter, narrower eustachian tubes of children. Otitis media in children is not associated with putting things in their ears, immature immune systems, or poor hand-washing techniques. (less)

During a Weber test, the client reports lateralization of sound to the good ear. The nurse interprets this as which the following?

There is a sensorineural hearing impairment. 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. (less)

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 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. (less)

When assessing the ears of older adults, it is necessary to remember that physiologic changes take place as people age. What is a physiologic change that takes place in the ear of an older adult?

Tympanic membrane is more opaque The cartilage and skin around the external ear may be less pliable in older adults. The stiff hairs in the canal may require a smaller otoscope tip to separate them and increase visualization of the tympanic membrane. The membrane itself may seem more opaque and less mobile. The cone of light does not become brighter as people age nor does the external ear canal enlarge. (less)

The nurse is using audiometry to screen the hearing of elementary school students. Which best describes audiometry?

Uses headphones and a box that delivers tones to each ear at variable frequencies and volumes. 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. (less)

When providing patient education on hearing, patients should be reminded to utilize ear plugs when they are what? (Mark all that apply.)

Using lawnmowers • At train stations • At concerts 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). (less)

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 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. (less)

A client who works in a manufacturing plant is attending a teaching session on plant safety. Which of the following would be an important risk prevention measure to teach regarding hearing?

Wearing ear protection when in the work environment An important risk prevention strategy would be to use ear protection when working or spending time in high noise levels. Even brief exposure can have harmful effects, and cleaning ears regularly would have no effect on preventing hearing loss due to environmental exposure. (less)

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