Chapter 17 Assessing Ears
Which portion of the middle ear equalizes pressure?
tympanic membrane
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 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?"
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
The cone of light is located in the
external 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." (using a tuning fork, you put it on the bone and the patient will hear it if their bone conduction is intact, then you put it near their ear to see if their air conduction is intact)
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
Upon examination, the Advanced Practice Nurse finds that a patient has otitis media with effusion. What assessment finding is most clearly indicative of this diagnosis? Effusion is liquid
A diffuse cone of light.
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
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\
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
A patient has Darwin tubercle. What is this?
A small painless nodule on the helixThe re
High doses of this medication can produce bilateral tinnitus?
Aspirin
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.
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?
Otosclerosis of the left ear
Which terms refers to the progressive hearing loss associated with aging?
Presbycusis
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
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.
The nurse is documenting an objective assessment of the client's ears. Which of the following would be the most appropriate documentation?
Hearing intact bilaterally on whisper test
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
A mother asks why her school-age child develops so many ear infections after having a head cold. When explaining the process, which structure on the diagram should the nurse identify that connects the throat to the ear?
What looks like a red vessel coming down from the ear drum
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 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?
Responsible for protecting internal structures of the ear from foreign substances.
During a physical examination the nurse performs a test where she puts the tuning fork behind your mastoid process. What assessment is the nurse performing?
Rinne Test
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 nurse performs an inspection and palpation of the auricle when examining the ear of a client. Which documentation by the nurse demonstrates a normal finding?
Darwin's tubercle (I have no idea why)
What is otosclerosis?
Disease of the inner ear and middle ear bone, where it becomes solid with a spongey consistency and does not transmit sound as well as when it was flexible.
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 antibiotic therapy.
How do you do the Weber test?
The nurse activates the tuning fork and places it on the midline of the parietal bone in line with both ears.
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
Which question asked by the nurse is assessing problems with tinnitus?
"Do you experience buzzing in your ears?"
A nurse is assessing a client with referred otalgia. In order to identify the associated manifestations of this problem, the nurse should ask which question?
"Have you had any recent infectious contacts?"
A client presents with otalgia (ear ache) and yellow-green discharge from the external ear canal. Which question should the nurse ask to determine the cause of this problem?
"Have you had any recent trauma to the inside of your ear?"
A client reports the onset of tinnitus. What question should the nurse ask the client to further assess this condition? tinnitus=ringing in the ear
"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."
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
"It is difficult to prevent hearing loss or worsening of hearing."
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 tympanic membrane vibrates at various speeds in response to various pitches of sounds. 3)The ossicles within the middle ear act as a moveable bridge to transmit these vibrations to the oval window, which amplifies the sound waves. 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.
An increased risk of falls is dangerous for any patient. What patient would be at an increased risk of falls?
A patient with vertigo.
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.
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?
Ask whether the client is experiencing ear pain or pressure.
When providing client education on hearing, the nurse should remind clients to utilize ear plugs when they are what? (Select all that apply.)
At concerts At train stations Using lawnmowers
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.
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
Conductive hearing loss.
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 examination
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
The nurse is assessing a 5-month-old Asian American infant whose mother has brought him to the clinic with reports that the baby is pulling at the ear and is sleepless and crying at night. When assessing the infant's ears, what color cerumen would the nurse expect to find? (cerumen is ear wax)
Grey
Which finding should a nurse recognize as normal when assessing the ears of an elderly client?
High-tone frequency loss
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? Visualizing portions of the stapes Holding the otoscope so that the thumb is by the window Pulling the client's ear down and back Holding the client's ear at the helix Rotating the otoscope slightly
Holding the otoscope so that the thumb is by the window Holding the client's ear at the helix (top of ear) Rotating the otoscope slightly
When providing client teaching about the ears, what should the nurse be sure to include?
How the client cleans the ears
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.
Keeps the tympanic membrane soft Has bacteriostatic properties Serves as a defense against foreign bodies Has a sticky consistency
When teaching a class of school-age children about hygiene, the nurse should include which information about the ears? a)to clean once a day b) to never put anything smaller than your elbows in your ears c) let your parents do your ear cleaning once per day
Never put anything smaller than your elbow in your ears?
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.
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?
Otitis Externa
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?
Otitis externa. Because when he is wiggling it, he is moving the outside, which implies infection of the outside.
Which of the following describes a condition characterized by abnormal spongy bone formation around the stapes?
Otosclerosis
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?
Pain on manipulation of the auricle
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
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
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. (This is the balance test)
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 (hearing loss caused by natural aging)
When moving a client's left auricle up and back, the client reports pain. What should the nurse do?
Press on the left tragus to confirm the presence of discharge. (the little flap in the middle of the ear, towards the front of the ear, stands alone)
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 tympanic membrane
What action should the nurse implement when assessing the ear of an adult client using an otoscope?
Pull the auricle 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 absent light reflex means that when you shine the light, it doesn't make the normal cone of light that it does when you shine a light into an normal ear. When this reflex is gone, that means that the ear is inflamed)
A nurse is caring for a child with an inner ear infection. The child's mother is worried because the child is having recurrent ear infections and wants to know how the function of the inner ear might be affected. Based on this information, what is the best description the nurse can tell the mother about the function of the inner ear?
Responsible for the transmitting sound waves Responsible for providing information about the body position to the brain
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
The nurse is presenting an educational event for gardeners. When discussing the ears, what would be an important topic to cover?
Skin cancer prevention
A nurse is aware that damage to which structure of the ear leads to sensorineural hearing loss? Sensorineural =hearing loss caused by a lesion or disease of the inner ear or auditory nerve
Spiral organ of Corti (the receptor organ for hearing)
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
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?
Umbo (looks like a stick at the center of the ear drum) the tympanic membrane and the eardrum are the same thing
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 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.) a)Place the client in semi-Fowler's position on the examination table b)Perform the whisper, Weber, and Rinne tests before inspection c)Have the client sit on the examination table d) Place the client's ears at the nurse's eye level e) Make sure the client is comfortable in a quiet room
a)Have the client sit on the examination table b)Make sure the client is comfortable in a quiet room c)Place the client's ears at the nurse's eye level
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.
The transmission of sound waves through the external ear and the middle ear is known as
conductive hearing
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
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
Transmission of sound waves in the inner ear is known as
perceptive hearing.
Which characteristic feature of the tympanic membrane should a nurse anticipate finding in a client with otitis media?
red, bulging with an absent light reflex
When assessing the tympanic membrane, a variation of normal is a tympanic membrane with what?
sclerosis (some hardening)
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. (just remember weber is forehead)
True of False, antibiotics can cause ringing in the ears? (tinnitus)
true
True or False: The innermost bone in the ear is called the Stapes?
true
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?
watery or bloody