Health Assessment: Ears
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? a) Whisper b) Romberg c) Rinne d) Weber
Correct response: Romberg Explanation: The nurse should perform the Romberg test to assess equilibrium in the client. The Weber test and the Rinne test are used to distinguish between sensorineural and conductive hearing loss. The whisper test is used to assess hearing loss in a client. (less) Reference: Chapter 17: Assessing Ears, p. 340.
Which of the following is a symptom related to vertigo? a) Fainting b) Syncope c) Loss of consciousness d) Spinning sensation
Spinning sensation. Explanation: 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) Reference: Chapter 17: Assessing Ears, p. 331.
What components of sound does the cochlea interpret? (Select all that apply.) a) Amplitude b) Decibel c) Tone d) Frequency e) Direction
Correct response: • Amplitude • Frequency Explanation: The cochlea interprets two components of sound: amplitude (volume) and frequency (pitch). The cochlea does not interpret tone, direction, or decibel. (less) Reference: Weber, J., & Kelley, J. H. (2014). Health Assessment in Nursing, 5th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, Chapter 17: Assessing Ears, p. 340.
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? a) "The child must wear ear plugs while flying." b) "He shouldn't fly with anyone who is immunocompromised." c) "It's safe to fly because the tubes will equalize pressure." d) "He should avoid flying for 6 months after tube placement."
Correct response: "It's safe to fly because the tubes will equalize pressure." Explanation: Pressure equalization tubes equalize pressure on either sides of the eardrum; so it's a great time to fly if one has tubes in the ears. The child should wear ear plugs to keep water out of the ears when swimming. Wearing ear plugs while flying may diminish the pressure equalization advantage of the tubes. Clients do not have to avoid flying for any period of time after tube placement. Ear tubes do not have an effect on immunocompromised clients. (less) Reference: Weber, J., and Kelley, J. Health Assessment in Nursing, 5th ed., Philadelphia: Wolters Kluwer Health, 2014, Chapter 17: Assessing Ears pg. 337.
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? a) "You have nerve damage in your ears." b) "You have a conductive hearing loss." c) "You have a high frequency hearing loss." d) "You have a unilateral hearing loss."
Correct response: "You have a conductive hearing loss." Explanation: 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) Reference: Chapter 17: Assessing Ears pp. 335-341.
The nurse notes a tophus of the ear of an older adult. Which assessment data is consistent with a tophus? a) Scarring of the tympanic membrane b) A hard nodule composed of uric acid crystals c) A sac with a membranous lining filled with fluid d) Redness and bulging of the eardrum
Correct response: A hard nodule composed of uric acid crystals Explanation: 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) Reference: Chapter 17: Assessing Ears, p. 336.
An increased risk of falls is dangerous for any patient. What patient would be at an increased risk of falls? a) A patient with a hearing loss of 45 dB. b) A patient with acute otitis media. c) A patient with vertigo. d) A patient with damage to the VIIIth cranial nerve.
Correct response: A patient with vertigo. Explanation: Vertigo is defined as the misperception or illusion of motion either of the person or the surroundings. A patient suffering from vertigo will be at an increased risk of falls. This makes options A, B and D incorrect. (less) Reference: Chapter 17: Assessing Ears, p. 331.
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? a) Ask the mother how long the tubes have been in place. b) Schedule appointment at hospital for tubes to be removed surgically. c) Ask healthcare provider about prescribing antibiotics before removal. d) Schedule first available office appointment.
Correct response: Ask the mother how long the tubes have been in place. Explanation: Ear tubes generally fall out spontaneously in 2-5 years after placement, and the membrane most often closes. The client does not need manual removal in the office or operating room unless the child is experiencing problems. Antibiotics are indicated for infection and are not necessary for removal. (less) Reference: Chapter 17: Assessing Ears pg. 337.
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? a) Darwin's tubercle b) Pale blue coloration c) Ulcerated, crusted nodules d) Nontender, hard tophi
Correct response: Darwin's tubercle Explanation: The nurse should document Darwin's tubercle as a normal finding upon examination of the auricle. Darwin's tubercle is a clinically insignificant projection seen on the auricle. Nontender, hard tophi are manifestations of gout. Ulcerated, crusted nodules can be a sign of skin cancer. Pale blue coloration of the auricle could be due to frostbite. (less) Reference: Chapter 17: Assessing Ears, p. 336.
A nurse is educating a client about the function of the parts of the auditory system. Which is the function of the eustachian tube? a) Sends sensory information to the cerebellum and midbrain. b) Separates the external from the middle ear. c) Transmits vibration to the fluid filled inner ear at the oval window. d) Equalizes the pressure in the middle ear with atmospheric pressure.
Correct response: Equalizes the pressure in the middle ear with atmospheric pressure. Explanation: 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) Reference: Chapter 17: Assessing Ears, p. 328.
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? a) Eustachian tube b) The malleus c) The pinna d) The meatus
Correct response: Eustachian tube Explanation: 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) Reference: Chapter 17: Assessing Ears, p. 328.
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? a) Fluid collects in the middle ear causing an obstruction of the auditory tube. b) An upper respiratory infection spreads through the auditory tube. c) This condition is usually associated with a puncture eardrum. d) This condition develops if acute purulent otitis media is not treated promptly.
Correct response: Fluid collects in the middle ear causing an obstruction of the auditory tube. Explanation: Serous otitis media results from fluid that collects in the middle ear, causing an obstruction of the auditory tube. This condition may stem from infection, allergy, tumors, or sudden changes in altitude. Symptoms include crackling sensations and fullness in the ear, with some hearing loss. Acute purulent otitis media is generally caused by an upper respiratory infection spreading through the auditory tube. Pus forms and collects in the middle ear to create pressure on the eardrum. Chronic otitis media can develop if acute purulent otitis media is not treated promptly. Chronic purulent otitis media is usually associated with a punctured eardrum or may be a complication of acute otitis media, mastoiditis, or a severe upper respiratory infection. (less) Reference: Chapter 17: Assessing Ears, p. 331.
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? a) Yellowish-white b) Red c) Gray d) Bluish-white
Correct response: Gray Explanation: The healthy tympanic membrane appears pearly gray and is positioned obliquely at the base of the ear canal. This makes options A, B and D incorrect. (less) Reference: Chapter 17: Assessing Ears, p. 337.
When inspecting the tympanic membrane, which of the following structures does the nurse expect to identify? a) Pars tensa, pars flaccida, vestibule, cone of light b) Cone of light, incus, umbo, cochlea c) Handle of malleus, short process of malleus, cone of light d) Pars tensa, umbo, handle of malleus, ossicles
Correct response: Handle of malleus, short process of malleus, cone of light Explanation: Visualization of the tympanic membrane using an otoscope includes inspection of the cone of light, the short process of the malleus, and the handle of the maleus. The cochlea, vestibule, and stapes (part of the ossicles) are not normally visualizable. (less) Reference: Weber, J., & Kelley, J. H. (2014). Health Assessment in Nursing, 5th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, Chapter 17: Assessing Ears, p. 337.
The nurse is documenting an objective assessment of the client's ears. Which of the following would be the most appropriate documentation? a) Hearing intact bilaterally on whisper test b) Hearing intact on right and left with Rinne test c) No decrease in hearing evident on Weber test d) Client states experiencing no decrease in hearing
Correct response: Hearing intact bilaterally on whisper test Explanation: Documentation of the whisper test should be "hearing intact bilaterally on whisper test." Documentation of the Rinne and Weber test results usually validates normal findings (e.g., "No unexpected findings on Weber and Rinne tests."). The report from the client is a subjective assessment finding. (less) Reference: Chapter 17: Assessing Ears, p. 338.
The client is having a Weber test. During a Weber test, where should the tuning fork be placed? a) Near the external meatus of each ear. b) On the mastoid process behind the ear. c) Under the bridge of the nose. d) In the midline of the client's skull or in the center of the forehead.
Correct response: In the midline of the client's skull or in the center of the forehead. Explanation: 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) Reference: Chapter 17: Assessing Ears, p. 338.
Which precaution should a nurse take to ensure the safety of a client when performing the Romberg test? a) Place arms around the client without touching b) Offer assistance by holding the client's arm c) Tell the client to keep the eyes open & focused ahead d) Instruct the client to hold on to a chair
Correct response: Place arms around the client without touching Explanation: During the Romberg test, the nurse should put his or her arms around the client without touching to prevent the client from falling. The eyes are closed to assess the client's ability to maintain equilibrium without looking or holding onto something. The client should not be instructed to hold on to a chair during the test as it may interfere with the assessment of equilibrium. The nurse should not hold the client's arm as it would give support to the client and affect the result. (less) Reference: Weber, J., & Kelley, J. H. (2014). Health Assessment in Nursing, 5th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, Chapter 17: Assessing Ears, p. 314.
Which terms refers to the progressive hearing loss associated with aging? a) Otalgia b) Presbycusis c) Sensorineural hearing loss d) Exostoses
Correct response: Presbycusis Explanation: Both middle and inner ear age-related changes result in hearing loss. Exostoses refers to small, hard, bony protrusions in the lower posterior bony portion of the ear canal. Otalgia refers to a sensation of fullness or pain in the ear. Sensorineural hearing loss is loss of hearing related to damage of the end organ for hearing and/or cranial nerve VIII. (less) Reference: Chapter 17: Assessing Ears, p. 330.
What action should the nurse implement using an otoscope when assessing the ear of an adult client? a) Choose the smallest speculum for client comfort b) Insert the speculum gently down and backward c) Pull the auricle out, up, and back d) Hold the speculum in the nondominant hand
Correct response: Pull the auricle out, up, and back Explanation: The nurse should pull the auricle out, up, and back to straighten the external auditory canal. This is because the external auditory canal is S-shaped in the adult. The outer part of the canal curves up and back, and the inner part of the canal curves down and forward. The nurse should choose the largest speculum that fits comfortably into the client's ear. The nurse should hold the speculum in the dominant hand and insert the speculum gently down and forward. (less) Reference: Chapter 17: Assessing Ears, p. 335.
What action should the nurse implement when assessing the ear of an adult client using an otoscope? a) Insert the speculum gently down and backward. b) Choose the smallest speculum for client comfort. c) Pull the auricle out, up, and back. d) Hold the speculum in the non-dominant hand.
Correct response: Pull the auricle out, up, and back. Explanation: The nurse should pull the auricle out, up, and back to straighten the external auditory canal. This is because the external auditory canal is S-shaped in the adult. The outer part of the canal curves up and back, and the inner part of the canal curves down and forward. The nurse should choose the largest speculum that fits the client's ear. The nurse should hold the speculum in the dominant hand and insert the speculum gently down and forward. (less) Reference: Weber, J., & Kelley, J. H. (2014). Health Assessment in Nursing, 5th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, Chapter 17: Assessing Ears, p. 337.
Which characteristic feature of the tympanic membrane should a nurse anticipate finding in a client with otitis media? a) Pearly, translucent with no bulging b) Red, bulging with an absent light reflex c) Yellowish, bulging with fluid bubbles d) Gray, translucent with retraction
Correct response: Red, bulging with an absent light reflex Explanation: 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 retraction is a normal finding in the tympanic membrane. (less) Reference: Weber, J., & Kelley, J. H. (2014). Health Assessment in Nursing, 5th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, Chapter 17: Assessing Ears, p. 337.
Which characteristic feature of the tympanic membrane should a nurse anticipate finding in a client with acute otitis media? a) Yellowish, bulging, with fluid bubbles b) Pearly, translucent, with no bulging c) Gray, translucent, with no retraction d) Red, bulging, with an absent light reflex
Correct response: Red, bulging, with an absent light reflex Explanation: 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) Reference: Chapter 17: Assessing Ears, p. 337.
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? a) Rinne test b) Audiometric test c) Weber test d) Romberg test
Correct response: Romberg test Explanation: The Romberg test is used to evaluate a person's ability to sustain balance. The Audiometric test measures the hearing acuity precisely, while the Rinne test and the Weber test identify the types of 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? a) Tinnitus and sensorineural hearing loss b) Impaired facial movement c) Reduced urinary output d) Signs of hypotension
Correct response: Tinnitus and sensorineural hearing loss Explanation: 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) Reference: Chapter 17: Assessing Ears, p. 334.
When planning care for a patient with an inner ear infection, the nurse will include interventions to address which potential problem? a) Fever b) Vertigo c) Headache d) Rhinorrhea
Correct response: Vertigo Explanation: 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) Reference: Weber, J., & Kelley, J. H. (2014). Health Assessment in Nursing, 5th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, Chapter 17: Assessing Ears, p. 331.
Question: When performing a Rinne test, the nurse would perform the steps in what order? 1. place the tuning fork in front of the ear and ask the patient if she can hear the sound 2. place the base of a vibrating tuning fork on the mastoid bone until the patient says she cannot hear the sound
Correct response: place the base of a vibrating tuning fork on the mastoid bone until the patient says she cannot hear the sound place the tuning fork in front of the ear and ask the patient if she can hear the sound Reference: Chapter 17: Assessing Ears, p. 339.
Which action by the nurse is consistent with Weber's test? a) The nurse uses a bulb insufflator attached to an otoscope to observe movement of the tympanic membrane. b) The nurse shields their mouth and whispers a simple sentence approximately 18 inches from the patient's ear. c) The nurse strikes the tuning fork and places it on the patient's mastoid process to measure bone conduction. d) The nurse activates the tuning fork and places it on the midline of the parietal bone in line with both ears.
The nurse activates the tuning fork and places it on the midline of the parietal bone in line with both ears. Explanation: 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) Reference: Chapter 17: Assessing Ears, p. 338.
