Chapter 17: Assessing Ears

A client presents with otalgia and yellow-green discharge from the external ear canal. Which question should the nurse ask to determine the cause of this problem? a. "Have you had any recent trauma to the inside of your ear?" b. "Do you hear ringing in your ears?" c. "Are their times when you feel dizzy?" d. "Have you ever taken medication that is ototoxic?"

a. "Have you had any recent trauma to the inside of your ear?" Otalgia and yellow-green discharge from the external ear canal suggest a ruptured tympanic membrane. In order to identify the cause of the rupture, it would be most effective to ask the client about trauma to the inside of the ear. Asking the client about ringing in the ears would suggest the nurse suspects tinnitus. The yellow-green drainage and pain are not associated with this condition. Asking the client about feeling dizzy suggests the nurse suspects vertigo. Yellow-green drainage and pain are not associated with this condition. Asking the client if she has ever taken medication that is ototoxic suggests the nurse is focusing the assessment on sensorineural hearing loss. Discharge and pain are not associated with this condition.

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. A story his wife is telling him b. The bass speakers of his stereo system c. His son giving him directions to a restaurant d. The sound of his car engine starting

a. 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.

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? a. At the center of the client's forehead b. On the client's mastoid process c. In front of the external auditory canal d. Behind the external auditory canal

a. At the center of the client's forehead During a Weber test for assessment of hearing loss, the nurse should place the tuning fork at the center of the client's forehead. Placing the base of the tuning fork at the client's mastoid process and placing the prongs of the tuning fork in front of the external auditory canal are part of the Rinne test. Placing the base of the tuning fork in front of or behind the external auditory canal is an inappropriate technique.

When providing client education on hearing, the nurse should remind clients to utilize ear plugs when they are what? (Select all that apply.) a. At train stations b. Cleaning their homes c. Using lawnmowers d. Working with children e. At concerts

a. At train stations c. Using lawnmowers e. At concerts As nurses, prevention is key, and clients 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).

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 develops if acute purulent otitis media is not treated promptly. d. This condition is usually associated with a puncture eardrum.

a. Fluid collects in the middle ear causing an obstruction of the auditory tube. 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.

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? a. Grey b. Dark brown c. Light yellow d. Gold

a. Grey Grey to white cerumen is often flakey and misdiagnosed as eczema. This type of cerumen, called dry cerumen, is most prevalent in Asians and Native Americans. Dark brown, light yellow, or gold cerumen is less common in Asian Americans.

The eustachian tube is a passage between the middle ear and the nasopharynx. What is the function of the eustachian tube? a. Helps to regulate pressure in the middle ear b. Protects the middle ear c. Allows for drainage of fluid from the middle ear d. Maintains fluid in the middle ear

a. Helps to regulate pressure in the middle ear The eustachian tube, a conduit that connects the middle ear to the nasopharynx, allows for pressure regulation of the middle ear. The other options do not accurately describe the function of the eustachian tube.

When providing client teaching about the ears, what should the nurse be sure to include? a. How the client cleans the ears b. Basic anatomy and physiology of the ears c. How to use cotton-tipped applicators safely d. Potential infection from self-cleaning of ears

a. How the client cleans the ears It is important to address how the client cleans the ears. Many people associate cerumen in the ear canal with lack of hygiene and therefore clean their ears routinely. Often, clients think that cotton-tipped applicators are for this purpose. This self-care behavior is unsafe, placing clients at risk for cerumen impaction. Nurses should reinforce proper cleaning techniques. Since cleaning with cotton-tipped applicators is not correct, the nurse would not teach the client how to use the applicators to clear the ears. The nurse would not teach the client about basic anatomy and physiology of the ears. The option of potential infection from self-cleaning of ears is not correct.

A client has been diagnosed with conductive hearing loss. The nurse understands that which of the following could be the cause of this type of hearing loss? a. Perforated eardrum b. Damage to cranial nerve VIII c. Dysfunction of the temporal lobe of the brain d. Injury to the organ of Corti

a. Perforated eardrum The transmission of sound waves through the external and middle ear is referred to as conductive hearing and the transmission of sound waves in the inner ear is referred to as perceptive or sensorineural hearing. Therefore, a conductive hearing loss would be related to a dysfunction of the external or middle ear (e.g., impacted ear wax, otitis media, foreign object, perforated eardrum, drainage in the middle ear, or otosclerosis). A sensorineural loss would be related to dysfunction of the inner ear (i.e., cranial nerve VIII, temporal lobe of brain, or organ of Corti).

An adult farm worker presents at the ED after falling out of a hay loft. The client states falling approximately 4 hours ago and did not lose consciousness. The client is experiencing only a mild headache. When asked why the client came to the ED, the client states that he had a clear discharge from the right ear ever since the accident. What should this finding indicate to the nurse? a. Possible basilar skull fracture b. Possible otitis externa c. Possible otitis media d. Possible mass in the ear

a. Possible basilar skull fracture Hemotympanum, otorrhea, or tympanic membrane rupture may indicate barotrauma from pressure changes or a basilar skull fracture. Otitis externa is a outer ear infection. Otitis media is an inner ear infection. The drainage from the ear is a classic sign of a possible basilar skull fracture. Possible mass in the ear is not consistent with this client's symptoms.

Which terms refers to the progressive hearing loss associated with aging? a. Presbycusis b. Exostoses c. Otalgia d. Sensorineural hearing loss

a. Presbycusis 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.

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? a. Presbycusis b. Tinnitus c. Conductive hearing loss d. Sensorineural hearing loss

a. Presbycusis Presbycusis results from gradual degeneration of nerves and sensory hair cells of the organ of Corti and may be related to either aging or use of ototoxic drugs. Tinnitus is a perception of buzzing or ringing in the ear(s) that does not correspond to an external sound. Disruption of sound wave transmission through the external or middle ear results in conductive hearing loss. Sensorineural hearing loss results from a problem from the inner ear to the auditory cortex.

What action should the nurse implement using an otoscope when assessing the ear of an adult client? a. Pull the auricle out, up, and back b. Choose the smallest speculum for client comfort c. Hold the speculum in the nondominant hand d. Insert the speculum gently down and backward

a. Pull the auricle out, up, and back 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.

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? a. Redness and bulging of the eardrum b. Clear discharge in the ear canal c. Bloody discharge in the ear canal d. Dense white patches on the tympanic membrane

a. Redness and bulging of the eardrum Redness and bulging of the eardrum are characteristic of otitis media with effusion. Clear or bloody discharge occurs with rupture of the tympanic membrane. Dense white patches on the tympanic membrane are noted with scarring of the tympanic membrane.

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? a. The client has unilateral hearing loss b. The client has loss of high-frequency sounds c. The client has loss of low-frequency sounds d. The client has bilateral hearing loss

a. The client has unilateral hearing loss The whisper test evaluates loss of high-frequency sounds. The Weber test helps to differentiate the cause of unilateral hearing loss. In the Rinne test, use of a tuning fork helps the nurse determine if hearing is equal in both ears and if there is either a conductive or a sensorineural hearing loss by allowing the nurse to compare the difference in bone conduction (BC) versus air conduction (AC). Remember AC has less resistance than BC. Option D is a distracter for this question.

Which action by the nurse is consistent with Weber's test? a. The nurse activates the tuning fork and places it on the midline of the parietal bone in line with both ears. b. The nurse strikes the tuning fork and places it on the client's mastoid process to measure bone conduction. c. The nurse uses a bulb insufflator attached to an otoscope to observe movement of the tympanic membrane. d. The nurse shields their mouth and whispers a simple sentence approximately 18 inches from the client's ear.

a. 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 client'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 client's ear.

A client 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? a. Tinnitus b. Vertigo c. Nystagmus d. Otalgia

a. Tinnitus Tinnitus is a sign of ototoxicity, which can occur when a client's dose is too high

Which portion of the middle ear equalizes pressure? a. Tympanic membrane b. Ossicles c. Auricle d. Cochlea

a. Tympanic membrane The tympanic membrane of the middle ear equalizes pressure. Ossicles, which are held in place by joints, muscles, and ligaments, assist in the transmission of sound. The auricle collects the sound waves and directs vibrations into the external auditory canal. The cochlea is a winding, snail-shaped bony tube that forms a portion of the inner ear and contains the organ of Corti; the transducer of hearing.

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? a. Vertigo b. Otalgia c. Tinnitus d. Otorrhea

a. Vertigo A subjective assessment question for vertigo is "Have you ever felt dizzy or had problems with balance?" Tinnitus is ringing of the ears. Otalgia is an earache. Otorrhea is drainage from the ears. None of these would be a priority assessment in this situation.

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 a. acute otitis media. b. serous otitis media. c. skull trauma. d. trauma from infection.

a. acute otitis media. In acute otitis media there is a bulging red membrane with decreased or absent light reflex.

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 a. infection. b. skull injury. c. vestibular disorders. d. healed perforations.

a. infection. With otitis media, the membrane does not move or flutter when the bulb is inflated.

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: a. whispered sounds b. the calling bell c. the tuning fork d. the sound of "th"

a. whispered sounds The inability of the client to hear whispered sounds indicates presbycusis, which is a gradual sensorineural hearing loss due to degeneration of the cochlea or vestibulocochlear nerve, common in older clients. The inability to hear the calling bell may indicate deafness. The inability to hear the tuning fork may indicate sensorineural or conductive hearing loss.

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? a. "Do you have any ear pain?" b. "Do you experience any ringing, roaring, or crackling in your ears?" c. "Do you have any ear drainage?" d. "Are you ever concerned that you may be losing your ability to hear well?"

b. "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.

You are teaching a class on diseases of the ear. What would you teach the class is the most characteristic symptom of otosclerosis? a. The client being distressed in the mornings b. A progressive, bilateral loss of hearing c. A red and swollen ear drum d. The client describing a history of having had a recent upper respiratory infection.

b. A progressive, bilateral loss of hearing A progressive, bilateral loss of hearing is the characteristic symptom of otosclerosis. Tinnitus appears as the loss of hearing progresses; it is especially noticeable at night, when surroundings are quiet, and may be quite distressing to the client. The eardrum appears pinkish-orange from structural changes in the middle ear. The client often describes a history of having had a recent upper respiratory infection in case of otitis media, not otosclerosis.

High doses of this medication can produce bilateral tinnitus? a. Antivert b. Aspirin c. Promethazine d. Dramamine

b. Aspirin At high doses, aspirin toxicity can produce bilateral tinnitus. Antivert and Dramamine is used for nausea and vomiting related to motion sickness. Antiemetics such as promethazine (Phenergan) suppositories help control the nausea and vomiting and the vertigo because of the antihistamine effect.

The client is having a Weber test. During a Weber test, where should the tuning fork be placed? a. On the mastoid process behind the ear. b. In the midline of the client's skull or in the center of the forehead. c. Near the external meatus of each ear. d. Under the bridge of the nose

b. 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.

When teaching a class of school-age children about hygiene, the nurse should include which information about the ears? a. Ears should be cleaned with cotton applicators once a day at bedtime. b. Never put anything smaller than your elbow in your ears. c. Only allow your parents clean out your ears with cotton applicators. d. Producing less earwax can lead to a hearing loss.

b. Never put anything smaller than your elbow in your ears. The nurse should reinforce proper cleaning techniques such as cleaning the bowl of the helix and never introducing anything into the external auditory canal. An elbow will not fit into an ear canal; therefore stating not to put anything smaller than an elbow into the ears, eliminates putting anything into the external ear canal. It's also a fun way to educate school age children. Cotton tipped applicators can cause complications and should not be used to clean the ears. An increased amount of earwax, not decreased, can lead to conductive hearing loss.

A client comes to the clinic and reports pain when he touches his ear. With what is this finding most consistent? a. Acoustic neuroma b. Otitis externa c. Otitis media d. Meniere disease

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

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. Audiometric test b. Romberg test c. Weber test d. Rinne test

b. Romberg test 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

A 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? a. The arm of the stapes b. The short process of the malleus c. The head of the incus d. The long process of the stapes

b. The short process of the malleus During visualization of the normal tympanic membrane, it is intact and translucent and the short process of the malleus is visible. The nurse practitioner would not expect to see the stapes or the head of the incus.

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. "He should avoid flying for 6 months after tube placement." b. "The child must wear ear plugs while flying." c. "It's safe to fly because the tubes will equalize pressure." d. "He shouldn't fly with anyone who is immunocompromised."

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

A client has been receiving intravenous antibiotics for several weeks. Which prevention strategy would be best for the nurse to recommend for this client? a. Whisper hearing test b. Rubbing fingers test c. Formal hearing test d. Tuning fork test

c. Formal hearing test One group at risk for developing a hearing loss is those who are receiving intravenous antibiotics. The prevention strategy that would be applicable for this client would be a formal hearing test. Although the other tests including whisper hearing test, rubbing fingers test and tuning fork test can be used to test hearing, these are not considered the gold standard. These tests would not be the best prevention strategy to rule out hearing loss in this case.

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

c. Gray 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.

Which finding should a nurse recognize as normal when assessing the ears of an elderly client? a. Decrease in cerumen production b. Shortened earlobes c. High-tone frequency loss d. Bulging tympanic membrane

c. High-tone frequency loss Presbycusis, a gradual hearing loss, is common after the age of 50 years. It begins with a loss of the ability to hear high-frequency tones. Cerumen production may increase in older age or become drier and build up as the cilia become more rigid. The earlobes become elongated in older age. A bulging tympanic membrane is not a normal finding at any age.

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? a. Foreign body b. Acute otitis media c. Otitis externa d. Perforated tympanic membrane

c. Otitis externa The key to this condition is that the child was at the beach. Otitis externa occurs as an infection of the external canal from swimming. It presents with a pain and swelling of the ear canal, fever, and purulent drainage. There was no data to support the presence of a foreign object. Acute otitis media is an infection behind the tympanic membrane that presents with many of the same symptoms but the pain is behind the ear and the tympanic membrane is red and swollen, with a loss of the cone of light. A perforated tympanic membrane will produce drainage in the ear canal, a perforation will be present in the tympanic membrane, and the pain most often subsides once the pressure is released from the ear.

Which precaution should a nurse take to ensure the safety of a client when performing the Romberg test? a. Instruct the client to hold on to a chair b. Offer assistance by holding the client's arm c. Place arms around the client without touching d. Tell the client to keep the eyes open & focused ahead

c. Place arms around the client without touching 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.

A client 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? a. Malleus b. Incus c. Stapes d. Umbo

c. Stapes Sound waves are transmitted through auditory ossicles as the vibration of the eardrum causes the malleus, the incus, and then the stapes to vibrate. As the stapes vibrates at the oval window, the sound waves are passed to the fluid in the inner ear. The umbo is the base of the malleus.

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? a. Handle and short process of the malleus b. Pars flaccida c. Umbo d. Pars tensa

c. Umbo The malleus is the nearest auditory ossicle that can be seen through the translucent membrane and includes a handle and short process, which are closer to the edge of the membrane, and the umbo, or base, which is a center point landmark of the tympanic membrane. Pars flaccida is the top portion of the membrane, which appears to be less taut than the bottom portion. Pars tensa is the bottom of the membrane, which appears to be taut.

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 a. normal hearing. b. sensorineural hearing loss. c. conductive hearing loss. d. central hearing loss.

c. conductive hearing loss. With conductive hearing loss, bone conduction (BC) sound is heard longer than or equally as long as air conduction (AC) sound.

An adult client visits the clinic and complains of tinnitus. The nurse should ask the client if she has been a. dizzy. b. hypotensive. c. taking antibiotics. d. experiencing ear drainage.

c. taking antibiotics. Ringing in the ears (tinnitus) may be associated with excessive earwax buildup, high blood pressure, or certain ototoxic medications (such as streptomycin, gentamicin, kanamycin, neomycin, ethacrynic acid, furosemide, indomethacin, or aspirin), loud noises, or other causes.

A client reports the onset of tinnitus. What question should the nurse ask the client to further assess this condition? a. "Do you clean your ears with cotton-tipped applicators?" b. "Did you experience a lot of ear infections as a child?" c. "Are you having trouble hearing the phone ring?" d. "Have you taken any antibiotics in the past few weeks?"

d. "Have you taken any antibiotics in the past few weeks?" Tinnitus is the feeling of ringing in the ears and may be associated with excessive wax buildup, high blood pressure, or certain ototoxic medications, such as antibiotics. Cleaning the ear with cotton-tipped applicators places the client at risk for ear damage. Ear infections can cause loss of hearing. Not hearing the p hone ring may be a sign of hearing loss.

A client has Darwin tubercle. What is this? a. A type of skin cancer found on the ear b. A growth in the ear canal c. A growth in the bony labyrinth d. A small painless nodule on the helix

d. A small painless nodule on the helix Small painless nodules on the helix are a variation of normal anatomy known as darwinian tubercle.

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. Transmits vibration to the fluid filled inner ear at the oval window. b. Separates the external from the middle ear. c. Sends sensory information to the cerebellum and midbrain. d. Equalizes the pressure in the middle ear with atmospheric pressure.

d. 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.

When inspecting the tympanic membrane, which of the following structures does the nurse expect to identify? a. Cone of light, incus, umbo, cochlea b. Pars tensa, umbo, handle of malleus, ossicles c. Pars tensa, pars flaccida, vestibule, cone of light d. Handle of malleus, short process of malleus, cone of light

d. Handle of malleus, short process of malleus, cone of light 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 malleus. The cochlea, vestibule, and stapes (part of the ossicles) are not normally visualizable.

Student nurses are spending time in the laboratory learning the proper use of an otoscope. What technique would these students learn for best visualization of the tympanic membrane in an adolescent? a. Hold the ear at the tragus and lift up and back b. Hold the ear at the pinna and pull down and back c. Hold the ear at the auricle and pull down and back d. Hold the ear at the helix and lift up and back

d. Hold the ear at the helix and lift up and back Hold the adolescent's ear at the helix and lift up and back to align the canal for best visualization of the tympanic membrane. In children younger than 3 years, the nurse would pull down and back to visualize the tympanic membrane. The nurse always lifts from the helix, not the auricle (pinna) and never from the tragus.

The nurse palpates a client's auricles and notes an enlarged lymph node on one ear. No redness is observed, and the client denies pain or tenderness. What is the nurse's best action? a. Document the finding as an isolated benign node. b. Inform the client of the need for ear drops. c. Refer the client to an audiologist for an audiogram. d. Notify the healthcare provider about the finding.

d. 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.

Which characteristic feature of the tympanic membrane should a nurse anticipate finding in a client with acute otitis media? a. Pearly, translucent, with no bulging b. Yellowish, bulging, with fluid bubbles c. Gray, translucent, with no retraction d. Red, bulging, with an absent light reflex

d. 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.

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? a. Rhinorrhea b. Fever c. Headache d. Vertigo

d. 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 client could develop vertigo. Rhinorrhea, fever, and headache are not potential problems associated with an inner ear infection.

The nurse assessing for unilateral hearing loss by using a tuning fork. What test is the nurse performing? a. Watch tick test b. Rinne test c. Whisper test d. Weber's test

d. Weber's test The Weber's test uses bone conduction to test lateralization of sound and is useful in detecting unilateral hearing loss. In the Rinne test, the examiner shifts the stem of a vibrating tuning fork between two positions to test air conduction of sound and bone conduction of sound. The whisper test involves covering the untested ear and whispering from a distance of 2 or 3 feet from the unoccluded ear and determining the client's ability to repeat what was whispered. The watch tick test relies on the ability of the client to perceive the high-pitched sound made by a watch held at the client's auricle.

The nurse is preparing to examine the ears of an adult client with an otoscope. The nurse should plan to a. ask the client to tilt the head slightly forward. b. release the auricle during the examination. c. use a speculum that measures 10 mm in diameter. d. firmly pull the auricle out, up, and back.

d. firmly pull the auricle out, up, and back. Use the thumb and fingers of your opposite hand to grasp the client's auricle firmly but gently. Pull out, up, and back to straighten the external auditory canal. Do not alter this positioning at any time during the otoscope examination.

The nurse is planning to perform an ear examination on an adult client. After explaining the procedures to the client, the nurse should a. ask the client to remain standing. b. show the client the otoscope. c. ask the client to remove his contact lenses. d. observe the client's response to the explanations.

d. observe the client's response to the explanations. As you prepare the client for the ear examination, carefully note how the client responds to your explanations.