PrepU CH 59: Assessment & Management of Patients with Hearing & Balance Disorders
A client has a history of hearing loss and is returning for an annual hearing examination. During client education, the nurse explains that hearing involves which areas of the ear? middle section inner section outer section all sections
all sections Explanation: Sound is perceived because of a chain reaction involving all three areas of the ear. Chapter 59: Assessment and Management of Patients with Hearing and Balance Disorders.
Changes in pressure at high altitudes can cause discomfort in the ears. Which structure within the middle ear is instrumental in equalizing pressure? semicircular canals eustachian tubes incus tubes fallopian tubes
eustachian tubes 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. Chapter 59: Assessment and Management of Patients with Hearing and Balance Disorders, ASSESSMENT OF THE EAR, p. 1937.
A client with a conductive hearing disorder caused by ankylosis of the stapes in the oval window undergoes a stapedectomy to remove the stapes and replace the impaired bone with a prosthesis. After the stapedectomy, the nurse should provide which client instruction? "Don't fly in an airplane, climb to high altitudes, make sudden movements, or expose yourself to loud sounds for 30 days." "Lie in bed with your head elevated, and refrain from blowing your nose for 24 hours." "Shampoo your hair every day for 10 days to help prevent ear infection." "Try to ambulate independently after about 24 hours."
"Don't fly in an airplane, climb to high altitudes, make sudden movements, or expose yourself to loud sounds for 30 days." Explanation: The nurse should instruct the client to avoid air travel, sudden movements that may cause trauma, and exposure to loud sounds and pressure changes (such as from high altitudes) for 30 days after a stapedectomy. Immediately after surgery, the client should lie flat with the surgical ear facing upward; nose blowing is permitted but should be done gently and on one side at a time. The client's first attempt at postoperative ambulation should be supervised to prevent falls caused by vertigo and light-headedness. The client must avoid shampooing and swimming to keep the dressing and the ear dry. Chapter 59: Assessment and Management of Patients with Hearing and Balance Disorders.
Which statement describes benign paroxysmal positional vertigo (BPPV)? BPPV is caused by tympanic membrane infection. The vertigo is usually accompanied by nausea and vomiting; generally, however, hearing is not impaired. BPPV is stimulated by the use of certain medications, such as acetaminophen. The onset of BPPV is gradual.
The vertigo is usually accompanied by nausea and vomiting; generally, however, hearing is not impaired. Explanation: BPPV is a brief period of incapacitating vertigo that occurs when the position of the client's head is changed with respect to gravity. The vertigo is usually accompanied by nausea and vomiting; however, generally, hearing impairment does not occur. The onset of BPPV is sudden and followed by a predisposition to positional vertigo, usually for hours to weeks but occasionally months or years. BPPV is thought to be caused by the disruption of debris within the semicircular canal. This debris forms from small crystals of calcium carbonate from the inner ear structure, the utricle. BPPV is frequently stimulated by head trauma, infection, or other events. Chapter 59: Assessment and Management of Patients with Hearing and Balance Disorders, Benign Paroxysmal Positional Vertigo, p. 1954.
What aspect should the nurse closely monitor for in clients who have been administered salicylates, loop diuretics, quinidine, quinine, or aminoglycosides? Signs of hypotension Tinnitus and sensorineural hearing loss Reduced urinary output Impaired facial movement
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. Chapter 59: Assessment and Management of Patients with Hearing and Balance Disorders, CONDITIONS OF THE INNER EAR, pp. 1957-1958.
The nurse identifies the nursing diagnosis of deficient knowledge related to a new hearing aid for a client. After teaching a client about caring for his new hearing aid, the nurse determines that the outcome has been achieved when the client states which of the following? "I need to wipe the ear mold daily with a moist washcloth." "I need to keep my ear canal clean and dry." "I should insert the ear mold when it is wet." "I should wash the receiver with soap and water once a week."
"I need to keep my ear canal clean and dry." Explanation: The client demonstrates understanding of the care of a hearing aid when stating the need to keep the ear canal clean and dry. The ear mold is the only part of the hearing aid that can be washed frequently, that is daily with soap and water. It should be allowed to dry completely before it is snapped into the receiver or inserted into the ear. Chapter 59: Assessment and Management of Patients with Hearing and Balance Disorders, Hearing Aids, p. 1959.
The nurse is supervising a family member who instilling ear drops into the client's ear. Which of the following statements, made by the family member, would require further nursing instruction? "I squeeze the dropper to put a drop of medicine in the ear." "Turn your head to the side so I can put these drops in." "Let me put this cotton ball in your ear because I put the drop in." "These drops are cold from being on the window sill."
"These drops are cold from being on the window sill." Explanation: When the family member states that the drops are cold, the nurse would encourage the family member to place the bottle in a warm bath or warm the bottle in their hands. Cold or hot liquids, instilled in the ear, may cause dizziness and potential for injury. Chapter 59: Assessment and Management of Patients with Hearing and Balance Disorders, CONDITIONS OF THE EXTERNAL EAR, pp. 1946-1947.
When preparing a teaching plan for a client diagnosed with otitis externa, the nurse instructs the client to avoid any water sport for which duration? 3 to 5 days 7 to 10 days 10 to 14 days 5 to 7 days
7 to 10 days Explanation: A client with otitis externa should refrain from any water sport for approximately 7 to 10 days to allow the canal to heal completely. Otherwise, recurrence is highly likely. Chapter 59: Assessment and Management of Patients with Hearing and Balance Disorders, External Otitis (Otitis Externa), p. 1947.
A dietary modification for a patient with Ménière's disease would be: Fluid restriction to 2 L/day. An increase in vitamin C to 1.5 g/day. A decrease in sodium intake to 1500 mg daily. An increase in calcium to 1 g/day.
A decrease in sodium intake to 1500 mg daily. Explanation: Patients with Ménière's disease can be successfully treated by adhering to a low-sodium (1000 to 1500 mg/day) diet, with no caffeine and alcohol. Chapter 59: Assessment and Management of Patients with Hearing and Balance Disorders, Ménière's Disease, p. 1954.
Which symptoms may a client with Ménière disease report before an attack? Low blood pressure Nystagmus A full feeling in the ear Photosensitivity
A full feeling in the ear Explanation: Clients with Ménière disease experience symptoms of headache and a full feeling in the ear before an attack. Nystagmus is an episodic symptom that occurs during an attack, and, at times, the client is symptom free. Ménière disease does not cause low blood pressure or photosensitivity. Chapter 59: Assessment and Management of Patients with Hearing and Balance Disorders, Ménière's Disease, pp. 1953-1954.
The nurse is teaching a class on diseases of the ear. What would the nurse teach the class is the most characteristic symptom of otosclerosis? The client being distressed in the mornings The client describing a recent upper respiratory infection A red and swollen ear drum A progressive, bilateral loss of hearing
A progressive, bilateral loss of hearing Explanation: 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. Chapter 59: Assessment and Management of Patients with Hearing and Balance Disorders, Otosclerosis, p. 1952.
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 red and swollen ear drum The client being distressed in the mornings The client describing a history of having had a recent upper respiratory infection
A progressive, bilateral loss of hearing Explanation: 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. Chapter 59: Assessment and Management of Patients with Hearing and Balance Disorders, Otosclerosis, p. 1952.
The client has been diagnosed with objective vertigo. Which symptom would the nurse relate to the tentative diagnosis? Pain in the outer ear Hearing ability fluctuations A sensation of things moving Frequency of a headache
A sensation of things moving Explanation: Objective vertigo includes the sensation that the environment is moving or a sense that things are moving around oneself. The symptoms do not include a headache, pain in the outer ear, and difficulty hearing. Chapter 59: Assessment and Management of Patients with Hearing and Balance Disorders, CONDITIONS OF THE INNER EAR, pp. 1953-1954.
High doses of which medication can produce bilateral tinnitus? Dimenhydrinate Promethazine Aspirin Meclizine
Aspirin Explanation: At high doses, aspirin toxicity can produce bilateral tinnitus. Meclizine and dimenhydrinate are used for nausea and vomiting related to motion sickness. Antiemetics, such as promethazine suppositories, help control nausea and vomiting and vertigo through an antihistamine effect. Chapter 59: Assessment and Management of Patients with Hearing and Balance Disorders, ASSESSMENT OF THE EAR, p. 1937.
The nurse and a colleague are performing the Epley maneuver with a client who has a diagnosis of benign paroxysmal positional vertigo. The nurses should begin this maneuver by performing what action? Placing the client in a prone position Instilling 15 mL of warm normal saline into one of the client's ears Assessing the client's baseline hearing by performing the whisper test Assisting the client into a sitting position
Assisting the client into a sitting position Explanation: The Epley maneuver is performed by placing the client in a sitting position, turning the head to a 45-degree angle on the affected side, and then quickly moving the client to the supine position. Saline is not instilled into the ears and there is no need to assess hearing before the test. Chapter 59: Assessment and Management of Patients with Hearing and Balance Disorders, Benign Paroxysmal Positional Vertigo, p. 1956.
The nurse is caring for a client experiencing hearing loss. The nurse uses the otoscope to assess the ear canal and tympanic membrane and notes a significant accumulation of cerumen. Which documentation of hearing loss type would be most accurate? Conductive Central Mixed Sensorineural
Conductive Explanation: Conductive hearing loss occurs from an obstruction in the outer or middle ear such as from cerumen. Mixed hearing loss is a combination of conductive and sensorineural problems. Central hearing loss involves injury or damage to the nerves or the nuclei of the central nervous system. Sensorineural involves damage to the inner ear. Chapter 59: Assessment and Management of Patients with Hearing and Balance Disorders, HEARING LOSS, p. 1944.
Which of the following medications may be used in the treatment of motion sickness? Peroxide in glycerol (Debrox) Dimenhydrinate (Dramamine) Intravenous Diazepam (Valium) Furosemide (Lasix)
Dimenhydrinate (Dramamine) Explanation: Over-the-counter antihistamines such as dimenhydrinate (Dramamine) or meclizine hydrochloride (Antivert) may provide some relief of nausea and vomiting by blocking the conduction of the vestibular pathway of the inner ear. Debrox is a cerumenolytic agent. Lasix and IV Valium would not be used in the treatment of motion sickness. Chapter 59: Assessment and Management of Patients with Hearing and Balance Disorders, CONDITIONS OF THE INNER EAR, p. 1953.
Health teaching for a patient who suffers from motion sickness would include recommending the use of which one of the following over-the-counter drugs? Scopolamine Ephedrine Phenergan Dramamine
Dramamine Explanation: Scopolamine and Phenergan are popular anticholinergics; ephedrine is a popular sympathomimetic. Dramamine and Antivert are over-the-counter antihistamines that act by blocking the conduction of the vestibular pathway of the inner ear. Chapter 59: Assessment and Management of Patients with Hearing and Balance Disorders, CONDITIONS OF THE INNER EAR, p. 1953.
A nurse is performing an otoscopic examination on a client. Which finding would the nurse document as abnormal? Tympanic membrane pearly gray Umbo in the center of the tympanic membrane Manubrium superior to the umbo External auditory canal erythema
External auditory canal erythema Explanation: An erythematous external auditory canal would be considered an abnormal finding. The tympanic membrane is normally pearly gray and translucent. The umbo, which is located in the center of the eardrum, extends from the superior manubrium. Chapter 59: Assessment and Management of Patients with Hearing and Balance Disorders, ASSESSMENT OF THE EAR, p. 1939.
If untreated, squamous cell carcinoma of the external ear can spread through the temporal bone, causing which effect? Nystagmus Diplopia Motor impairment Facial nerve paralysis
Facial nerve paralysis Explanation: If untreated, squamous cell carcinomas of the ear can spread through the temporal bone, causing facial nerve paralysis and hearing loss. Chapter 59: Assessment and Management of Patients with Hearing and Balance Disorders, Masses of the External Ear, p. 1948.
The nurse is performing a Weber test on a client. During this test, where should the nurse place the tuning fork? Near the external meatus of each ear In the midline of the client's skull or in the center of the forehead Under the bridge of the nose On the mastoid process behind the ear
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. Chapter 59: Assessment and Management of Patients with Hearing and Balance Disorders, ASSESSMENT OF THE EAR, pp. 1940-1941.
A client comes to the walk-in clinic complaining of a "bug in my ear." What action should be taken when there is an insect in the ear? Instillation of hot water Instillation of mineral oil Use of a small forceps Instillation of carbamide peroxide
Instillation of mineral oil Explanation: Mineral oil is instilled into the ear to smother an insect. Carbamide peroxide is used to soften dried cerumen and small forceps are used to remove solid objects. Hot liquids cause dizziness and should not be instilled in the ear. Chapter 59: Assessment and Management of Patients with Hearing and Balance Disorders, CONDITIONS OF THE EXTERNAL EAR, p. 1947.
The nurse is caring for a patient with Ménière's disease who is hospitalized with severe vertigo. What medication does the nurse anticipate administering to shorten the attack? Meclizine (Antivert) Furosemide (Lasix) Cortisporin otic solution Gentamicin (Garamycin) intravenously
Meclizine (Antivert) Explanation: Pharmacologic therapy for Ménière's disease consists of antihistamines, such as meclizine, which shortens the attack. Chapter 59: Assessment and Management of Patients with Hearing and Balance Disorders, Ménière's Disease, p. 1954.
The nurse is preparing teaching for a client with Ménière's disease. Which dietary instruction will the nurse emphasize? Select all that apply. Limit intake of salt Include pickled vegetables Eat meals at regular intervals Drink water liberally Limit alcohol intake
Limit intake of salt Eat meals at regular intervals Drink water liberally Limit alcohol intake Explanation: Most clients with Ménière's disease can be successfully treated with diet and medication. Dietary teaching should include limiting alcohol intake as it may change the volume and concentration of the inner ear fluid and worsen symptoms. The client should be instructed to drink plenty of fluids every day. Water and low-sugar beverages are recommended along with limiting beverages with caffeine because of the diuretic effect. Foods high in salt should be avoided and meals should be eaten at regular intervals to ensure that the fluid level remains consistent in the ear. Pickled vegetables like sauerkraut, olives and pickles have a high sodium content and should be avoided. Sodium causes fluid retention and can make symptoms worse. Chapter 59: Assessment and Management of Patients with Hearing and Balance Disorders, Chart 59-8 Patient Education: Dietary Guidelines for Patients with Ménière Disease, p. 92.
A patient is participating in aural rehabilitation. The nurse understands that this type of training emphasizes which of the following? Functional skills Listening skills Occupational skills Social skills
Listening skills Explanation: Auditory training emphasizes listening skills, so the person who is hearing-impaired concentrates on the speaker. Chapter 59: Assessment and Management of Patients with Hearing and Balance Disorders, AURAL REHABILITATION, p. 1958.
Hearing aids help with which of the following problems? Improves communication skills Improves discrimination of words Improves understanding of speech Makes sounds louder
Makes sounds louder Explanation: A hearing aid makes sounds louder, but it does not improve a patient's ability to discriminate words or understand speech. Hearing aids amplify all sounds, including background noise, which may be disturbing to the wearer. It does not improve communication skills. Chapter 59: Assessment and Management of Patients with Hearing and Balance Disorders, Hearing Aids, p. 1958.
The nurse is assessing a client with multiple sclerosis who is demonstrating involuntary, rhythmic eye movements. What term will the nurse use when documenting these eye movements? Nystagmus Tinnitus Vertigo Astigmatism
Nystagmus Explanation: Vertigo is an illusion of movement where the individual or the surroundings are sensed as moving. Tinnitus refers to a subjective perception of sound with internal origin. Nystagmus refers to involuntary rhythmic eye movement. Astigmatism is a defect is visual acuity. Chapter 59: Assessment and Management of Patients with Hearing and Balance Disorders, CONDITIONS OF THE INNER EAR, p. 1953.
Which of the following describes vertigo? Select all that apply. Syncope Fainting Objects are moving around him or her Spinning sensation Misperception of motion
Objects are moving around him or her Spinning sensation Misperception of motion Explanation: Vertigo is defined as the misperception or illusion of motion of the person or their surroundings. Most people with vertigo describe a spinning sensation or say they feel as though objects are moving around them. Syncope, fainting, and loss of consciousness are not forms of vertigo and usually indicate disease in the cardiovascular system. Chapter 59: Assessment and Management of Patients with Hearing and Balance Disorders, CONDITIONS OF THE INNER EAR, pp. 1953-1954.
The nurse on a cruise ship is assessing clients for motion sickness. Which of the following is a common misconception? Medications help the symptoms. Pallor and diaphoresis is a first symptom. Repeated motion is the cause. Once symptoms occur, they will always be present.
Once symptoms occur, they will always be present. Explanation: When the client experiences motion sickness, the client will use that data to avoid further symptoms in the future. The client can use medication, change location or position, and recognize symptoms earlier for symptom management. The other options are correct and teachable statements. Chapter 59: Assessment and Management of Patients with Hearing and Balance Disorders, Motion Sickness, p. 1953.
The nurse is developing a plan of care for a patient with severe vertigo. What expected outcome statement would be a priority for this patient? Patient will experience no falls due to balance disorder. Patient will have decreased fear and anxiety. Patient will perform exercises as prescribed. Patient will take medications as prescribed.
Patient will experience no falls due to balance disorder. Explanation: Although all of these are expected outcomes for a patient with vertigo, the priority expected outcome is that the patient will experience no falls due to the balance disturbance, as falls poses the greatest risk to the patient's health. Chapter 59: Assessment and Management of Patients with Hearing and Balance Disorders, CONDITIONS OF THE INNER EAR, p. 1955.
Which terms refers to the progressive hearing loss associated with aging? Sensorineural hearing loss Exostoses Presbycusis Otalgia
Presbycusis Explanation: Age-related changes of both the middle and inner ear result in hearing loss. Exostoses refer 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. Chapter 59: Assessment and Management of Patients with Hearing and Balance Disorders, HEARING LOSS, p. 1945.
Which condition refers to hearing loss associated with degenerative changes? Presbyopia Myopia Strabismus Presbycusis
Presbycusis Explanation: The term presbycusis refers to hearing loss associated with degenerative changes. Chapter 59: Assessment and Management of Patients with Hearing and Balance Disorders, HEARING LOSS, p. 1945.
The nurse is instructing the client with dried cerumen blocking the ear canal on potential methods to reduce symptoms. Which at-home methods of cerumen removal are discouraged? Irrigating the ear with warm water and a rubber-bulb syringe Removing the cerumen by means of a cotton tip applicator Instilling 1 to 2 drops of half-strength peroxide in the ear Using warm glycerin or mineral oil to soften the cerumen
Removing the cerumen by means of a cotton tip applicator Explanation: The nurse is an important resource person to consult when a client has an issue with the ear structure or hearing. The nurse is correct to discourage placing anything down the ear canal that could push the cerumen deeper toward or puncture the tympanic membrane. The other options are appropriate to soften and lubricate the cerumen or to irrigate the cerumen from the ear. Chapter 59: Assessment and Management of Patients with Hearing and Balance Disorders, External Otitis (Otitis Externa), p. 1947.
Which test uses a tuning fork shifted between two positions to assess hearing? Watch tick Whisper Rinne Weber
Rinne Explanation: 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 1 or 2 feet from the unoccluded ear, then determining the ability of the client 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 Weber test uses bone conduction to test lateralization of sound. Chapter 59: Assessment and Management of Patients with Hearing and Balance Disorders, ASSESSMENT OF THE EAR, p. 1941.
Which test would be used to determine an inner ear dysfunction? acoustic reflex testing pure-tone testing tympanometry Romberg test
Romberg test Explanation: A Romberg test is used to evaluate a person's ability to sustain balance. Because central nervous system lesions cause similar abnormal results, additional testing is needed to confirm inner ear dysfunction. Tympanometry assists in detection of fluid in the middle ear. Pure-tone testing determines the faintest tones a person can hear and is a test of the middle ear. Acoustic reflex testing is done to assess the loudness level at which the acoustic reflex occurs and is a test of the middle ear. Chapter 59: Assessment and Management of Patients with Hearing and Balance Disorders.
What kind of otitis media is a pathogen-free fluid behind the tympanic membrane, resulting from irritation associated with respiratory allergies and enlarged adenoids? Sterile otitis media Infectious otitis media Serous otitis media Purulent otitis media
Serous otitis media Explanation: Serous otitis media, a collection of pathogen-free fluid behind the tympanic membrane, results from irritation associated with respiratory allergies and enlarged adenoids. The other options are distractors for this question. Purulent otitis media usually results from the spread of microorganisms from the eustachian tube to the middle ear during upper respiratory infections. Chapter 59: Assessment and Management of Patients with Hearing and Balance Disorders, Serous Otitis Media, p. 1949.
Which symptom is related to vertigo? Spinning sensation Syncope Loss of consciousness Fainting
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 as though objects are moving around them. Chapter 59: Assessment and Management of Patients with Hearing and Balance Disorders, CONDITIONS OF THE INNER EAR, p. 1953.
A nurse is preparing to perform the whisper test to assess a client's gross auditory acuity. Which of the following would be most appropriate for the nurse to do? Stand at a position diagonal to the client. Speak a phrase in a low normal tone of voice. Stand about 1 to 2 feet away from the ear to be tested. Have the client use a finger to occlude the ear to be tested.
Stand about 1 to 2 feet away from the ear to be tested. Explanation: When performing the whisper test, the nurse covers the untested ear with the palm of the hand and then whispers softly from a distance of 1 to 2 feet from the unoccluded ear and out of the client's sight. The client with normal hearing can correctly repeat what was whispered. Chapter 59: Assessment and Management of Patients with Hearing and Balance Disorders, ASSESSMENT OF THE EAR, p. 1940.
A client comes to the walk-in clinic complaining of an earache. The cause is found to be impacted cerumen. The client asks the nurse what he can do at home to soften hardened cerumen. What should the nurse recommend to a client to soften hardened cerumen? Take nonprescription preparations. Avoid harsh sunlight. Increase intake of red meat. Increase intake of beta-carotene.
Take nonprescription preparations. Explanation: The nurse should recommend nonprescription preparations that are available for softening hardened cerumen. Increasing the intake of red meat or beta-carotene or avoiding harsh sunlight will not soften the cerumen. Chapter 59: Assessment and Management of Patients with Hearing and Balance Disorders, CONDITIONS OF THE EXTERNAL EAR, p. 1946.
The nurse is assessing a client for objective signs of hearing difficulties. Which symptom leads the nurse to take alternate measures to ensure client understanding of teaching? The client leans forward and turns the head. The client quietly reads the instructional literature. The client interrupts by asking the nurse to repeat instruction. The client is quiet and responds appropriately.
The client leans forward and turns the head. Explanation: The nurse assesses objective signs of leaning forward and turning the head as indicative of difficulty hearing. The nurse would use alternate formats of teaching to reinforce key points. Asking to repeat information is a subjective indication of hearing difficulty. Responding appropriately and reading instructional literature does not indicate a hearing difficulty. Chapter 59: Assessment and Management of Patients with Hearing and Balance Disorders.
A patient comes to the clinic with some hearing loss. The physician is unable to observe the tympanic membrane due to the accumulation of cerumen. What intervention can the nurse provide so that observation can be made? The ear can be irrigated with cool water until all of the wax is removed. The nurse can remove the wax with a cerumen curette. The nurse can instill mineral oil into the canal and immediately irrigate to remove the adherent wax. The nurse can instill a small amount of mineral oil into the canal and have the patient return for removal of the wax.
The nurse can instill a small amount of mineral oil into the canal and have the patient return for removal of the wax. Explanation: If the tympanic membrane cannot be visualized because of cerumen, the cerumen may be removed by gently irrigating the external canal with warm water (unless contraindicated). If adherent cerumen is present, a small amount of mineral oil or over-the-counter cerumen softener may be instilled into the ear canal and the patient instructed to return for subsequent removal of the cerumen and inspection of the ear. The use of instruments such as a cerumen curette for cerumen removal is reserved for otolaryngologists and nurses with specialized training because of the danger of perforating the tympanic membrane or excoriating the external auditory canal. Chapter 59: Assessment and Management of Patients with Hearing and Balance Disorders, Cerumen Impaction, p. 1947.
The nurse is working in the emergency department when a physician asks for help as the client is performing a Romberg test. In which position would the nurse stand to be most helpful? The nurse would stand between the client and physician. The nurse would stand directly in front of the client. The nurse would stand laterally to the client, opposite side to where the physician is standing. The nurse would stand across the room but in direct alignment from the client.
The nurse would stand laterally to the client, opposite side to where the physician is standing. Explanation: The Romberg test is used to evaluate a person's ability to sustain balance. The client stands with the feet together and arms extended. In the event that the client begins to sway (an abnormal result), the nurse is most helpful to stand on the lateral side of the client, opposite side to where the physician is standing to ensure that the client does not fall. Chapter 59: Assessment and Management of Patients with Hearing and Balance Disorders.
Acoustic neuromas are benign tumors of which of the following cranial nerves? VI VIII VII V
VIII Explanation: Acoustic neuromas are slow-growing, benign tumors of cranial nerve VIII, usually arising from the Schwann cells of the vestibular portion of the nerve. Chapter 59: Assessment and Management of Patients with Hearing and Balance Disorders, Acoustic Neuroma, pp. 1957-1958.
A client is diagnosed with Meniere's disease. The nurse would most likely expect the client to report which of the following? Vertigo Nausea Ear fullness Tinnitus
Vertigo Explanation: Although tinnitus, nausea, vomiting and ear fullness may be noted, vertigo is usually the most troublesome and common complaint associated with Meniere's disease. Chapter 59: Assessment and Management of Patients with Hearing and Balance Disorders, Ménière's Disease, p. 1953.
The clinical manifestations of motion sickness are caused by an overstimulation in what system? Cardiovascular Cochlear Gastrointestinal Vestibular
Vestibular Explanation: Motion sickness is a disturbance of equilibrium caused by constant motion. The syndrome manifests itself in sweating, pallor, nausea, and vomiting caused by vestibular overstimulation. Motion sickness is not caused by cardiovascular, cochlear, or gastrointestinal overstimulation. Chapter 59: Assessment and Management of Patients with Hearing and Balance Disorders, Motion Sickness, p. 1953.
Which instructions regarding swimming should the nurse give to a client who is recovering from otitis externa? Wear a scarf. Insert a loose cotton earplug in the external ear. Wear soft plastic earplugs. Avoid cold water.
Wear soft plastic earplugs. Explanation: The nurse should advise the client to wear soft plastic earplugs to prevent trapping water in the ear while swimming. Cotton can be used, but if so it needs to be covered in petroleum jelly to prevent water from entering the external canal. Wearing a scarf does not help prevent or treat otitis externa. Swimming in cold water is not related to otitis externa. Chapter 59: Assessment and Management of Patients with Hearing and Balance Disorders, External Otitis (Otitis Externa), p. 1947.
A nurse is preparing a presentation for a local community about hearing loss and prevention. Which of the following would the nurse integrate into the presentation as the most effective preventive measure? Maintaining daily hygiene for the ears Having yearly audiometric testing Wearing ear protection when exposed to noise Obtaining prompt treatment for ear infections
Wearing ear protection when exposed to noise Explanation: Noise is a serious and very common factor associated with hearing loss. Hearing loss from noise is permanent, because noise destroys the hair cells in the organ of Corti. Therefore, wearing ear protection when exposed to noise is the most effective preventive measure available. Although appropriate ear hygiene and prompt treatment for infections are important, protecting the ears from noise is the priority. Audiometric testing is the single most important diagnostic instrument for detecting hearing loss; however, routine testing each year is not a current recommendation. Chapter 59: Assessment and Management of Patients with Hearing and Balance Disorders, HEARING LOSS, p. 1945.
A nurse needs to change a dressing on an abdominal wound for a patient who is hearing-impaired and whose speech is difficult to understand. Which of the following is the best approach for the nurse? Change the dressing while the patient is reading the steps of the treatment because distraction decreases anxiety. Minimize misunderstandings by completing the patient's sentences (e.g., fill-in-the-blanks) to decrease the patient's embarrassment. Write down the steps of the procedure for the patient to read before beginning the treatment. Use nonverbal signals of agreement (head nodding), even if unsure, to instill confidence and trust.
Write down the steps of the procedure for the patient to read before beginning the treatment. Explanation: Written communication is an excellent resource and means of mutual understanding. Distraction is not appropriate because a hearing-impaired person needs the care provider's full attention. Do not pretend to understand or complete the person's sentences for them. Chapter 59: Assessment and Management of Patients with Hearing and Balance Disorders, HEARING LOSS, p. 1946.
During assessment for cranial nerve functions, the client closes the eyes and begins to fall to one side. Which cranial nerve alteration causes this response? cranial nerve VII optic nerve facial nerve cranial nerve VIII
cranial nerve VIII Explanation: Nerve receptors for balance are found both in the vestibule and semicircular canals. They transmit information about motion through the vestibular nerve, which joins with the cochlear nerve to form the eighth cranial nerve (formally called the auditory or acoustic nerve). Chapter 59: Assessment and Management of Patients with Hearing and Balance Disorders.
