Assessment and Management of Patients With Hearing and Balance Disorders.
A patient with a sudden onset of hearing loss tells the nurse that he would like to begin using hearing aids. The nurse understands that the health professional dispensing hearing aids would have what responsibility? A) Test the patient's hearing promptly. B) Perform an otoscopy. C) Measure the width of the patient's ear canal. D) Refer the patient to his primary care physician.
D
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? a) Furosemide (Lasix) b) Cortisporin otic solution c) Meclizine (Antivert) d) Gentamicin (Garamycin) intravenously
Meclizine (Antivert)
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. 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. Speak a phrase in a low normal tone of voice
Stand about 1 to 2 feet away from the ear to be tested.
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? a) "Shampoo your hair every day for 10 days to help prevent ear infection." b) "Lie in bed with your head elevated, and refrain from blowing your nose for 24 hours." c) "Don't fly in an airplane, climb to high altitudes, make sudden movements, or expose yourself to loud sounds for 30 days." d) "Try to ambulate independently after about 24 hours."
don't fly in an airplanes, climb to high altitudes, make sudden movements, or expose yourself to loud sounds for 30 days
Which of the following instructions regarding swimming should the nurse give to the client who is recovering from otitis externa? Choose the correct option. a) Wear a scarf. b) Avoid cold water. c) Wear soft plastic earplugs. d) Insert a loose cotton earplug in the external ear.
wear soft plastic earplugs
A client is being prepared for a cochlear implant. Which client statement would alert the nurse to the need for additional teaching? A) "I'm going to be able to hear normally again." B) "I'll have a small incision behind my ear." C) "I'll wear an external transmitter and microphone." D) "I'll be able to hear medium and loud sounds for once."
A) "I'm going to be able to hear normally again." Explanation: A cochlear implant does not restore normal hearing. Rather, it helps the person detect medium to loud environmental sounds and conversation. A small receiver is implanted in the temporal bone through a postauricular incision with electrodes placed into the inner ear. The microphone and transmitter are worn on an external unit.
A client who has been fitted with a hearing aid comes for a follow-up evaluation. During the visit, the client states, "I've noticed that I still don't seem to hear well enough. The hearing aid doesn't seem to make the sounds louder." Which of the following might the nurse determine as the possible cause? A) Client has cerumen in the ear. B) The client has an ear infection. C) The mold is not properly fitted. D) Ear mold is loose.
A) Client has cerumen in the ear. Explanation: The client reports that the hearing aid is not helping, such that the sounds are not loud enough. This statement is consistent with inadequate amplification. Cerumen in the ears is a possible cause. A loose ear mold would cause a whistling noise. An improperly fitted mold or middle ear infection would lead to pain from the mold.
An 88-year-old client has a history of hearing loss and is returning for his annual hearing examination. During your client education session, you explain to the client that hearing involves which areas of the ear? The middle section of the ear is involved in perceiving sound. The outer section of the ear is involved in perceiving sound. The inner section of the ear is involved in perceiving sound. All sections of the ear are involved in perceiving sound.
All sections of the ear are involved in perceiving sound.
A patient is scheduled to have an electronystagmography as part of a diagnostic workup for Ménière's disease. What question is it most important for the nurse to ask the patient in preparation for this test? A) Have you ever experienced claustrophobia or feelings of anxiety while in enclosed spaces? B) Do you currently take any tranquilizers or stimulants on a regular basis? C) Do you have a history of falls or problems with loss of balance? D) Do you have a history of either high or low blood pressure?
B
A patient newly diagnosed with otitis media reports the pain and pressure in the ear has suddenly disappeared. What is the best action by the nurse? a) Irrigate the ear. b) Assess tympanic membrane. c) Educate on therapeutic effects of medications. d) Document effectiveness of medications.
Assess tympanic membrane
The parent of a young client with severe hearing loss is quite concerned about the child's future independence because of impaired hearing. Which type of hearing loss is usually irreversible? A) tinnitus B) sensorineural C) noise exposure D) conductive
B) sensorineural Explanation: Sensorineural hearing loss usually is irreversible.
The nurse is admitting a patient to the unit who is scheduled to have an ossiculoplasty. What postoperative assessment will best determine whether the procedure has been successful? A) Otoscopy B) Audiometry C) Balance testing D) Culture and sensitivity testing of ear discharge
B
There are several types of hearing loss. Which type of hearing loss benefits most from the use of a hearing aid? A) Acquired B) Conductive C) Sensorineural D) Genetic
B) Conductive Explanation: Diminished hearing results from a conductive loss, sensorineural loss, or both. Clients with a conductive hearing loss benefit more from the use of a hearing aid because the structures that convert sound into energy and facilitate perception of sound in the brain continue to function. Genetic and acquired are not types of hearing loss.
The nurse is assessing a client's hearing using the Rinne test. When providing instruction to elicit client feedback, which instruction is essential? A) Raise your hand when the sound exceeds the vibration. B) Raise your hand when you no longer hear sound. C) Raise your hand when you hear the vibration. D) Raise your hand when the vibration exceeds the sound
B) Raise your hand when you no longer hear sound. Explanation: It is essential to provide clear directions on when the client is to notify the nurse of client response. The information gleaned from the response is what the nurse uses to interpret the test. The correct time to induce feedback is when the vibration is held.
During his annual physical examination, a retired airplane mechanic reports noticeable hearing loss. The nurse practitioner prescribes a series of hearing tests to confirm or rule out noise-induced hearing loss, which is classified as a: A) Psychogenic issue. B) Sensorineural loss. C) Conduction problem. D) Mixed cause.
B) Sensorineural loss. Explanation: Noise-induced hearing loss refers to hearing loss that follows a long period of exposure to loud noise. It is inherent in jobs that involve heavy machinery, noisy engines, and artillery.
The nurse is assessing a patient with multiple sclerosis who is demonstrating involuntary, rhythmic eye movements. What term will the nurse use when documenting these eye movements? A) Vertigo B) Tinnitus C) Nystagmus D) Astigmatism
C
A child goes to the school nurse and complains of not being able to hear the teacher. What test could the school nurse perform that would preliminarily indicate hearing loss? A) Audiometry B) Rinne test C) Whisper test D) Weber test
C
A patient has been diagnosed with serous otitis media for the third time in the past year. How should the nurse best interpret this patient's health status? A) For some patients, these recurrent infections constitute an age-related physiologic change. B) The patient would benefit from a temporary mobility restriction to facilitate healing. C) The patient needs to be assessed for nasopharyngeal cancer. D) Blood cultures should be drawn to rule out a systemic infection.
C
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? A) Irrigating the ear with warm water and a rubber-bulb syringe B) Instilling 1 to 2 drops of half-strength peroxide in the ear C) Removing the cerumen by means of a cotton tip applicator D) Using warm glycerin or mineral oil to soften the cerumen
C) 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.
Which test would be used to determine an inner ear dysfunction? A) acoustic reflex testing B) pure-tone testing C) Romberg test D) tympanometry
C) 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.
The nurse is assessing a client for objective symptoms of hearing difficulties. Which symptom leads the nurse to take alternate measures to ensure client understanding of teaching? A) The client interrupts by asking the nurse to repeat instruction. B) The client is quiet and responds appropriately. C) The client leans forward and turns the head. D) The client quietly reads the instructional literature.
C) The client leans forward and turns the head. Explanation: The nurse assesses objective symptoms of leaning forward and turning the head as symptoms of having 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.
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) Signs of hypotension B) Reduced urinary output C) Tinnitus and sensorineural hearing loss D) Impaired facial movement
C) 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.
A client who has a lengthy history of progressive hearing loss is very forthright about the condition, and the nurse wants to develop a communication strategy for this client's hospital stay. Which communication strategy has proven to be the most effective? A) speech reading B) signing C) the one the client will use D) writing
C) the one the client will use Explanation: Although there are several communication strategies for clients with significant hearing loss, the only effective method is the one the client will consistently use.
Which precautions should the nurse take when a client is at risk of injury secondary to vertigo and probable imbalance? A) Immobilize the head to reduce the risk of falling B)Keep his or her eyes closed. C) Grasp the siderails when rising to a standing position. D) Refrain from looking at one place.
C)Grasp the siderails when rising to a standing position. Explanation: The nurse should have the client use firm supports, such as siderails, whenever arising. There is no need to limit the client's gaze or head movements. Keeping the eyes closed can exacerbate disorientation.
An older adult with a recent history of mixed hearing loss has been diagnosed with a cholesteatoma. What should this patient be taught about this diagnosis? Select all that apply A) Cholesteatomas are benign and self-limiting, and hearing loss will resolve spontaneously. B) Cholesteatomas are usually the result of metastasis from a distant tumor site. C) Cholesteatomas are often the result of chronic otitis media. D) Cholesteatomas, if left untreated, result in intractable neuropathic pain. E) Cholesteatomas usually must be removed surgically
C,E
The nurse is discharging a patient home after mastoid surgery. What should the nurse include in discharge teaching? A) "Try to induce a sneeze every 4 hours to equalize pressure." B) "Be sure to exercise to reduce fatigue." C) "Avoid sleeping in a side-lying position." D) "Don't blow your nose for 2 to 3 weeks."
D
A child has been experiencing recurrent episodes of acute otitis media (AOM). The nurse should anticipate that what intervention is likely to be ordered? A) Ossiculoplasty B) Insertion of a cochlear implant C) Stapedectomy D) Insertion of a ventilation tube
D
A nurse is teaching preventative measures for otitis externa to a group of older adults. What action should the nurse encourage? A) Rinsing the ears with normal saline after swimming B) Avoiding loud environmental noises C) Instilling antibiotic ointments on a regular basis D) Avoiding the use of cotton swabs
D
A patient presents to the ED complaining of a sudden onset of incapacitating vertigo, with nausea and vomiting and tinnitus. The patient mentions to the nurse that she suddenly cannot hear very well. What would the nurse suspect the patient's diagnosis will be? A) Ossiculitis B) Ménière's disease C) Ototoxicity D) Labyrinthitis
D
A client undergoing mastoid surgery asks the nurse about the pain following the surgery. Which response by the nurse is appropriate? A) "Most client report a sharp shooting pain for 1 to 2 months following the surgery from the eustachian tube opening." B) "The incisional pain usually last 3 weeks. The doctor will make sure you have enough pain medications." C) "Usually there is a constant throbbing pain for the first week. Most client report no pain with the use of the pain medications." D) "Usually the incisional pain is mild and controlled by the prescribed medication for the first 24 hours."
D) "Usually the incisional pain is mild and controlled by the prescribed medication for the first 24 hours." Explanation: The incisional pain from mastoid surgery is usually mild and controlled by prescribed pain medications. The client should be taking medications routinely the first 24 hours and as needed after 24 hours. Incisional pain usually does not last 3 weeks. The client may feel a sharp shooting pain when the eustachian tube is open for 2 to 3 weeks following surgery. A constant throbbing pain may indicate an infection and should be investigated.
The client has been diagnosed with objective vertigo. Which symptom would the nurse relate to the tentative diagnosis? A) Hearing ability fluctuations B) Frequency of a headache C) Pain in the outer ear D) A sensation of things moving
D) 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.
The nurse is performing the Rinne test on a client with a sensorineural hearing loss. Which of the following would the nurse expect? A) Hearing of the sound better in the affected ear B) Air-conducted sound louder than bone-conducted sound C) Sound described as being centered in the middle of the head D) Air-conducted sound heard longer than bone-conducted sound
D) Air-conducted sound heard longer than bone-conducted sound Explanation: With the Rinne test, a person with sensorineural hearing loss hears air-conducted sound longer than bone-conducted sound. A person with normal hearing would report that the air-conducted sound is louder than the bone-conducted sound. Hearing the sound better in the affected ear would be reported by a client with conductive hearing loss during the Weber test. Describing the sound as centered in the middle of the head would be reported by a person with normal hearing during the Weber test.
A nurse practitioner explains to a patient recently diagnosed with noise-induced hearing loss that the basic altered physiology in the ear is the result of: A) Hardening of the tympanic membrane. B) Malfunctioning of the incus and the staples. C) Stenosis of the semicircular canals. D) Damage to the hair cells inside the cochlea.
D) Damage to the hair cells inside the cochlea. Explanation: About 25% of all Americans who have a hearing loss have noise-induced hearing loss caused by damage to the hair cells found inside the cochlea. These cells convert sound energy into electrical signals that travel to the brain. Once damaged, they cannot be repaired.
You are teaching the daughter how to instill ear drops into her father's ear to remove impacted cerumen. What is a priority action to teach this woman? A) Direct the flow of the ear drops toward the eardrum. B) Insert the irrigating syringe deeply. C) Refrigerate before instillation. D) Place the container in warm water before instillation.
D) Place the container in warm water before instillation. Explanation: If irrigation or instillation of liquids is ordered, the nurse should warm the liquid to body temperature by placing the container in warm water. Cold or hot liquids cause dizziness, and the potential for injury exists if the liquid is hot. The nurse should avoid inserting the irrigating syringe too deeply so as not to close off the auditory canal. The nurse should direct the flow toward the roof of the canal, rather than the eardrum.
A nurse is performing an otoscopic examination on a client. Which finding would the nurse document as abnormal? External auditory canal erythema Umbo in the center of the tympanic membrane Tympanic membrane pearly gray Manubrium superior to the umbo
External auditory canal erythema
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? a) Instillation of mineral oil b) Use of a small forceps c) Instillation of hot water d) Instillation of carbamide peroxide
Instillation of mineral oil
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 have decreased fear and anxiety. Patient will experience no falls due to balance disorder. Patient will perform exercises as prescribed. Patient will take medications as prescribed.
Patient will experience no falls due to balance disorder.
Which nursing goal is a priority when caring for a client newly diagnosed with vertigo. a) Patient will have a caretaker with him or her in the home. b) Patient will closes eyes as needed to reduce symptoms. c) Patient will maintain therapeutic medication schedule. d) Patient will remain safe while ambulating in the home.
Patient will remain safe while ambulating in thehome
The nurse is performing an assessment of a patient's ears. When looking at the tympanic membrane, the nurse observes a healthy membrane. What should the appearance be? Pearly gray and translucent Dark yellow with cerumen White and cloudy Pink with white exudate
Pearly gray and translucent
Which of the following is hearing loss associated with degenerative changes? a) Strabismus b) Myopia c) Presbycusis d) Presbyopia
Presbycusis
A client who comes to the ambulatory care facility states, "It feels like things are moving or spinning around me." The nurse interprets this as indicating which of the following? a) Vertigo b) Dizziness c) Motion sickness d) Nystagmus
Vertigo
Which of the following manifestations is the most problematic for the patient diagnosed with Meniere's disease? a) Hearing loss b) Diaphoresis c) Vertigo d) Tinnitus
Vertigo
Which nursing diagnosis takes highest priority for a client admitted for evaluation for Ménière's disease? a) Imbalanced nutrition: Less than body requirements related to nausea and vomiting b) Risk for deficient fluid volume related to vomiting c) Acute pain related to vertigo d) Risk for injury related to vertigo
Risk for injury related to vertigo
A client is diagnosed as having serous otitis media. When describing this condition to the client, which of the following would be most accurate? a) "You have a common infection in one of the bones of your face." b) "Your eardrum has ruptured because of the extreme pressure in your middle ear from the infection." c) "It has resulted from the several recurrent episodes of acute otitis media you've had." d) "You have some fluid that has collected in your middle ear but no infection."
You have some fluid that has collected inyour middle ear but no infection
When performing the Weber test, where would the nurse place the vibrating tuning fork?
patient's head or forehead
Which of the following are methods of removing foreign bodies from the ear? Select all that apply. Stapedotomy Stapedectomy Suction Irrigation Instrumentation
irrigation instrumentation suction
A hearing-impaired patient is scheduled to have an MRI. What would be important for the nurse to remember when caring for this patient? A) Patient is likely unable to hear the nurse during test. B) A person adept in sign language must be present during test. C) Lip reading will be the method of communication that is necessary. D) The nurse should interact with the patient like any other patient.
A
A patient diagnosed with arthritis has been taking aspirin and now reports experiencing tinnitus and hearing loss. What should the nurse teach this patient? A) The hearing loss will likely resolve with time after the drug is discontinued. B) The patient's hearing loss and tinnitus are irreversible at this point. C) The patient's tinnitus is likely multifactorial, and not directly related to aspirin use. D) The patient's tinnitus will abate as tolerance to aspirin develops.
A
A patient is postoperative day 6 following tympanoplasty and mastoidectomy. The patient has phoned the surgical unit and states that she is experiencing occasional sharp, shooting pains in her affected ear. How should the nurse best interpret this patient's complaint? A) These pains are an expected finding during the first few weeks of recovery. B) The patient's complaints are suggestive of a postoperative infection. C) The patient may have experienced a spontaneous rupture of the tympanic membrane. D) The patient's surgery may have been unsuccessful.
A
A patient with mastoiditis is admitted to the post-surgical unit after undergoing a radical mastoidectomy. The nurse should identify what priority of postoperative care? A) Assessing for mouth droop and decreased lateral eye gaze B) Assessing for increased middle ear pressure and perforated ear drum C) Assessing for gradual onset of conductive hearing loss and nystagmus D) Assessing for scar tissue and cerumen obstructing the auditory canal
A
A patient with otosclerosis has significant hearing loss. What should the nurse do to best facilitate communication with the patient? A) Sit or stand in front of the patient when speaking. B) Use exaggerated lip and mouth movements when talking. C) Stand in front of a light or window when speaking. D) Say the patient's name loudly before starting to talk
A
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 describing a recent upper respiratory infection b) A progressive, bilateral loss of hearing c) A red and swollen ear drum d) The client being distressed in the mornings
A progressive, bilateral loss of hearing
A client has been diagnosed with otosclerosis. The nurse explains to the client that this is a common cause of hearing impairment among adults and is the result of a bony overgrowth of the: A) stapes B) labyrinth C) incus D) tympanic membrane
A) stapes Explanation: Otosclerosis is the result of a bony overgrowth of the stapes and a common cause of hearing impairment among adults.
High doses of which of the following medications can produce bilateral tinnitus? a) Promethazine b) Aspirin c) Dramamine d) Antivert
Aspirin
Which of the following instructions regarding swimming should the nurse give to the patient who is recovering from otitis externa? a) Avoid swimming for 7-10 days b) Avoid cold water c) Wear a scarf d) Insert a loose cotton pledget in the external ear
Avoid swimming for 7-10 days or wear soft plastic ear plugs
A group of high school students is attending a concert, which will be at a volume of 80 to 90 dB. What is a health consequence of this sound level? A) Hearing will not be affected by a decibel level in this range. B) Hearing loss may occur with a decibel level in this range. C) Sounds in this decibel level are not perceived to be harsh to the ear. D) Ear plugs will have no effect on these decibel levels.
B
A patient has undergone diagnostic testing and has been diagnosed with otosclerosis? What ear structure is primarily affected by this diagnosis? A) Malleus B) Stapes C) Incus D) Tympanic membrane
B
The nurse and a colleague are performing the Epley maneuver with a patient who has a diagnosis of benign paroxysmal positional vertigo. The nurses should begin this maneuver by performing what action? A) Placing the patient in a prone position B) Assisting the patient into a sitting position C) Instilling 15 mL of warm normal saline into one of the patient's ears D) Assessing the patient's baseline hearing by performing the whisper test
B
The nurse is caring for a patient who has undergone a mastoidectomy. In an effort to prevent postoperative infection, what intervention should the nurse implement? A) Teach the patient about the risks of ototoxic medications. B) Instruct the patient to protect the ear from water for several weeks. C) Teach the patient to remove cerumen safely at least once per week. D) Instruct the patient to protect the ear from temperature extremes until healing is complete.
B
Which nursing suggestion would be most helpful to the client with recurrent otitis externa? A) Use a cotton applicator to ensure that the ear canal is dry. B) Place ear plugs into the ears before swimming C) Flush the ear with hydrogen peroxide D) Avoid lying on the side of the affected ear
B) Place ear plugs into the ears before swimming Explanation: The nurse instructs the client to carry out the medical treatment and provides health teaching to prevent recurrence. For example, he or she advises swimmers to wear soft plastic ear plugs to prevent trapping water in the ear. A cotton tip applicator should not be placed into the ear canal because it could perforate the eardrum. Above all, the nurse advises the client to avoid the use of nonprescription remedies unless they have been approved by the physician and to contact the physician if symptoms are not relieved in a few days.
Which phrase defines ossiculoplasty? A) Incision into the tympanic membrane B) Surgical reconstruction of the middle ear bones C)Surgical repair of the eardrums D) Incision into the eardrum
B) Surgical reconstruction of the middle ear bones Explanation: Ossiculoplasty is performed to restore hearing. Surgical repair of the eardrum is termed tympanoplasty. Tympanotomy, or myringotomy, is the term used to refer to incision into the tympanic membrane.
Which of the following nursing interventions would most likely facilitate effective communication with a hearing-impaired patient? A) Ask the patient to repeat what was said in order to evaluate understanding. B) Stand directly in front of the patient to facilitate lip reading. C) Reduce environmental noise and distractions before communicating. D) Raise the voice to project sound at a higher frequency.
C
The nurse is instructing a client's family members on the most incapacitating symptom of Ménière's disease. Which nursing instruction associated with the symptom is most helpful? A) Sit in front of the client when speaking. B) Ensure low lighting in the room. C) Assist the client when ambulating. D) Keep a bucket beside the bed
C) Assist the client when ambulating. Explanation: The most incapacitating symptom of Ménière's disease is vertigo. When the client is experiencing vertigo or dizziness, the gate is unsteady. Having a person assist the client when ambulating is most helpful in preventing falls. Keeping a bucket at the bedside is helpful if the client is experiencing nausea. Photophobia is not a main symptom of Ménière's disease. If the client experiences hearing loss, being able to see the client's lips may be helpful.
You are doing discharge teaching with a client after a stapedectomy. Why would it be important for you to advise the client to refrain from blowing the nose? A) It may cause sudden headaches. B) It may cause vertigo. C) It may dislodge the prosthesis. D) It may cause excessive drainage.
C) It may dislodge the prosthesis. Explanation: The nurse should advise a client who has undergone a stapedectomy to refrain from blowing the nose because it may dislodge the prosthesis. It does not lead to sudden headaches, vertigo, or excessive drainage.
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? A) Stand at a position diagonal to the client. B) Have the client use a finger to occlude the ear to be tested. C) Stand about 1 to 2 feet away from the ear to be tested. D) Speak a phrase in a low normal tone of voice.
C) 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 wtih the palm of the hand and then whispers softly form 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.
After mastoid surgery, an 81-year-old patient has been identified as needing assistance in her home. What would be a primary focus of this patient's home care? A) Preparation of nutritious meals and avoidance of contraindicated foods B) Ensuring the patient receives adequate rest each day C) Helping the patient adapt to temporary hearing loss D) Assisting the patient with ambulation as needed to avoid falling
D
Following a motorcycle accident, a 17-year-old man is brought to the ED. What physical assessment findings related to the ear should be reported by the nurse immediately? A) The malleus can be visualized during otoscopic examination. B) The tympanic membrane is pearly gray. C) Tenderness is reported by the patient when the mastoid area is palpated. D) Clear, watery fluid is draining from the patient's ear.
D
The nurse is reviewing the health history of a newly admitted patient and reads that the patient has been previously diagnosed with exostoses. How should the nurse accommodate this fact into the patient's plan of care? A) The nurse should perform the Rinne and Weber tests. B) The nurse should arrange for audiometry testing as soon as possible. C) The nurse should collaborate with the pharmacist to assess for potential ototoxic medications. D) No specific assessments or interventions are necessary to addressing exostoses.
D
Which of the following nurse's actions carries the greatest potential to prevent hearing loss due to ototoxicity? A) Ensure that patients understand the differences between sensory hearing loss and conductive hearing loss. B) Educate patients about expected age-related changes in hearing perception. C) Educate patients about the risks associated with prolonged exposure to environmental noise. D) Be aware of patients' medication regimens and collaborate with other professionals accordingly.
D
The nurse is talking with a patient diagnosed with Ménière's disease about the patient's symptoms. What symptom does the patient inform the nurse is the most troublesome? A) Nausea B) Diarrhea C) Tinnitus D) Vertigo
D) Vertigo Explanation: Vertigo is 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. Vertigo is usually the most troublesome complaint related to Ménière's disease.
A patient is newly diagnosed with otitis externa. Which of the following should the nurse teach the patient before the patient leaves the clinic? a) Cleaning ear canal with cotton-tip applicator after showering b) Proper instillation of prescribed ear drops c) Side effects of oral antibiotics d) Strategies to cope with the temporary sensorineural hearing loss
Proper instillation of prescribed ear drops
You are admitting a 30-year-old who has a hearing impairment. The client is accompanied by family members. What information would be important to ask the family members to help you care for your client? a) How the client lost their hearing b) The client's preferred method of communication c) How much the client weighs d) What allergies the client has
The client's preferred method of communication
An advanced practice nurse has performed a Rinne test on a new patient. During the test, the patient reports that air-conducted sound is louder than bone-conducted sound. How should the nurse best interpret this assessment finding? A) The patient's hearing is likely normal. B) The patient is at risk for tinnitus. C) The patient likely has otosclerosis. D) The patient likely has sensorineural hearing loss.
A
The advanced practice nurse is attempting to examine the patient's ear with an otoscope. Because of impacted cerumen, the tympanic membrane cannot be visualized. The nurse irrigates the patient's ear with a solution of hydrogen peroxide and water to remove the impacted cerumen. What nursing intervention is most important to minimize nausea and vertigo during the procedure? A) Maintain the irrigation fluid at a warm temperature. B) Instill short, sharp bursts of fluid into the ear canal. C) Follow the procedure with insertion of a cerumen curette to extract missed ear wax. D) Have the patient stand during the procedure.
A
The nurse in the ED is caring for a 4 year-old brought in by his parents who state that the child will not stop crying and pulling at his ear. Based on information collected by the nurse, which of the following statements applies to a diagnosis of external otitis? A) External otitis is characterized by aural tenderness. B) External otitis is usually accompanied by a high fever. C) External otitis is usually related to an upper respiratory infection. D) External otitis can be prevented by using cotton-tipped applicators to clean the ear.
A
The nurse is discussing the results of a patient's diagnostic testing with the nurse practitioner. What Weber test result would indicate the presence of a sensorineural loss? A) The sound is heard better in the ear in which hearing is better. B) The sound is heard equally in both ears. C) The sound is heard better in the ear in which hearing is poorer. D) The sound is heard longer in the ear in which hearing is better.
A
The nurse is providing discharge education for a patient with a new diagnosis of Ménière's disease. What food should the patient be instructed to limit or avoid? A) Sweet pickles B) Frozen yogurt C) Shellfish D) Red meat
A
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? A) "These drops are cold from being on the window sill." B) "Let me put this cotton ball in your ear because I put the drop in." C) "Turn your head to the side so I can put these drops in." D) "I squeeze the dropper to put a drop of medicine in the ear."
A) "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.
The occupational nurse is advising a customer service representative client on assistive devices for hearing because the client has progressive hearing loss. In discussing the options with the client, which type would be the last option offered by the nurse? A) American sign language B) Text-based telecommunications C) Battery-operated hearing aid D) Headsets with amplifiers
A) American sign language Explanation: Although the American sign language is an asset to use for communication, a client with an occupation of customer service representative needs accommodations to be able to understand the spoken word.
A client newly diagnosed with otitis media reports that the pain and pressure in the ear has suddenly disappeared. What is the best action by the nurse? A) Assess the tympanic membrane. B) Document the effectiveness of medications. C) Educate the client on the therapeutic effects of medications. D) Irrigate the ear.
A) Assess the tympanic membrane. Explanation: A client diagnosed with otitis media who feels sudden relief of pain and/or pressure should be assessed for a tympanic membrane rupture. Educating the client on the therapeutic effects of medications is appropriate for newly diagnosed otitis media, but it does not address the sudden disappearance of pain and pressure. Because the medication usually takes 48 to 72 hours to be effective, documenting the medication as effective would be inappropriate. It is not necessary to irrigate an ear with otitis media.
A mother brings her daughter to the clinic for an evaluation because the child is complaining of ear pain. Which of the following would lead the nurse to suspect that the child is experiencing otitis externa and not otitis media? A) Aural tenderness B) Bulging eardrum C) Fever D) Ear drainage
A) Aural tenderness Explanation: A client with otitis externa typically experiences aural tenderness. This finding is usually absent in clients with otitis media. Fever and ear drainage may be present with either otitis externa or otitis media. A bulging eardrum would suggest otitis media.
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? A) Conductive B) Mixed C) Central D) Sensorineural
A) 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.
Which precaution should the nurse take when a client is at risk of injury secondary to vertigo and probable imbalance? A) Have the client wait for help before moving B) Encourage the client to move the head slowly C) Restrict the client from focusing on one spot D) Recommend that the client keep his or her eyes closed
A) Have the client wait for help before moving Explanation: The nurse should have the client wait to move until help arrives. Safety measures such as assisted ambulation are implemented to prevent falls and injury. The client should restrict movement. The client should keep his or her eyes open and focus on one spot to reduce vertigo.
The nurse is developing a plan of care for a client with Meniere's disease and identifies a nursing diagnosis of excess fluid volume related to fluid retention in the inner ear. Which intervention would be most appropriate to include in the plan of care? A) Limit foods that are high in sodium. B) Encourage intake of caffeinated fluids. C) Administer prescribed antihistamine. D) Restrict high-potassium foods.
A) Limit foods that are high in sodium. Explanation: Sodium and fluid retention disrupts the delicate balance between the endolymph and perilymph in the inner ear. Therefore, many clients can control their symptoms by adhering to a low-sodium diet. Caffeinated fluids are to be avoided because of their diuretic effect. Diuretics, not antihistamines, would be prescribed to lower the pressure in the endolymphatic system. Foods high in potassium would be encouraged if the client is prescribed a diuretic that causes potassium loss.
A patient is participating in aural rehabilitation. The nurse understands that this type of training emphasizes which of the following? A) Listening skills B) Social skills C) Occupational skills D) Functional skills
A) Listening skills Explanation: Auditory training emphasizes listening skills, so the person who is hearing-impaired concentrates on the speaker
Which condition is characterized by the formation of abnormal spongy bone around the stapes? A) Otosclerosis B) Middle ear effusion C) Chronic otitis media D) Otitis externa
A) Otosclerosis Explanation: Otosclerosis is more common in females than males and is frequently hereditary. A middle ear effusion is denoted by fluid in the middle ear without evidence of infection. Chronic otitis media is defined as repeated episodes of acute otitis media, causing irreversible tissue damage and persistent tympanic membrane perforation. Otitis externa refers to inflammation of the external auditory canal.
Which terms refers to the progressive hearing loss associated with aging? A) Presbycusis B) Exostoses C) Otalgia D) Sensorineural hearing loss
A) 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.
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? A) Write down the steps of the procedure for the patient to read before beginning the treatment. B) Change the dressing while the patient is reading the steps of the treatment because distraction decreases anxiety. C) Use nonverbal signals of agreement (head nodding), even if unsure, to instill confidence and trust. D) Minimize misunderstandings by completing the patient's sentences (e.g., fill-in-the-blanks) to decrease the patient's embarrassment.
A) 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.
The nurse is providing care for a patient who has benefited from a cochlear implant. The nurse should understand that this patient's health history likely includes which of the following? Select all that apply. A) The patient was diagnosed with sensorineural hearing loss. B) The patient's hearing did not improve appreciably with the use of hearing aids. C) The patient has deficits in peripheral nervous function. D) The patient's hearing deficit is likely accompanied by a cognitive deficit. E) The patient is unable to lip-read.
A,B
High doses of which medication can produce bilateral tinnitus? A) Promethazine B) Aspirin C) Meclizine D) Dimenhydrinate
B) 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
A nurse is planning preoperative teaching for a patient with hearing loss due to otosclerosis. The patient is scheduled for a stapedectomy with insertion of a prosthesis. What information is most crucial to include in the patient's preoperative teaching? A) The procedure is an effective, time-tested treatment for sensory hearing loss. B) The patient is likely to experience resolution of conductive hearing loss after the procedure. C) Several months of post-procedure rehabilitation will be needed to maximize benefits. D) The procedure is experimental, but early indications suggest great therapeutic benefits.
B
The nurse is planning the care of a patient who is adapting to the use of a hearing aid for the first time. What is the most significant challenge experienced by a patient with hearing loss who is adapting to using a hearing aid for the first time? A) Regulating the tone and volume B) Learning to cope with amplification of background noise C) Constant irritation of the external auditory canal D) Challenges in keeping the hearing aid clean while minimizing exposure to moisture
B
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 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.
The nurse caring for a client with Ménière's disease needs to assist with what when the client is experiencing an attack? A) Sleeping B) ADLs C) Coughing D) URIs
B) ADLs Explanation: The client with Ménière's disease requires a great deal of emotional support because of the unpredictability of the attacks and the resulting impairments. During an attack, the nurse administers prescribed drugs, limits movement, and promotes the client's safety. He or she assists the client with activities of daily living because the least amount of motion can produce severe vertigo. The nurse cannot assist with sleeping, coughing. Option D is a distractor for this question
A client you are caring for has a hearing loss. The client tells you he is self-conscious about his hearing loss. What advice should the nurse give a self-conscious client with hearing loss to protect his self-esteem? A) Follow lip movements closely. B) Be forthright and inform others about the hearing deficit. C) Pretend to follow conversations by nodding the head. D) Avoid excess socializing.
B) Be forthright and inform others about the hearing deficit. Explanation: The nurse should encourage clients with a hearing loss to be forthright and inform others about their hearing deficit. Clients should be advised not to hide the fact that they do not understand what has been said and should be encouraged to maintain friendships because a physical impairment is unlikely to affect genuine friendships.
Which nursing goal is a priority when caring for a client newly diagnosed with vertigo? A) Client will maintain therapeutic medication schedule. B) Client will remain safe while ambulating in the home. C) Client will have a caretaker with him or her in the home. D) Client will close eyes as needed to reduce symptoms
B) Client will remain safe while ambulating in the home. Explanation: Safety is always a concern when a client is experiencing vertigo. The goal of the nurse's instruction and care is for the client to remain safe. Maintaining a therapeutic medication schedule and caretaker and establishing strategies to reduce symptoms are important but not of highest priority.
Which action by the nurse has the highest priority when caring for a client diagnosed with vertigo? A) Encourage the client to keep his or her eyes open. B) Educate the client on using the call light for assistance with ambulation. C) Encourage the client to stare straight ahead, focusing on one object. D) Administer antivertiginous medication as ordered.
B) Educate the client on using the call light for assistance with ambulation. Explanation: The client should restrict movement and change positions slowly to prevent an injury related to the vertigo. The prevention of injury related to the vertigo should be the highest priority nursing intervention; therefore, the nurse needs to teach the client about using the call light for assistance with ambulation. All other interventions are appropriate but do not address safety. The client should keep his or her eyes open and focus on one spot to reduce vertigo.
A nurse practitioner in an emergency room receives a telephone call from a mother whose 4-year-old child has a mosquito stuck in his external ear canal. Which of the following is the best information the nurse could give the mother? A) Insert a cotton-tipped applicator (e.g., Q-tip) to trap the insect and slowly pull the applicator backward. B) Instill a few drops of warmed mineral oil to cover the insect. C) Irrigate the ear canal with warm water to flush out the insect. D) Use an aural suction cup to pull out the insect.
B) Instill a few drops of warmed mineral oil to cover the insect. Explanation: Removing a foreign body from the external auditory canal can be quite challenging. The three standard methods for removing foreign bodies are the same as those for removing cerumen: irrigation, suction, and instrumentation. Foreign vegetable bodies and insects tend to swell; thus, irrigation is contraindicated. Usually, an insect can be dislodged by instilling mineral oil, which will kill the insect and allow it to be removed.
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? A) Avoid harsh sunlight. B) Take nonprescription preparations. C) Increase intake of beta-carotene. D) Increase intake of red meat.
B) 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.
A patient is being discharged home after mastoid surgery. What topic should the nurse address in the patient's discharge education? A) Expected changes in facial nerve function B) The need for audiometry testing every 6 months following recovery C) Safe use of analgesics and antivertiginous agents D) Appropriate use of OTC ear drops
C
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) Under the bridge of the nose C) In the midline of the client's skull or in the center of the forehead D) Near the external meatus of each ear
C) 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.
Which symptoms may a client with Ménière disease report before an attack? A) Nystagmus B) Low blood pressure C) Photosensitivity D) A full feeling in the ear
D) 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.
A nurse is preparing a plan of care for a client with otitis externa. Based on the typical assessment findings, which of the following would the nurse most likely identify as the priority nursing diagnosis? A) Disturbed sensory perception: auditory related to sensorineural hearing loss. B) Hyperthermia related to elevated temperature secondary to infection C) Risk for infection related to drainage from the ear canal D) Acute pain related to inflammation
D) Acute pain related to inflammation Explanation: The client with otitis externa typically reports pain as well as aural tenderness, making the nursing diagnosis of acute pain the priority. A major component of therapy is relief of the pain and discomfort with analgesics and antibiotics and corticosteroid agents to soothe the inflamed tissues. Inflammation is present, which could lead to infection, but this would not be the priority. Typically, clients with otitis externa experience a conductive hearing loss. Fever may or may not be present
The nurse is working in the triage section of a walk-in clinic. Which triad of common symptoms, when placed together, indicate Ménière's disease? A) Blurred vision, vertigo, nausea B) Syncope, vertigo, ear pain C) Disorientation, vertigo, nausea D) Hearing loss, vertigo, tinnitus
D) Hearing loss, vertigo, tinnitus Explanation: Hearing loss, vertigo, and tinnitus are common symptoms of many disease processes but, when placed together, indicate Ménière's disease. The other options do not include the accurate triad of symptoms.
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? A) Cortisporin otic solution B) Gentamicin (Garamycin) intravenously C) Furosemide (Lasix) D) Meclizine (Antivert)
D) Meclizine (Antivert) Explanation: Pharmacologic therapy for Ménière's disease consists of antihistamines, such as meclizine, which shortens the attack (NIDCD, 2010).
A client comes to the emergency department, reporting that a bee has flown into his ear and is stuck. The client reports a significant amount of pain. Which of the following would be most appropriate to use to remove the bee? A) Hair pin B) Irrigation C) Tweezers D) Mineral oil
D) Mineral oil Explanation: An insect in the ear canal can be dislodged by instilling mineral oil, which kills the insect and allows removal. Irrigation is contraindicated because the insect would swell. Hair pin or tweezers should not be used due to the risk for trauma.
The nurse on a cruise ship is assessing clients for motion sickness. Which of the following is a common misconception? A) Pallor and diaphoresis is a first symptom. B) Medications help the symptoms. C) Repeated motion is the cause. D) Once symptoms occur, they will always be present.
D) 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.
Which test uses a tuning fork shifted between two positions to assess hearing? A) Whisper B) Weber C) Watch tick D) Rinne
D) 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.
Which diagnostic test distinguishes between conductive and sensorineural hearing loss? A) Whisper test B) Audiometry C) Weber test D) Rinne test
D) Rinne test Explanation: The Rinne test is useful for distinguishing between conductive and sensorineural hearing loss. In the whisper test, the patient with normal acuity can correctly repeat what was whispered. Audiometry is used to detect hearing loss. The Weber test uses bones conduction to test lateralization of sound.
A nurse is doing discharge teaching with a client who is hearing impaired. What is the best way to make sure the client understands the teaching? A) Mime B) Speak slowly C) Learn a second language D) Use illustrations
D) Use illustrations Explanation: The nurse uses illustrations, pamphlets, and written directions to aid teaching and includes a family member. He or she asks the client to repeat information and demonstrate technical skills. The nurse initiates a referral to a community agency to evaluate if and how well the client is performing self-care after discharge. The nurse could speak slowly and learn a second language but they would not mime.
When caring for a client after ear surgery, what is an important aspect of nursing care? A) Assess social support. B) Feed small frequent meals to minimize nausea. C) Fit for a hearing aid. D) Validate client's feelings of discomfort.
D) Validate client's feelings of discomfort. Explanation: Validate client's feelings of discomfort. This measure promotes the nurse-client relationship and reassures the client that his or her needs are important.
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? A) Having yearly audiometric testing B) Obtaining prompt treatment for ear infections C) Maintaining daily hygiene for the ears D) Wearing ear protection when exposed to noise
D) 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.
Loud, persistent noise has been found to cause all of the following symptoms except a) increased blood pressure. b) increased heart rate. c) decreased GI activity. d) constriction of peripheral blood vessels.
Decreased GI activity
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? a) "I need to keep my ear canal clean and dry." b) "I should wash the receiver with soap and water once a week." c) "I should insert the ear mold when it is wet." d) "I need to wipe the ear mold daily with a moist washcloth."
I need to keep my ear canal clean and dry
Which nursing suggestion would be most helpful to the client with recurrent otitis externa? Use a cotton applicator to ensure that the ear canal is dry. Flush the ear with hydrogen peroxide Place ear plugs into the ears before swimming Avoid lying on the side of the affected ear
Place ear plugs into the ears before swimming
You are teaching the daughter how to instill ear drops of her father to remove impacted cerumen. What is a priority action to teach this woman? a) Insert the irrigating syringe deeply. b) Refrigerate before instillation. c) Place the container in warm water before instillation. d) Direct the flow of the ear drops toward the eardrum.
Place the container in warm water before instillation
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 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. 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.
