Assessment Ch. 17 Ears

A nurse is interviewing a client as part of a routine examination of his ears and hearing. The nurse notes that this client has high blood pressure. Which of the following questions regarding his hearing should the nurse ask that is associated with his high blood pressure?

"Do you experience any ringing, roaring, or crackling in your ears?"

A client presents with otalgia and yellow-green discharge from the external ear canal. Which question should the nurse ask to determine the cause of this problem?

"Have you had any recent trauma to the inside of your ear?"

The client asks the nurse why the nurse put the tuning fork on the bone behind the ear. Which is the best response by the nurse?

"It identifies a problem with the normal pathways for sound to travel to your inner ear."

An adult client tells the nurse that his 80-year-old father is almost completely deaf. After an explanation to the client about risk factors for hearing loss, the nurse determines that the client needs further instruction when the client says

"It is difficult to prevent hearing loss or worsening of hearing."

The results of a client's Rinne test are as follows: bone conduction > air conduction. How should the nurse explain these findings to the client?

"You have a conductive hearing loss."

What components of sound does the cochlea interpret? (Select all that apply.)

-frequency -amplitude

When providing client education on hearing, the nurse should remind clients to utilize ear plugs when they are what? (Select all that apply.)

-using lawnmowers -at concerts -at train stations

An increased risk of falls is dangerous for any client. What client would be at an increased risk of falls?

A client with vertigo.

The nurse notes a tophus of the ear of an older adult. Which assessment data is consistent with a tophus?

A hard nodule composed of uric acid crystals

A client has Darwin tubercle. What is this?

A small painless nodule on the helix

A mother of a small child calls the clinic and asks to schedule an appointment for ear tube removal. The call is transferred to the nurse. What is the nurse's best action?

Ask the mother how long the tubes have been in place.

A nurse is educating a client about the function of the parts of the auditory system. Which is the function of the eustachian tube?

Equalizes the pressure in the middle ear with atmospheric pressure.

A client visits a community clinic reporting severe allergies causing a "crackling sensation" in the ear. The physician diagnoses serous otitis media. Which of the following is a characteristic of this condition?

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

A six-month old male infant is brought to the emergency department by his parents for inconsolable crying and pulling at his right ear. When assessing this infant the nurse is aware that the tympanic membrane should be what color in a healthy ear?

Gray

The eustachian tube is a passage between the middle ear and the nasopharynx. What is the function of the eustachian tube?

Helps to regulate pressure in the middle ear

The client is having a Weber test. During a Weber test, where should the tuning fork be placed?

In the midline of the client's skull or in the center of the forehead.

The nurse palpates a client's auricles and notes an enlarged lymph node on one ear. No redness is observed, and the client denies pain or tenderness. What is the nurse's best action?

Notify the healthcare provider about the finding.

A client comes to the clinic and reports pain when he touches his ear. With what is this finding most consistent?

Otitis externa

Which of the following describes a condition characterized by abnormal spongy bone formation around the stapes?

Otosclerosis

Which precaution should a nurse take to ensure the safety of a client when performing the Romberg test?

Place arms around the client without touching

The nurse is assessing the hearing of an older adult. Which type of hearing problem might the nurse expect to find in the older adult?

Presbycusis

Some clients with acoustic neuromas have vertigo. What is a priority nursing action with clients with vertigo?

Protect the client from injury

A client admitted to the health care facility is diagnosed with vertigo. Which test is appropriate for the nurse to perform to assess for equilibrium in the client?

Romberg

A client presents at the clinic complaining of a loss of balance. What test should the nurse expect the physician to carry out on a client with a loss of balance?

Romberg test

The nursing instructor is discussing ear problems. What would the instructor indicate is an abnormal finding?

Tenderness of the mastoid process

What structure in the inner ear senses the position and movements of the head and helps to maintain balance?

The labyrinth

Which action by the nurse is consistent with Weber's test?

The nurse activates the tuning fork and places it on the midline of the parietal bone in line with both ears.

A nurse practitioner is assessing the tympanic membrane of a client who has come to the clinic. What would the nurse practitioner expect to visualize if the client has a normal otoscopic evaluation?

The short process of the malleus

A 52-year-old client fails the Romberg test. The nurse explains that this might indicate a dysfunction in what part of the ear?

The vestibular portion of the inner ear

During a pharmacology class the students are told that some drugs need to be closely monitored. What aspect should the nurse closely monitor for in clients who have been administered salicylates, loop diuretics, quinidine, quinine, or aminoglycosides?

Tinnitus and sensorineural hearing loss

When planning care for a client with an inner ear infection, the nurse will need to include interventions for which of the following potential problems?

Vertigo

The nurse assessing for unilateral hearing loss by using a tuning fork. What test is the nurse performing?

Weber's test

After examining the client's tympanic membranes, the nurse documents "Right tympanic membrane, red and bulging with no light reflex." The nurse recognizes that these are signs of

acute otitis media.

The nurse has performed the Rinne test on an older adult client. After the test, the client reports that her bone conduction sound was heard longer than the air conduction sound. The nurse determines that the client is most likely experiencing

conductive hearing loss.

In the hearing pathway, hair cells of the spiral organ of Corti are stimulated by movement of

fluid

The nurse is assessing a 5-month-old Asian American infant whose mother has brought him to the clinic with reports that the baby is pulling at the ear and is sleepless and crying at night. When assessing the infant's ears, what color cerumen would the nurse expect to find?

grey

The nurse is planning to perform an ear examination on an adult client. After explaining the procedures to the client, the nurse should

observe the client's response to the explanations.

A client is diagnosed with otosclerosis, a condition in which the auditory ossicles develop a spongy consistency, which results in conductive hearing loss. It appears that the worst site is the inner most bone, which transmits sound waves through the oval window. Which bone is this?

stapes

The nurse is planning to conduct the Weber test on an adult male client. To perform this test, the nurse should plan to

strike a tuning fork and place it on the center of the client's head or forehead.