Nusr 114 Exam 1 Chapter 17 (assessing the ears) prepU
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?"
Which question asked by the nurse is assessing problems with tinnitus?
"Do you experience buzzing in your ears?"
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
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 client has Darwin tubercle. What is this?
A small painless nodule on the helix
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
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.
When providing client education on hearing, the nurse should remind clients to utilize ear plugs when they are what? (Select all that apply.)
At concerts. At train stations. Using lawnmowers.
The transmission of sound waves through the external ear and the middle ear is known as
Conductive hearing
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
A nurse is inspecting the ears of an Asian client and observes that her earlobes appear soldered, or tightly attached to adjacent skin with no apparent lobe. Which of the following should the nurse do next?
Continue with the examination
A nurse performs an inspection and palpation of the auricle when examining the ear of a client. Which documentation by the nurse demonstrates a normal finding?
Darwin's tubercle
A nurse is educating a client about the function of the parts of the auditory system. Which is the function of the eustachian tube?
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
Which finding should a nurse recognize as normal when assessing the ears of an elderly client?
High-tone frequency loss
When teaching a class of school-age children about hygiene, the nurse should include which information about the ears?
Never put anything smaller than your elbow in your ears.
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.
You are a pediatric nurse caring for a child who has been brought to the clinic with otitis externa. What assessment finding is characteristic of otitis externa?
Pain on manipulation of the auricle
A client has been diagnosed with conductive hearing loss. The nurse understands that which of the following could be the cause of this type of hearing loss?
Perforated eardrum
Which terms refers to the progressive hearing loss associated with aging?
Presbycusis
A nurse examines the ear of a client diagnosed with an obstructed eustachian tube. What finding should the nurse anticipate upon assessment?
Prominent landmarks on the tympanic membrane
Which characteristic feature of the tympanic membrane should a nurse anticipate finding in a client with acute otitis media?
Red, bulging, with an absent light reflex
After conducting a health history, the nurse decides to perform the assessment shown. What finding did the nurse use to make this clinical determination?
Reduced hearing in one ear
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
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
Which action by the nurse is consistent with the Rinne test?
The nurse strikes the tuning fork and places it on the client's mastoid process to measure bone conduction.
A mother asks why her school-age child develops so many ear infections after having a head cold. When explaining the process, which structure on the diagram should the nurse identify that connects the throat to the ear?
The proximal end of the Eustachian tube connects the middle ear to the nasopharynx.
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
A nurse performs an initial examination of a client brought to the emergency department after sustaining a head injury in an automobile accident. Which characteristic of discharge from the ears should alert the nurse that the client has a cerebrospinal fluid leak?
Watery or bloody
A nurse performs a hearing test on an elderly client. Which result should the nurse recognize as an indication that presbycusis is present? An inability to hear:
Whispered sounds
The nurse is preparing to examine the ears of an adult client with an otoscope. The nurse should plan to
firmly pull the auricle out, up, and back.
A client comes to the clinic and reports pain when he touches his ear. With what is this finding most consistent?
otitis externa
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.