Chapter 50: Assessment of the Ear and Hearing Nursing School Test Banks

Chapter 50: Assessment of the Ear and Hearing

Test Bank

MULTIPLE CHOICE

1. The nurse notes that a clients tympanic membrane moves in response to air injected into the external canal. What is the nurses best action?

a.

Notify the health care provider.

b.

Document the finding.

c.

Prepare to wash the external ear canal.

d.

Immediately remove the otoscope.

ANS: B

The healthy ear should have a tympanic membrane that is mobile when air is injected into the external canal. This normal finding should be documented in the clients chart. Because the mobile tympanic membrane is an expected finding, the nurse does not need to remove the otoscope immediately from the clients ear canal. No cerumen is impacting the ear canal, so irrigation is not appropriate. The physician does not need to be notified about a normal finding.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialSystem-Specific Assessments) MSC: Integrated Process: Nursing Process (Assessment)

2. The nurse is performing an ear assessment on an older adult. Which assessment finding does the nurse document in the clients chart as an expected age-related change?

a.

Coarse hair is seen in the auditory canal.

b.

Tympanic membrane is intact and bulging.

c.

Impacted cerumen is present in the auditory canal.

d.

Small, painless nodules are noted on the helix of the pinna.

ANS: A

Growth of coarse hair in the auditory canal occurs in some older men and women. It does not interfere with hearing and is considered a normal variation related to aging; it would be considered abnormal in a younger adult. Bulging tympanic membranes, impacted cerumen, and pinna nodules are not expected findings in the older adult.

DIF: Cognitive Level: Comprehension/Understanding REF: Chart 50-1, p. 1082

TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialSystem-Specific Assessments) MSC: Integrated Process: Nursing Process (Assessment)

3. Which client is at highest risk for hearing loss?

a.

Client with heart failure receiving digoxin (Lanoxin), 0.125 mg orally daily

b.

Client with asthma receiving high-dose methylprednisolone (Solu-Medrol) therapy

c.

Client with osteomyelitis receiving IV gentamicin (Garamycin)

d.

Client with hyperkalemia being treated with intravenous glucose and insulin

ANS: C

Gentamicin is an aminoglycoside that can cause ototoxicity. Assessment of hearing should be done before and during therapy. Digoxin, methylprednisolone, and insulin do not put the client at risk for hearing loss.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral TherapiesAdverse Effects/Contraindications/Interactions/Side Effects)

MSC: Integrated Process: Nursing Process (Assessment)

4. The nurse is caring for an older adult client with sensorineural hearing loss. Which assessment finding does the nurse correlate with the clients health history?

a.

History of frequent ear infections

b.

Swims frequently

c.

Worked in a sawmill for the last 20 years

d.

Had a tumor removed from his left eardrum last year

ANS: C

Sensorineural hearing loss is caused by damage to the cochlear hair cells. This damage may be caused by exposure to loud noises, including noise from machinery in factories or sawmills. Tumor removal from the eardrum, swimming, and ear infections do not increase the risk for sensorineural hearing loss because conduction of sound through the nerves is not affected.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialSystem-Specific Assessments) MSC: Integrated Process: Nursing Process (Assessment)

5. The nurse is caring for a client who will undergo electronystagmography testing the following day. Which instruction does the nurse provide for the client?

a.

You should drink only caffeine-free beverages the day of and the day before the test.

b.

Do not chew gum or clean your ears for 24 hours after the test is completed.

c.

You may feel flushed as the contrast dye is injected through your IV for the test.

d.

You will be sedated for the test, so you need someone to drive you home.

ANS: A

Caffeinated drinks may interfere with the test results, so the client should be sure to drink only decaffeinated beverages during the 24 to 48 hours before the test. Clients may chew gum or clean their ears after the test, if desired. Neither IV contrast nor sedation is used for the test.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiologic Integrity (Reduction of Risk PotentialDiagnostic Tests)

MSC: Integrated Process: Teaching/Learning

6. The nurse is caring for a client who may have an ear infection. Which intervention is used to prevent spread of the infection to other clients?

a.

A new sterile otoscope speculum is used to examine each of the clients ears.

b.

The nurse washes his hands after removing hearing aids from the clients ears.

c.

Hearing aids are cleaned with alcohol before they are re-inserted into the clients ears.

d.

The tuning fork is cleaned with hydrogen peroxide before and after use with the client.

ANS: B

Washing hands after removal of a hearing aid should prevent any spread of infection between clients. Hearing aids may harbor infectious microorganisms, especially in clients who may have an ear infection. The other answers pertain to the possible spread of infection from one ear to the othernot to other clients.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Safe and Effective Care Environment (Safety and Infection ControlStandard Precautions/Transmission-Based Precautions/Surgical Asepsis)

MSC: Integrated Process: Nursing Process (Implementation)

7. The nurse is caring for a client who is hard of hearing. Which intervention best helps the client with communication?

a.

Speaking loudly and adding extra inflections to the tone of voice

b.

Bending over the client so that he or she can see the nurses lips more easily

c.

Closing the door to the room and making sure that lighting is adequate

d.

Asking the clients spouse to answer questions that are not heard by the client

ANS: C

Environmental noise decreases the hearing-impaired clients ability to hear conversation. The room should be adequately lit so the client can read supplemental written notes. Bending down to the client may be seen as condescending or offensive. Speaking loudly, with extra inflections, can actually make it harder for the client to understand the nurse. The nurse should not bend over the client and should instead sit to meet the clients eye level. The clients spouse should be used only as a last resort if no other means of communication are possible.

DIF: Cognitive Level: Comprehension/Understanding REF: p. 1080

TOP: Client Needs Category: Psychosocial Integrity (Therapeutic Communication)

MSC: Integrated Process: Communication and Documentation

8. Which statement indicates that a client needs additional teaching about protecting the ears and preventing hearing loss?

a.

I will start a smoking cessation program and will take a multivitamin every day.

b.

I will wear earplugs whenever I cut the grass or use my snow blower.

c.

I will blow my nose gently, one nostril at a time, whenever I get a cold or the flu.

d.

I will take Motrin (ibuprofen) instead of Tylenol (acetaminophen) for pain.

ANS: D

Motrin (ibuprofen) can be ototoxic. Its use should be avoided to help prevent additional hearing loss. Blowing the nose gently can help prevent damage to the tympanic membrane. Smoking reduces oxygen supply to the cochlea, possibly increasing damage to the sensory cells, and should be avoided. Clients should use earplugs whenever they are exposed to loud noises to help prevent cochlear hair cell damage.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Health Promotion and Maintenance (Health and Wellness)

MSC: Integrated Process: Nursing Process (Evaluation)

9. Which is the best assessment question for the nurse to ask a client with tinnitus?

a.

How exactly do you clean your ears?

b.

Have you had your hearing checked lately?

c.

Do you have ringing in both ears or in only one ear?

d.

Does the ringing make it hard for you to sleep at night?

ANS: C

Determining whether the tinnitus is in one or both ears provides valuable information about the cause of the problem. Tinnitus is not related to how the client cleans his or her ears. Asking about the last hearing check will not help determine the cause of the tinnitus. Asking about nighttime tinnitus is helpful but is less important than asking if the problem is present in one or both ears.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialPotential for Alterations in Body Systems) MSC: Integrated Process: Nursing Process (Assessment)

10. The nurse notes reddened areas behind both ears. What does the nurse ask the client?

a.

Do you wear eyeglasses?

b.

Do you have any allergies?

c.

Do you use dandruff shampoo?

d.

Have you been around anyone with lice?

ANS: A

The presence of reddened areas behind both ears strongly suggests constant pressure, such as that incurred from wearing eyeglasses or sunglasses. Dandruff shampoo, allergies, and lice would not cause reddened areas only behind the ears.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialSystem-Specific Assessments) MSC: Integrated Process: Nursing Process (Assessment)

11. Which statement indicates that a client needs additional teaching about ear hygiene?

a.

I will wash my hands before I put in my earplugs at work.

b.

I will clean my ears with plain warm water and a washcloth every day.

c.

I will use a cotton swab to get the extra water out of my ears after I swim.

d.

I can rinse my ears with half-strength hydrogen peroxide if ear wax builds up.

ANS: C

Cotton swabs should not be inserted into the ear canal because injury to the tympanic membrane can result. The cotton swab can push cerumen deeper into the ear canal, possibly resulting in impaction. Hands should always be washed before earplug insertion to prevent ear infection. Ears should be cleaned with plain warm water and a washcloth to prevent irritation of the ear canal. The ears may be safely rinsed with half-strength hydrogen peroxide to remove excess ear wax within the ear canal.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Health Promotion and Maintenance (Self-Care)

MSC: Integrated Process: Nursing Process (Evaluation)

12. Several clients come to the emergency department following an accident. Which client does the nurse assess first?

a.

Client with clear watery drainage from the ear canals

b.

Client who reports tinnitus and pain in the right ear

c.

Client with a deep, 1-inch laceration to the pinna

d.

Client who has had severe difficulty hearing since the accident

ANS: A

Clear watery drainage from the ears following trauma suggests a basal skull fracture and should be assessed immediately. Tinnitus and pain, lacerations, and hearing loss all may be assessed by the nurse in a timely manner, after the possible skull fracture.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialSystem-Specific Assessments) MSC: Integrated Process: Nursing Process (Assessment)

13. A client asks the nurse why there is waxy yellow stuff on the cotton swab when he cleans his ears. Which is the nurses best response?

a.

The yellow ear wax helps transmit sound to your middle ear.

b.

The yellow ear wax indicates that you have an infection in your ears.

c.

The yellow ear wax helps protect and lubricate the inside of your ear canal.

d.

The yellow ear wax builds up when you dont clean your ears often enough.

ANS: C

The ear canal is lined with ear wax (cerumen), which offers protection and lubrication. Ear wax does not help with sound transmission and does not indicate ear infection or buildup because of infrequent cleaning.

DIF: Cognitive Level: Comprehension/Understanding REF: p. 1078

TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationPathophysiology)

MSC: Integrated Process: Teaching/Learning

14. A client is scheduled for a caloric test to evaluate the vestibular portion of the inner ear. Which statement by the client leads the nurse to conclude that more teaching is necessary?

a.

I can eat a hearty breakfast before the procedure.

b.

I will have to stay in bed after the procedure to prevent nausea.

c.

Warm water will be infused into my affected ear.

d.

I may experience dizziness after the water is inserted.

ANS: A

The client usually is asked to fast for several hours before the caloric test. A hearty breakfast is not a good idea because nausea and vomiting is a common reaction following the test. Fasting will lower the risk of aspiration. The other responses demonstrate adequate knowledge of this procedure and its follow-up care.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiologic Integrity (Reduction of Risk PotentialDiagnostic Tests)

MSC: Integrated Process: Nursing Process (Evaluation)

MULTIPLE RESPONSE

1. The nurse is caring for an older client who presents with dizziness and difficulty hearing. Which of the nurses assessment findings will require collaboration with the clients primary health care provider? (Select all that apply.)

a.

Tympanic membrane is retracted, with multiple air bubbles.

b.

The client reports inability to hear high-frequency voices and sounds.

c.

Clear watery drainage is present in the ear canal and is positive for glucose.

d.

Tympanic membrane is shiny and translucent, with light reflex noted.

e.

Hearing test indicates positive Rinne test, with AC > BC noted bilaterally.

f.

The client reports dizziness after taking naproxen (Aleve) for arthritis pain.

ANS: A, C, F

Aleve can cause ototoxicity, which can present as dizziness. Retraction of the tympanic membrane with air bubbles indicates an ear infection, which may be treated with antibiotics. Clear, watery, glucose-positive drainage from the ear canal suggests a basal skull fracture. An inability to hear high-frequency voices and sounds are commonly found in older adults as normal age-related changes. A shiny, translucent, tympanic membrane with a light reflex is a normal assessment finding, as is a positive Rinne test with AC > BC noted bilaterally.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialPotential for Alterations in Body Systems) MSC: Integrated Process: Nursing Process (Assessment)

2. Which statements by a client alert the nurse that the client may have some psychosocial issues with impaired hearing? (Select all that apply.)

a.

I get so angry when I cannot hear what my daughter says.

b.

When I use my hearing aids, I hear the choir so clearly.

c.

I dont mind sitting in my chair all day long and not playing bingo.

d.

My family never seems to visit anymore because their voices all seem so distant.

e.

No one asks my opinion because I cannot hear their question.

f.

My grandchildren do not think that I am funny anymore because I cannot hear their jokes.

ANS: A, C, D, E, F

The client may become angry, frustrated, and depressed by an inability to hear and may respond appropriately. The inability to hear often isolates the client from the world, as depicted by sitting in a chair all day long, the perception of the family being distant, and no one asking for an opinion or joking around. The nurse must be sensitive to the depression resulting from the sensory isolation of hearing loss. If hearing aids are working so that the client can clearly hear a choir, psychosocial issues may be less of a problem.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Psychosocial Integrity (Grief and Loss)

MSC: Integrated Process: Nursing Process (Assessment)

OTHER

1. A client is being taught how to safely irrigate ears to remove cerumen. What is the correct order of self-ear irrigation? (Separate letters by a comma and space as follows: a, b, c, d.)

a. Fill the syringe with lukewarm water.

b. Hold the head at a 30-degree angle.

c. Insert the tip of the syringe carefully into the ear canal and aim toward the canal roof.

d. Tilt the head at a 90-degree angle to remove excess fluid.

e. Use one hand to hold the syringe and the other to push the plunger.

f. Repeat the procedure on the opposite ear.

g. Continue the procedure until at least a cup of fluid has flowed into and out of the ear.

h. The ear should fill with fluid and the water will flow out with cerumen.

ANS:

a, c, b, e, g, h, d, f

Safe irrigation of the ear promotes cerumen removal without the use of penetrating objects. Warm water through the irrigating syringe will soften the cerumen, and the angle of the head will allow the cerumen to flow out of the ear. The order of the irrigation is important for safe removal of cerumen.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Health Promotion and Maintenance (Self-Care)

MSC: Integrated Process: Teaching/Learning

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