Ch 17 Ears

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1. When assessing the client's ear, which finding should the nurse identify as indicating a need for further assessment and possible treatment?
A) Darwin tubercle
B) Red, flaky cerumen
C) Tender tragus
D) Pearly gray tympanic membrane
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Terms in this set (30)
1. When assessing the client's ear, which finding should the nurse identify as indicating a need for further assessment and possible treatment?
A) Darwin tubercle
B) Red, flaky cerumen
C) Tender tragus
D) Pearly gray tympanic membrane
C) Tender tragus
2. A client asks why cerumen is important, stating, It just clogs up the ears anyway. How should the nurse best describe the purpose of cerumen?
A) It helps protect the delicate ear drum from loud noise that may be damaging.
B) It helps to keep the ear drum soft and functioning well.
C) It helps to amplify the sound waves through the inner ear.
D) It helps create the translucent, pearly color of the ear drum.
B) It helps to keep the ear drum soft and functioning well.
3. A client's electronic health record states that he has been diagnosed with sensorineural hearing loss. Which condition should the nurse most likely identify as a cause?
A) Perforated eardrum
B) Otosclerosis
C) Inner ear problem
D) Otitis media
C) Inner ear problem
4. A 55-year-old client is being evaluated for a suspected hearing impairment. Which of the nurse's health interview questions is most likely to yield relevant data?
A) Are you having difficulty hearing high-frequency sounds?
B) Do you notice any drainage from your ears?
C) Are you experiencing any pain in your ears?
D) Have you felt any popping sensations in your ears?
A) Are you having difficulty hearing high-frequency sounds?
5. A client presents to an ambulatory clinic with purulent, bloody drainage of the ear. Which of the following should the nurse assess first?
A) Assess the client's tympanic membrane.
B) Palpate the client's tragus.
C) Inspect the client's external ear canal.
D) Perform hearing assessments.
C) Inspect the client's external ear canal.
6. A 66-year-old client states that he has increasing difficulty hearing high-pitched sounds. The patient's statement most likely suggests that he has what diagnosis?
A) Vertigo
B) Otalgia
C) Tinnitus
D) Presbycusis
D) Presbycusis
7. A client who works in a manufacturing plant is attending a teaching session on plant safety. Which of the following would be an important risk prevention measure to teach regarding hearing?
A) Limiting loud noise exposure to 1 hour per day
B) Taking a 10-minute break every 2 hours
C) Wearing ear protection when in the work environment
D) Cleaning ears regularly to prevent ear infections
C) Wearing ear protection when in the work environment
8. A nurse palpates a client's ear and finds that the tragus is exquisitely tender. The nurse should suspect which of the following health problems?
A) Otitis media
B) Otitis externa
C) Ruptured tympanic membrane
D) Mastoiditis
B) Otitis externa
9. The emergency department nurse notes a clear, watery discharge from the client's ear following a bicycle accident. Which of the following actions should the nurse do next?
A) Refer the client immediately for further evaluation.
B) Assess for foreign body impaction.
C) Examine for postauricular cysts.
D) Position the patient to facilitate drainage.
A) Refer the client immediately for further evaluation.
10. While using an otoscope to assess the ears of an 8-year-old boy, the nurse observes white spots on the boy's tympanic membrane. The nurse also observes that no redness is present. Which action would be most appropriate?
A) Assess the boy for previous trauma to his skull.
B) Determine whether impacted cerumen is present.
C) Ask the mother whether the child has had numerous ear infections.
D) Assess the child for further symptoms of acute otitis media.
C) Ask the mother whether the child has had numerous ear infections.
11. After having a client perform a Romberg test, which of the following would indicate to the nurse that the test is negative? A) Client moves the feet apart during the test B) Client sways slightly during the test C) Client maintains the position during the test D) Client keeps his or her eyes close during the testC) Client maintains the position during the test12. The results of a client's Rinne test suggest that bone conduction and air conduction are both reduced. Which of the following would be most appropriate? A) Perform a Romberg test. B) Take a swab of the client's tympanic member. C) Repeat the test in 5 to 10 minutes. D) Refer the client for further evaluation.D) Refer the client for further evaluation.13. The nurse has completed a focused ear and hearing assessment and gathered the following data: the client speaks very softly, denies hearing loss, and has never had and cannot afford additional hearing tests; the client fails the whisper test. Which nursing diagnosis would be most appropriate? A) Ineffective health maintenance related to denial of hearing problem and inadequate resources for additional testing B) Impaired social interaction, related to decreased ability to maintain contact with friends C) Impaired verbal communication, related to lack of understanding of hearing deficit D) Readiness for enhanced communication related to auditory integrity and need for hearing therapyA) Ineffective health maintenance related to denial of hearing problem and inadequate resources for additional testing14. The nurse is performing an ear assessment of an adult client. Which of the following actions constitutes the correct procedure for using an otoscope when examining the client's ears? A) Keeping the dominant hand away from the client's head B) Inserting the speculum down and forward into the ear canal C) Using the smallest speculum on the otoscope head D) Holding the otoscope in the nondominant handB) Inserting the speculum down and forward into the ear canal15. During a Weber test, the client reports lateralization of sound to the good ear. How should the nurse interpret this assessment finding? A) The good ear cannot receive sound vibrations. B) There is a dysfunction of the middle ear. C) The poor ear is receiving sound vibrations by air. D) There is a sensorineural hearing impairment.D) There is a sensorineural hearing impairment.16. A nurse is performing an otoscopic exam of a client's right tympanic membrane. At which location would the nurse document seeing the cone of light if it were in the appropriate place? A) In the center of the membrane B) In the 5 o'clock position C) In the 7 o'clock position D) In the upper left quadrantB) In the 5 o'clock position17. While inspecting the client's tympanic membrane, the nurse notes a pearly gray and shiny appearance. The nurse would interpret this finding as which of the following? A) Scarring from previous infections B) Otitis media C) Normal tympanic membrane D) Otitis externaC) Normal tympanic membrane18. The nurse is preparing to perform the Rinne test on a client. The nurse should place the tuning fork at which location first? A) Center of the client's forehead B) On the client's mastoid process C) In front of the client's external auditory canal D) At the base of the client's skullB) On the client's mastoid process19. A nurse is preparing a teaching session for a group of new parents about ear infections and measures to prevent them. The nurse is planning to address the reasons why children are more susceptible to these infections than adults. Which of the following would the nurse describe? A) Young children have a tendency to stick objects into their ear canal. B) The size and shape of children's eustachian tubes makes them vulnerable. C) Children's immune systems lack the maturity to fight infections. D) Children generally have poorer hygiene than adults.B) The size and shape of children's eustachian tubes makes them vulnerable.20. Which of the following, if obtained during the health history, would alert the nurse to a possible risk factor for ear-related problems? A) Frequent use of acetaminophen (Tylenol) B) Frequent use of cotton-tipped applicators inside the ear C) Preference for showers rather than baths D) In adequate hygiene practicesB) Frequent use of cotton-tipped applicators inside the ear21. The nurse's assessment of an older adult client's ears and hearing suggests the possible presence of conductive hearing loss. Which of the following is the most likely etiology of this abnormal assessment finding? A) Otitis media B) Cranial nerve VIII damage C) Trauma to the temporal lobe D) Age-related hearing changesA) Otitis media22. A client has sought care at the clinic, telling the nurse, This ringing in my ears has gone on for weeks, and it's driving me crazy. The patient denies exposure to excessive noise levels. The nurse recognizes the likely presence of tinnitus and should follow up with which of the following questions? A) Did your parents even complain of something similar? B) What medications are you currently taking? C) How would you describe your overall level of health? D) How do you usually clean your ears?B) What medications are you currently taking?23. A clinic client's primary complaint is earache (otalgia). Consequently, the nurse's assessment is focusing on potential causes of the client's pain. What question should the nurse include in the health interview? A) What do you do for a living? B) Do you know if your vaccinations are up to date? C) Do you take over-the-counter medications or supplements? D) Have you been swimming lately?D) Have you been swimming lately?24. The nurse's assessment of an 81-year-old client's hearing has corroborated her recent history of hearing loss. The nurse questions the client about her use of hearing aids, to which the client responds, I've got enough frustration in my life without having to fiddle with those. The nurse should suspect which of the following? A) The client may misunderstand the factors underlying her hearing loss. B) The client may have had a negative experience with hearing aids in the past. C) The client may be unable to afford the cost of hearing aids. D) The client may be unwilling to adhere to treatment regimens.B) The client may have had a negative experience with hearing aids in the past.25. A nurse health promotion teaching is focusing on hygiene and the prevention of illness. When instructing clients how to clean their ears, what action should the nurse recommend? A) Washing with a warm, moist washcloth B) Gently irrigating with normal saline C) Cleaning with cotton-tipped applicator D) Irrigating with mildly soapy waterA) Washing with a warm, moist washcloth26. A 2-year-old girl has been brought to the ambulatory clinic by her mother who states, She's put a pea in her ear, and I think she did it 2 days ago because that was the last time we ate them. The nurse's otoscopic examination confirms the presence of this foreign body in the girl's middle ear. How should the nurse best respond to this assessment finding? A) Attempt to remove the pea using sterile forceps. B) Irrigate the ear canal with warm tap water to remove the pea. C) Instruct the mother to watch the girl's ear closely and return for care if it does not fall out in the next few days. D) Refer the girl to her primary care provider for prompt removal of the pea.D) Refer the girl to her primary care provider for prompt removal of the pea.27. Otoscopic examination of a 69-year-old client's tympanic membrane reveals that it is red, bulging, and distorted. The nurse also notes a diminished light reflex. To what should the nurse most likely attribute this assessment finding? A) Repeated ear infections B) Trauma C) Age-related changes D) Acute otitis mediaD) Acute otitis media28. A nurse is conducting a focused ear and hearing assessment of an adult client who has a history of mild hearing loss. When performing the whisper test, what instruction should the nurse begin with? A) Please close your eyes and listen carefully to what I say. B) Please cover your ear that has the weakest hearing. C) Please tell me when you can hear me talking. D) Please repeat the words that I say.B) Please cover your ear that has the weakest hearing.29. The nurse is completing a client's ear assessment. What assessment finding would indicate the need to perform Weber's test? A) The client has unilateral hearing loss. B) The client has suspected otitis externa. C) The client is older than age 65. D) The client has a history of stroke.A) The client has unilateral hearing loss.30. A 12-year-old boy has been brought to the emergency department after being hit in the head with a pitch during a baseball game. The emergency department nurse's comprehensive assessment includes examination of the boy's ears with an otoscope. What assessment finding would suggest trauma to the middle ear or inner ear? A) White spots on the tympanic membrane B) Dark red or bluish tympanic membrane C) Yellowish, bulging tympanic membrane D) Clear tympanic membraneB) Dark red or bluish tympanic membrane