1. The nurse notes that a client’s tympanic membrane moves
in response to air injected into the external canal. What is the nurse’s 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 client’s chart. Because the mobile tympanic membrane is an
expected finding, the nurse does not need to remove the otoscope immediately
from the client’s 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 Potential—System-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 client’s 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 Potential—System-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 Therapies—Adverse
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 client’s 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 Potential—System-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 Potential—Diagnostic 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 client’s ears.
b. The nurse
washes his hands after removing hearing aids from the client’s ears.
c. Hearing
aids are cleaned with alcohol before they are re-inserted into the client’s
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
other—not 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 Control—Standard 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 nurse’s lips more easily
c. Closing
the door to the room and making sure that lighting is adequate
d. Asking
the client’s spouse to answer questions that are not heard by the client
ANS: C
Environmental noise decreases the hearing-impaired client’s
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 client’s eye
level. The client’s 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 Potential—Potential 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 Potential—System-Specific Assessments) MSC: Integrated
Process: Nursing Process (Assessment)
Category | ATI |
Release date | 2021-09-14 |
Pages | 8 |
Language | English |
Comments | 0 |
Sales | 0 |
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