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)