Perla L. DiBerardino
Assignment CAP2 – CAP2 – Dec. Dec. 14, 2013
Topic: Ear Disorder
BSN 4-1
1. A nursing student is assigned to care for a client with a documented diagnosis of presbycusis. The nursing student reviews the client’s record expecting to note which of the following documentation? a. The client has a conductive hearing loss b. The client has a sensorineural hearing loss c. The client experiences continuous nystagmus nystagmus d. The client has been experiencing dizziness and ringing in the ears Answer:
B
Rationale: Presbycusis is a type of hearing loss that occurs with aging. It is a gradual sensorineural loss caused by nerve degeneration in the inner ear or auditory nerve. It is not a conductive hearing loss, nor n or it is specifically associated with nystagmus, dizziness, or ringing in the ears. Reference:Q&A Review for the NCLEX-PN Examination by Linda Silvestri p. 357 2. A nursing instructor asks a nursing student to demonstrate the procedure for performing an otoscopic examination on an adult client. Which observation, if made by the instructor, indicates the correct procedure? a. The nursing student pulls the pinna up u p and back to assist in inserting the speculum b. The nursing student obtains a small speculum to d ecrease the discomfort of the examination c. The nursing student pulls the earlobe down and back to assist in inserting the speculum d. The nursing student tilts the client’s head forward and down before inserting the speculum Answer:
A
Rationale: The correct procedure for performing the otoscopic ex amination on an adult client is to pull the pinna up and back and to visualize the external canal while slowly inserting the speculum. The nurse tilts the client’s head slightly away and holds the otoscope upside down as if it were a large pen. A small speculum may not provide adequate visualization of the ear canal and would be more appropriately used in pediatric setting.
Reference: Q&A Review for the NCLEX-PN Examination by Linda Silvestri p. 362 3. A client has had same-day surgery to insert a ventilating tube in the tympanic membrane. The nurse teaches the client to implement which postoperative measure? a. Use a shower cap if taking a shower b. Swim only with the head above water c. Avoid taking any medication for pain d. Wash the hair quickly in 2 minutes or less Answer:
A
Rationale: After insertion of tubes in the tympanic membrane, it is important to avoid getting wet in the ears. For this reason, swimming, showering, or washing the hair is avoided after surgery until the time frame designated for each is identified by the surgeon. A shower cap or ear plug may be used when showering if allowed by the physician. Reference: Q&A Review for the NCLEX-PN Examination by Linda Silvestri p. 670
4. A 50-year old man has been taking aspirin regularly for 6 months to prevent a heart attack. He informed the nurse that he has noticed a constant “ringing” in both ears. How should the nurse respond to the client’s comment? a. Tell the client that tinnitus is associated with the aging process b. Inform the client he needs a Webber test done. c. Schedule the client for audiometric testing. d. Inform the client that the “ringing” may be related to the aspirin he has been taking Answer:
D
Rationale: Tinnitus is a side effect of aspirin. Aspirin contains salicylate, which is an ototoxic drug that can induce reversible hearing loss and tinnitus. The nurse should encourage the client to inform the ph ysician of the symptom. Tinnitus is not a function of aging. The Weber test and audiometric testing are u seful for determining hearing loss but are not necessarily helpful in the management or diagnosis of drug-induced tinnitus. Reference: Lippincott’s Review for NCLEX-RN, Diane Billings, p. 498 5. Mrs. Cruz has a negative result on the Rinne test. This means she hears the vibrations from a tuning fork: a. Longer or louder by bone conduction than by air conduction b. Poorly by both air and bone conduction
c. Longer by air conduction than by bone conduction d. Equally well by air and bone conduction Answer:
A
Rationale: To perform the Rinne test, the nurse holds the base of an activated tuning fork on the mastoid bone until the patient can no longer hear the vibrations, then holds the still vibrating fork near the external ear, a negative result means the patient hears vibration longer or louder by bone conduction than by air conduction, which indicates a conductive hearing loss. A person without a hearing problem shou ld hear the sound about twice as long by air conduction. Sound heard poorly by both air and bone conduction may indicate sensori-neural hearing loss. Reference: Nurse Test Review Series-Medical-Surgical Nursing by Frances Martin & Laura Gasparis, p. 73 6. When teaching family members how to speak to a hearing-impaired patient, all of the following nursing interventions can be helpful except: a. Speak directly to the person in a loud, distinct voice b. Remove background noises, such as radio, stereo, or television c. Use body language and gestures along with speech d. Enunciate clearly, and face the patient directly Answer:
A
Rationale: A hearing-impaired patient cannot distinguish one high-frequency consonant from another, so speaking loudly will not necessarily help him hear. All the other interventions are appropriate when speaking to a h earing-impaired patient. The nurse can also encourage the patient to wear a hearing aid. Reference: Nurse Test Review Series – Fundamentals of Nursing by June Olsen & Laura Gasparis, p. 183 7. Which of the following physical assessment maneuvers will allow the nurse to differentiate the ear pain of a patient with otitis externa from the ear pain of a patient with otitis media? a. Manipulation of the auricle b. Irrigating the ear canal with cool water c. Rinne and Weber tests d. Whisper test Answer:
A
Rationale: The pain of otitis externa can be differentiated from that associated with
otitis media by the manipulation of the auricle. In external otitis, this maneuver increases pain, whereas the patient with otitis media experiences no change in pain perception. Rinne and Weber tests are used to diagnose sensori-neural hearing loss. The caloric test (irrigation with cool water) evaluates vestibulo-ocular reflex. The whisper test evaluates hearing loss. Reference: http://quizlet.com/14048835/nclex-review-eye-ear-disorders-flash-cards/
8. The public health nurse is preparing to teach the members of the local swim club about care of the ears. Which of the following statements would be appropriate for the nurse to include? a. Use a clean cotton swab to dry the ear canal after swimming. b. A tight-fitting swim cap is preferred to earplugs for keeping water out of the ear. c. If there is debris in the ear canal, irrigate the ear with cold water. d. After an episode of acute inflammation, the swimmer should wait 7-10 days before returning to the water. Answer:
D
Rationale: Guidelines include: Stay out of the water until the acute inflammatory process is completely resolved-ideally, 7-10 days before resuming water activities; and use silicone earplugs, and dry the outer ear with a towel, then use a hair dryer on the lowest setting several inches from the ear to dry the canal. Do not insert cotton swabs or other objects into the ear canal to dry it. A tight-fitting swim cap does not keep water out of the ear. Repeated exposure to cold water encourages the growth of exostoses in the ear canal. Reference: http://quizlet.com/14048835/nclex-review-eye-ear-disorders-flash-cards/
9.
Following a tympanoplasty, the nurse should maintain the client in which position? a. b. c. d.
Semi-Fowler’s with the operative ear facing down Low Trendelenburg with the head in neutral position Flat with the head turned to the side with the operative ear facing up Supine with a small neck roll to allow for drainage Answer:
C
Rationale: Following a tympanoplasty the client should be maintained flat with the head turned to the non-operative side for at least 12 hours. Answers A, B, and D are incorrect positions following ear surgery.
Reference: http://my.safaribooksonline.com/book/medicine/9780132684101/caring-for-theclient-with-sensorineural-disorders/ch08lev1sec8 10. A nurse is reviewing the physician's orders on a client admitted to the hospital with a diagnosis of an acute attack of Meniere's disease. Which of the following orders, if noted on the client's chart, would the nurse question? a) the administration of a sedative b) the administration of an antihistamine c) the administration of vasoconstrictor d) bedrest Answer:
C
Rationale: Medical interventions during the acute phase of Meniere's disease include using atropine or diazepam (Valium) to decrease the autonomic nervous system function. Diphenhydramine (Benadryl) may be prescribed for its antihistamine effects, and a vasodilator also will be prescribed. The client will remain on bedrest during the acute attack, and when allowed to be out of bed, the client will need assistance with walking, sitting, or standing. Reference: http://www.nclexpinoy.com/2011/08/nclex-review-about-ear-infection46-50.html
