When assessing the client's ear, which finding should the nurse identify as indicating a need for further assessment and possible treatment?
B) Tender tragus
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?
B) It helps to keep the ear drum soft and functioning well.
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?
C) Inner ear problem
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?
A client presents to an ambulatory clinic with purulent, bloody drainage of the ear.Which of the following should the nurse assess first?
B) Inspect the client's external ear canal.
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?
C) Presbycusis
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
Wearing ear protection when in the work environment
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?
D) Otitis externa
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?
B) Refer the client immediately for further evaluation
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?
B) Ask the mother whether the child has had numerous ear infections.
After having a client perform a Romberg test, which of the following would indicate to the nurse that the test is negative?
C) Client maintains the position during the test
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?
C) Refer the client for further evaluation
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?
D) Ineffective health maintenance related to denial of hearing problem and inadequate resources for additional testing
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) Inserting the speculum down and forward into the ear canal
During a Weber test, the client reports lateralization of sound to the good ear. How should the nurse interpret this assessment finding?
D) There is a sensorineural hearing impairment.
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 5 o'clock position
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?
C) Normal tympanic membrane
The nurse is preparing to perform the Rinne test on a client. The nurse should place the tuning fork at which location first?
A) On the client's mastoid process
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?
D) The size and shape of children's eustachian tubes makes them vulnerable.
Which of the following, if obtained during the health history, would alert the nurse to a possible risk factor for ear-related problems?
C) Frequent use of cotton-tipped applicators inside the ear
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?
C) Otitis media
A client has sought care at the clinic, telling the nurse, ìThis ringing in my ears has gone on for weeks, and it's driving me crazy.î 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) ìWhat medications are you currently taking?
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?
C) ìHave you been swimming lately?
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, ìI've got enough frustration in my life without having to fiddle with those.î The nurse should suspect which of the following?
A) The client may have had a negative experience with hearing aids in the past.
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?
D) Washing with a warm, moist washcloth
A 2-year-old girl has been brought to the ambulatory clinic by her mother who states,ìShe'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.î 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.
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?
D) Acute otitis media
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?
B) ìPlease cover your ear that has the weakest hearing.î
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.
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?
