Chapter 50: Assessment of the Ear and Hearing

Chapter 50: Assessment of the Ear and Hearing

 

Complete Chapter Questions With Answers

 

Sample Questions Are Posted Below

 

MULTIPLE CHOICE

 

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)