Chapter 14 My Nursing Test Banks

DAmico/Barbarito Health & Physical Assessment in Nursing, 2/e
Chapter 14

Question 1

Type: HOTSPOT

A client is having difficulty maintaining equilibrium. The client is unable to ambulate without pushing a wheelchair or using a walker. Draw an arrow indicating which part of the ear is not functioning adequately.

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Correct Answer:

Rationale : The ear is divided into three areas: the external ear, the middle ear, and the inner ear. All three are involved in hearing, but only the inner ear is involved in equilibrium. The vestibular apparatus contained in the inner ear must be working adequately for the client to be able to maintain a sense of balance.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 14.1: Identify the anatomy and physiology of the ear, nose, mouth, and throat.

Question 2

Type: MCSA

The client is experiencing the effects of a recent cerebrovascular accident. The client is unable to hear out of the left ear. Which of the following cranial nerves was most likely affected?

1. Cranial nerve I

2. Cranial nerve XII

3. Cranial nerve VIII

4. Cranial nerve VII

Correct Answer: 3

Rationale 1: The sense of smell is controlled by cranial nerve I.

Rationale 2: Tongue movement is controlled by cranial nerve XII.

Rationale 3: Hearing and balance is controlled by cranial nerve VII.

Rationale 4: The sense of taste is controlled by cranial nerves VII and IX.

Global Rationale: Hearing and balance is controlled by cranial nerve VII. The sense of smell is controlled by cranial nerve I. Tongue movement is controlled by cranial nerve XII. The sense of taste is controlled by cranial nerves VII and IX.

Cognitive Level: Understanding

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 14.1: Identify the anatomy and physiology of the ear, nose, mouth, and throat.

Question 3

Type: MCHS

The nurse is assessing the clients vestibule of the oral cavity. The student nurse requests information regarding the vestibule and the mouth. Draw an arrow to the structure that separates the vestibule from the mouth.

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Correct Answer:

Rationale : The vestibule is made up of the lips, buccal mucosa, outer surface of the gums and the teeth and cheeks. The mouth is separated from the vestibule by the teeth. The mouth is made up of the tongue, hard and soft palate, uvula, mandibular arch, and axillary arch.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 14.1: Identify the anatomy and physiology of the ear, nose, mouth, and throat.

Question 4

Type: MCSA

The nurse educates the client about the major functions of the nose and sinuses. Which of the following structures is specifically responsible for filtering, moistening, and warming air that enters the lower portion of the respiratory tract?

1. Olfactory cells

2. Columella

3. Turbinates

4. Nares

Correct Answer: 3

Rationale 1: The olfactory cells assist the client to smell.

Rationale 2: The columella is located at the base of the nose and helps form the nares.

Rationale 3: The superior, middle, and inferior turbinates are specifically responsible for warming, moistening, and filtering the air before it enters the trachea and lungs.

Rationale 4: The nares are structures that lead into the internal vestibule and nasal cavity.

Global Rationale: The superior, middle, and inferior turbinates are specifically responsible for warming, moistening, and filtering the air before it enters the trachea and lungs. The olfactory cells assist the client to smell. The columella is located at the base of the nose and helps form the nares. The nares are structures that lead into the internal vestibule and nasal cavity.

Cognitive Level: Understanding

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 14.1: Identify the anatomy and physiology of the ear, nose, mouth, and throat.

Question 5

Type: MCSA

Which of the following structures attaches the tongue to the floor of the mouth?

1. Hard palate

2. Papillae

3. Frenulum

4. Alveoli sockets

Correct Answer: 3

Rationale 1: The hard palate is the anterior portion of the roof of the mouth.

Rationale 2: The papillae contain the taste buds and assist with moving food within the mouth. The papillae are located on the dorsal surface of the tongue.

Rationale 3: The frenulum connects the anterior portion of the tongue to the floor of the mouth.

Rationale 4: The alveoli sockets contain the teeth within the mandible and maxilla.

Global Rationale: The frenulum connects the anterior portion of the tongue to the floor of the mouth. The hard palate is the anterior portion of the roof of the mouth. The papillae contain the taste buds and assist with moving food within the mouth. The papillae are located on the dorsal surface of the tongue. The alveoli sockets contain the teeth within the mandible and maxilla.

Cognitive Level: Remembering

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 14.1: Identify the anatomy and physiology of the ear, nose, mouth, and throat.

Question 6

Type: MCMA

The nurse is performing a focused interview with a client who has been cleaning the ears with a cotton-tipped applicator. The nurse should educate the client about which of the following complications that can occur as a result of this practice?

Standard Text: Select all that apply.

1. The client has a higher risk of developing otitis externa.

2. The client has a higher risk of developing tophi along the outer rim of the ears.

3. The client could perforate the tympanic membrane.

4. The client could require tympanostomy tubes.

5. The clients cerumen might become impacted.

Correct Answer: 3,5

Rationale 1: The client has a higher risk of developing otitis externa. Otitis externa is an infection of the clients outer ear. This client does not have an increased risk of developing otitis externa.

Rationale 2: The client has a higher risk of developing tophi along the outer rim of the ears. Tophi are small white nodules that are found on the helix or antihelix. These nodules are a sign of gout and contain uric acid crystals.

Rationale 3: The client could perforate the tympanic membrane. This client is at risk for perforating the tympanic membrane with the cotton-tipped applicator. The inside of the ear should not be cleaned. Cerumen moves to the outside of the ear canal naturally.

Rationale 4: The client could require tympanostomy tubes. Tympanostomy tubes are placed when clients develop repeated otitis media infections. These tubes help relieve middle ear pressure and allow drainage that occurs as a result of the infection. This client does not require tympanostomy tubes.

Rationale 5: The clients cerumen might become impacted. This client is at risk for impacting the cerumen within the ears with the cotton-tipped applicator. The inside of the ear should not be cleaned. Cerumen moves to the outside of the ear canal naturally.

Global Rationale: Otitis externa is an infection of the clients outer ear. This client does not have an increased risk of developing otitis externa. Tophi are small white nodules that are found on the helix or antihelix. These nodules are a sign of gout and contain uric acid crystals. This client is at risk for perforating the tympanic membrane with the cotton-tipped applicator. The inside of the ear should not be cleaned. Cerumen moves to the outside of the ear canal naturally. Tympanostomy tubes are placed when clients develop repeated otitis media infections. These tubes help relieve middle ear pressure and allow drainage that occurs as a result of the infection. This client does not require tympanostomy tubes. This client is at risk for impacting the cerumen within the ears with the cotton-tipped applicator. The inside of the ear should not be cleaned. Cerumen moves to the outside of the ear canal naturally.

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 14.2: Develop questions to be used when completing the focused interview.

Question 7

Type: MCSA

The nurse is performing a focused interview with the client. The nurse asks the client if the client has noticed any drainage from the ears, and the client states, Yes. Which of the following statements indicate that the client may have developed acute otitis media?

1. The ear canal itself is really red, raw, and sore.

2. I noticed that the drainage looked clear, like water.

3. The drainage looks like what is draining from my nose, kind of clear and mucousy.

4. It is kind of yellowish-reddish color.

Correct Answer: 4

Rationale 1: When the client complains that the ear canal is inflamed, painful, and with erythema, this indicates that the client may have developed otitis externa.

Rationale 2: Clear drainage from the ear may indicate that the client has developed a cerebrospinal fluid leak following trauma.

Rationale 3: Serous drainage can indicate that the client has developed drainage from the ears as a result of allergies.

Rationale 4: The client with acute otitis media will state that he is experiencing drainage from the ears that is purulent. Reddish-yellow drainage would be classified as purulent.

Global Rationale: The client with acute otitis media will state that they are experiencing drainage from the ears that is purulent. Reddish-yellow drainage would be classified as purulent. When the client complains that the ear canal is inflamed, painful, and with erythema, this indicates that the client may have developed otitis externa. Clear drainage from the ear may indicate that the client has developed a cerebrospinal fluid leak following trauma. Serous drainage can indicate that the client has developed drainage from the ears as a result of allergies.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 14.2: Develop questions to be used when completing the focused interview.

Question 8

Type: MCMA

The client was given several medications during a recent hospital admission. The client has come to the medical office with complaints of tinnitus and bilateral hearing loss. The nurse understands that which of the following medications are associated with hearing loss or tinnitus?

Standard Text: Select all that apply.

1. Streptomycin

2. Steroid inhalers

3. Aspirin

4. Neomycin

5. Acetaminophen

Correct Answer: 1,3,4

Rationale 1: Streptomycin. Streptomycin is an antibiotic that can cause hearing loss.

Rationale 2: Steroid inhalers. Steroid inhalers are associated with Candida (yeast infections) in the nasal mucosa.

Rationale 3: Aspirin. Aspirin can cause ringing in the ears.

Rationale 4: Neomycin. Neomycin is an antibiotic that can cause hearing loss.

Rationale 5: Acetaminophen. Acetaminophen is not associated with hearing loss.

Global Rationale: Streptomycin is an antibiotic that can cause hearing loss. Steroid inhalers are associated with Candida (yeast infections) in the nasal mucosa. Aspirin can cause ringing in the ears. Neomycin is an antibiotic that can cause hearing loss. Acetaminophen is not associated with hearing loss.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 14.3: Describe the techniques required for assessment of the structures of the ear, nose, mouth, and throat.

Question 9

Type: MCSA

The client has developed anosmia. The healthcare provider educates the client about the possible causes. The nurse recognizes that which of the following would be an unexpected explanation for this condition?

1. Commonly associated with gingivitis

2. Possibly linked to heredity

3. Related to a diet deficient in zinc

4. An indicator of a neurological problem

Correct Answer: 1

Rationale 1: Anosmia is the inability to smell. It is unrelated to gingivitis. Clients with gingivitis often complain of a bad taste in their mouth.

Rationale 2: Anosmia is the inability to smell. Anosmia may be related to genetic makeup.

Rationale 3: Anosmia is the inability to smell. Anosmia may be related to a diet that is deficient in food containing zinc.

Rationale 4: Anosmia is the inability to smell. Anosmia may be related to a neurological disorder.

Global Rationale: Anosmia is the inability to smell. Anosmia may be related to a neurological disorder, genetic makeup, or a diet that is deficient in food containing zinc. It is unrelated to gingivitis. Clients with gingivitis often complain of a bad taste in their mouth.

Cognitive Level: Understanding

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 14.3: Describe the techniques required for assessment of the structures of the ear, nose, mouth, and throat.

Question 10

Type: MCSA

The client has been brought via ambulance to the emergency room following a motor vehicle accident. The nurse notes that the clients ear is draining clear fluid. What is the nurses priority nursing action?

1. Request information from the client regarding any chronic allergies.

2. Test the drainage for glucose.

3. Ask the patient if she has experienced a recent middle ear infection.

4. Irrigate the ear with warm mineral oil, peroxide, and flush with warm water.

Correct Answer: 2

Rationale 1: Chronic allergies would not result in clear fluid draining from the clients ear. However, an acute allergic reaction may result in serous fluid that drains from the clients ear.

Rationale 2: When a clients ear is draining clear fluid, this might indicate the client has a cerebrospinal fluid leak. The fluid should be tested for glucose. Glucose is present in cerebrospinal fluid.

Rationale 3: A recent middle ear infection may result in purulent or bloody drainage from the clients ear.

Rationale 4: The ear should not be irrigated at this time. Irrigation with warm mineral oil, peroxide, and flushing with warm water is often used to remove cerumen. There is nothing to suggest that the client has impacted cerumen.

Global Rationale: When a clients ear is draining clear fluid, this might indicate the client has a cerebrospinal fluid leak. The fluid should be tested for glucose. Glucose is present in cerebrospinal fluid. Chronic allergies would not result in clear fluid draining from the clients ear. However, an acute allergic reaction may result in serous fluid that drains from the clients ear. A recent middle ear infection may result in purulent or bloody drainage from the clients ear. The ear should not be irrigated at this time. Irrigation with warm mineral oil, peroxide, and flushing with warm water is often used to remove cerumen. There is nothing to suggest that the client has impacted cerumen.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 14.3: Describe the techniques required for assessment of the structures of the ear, nose, mouth, and throat.

Question 11

Type: MCSA

The nurse is assessing the tympanic membrane of a client and notes the presence of a bluish color. The nurse would suspect which of the following?

1. Acute otitis media

2. Recent head trauma

3. Blocked eustachian tubes

4. History of frequent middle ear infections

Correct Answer: 2

Rationale 1: Acute otitis media is associated with a reddish or yellowish tinge on the tympanic membrane.

Rationale 2: The presence of a bluish tinge on the tympanic membrane is most likely due to blood in the middle ear and may be indicative of recent head trauma.

Rationale 3: A blocked eustachian tube will cause the tympanic membrane to retract.

Rationale 4: Previous middle ear infections will result in white patches noted on the tympanic membrane that indicate scarring.

Global Rationale: The presence of a bluish tinge on the tympanic membrane is most likely due to blood in the middle ear and may be indicative of recent head trauma. Acute otitis media is associated with a reddish or yellowish tinge on the tympanic membrane. A blocked eustachian tube will cause the tympanic membrane to retract. Previous middle ear infections will result in white patches noted on the tympanic membrane that indicate scarring.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 14.4: Explain the use of otoscope.

Question 12

Type: MCSA

The nursing is performing an otoscopic examination on an adult client and is unable to visualize the tympanic membrane. The nurse should perform which of the following steps to better visualize this structure?

1. Pull the pinna up and back, then reinsert the otoscope

2. Tell the client to move away from the speculum if they experience any pain as the otoscope is advanced.

3. Reinsert the otoscope quickly and press against both sides of the inner auditory canal.

4. Pull the pinna down and back, then reinsert the otoscope.

Correct Answer: 1

Rationale 1: To avoid trauma to the ear, the otoscope is to be removed and the pinna should be pulled up and back for better visualization.

Rationale 2: The client should be instructed to state any feelings of discomfort or pain but not to pull away because this may result in injury during this examination.

Rationale 3: The otoscope should not be inserted quickly and should not be pressed against either side of the inner auditory canal because it would be painful for the client.

Rationale 4: Pulling down and back is recommended in children because of the shape of their auditory canal.

Global Rationale: To avoid trauma to the ear, the otoscope is to be removed and the pinna should be pulled up and back for better visualization. The client should be instructed to state any feelings of discomfort or pain but not to pull away because this may result in injury during this examination. The otoscope should not be inserted quickly and should not be pressed against either side of the inner auditory canal because it would be painful for the client. Pulling down and back is recommended in children because of the shape of their auditory canal.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 14.4: Explain the use of otoscope.

Question 13

Type: MCMA

The nurse is examining a clients ears and notes that right ear is occluded with wax. The nurse would choose which of the following to remove the earwax?

Standard Text: Select all that apply.

1. Irrigation with warm mineral oil, peroxide, followed by warm water

2. A sharp instrument to break up the ear wax

3. Irrigation with a cold solution

4. A cerumen spoon to remove the wax

5. Irrigation with warm sudsy water

Correct Answer: 1,4

Rationale 1: Irrigate the ear canal with warm mineral oil, peroxide, followed by warm water. Care must be taken when removing cerumen. Warmed mineral oil and peroxide soften the earwax and the ear can be irrigated with warm water afterwards.

Rationale 2: A sharp instrument to break up the ear wax within the ear canal. Sharp instruments should not be placed within the ear canal because it may injure the tympanic membrane.

Rationale 3: Irrigate the ear canal with a cold solution. Cold solutions may harden the ear wax, making it more difficult to remove.

Rationale 4: A cerumen spoon can be placed in the ear canal to remove the wax. The cerumen can also be safely removed with a cerumen spoon. The cerumen spoon is designed to remove the wax safely without risking injury or perforation of the eardrum.

Rationale 5: Irrigate the ear canal with warm sudsy water. Warm, sudsy solutions may irritate the ear canal.

Global Rationale: Care must be taken when removing cerumen. Warmed mineral oil and peroxide soften the earwax and the ear can be irrigated with warm water afterwards. Sharp instruments should not be placed within the ear canal because it may injure the tympanic membrane. Cold solutions may harden the ear wax, making it more difficult to remove. The cerumen can also be safely removed with a cerumen spoon. The cerumen spoon is designed to remove the wax safely without risking injury or perforation of the eardrum. Warm, sudsy solutions may irritate the ear canal.

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 14.4: Explain the use of otoscope.

Question 14

Type: MCMA

During the focused interview, the client admits to regularly abusing cocaine. Which of the following findings does the nurse expect to discover during the physical assessment of the clients nose?

Standard Text: Select all that apply.

1. The nurse notes that the nasal septum has perforated.

2. Temporomandibular joint pain when the client opens and closes the mouth

3. The septum is noted to be very pale in color.

4. Yeast infection of nasal mucosa and in mouth

5. Difficulty swallowing water

Correct Answer: 1,3

Rationale 1: The nurse notes that the nasal septum has perforated. When a client is abusing cocaine, the nurse may note that the nasal septum has broken down and has even perforated.

Rationale 2: Temporomandibular joint pain when the client opens and closes the mouth. Temporomandibular joint pain could be the result of otitis externa or might indicate temporomandibular joint dysfunction. It is unrelated to cocaine use.

Rationale 3: The septum is noted to be very pale in color. When a client is abusing cocaine, the nasal mucosa might appear vasoconstricted and very pale in color.

Rationale 4: Yeast infection of nasal mucosa and in mouth. Steroid inhalers can cause growth of Candida in the nose, mouth, or throat. It is unrelated to cocaine use.

Rationale 5: Difficulty swallowing water. If the client experiences difficulty in swallowing, this may be due to a neurological or gastrointestinal problem, or it may be related to ill-fitting dentures or malocclusion.

Global Rationale: When a client is abusing cocaine, the nurse may note that the nasal septum has broken down and has even perforated. Temporomandibular joint pain could be the result of otitis externa or might indicate temporomandibular joint dysfunction. It is unrelated to cocaine use. When a client is abusing cocaine, the nasal mucosa might appear vasoconstricted and very pale in color. Steroid inhalers can cause growth of Candida in the nose, mouth, or throat. It is unrelated to cocaine use. If the client experiences difficulty in swallowing, this may be due to a neurological or gastrointestinal problem, or it may be related to ill-fitting dentures or malocclusion.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 14.5: Differentiate normal from abnormal findings in physical assessment of the ear, nose, mouth, and throat.

Question 15

Type: MCSA

The nurse is caring for a client who was admitted to the medical unit. The healthcare provider states that the clients Romberg test was positive. As the nurse plans to meet the clients elimination needs, the nurse would implement which of the following interventions?

1. Allow the client to walk independently.

2. Obtain an order for a catheter.

3. Limit fluid intake.

4. Obtain a bedside commode.

Correct Answer: 4

Rationale 1: A positive Romberg sign indicates problems with the vestibular apparatus that controls balance. This client might experience difficult ambulating and has a higher risk of falling. The nurse must help the client eliminate safely.

Rationale 2: Catheter insertion is invasive and increases the clients risk of developing a urinary tract infection.

Rationale 3: Restricting fluid intake is not indicated in this situation.

Rationale 4: A positive Romberg sign indicates problems with the vestibular apparatus that controls balance. This client might experience difficult ambulating and has a higher risk of falling. The nurse must help the client eliminate safely. Obtaining a bedside commode for the client will help prevent the client from falling while attempting to ambulate independently to and from the bathroom.

Global Rationale: A positive Romberg sign indicates problems with the vestibular apparatus that controls balance. This client might experience difficult ambulating and has a higher risk of falling. The nurse must help the client eliminate safely. Obtaining a bedside commode for the client will help prevent the client from falling while attempting to ambulate independently to and from the bathroom. Catheter insertion is invasive and increases the clients risk of developing a urinary tract infection. Restricting fluid intake is not indicated in this situation.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 15. 5: Differentiate normal from abnormal findings in physical assessment of the ear, nose, mouth, and throat.

Question 16

Type: MCSA

A client with a fever is also complaining of difficulty hearing. The nurse realizes this client might be experiencing which of the following disorders?

1. Sinusitis

2. Otitis media

3. Tonsillitis

4. Otitis externa

Correct Answer: 2

Rationale 1: Sinusitis is associated with facial pain, inflammation, and nasal discharge.

Rationale 2: Fever and hearing loss are clinical manifestations associated with otitis media.

Rationale 3: Tonsillitis is associated with reddened, inflamed tonsils and a fever.

Rationale 4: Otitis externa is associated with a red, swollen auricle and ear canal. Clients with otitis externa also might have a fever.

Global Rationale: Fever and hearing loss are clinical manifestations associated with otitis media. Sinusitis is associated with facial pain, inflammation, and nasal discharge. Tonsillitis is associated with reddened, inflamed tonsils and a fever. Otitis externa is associated with a red, swollen auricle and ear canal. Clients with otitis externa also might have a fever.

Cognitive Level: Understanding

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 14.5: Differentiate normal from abnormal findings in physical assessment of the ear, nose, mouth, and throat.

Question 17

Type: MCSA

The emergency room triage nurse is assessing a child who has a history of a cough and nasal congestion for the last three days. When assessing patency of the nares, the nurse notes that the child is unable to breathe through the right nostril. The nurse would interpret these assessment findings as which of the following?

1. Produced by severe nasal inflammation or obstruction

2. Normal for a child

3. A result of chronic allergies

4. A result of sinusitis

Correct Answer: 1

Rationale 1: If the client cannot breathe through each naris, severe inflammation or an obstruction may be present.

Rationale 2: This is not a normal finding in an adult or a child.

Rationale 3: If nasal mucosa is pale and boggy or swollen, the client may have chronic allergies. Due to the clients history, this is an acute problem and not associated with chronic allergies.

Rationale 4: The client with sinusitis will have tenderness over sinus cavities.

Global Rationale: If the client cannot breathe through each naris, severe inflammation or an obstruction may be present. This is not a normal finding in an adult or a child. If nasal mucosa is pale and boggy or swollen, the client may have chronic allergies. Due to the clients history, this is an acute problem and not associated with chronic allergies. The client with sinusitis will have tenderness over sinus cavities.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 14.5: Differentiate normal from abnormal findings in physical assessment of the ear, nose, mouth, and throat.

Question 18

Type: MCSA

A client presents in the healthcare providers office with complaints of headache and malaise. The nurse assesses the client and finds that the client has severe pain when the sinuses are palpated. The nurse would suspect which of the following disorders?

1. Sinusitis

2. Mastoiditis

3. Chronic allergies

4. Anemia

Correct Answer: 1

Rationale 1: Pain is a common finding during palpation of the sinuses when an infection or inflammation is present in the sinuses.

Rationale 2: Mastoiditis is associated with pain and tenderness over the mastoid process, which is located behind the clients ears.

Rationale 3: The client with chronic allergies may have pale, boggy, or swollen nasal mucosa.

Rationale 4: Anemia would be associated with pale mucous membranes.

Global Rationale: Pain is a common finding during palpation of the sinuses when an infection or inflammation is present in the sinuses. Mastoiditis is associated with pain and tenderness over the mastoid process, which is located behind the clients ears. The client with chronic allergies may have pale, boggy, or swollen nasal mucosa. Anemia would be associated with pale mucous membranes.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 14.5: Differentiate normal from abnormal findings in physical assessment of the ear, nose, mouth, and throat.

Question 19

Type: MCSA

The nurse is educating a group of teenagers in high school about the risks of chewing tobacco. The nurse would include information about which of the following signs of oral cancer?

1. Bleeding and inflamed gums

2. Smooth and shiny tongue

3. Red, swollen tonsils

4. Ulcerations on the lip or under the tongue

Correct Answer: 4

Rationale 1: Bleeding and inflamed gums are associated with gingivitis.

Rationale 2: A smooth, shiny tongue is associated with deficiencies of vitamin B and iron.

Rationale 3: Red and swollen tonsils are associated with tonsillitis

Rationale 4: Oral cancers are most commonly found on the lower lip or the base of the tongue. They do not heal normally.

Global Rationale: Oral cancers are most commonly found on the lower lip or the base of the tongue. They do not heal normally. Bleeding and inflamed gums are associated with gingivitis. A smooth, shiny tongue is associated with deficiencies of vitamin B and iron. Red and swollen tonsils are associated with tonsillitis.

Cognitive Level: Understanding

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 14.5: Differentiate normal from abnormal findings in physical assessment of the ear, nose, mouth, and throat.

Question 20

Type: MCMA

A client arrives in the emergency room with complaints of intermittent nosebleeds for the past two days. Which of the following assessments would be a priority for the nurse is this situation?

Standard Text: Select all that apply.

1. Request information from the client regarding increased propensity for bruising or bleeding.

2. Assess the tonsils for redness or swelling.

3. Obtain a blood pressure.

4. Check for deviated septum.

5. Request information from the client to determine if there was any recent thin, watery drainage from the nose.

Correct Answer: 1,3,5

Rationale 1: Request information from the client regarding increased propensity for bruising or bleeding. The client may have a blood coagulation disorder that may result in increased bruising or bleeding. This disorder may have produced the episodes of epistaxis.

Rationale 2: Assess the tonsils for redness or swelling. Red, swollen tonsils are associated with tonsillitis. Tonsillitis is not associated with epistaxis.

Rationale 3: Obtain a blood pressure. Hypertension is a contributory factor to the occurrence of nosebleeds. The nurse should assess the clients blood pressure to determine if it is elevated.

Rationale 4: Check for deviated septum. A deviated septum is not associated with epistaxis.

Rationale 5: Request information from the client to determine if there was any recent thin, watery drainage from the nose. Thin, watery drainage from the nose is associated with rhinitis. Rhinitis is associated with epistaxis.

Global Rationale: The client may have a blood coagulation disorder that may result in increased bruising or bleeding. This disorder may have produced the episodes of epistaxis. Red, swollen tonsils are associated with tonsillitis. Tonsillitis is not associated with epistaxis. Hypertension is a contributory factor to the occurrence of nosebleeds. The nurse should assess the clients blood pressure to determine if it is elevated. A deviated septum is not associated with epistaxis. Thin, watery drainage from the nose is associated with rhinitis. Rhinitis is associated with epistaxis.

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 14.5: Differentiate normal from abnormal findings in physical assessment of the ear, nose, mouth, and throat.

Question 21

Type: MCSA

The nurse is examining a 14-month-old child when the mother tells the nurse that the child cries frequently, has a fever, and is pulling at both ears. The nurse suspects the child has which of the following disorders from this assessment data?

1. Otitis media

2. Otitis externa

3. Hemotympanum

4. Tophi

Correct Answer: 1

Rationale 1: The auditory canal of infants is shorter and has an upward curve that persists until about the age of 3. In addition, their auditory tube is more horizontal than the adult, which leads to easier migration of organisms from the throat to the middle ear. Infants and children with otitis media often display the behavior of pulling at their ears.

Rationale 2: Otitis externa is an infection of the external auditory canal manifested by red, swollen ear canal, fever, and purulent drainage.

Rationale 3: Hemotympanum is a bluish tinge of the tympanic membrane indicating the presence of blood in the middle ear. It is usually associated with head trauma.

Rationale 4: Tophi are small white nodules on the helix or antihelix. These nodules contain uric acid crystals and are a sign of gout.

Global Rationale: The auditory canal of infants is shorter and has an upward curve that persists until about the age of 3. In addition, their auditory tube is more horizontal than the adult, which leads to easier migration of organisms from the throat to the middle ear. Infants and children with otitis media often display the behavior of pulling at their ears. Otitis externa is an infection of the external auditory canal manifested by red, swollen ear canal, fever, and purulent drainage. Hemotympanum is a bluish tinge of the tympanic membrane indicating the presence of blood in the middle ear. It is usually associated with head trauma. Tophi are small white nodules on the helix or antihelix. These nodules contain uric acid crystals and are a sign of gout.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 14.5: Differentiate normal from abnormal findings in physical assessment of the ear, nose, mouth, and throat.

Question 22

Type: MCSA

The nurse is triaging a client and notes pallor and cyanosis of the oral cavity and lips. Based on this finding, the nurse would implement which of the following actions first?

1. Administer IV fluids.

2. Provide oral hygiene.

3. Administer oxygen.

4. Provide a warm drink.

Correct Answer: 3

Rationale 1: There is no indication the client has an electrolyte or fluid imbalance at this time, making the administration of IV fluids inappropriate at this time.

Rationale 2: Pallor and cyanosis of the oral cavity and lips are assessment findings that indicate hypoxia. Providing oral hygiene is not an appropriate intervention because it will not increase the clients oxygenation levels.

Rationale 3: Pallor and cyanosis of the oral cavity and lips are assessment findings that indicate hypoxia. The nurse should apply oxygen for the client.

Rationale 4: Pallor and cyanosis of the oral cavity and lips are assessment findings that indicate hypoxia. Providing a warm drink will not correct the clients oxygenation problem.

Global Rationale: Pallor and cyanosis of the oral cavity and lips are assessment findings that indicate hypoxia. The nurse should apply oxygen for the client. There is no indication the client has an electrolyte or fluid imbalance at this time, making the administration of IV fluids inappropriate at this time. Providing oral hygiene is not an appropriate intervention because it will not increase the clients oxygenation levels. Providing a warm drink will not correct the clients oxygenation problem.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 14.5: Differentiate normal from abnormal findings in physical assessment of the ear, nose, mouth, and throat.

Question 23

Type: MCSA

The nurse is assessing the clients nasal mucosa and notes the presence of a thin, watery discharge. The client complains of sneezing and nasal congestion. The nurse would suspect which of the following in this situation?

1. Rhinitis

2. Perforated septum

3. Previous epistaxis

4. Nasal polyps

Correct Answer: 1

Rationale 1: These clinical manifestations are associated with rhinitis. Rhinitis is inflammation of the nasal mucosa due to a viral infection or allergy.

Rationale 2: A perforated septum is a hole in the septum caused by chronic infection, trauma, or sniffing cocaine. It can be detected by shining a penlight through the naris on the other side.

Rationale 3: With a history of epistaxis, the nurse would note that there is old dried blood on the nasal mucosa.

Rationale 4: Nasal polyps are pale, round, firm, nonpainful overgrowth of nasal mucosa.

Global Rationale: These clinical manifestations are associated with rhinitis. Rhinitis is inflammation of the nasal mucosa due to a viral infection or allergy. A perforated septum is a hole in the septum caused by chronic infection, trauma, or sniffing cocaine. It can be detected by shining a penlight through the naris on the other side. With a history of epistaxis, the nurse would note that there is old dried blood on the nasal mucosa. Nasal polyps are pale, round, firm, nonpainful overgrowth of nasal mucosa.

Cognitive Level: Understanding

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 14.5: Differentiate normal from abnormal findings in physical assessment of the ear, nose, mouth, and throat.

Question 24

Type: MCSA

The nurse is assessing the oral cavity of a client and notes a blackish, furry-looking coating on the tongue. Which of the following questions would be appropriate for the nurse to include when obtaining further assessment data?

1. Have you eaten licorice lately?

2. How often do you brush your tongue?

3. Have you recently taken antibiotics?

4. Have you ever had this happen before?

Correct Answer: 3

Rationale 1: This finding is unrelated to food intake such as eating licorice.

Rationale 2: This finding is not related to poor oral hygiene practices.

Rationale 3: The presence of a black, furry-looking coating on the tongue is usually related to an overgrowth of fungus due to inhibition of normal bacteria due to antibiotic use.

Rationale 4: It may helpful for the nurse to determine if the condition has occurred previously but it is not the most important question. The nurse should question the client regarding recent antibiotic use.

Global Rationale: The presence of a black, furry-looking coating on the tongue is usually related to an overgrowth of fungus due to inhibition of normal bacteria due to antibiotic use. This finding is not related to poor oral hygiene practices. It is unrelated to food intake such as eating licorice. It may helpful for the nurse to determine if the condition has occurred previously but it is not the most important question. The nurse should question the client regarding recent antibiotic use.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 14.5: Differentiate normal from abnormal findings in physical assessment of the ear, nose, mouth, and throat.

Question 25

Type: MCSA

An elderly client says, I cant seem to hear as well as I could when I was younger. The nurse suspects this client is experiencing which of the following disorders?

1. Presbycusis

2. Mastoiditis

3. Otitis media

4. Otitis externa

Correct Answer: 1

Rationale 1: Age-related changes include loss of low- and high-frequency hearing, also known as presbycusis.

Rationale 2: Mastoiditis is a complication of either a middle ear infection or a throat infection. The client would complain of pain or tenderness behind the ear.

Rationale 3: Otitis media is an infection of the middle ear producing a red, bulging eardrum, fever, and hearing loss.

Rationale 4: Otitis externa is an infection of the outer ear, often called swimmers ear. Otitis externa causes redness and swelling of the auricle and ear canal.

Global Rationale: Age-related changes include loss of low- and high-frequency hearing, also known as presbycusis. Mastoiditis is a complication of either a middle ear infection or a throat infection. The client would complain of pain or tenderness behind the ear. Otitis media is an infection of the middle ear producing a red, bulging eardrum, fever, and hearing loss. Otitis externa is an infection of the outer ear, often called swimmers ear. Otitis externa causes redness and swelling of the auricle and ear canal.

Cognitive Level: Understanding

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 14.5: Differentiate normal from abnormal findings in physical assessment of the ear, nose, mouth, and throat.

Question 26

Type: MCSA

The nurse is assessing the oral mucosa of a pregnant female and notes enlargement of the gums. The client states that regular oral hygiene is performed and that she does not understand why this has occurred. Which of the following is the nurses best response?

1. You may have oral cancer.

2. You are experiencing a normal change during pregnancy.

3. You may have leukoplakia.

4. You need to decrease the frequency of your oral hygiene.

Correct Answer: 2

Rationale 1: Early signs of oral cancer are manifested by ulcers in the lower lip and under the tongue that do not heal normally.

Rationale 2: Gingival hyperplasia (enlargement of the gums) is a normal physiologic change associated with pregnancy. It is also seen in clients with leukemia and prolonged use of Dilantin.

Rationale 3: Leukoplakia is a whitish thickening of the mucous membrane in the mouth or tongue. It cannot be scraped off. It is most often associated with heavy smoking or drinking, and it can be a precancerous condition.

Rationale 4: Advanced gingivitis and poor dental hygiene are manifested by swollen red gums that will bleed when brushed, and will show separation of the gum from the tooth.

Global Rationale: Gingival hyperplasia (enlargement of the gums) is a normal physiologic change associated with pregnancy. It is also seen in clients with leukemia and prolonged use of Dilantin. Early signs of oral cancer are manifested by ulcers in the lower lip and under the tongue that do not heal normally. Leukoplakia is a whitish thickening of the mucous membrane in the mouth or tongue. It cannot be scraped off. It is most often associated with heavy smoking or drinking, and it can be a precancerous condition. Advanced gingivitis and poor dental hygiene are manifested by swollen red gums that will bleed when brushed, and will show separation of the gum from the tooth.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 14.6: Describe developmental, psychosocial, cultural, and environmental variations in assessment techniques and findings.

Question 27

Type: MCMA

The nurse is discharging an 11-month-old child who was brought to the emergency room for the treatment of an ear infection and fever. The nurse would include which of the following statements in the discharge teaching to the parents?

Standard Text: Select all that apply.

1. The babys last bottle before bedtime should only contain water.

2. It is important not to prop the babys bottle during feeding.

3. You must rinse the babys mouth right after the baby falls asleep.

4. You must perform oral hygiene more frequently throughout the day.

5. The last bottle of the evening should not be given just before the baby goes to sleep.

Correct Answer: 2,5

Rationale 1: The babys last bottle before bedtime should only contain water. Milk should not be replaced with water because the baby may not receive enough nutrition. Bottles should not be given just before bedtime.

Rationale 2: It is important not to prop the babys bottle during feeding. A primary source of ear infection in infants and small children is the practice of propping the bottle with milk or juice. The sugar in these liquids remains in the mouth and contributes to the potential for infection in the throat, which travels through the shorter, narrower, and more horizontal auditory tube.

Rationale 3: You must rinse the babys mouth right after the baby falls asleep. This would not be appropriate and might be dangerous for the baby. Providing oral hygiene for children immediately before bedtime might be helpful to help reduce the risk of ear infections.

Rationale 4: You must perform oral hygiene more frequently throughout the day. Increasing the oral hygiene frequency throughout the day will not improve this situation if bottle propping is occurring or if the baby is given a bottle immediately prior to bedtime.

Rationale 5: The last bottle of the evening should not be given just before the baby goes to sleep. A major source of ear infection in infants and small children is the practice of giving the baby a bottle at bedtime. The sugar in these liquids remains in the mouth and contributes to the potential for infection in the throat, which travels through the shorter, narrower, and more horizontal auditory tube.

Global Rationale: Milk should not be replaced with water because the baby may not receive enough nutrition. Bottles should not be given just before bedtime. A primary source of ear infection in infants and small children is the practice of propping the bottle with milk or juice. The sugar in these liquids remains in the mouth and contributes to the potential for infection in the throat, which travels through the shorter, narrower, and more horizontal auditory tube. This would not be appropriate and might be dangerous for the baby. Providing oral hygiene for children immediately before bedtime might be helpful to help reduce the risk of ear infections. Increasing the oral hygiene frequency throughout the day will not improve this situation if bottle propping is occurring or if the baby is given a bottle immediately prior to bedtime. A major source of ear infection in infants and small children is the practice of giving the baby a bottle at bedtime. The sugar in these liquids remains in the mouth and contributes to the potential for infection in the throat, which travels through the shorter, narrower, and more horizontal auditory tube.

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 14.6: Describe developmental, psychosocial, cultural, and environmental variations in assessment techniques and findings.

Question 28

Type: MCSA

The nurse is assessing the ears, nose and mouth of an Asian client with a student nurse. Which of the following statements made by the nurse to the student nurse about cultural differences is accurate?

1. Asians are more likely to experience greater difficulty with otitis media than people from other cultures.

2. Sometimes in Asians and Native Americans, their ear wax looks dry and dark.

3. Asians have a higher risk of having issues associated with cleft lips and cleft palates.

4. Asians have a high incidence of tooth decay.

Correct Answer: 2

Rationale 1: Asians do not have a tendency to develop otitis media more than other cultures.

Rationale 2: Cerumen appears dry and gray to brown in Asians and Native Americans. Cerumen found in Caucasians and African Americans looks moist and yellow-orange in color.

Rationale 3: Cleft lip and palate occur with greatest frequency in Asians and least often in African Americans.

Rationale 4: Caucasians have the highest incidence of tooth decay.

Global Rationale: Cerumen appears dry and gray to brown in Asians and Native Americans. Cerumen found in Caucasians and African Americans looks moist and yellow-orange in color. Asians do not have a tendency to develop otitis media more than other cultures. Cleft lip and palate occur with greatest frequency in Asians and least often in African Americans. Caucasians have the highest incidence of tooth decay.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 14.6: Describe developmental, psychosocial, cultural, and environmental variations in assessment techniques and findings.

Question 29

Type: MCSA

The nurse is assessing several children in a pediatric clinic. Which of the following children might be experiencing delayed development?

1. The 6-year-old child has lost 2 deciduous teeth.

2. The 26-month-old child has one baby tooth.

3. The 4-month-old infant is drooling.

4. The 2-month-old infants salivary glands are not producing saliva.

Correct Answer: 2

Rationale 1: Eruption of permanent teeth begins at around age 6 and continues through adolescence.

Rationale 2: Deciduous (baby) teeth begin to erupt between 6 months and 2 years of age. A 26-month-old child might be expected to have more than one deciduous tooth.

Rationale 3: Drooling of saliva occurs for several months after saliva is produced (3 months old) until swallowing saliva is learned.

Rationale 4: Salivation begins at 3 months of age.

Global Rationale: Eruption of permanent teeth begins at around age 6 and continues through adolescence. Deciduous (baby) teeth begin to erupt between 6 months and 2 years of age. A 26-month-old child might be expected to have more than one deciduous tooth. Drooling of saliva occurs for several months after saliva is produced (3 months old) until swallowing saliva is learned. Salivation begins at 3 months of age.

Cognitive Level: Understanding

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 14.6: Describe developmental, psychosocial, cultural, and environmental variations in assessment techniques and findings.

Question 30

Type: MCMA

During the focused interview, the client provides information to the nurse regarding her daughters recent diagnosis with cancer. The client is exhibiting clinical manifestations associated with anxiety. During the physical assessment, which of the following findings might be expected?

Standard Text: Select all that apply.

1. The client complains of pain when the tragus is gently manipulated.

2. The client has several small ulcers on her lip.

3. Pale nasal mucosa

4. Small sores are noted within the mouth.

5. Perforated nasal septum

Correct Answer: 1,2,4

Rationale 1: The client complains of pain when the tragus is gently manipulated. Pain that occurs with manipulation of the tragus may accompany temporomandibular joint dysfunction that may be associated with jaw clenching. Jaw clenching can accompany psychological stress.

Rationale 2: The client has several small ulcers on her lip. Clients who are under a great deal of stress might bite their lips.

Rationale 3: Pale nasal mucosa. Pale nasal mucosa is associated with cocaine use, infection, hypoxia, and allergies.

Rationale 4: Small sores are noted within the mouth. Clients who are under a great deal of stress might present with ulcers in their mouth.

Rationale 5: Perforated nasal septum. A perforated nasal septum is associated with cocaine use.

Global Rationale: Pain that occurs with manipulation of the tragus may accompany temporomandibular joint dysfunction that may be associated with jaw clenching. Jaw clenching can accompany psychological stress. Clients who are under a great deal of stress might bite their lips. Pale nasal mucosa is associated with cocaine use, infection, hypoxia, and allergies. Clients who are under a great deal of stress might present with ulcers in their mouth. A perforated nasal septum is associated with cocaine use.

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 14.6: Describe developmental, psychosocial, cultural, and environmental variations in assessment techniques and findings.

Question 31

Type: MCMA

The nurse is conducting a hearing assessment on an older adult client with impacted cerumen noted in the right ear canal. When performing the Weber test, the nurse would expect to learn which of the following?

Standard Text: Select all that apply.

1. Air conduction is longer than bone conduction.

2. Bone conduction is longer than air conduction.

3. Sound lateralized to the right ear.

4. The client is unable to maintain balance while standing.

5. The 4 year old placed a pea into his nose during lunch.

Correct Answer: 3

Rationale 1: The Rinne test, not the Weber test, compares air and bone conduction.

Rationale 2: The Rinne test, not the Weber test, compares air and bone conduction.

Rationale 3: The Weber test uses bone conduction to evaluate hearing in a person who hears better in one ear than in the other. With impacted cerumen, an ear infection, or a perforated tympanic membrane, the sound will lateralize to the affected ear during the Weber test.

Rationale 4: The Romberg test is used to determine equilibrium and the clients ability to maintain balance while standing.

Rationale 5: The 4 year old placed a pea into his nose during lunch. Children are more likely to introduce foreign objects into their mouth and nose. This behavior is not associated with gum or oral mucosa problems.

Global Rationale: The Rinne test compares air and bone conduction. Normally, the sound is heard twice as long by air conduction than by bone conduction after bone conduction stops. The Weber test uses bone conduction to evaluate hearing in a person who hears better in one ear than in the other. With impacted cerumen, an ear infection, or a perforated tympanic membrane, the sound will lateralize to the affected ear during the Weber test. The Romberg test is used to determine equilibrium and the clients ability to maintain balance while standing.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 14.8: Apply critical thinking in selected simulations related to physical assessment of the structures of the ear, nose, mouth, and throat.

Question 32

Type: MCSA

The nurse is performing the Weber test. The nurse documents that the sound lateralized to the clients right ear. The student nurse observing the assessment asks the nurse about the meaning of this documentation. Which of the following is the nurses best response?

1. This just means that I am unable to visualize the clients tympanic membrane.

2. It refers to the clients inability to hear whispered statements.

3. The client is able to hear bone-conducted sound longer than air conducted sound.

4. The client is able to hear bone-conducted sound better through the impaired ear.

Correct Answer: 4

Rationale 1: While it is possible that the nurse is unable to visualize the tympanic membrane due to cerumen and this is the reason for sound lateralizing to one ear during the Weber test, this is not the nurses best response.

Rationale 2: The clients ability to hear whispered statements at 12 feet away is assessed during the whisper test.

Rationale 3: The Weber test is performed to determine if during bone conduction, with the use of a tuning fork, the client hears the sound in one ear better than the other. If there is impaired conduction in one ear, the sound will lateralize to that ear during the Weber test.

Rationale 4: The Rinne test compares air and bone conduction of sound with the use of a tuning fork.

Global Rationale: While it is possible that the nurse is unable to visualize the tympanic membrane due to cerumen and this is the reason for sound lateralizing to one ear during the Weber test, this is not the nurses best response. The Weber test is performed to determine if during bone conduction, with the use of a tuning fork, the client hears the sound in one ear better than the other. If there is impaired conduction in one ear, the sound will lateralize to that ear during the Weber test. The clients ability to hear whispered statements at 12 feet away is assessed during the whisper test. The Rinne test compares air and bone conduction of sound with the use of a tuning fork.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 14.8: Apply critical thinking in selected simulations related to physical assessment of the structures of the ear, nose, mouth, and throat.

Question 33

Type: MCSA

The client admits to cleaning his ears with a cotton-tipped applicator. As a consequence, the client has developed impacted cerumen and unilateral hearing loss. As the nurse prepares the clients plan of care, which of the following nursing diagnoses is most applicable?

1. Acute pain

2. Knowledge deficit

3. Acute confusion

4. Unilateral neglect

Correct Answer: 2

Rationale 1: Acute pain would be appropriate if the client had perforated the tympanic membrane with the cotton-tipped applicator. However, there are no data to suggest this.

Rationale 2: Of the choices, the best nursing diagnosis for this client is knowledge deficit regarding how to adequately care for his ears. Another possible nursing diagnosis that would be applicable for this client is disturbed sensory perception because he will be unable to hear well out of the ear that is impacted with cerumen.

Rationale 3: Acute confusion is not an appropriate nursing diagnosis. This client will not develop confusion as a result of unilateral hearing loss.

Rationale 4: The client will not neglect one side as a result of unilateral hearing loss.

Global Rationale: Of the choices, the best nursing diagnosis for this client is knowledge deficit regarding how to adequately care for his ears. Another possible nursing diagnosis that would be applicable for this client is disturbed sensory perception because he will be unable to hear well out of the ear that is impacted with cerumen. Acute pain would be appropriate if the client had perforated the tympanic membrane with the cotton-tipped applicator. However, there are no data to suggest this. Acute confusion is not an appropriate nursing diagnosis. This client will not develop confusion as a result of unilateral hearing loss. The client will not neglect one side as a result of unilateral hearing loss.

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 14.8: Apply critical thinking in selected simulations related to physical assessment of the structures of the ear, nose, mouth, and throat.

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