Chapter 63 My Nursing Test Banks

Osborn,_2e
Chapter 63

Question 1

Type: MCSA

A patient is admitted with a ruptured tympanic membrane (TM). This may result in a hearing loss due to the disruption of which function of the TM?

1. Separating the outer and inner ear

2. Vibrating with sound waves

3. Covering the eustachian tube

4. Covering the mastoid process

Correct Answer: 2

Rationale 1: The tympanic membrane separates the outer and middle ear, not the outer and inner ear.

Rationale 2: The TM vibrates in response to sound waves. If the TM is perforated, vibration is diminished.

Rationale 3: The tympanic membrane does not cover the eustachian tube, which connects with the middle ear.

Rationale 4: The mastoid process is part of the outer ear but is not covered by the TM.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 63-1

Question 2

Type: MCSA

A patient complains of feeling off balance. The nurse should consider that the patient might have a disorder affecting which structure?

1. Organ of Corti

2. Vestibular system

3. Middle ear

4. Cochlea

Correct Answer: 2

Rationale 1: The organ of Corti is located in the cochlea, which is responsible for hearing.

Rationale 2: The vestibular system, which is part of the inner ear, is responsible for balance.

Rationale 3: The bones in the middle ear vibrate with sound and do not affect balance.

Rationale 4: The cochlea, which is located in the inner ear, is responsible for hearing.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 63-1

Question 3

Type: MCSA

A diver is admitted complaining of ear pain and hearing loss. On examination, the nurse notes a rupture in the tympanic membrane. The nurse would conduct further assessment for which type of hearing loss?

1. Conductive hearing loss

2. Sensorineural hearing loss

3. Noise-induced hearing loss

4. Mixed hearing loss

Correct Answer: 1

Rationale 1: A rupture in the tympanic membrane interferes with sound conduction, so this is a conductive hearing loss.

Rationale 2: Sensorineural hearing loss occurs when the nerves of the inner ear are damaged. Another type of hearing loss is more likely.

Rationale 3: The most obvious reason for the perforation of this patients tympanic membrane is barotrauma from diving. There is no information to implicate noise as the etiology of this loss.

Rationale 4: There is no assessment data supporting sensorineural hearing loss, one of the components of mixed hearing loss.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 63-2

Question 4

Type: MCSA

A patient is diagnosed with otosclerosis. The nurse plans interventions related to which type of hearing loss?

1. Sensorineural

2. Mixed

3. Conductive

4. Cochlear

Correct Answer: 3

Rationale 1: Sensorineural losses are caused by damage to auditory nerves or small hair cells in the inner ear. Otosclerosis is not associated with this type of damage.

Rationale 2: A mixed hearing loss refers to both a conductive and sensorineural loss at the same time. Otosclerosis is not associated with mixed hearing loss.

Rationale 3: A conductive hearing loss occurs when there is a problem conducting sound waves through the outer ear, tympanic membrane, or middle ear. Otosclerosis is a condition in which the structures of the ear begin to harden, which would interfere with their ability to vibrate.

Rationale 4: Cochlear does not describe a type of hearing loss.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 63-2

Question 5

Type: MCSA

An older patient has been diagnosed with presbycusis. The nurse would plan interventions to address which kind of hearing loss that is a common result of aging?

1. Sensorineural

2. Air conduction

3. Conductive

4. Mixed

Correct Answer: 1

Rationale 1: Presbycusis is usually a sensorineural hearing disorder caused by gradual changes in the inner ear resulting from the loss of hair cells in the organ of Corti.

Rationale 2: Interference of air conduction is not the result of aging.

Rationale 3: Presbycusis is usually another type of hearing loss.

Rationale 4: Presbycusis is usually another type of hearing loss.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 63-6

Question 6

Type: MCSA

A patient diagnosed with profound noise-induced hearing loss (NIHL) states, I am going to wear ear protection at work from now on. How long before my hearing gets better? How should the nurse respond?

1. If you rest your ears from noise, you should be back to normal in a week or so.

2. As soon as the inflammation in your ear canal clears, your hearing will be much better.

3. Often the nerve damage in your type of hearing loss is permanent, and hearing does not improve.

4. It is too late to use ear protection now.

Correct Answer: 3

Rationale 1: With profound NIHL, it is unlikely that hearing will ever return to normal.

Rationale 2: NIHL is not caused by inflammation of the ear canal.

Rationale 3: NIHL is caused by nerve damage. The nerve endings do not regenerate, and hearing loss is permanent.

Rationale 4: The patient should protect the remaining hearing.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 63-2

Question 7

Type: MCSA

When taking a health history, the nurse asks a patient about taking over-the-counter medications. The patient reports taking large doses of aspirin to relieve daily headaches. This comment should alert the nurse to further assess the patients hearing for which reason?

1. The headaches are probably caused by a hearing disorder.

2. Aspirin can be ototoxic.

3. Most headaches are caused by disorders of the inner ear.

4. The patient is trying to treat a serious condition without medical intervention.

Correct Answer: 2

Rationale 1: It would be unusual for headaches to be the direct result of hearing loss.

Rationale 2: Some medications, including salicylates (aspirin), are ototoxic. They can cause permanent sensorineural hearing loss by damaging the nerves in the inner ear.

Rationale 3: Headaches occur for a variety of reasons, and most are not related to inner ear disorders.

Rationale 4: The relevant information is the large doses of aspirin being taken. It is true that the patient needs medical care, but this is not the reason it is important to assess hearing.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 63-4

Question 8

Type: MCSA

A patient tells the nurse that the only way he can adequately clean his ears is with a cotton-tipped applicator. What is the nurses best

action regarding this statement?

1. Instruct the patient on the proper use of cotton-tipped applicators.

2. Educate the patient about the danger of using cotton-tipped applicators for this purpose.

3. Instruct the patient to use cotton-tipped applicators only when necessary.

4. Check to see if the ears are clean.

Correct Answer: 2

Rationale 1: There is no proper way to use cotton-tipped applicators because they should never be used to clean the ears.

Rationale 2: Cotton-tipped applicators or any small object should never be used to clean inside the ears because of the risk of tympanic membrane rupture. Such objects may also force cerumen further into the ear, causing a blockage.

Rationale 3: Cotton-tipped applicators should never be used to clean the ears under any circumstances.

Rationale 4: Checking the ears for a blockage is appropriate in any exam, but educating the patient has a higher priority.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 63-3

Question 9

Type: MCSA

A nurse is working with a patient who experienced the sudden onset of dizziness, nausea, and hearing loss. A diagnosis of Mnires disease has been made. How should the nurse instruct the patient?

1. Use tranquilizers to help cope with the disease.

2. Avoid tobacco, alcohol, and caffeine.

3. Take OTC medications for the nausea.

4. Stay in bed until symptoms subside.

Correct Answer: 2

Rationale 1: Tranquilizers, or any medication that may cause vertigo, should be avoided.

Rationale 2: Tobacco, alcohol, and caffeine can exacerbate inner ear fluid imbalance.

Rationale 3: Mnires disease requires medical intervention. The patient should not self-medicate.

Rationale 4: Bed rest is not required in the treatment of Mnires disease.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 63-7

Question 10

Type: MCSA

The nurse is working with a patient newly diagnosed with benign paroxysmal positional vertigo (BPPV). Which instruction should the nurse provide for this patient?

1. Importance of bed rest

2. Importance of medication regimen to eliminate the disorder

3. Modifications in daily activities

4. Adapting to long-term balance disorder

Correct Answer: 3

Rationale 1: Bed rest should be avoided because it causes skeletal muscle weakness.

Rationale 2: Nausea may be associated with BPPV and antiemetic medications may be used, but they do not prevent the dizziness.

Rationale 3: Modifications in daily activities, such as avoiding bending down to pick up objects, may be necessary to cope with the dizziness.

Rationale 4: BPPV is not life threatening and is frequently self-limiting because symptoms often subside or disappear within 2 months of

onset. It is not a long-term balance disorder.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 63-7

Question 11

Type: MCSA

The nurse is working with a patient who has just purchased hearing aids. Which instruction should be part of the nurses teaching?

1. Wear the devices only when you think you are going to need them.

2. Leave the devices on when you are not wearing them.

3. Only wear the devices for a part of the day at first.

4. Bring the device back to the clinic when the battery needs to be changed.

Correct Answer: 3

Rationale 1: The patient should not try to predict when the devices will be needed.

Rationale 2: The devices should be turned off when not in use.

Rationale 3: The patient needs to adjust to wearing the devices and should wear them for only part of the day initially.

Rationale 4: The patient should be able to replace the battery as needed.

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 63-3

Question 12

Type: MCSA

A patient experiences an increase in ear pain when the auricle is pulled up and back. The nurse would conduct additional assessment for which condition?

1. Otitis externa

2. Otitis media

3. Labyrinthitis

4. Exostosis

Correct Answer: 1

Rationale 1: The pain of otitis externa can be differentiated from that associated with otitis media by manipulating the auricle. The pain of otitis externa is particularly intense when the outer part of the ear is pulled or pressed on.

Rationale 2: Manipulation of the auricle may cause no pain with otitis media.

Rationale 3: Labyrinthitis manifests as vertigo, nausea, vomiting, and loss of balance.

Rationale 4: Exostosis is asymptomatic in most cases.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 63-7

Question 13

Type: MCSA

A patient with chronic acute otitis media infections is having a myringotomy. What discharge instructions should the nurse provide?

1. Avoid getting any water into the ears.

2. Wash hair only with warm water.

3. Make sure showers are completed within 10 minutes.

4. Avoid gum chewing.

Correct Answer: 1

Rationale 1: While the tube is in place, it is important to avoid getting water in the ear canal because it may then enter the middle ear space.

Rationale 2: The temperature of the water is not a major concern.

Rationale 3: The length of the shower is not a major concern.

Rationale 4: Gum chewing may produce discomfort, but it is not prohibited after myringotomy.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 63-5

Question 14

Type: MCMA

A patient is experiencing a severe episode of Mnires disease. Which medication to help reduce the sensation of spinning and nausea does the nurse anticipate providing?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Meclizine (Antivert)

2. Ofloxacin drops (Floxin Otic)

3. Diphenhydramine (Benadryl)

4. Phenergan

5. Dimenhydrinate (Dramamine)

Correct Answer: 1,3,5

Rationale 1: Meclizine is administered to prevent vertigo and nausea.

Rationale 2: Ofloxacin is an antibiotic and would not be used in treatment of Mnires disease.

Rationale 3: Diphenhydramine helps prevent the vertigo and nausea associated with Mnires disease.

Rationale 4: Phenergan is an antiemetic and is not used to prevent vertigo.

Rationale 5: Dimenhydrinate can help prevent vertigo and nausea of Mnires disease.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 63-7

Question 15

Type: MCMA

The nurse is instructing a patient who has a hearing and balance disorder. Which guidelines should the nurse discuss?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Changing positions slowly

2. Avoiding bending over to pick things up

3. Using two or more pillows at night

4. Sitting on the edge of the bed for a few moments when arising

5. Standing very still when vertigo occurs

Correct Answer: 1,2,3,4

Rationale 1: The patient should be instructed to get up slowly.

Rationale 2: The patient should avoid bending over to pick things up.

Rationale 3: The patient should sleep on two or more pillows.

Rationale 4: The patient should sit on the side of the bed for a few moments before standing.

Rationale 5: The patient should sit down or lie down immediately when vertigo occurs.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 63-5

Question 16

Type: MCSA

Which nursing diagnosis is a priority for a patient with severe symptoms of tinnitus, vertigo, sensorineural hearing deficit, nausea, and vomiting?

1. Disturbed Sensory Perception

2. Imbalanced Nutrition: Less than Body Requirements

3. Ineffective Individual Coping

4. Disturbed Sleep Patterns

Correct Answer: 1

Rationale 1: The symptoms listed are for labyrinthitis or Mnires disease, disorders of the inner ear, in which balance and coordination of motor skills related to gravitational pull are disturbed. Disturbed Sensory Perception is the appropriate diagnosis for these symptoms.

Rationale 2: The patient with these symptoms may be unable to eat due to nausea. However, there is not enough information in this question to make this diagnosis.

Rationale 3: The scenario does not indicate that the patient is not coping with these symptoms.

Rationale 4: Symptoms of vertigo and tinnitus alter the ability to rest and sleep, but the scenario does not provide that information.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Safe Effective Care Environment

Client Need Sub: Management of Care

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 63-7

Question 17

Type: MCMA

Which nursing interventions are most appropriate for a patient with a nursing diagnosis of Impaired Verbal Communication related to hearing deficit?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Speak face-to-face, but do not over-articulate words.

2. Respond to the call light promptly.

3. Use touch to gain the patients attention.

4. Speak clearly.

5. Speak in a higher pitch.

Correct Answer: 1,2,3,4

Rationale 1: Facing away from the patient does not alert the patient to the need to communicate. Many patients with hearing deficits can read lips to some extent.

Rationale 2: Responding quickly helps to reduce fear and anxiety.

Rationale 3: Touching the patient is an alert that communication is about to begin.

Rationale 4: It is easier for the patient to understand if the nurses speech is clear.

Rationale 5: With many hearing problems, the ability to hear high-pitched sounds is often impaired first.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 63-7

Question 18

Type: MCSA

Which physical assessment finding should the nurse anticipate in the patient with otosclerosis?

1. Rinne test results show that bone conduction is equal to or greater than air conduction.

2. The patient has severe vertigo.

3. Purulent drainage is observed or reported with cyanosis of the tympanic membrane.

4. Diminished hearing is noted with higher tones, such as a womans speaking voice.

Correct Answer: 1

Rationale 1: The Rinne test differentiates between bone and air conduction. In otosclerosis, there is greater bone conduction due to the calcification and fixation of the malleus, incus, and stapes (bony ossicles).

Rationale 2: Severe vertigo is the hallmark symptom of inner ear disturbances, not the middle ear stapes fixation associated with otosclerosis.

Rationale 3: Purulent drainage with cyanosis of the tympanic membrane represents an acute or chronic middle ear infection that has caused a rupture of the tympanic membrane. Infection is not related to otosclerosis.

Rationale 4: Diminished hearing begins with the lower pitches. Higher tones are more easily heard by a patient with otosclerosis.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 63-7

Question 19

Type: MCSA

A young child is being seen with an impaction of the ear canal caused by a large plastic bead. The nurse prepares to assist with which procedure to remove the bead?

1. Suction using a soft piece of tubing

2. Instillation of lidocaine drops

3. Instillation of mineral oil

4. Forceps

Correct Answer: 1

Rationale 1: Smooth, round objects are a challenge to remove from the ear. Suction applied with a piece of soft tubing may be effective.

Rationale 2: Instilling lidocaine would be ineffective.

Rationale 3: Mineral oil would make the bead slick and more difficult to remove.

Rationale 4: Forceps would not grasp the bead and could damage the ear canal if force is applied.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 63-7

Question 20

Type: MCSA

A 25-year-old patient has had surgery for a cochlear implant. Which statement by a family member does the nurse evaluate as indicating understanding about this device?

1. A cochlear implant wont replace normal hearing; it will improve sound perception.

2. It will be much nicer than a hearing aid, as nothing needs to be worn or will be visible.

3. The speaking voice will improve too.

4. These are so easy to use that she will be hearing well very soon.

Correct Answer: 1

Rationale 1: A cochlear implant assists in restoring sound perception but does not replace normal hearing.

Rationale 2: The cochlear implant is placed under the skin behind the ear and is visible.

Rationale 3: At this patients age, it is not likely that voice quality will be improved.

Rationale 4: Several months of training with an audiologist and speech pathologist are needed to learn to interpret sounds.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 63-7

Question 21

Type: MCSA

The nurse knows that a patient may develop sensorineural hearing loss as a result of ototoxic drugs. Which patient would be at highest risk for this type of hearing deficit?

1. A patient with methicillin-resistant Staphylococcus aureus (MRSA) on high doses of vancomycin (Vancocin)

2. A patient on low-dose aspirin to prevent stroke

3. A patient on steroids (Prednisone) for chronic spondylolisthesis

4. A patient using atorvastatin (Lipitor) to prevent heart disease and stroke

Correct Answer: 1

Rationale 1: Ototoxic drugs damage the hair cells of the organ of Corti, resulting in sensorineural hearing loss. Vancomycin is ototoxic.

Rationale 2: Aspirin is ototoxic, but low doses are not high risk.

Rationale 3: Steroids are not ototoxic.

Rationale 4: Atorvastatin is not ototoxic.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 63-2

Question 22

Type: MCSA

A patient with a sore throat and head cold is complaining of trouble with hearing. The nurse should conduct additional assessment for which most likely condition?

1. Swimmers ear

2. A middle ear infection

3. Otosclerosis

4. An inner ear infection

Correct Answer: 2

Rationale 1: Swimmers ear does not manifest with symptoms of head cold, sore throat, and auditory compromise.

Rationale 2: Middle ear infections are often caused by a head cold that spreads. The cold may also cause a sore throat.

Rationale 3: Otosclerosis manifests with hearing loss but does not cause sore throat and head cold symptoms.

Rationale 4: Inner ear infections usually cause vertigo, which is not indicated in this patients complaint.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 63-4

Question 23

Type: MCSA

During a Weber test, a patient is found to have increased hearing in the right ear. The nurse realizes that this finding is consistent with which condition?

1. Normal aging

2. Conductive hearing loss in the left ear

3. Possible buildup of cerumen or otitis media in the right ear

4. Perforated left eardrum

Correct Answer: 3

Rationale 1: Lateralization is not associated with normal aging.

Rationale 2: If the patient has conductive hearing loss, the sound will lateralize to the ear with the loss because sound is being conducted directly through the bone to the ear. So if this patients loss were conductive, the loss would be in the right ear, not the left.

Rationale 3: A buildup of cerumen or otitis media in the ear can cause conductive hearing loss. In the Weber test, sound is lateralized to the ear with the conductive loss.

Rationale 4: Perforation of the left eardrum would result in a conductive hearing loss. In the Weber test, sound lateralizes to the ear with the conductive loss.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 63-4

Question 24

Type: MCSA

Which hearing assessment is the nurse performing in this image?

1. Rinne test

2. Tympanogram

3. Schwabach test

4. Weber test

Correct Answer: 4

Rationale 1: In the Rinne test, a vibrating tuning fork is placed on the patients mastoid bone to determine the conduction of sound by bone and air conduction.

Rationale 2: A tympanogram is conducted by inserting the measuring device into the ear canal.

Rationale 3: The Schwabach test is done by placing an activated tuning fork on the mastoid process of first the patient and then the examiner.

Rationale 4: The Weber test is performed by placing the base of a vibrating tuning fork on the midline vertex of the patients head. Sound should normally be heard equally in both ears.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 63-7

Question 25

Type: MCSA

Which nursing diagnosis is the top priority for a patient complaining of dizziness and disequilibrium with head movements?

1. Fluid Volume Deficit

2. Impaired Adjustment

3. Ineffective Coping

4. Risk for Injury

Correct Answer: 4

Rationale 1: Not enough information is given in the question to determine if the symptoms of dizziness and disequilibrium are due to a fluid imbalance.

Rationale 2: Impaired Adjustment is defined as a disability requiring a change in lifestyle, characterized by inadequate support system, impaired cognition, sensory overload assault to self-esteem, altered loss of control, or incomplete grieving. This NANDA diagnosis does not apply to the physical symptoms of dizziness and disequilibrium.

Rationale 3: Ineffective Coping is defined as an inability or incomplete ability to deal with stressors and/or to apply strategies to deal with stress or a perceived threat. This is not the priority diagnosis for this patient.

Rationale 4: Dizziness and disequilibrium, caused by changes within the vestibule and semicircular canals of the inner ear, create a risk for potential injury from falling from loss of balance. This is the top priority for this patient.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 63-7

Question 26

Type: MCMA

A patient diagnosed with swimmers ear says, I havent been swimming in 2 years. How should the nurse respond to this statement?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Let me recheck your chart to be certain I did not misinterpret the diagnosis.

2. You must have gotten lots of water in your ear while showering.

3. Swimmers ear is usually a bacterial infection.

4. Swimmers ear can be caused by wearing ear plugs, earphones, or earbuds.

5. Swimmers ear is the common name for otitis externa, which has many causes.

Correct Answer: 4,5

Rationale 1: There is probably no misinterpretation of the diagnosis.

Rationale 2: Swimmers ear does not require exposure of the ear to water.

Rationale 3: This is true, but it does not address the patients concern.

Rationale 4: Swimmers ear can be caused by the insertion of any object into the ear canal.

Rationale 5: Swimmers ear is the common name for otitis externa. The nurse should also explain that swimming is not the only causative factor for this disorder.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 63-4

Question 27

Type: MCMA

During an otoscopic examination, the nurse notes a number of lumps in the patients ear canal. Which assessment questions should the nurse ask?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Have you noticed that you are not hearing as well?

2. Have you ever spent time in saltwater?

3. Do you frequently wear earbuds or earphones?

4. Have you ever been a surfer?

5. Do you clean your ear with a cotton-tipped applicator?

Correct Answer: 1,2,4

Rationale 1: Exostosis, the condition that causes bony overgrowth into the ear canal, can result in hearing loss.

Rationale 2: Exostosis, the condition that causes bony overgrowth into the ear canal, is linked to saltwater exposure.

Rationale 3: There is no connection between the condition that causes these bony overgrowths and the use of earbuds or earphones.

Rationale 4: Surfers experience this condition, known as exostosis, due to exposure to cold and saltwater.

Rationale 5: The use of cotton-tipped applicators is not associated with these bony overgrowths.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 63-4

Question 28

Type: MCMA

A mother brings a 4-year-old into the emergency department and reports that the child put a piece of unpopped popcorn in the ear. Which equipment should the nurse collect to treat this condition?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. An otoscope

2. Mineral oil

3. Irrigation supplies

4. Suction equipment

5. Liquid soap

Correct Answer: 1,4

Rationale 1: The first action should be to check the ear canal to see if the foreign object is still there.

Rationale 2: Mineral oil would make the popcorn slippery and may make it swell.

Rationale 3: Irrigation is not the recommended method of removal of a seed such as an unpopped corn kernel because liquids could make the seed swell.

Rationale 4: It is sometimes possible to remove hard objects with gentle suction.

Rationale 5: There is no indication that liquid soap would be helpful in removing this foreign object.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 63-7

Question 29

Type: MCMA

A child has been diagnosed with perforation of the tympanic membrane (TM) secondary to a middle ear infection. What discharge information should the nurse provide the parents?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Your childs hearing loss will probably be permanent.

2. Keep the ear canal dry.

3. The eardrum will probably heal well on its own.

4. You will need to call an ear surgeon for an appointment to repair this perforation.

5. Most perforations indicate congenital weakness in the eardrum, so this is likely to occur again.

Correct Answer: 2,3

Rationale 1: If the perforation is small and heals well, hearing will likely return to normal.

Rationale 2: When the TM has been perforated, the ear canal must be kept dry. Fluid introduced into the canal can enter the middle ear.

Rationale 3: The TM generally heals within a few months with no further intervention.

Rationale 4: Surgery is rarely needed to repair perforation of the TM.

Rationale 5: The perforations are generally caused by pressure from middle ear infections or from trauma and do not indicate congenital weakness of the eardrum.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 63-5

Question 30

Type: MCSA

An infant is born with low-set ears. What important information should the nurse provide the parents?

1. Low-set ears are often a family characteristic.

2. Genetic testing will be required.

3. Once the baby is older, plastic surgery can improve the appearance of the ears.

4. As long as hearing is intact, ear position is not important.

Correct Answer: 2

Rationale 1: This is not the most important information the nurse can give the parents.

Rationale 2: Low-set ears are often an indicator of genetic disorders. Testing should be done.

Rationale 3: Appearance is not the most important factor associated with low-set ears.

Rationale 4: Ear position can indicate other disorders.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 63-4

Question 31

Type: MCMA

A child is at risk of developing mastoiditis due to a severe middle ear infection. The nurse would teach the parents that it is important to report which signs?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Sudden increase in fever

2. Redness behind the ear

3. Ear sticking out more than normal

4. Redness of the throat

5. Dizziness

Correct Answer: 1,2,3,5

Rationale 1: Mastoiditis is another source of infection and inflammation, so fever may increase suddenly.

Rationale 2: Redness behind the ear may indicate that the mastoid bone in infected.

Rationale 3: Sticking out of the ear is caused by swelling of the tissues around the mastoid bone.

Rationale 4: Redness of the throat is not specifically associated with mastoiditis.

Rationale 5: The child with mastoiditis may report changes in position sense.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 63-7

Question 32

Type: MCMA

A patient has been diagnosed with a balance disorder that is expected to clear on its own in a few weeks. Which safety information should the nurse provide?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Use a stepladder to get things off high shelves instead of reaching up over your head.

2. Dont pick up objects from the floor.

3. Do not drink alcohol until your condition passes.

4. Have someone put nonslip surfaces in the floor of your shower.

5. Be certain to drink enough fluids while you are sick.

Correct Answer: 3,4,5

Rationale 1: This patient should not climb a stepladder.

Rationale 2: This statement is unrealistic in that picking up objects from the floor, such as shoes or clothing, is part of everyday life. The nurse should teach the patient a method of picking up these objects safely, such as using an assistive device.

Rationale 3: Alcohol can cause vertigo and should be avoided.

Rationale 4: The patient is at risk for falls, and nonslip surfaces can make slick surfaces such as the shower floor less of a hazard.

Rationale 5: Dehydration can cause vertigo, so the patient should stay well hydrated.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 63-5

Question 33

Type: MCMA

The nurse is assessing a 75-year-old patient. Which patient statements would alert the nurse that the patient may have presbycusis?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. I have lots of earwax in my left ear.

2. My ears ring all the time.

3. I have a hard time hearing my granddaughters voice.

4. I just cant hear when the room is noisy.

5. I woke up this morning unable to hear out my left ear.

Correct Answer: 2,3,4

Rationale 1: Presbycusis is usually sensorineural in origin. Excessive earwax causes a correctable conductive hearing loss.

Rationale 2: Tinnitus is common in those diagnosed with presbycusis.

Rationale 3: High-pitched sounds, such as those produced by young females, are often the first tones to be lost when presbycusis is present.

Rationale 4: Inability to hear when there is a lot of background noise is a symptom of presbycusis.

Rationale 5: Presbycusis is a slowly developing condition. Sudden hearing loss is not an expected finding.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 63-6

Question 34

Type: MCMA

The nurse is reviewing the laboratory results of an elderly female patient who complains of being dizzy. Which laboratory results would the nurse evaluate as a possible cause of this condition?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Potassium of 3.4 mEq/L

2. Sodium level of 131 mEq/L

3. Blood glucose of 75 mg/dL

4. BUN of 26 mg/dL

5. Hematocrit of 40%

Correct Answer: 1,2,3

Rationale 1: A low potassium level can cause light-headedness.

Rationale 2: A low sodium level can cause light-headedness.

Rationale 3: Blood glucose of 75 mg/dL is on the low side of normal. If this is lower than the patients normal glucose, dizziness may occur.

Rationale 4: BUN of 26 is slightly elevated but would not be likely to cause dizziness.

Rationale 5: A hematocrit of 40% is normal for a female.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 63-6

Question 35

Type: MCMA

The nurse is holding a community educational session for parents of toddlers. Which guidelines should the nurse discuss to promote healthy ears and hearing in these children?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Clean the childs ear canal with the finger.

2. Avoid taking the child to places where the noise level is high.

3. Teach the child the importance of wearing a helmet when riding a bike.

4. Rinse the childs hair with a weak saltwater solution after shampooing.

5. When flying, give the child something to drink during landings.

Correct Answer: 2,3,5

Rationale 1: Nothing, not even fingers, should be inserted in the ear canal.

Rationale 2: A high noise level may damage the childs ears.

Rationale 3: Children should be taught to always wear a snug-fitting helmet when riding a bike.

Rationale 4: The hair should be rinsed with clean water.

Rationale 5: Swallowing equalizes the pressure within the ears during landing.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 63-3

 

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