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A nursing student is presenting a report on M?©ni?¨re disease to other members of the class. What symptom would the student list?
- A. Pinkish-orange eardrum
- B. Nystagmus of the eyes
- C. Enlarged lymph nodes behind the ear
- D. Swelling and redness in the auditory canal
Correct Answer: B
Rationale: Nystagmus of the eyes may occur in a client with M?©ni?¨re disease caused by an imbalance in vestibular control of eye movements. Pinkish-orange eardrums, enlarged lymph nodes, or swelling and redness in the auditory canal are not observed in a client with M?©ni?¨re disease.
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The nurse is instructing a client's family members on the most incapacitating symptom of M?©ni?¨re disease. Which nursing instruction associated with the symptom is most helpful?
- A. Assist the client when ambulating.
- B. Keep a bucket beside the bed.
- C. Ensure low lighting in the room.
- D. Sit in front of the client when speaking.
Correct Answer: A
Rationale: The most incapacitating symptom of M?©ni?¨re disease is vertigo. When the client is experiencing vertigo or dizziness, gait becomes unsteady. Having a person assist the client when ambulating is most helpful in preventing falls. Keeping a bucket at the bedside is helpful if the client is experiencing nausea. Photophobia is not a main symptom of M?©ni?¨re disease. If the client experiences hearing loss, being able to see the nurse's lips may be helpful.
Which symptom reported by a client would the nurse relate to a tentative diagnosis of objective vertigo?
- A. Frequency of a headache
- B. Pain in the outer ear
- C. Hearing ability fluctuations
- D. A sensation of things moving
Correct Answer: D
Rationale: Objective vertigo includes the sensation that the environment is moving or a sense that things are moving around oneself. The symptoms do not include a headache, pain in the outer ear, or difficulty hearing.
A nurse anticipates that an 8-year-old client has otitis externa from symptoms stated on the history. Which symptom(s), from the history and physical examination, would confirm the diagnosis? Select all that apply.
- A. Discomfort in the ear
- B. Redness of the ear canal
- C. Pus noted in the ear canal
- D. Conductive hearing loss
- E. Tympanic membrane may appear normal
Correct Answer: A,B,C,D,E
Rationale: The diagnosis of otitis externa (inflammation of the tissue of the outer ear) is confirmed by reports of pain, discharge from the external auditory canal, aural tenderness (usually not present in middle ear infections), and occasionally fever, cellulitis, and lymphadenopathy. Other symptoms may include pruritus and conductive hearing loss or a feeling of fullness in the ear. On otoscopic examination, the ear canal is erythematous and edematous. Discharge may be yellow or green and foul smelling. In fungal infections, hairlike black spores may be visible.
A client comes to the walk-in clinic reporting feeling a 'bug in my ear.' What action should be taken when there is an insect in the ear?
- A. Instillation of mineral oil
- B. Instillation of carbamide peroxide
- C. Instillation of hot water
- D. Use of a small forceps
Correct Answer: A
Rationale: Mineral oil is instilled into the ear to smother an insect. Carbamide peroxide is used to soften dried cerumen, and small forceps are used to remove solid objects. Hot liquids cause dizziness and should not be instilled in the ear.
The nurse is caring for a client with symptoms of ototoxicity from aminoglycoside administration. On which structure does the medication produce the ototoxic effect?
- A. The auditory canal
- B. The eighth cranial nerve
- C. The tympanic membrane
- D. The cochlear nerve
Correct Answer: B
Rationale: Ototoxicity describes the detrimental effect of aminoglycosides on the eighth cranial nerve. Signs and symptoms include tinnitus and sensorineural bearing. The other options are not related to the ototoxic effects.