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An older adult in the family practice clinic reports a decrease in hearing over a week. What action by the nurse is most appropriate?
- A. Assess for cerumen buildup.
- B. Applying ice four times a day
- C. Perform tuning fork tests.
- D. Review the medication list.
Correct Answer: A
Rationale: All options are possible actions for the client with hearing loss. The first action the nurse should take is to assess for cerumen buildup, as it is a common cause of sudden hearing loss in older adults. The other actions may follow but are not the priority.
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The student nurse is performing a Weber tuning fork test. What technique is most appropriate?
- A. Holding the vibrating tuning fork 10 to 12 inches from the clients ear
- B. Placing the vibrating fork in the middle of the clients head
- C. Placing the vibrating fork in the middle of the clients head
- D. Tapping the vibrating tuning fork against the bridge of the nose
Correct Answer: B
Rationale: The Weber tuning fork test involves placing the vibrating tuning fork in the middle of the client's head and asking in which ear the client hears the vibrations loudest. The other techniques are incorrect.
The clients chart indicates a sensorineural hearing loss. What assessment question does the nurse ask to determine the possible cause?
- A. Do you feel like something is in your ear?
- B. Do you have frequent ear infections?
- C. Have you been exposed to loud noises?
- D. Have you been told your ear bones don't move?
Correct Answer: C
Rationale: Sensorineural hearing loss can occur from damage to the cochlea, the eighth cranial nerve, or the brain. Exposure to loud noises is one etiology. The other questions relate to conductive hearing loss.
A nursing student is instructed to remove a clients ear packing and instill eardrops. What action by the student requires intervention by the registered nurse?
- A. Assessing the eardrum with an otoscope.
- B. Warming the eardrops in water for 5 minutes.
- C. Using a cotton swab to clean the ear canal.
- D. Instilling eardrops at room temperature.
Correct Answer: A
Rationale: Assessing the eardrum with an otoscope requires specialized training and is not within the scope of a nursing student. Warming eardrops and instilling them at room temperature are appropriate. Using a cotton swab is not ideal but does not require immediate intervention.
A nurse is teaching a client about ear hygiene and health. What client statement indicates a need for further teaching?
- A. A soft cotton swab is alright to clean my ears with.
- B. I make sure my ears are dry after I go swimming.
- C. I stop good ear plugs when I practice with the band.
- D. Keeping my diabetes under control helps my ears.
Correct Answer: A
Rationale: Clients should be taught not to put anything larger than their fingertip into their ears. Using a cotton swab, although soft, can cause damage to the ears and cerumen buildup. The other statements are accurate.
A client has Ménière's disease with frequent attacks. About what drugs does the nurse plan to teach the client? (Select all that apply.)
- A. Broad-spectrum antibiotics
- B. Chlorpromazine hydrochloride (Thorazine)
- C. Diphenhydramine (Benadryl)
- D. Meclizine (Antivert)
- E. Nonsteroidal anti-inflammatory drug (NSAID)
Correct Answer: B,C,D
Rationale: Drugs such as chlorpromazine, diphenhydramine, and meclizine can all be used to treat Ménière's disease. Antibiotics and NSAIDs are not used.