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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.
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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 community group about noise-induced hearing loss. Which client who does not use ear protection should the nurse refer to an audiologist as the priority?
- A. Client with an hour car commute on the freeway each day.
- B. Client who rides a motorcycle daily.
- C. Client who sat in the back at a rock concert recently.
- D. Client who uses a chainsaw for 6 to 7 hours a day.
Correct Answer: D
Rationale: A chainsaw becomes dangerous to hearing after 2 hours of exposure without hearing protection. This client needs to be referred as the priority. Normal car traffic is safe for longer than 2 hours. Motorcycle noise is safe for about 8 hours. The safe exposure time for a front-row rock concert seat is 3 minutes, but this client was in the back, and so had less exposure. In addition, a one-time exposure is less damaging than chronic exposure.
A hospitalized client has Ménière's disease. What menu selections demonstrate good knowledge of the recommended diet for this disorder? (Select all that apply.)
- A. Chinese stir fry with vegetables.
- B. Broiled chicken breast.
- C. Chocolate espresso cookies.
- D. Chili with tortilla chips.
- E. Green herbal tea with meals.
Correct Answer: B,E
Rationale: The diet recommendations for Ménière's disease include low-sodium, caffeine-free foods and fluids distributed evenly throughout the day. Plenty of water is also needed. The broiled chicken breast and herbal tea are the best selections. The stir fry is high in sodium and possibly monosodium glutamate (MSG, also not recommended). The cookies and chili with tortilla chips are high in sodium.
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.
During ear irrigation, what action should the nurse take if the client becomes nauseated?
- A. Continue the procedure slowly.
- B. Stop the procedure immediately.
- C. Administer an antiemetic medication.
- D. Encourage the client to breathe deeply.
Correct Answer: B
Rationale: During ear irrigation, if the client becomes nauseated, the nurse should stop the procedure immediately to prevent further discomfort or complications. The other options are not appropriate in this context.