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The nurse is caring for a client in the triage section of a walk-in clinic. Which triad of common symptoms suggests a diagnosis of M?©ni?¨re disease?
- A. Blurred vision, vertigo, nausea
- B. Syncope, vertigo, ear pain
- C. Disorientation, vertigo, nausea
- D. Hearing loss, vertigo, tinnitus
Correct Answer: D
Rationale: Hearing loss, vertigo, and tinnitus are common symptoms of many disease processes but, when placed together, indicate M?©ni?¨re disease. The other options do not include the accurate triad of symptoms.
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The nurse, employed in an ear, nose, and throat (ENT) physician's office, is obtaining a client history. The nurse documents the client's statements. Which symptom(s) may indicate a diagnosis of otosclerosis? Select all that apply.
- A. It seems that I increasingly could not hear my kids talk to me.'
- B. I woke up on Monday and had ear pain with a marked decrease in hearing.'
- C. I now notice a ringing in my ears especially when I lay down to sleep at night.'
- D. I can hear better when someone speaks in low tones.'
- E. I can hear best when you put the tuning fork behind my ear.'
Correct Answer: A,C,E
Rationale: Although the cause of otosclerosis is unknown, there are specific symptoms because of the interference of the vibrations in the ear. The symptoms of diagnosis of otosclerosis include a progressive, bilateral hearing loss; tinnitus especially noted at night; and the outcome of the Rinne test as being that sound is heard best with the tuning fork behind the ear. The nurse would not identify an abrupt onset of hearing loss or improvement of hearing in low tones.
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.
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.
The nurse is caring for a client who is post-stapedectomy. What would the nurse include in the nursing care?
- A. Place the client on the operative side.
- B. Keep the affected ear packed with cotton.
- C. Encourage the client to exercise within 24 hours.
- D. Assess the facial nerve.
Correct Answer: D
Rationale: After surgery, the nurse positions the client on the nonoperative side and takes care to prevent dislodgment of the prosthesis as a result of coughing, sneezing, or vomiting. Nausea and dizziness are common problems. The nurse assesses facial nerve function by checking symmetry when the client smiles or frowns. The nurse does not keep the ear packed with cotton or encourage the client to exercise.
The nurse is obtaining a history from a client complaining of ear pain and dizziness. Which assessment finding is the best evidence that the client has a perforated eardrum?
- A. Fluid draining in the external canal
- B. Pain has resolved
- C. Elevated white blood cell count
- D. Inflammation and a reddened eardrum
Correct Answer: A
Rationale: Noting the actual fluid in the ear canal alerts the nurse to the fact that there is a perforation in the tympanic membrane. The other options are also signs of a perforation but also signs of otitis media without perforation.