Nokea
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.
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The nurse is instructing a client on the benefits of a cochlear implant. The client asks, 'How am I able to interpret sound?' The nurse credits which of the following as significant in the production of hearing?
- A. External microphone
- B. Internal processor
- C. Amplifier
- D. Auditory nerve
Correct Answer: D
Rationale: The nurse credits stimulation of the auditory nerve in the transmission of the electrical signals to the brain for interpretation. The external processor and internal processor bring the sounds from the environment and send them to the internal processor, which converts to the electrical signal. An amplifier is used with typical hearing aids.
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, 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.
Which nursing suggestion would be most helpful to the client with recurrent otitis externa?
- A. Use a cotton applicator to ensure that the ear canal is dry.
- B. Place ear plugs into the ears before swimming
- C. Flush the ear with hydrogen peroxide
- D. Avoid lying on the side of the affected ear
Correct Answer: B
Rationale: The nurse instructs the client to carry out the medical treatment and provides health teaching to prevent recurrence. For example, the nurse advises swimmers to wear soft plastic ear plugs to prevent trapping water in the ear. A cotton tip applicator should not be placed into the ear canal because it could perforate the eardrum. Above all, the nurse advises the client to avoid the use of nonprescription remedies unless they have been approved by the physician and to contact the physician if symptoms are not relieved in a few days.
The nurse is caring for a client experiencing hearing loss. The nurse uses the otoscope to assess the ear canal and tympanic membrane and notes a significant accumulation of cerumen. Which documentation of hearing loss type would be accurate?
- A. Conductive
- B. Mixed
- C. Central
- D. Sensorineural
Correct Answer: A
Rationale: Conductive hearing loss occurs from an obstruction in the outer or middle ear such as from cerumen. Mixed hearing loss is a combination of conductive and sensorineural problems. Central hearing loss involves injury or damage to the nerves or the nuclei of the central nervous system. Sensorineural involves damage to the inner ear.