Nokea
The nurse is caring for a client who just returned from a trip requiring an airline flight. The client reported ear pain upon descent. The nurse is correct in stating which site as being the pressure equalizer in the ear?
- A. Eustachian tube
- B. Auricle
- C. Tympanic membrane
- D. Labyrinth
Correct Answer: A
Rationale: The eustachian tube extends from the floor of the middle ear to the pharynx. It equalizes air pressure in the middle ear. The auricle is the fleshy portion of the outer ear which funnels sound waves to the inner ear. The tympanic membrane is the eardrum. The labyrinth is the inner ear which contains fluid.
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The client is consulting with a physician regarding a potential diagnosis of M?©ni?¨re disease. The nurse is assisting in positional testing and documentation. Which diagnostic test would the nurse anticipate to obtain a more precise evaluation of vestibular function?
- A. Audiometry
- B. Electronystagmography
- C. Caloric stimulation test
- D. Romberg test
Correct Answer: B
Rationale: The electronystagmography is a more precise method for evaluation vestibular function. It is performed in conjunction with caloric stimulation. When the fluid is instilled in the ear, a machine records the duration and velocity of eye movements with electrodes attached around the eye. Audiometry measures hearing acuity. The Romberg test measures balance.
The nurse is establishing a visual test using the Snellen chart for a client experiencing visual changes. At which distance should the nurse instruct the client to stand?
- A. A 10-feet distance
- B. A 20-feet distance
- C. A 30-feet distance
- D. A 40-feet distance
Correct Answer: B
Rationale: The nurse is correct in instructing the client to stand at a 20-feet distance from the Snellen chart. Often, the nurse places tape on the floor to denote the correct distance for the client to stand.
A client is having problems with dizziness and complains of the 'room spinning.' The physician performs the caloric stimulation test. The nurse knows that a diminished response in one eye during the caloric stimulation test is indicative of what?
- A. Inner ear disorder
- B. Middle ear disorder
- C. Outer ear disorder
- D. Age-related macular degeneration
Correct Answer: A
Rationale: During the caloric stimulation test, a diminished response in one eye is significant for an inner ear disorder such as M?©ni?¨re disease. It does not signify a middle ear disorder, an outer ear disorder, or age-related macular degeneration.
The nurse is evaluating the client taking the color vision test. Which response would the nurse anticipate when caring for a client with normal color vision?
- A. The nurse would anticipate the client identifying numbers and shapes.
- B. The nurse would anticipate a cross-eyed appearance.
- C. The nurse would anticipate responding to the color names in the pictures.
- D. The nurse would anticipate no differentiation in between colors.
Correct Answer: A
Rationale: The nurse is correct to anticipate the client being able to identify numbers and shapes dictated by different color codes. The other options do not test for color vision or indicate an inability to differentiate colors.
What is located in the cochlea of the inner ear?
- A. Semicircular canals
- B. Labyrinth
- C. Vestibulocochlear nerve
- D. Organ of Corti
Correct Answer: D
Rationale: The fluid motion created by the vibrating stapes excites the nerve endings in the sensitive sound receptors of the organ of Corti located in the cochlea. The labyrinth is the name for the inner ear, and the semicircular canals and vestibulocochlear nerves are other components of the inner ear.