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Which symptom reported by a client would the nurse relate to a tentative diagnosis of objective vertigo?
- A. Frequency of a headache
- B. Pain in the outer ear
- C. Hearing ability fluctuations
- D. A sensation of things moving
Correct Answer: D
Rationale: Objective vertigo includes the sensation that the environment is moving or a sense that things are moving around oneself. The symptoms do not include a headache, pain in the outer ear, or difficulty hearing.
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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 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.
The nurse is evaluating the independent care of a client recovering from a stapedectomy. Which action made by the client indicates a need for further teaching?
- A. The client turns head slowly when family approaches.
- B. The client uses clean technique to clean the wound.
- C. The client takes antibiotics on schedule
- D. The client asks for assistance upon ambulation.
Correct Answer: B
Rationale: The client needs further instructions on using aseptic technique when completing wound care. Using aseptic technique reduces the introduction and transmission of microorganisms and protects the client from introduction of pathogens. The other options are appropriate actions for the client recovering from a stapedectomy to take.
The nurse is caring for a client with recurrent ear infections. The nurse assesses the client for further infectious processes traveling deeper into the tissue and becoming more lethal. Which infection, originated in the ear, is of most concern?
- A. Mastoiditis
- B. Meningitis
- C. Sinusitis
- D. Labyrinthitis
Correct Answer: B
Rationale: The infection stemming from the ear may extend to the meninges, causing meningitis, or a brain abscess could occur. This could be life threatening. The other options are also potential complications of an ear infection but not as much of a concern as meningitis.
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.