![]() Nerve damage from listening to loud music c. The patient undergoing a Weber test says that the sound is louder in her left ear. 1246 OBJ: 2 TOP: Rinne Test KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance: Prevention and early detection of disease 10. The normal finding for the Rinne test is that AC is greater than BC (AC>BC). Cochlear defect ANS: A When the bone conduction (BC) is greater than the air conduction (AC), the results of the Rinne test will read, BC>AC, which means the patient has a conductive hearing loss. The nurse translates this to mean that the patient has: a. The nurse assessing the results of a Rinne test sees the notation of BC >AC. 1245 OBJ: 4 TOP: Testing for Ear Disorders KEY: Nursing Process Step: Planning MSC: NCLEX: Health Promotion and Maintenance: Prevention and early detection of disease 9. DIF: Cognitive Level: Comprehension REF: p. Coffee and tea should also be avoided before the test. Nothing to eat or drink (NPO) 3 hours before the test ANS: D Electronystagmography is used to detect vestibular lesions and requires a 3-hour period of NPO before the test. Use of tea or coffee on the morning of test b. The nursing instruction for this test will include: a. When a patient has a suspected vestibular disorder, the physician orders an electronystagmography test. 1243 OBJ: 7 TOP: Audiometry KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Prevention and early detection of disease 8. The other specialists treatment ear, nose, and throat (ENT) disorders. Audiologist ANS: D Audiologists assess patients for hearing aids. The clinic nurse makes arrangements for an evaluation for a hearing aid by an: a. The patient reports her hearing loss has become more severe over the last 3 months. 1241 OBJ: 5 TOP: External Auditory Canal KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity: Physiological adaptation 7. Cleaning ears with something like an applicator will pack the cerumen in the canal. Pearly tympanic membrane ANS: C Obstruction of the external canal with cerumen will result in a hearing loss. On examining her ears, the nurse anticipates: a. The 75-year-old patient complains to the nurse that although she has cleaned her ears with cotton-tipped applicators for weeks, she still cannot hear her television unless the volume is loud and she misses a great deal of conversations. ![]() 1254 OBJ: 1 TOP: Gentamicin KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity: Pharmacological therapies 6. Gentamicin is ototoxic and can cause hearing impairment. ![]() ANS: C Reduced urine output would cause the drug to stay in the system rather than being excreted, which could result in a drug saturation. Because the 94-year-old patient is receiving gentamicin sulfate (Garamycin) in a continuous intravenous (IV) infusion, the nurse will add to the nursing care plan the diagnosis, "Risk for injury" and will make implementation of: a. 1243 OBJ: 1 TOP: Hearing Assessment: Medical History KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance: Prevention and early detection of disease 5. Presbycusis ANS: A A sinus infection can be an acute cause of hearing deficits and can create problems with balance. When making the initial assessment on a patient with a hearing deficit, the patient reports that he often feels off balance and is dizzy when he stands up. 1241 OBJ: 5 TOP: Age-Related Changes KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity: Physiological adaptation 4. DIF: Cognitive Level: Application REF: p. The other three options are normal age-related changes. Hair in the ear canal ANS: B Otitis externa is an outer ear infection and therefore an exception. The 75-year-old patient has normal age-related changes in his ear that include all except: a. ![]() 1245 OBJ: 2 TOP: Caloric Test KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance: Prevention and early detection of disease 3. Nystagmus ANS: D When warm or cold water is introduced into the ear, the appearance of nystagmus is a positive indication that the hearing problem has its cause in the labyrinth. The nurse assisting with a caloric test notes the specific patient response that indicates that the hearing disorder is a problem in the labyrinth, which is: a. 1242 OBJ: 5 TOP: Definitions KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity: Physiological adaptation 2. ![]() Ringing in ears ANS: C Otic- is the root word for ear, and -algia is the root term for pain of any type. When the nurse reads in the patient's history that the patient has experienced otalgia, the nurse knows that the patient has: a. ![]()
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