Question 1

The nurse is instructing a patient who has a hearing and balance disorder. Which guidelines should the nurse discuss?. Select all that apply.

Accepted Answer

The nurse should instruct the patient to change positions slowly, avoid bending over to pick things up, use two or more pillows at night, and sit on the edge of the bed for a few moments when arising. These guidelines will help prevent falls and minimize vertigo episodes. Standing very still when vertigo occurs may actually worsen the symptoms, so it is not a recommended guideline.

Question 2

A patient complains of feeling "off balance." The nurse should consider that the patient might have a disorder affecting which structure?

Accepted Answer

The vestibular system is responsible for maintaining balance and spatial orientation, so a patient complaining of feeling "off balance" may have a disorder affecting this structure. The Organ of Corti, middle ear, and cochlea are all part of the auditory system and would not necessarily be related to balance issues.

Question 3

The nurse is working with a patient newly diagnosed with benign paroxysmal positional vertigo (BPPV). Which instruction should the nurse provide for this patient?

Accepted Answer

The nurse should provide instruction on modifications in daily activities, such as avoiding abrupt head movements and sleeping with the head elevated to help relieve symptoms of BPPV. Bed rest is not necessary and medication is not typically used to treat BPPV. BPPV is usually a self-limited disorder that resolves over time, so adapting to a long-term balance disorder is not typically necessary.

Question 4

A patient tells the nurse that the only way he can adequately clean his ears is with a cotton-tipped applicator. What is the nurse's best action regarding this statement?

Accepted Answer

The nurse's best action is to educate the patient about the danger of using cotton-tipped applicators for cleaning the ears. This is because the use of cotton-tipped applicators can push earwax or debris further into the ear canal, leading to injury or infection. Using cotton-tipped applicators can also damage the delicate structures of the ear. Therefore, it is important for the nurse to provide patient education on this matter.

Question 5

A patient experiences an increase in ear pain when the auricle is pulled up and back. The nurse would conduct additional assessment for which condition?

Accepted Answer

Pulling up and back on the auricle is known as the "traction test," and if this maneuver reproduces pain, it is suggestive of otitis externa (inflammation of the outer ear canal). Otitis media (inflammation of the middle ear), labyrinthitis (inflammation of the inner ear), and exostosis (bony growth in the ear canal) would not typically cause increased pain with this maneuver.

Question 6

A patient is experiencing a severe episode of Ménière's disease. Which medication to help reduce the sensation of spinning and nausea does the nurse anticipate providing?. Select all that apply.

Accepted Answer

The answer of A patient is experiencing a severe episode...

Question 7

A patient is diagnosed with otosclerosis. The nurse plans interventions related to which type of hearing loss?

Accepted Answer

Otosclerosis is a condition in which the bone in the middle ear becomes overgrown and impairs the transmission of sound waves to the inner ear. This type of hearing loss is referred to as conductive.

Question 8

A patient diagnosed with profound noise-induced hearing loss (NIHL) states, "I am going to wear ear protection at work from now on. How long before my hearing gets better?" How should the nurse respond?

Accepted Answer

Profound NIHL is typically permanent and irreversible. While it is important to wear ear protection to prevent further damage, it will not reverse the existing damage. A patient with this type of hearing loss may benefit from assistive devices or hearing aids to improve communication and quality of life.

Question 9

A patient is admitted with a ruptured tympanic membrane (TM). This may result in a hearing loss due to the disruption of which function of the TM?

Accepted Answer

The tympanic membrane (TM) vibrates in response to sound waves, transmitting the vibrations to the inner ear. A rupture in the TM disrupts this function, resulting in hearing loss. The TM does not separate the outer and inner ear (A), cover the eustachian tube (C), or cover the mastoid process (D).

Question 10

Which physical assessment finding should the nurse anticipate in the patient with otosclerosis?

Accepted Answer

Otosclerosis is a condition that affects the bones of the middle ear, leading to conductive hearing loss. In this condition, bone conduction is often equal to or greater than air conduction, which is reflected in the Rinne test results.

Question 11

An older patient has been diagnosed with presbycusis. The nurse would plan interventions to address which kind of hearing loss that is a common result of aging?

Accepted Answer

Presbycusis is a type of hearing loss that occurs due to aging, and it is usually caused by damage to the hair cells of the inner ear or the auditory nerve. This type of hearing loss is called sensorineural because it affects the nerve pathways that transmit sound signals from the inner ear to the brain. Interventions for presbycusis may include hearing aids, cochlear implants, or assistive listening devices.

Question 12

A 25-year-old patient has had surgery for a cochlear implant. Which statement by a family member does the nurse evaluate as indicating understanding about this device?

Accepted Answer

A cochlear implant does not provide normal hearing, but it does improve sound perception. It is important for the family member to understand that the implant will not completely replace normal hearing. Option B is incorrect because a cochlear implant does require an external device that is visible. Option C is partially correct, as a cochlear implant may improve speech perception, but it does not necessarily improve the actual speaking voice. Option D is incorrect because although a cochlear implant is easy to use, it still requires an adjustment period and ongoing auditory rehabilitation to achieve optimal results.

Question 13

Which nursing diagnosis is a priority for a patient with severe symptoms of tinnitus, vertigo, sensorineural hearing deficit, nausea, and vomiting?

Accepted Answer

Disturbed Sensory Perception is the priority nursing diagnosis because the patient is experiencing severe symptoms related to their senses, including tinnitus, vertigo, and sensorineural hearing deficit. These symptoms can lead to difficulty with balance, communication, and overall quality of life. Additionally, the symptoms of nausea and vomiting can further impact the patient's ability to manage and cope with their condition. Therefore, addressing the patient's sensory deficits is crucial for their well-being and quality of life.

Question 14

Which nursing interventions are most appropriate for a patient with a nursing diagnosis of Impaired Verbal Communication related to hearing deficit?. Select all that apply.

Accepted Answer

The answer of Which nursing interventions are most appropriate for...

Question 15

A patient with chronic acute otitis media infections is having a myringotomy. What discharge instructions should the nurse provide?

Accepted Answer

After a myringotomy, the patient should avoid getting any water in the ear to prevent infection.

Question 16

A young child is being seen with an impaction of the ear canal caused by a large plastic bead. The nurse prepares to assist with which procedure to remove the bead?

Accepted Answer

The answer of A young child is being seen with...

Question 17

When taking a health history, the nurse asks a patient about taking over-the-counter medications. The patient reports taking large doses of aspirin to relieve daily headaches. This comment should alert the nurse to further assess the patient's hearing for which reason?

Accepted Answer

Aspirin can be ototoxic, meaning it can cause damage to the inner ear leading to hearing loss or tinnitus (ringing in the ears). Therefore, the nurse should assess the patient's hearing to monitor for any potential hearing problems that may be associated with the large doses of aspirin.

Question 18

The nurse is working with a patient who has just purchased hearing aids. Which instruction should be part of the nurse's teaching?

Accepted Answer

It is recommended to gradually increase the use of hearing aids, starting with a few hours a day and gradually increasing to full-time use. This allows the patient to adapt to the new sounds and prevent overwhelming stimulation. Options A and B are not recommended as the patient may miss important sounds if they only wear the devices when they think they need them or leave them on when not in use. Option D is not necessary as patients can usually change the batteries themselves.

Question 19

A nurse is working with a patient who experienced the sudden onset of dizziness, nausea, and hearing loss. A diagnosis of Ménière's disease has been made. How should the nurse instruct the patient?

Accepted Answer

The nurse should instruct the patient to avoid triggers that can exacerbate symptoms, such as tobacco, alcohol, and caffeine. Tranquilizers may be prescribed, but this is not the first-line treatment and should not be self-administered. OTC medications may not be effective or safe for the patient and may interact with prescribed medications. Staying in bed until symptoms subside is not an effective long-term solution and can lead to decreased mobility and independence.

Question 20

A diver is admitted complaining of ear pain and hearing loss. On examination, the nurse notes a rupture in the tympanic membrane. The nurse would conduct further assessment for which type of hearing loss?

Accepted Answer

Rupture in the tympanic membrane indicates damage to the middle ear, which is responsible for conducting sound vibrations to the inner ear. This type of hearing loss is known as conductive hearing loss.

Quiz 63: Caring for the Patient With Hearing and Balance Disorders