Preview Extract
Chapter 69
1. The nurse notes that the cerumen in a client’s ear may indicate an infection. The nurse
makes that assessment because the cerumen (earwax) is:
1. Hardened, dry, and foul-smelling.
2. Brown, wet, and sticky.
3. Dry, white, and flaky.
4. Absent.
Answer: Hardened, dry, and foul smelling.
Rationale:
Cerumen should be moist, and may vary in color from brown to white. Hardened, dry, or
foul-smelling cerumen may indicate an infection. In a majority of Asians and Native
Americans, cerumen is dry, white and flaky. In African Americans and Caucasians, cerumen
is brown, wet, and sticky. Cerumen lubricates the ear and is always present.
2. In a darkened room, the nurse uses a penlight against the client’s cheek to transluminate
through the roof of the mouth. A normal finding would be:
1. A faint glow can be seen through the bones.
2. There is no light transmission.
3. There is diminished light transmission.
4. Seen in absence of soft palate defects.
Answer: A faint glow can be seen through the bones.
Rationale:
The penlight against the client’s cheek is used to determine if the client has sinusitis. When
the sinuses are clear, there is a faint glow through the bones. If the client has sinusitis, there
will be absent or diminished light transmission. Soft plate defects can be seen by visual
inspection of the palate.
3. The nurse detects that a client has a fruity breath odor. A fruity breath odor commonly
occurs with:
1. Diabetic ketoacidosis.
2. Poor oral hygiene.
3. Liver failure.
4. End-stage renal disease.
Answer: Diabetic ketoacidosis
Rationale:
Fruity breath odor commonly occurs with clients who are malnourished or are in diabetic
ketoacidosis. Fetid breath (halitosis) may be a symptom of tooth decay, poor oral hygiene,
gum and tonsil disease, or sinus disease. A musty smell to the breath is the result of liver
failure and nitrogenous breakdown. The odor of ammonia is caused by end-stage renal
disease.
4. One area the nurse should focus on when interviewing a client about a current health
problem is otalgia. Otalgia is defined as:
1. Ear pain.
2. Dizziness.
3. Ringing in the ears.
4. Fainting.
Answer: Ear pain.
Rationale:
Otalgia is ear pain. Dizziness may be a symptom of vertigo. Ringing in the ears is tinnitus.
Syncope is defined as fainting.
5. One piece of equipment needed to monitor a client with nasal or sinus problems is a/an:
1. Oxygen saturation monitor.
2. Pneumatoscope.
3. Tuning fork.
4. Mallous.
Answer: Oxygen saturation monitor.
Rationale:
An oxygen saturation monitor should be used to monitor oxygenation routinely for any client
with a nasal or sinus problem. A pneumatoscope is used to determine if there is an eardrum
rupture. A tuning fork is used to determine hearing loss. A mallous is a bone in the ear.
6. Which of the following symptoms may also be an objective symptom?
1. Tinnitus
2. Vertigo
3. Otalgia
4. Presyncope
Correct answer: Tinnitus
Rationale:
Tinnitus is primarily a localized, internal auditory perception usually not heard by others.
However, objective tinnitus can be heard by others and is caused by vascular problems of the
carotid arteries or jugular veins. Vertigo is the illusion of rotational movement, tilting, or
swaying, with feelings of imbalance during standing and walking. The client has to report the
sensation. Otalgia is ear pain that only the client feels and must report. Presyncope is a
feeling of fainting.
7. A 45-year-old client is admitted complaining of vertigo, hearing loss, unilateral aural
fullness, and tinnitus. Based on the client’s age and symptoms, the nurse feels the client is
suffering from:
1. Meniere’s disease.
2. Bell’s palsy.
3. Otosclerosis.
4. Anosmia.
Answer: Meniere’s disease.
Rationale:
Meniere’s disease is a dysfunction of the labyrinth, with symptoms of vertigo, hearing loss,
unilateral aural fullness, and tinnitus. It is most common between the ages of 30 and 60.
Bell’s palsy is an inflammation of the seventh cranial nerve that results in asymmetric facial
movements. Otosclerosis is a familial disorder in which irregular ossification occurs in the
stapes of the middle ear, causing conductive deafness, sensorineural hearing loss, and
tinnitus. Anosmia is the complete loss of smell.
8. Recreational activities can place individuals at risk for developing head and neck
problems. A history of alcohol use is strongly associated with:
1. Head and neck cancer.
2. Anosmia.
3. Allergic rhinitis.
4. Epistaxis.
Answer: Head and neck cancer.
Rationale:
Alcohol use is strongly associated with head and neck cancer. Anosmia is the complete loss
of smell; it may result from radiation treatments for head and neck cancer. Allergic rhinitis is
an inflammation of the nasal mucosa caused by an allergic substance. Alcohol does not cause
allergic rhinitis. Epistaxis is a nosebleed and is not associated with alcohol use.
9. One-third of all hearing loss can be attributed to:
1. Occupational noise exposure.
2. Ototoxic medications.
3. Environmental exposure to toxins.
4. Otitis media.
Answer: Occupational noise exposure.
Rationale:
One-third of all hearing loss can be attributed to occupational noise exposure. Experiencing
occupational noise on an acute or chronic basis can cause bilateral sensorineural hearing loss
at high frequencies. Sources of occupational high levels of noise include chain saws and other
power tools, jets, diesel locomotives, and lawn mower engines. Ototoxic medications,
recurrent otitis media, and environmental exposure to toxins can cause hearing disorders, but
they do not account for one-third of all hearing losses.
10. A client is admitted with trauma of the XII cranial nerve. This injury could cause the
client to have difficulty:
1. Speaking.
2. Hearing.
3. Tasting.
4. Smelling.
Answer: Speaking.
Rationale:
Trauma to the XII cranial nerve can cause paralysis of the tongue and interfere with a client’s
ability to speak. The sense of hearing is controlled by cranial nerve VIII. Taste is controlled
by cranial nerve IV, and smell is controlled by cranial nerve I.
11. Many individuals in the deaf community often refuse genetic services because of a history
of stigmatization. This reluctance is the result of:
1. Cultural influence.
2. Ignorance regarding available services.
3. High rate of noncompliance of treatments.
4. Low predictive value of genetic testing.
Answer: Culture influence.
Rationale:
Many individuals in the deaf community refuse genetic services because they were
stigmatized in the past by the culture in which they lived. For example, at one time in the
United States, deaf individuals were sterilized and prohibited from marrying, and programs
were developed to extinguish their language. Ignorance of available services or high rate of
noncompliance of treatments is not a factor in their reluctance to be tested. Today, genetic
testing and services are very reliable.
12. A client who is a chef is diagnosed with nasal polyps. This disorder could directly affect
his occupation because of __________ resulting from the polyps.
1. Anosmia
2. Vertigo
3. Epistaxis
4. Otalgia
Answer: Anosmia
Rationale:
Nasal polyps can cause anosmia, which is a complete loss of smell. The sense of taste is also
affected by the ability to smell. Vertigo is an illusion of movement caused by disorders of the
ear. Epistaxis is a nosebleed that may occur with nasal polyps, but would not affect his
occupation. Otalgia is ear pain.
13. The Romberg test assesses the patient’s ability to maintain an upright posture with arms
out in front, with eyes open and closed. One purpose of this test is to assess for:
1. Inner ear balance.
2. Conductive hearing loss.
3. Abnormal nystagmus.
4. Gag reflex.
Answer: Inner ear balance.
Rationale:
The Romberg test assesses inner ear balance. Disorders of the inner ear affect equilibrium.
Conductive hearing loss is assessed by such instruments as a tuning fork. One test that can be
used to assess abnormal nystagmus is the caloric test. The gag reflex can be assessed by
palpating the back of the client’s oral cavity with a tongue blade.
14. A client is a member of a rock band and complains that the noise from the concerts has
caused a hearing loss that makes it is difficult to hear friends talking. Hearing loss as a result
from recreational noise:
1. Is probably not the cause of this hearing loss.
2. Is probably the cause of this hearing loss.
3. Is temporary.
4. Is rare.
Answer: Is probably not the cause of this hearing loss
Rationale:
Recreational noise can cause bilateral sensorineural hearing loss at higher frequencies (3,000
to 6,000 Hz). Normal speech is 512 to 1,024 Hz. Therefore, the noise from the concerts
would not cause a hearing loss that would interfere with hearing conversation. Hearing loss
from recreational noise is not temporary or rare.
15. The nurse performs the caloric test to assess the abnormal nystagmus, tinnitus, or hearing
loss that is the result of:
1. Vestibular dysfunction.
2. Ruptured tympanic membrane.
3. Chronic otitis externa.
4. Chronic sinusitis.
Answer: Vestibular dysfunction.
Rationale:
The caloric test can differentiate eight cranial nerve lesions that result in vestibular
dysfunction. Noise exposure and chronic otitis externa can cause hearing loss but the loss is
not due to vestibular dysfunction. A ruptured tympanic membrane and chronic otitius externa
do not cause nystaymus or tinnitus. Chronic sinusitis does not cause nystagmus, tinnitus, or
hearing loss.
Test Bank for Timby's Introductory Medical-Surgical Nursing
Loretta A Donnelly-Moreno, Brigitte Moseley
9781975172237, 9781975172268
