[Osborn] chapter 69

Learning Outcomes [Number and Title]

Learning Outcome 1
Learning Outcome 2
Learning Outcome 3
Learning Outcome 4
Learning Outcome 5

Differentiate normal from abnormal findings of a physical

assessment of the ear, nose, and throat.
Identify the subjective and objective history data related to ear,
nose, and throat disorders that need to be obtained.
Identify the risk factors for ear, nose, and throat disorders.
Describe the psychosocial impact of disorders of the ear, nose,
and throat and how it impacts nursing care.
Describe the purpose, nursing responsibility, and significance
of results of diagnostic exams of the ear, nose, and throat.

Osborn, et al., Test Item File for Medical-Surgical Nursing: Preparation

for Practice Copyright 2010 by Pearson Education, Inc.

1. The nurse notes that the cerumen in a clients ear may indicate an infection. The nurse makes
that assessment because the cerumen (earwax) is:
1.
2.
3.
4.

Hardened, dry, and foul-smelling.

Brown, wet, and sticky.
Dry, white, and flaky.
Absent.

Correct 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.
Cognitive Level: Application
Nursing Process: Assessment
Client Need: Physiological Integrity
LO: 1

Osborn, et al., Test Item File for Medical-Surgical Nursing: Preparation

for Practice Copyright 2010 by Pearson Education, Inc.

2. In a darkened room, the nurse uses a penlight against the clients cheek to transluminate
through the roof of the mouth. A normal finding would be:
1.
2.
3.
4.

A faint glow can be seen through the bones.

There is no light transmission.
There is diminished light transmission.
Seen in absence of soft palate defects.

Correct Answer: A faint glow can be seen through the bones.

Rationale: The penlight against the clients 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.
Cognitive Level: Application
Nursing Process: Assessment
Client Need: Physiological Integrity
LO: 1

Osborn, et al., Test Item File for Medical-Surgical Nursing: Preparation

for Practice Copyright 2010 by Pearson Education, Inc.

3. The nurse detects that a client has a fruity breath odor. A fruity breath odor commonly occurs
with:
1.
2.
3.
4.

Diabetic ketoacidosis.
Poor oral hygiene.
Liver failure.
End-stage renal disease.

Correct 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.
Cognitive Level: Application
Nursing Process: Assessment
Client Need: Physiological Integrity
LO: 1

Osborn, et al., Test Item File for Medical-Surgical Nursing: Preparation

for Practice Copyright 2010 by Pearson Education, Inc.

4. One area the nurse should focus on when interviewing a client about a current health problem
is otalgia. Otalgia is defined as:
1.
2.
3.
4.

Ear pain.
Dizziness.
Ringing in the ears.
Fainting.

Correct 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.
Cognitive Level: Application
Nursing Process: Assessment
Client Need: Physiological Integrity
LO: 2

Osborn, et al., Test Item File for Medical-Surgical Nursing: Preparation

for Practice Copyright 2010 by Pearson Education, Inc.

5. One piece of equipment needed to monitor a client with nasal or sinus problems is a/an:
1.
2.
3.
4.

Oxygen saturation monitor.

Pneumatoscope.
Tuning fork.
Mallous.

Correct 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.
Cognitive Level: Application
Nursing Process: Assessment
Client Need: Physiological Integrity
LO: 2

Osborn, et al., Test Item File for Medical-Surgical Nursing: Preparation

for Practice Copyright 2010 by Pearson Education, Inc.

6. Which of the following symptoms may also be an objective symptom?

1.
2.
3.
4.

Tinnitus
Vertigo
Otalgia
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.
Cognitive Level: Application
Nursing Process: Assessment
Client Need: Physiological Integrity
LO: 2

Osborn, et al., Test Item File for Medical-Surgical Nursing: Preparation

for Practice Copyright 2010 by Pearson Education, Inc.

7. A 45-year-old client is admitted complaining of vertigo, hearing loss, unilateral aural fullness,
and tinnitus. Based on the clients age and symptoms, the nurse feels the client is suffering from:
1.
2.
3.
4.

Menieres disease.
Bells palsy.
Otosclerosis.
Anosmia.

Correct Answer: Menieres disease.

Rationale: Menieres 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.
Bells 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.
Cognitive Level: Application
Nursing Process: Assessment
Client Need: Physiological Integrity
LO: 3

Osborn, et al., Test Item File for Medical-Surgical Nursing: Preparation

for Practice Copyright 2010 by Pearson Education, Inc.

8. Recreational activities can place individuals at risk for developing head and neck problems. A
history of alcohol use is strongly associated with:
1.
2.
3.
4.

Head and neck cancer.

Anosmia.
Allergic rhinitis.
Epistaxis.

Correct 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.
Cognitive Level: Application
Nursing Process: Assessment
Client Need: Physiological Integrity
LO: 3

Osborn, et al., Test Item File for Medical-Surgical Nursing: Preparation

for Practice Copyright 2010 by Pearson Education, Inc.

9. One-third of all hearing loss can be attributed to:

1.
2.
3.
4.

Occupational noise exposure.

Ototoxic medications.
Environmental exposure to toxins.
Otitis media.

Correct 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.
Cognitive Level: Application
Nursing Process: Assessment
Client Need: Physiological Integrity
LO: 3

Osborn, et al., Test Item File for Medical-Surgical Nursing: Preparation

for Practice Copyright 2010 by Pearson Education, Inc.

10. A client is admitted with trauma of the XII cranial nerve. This injury could cause the client to
have difficulty:
1.
2.
3.
4.

Speaking.
Hearing.
Tasting.
Smelling.

Correct Answer: Speaking.

Rationale: Trauma to the XII cranial nerve can cause paralysis of the tongue and interfere with a
clients 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.
Cognitive Level: Application
Nursing Process: Assessment
Client Need: Psychosocial Integrity
LO: 4

Osborn, et al., Test Item File for Medical-Surgical Nursing: Preparation

for Practice Copyright 2010 by Pearson Education, Inc.

11. Many individuals in the deaf community often refuse genetic services because of a history of
stigmatization. This reluctance is the result of:
1.
2.
3.
4.

Cultural influence.
Ignorance regarding available services.
High rate of noncompliance of treatments.
Low predictive value of genetic testing.

Correct 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.
Cognitive Level: Application
Nursing Process: Assessment
Client Need: Psychosocial Integrity
LO: 4

Osborn, et al., Test Item File for Medical-Surgical Nursing: Preparation

for Practice Copyright 2010 by Pearson Education, Inc.

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.
2.
3.
4.

Anosmia
Vertigo
Epistaxis
Otalgia

Correct 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.
Cognitive Level: Application
Nursing Process: Assessment
Client Need: Psychosocial Integrity
LO: 4

Osborn, et al., Test Item File for Medical-Surgical Nursing: Preparation

for Practice Copyright 2010 by Pearson Education, Inc.

13. The Romberg test assesses the patients 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.
2.
3.
4.

Inner ear balance.

Conductive hearing loss.
Abnormal nystagmus.
Gag reflex.

Correct 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 clients oral cavity with a tongue blade.
Cognitive Level: Application
Nursing Process: Assessment
Client Need: Physiological Integrity
LO: 4

Osborn, et al., Test Item File for Medical-Surgical Nursing: Preparation

for Practice Copyright 2010 by Pearson Education, Inc.

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.
2.
3.
4.

Is probably not the cause of this hearing loss.

Is probably the cause of this hearing loss.
Is temporary.
Is rare.

Correct 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.
Cognitive Level: Application
Nursing Process: Assessment
Client Need: Physiological Integrity
LO: 5

Osborn, et al., Test Item File for Medical-Surgical Nursing: Preparation

for Practice Copyright 2010 by Pearson Education, Inc.

15. The nurse performs the caloric test to assess the abnormal nystagmus, tinnitus, or hearing
loss that is the result of:
1.
2.
3.
4.

Vestibular dysfunction.
Ruptured tympanic membrane.
Chronic otitis externa.
Chronic sinusitis.

Correct 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.
Cognitive Level:
Nursing Process:
Client Need:
LO: 5

Osborn, et al., Test Item File for Medical-Surgical Nursing: Preparation

for Practice Copyright 2010 by Pearson Education, Inc.