Chapter 60: Ear and Hearing Disorders Linton: Medical-Surgical Nursing, 7th Edition

1. A 94-year-old patient is receiving gentamicin sulfate (Garamycin) in a continuous intravenous (IV) infusion. The nurse adds to the nursing care plan the patient problem “Potential injury.” What nursing action should be implemented? a. Pull side rails in place. b. Assist with ambulation. c. Measure intake and output. d. Provide for a possible seizure. 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. Gentamicin is ototoxic and can cause hearing impairment. DIF: Cognitive Level: Application REF: p. 1193 OBJ: 2 TOP: Gentamicin KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity: Pharmacological Therapies 2. A 75-year-old patient reports to a 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. What should the nurse anticipate when examining her ears? a. Otitis externa b. Purulent drainage c. Dry cerumen across the canal d. Pearly tympanic membrane ANS: C Obstruction of the external canal with cerumen will result in a hearing loss. Cleaning the ears with something such as an applicator will pack the cerumen in the canal. DIF: Cognitive Level: Comprehension REF: p. 1186 OBJ: 1 TOP: External Auditory Canal KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity: Physiological Adaptation 3. Which patient problem should take priority in planning care for a patient with Ménière disease? a. Decreased soc