Author Question: The nurse is examining a client's ears and notes that right ear is occluded with wax. Which actions ... (Read 79 times)

Jramos095 · **on:** Jun 25, 2018

The nurse is examining a client's ears and notes that right ear is occluded with wax. Which actions by the nurse are appropriate to facilitate removal of the cerumen from the client's ear? Select all that apply.

1. Irrigating with warm mineral oil, peroxide, and flushing with warm water.
2. Inserting a sharp instrument to break up the ear wax.
3. Irrigating with a cold solution.
4. Inserting a cerumen spoon to remove the wax.
5. Irrigating with warm sudsy water.

Question 2

The nurse is assessing the tympanic membrane of a client and notes the presence of a darkened area. Based on this assessment data, which does the nurse suspect?

1. Acute otitis media.
2. Recent trauma.
3. Blocked Eustachian tubes.
4. History of frequent middle ear infections.

meganlapinski · **Reply #1 on:** Jun 25, 2018

Answer to Question 1

Correct Answer: 1, 4

Care must be taken when removing cerumen. Warmed mineral oil and peroxide soften the earwax and the ear can be irrigated with warm water afterwards. The cerumen can also be safely removed with a cerumen spoon. The cerumen spoon is designed to remove the wax safely without risking injury or perforation of the eardrum. Sharp instruments should not be placed within the ear canal because it may injure the tympanic membrane. Cold solutions may harden the ear wax, making it more difficult to remove. Warm, sudsy solutions may irritate the ear canal.

Answer to Question 2

Correct Answer: 2
The presence of a darkened area on the tympanic membrane is most likely due to blood in the middle ear and may be indicative of recent trauma. Acute otitis media is associated with a reddish or yellowish tinge on the tympanic membrane. A blocked Eustachian tube will cause the tympanic membrane to retract. Previous middle ear infections will result in white patches noted on the tympanic membrane that indicate scarring.