ENT Assessment

Question 1

General Approach
1. Greet the patient and explain the __________ that you will be using.

2. Use a ______ room that will be free from interruptions.
3. Ensure that the light in the room provides sufficient brightness to allow _____________ of the patient.
4. Place the patient in an ___________ on the examination table. For clients who cannot tolerate the sitting position, gain access to the patient’s head so that it can be rotated from side to side for assessment.
5. Visualize the __________ during the assessment process to allow adequate description of findings.
6. Always compare _______________________
7. Use a ____________ that is followed consistently each time the assessment is performed

Answer 1

(1) assessment techniques
(2) quiet
(3) adequate observation
(4) upright sitting position
(5) underlying structures
(6) right and left ears, sides of the nose, sinuses, mouth and throat.
(7) systematic approach

Question 2

Physical assessment of the ear consists of
three parts:
1. _______________
2. _______________
3. _______________

Answer 2

(1) Auditory screening (CNVIII)
(2) Inspection and palpation of the external ear
(3) Otoscopic assessment

Question 3

Equipment Needed for Eye Assessment

Answer 3

∙ Watch with a second hand for Romberg test
∙ Tuning fork
∙ Otoscope

Question 4

EXTERNAL EAR STRUCTURES
Inspect the ________, _________, and _________. Note size, shape and position

Answer 4

auricle / tragus / lobule

Question 5

External Ear Normal Findings:
• Ears are equal in size (1) ________ (4-10cm)
• (2) _________ aligns with the corner of the eye and within a 10-degree angle of the vertical position
• (3) _________ may be free, attached or soldered (tightly attached to adjacent skin with no apparent lobe)
• No (4) ________
• (5) ___________ is clinically insignificant

Answer 5

(1) bilaterally
(2) Auricle
(3) Earlobes
(4) lesions
(5) Darwin’s tubercle

Question 6

ABNormal Findings:

• (1) ____________
• (2) ____________
• (3) ____________
• (4) ____________

Answer 6

(1) Tophi
(2) Frostbite
(3) Postauricular Cyst
(4) Malaligned or low-set ears

Question 7

May be seen with genitourinary disorders or chromosomal defects.

Answer 7

Malaligned or low-set ears

Question 8

EXTERNAL EAR STRUCTURES
- Palpate the _______ and ________.

Answer 8

auricle / mastoid process

Question 9

EXTERNAL EAR STRUCTURES
Normal Findings:
• The auricle, tragus and mastoid process are _________.

Answer 9

not tender

Question 10

EXTERNAL EAR STRUCTURES
ABNormal Findings:
▪ A painful auricle and tragus is associated with (1) ________ or a ________.
▪ Tenderness over the mastoid process suggests (2) __________.
▪ Tenderness behind the ear may occur with (3) __________.

Answer 10

(1) otitis externa / postauricular cyst
(2) mastoiditis
(3) otitis media

Question 11

INTERNAL EAR STRUCTURES
∙ Inspect the __________. (use the otoscope)

Answer 11

external auditory canal

Question 12

INTERNAL EAR STRUCTURES
o Normal Findings:
▪ A small amount of odourless (1) _________ is the only discharge normally present.
▪(2) ________ may be yellow, orange, red, brown, gray or black and soft, moist, dry, flaky or even hard.

Answer 12

(1) cerumen (ear wax)
(2) Cerumen

Question 13

INTERNAL EAR STRUCTURES
o Abnormal Findings:
▪ Reddened, swollen canal – (1) ________
▪ (2) _______ (non-malignant nodular swellings)
▪ (3) _______

Answer 13

(1) otitis externa
(2) Exostoses
(3) Polyps

Question 14

Perform Voice-Whisper Test
1. Instruct the patient to _____________.
2. Stand _______ behind the patient’s other ear and whisper a _________ word or phrase that is evenly accented.
3. Ask the patient to _______ the word or phrase.
4. Repeat the test with the other ear.

Answer 14

(1) occlude one ear with finger
(2) 2 feet / two-syllable
(3) repeat

Question 15

Perform Voice-Whisper Test
o Normal Findings:
▪ The patient should be able to __________

Answer 15

repeat the words whispered from a distance of 2 feet.

Question 16

Performed if the client reports diminished or lost hearing in one ear

Answer 16

Weber’s Test

Question 17

Weber’s Test
1. Hold the handle of the tuning fork and strike the tines on the ________ to activate it.
2. Place the stem of the fork firmly against the _________.
3. Ask the patient if the sound is heard ________.

Answer 17

(1) ulnar border of the palm
(2) middle of the patient’s forehead, on top of the head at the midline.
(3) centrally or toward one side

Question 18

Weber’s Test
o Normal Findings:
▪ Vibrations are heard (1) ________.
▪ No (2) ________ of sound to either ear.

Answer 18

(1) equally well in both ears
(2) lateralization

Question 19

Weber’s Test
o ABNormal Findings:
▪ (1) ________ Hearing Loss
▪ (2) ________ Hearing Loss

Answer 19

(1) Conduction
(2) Sensoryneural

Question 20

Rinne Test
1. Stand behind or to the side of the patient and strike the ________.
2. Place the stem of the tuning fork against the patient’s right mastoid process to test ________.
3. Instruct the patient to indicate if ________.
4. Ask the patient to tell you when the sound _______.
5. When the patient says that the sound stopped, move the tuning fork, with the tines facing forward, in front of the __________, and ask the patient if the sound is still heard. Note the length of time the patient hears the sound (___________)
6. Repeat the test on the left ear.

Answer 20

(1) tuning fork
(2) bone conduction
(3) sound is heard
(4) stops
(5) right auditory meatus / testing air conduction

Question 21

Rinne Test
o Normal Findings:
▪ Air conduction sound is ________ than the bone conduction

Answer 21

normally longer

Question 22

Rinne Test
o Abnormal Findings:
▪ (1) ________ (BC≥AC)
▪ (2) ________ (AC≥BC)

Answer 22

(1) Conductive
(2) Sensorineural

Question 23

SCHWABACH TEST
1. Stand behind or to the side of the patient and strike the ________.
2. Place an activated tuning fork at the _____________ of the client. Instruct the patient to indicate if the sound is heard.
3. Ask the patient to tell you when the sound ______.
4. When the client no longer hears the sound, place the tuning fork on __________ and determine if you can still hear the sound.
5. Repeat the test on the left ear.

Answer 23

(1) turning fork
(2) tip of the mastoid process
(3) stops
(4) your mastoid process

Question 24

Schwabach Test
o Normal Findings: ___________
The nurse and the patient cannot hear the tuning fork at the same time

Answer 24

Equal Schwabach

Question 25

Schwabach Test
o Abnormal Findings:
▪ (1) _________ – Patient still hears tuning fork after the examiner have already stopped hearing it.
▪ (2) _________ – The examiner still hear the tuning fork after patient has already stopped hearing it.
▪ (3) _________ – are judged on the assumption that the examiner have normal hearing

Answer 25

(1) Prolonged Schwabach
(2) Shortened Schwabach
(3) Abnormal Schwabachs

Question 26

• Tests the client’s equilibrium
• Ask the client to stand with feet together and arm at sides and eyes open and then with the eyes closed.
• This assessment is primarily done in Neurologic Assessment

Answer 26

Romberg Test

Question 27

Romberg Test
Normal Findings:
▪ Client maintains position for _________ without swaying or with minimal swaying.

Answer 27

20 seconds

Question 28

∙ Readiness for enhanced communication related to use of hearing aid.

Answer 28

Wellness Diagnoses

Question 29

∙ Risk for injury related to hearing impairment

Answer 29

Risk Diagnoses

Question 30

∙ Disturbed sensory perception: Auditory related to conductive or sensorineural
hearing loss.

Answer 30

Actual Diagnoses

Question 31

ASSESSMENT OF THE MOUTH, NOSE, THROAT AND SINUSES
Equipment:
∙ __________
∙ __________
∙ __________
∙ __________
∙ __________
∙ __________

Answer 31

∙ Gloves
∙ 4x4 inch gauze
∙ Penlight
∙ Short, wide tipped speculum attached to the head of an otoscope
∙ Tongue depressor
∙ Nasal speculum

Question 32

Inspection and Palpation:
∙ Inspect the lips. Observe _______ and ________

Answer 32

lip consistency / color

Question 33

Inspection and Palpation of Lips:
Normal Findings
— Lips are ________

Answer 33

smooth and moist without lesions