A 16-year-old client with a history of chronic ear infections when younger comes to the clinic for a health exam. No ear pain, vertigo or hearing loss is reported during history taking. Inspection of the tympanic membranes (TM) reveals the presence of dense white patches on the TMs in both ears. Both TMs are a translucent gray with a light reflex at 5:00. All landmarks are visible. Based on these findings, which action should the nurse take next?

Record the findings in the client's record.

Clean the ears to remove excess wax build up.

Referral to an audiologist for a hearing evaluation.

Culture the white patches for possible fungal growth.

Answer and Explanation

The Correct Answer is A

A.   This is an appropriate first step in documenting any unusual findings during the assessment. However, based on the presence of dense white patches, the nurse should consider a referral for further evaluation, rather than just recording the findings.
B.   The dense white patches seen on the tympanic membrane are more likely related to past ear infections (such as tympanosclerosis) or other conditions, not excess wax. Cleaning the ears would not address the underlying cause and could potentially cause harm.
C.   This could be a reasonable action if there were concerns about hearing loss. However, the tympanic membranes appear mostly normal apart from the white patches, so hearing loss is not strongly indicated by the findings alone. A referral might be premature unless hearing issues are suspected.
D.   The dense white patches on the tympanic membranes could be indicative of tympanosclerosis, a benign condition related to previous infections or tube insertions, but fungal growth is not the most likely cause in this case.

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Correct Answer is B

Explanation

A. Facial asymmetry may indicate neurological issues, but it does not directly assess the stuporous state.
B. A stuporous state is characterized by a reduced level of consciousness, and the nurse should assess
the client’s response to stimuli to confirm the report of stupor.
C. A positive Romberg sign indicates a balance issue, but it is not directly related to confirming a stuporous state.
D. While pupillary response is important, it does not provide sufficient information to confirm a stuporous state without assessing responsiveness to stimuli.

A. Frozen, non-movable phalangeal joints. B. Distal interphalangeal joint nodules that deviate. C. Proximal intertarsal joint swelling of big toe. D. Non-painful enlarged interphalangeal joints.

Correct Answer is D

Explanation

A. Frozen or non-movable joints typically refer to severe joint damage such as in cases of rheumatoid arthritis or advanced osteoarthritis, but Heberden's nodes are characterized by bony growths at the distal interphalangeal joints and do not indicate frozen joints.
B. Heberden's nodes are bony enlargements found at the distal interphalangeal joints. However, they are not typically associated with deviation of the joints, which might occur with other conditions like rheumatoid arthritis.
C. Proximal intertarsal joint swelling, particularly of the big toe, is more likely associated with gout, not osteoarthritis. Heberden's nodes specifically refer to changes in the distal interphalangeal joints of the fingers.
D. Heberden's nodes are typically non-painful enlargements of the distal interphalangeal joints that result from osteoarthritis. The nurse should document the presence of these nodes and note if they are non-painful.

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Naxlex Comprehensive Predictor Exams

The nurse learns in report that a client is stuporous. Which assessment should the nurse perform to confirm this report?

Correct Answer is B

Explanation

During a health assessment, the client reports being treated for osteoarthritis. The nurse examines a client's hands and finds Heberden's nodes. Which finding should the nurse document in the client's medical record?

Correct Answer is D

Explanation

An older adult client is being evaluated for admission to an assisted living facility. During the health assessment, the nurse implements which technique to determine the client's ability to reside in this environment?

When the nurse is obtaining health history during an annual physical examination, the client reports having difficulty with erections for the past 8 months. Which information in the client's history should the nurse consider as a potential reason for erectile dysfunction?

During the precordium assessment, the nurse palpates the apical impulse of a client on the 5th intercostal space left mid-clavicular line. The pulse is more vigorous than expected. Which action should the nurse take in response to this finding?

Patient Data Exhibits Nurse analyzes the assessment findings. Click to indicate which findings are indicative of rheumatoid arthritis or are not applicable to that disease. Each row must have only one response option selected.

The nurse is performing oral inspection of a client with dark pigmented skin. The nurse observes a patchy discoloration of the buccal mucosa. Which action should the nurse take?

The nurse is performing a head-to-toe physical examination on a known victim of intimate partner violence. The visual exam reveals several round, flat, pinpoint, red spots. How should the nurse document this finding?

The nurse detects a possible extra heart sound while assessing an adult client. To verify this finding, which action should the nurse take?

The nurse assesses a young adult female who was brought to the emergency department (ED) by her boyfriend because she has not been feeling well all day and he believes she is getting worse. Which finding supports the nurse's suspicion that the client is experiencing appendicitis?