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 D

Explanation

A. This is not applicable in this case. A BMI of 14 kg/m² indicates severe malnutrition, not excess nutrition. The client is at risk for nutritional deficiencies, not an excess of nutrition.
B. While fluid volume might be a concern in severely malnourished clients, the primary issue in this scenario is related to nutrition rather than fluid imbalance. A low BMI suggests insufficient caloric intake.
C. Excess fluid volume is not typically associated with a low BMI. In fact, clients with a BMI this low may show signs of dehydration or fluid loss due to inadequate nutritional intake.
D. This is the most appropriate nursing diagnosis. A BMI of 14 kg/m² is indicative of severe malnutrition and the client is not meeting their nutritional needs, which could lead to further health complications.

A. Increase in sexual desire. B. Cessation of menstruation. C. Excessive vaginal moisture. D. Drenching night sweats.

Correct Answer is D

Explanation

A. This is unlikely to be associated with perimenopause. Often, perimenopause is linked to hormonal fluctuations that can lead to decreased libido rather than an increase.
B. While cessation of menstruation may indicate menopause, it is not typically seen during the perimenopausal phase, which is the time leading up to menopause. Perimenopause is characterized by irregular periods, not complete cessation.
C. Perimenopausal symptoms typically involve a decrease in vaginal moisture due to reduced estrogen levels. Excessive vaginal moisture would not be indicative of perimenopause and might suggest an infection or other conditions.
D. This is a classic symptom of perimenopause. Hormonal fluctuations during this time can lead to hot flashes and night sweats, which are commonly experienced as part of the transition toward menopause.

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Naxlex Comprehensive Predictor Exams

In assessing an adult client, the nurse calculates the body mass index (BMI) as 14 kg/m2. Which nursing problem should be included in this client's plan of care? Reference Range: Body mass index (BMI) [normal 18.0 to 24.9 kg/m2]

Correct Answer is D

Explanation

The nurse is obtaining a health history for a client during an annual physical examination. When evaluating the client for menopausal symptoms, which finding indicates the client is perimenopausal?

Correct Answer is D

Explanation

The nurse is assessing a client who has a history of kidney stones and returns to the clinic with flank pain. Which intervention should the nurse implement first?

The nurse observes that a client who is intoxicated has an ataxic gait. Which finding does the nurse expect to be positive upon further assessment of the client?

Which assessment finding, obtained during chest auscultation, should the nurse consider a normal finding?

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?

When assessing a client's range of motion, the nurse notes crepitation with movement of the left knee. Which information in the client's history is most likely related to this finding?