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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Free Nursing Study Resources

Correct Answer is ["A","C"]

Explanation

WRIST - ABLE TO BEND WRIST BACK TOWARD FOREARM:

Abduction

Abduction refers to the movement of a body part away from the body's midline. This movement is typically used for fingers, arms, or legs, but not for the wrist. Therefore, this choice is incorrect for the wrist's range of motion.

Flexion

Flexion refers to the bending of a joint that reduces the angle between two body parts. For the wrist, flexion would involve bending the wrist forward, toward the palm of the hand. Since the patient is able to bend the wrist backward (toward the forearm), this is not the correct choice.

Extension

Extension refers to straightening a joint, which increases the angle between the body parts. For the wrist, extension is the movement where the hand moves away from the palm (backward toward the forearm). This is the correct choice because the patient is able to bend the wrist back toward the forearm, which is extension.

Adduction

Adduction refers to the movement of a body part toward the body's midline. This is not relevant to the wrist, so it is an incorrect option.

SHOULDER - UNABLE TO MOVE THE ARM AWAY FROM THE BODY:

Extension

Extension refers to the movement that straightens a joint, increasing the angle between two parts of the body. For the shoulder, this would involve moving the arm behind the body, and it's not the movement of the arm away from the body, so this is not the correct choice.

Adduction

Adduction refers to moving a body part toward the midline of the body. For the shoulder, this would involve moving the arm closer to the body. This does not correspond to the action of moving the arm away from the body, so this is not the correct choice either.

Flexion

Flexion refers to the bending of a joint that decreases the angle between two body parts. For the shoulder, this would involve raising the arm forward, not moving it away from the body. This is not the correct choice for the described movement.

Abduction

Abduction refers to the movement of a body part away from the midline of the body. In this case, the shoulder movement of moving the arm away from the body is abduction. Since the client is unable to move the arm away from the body (i.e., is experiencing weakness or limited ROM), the shoulder’s range of motion has a restriction in abduction.

A. What medications have you taken for your cough? B. Have you been prescribed any medications for your cough? C. Have you tried any generic brands of cough syrup? D. What medications are you currently taking?

Correct Answer is A

Explanation

A. Asking the client directly about the medications they have taken for their cough provides specific
information about the treatments they’ve used, including over-the-counter or prescription options.
B. Asking if they have been prescribed medications for the cough might miss important details about over-the-counter medications or self-treatment.
C. Asking about generic brands of cough syrup is too specific and may miss other relevant medications the client is using to manage their chronic cough.
D. Asking about current medications is important for general health information, but it does not directly address treatment specific to the cough.

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Naxlex Comprehensive Predictor Exams

Correct Answer is ["A","C"]

Explanation

Which question by the nurse is likely to elicit the most information regarding a client's use of medications to treat a chronic cough?

Correct Answer is A

Explanation

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