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.

Nursing Test Bank

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Correct Answer is D

Explanation

A. This is a normal finding where the right pupil constricts when the light is directed at it, and the left pupil constricts consensually as well. This suggests normal function of the pupillary light reflex pathway, and no further evaluation is needed.
B. This also indicates normal pupillary function. Equal pupil size and appropriate constriction to light are typical findings, suggesting no immediate issues with the nervous system.
C. Pupil size should not change in response to distance unless there is a near response (accommodation). If the pupil size changes to distance of the light source instead of light reflex, this suggests potential abnormality in the pupillary reflex response.
D. This is an abnormal finding. A "notched" iris suggests possible damage or congenital anomalies, and minimal change in pupil size may indicate impaired pupil reflexes, requiring further evaluation to rule out neurological or ophthalmologic issues.

A. Palpate the radial pulses in both arms for a deficit. B. Use the stethoscope to listen over the carotid artery. C. Feel the volume of the dorsalis pedis and posterior tibialis pulses. D. Auscultate the apical pulse at the point of maximal impulse.

Correct Answer is D

Explanation

A. Palpating the radial pulses might not detect irregularities in pulse rate or rhythm as effectively as auscultation at the apical site.
B. Listening over the carotid artery may be useful in certain situations but is not the preferred method for assessing overall pulse rate.
C. Feeling the dorsalis pedis and posterior tibialis pulses provides information about peripheral circulation but does not assess the overall heart rate.
D. Auscultating the apical pulse is the most accurate method to assess the pulse rate, especially in clients with cardiovascular disease, as it provides direct measurement of heart activity.

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Naxlex Comprehensive Predictor Exams

While conducting a physical assessment, the nurse shines a pen light into a client's right eye and moves the light source to check the client's left eye. Which finding indicates the need for further evaluation?

Correct Answer is D

Explanation

When assessing an older adult client with a history of cardiovascular disease, dyspnea, and peripheral edema, which method is best for the nurse to use to assess the client's pulse rate?

Correct Answer is D

Explanation

Which finding, obtained during a skin assessment, should the school nurse report to the healthcare provider?

The nurse is doing a health assessment of a client who smoked three packs of cigarettes every day for the last twenty years before quitting two years ago. How should the nurse document the client's pack-years? (Enter the numerical value only.)

The nurse is obtaining a health history for a client being admitted for new onset seizures. Which action should the nurse implement to accurately record the health history findings?

A nurse performs a Tinetti assessment on an older adult client and calculates a balance score of 12 and a gait score of 8. Which do these results indicate?

A client states, "I am legally blind." Which assessment technique should the nurse use to obtain subjective data to support the client's statement?

The nurse begins a client's musculoskeletal assessment. While using the technique of inspection, the nurse assesses for which possible findings? Select all that apply.

When conducting a physical examination, the nurse uses a tuning fork to assess for which condition?

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?