A new client has been received into the emergency department following a pedestrian-automobile collision. The triage nurse recognizes which of the following as an emergency and correctly notifies the provider immediately?

Clear, watery drainage from the ear.

Enlarged post-auricular lymph nodes.

Odorless, brown cerumen in the ear.

White spots on the tympanic membrane.

Answer and Explanation

The Correct Answer is A

Choice A reason: Clear, watery ear drainage post-collision suggests cerebrospinal fluid (CSF) leak from a skull fracture. This urgent finding risks infection or brain injury, warranting immediate provider notification for imaging and intervention in this trauma case accurately.
Choice B reason: Enlarged post-auricular nodes may indicate infection, not an acute emergency. Post-trauma, this is less critical than potential CSF leak, making it a lower priority for immediate provider action in this collision scenario fully here.
Choice C reason: Odorless, brown cerumen is normal earwax, not an emergency. After a collision, this benign finding doesn’t signal trauma-related urgency, excluding it from requiring prompt provider notification compared to more severe signs entirely here.
Choice D reason: White tympanic membrane spots suggest scarring or infection, not immediate danger. Post-collision, this lacks the acuity of CSF leak, rendering it non-emergent and less urgent for provider attention in this context comprehensively here.

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Correct Answer is B

Explanation

Choice A reason: Prolonged tonsillar enlargement may cause throat issues or obstruction, but rhinorrhea stems from nasal inflammation, not tonsils. This focuses on oropharyngeal anatomy, missing the direct nasal etiology tied to runny nose in upper airway complaints here entirely.

Choice B reason: Allergies trigger nasal inflammation via histamine, causing rhinorrhea as IgE-mediated mast cells release mediators. A history of this is key, directly linking environmental triggers to the client’s runny nose, making it the most relevant assessment area accurately.

Choice C reason: Incomplete immunizations increase infection risk, but rhinorrhea more commonly ties to allergies or viruses than vaccine-preventable diseases here. This is less specific to the symptom’s etiology without fever or systemic signs, reducing its pertinence significantly.

Choice D reason: Epistaxis (nosebleeds) relates to vascular fragility, not mucus production like rhinorrhea. Past bleeding doesn’t explain runny nose, focusing on a separate nasal issue, making it less relevant to the upper airway complaint’s root cause in this case fully.

A. Increased air turbulence in the large airways. B. Air leaking from the alveoli into the pleural space. C. Air diverting from the trachea to the bronchi. D. Constriction of the respiratory passages.

Correct Answer is D

Explanation

Choice A reason: Turbulence in large airways causes coarse sounds, not high-pitched wheezes. Wheezes stem from narrowed smaller passages, like bronchioles, not broad airway dynamics, making this less accurate for the specific sound’s pathophysiology fully here.
Choice B reason: Air leaking into the pleural space (pneumothorax) reduces breath sounds, not causing wheezes. Wheezes arise from airway narrowing, not alveolar rupture, excluding this as the source of the auscultated adventitious sound entirely here fully.
Choice C reason: Air diversion from trachea to bronchi is normal airflow, not producing wheezes. Wheezes require obstruction or constriction in smaller airways, not tracheal branching, rendering this unrelated to the sound’s pathological origin comprehensively here.
Choice D reason: Wheezes result from constricted respiratory passages, like in asthma, where narrowed bronchioles vibrate with airflow. This high-pitched sound matches the pathophysiology of airway narrowing, making it the correct explanation for this finding accurately here.

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A new client has been received into the emergency department following a pedestrian-automobile collision. The triage nurse recognizes which of the following as an emergency and correctly notifies the provider immediately?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client presents with a cluster of upper airway complaints that include rhinorrhea. Which area of assessment would yield the most pertinent information to the etiology of rhinorrhea?

Correct Answer is B

Explanation

The nurse's auscultation of a client's lung fields reveals the presence of a wheeze. The nurse should recognize that this adventitious sound results from what pathophysiologic process in the lungs?

Correct Answer is D

Explanation

The client reports a decreased sense of smell for the past week. Which condition would the nurse assess for?

A 53 year-old client was recently diagnosed with benign prostatic hypertrophy (BPH). He is fearful and states, "My good friend just died from prostate cancer and I am concerned this will happen to me." What would be the most appropriate response by the nurse?

The nurse has completed the assessment of the client's ears. A small/moderate amount of brown cerumen was found in both ears. Which action by the nurse is warranted?

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