A nurse examines a patient’s tympanic membranes with an otoscope. The nurse understands the normal tympanic membrane exhibits which normal characteristic?

Choice A reason: There is no standard “grade 5” in tonsil size grading. The scale typically ranges from 0 to 4+, with 4+ indicating tonsils touching or overlapping, making this an incorrect and non-standard documentation term.

Choice B reason: Grade 3 tonsils are enlarged, occupying about 75% of the pharyngeal space, but not touching. The described tonsils are touching, which corresponds to a higher grade, making grade 3 incorrect for this finding.

Choice C reason: Grade 2+ tonsils are moderately enlarged, taking up about 50% of the pharyngeal space. The tonsils touching indicate a more severe enlargement, aligning with a higher grade, making this an incorrect documentation choice.

Choice D reason: Grade 4+ tonsils are severely enlarged, touching or overlapping in the midline, as described. This matches the standard tonsil grading scale, where 4+ indicates maximal swelling, making this the correct documentation.

Choice A reason: Statements from the victim are valuable but not required for reporting elder abuse. Mandatory reporters must act on reasonable suspicion, as victims may be unable or unwilling to report due to fear or incapacity, making this incorrect.

Choice B reason: Witness statements support abuse cases but are not mandatory for reporting. Nurses must report based on suspicion, as waiting for witness corroboration could delay protection, making this an incorrect requirement for notification.

Choice C reason: As a mandatory reporter, a nurse must notify authorities based on reasonable suspicion of abuse or neglect, as per legal standards. This ensures timely intervention to protect vulnerable elders, even without definitive proof, making this correct.

Choice D reason: Proof of abuse or neglect is not required for reporting, as mandatory reporters act on suspicion. Requiring proof could delay or prevent reporting, leaving elders at risk, making this an incorrect threshold for notification.