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A patient has been diagnosed with venous stasis. Which of these findings would the nurse most likely observe?

Pallor of the toes and cyanosis of the nail beds

Thin, shiny, atrophic skin

Brownish discoloration to the skin of the lower leg

Unilateral cool foot

Answer and Explanation

The Correct Answer is C

A. Pallor and cyanosis: Indicative of arterial insufficiency, not venous disease.

B. Thin, shiny skin: Seen in peripheral arterial disease (PAD).

C. Brownish discoloration: Caused by hemosiderin deposits from chronic venous congestion.

D. Unilateral cool foot: Suggests acute arterial obstruction.

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Correct Answer is D

Explanation

A. Change in cilia: This is not the cause of dry, flaky cerumen. It would not be typical to assess hearing loss based on this observation alone.

B. Poor hygiene: Dry, flaky cerumen is not indicative of poor hygiene. Hygiene-related cerumen would more likely be wet and impacted.

C. Lesions from eczema: While eczema can affect the ear canal, the dry cerumen itself is more likely to be a normal characteristic for some individuals, particularly in people of Asian descent.

D. Normal finding: The presence of dry, flaky cerumen is normal in certain ethnic groups, including East Asians, and usually requires no follow-up.

A. Make note of this finding for the report to the next shift B. Prepare to remove cerumen from the patient's ear. C. Irrigate the ear with rubbing alcohol. D. Notify the patient's health care provider

Correct Answer is D

Explanation

A. Make note of this finding: Delaying action by merely reporting the finding later may compromise patient care.

B. Prepare to remove cerumen: Sudden hearing loss is unlikely to be caused by cerumen buildup without further assessment.

C. Irrigate with rubbing alcohol: This is inappropriate and could harm the ear.

D. Notify the health care provider: Sudden sensorineural hearing loss can be a medical emergency and should be promptly evaluated by the healthcare provider.

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A patient has been diagnosed with venous stasis. Which of these findings would the nurse most likely observe?

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Naxlex Comprehensive Predictor Exams

During an assessment of a 20-year-old Asian patient, the nurse notices that he has dry, flaky cerumen in his canal. What is the significance of this finding? This finding:

Correct Answer is D

Explanation

A patient has been admitted after an accident at work. During the assessment, the patient is having trouble hearing and states, "I don't know what the matter is. All of a sudden, I can't hear you out of my left ear!" What should the nurse do next?

Correct Answer is D

Explanation

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