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:
Could be indicative of change in cilia; the nurse should assess for hearing loss.
Represents poor hygiene.
Is probably the result of lesions from eczema in his ear.
Is a normal finding and no further follow-up is necessary
The Correct Answer is D
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Liver enlargement: Pain from liver enlargement is typically felt in the right upper quadrant, not along the costovertebral angle.
B. Spleen enlargement: Splenic pain is usually located in the left upper quadrant, not in the costovertebral area.
C. Ovarian infection: Pain from ovarian infection is typically felt in the lower abdomen or pelvis, not the back.
D. Kidney inflammation: Pain along the costovertebral angles often indicates kidney inflammation or infection, such as pyelonephritis.
Correct Answer is {"A":{"answers":"D"},"B":{"answers":"A"},"C":{"answers":"C"},"D":{"answers":"B"}}
Explanation
|
Assessment Technique |
1 |
2 |
3 |
4 |
|
Percussion |
✅ |
|||
|
Inspection |
✅ |
|||
|
Palpation |
✅ |
|||
|
Auscultation |
✅ |
Rationale:
Begin with inspection to visually assess the abdomen for abnormalities. Auscultate before palpation and percussion to avoid altering bowel sounds. Determine areas of pain to avoid causing discomfort during palpation and percussion. Palpate to assess for tenderness or masses. Percuss last to evaluate organ size and detect abnormal fluid or gas.
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