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. Asking about cramping or tingling is unnecessary without other signs of compromised circulation.
B. Referral is not needed if perfusion is adequate.
C. Checking for claudication relates to arterial insufficiency, not absence of ulnar pulse.
D. Proceeding with the evaluation is appropriate if perfusion is adequate, as indicated by normal capillary refill and warm skin.
Correct Answer is ["C","D","E"]
Explanation
A. Murphy sign: This is used to assess for gallbladder inflammation, not appendicitis.
B. Shifting dullness: This is used to detect ascites, not appendicitis.
C. Obturator test: This test involves flexing the patient's right hip and knee and rotating the leg internally, causing pain if the appendix is inflamed.
D. Blumberg sign: This test for rebound tenderness indicates peritoneal irritation, commonly associated with appendicitis.
E. Iliopsoas muscle test: This test involves extending the right leg against resistance, which can elicit pain in cases of appendicitis.
F. Fluid wave: This is used to assess for ascites, not appendicitis.
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