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

Answer and Explanation

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.

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Correct Answer is C

Explanation

A. Determine areas of tenderness: While identifying tenderness is important, it is not the reason for auscultating first.

B. Allows the patient to relax: Relaxation is helpful but not the primary reason for the sequence.

C. Prevents distortion of bowel sounds: Percussion and palpation can stimulate or suppress bowel sounds, leading to inaccurate findings if performed before auscultation.

D. Prevents distortion of vascular sounds: Vascular sounds (bruits) are less likely to be affected by percussion or palpation.

A. Shine a light across the pupil from the side, and observe for direct and consensual pupillary constriction. B. Ask the patient to follow the penlight in eight directions, and observe for bilateral pupil constriction. C. Shine a penlight from directly in front of the patient, and inspect for pupillary constriction. D. Ask the patient to focus on a distant object. Then ask the patient to follow the penlight to approximately 7 cm from the nose.

Correct Answer is A

Explanation

A. Shine a light across the pupil from the side: To assess the pupillary light reflex, the nurse should shine a light across the pupil from the side and observe for both direct and consensual constriction (the constriction of both pupils when one is exposed to light).

B. Follow the penlight: This tests for accommodation (focusing on near objects) rather than the pupillary light reflex.

C. Shine a penlight directly in front: This method doesn’t assess both direct and consensual constriction properly.

D. Focus on a distant object: This assesses accommodation, not the pupillary light reflex.

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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:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is A

Explanation

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