The nurse examines a client's auditory canal and tympanic membrane with an otoscope. The nurse recognizes that which of the following is considered an abnormal finding?
A shiny, pearly white color tympanic membrane
The presence of cerumen
The presence of a cone of light
A yellow or amber color to the tympanic membrane.
The Correct Answer is D
A. A shiny, pearly white color tympanic membrane: This is a normal finding. A healthy tympanic membrane often appears shiny and pearly white.
B. The presence of cerumen: This is a normal finding. Cerumen, or earwax, is a natural substance that helps protect the ear canal.
C. The presence of a cone of light: This is a normal finding. The cone of light is a reflection of the otoscope light on the tympanic membrane and is a normal variation.
D. A yellow or amber color to the tympanic membrane: This is considered an abnormal finding. A yellow or amber coloration of the tympanic membrane can indicate the presence of fluid or infection behind the eardrum, which may be a sign of otitis media or other ear conditions.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Have the client breathe quickly:
This choice is incorrect because having the client breathe quickly is not a technique for assessing tactile fremitus. Tactile fremitus is assessed by feeling vibrations on the chest wall while the patient speaks, not during normal breathing.
B. Palpate the chest symmetrically:
This choice is correct. To assess tactile fremitus, the nurse places the palms or ulnar aspects of both hands firmly against the patient's chest while the patient speaks a phrase. The nurse should palpate the chest symmetrically to detect vibrations equally on both sides, which can help identify abnormalities in the lungs.
C. Ask the client to cough:
This choice is incorrect. Asking the client to cough is not a technique for assessing tactile fremitus. Tactile fremitus is evaluated by feeling vibrations while the patient speaks, not while coughing.
D. Use the bell of the stethoscope:
This choice is incorrect. Tactile fremitus is assessed by palpation, not auscultation with a stethoscope. Using the bell of the stethoscope is a technique for listening to low-pitched sounds, not for assessing tactile fremitus.
Correct Answer is A
Explanation
A. Auricle (Pinna):
The auricle, also known as the pinna, is the visible external part of the ear. It consists of movable cartilage and skin. When administering eardrops, pulling the auricle up and back helps to straighten the ear canal, allowing the drops to enter the ear effectively.
B. Mastoid Process:
The mastoid process is a bony prominence located behind the ear. It is not a part of the outer ear structure involved in administering eardrops.
C. Outer Meatus:
The outer meatus, also known as the external acoustic meatus or ear canal, is the tube-like structure leading from the auricle to the eardrum. It is the passage through which eardrops are administered. Pulling the auricle up and back helps to straighten the outer meatus for the proper administration of eardrops.
D. Concha:
The concha refers to the bowl-shaped depression next to the ear canal. While it is a part of the outer ear, pulling the concha is not a technique used for administering eardrops. The auricle, specifically, is manipulated to facilitate the process.
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