The nurse explains the different parts of the ear to a client while teaching the client how to administer eardrops. The nurse pulls the upper ear that consists of movable cartilage and skin up and back and recognizes that this part is called the:

Auricle.

Mastoid process.

Outer meatus.

Concha.

Answer and Explanation

The Correct Answer is A

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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Correct Answer is ["A","B","C","D","E"]

Explanation

A. Use of accessory muscles

Explanation: Using accessory muscles during breathing indicates increased effort to breathe, which can be a sign of respiratory distress. It suggests that the client is having difficulty breathing and is using additional muscles to aid in the process. This finding should be reported to the practitioner for further evaluation.

B. Nail bed greater than 160 degrees

Explanation: A nail bed angle greater than 160 degrees, also known as clubbing, is an abnormal finding and can be associated with chronic respiratory or cardiovascular conditions. It may indicate insufficient oxygenation and should be reported to the practitioner for evaluation.

C. Circumoral cyanosis

Explanation: Circumoral cyanosis, which is a bluish discoloration around the mouth, indicates inadequate oxygenation. It can be a sign of respiratory or cardiac problems and should be reported to the practitioner for further assessment and intervention.

D. Pursed lip breathing

Explanation: Pursed lip breathing is a technique often used by individuals with respiratory difficulties to improve oxygen exchange. However, if it's observed in a person who does not normally use this technique, it could indicate respiratory distress and should be reported to the practitioner for evaluation.

E. Anteroposterior-to-transverse diameter of 1:1

Explanation: An anteroposterior-to-transverse diameter of 1:1 (also known as barrel chest) is an abnormal finding often associated with chronic obstructive pulmonary disease (COPD). It suggests overinflation of the lungs and can impair effective breathing. This finding should be reported to the practitioner for further evaluation.

A. Percussion of the posterior chest B. Inspection of the shape and configuration of the chest wall C. Placing the palmar surface of the fingers of one hand against the chest and having the client repeat "ninety nine" D. Placing hands sideways on the posterolateral chest wall with thumbs pointing together at the level of T9 or T10

Correct Answer is D

Explanation

A. Percussion of the posterior chest: Percussion helps assess the underlying structures of the chest but does not directly confirm symmetric chest expansion.

B. Inspection of the shape and configuration of the chest wall: Inspection is a crucial part of assessing chest symmetry. Any deformities, asymmetry, or abnormalities in the shape and configuration of the chest wall can be visually identified.

C. Placing the palmar surface of the fingers of one hand against the chest and having the client repeat "ninety-nine": This technique, known as tactile fremitus, involves feeling for vibrations or tremors while the client repeats a phrase. While it can provide information about underlying lung conditions, it's not primarily used to confirm symmetric chest expansion.

D. Placing hands sideways on the posterolateral chest wall with thumbs pointing together at the level of T9 or T10: This technique, known as chest expansion measurement, is used to assess symmetric chest expansion. Placing hands in this manner allows the nurse to feel for bilateral chest expansion during inspiration, ensuring that both sides of the chest expand symmetrically.

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The nurse explains the different parts of the ear to a client while teaching the client how to administer eardrops. The nurse pulls the upper ear that consists of movable cartilage and skin up and back and recognizes that this part is called the:

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Naxlex Comprehensive Predictor Exams

Which of the following assessment findings should the nurse report to the practitioner? (Select all that apply)

Correct Answer is ["A","B","C","D","E"]

Explanation

The nurse is assessing the symmetry of the client's chest. The nurse recognizes that a client's symmetric expansion of the chest is best confirmed by:

Correct Answer is D

Explanation

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The nurse explains the different parts of the ear to a client while teaching the client how to administer eardrops. The nurse pulls the upper ear that consists of movable cartilage and skin up and back and recognizes that this part is called the:

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