The nurse has completed the assessment of the client's ears. A small/moderate amount of brown cerumen was found in both ears. Which action by the nurse is warranted?
Assess for further signs of infection
Document this normal finding
Set up a teaching session regarding ear hygiene
Make a note on the chart so the clinician can order ear drops
The Correct Answer is B
Choice A reason: Small/moderate brown cerumen is normal, not a sign of infection, which shows pus or redness. Assessing further wastes effort, as cerumen protects the canal, and no symptoms like pain or hearing loss suggest pathology here requiring investigation.
Choice B reason: Documenting small/moderate brown cerumen as normal is correct, as it’s a protective earwax variant. Absent symptoms, this finding needs no intervention, aligning with standard practice to record typical ear assessments without escalating care unnecessarily in this case.
Choice C reason: Teaching hygiene isn’t needed for normal cerumen levels, which self-regulate. Excessive cleaning risks impaction or injury, and with no blockage or symptoms, this action overcomplicates a routine finding better left to natural ear processes here.
Choice D reason: Noting for ear drops assumes intervention for a non-issue. Normal brown cerumen doesn’t require softening or removal unless symptomatic, making this step premature and unnecessary, diverging from evidence-based care for typical ear findings fully.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Turbulence in large airways causes coarse sounds, not high-pitched wheezes. Wheezes stem from narrowed smaller passages, like bronchioles, not broad airway dynamics, making this less accurate for the specific sound’s pathophysiology fully here.
Choice B reason: Air leaking into the pleural space (pneumothorax) reduces breath sounds, not causing wheezes. Wheezes arise from airway narrowing, not alveolar rupture, excluding this as the source of the auscultated adventitious sound entirely here fully.
Choice C reason: Air diversion from trachea to bronchi is normal airflow, not producing wheezes. Wheezes require obstruction or constriction in smaller airways, not tracheal branching, rendering this unrelated to the sound’s pathological origin comprehensively here.
Choice D reason: Wheezes result from constricted respiratory passages, like in asthma, where narrowed bronchioles vibrate with airflow. This high-pitched sound matches the pathophysiology of airway narrowing, making it the correct explanation for this finding accurately here.
Correct Answer is B
Explanation
Choice A reason: Ophthalmoscopy checks cranial nerve II (optic), not III, IV, or VI. It visualizes the retina, missing the eye movement control these nerves govern, making it irrelevant to their motor function assessment entirely here fully.
Choice B reason: The 6 cardinal fields test cranial nerves III (eye movement, pupil), IV (superior oblique), and VI (lateral rectus). This single technique evaluates all three by tracking coordinated eye motion, making it the most efficient method accurately here.
Choice C reason: Vibration on eyelids tests sensation, possibly cranial nerve V, not III, IV, or VI. These nerves control eye movement, not sensory input, excluding this from assessing their motor roles in this neurological exam fully here.
Choice D reason: Head turning with hand tracking involves neck muscles and possibly cranial nerve XI, not just III, IV, VI. This dilutes focus on eye-specific movements, making it less precise for these cranial nerves’ assessment entirely here.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.