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

Answer and Explanation

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.

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Correct Answer is B

Explanation

Choice A reason: Rapid ankle oscillations might suggest tremor, possibly basal ganglia issues, not cerebellar dysfunction. The heel-shin test assesses coordination, where cerebellar damage causes drift, not rhythmic shaking, making this less indicative of the target pathology here.
Choice B reason: Heel deviation to one side in the heel-shin test signals cerebellar dysfunction, impairing coordination. The cerebellum fine-tunes movement; damage causes ataxia, leading to inaccurate sliding, making this the key sign of cerebellar issues accurately.
Choice C reason: Pain and knee flexion suggest joint or nerve issues, not cerebellar dysfunction. This test evaluates smooth motion, not pain response; cerebellar problems show ataxia, not discomfort, disconnecting this from the intended motor assessment fully.
Choice D reason: Paresthesia (tingling) indicates sensory nerve issues, not cerebellar motor control. The cerebellum coordinates movement, not sensation; this response misses the coordination focus of the heel-shin test, excluding it as a cerebellar sign here entirely.

A. Prolonged tonsillar enlargement B. History of allergies C. Incomplete immunization record D. History of epistaxis nosebleeds

Correct Answer is B

Explanation

Choice A reason: Prolonged tonsillar enlargement may cause throat issues or obstruction, but rhinorrhea stems from nasal inflammation, not tonsils. This focuses on oropharyngeal anatomy, missing the direct nasal etiology tied to runny nose in upper airway complaints here entirely.

Choice B reason: Allergies trigger nasal inflammation via histamine, causing rhinorrhea as IgE-mediated mast cells release mediators. A history of this is key, directly linking environmental triggers to the client’s runny nose, making it the most relevant assessment area accurately.

Choice C reason: Incomplete immunizations increase infection risk, but rhinorrhea more commonly ties to allergies or viruses than vaccine-preventable diseases here. This is less specific to the symptom’s etiology without fever or systemic signs, reducing its pertinence significantly.

Choice D reason: Epistaxis (nosebleeds) relates to vascular fragility, not mucus production like rhinorrhea. Past bleeding doesn’t explain runny nose, focusing on a separate nasal issue, making it less relevant to the upper airway complaint’s root cause in this case fully.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is B

Explanation

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