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 C

Explanation

Choice A reason: Hyperthyroidism may cause eye issues like exophthalmos, not cataracts. Lens opacity from aging or smoking outweighs thyroid risk, making this 55-year-old less prioritized for cataract screening than older, smoking-exposed clients in this context fully.
Choice B reason: Minimal alcohol (two beers weekly) at 30 poses no cataract risk. Age and smoking are stronger factors; this young client lacks the cumulative exposure or oxidative stress tied to lens clouding, excluding them entirely here.
Choice C reason: At 75, with 50 years of smoking, this client faces high cataract risk. Aging degrades lens proteins, and smoking’s oxidative damage accelerates opacity, making this the priority for assessment and education on cataract prevention accurately here.
Choice D reason: Arteriosclerosis at 40 affects vessels, not lenses directly. While vascular health matters, age and smoking outweigh this risk for cataracts, rendering this client lower priority than the older, heavily smoking individual in this scenario fully.

A. "Ear candles are a good way to help remove impacted cerumen." B. "You should gently irrigate with normal saline." C. "Wash the pinna of your ear with a warm, moist washcloth." D. "If you note fullness in your ear, try to remove the impaction with a cotton swab."

Correct Answer is C

Explanation

Choice A reason: Ear candles are unsafe, risking burns or wax deeper in the canal. They don’t effectively remove cerumen and can perforate the eardrum, contradicting evidence-based hygiene practices for preventing ear infections or blockages entirely in this context.

Choice B reason: Irrigation with saline is for impacted cerumen, not routine hygiene. It’s a clinical procedure, not a daily prevention measure, and risks pushing wax further or damaging the canal if done improperly, making it less suitable here.

Choice C reason: Washing the pinna with a warm, moist washcloth safely cleans the outer ear, preventing debris buildup without risking the canal or eardrum. This simple, effective hygiene step aligns with illness prevention goals for routine ear care perfectly.

Choice D reason: Cotton swabs can push cerumen deeper, causing impaction or eardrum perforation. This unsafe practice increases infection risk, opposing hygiene goals, and is widely discouraged in favor of external cleaning for safe ear maintenance consistently.

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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

Correct Answer is C

Explanation

A health promotion teaching is focusing on hygiene and the prevention of illness. When instructing clients on how to clean their ears, what action should the nurse recommend?

Correct Answer is C

Explanation

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