When the nurse collects objective data, which finding requires immediate follow-up?

Moist nasal mucosa

Cerumen in the ear

Enlarged lymph node in the neck

Acne lesions on the face and upper chest

Answer and Explanation

The Correct Answer is C

A. Moist nasal mucosa: This is generally a normal finding and does not usually require immediate follow-up unless there are other symptoms suggesting infection or other issues.

B. Cerumen in the ear: While cerumen can impact hearing, it is typically not an urgent issue and can be managed with appropriate ear care.

C. Enlarged lymph node in the neck: Enlarged lymph nodes can indicate an underlying infection or malignancy, especially if persistent or accompanied by other symptoms, thus requiring immediate follow-up.

D. Acne lesions on the face and upper chest: Acne is common and usually not an urgent concern unless it is severe or causing significant distress.

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Correct Answer is C

Explanation

Rationale:
A. Fever: While fever might be a symptom of infection, it is not specific to inner ear infections.

B. Headache: This can be a symptom associated with inner ear infections, but vertigo is a more specific concern.

C. Vertigo: Inner ear infections often cause vertigo (dizziness or spinning sensations), so interventions for managing vertigo are crucial.

D. Rhinorrhea: This symptom is more commonly associated with upper respiratory infections rather than inner ear infections.

A. Use tangential lighting. B. Assist the client to a standing position. C. Use perpendicular lighting. D. Focus a penlight on the client's chest.

Correct Answer is C

Explanation

A. Use tangential lighting: Tangential lighting is not typically used for assessing heart impulses; it is more useful for examining surface characteristics of the skin.

B. Assist the client to a standing position: The client should be in a supine or semi-recumbent position for accurate inspection of apical heart impulses, not standing.

C. Use perpendicular lighting: Perpendicular lighting is crucial for accurately visualizing apical heart impulses, as it helps to clearly observe the movement of the heart against the chest wall.

D. Focus a penlight on the client's chest: While a penlight can be used in physical assessments, perpendicular lighting is more effective for clearly seeing the apical heart impulses.

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When the nurse collects objective data, which finding requires immediate follow-up?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

When planning care for a client with an inner ear infection, the nurse will need to include interventions for which of the following potential problems?

Correct Answer is C

Explanation

The nurse is planning to inspect a client's apical heart impulses. What should the nurse do to ensure an accurate assessment of this organ?

Correct Answer is C

Explanation

The nurse notes a break in the skin, which appears blister-like, it looks superficial with loss up to the dermis layer. The nurse would interpret this finding as indicating which stage of pressure ulcer?

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When the nurse collects objective data, which finding requires immediate follow-up?

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A nurse is performing a head-to-toe assessment and is preparing to examine the client's ears. Which equipment would the nurse need to have readily available?