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 D

Explanation

A. To allow for the client to focus on the illness: Accurate and complete information is crucial for developing a proper care plan but not directly related to the client’s focus on their illness.

B. To allow for the client to spend more time with the nurse: Accurate information helps in forming a plan but does not necessarily impact the amount of time spent with the nurse.

C. To allow the nurse more time to know the client: While knowing the client is important, the primary reason for accurate information is to develop effective interventions.

D. To develop a plan with interventions that promote health: Accurate and complete assessment information is essential for developing a comprehensive care plan and interventions that address the client’s health needs.

A. Facial, Trigeminal, Vestibulocochlear B. Oculomotor, Trochlear, and Abducens C. Spinal Accessory, Facial, Trigeminal D. Glossopharyngeal, Vagus, Hypoglossal

Correct Answer is B

Explanation

A. Facial, Trigeminal, Vestibulocochlear: The Facial nerve (VII) is primarily responsible for facial expressions and taste sensation. The Trigeminal nerve (V) is involved in facial sensation and chewing. The Vestibulocochlear nerve (VIII) deals with hearing and balance, not eye movements.

B. Oculomotor, Trochlear, and Abducens: The Oculomotor nerve (III) controls most of the eye's movements, including constriction of the pupil. The Trochlear nerve (IV) innervates the superior oblique muscle, enabling downward and outward eye movements. The Abducens nerve (VI) controls the lateral rectus muscle, responsible for lateral eye movement.

C. Spinal Accessory, Facial, Trigeminal: The Spinal Accessory nerve (XI) controls neck and shoulder movements, not eye movements. The Facial nerve (VII) and Trigeminal nerve (V) are also not involved in eye movements.

D. Glossopharyngeal, Vagus, Hypoglossal: The Glossopharyngeal nerve (IX) is involved in taste and salivation. The Vagus nerve (X) controls parasympathetic functions and throat muscles. The Hypoglossal nerve (XII) controls tongue movements. None of these nerves are responsible for eye movements.

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

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Naxlex Comprehensive Predictor Exams

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Correct Answer is D

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Correct Answer is B

Explanation

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