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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Planning: Planning involves setting goals and interventions based on data collected, but data collection itself is not part of this phase.
B. Diagnosis: Diagnosis involves analyzing collected data to identify health issues, but data collection is a separate process that occurs before this phase.
C. Evaluation: Evaluation assesses the effectiveness of interventions and progress towards goals, but data collection is performed earlier in the process.
D. Assessment: Data collection is a fundamental part of the assessment phase in the nursing process, where information is gathered to identify patient needs and conditions.
Correct Answer is B
Explanation
A. Facial, Trigeminal, Vestibulocochlear: The Facial nerve (VII) controls facial expressions, the Trigeminal nerve (V) is involved in facial sensation, and the Vestibulocochlear nerve (VIII) handles hearing and balance, none of which are directly related to eye movements.
B. Oculomotor, Trochlear, and Abducens: The Oculomotor nerve (III) controls most eye movements, the Trochlear nerve (IV) controls the superior oblique muscle for downward and outward movements, and the Abducens nerve (VI) controls the lateral rectus muscle for lateral eye movement.
C. Spinal Accessory, Facial, Trigeminal: The Spinal Accessory nerve (XI) controls neck and shoulder movements, while the Facial nerve (VII) and Trigeminal nerve (V) are not involved in eye movements.
D. Glossopharyngeal, Vagus, Hypoglossal: The Glossopharyngeal nerve (IX) is involved in taste and salivation, the Vagus nerve (X) affects parasympathetic functions, and the Hypoglossal nerve (XII) controls tongue movements, none of which are related to eye movements.
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