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 C
Explanation
A. Diverticulosis: This condition involves the formation of pouches in the colon and is not associated with Murphy's sign.
B. Nephrolithiasis: This refers to kidney stones and is not associated with Murphy's sign.
C. Acute Cholecystitis: Murphy's sign is a clinical test for acute cholecystitis, which is inflammation of the gallbladder. It is positive when the patient experiences pain upon palpation of the gallbladder area during inhalation.
D. Appendicitis: Appendicitis is an inflammation of the appendix and is not related to Murphy's sign.
Correct Answer is D
Explanation
A. Mental status examination: This part of the assessment evaluates cognitive functions, not sensory functions related to cranial nerve VIII.
B. Mouth and throat: This area assesses cranial nerves related to swallowing and speech but not the sensory function of cranial nerve VIII.
C. Head and face: This includes assessing cranial nerves related to facial sensation and movement but not the auditory function of cranial nerve VIII.
D. Ears: Cranial nerve VIII, the vestibulocochlear nerve, is responsible for hearing and balance, so assessing sensory function related to this nerve occurs during the examination of the ears.
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