Which of the following are objective assessment findings(s) of the ear? Select all that apply
Cerumen buildup
Skin is dry and flaky
Pain at the pinna
Cone of light visualized
Tenderness of the neck
Correct Answer : A,B,D
A. Cerumen (earwax) accumulation is something the nurse can directly observe during inspection of the external auditory canal. Because it is visible and measurable, it is considered an objective finding.
B. The condition of the skin around the ear can be directly observed. Dryness and flakiness are visible physical characteristics, making this an objective assessment finding.
C. Pain is a subjective symptom, meaning it is reported by the client and cannot be directly measured or observed by the nurse. Even if the nurse elicits pain by palpation, the sensation itself is based on the client’s report, making it subjective.
D. Visualization of the cone of light during otoscopic examination is a directly observable physical sign of the tympanic membrane’s condition. This makes it an objective finding.
E. Tenderness, like pain, is based on the client’s report during palpation. Although the nurse performs the assessment, the determination of tenderness depends on the client’s perception, making it subjective.
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Related Questions
Correct Answer is B
Explanation
A. Reports of mucus buildup are subjective because they rely on the client’s personal perception and self-report. Subjective data are symptoms, not directly measurable by the nurse.
B. Tympanic membrane translucent is an objective finding because it can be observed and measured during otoscopic examination. Objective data are measurable or visible signs that the nurse can directly assess. The translucency of the tympanic membrane indicates a healthy ear without infection or fluid buildup.
C. Pain and tenderness behind the ear are primarily subjective, as pain is reported by the client. While tenderness can be assessed by palpation, the pain component is still experienced by the client, making it partially subjective.
D. Coughing and sneezing may be observable, but they are not specific to the ear and are typically considered related to upper respiratory symptoms, not direct objective data from an ear assessment.
Correct Answer is D
Explanation
A. Offering thin liquids to promote hydration can increase the risk of aspiration in clients with stroke-related dysphagia. Thin liquids are harder to control during swallowing, so thickened liquids are often recommended until swallowing ability is assessed. This option is unsafe for airway protection.
B. Avoiding oral care is incorrect. Oral hygiene is crucial for stroke clients because poor oral care increases the risk of aspiration pneumonia from bacteria in the mouth. Oral care should be performed carefully and frequently.
C. Encouraging the client to lie flat after meals increases the risk of aspiration, as gravity can allow food or liquids to enter the airway. This position should be avoided in clients with swallowing difficulties.
D. Positioning the client upright during and after eating is the correct action. Maintaining an upright position (ideally 90 degrees in a chair or as upright as tolerated in bed) facilitates safe swallowing, reduces the risk of aspiration, and supports airway protection. Clients should remain upright for at least 30–60 minutes after meals to further reduce aspiration risk.
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