A nurse is caring for a client who complains that he feels as though his ear is blocked and tells the nurse that he has a history of cerumen impaction in the external ear. The nurse, inspecting the ears for cerumen impaction, checks for which finding?
The presence of edema in the external auditory canal
A yellowish or brownish waxy material in the external auditory canal
Redness and swelling of the tympanic membrane
An external auditory canal that is longer than normal
The Correct Answer is B
Choice A Reason: The presence of edema in the external auditory canal is not a sign of cerumen impaction, but it may indicate other conditions such as otitis externa or allergic reaction.
Choice B Reason: A yellowish or brownish waxy material in the external auditory canal is a sign of cerumen impaction, as it shows that there is excess or hardened earwax that blocks the ear canal.
Choice C Reason: Redness and swelling of the tympanic membrane are not signs of cerumen impaction, but they may indicate other conditions such as otitis media or trauma.
Choice D Reason: An external auditory canal that is longer than normal is not a sign of cerumen impaction, but it may be a normal variation or a result of aging.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A Reason: Impaired skin integrity is not the most appropriate nursing diagnosis for a client with Addison's disease, as it does not reflect the main problem of adrenal insufficiency and cortisol deficiency.
Choice B Reason: Fluid volume overload is not the most appropriate nursing diagnosis for a client with Addison's disease, as it does not reflect the main problem of adrenal insufficiency and aldosterone deficiency.
Choice C Reason: Imbalanced nutrition: more than body requirements is not the most appropriate nursing diagnosis for a client with Addison's disease, as it does not reflect the main problem of adrenal insufficiency and weight loss.
Choice D Reason: Risk for injury is the most appropriate nursing diagnosis for a client with Addison's disease, as it reflects the main problem of adrenal insufficiency and hypotension, which can cause falls, fainting, or shock.
Correct Answer is A
Explanation
Choice A Reason: Checking blood sugar then eating breakfast prior to injecting insulin indicates that additional teaching is necessary, as it may cause hyperglycemia or hypoglycemia depending on the type and timing of insulin. The client should inject insulin before eating breakfast according to their blood sugar level and carbohydrate intake.
Choice B Reason: Rotating sites from arms, legs, and abdomen indicates that no additional teaching is necessary, as it helps to prevent lipodystrophy and ensure consistent absorption of insulin.
Choice C Reason: Ensuring the use of insulin syringe with units indicates that no additional teaching is necessary, as it helps to prevent dosing errors and ensure accurate administration of insulin.
Choice D Reason: Activating the safety lock on the syringe before disposing in a sharps container indicates that no additional teaching is necessary, as it helps to prevent needlestick injuries and infection transmission.
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