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: You will not remain NPO for 8 hours before the procedure, but you will be instructed to stop eating and drinking for 4 to 6 hours before the procedure.
Choice B Reason: A flexible tube is not introduced through the nose during the procedure, but through the mouth and down the esophagus.
Choice C Reason: During the procedure, a contrast dye is not administered via IV, but a sedative and an anesthetic spray are given to help you relax and numb your throat.
Choice D Reason: You will be awake while the procedure is performed, but you will not feel any pain or discomfort as the tube passes through your digestive tract.
Correct Answer is A
Explanation
Choice A Reason: Contacting the health care provider is the first nursing action that the nurse should perform, as it indicates that the client may have compartment syndrome, which is a medical emergency that requires immediate intervention to prevent tissue necrosis and nerve damage.
Choice B Reason: Administering PRN pain medication is not the first nursing action that the nurse should perform, as it may not relieve the pain and may mask the symptoms of compartment syndrome.
Choice C Reason: Documenting the findings is not the first nursing action that the nurse should perform, as it may delay the treatment and worsen the outcome of compartment syndrome.
Choice D Reason: Elevating the extremity is not the first nursing action that the nurse should perform, as it may decrease blood flow and increase tissue ischemia in compartment syndrome.
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