The nurse examines a client's auditory canal and tympanic membrane with an otoscope. The nurse recognizes that which of the following is considered an abnormal finding?
A shiny, pearly white color tympanic membrane
The presence of cerumen
The presence of a cone of light
A yellow or amber color to the tympanic membrane.
The Correct Answer is D
A. A shiny, pearly white color tympanic membrane: This is a normal finding. A healthy tympanic membrane often appears shiny and pearly white.
B. The presence of cerumen: This is a normal finding. Cerumen, or earwax, is a natural substance that helps protect the ear canal.
C. The presence of a cone of light: This is a normal finding. The cone of light is a reflection of the otoscope light on the tympanic membrane and is a normal variation.
D. A yellow or amber color to the tympanic membrane: This is considered an abnormal finding. A yellow or amber coloration of the tympanic membrane can indicate the presence of fluid or infection behind the eardrum, which may be a sign of otitis media or other ear conditions.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Checks the instrument gauge to ensure the reading starts at zero:
This action is correct. Before taking a blood pressure reading, it's essential to ensure that the instrument's gauge starts at zero. This ensures accurate measurement as the reading reflects the pressure above zero.
B. Centers the cuff bladder over the client's brachial artery:
This action is correct. Proper placement of the blood pressure cuff over the brachial artery is crucial for accurate readings. Centering the cuff ensures that the artery is correctly compressed for measurement.
C. Places the client's arm above the level of the client's heart:
This action is incorrect. Placing the arm above heart level can result in a falsely low blood pressure reading. The arm should be at the same level as the heart to obtain an accurate measurement.
D. Wraps the blood pressure cuff around the client's arm using firm pressure:
This action is correct, but it's important to note that while the cuff should be snug, it should not be too tight or too loose. Wrapping the cuff with firm, even pressure ensures proper compression of the artery for an accurate measurement.
Correct Answer is A
Explanation
A. The atria contract toward the end of diastole and push the remaining blood into the ventricles.
This choice is correct. During atrial systole (atrial contraction), the atria contract, pushing the remaining blood into the ventricles. This additional filling of the ventricles optimizes cardiac output.
B. The atria contract during systole and attempt to push against closed valves.
This statement is incorrect. The atria do not contract during systole; they contract during diastole (atrial systole) to fill the ventricles.
C. Atrial kick is the pressure exerted against the atria as the ventricles contract during systole.
This statement is incorrect. Atrial kick refers to the atrial contraction, not the pressure exerted against the atria.
D. Contraction of the atria at the beginning of diastole can be felt as a palpitation.
This statement is not entirely accurate. A palpitation is a sensation of rapid or strong heartbeat, which might be felt during various cardiac events, not specifically during atrial contraction at the beginning of diastole.
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