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.

Answer and Explanation

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.

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Correct Answer is C

Explanation

A. VI

Cranial Nerve VI is the Abducent Nerve, which controls the movement of the lateral rectus muscle, allowing the eye to move laterally (abduct). Dysfunction of this nerve can cause difficulty in moving the eye outward.

B. V

Cranial Nerve V is the Trigeminal Nerve. It has both sensory and motor functions. Sensory functions include providing sensation to the face, sinuses, and teeth. Motor functions include controlling the muscles used for chewing (mastication).

C. II

Cranial Nerve II is the Optic Nerve. It is purely a sensory nerve responsible for vision. The optic nerve carries visual information from the retina of the eye to the brain.

D. III

Cranial Nerve III is the Oculomotor Nerve. It is primarily a motor nerve but also has some autonomic functions. It controls most of the eye movements (except lateral movement controlled by VI) and regulates the size of the pupil and the shape of the lens in the eye for focusing.

A. Bronchovesicular breath sounds and normal in that location. B. Normally auscultated over the trachea. C. Vesicular breath sounds and normal in that location. D. Bronchial breath sounds and normal in that location

Correct Answer is C

Explanation

A. Bronchovesicular breath sounds and normal in that location:

Bronchovesicular breath sounds are medium-pitched sounds heard over the major bronchi and are usually equal on inspiration and expiration. They are typically heard in the 1st and 2nd intercostal spaces anteriorly and between the scapulae posteriorly. While they might be normal in certain locations, hearing them over peripheral lung fields might indicate an abnormality.

B. Normally auscultated over the trachea:

This statement doesn't specify a particular type of breath sound. Tracheal breath sounds are harsh and relatively high-pitched, heard directly over the trachea. They are normal over the trachea but are not normally heard in the lung periphery.

C. Vesicular breath sounds and normal in that location:

Vesicular breath sounds are low-pitched, soft sounds heard over most of the lungs during inspiration. They are longer on inspiration than expiration and are considered normal breath sounds heard in the peripheral lung fields. Hearing vesicular sounds in the posterior lower lobes is typical and indicates normal lung function.

D. Bronchial breath sounds and normal in that location:

Bronchial breath sounds are high-pitched and loud, heard primarily over the trachea and larynx. If heard in the peripheral lung fields, especially in the lower lobes, it can suggest an abnormality such as consolidation or compression of lung tissue.

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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?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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