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 B
Explanation
A. Inform the client that his breast enlargement is benign, and normal for a man of his age:
This choice is not appropriate because while gynecomastia can be benign, it should not be assumed without a proper medical evaluation. Gynecomastia can have various causes, including hormonal imbalances or underlying medical conditions. It's crucial to identify the cause through a medical assessment.
B. Explain that this condition may be the result of hormonal changes, and recommend that he see his physician:
This is the correct choice. Gynecomastia can indeed be caused by hormonal changes, but it can also be due to medications, certain health conditions, or hormonal imbalances. Therefore, the nurse should recommend a medical evaluation to determine the underlying cause and appropriate management.
C. Recommend that he alter his diet to include fewer fats and more lean proteins:
This choice is not relevant to gynecomastia. Gynecomastia is not typically caused by dietary factors, so altering the diet would not be a suitable response to this situation.
D. Explain that gynecomastia in men is usually associated with prostate enlargement and recommend that he be thoroughly screened:
This choice is incorrect. Gynecomastia is not directly associated with prostate enlargement. While both conditions can occur in older men, they are distinct medical issues. Screening for prostate enlargement is not indicated based solely on the presence of gynecomastia. Proper evaluation and assessment of each condition are necessary.
Correct Answer is D
Explanation
. Presence of breath sounds: While assessing the anterior chest, the nurse should listen for breath sounds over various areas of the lungs. However, this is related to auscultation, not inspection.
B. Diaphragmatic excursion: Diaphragmatic excursion involves assessing the movement of the diaphragm during breathing. This is typically done by percussing the level where dullness changes to resonance during inhalation and exhalation. It is more related to percussion, not inspection.
C. Symmetric chest expansion: Symmetric chest expansion refers to the equal expansion of both sides of the chest during inhalation. The nurse can observe and palpate the chest to assess if it expands symmetrically on both sides. This is a crucial aspect of the inspection of the anterior chest.
D. Shape and configuration of the chest wall: The shape and configuration of the chest wall, including abnormalities or deformities, should be assessed during inspection. This includes observing for any asymmetry, deformities, masses, or scars on the anterior chest.
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