The nurse has completed the assessment of the client's ears. A small/moderate amount of brown cerumen was found in both ears. Which action by the nurse is warranted?

Assess for further signs of infection

Document this normal finding

Set up a teaching session regarding ear hygiene

Make a note on the chart so the clinician can order ear drops

Answer and Explanation

The Correct Answer is B

Choice A reason: Small/moderate brown cerumen is normal, not a sign of infection, which shows pus or redness. Assessing further wastes effort, as cerumen protects the canal, and no symptoms like pain or hearing loss suggest pathology here requiring investigation.

Choice B reason: Documenting small/moderate brown cerumen as normal is correct, as it’s a protective earwax variant. Absent symptoms, this finding needs no intervention, aligning with standard practice to record typical ear assessments without escalating care unnecessarily in this case.

Choice C reason: Teaching hygiene isn’t needed for normal cerumen levels, which self-regulate. Excessive cleaning risks impaction or injury, and with no blockage or symptoms, this action overcomplicates a routine finding better left to natural ear processes here.

Choice D reason: Noting for ear drops assumes intervention for a non-issue. Normal brown cerumen doesn’t require softening or removal unless symptomatic, making this step premature and unnecessary, diverging from evidence-based care for typical ear findings fully.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is B

Explanation

Choice A reason: Food restrictions identify allergies or preferences, but not intake patterns. This limits nutritional status insight, missing recent consumption data critical for assessing current health, making it less foundational for this initial evaluation fully here.
Choice B reason: A 24-hour recall details recent intake, offering a snapshot of diet quality and quantity. This directly informs nutritional status, habits, and deficits, making it the most appropriate starting question for a comprehensive assessment accurately here.
Choice C reason: Family obesity history suggests genetic risk, not the client’s nutrition. This indirect data lacks specificity on current intake, rendering it less useful than a direct dietary recall for this nutritional assessment entirely and fully here.
Choice D reason: Meal frequency provides structure, not content or quality. It’s less informative than a 24-hour recall, which captures specifics of what’s eaten, making it secondary for initiating a detailed nutritional evaluation comprehensively here fully.

A. The client will close the eyes and identify what number the nurse writes in the palm of the client's hand with a blunt-ended object. B. The nurse will simultaneously touch the client in the same area on both sides of the body, and the client will identify where the touch occurred. C. The nurse will ask the client to close his eyes, and will ask that he identify a familiar object placed in the client’s hand. D. The client is asked to identify the number of points felt when the nurse touches the client with the ends of two applicators at the same time.

Correct Answer is A

Explanation

Choice A reason: Graphesthesia tests cortical sensory function by tracing numbers on the palm with eyes closed. A right-sided stroke may impair this on the left side, making this the correct method to assess parietal lobe processing accurately here.
Choice B reason: Simultaneous bilateral touch tests extinction, not graphesthesia. This assesses neglect, not the ability to interpret shapes, missing the specific sensory integration focus needed for graphesthesia in this stroke assessment entirely and fully here.
Choice C reason: Identifying objects with eyes closed tests stereognosis, not graphesthesia. This evaluates tactile recognition, not number tracing, diverging from the precise cortical sensory skill targeted in this neurological exam for stroke effects here.
Choice D reason: Two-point discrimination tests sensory acuity, not graphesthesia. This measures point differentiation, not shape recognition, making it unrelated to assessing the parietal lobe’s interpretive ability post-stroke as intended in this scenario fully.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

The nurse has completed the assessment of the client's ears. A small/moderate amount of brown cerumen was found in both ears. Which action by the nurse is warranted?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is preparing to perform a nutritional assessment of a newly admitted client. What question would be most appropriate for the nurse to ask when initiating the assessment?

Correct Answer is B

Explanation

Correct Answer is A

Explanation

The nurse is performing a peripheral vascular assessment of an adult client. The nurse is palpating the client's peripheral pulses but knows that some are not palpable, even in healthy clients. What pulse is not palpable in a large proportion of healthy clients?

The client reports a decreased sense of smell for the past week. Which condition would the nurse assess for?

An older adult client has been admitted due to decreased cognition. What assessment finding is most suggestive of delirium as the cause of the client's cognitive impairment?

A client has a family history of prostate cancer and is committed to regular screening. What should the nurse teach the client about prostate-specific antigen (PSA) blood testing?

The nurse is testing for motor functioning by having the client lie down and slide the heel of the right foot down the left shin and then slide the heel of the left foot down the right shin. Which response by the patient would indicate that there may be cerebellar dysfunction?