The nurse is examining a patient's ears, which of the following findings is considered the expected findings?
The cone of light at 7 o'clock in the right ear and 5 o'clock in the left ear with a pink and moist tympanic membrane.
The cone of light at 7 o'clock in the right ear and 5 o'clock in the left ear with a pearly gray tympanic membrane.
The cone of light at 5 o'clock in the right ear and 7 o'clock in the left ear with a pink and moist tympanic membrane.
The cone of light at 5 o'clock in the right ear and 7 o'clock in the left ear with a pearly gray tympanic membrane.
The Correct Answer is B
A. The cone of light at 7 o'clock in the right ear and 5 o'clock in the left ear with a pink and moist tympanic membrane is not a typical finding, as the tympanic membrane should be pearly gray.
B. The cone of light at 7 o'clock in the right ear and 5 o'clock in the left ear with a pearly gray tympanic membrane is the expected finding for a normal ear exam, showing the healthy tympanic membrane and the proper positioning of the cone of light.
C. The cone of light at 5 o'clock in the right ear and 7 o'clock in the left ear with a pink and moist tympanic membrane is incorrect, as the tympanic membrane should be pearly gray, not pink and moist.
D. The cone of light at 5 o'clock in the right ear and 7 o'clock in the left ear with a pearly gray tympanic membrane is an incorrect positioning of the cone of light (should be at 7 o'clock for the right ear and 5 o'clock for the left).
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Reposition the client every 2 hr: This is an essential action to prevent pressure ulcers and skin breakdown, especially for bedridden patients. Frequent repositioning helps alleviate pressure on bony prominences.
B. Assess the client's skin for increased coolness: While assessing skin temperature is important, it is not as immediate as repositioning the patient. Increased coolness may suggest poor circulation.
C. Keep the client's skin moist: Keeping the skin moist can lead to skin breakdown and increases the risk for pressure ulcers. Dry skin is typically preferred to avoid moisture-related damage.
D. Massage the client's red bony prominences: Massaging reddened skin can actually damage the tissue and worsen pressure injuries. It is advised to avoid massaging bony prominences that show signs of pressure.
Correct Answer is C
Explanation
A. Exposed bone refers to a stage 4 pressure ulcer, which involves full-thickness tissue loss with bone, muscle, or tendon exposure.
B. Blood-filled blisters are more indicative of a stage 2 ulcer, which involves partial-thickness skin loss with blister formation.
C. A stage 3 ulcer is characterized by full-thickness skin loss, with damage extending into subcutaneous tissue, where necrosis may occur.
D. Partial-thickness skin loss is a characteristic of a stage 2 pressure ulcer, not stage 3.
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