When the nurse collects objective data, which finding requires immediate follow-up?

Moist nasal mucosa

Cerumen in the ear

Enlarged lymph node in the neck

Acne lesions on the face and upper chest

Answer and Explanation

The Correct Answer is C

A. Moist nasal mucosa: This is generally a normal finding and does not usually require immediate follow-up unless there are other symptoms suggesting infection or other issues.

B. Cerumen in the ear: While cerumen can impact hearing, it is typically not an urgent issue and can be managed with appropriate ear care.

C. Enlarged lymph node in the neck: Enlarged lymph nodes can indicate an underlying infection or malignancy, especially if persistent or accompanied by other symptoms, thus requiring immediate follow-up.

D. Acne lesions on the face and upper chest: Acne is common and usually not an urgent concern unless it is severe or causing significant distress.

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Correct Answer is D

Explanation

A. External Eye Structures: This assessment involves examining the visible parts of the eye and surrounding structures, not the distance vision.

B. Near Vision: Near vision is typically assessed using a reading chart held at a close distance, not a chart mounted on the wall.

C. Peripheral Vision: Peripheral vision assessments involve testing the field of vision to detect loss or abnormalities, rather than focusing on distant vision.

D. Distant Vision: Standing 20 feet from a chart to read letters tests distant vision, as it assesses the ability to see objects clearly at a distance.

A. Reduce all environmental noise. B. Percuss the region before auscultating. C. Palpate the region before auscultating. D. Assist the client to a sitting position.

Correct Answer is A

Explanation

A. Reduce all environmental noise: Minimizing environmental noise ensures that bowel sounds can be clearly heard during auscultation.

B. Percuss the region before auscultating: Percussion is not necessary before auscultation for detecting bowel sounds; auscultation should be done first.

C. Palpate the region before auscultating: Palpation can alter bowel sounds or cause false findings, so it is best to auscultate first.

D. Assist the client to a sitting position: The client’s position is less critical than reducing background noise; the client can be in various positions as long as the area is accessible.

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When the nurse collects objective data, which finding requires immediate follow-up?

Nursing Test Bank

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