Wgu rn hesi health assessment proctored exam
A 16-year-old client with a history of chronic ear infections when younger comes to the clinic for a health exam. No ear pain, vertigo or hearing loss is reported during history taking. Inspection of the tympanic membranes (TM) reveals the presence of dense white patches on the TMs in both ears. Both TMs are a translucent gray with a light reflex at 5:00. All landmarks are visible. Based on these findings, which action should the nurse take next?
Explanation & Rationale
A. Referral to an audiologist: The client denies hearing loss, so a referral is unnecessary at this time. B. Culture the white patches: Dense white patches on the TM are likely tympanosclerosis, a benign finding from previous infections, and do not require culturing. C. Record the findings: Tympanosclerosis is a common and benign finding. No intervention is needed. D. Clean the ears: There is no indication of wax buildup affecting the findings.
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