The nurse is assessing a 20-year-old client and notes the presence of bilateral earlobe creases. The nurse would choose which of the following actions? Standard Text: Select all that apply
1. Refer the client to a plastic surgeon.
2. Document this finding as normal.
3. Document the finding and notify the healthcare provider.
4. Ask the client about any history of injuries to his ears.
5. Assess the client's risk factors for coronary artery disease.
3,4,5
Rationale 1: Refer the client to a plastic surgeon. The client may have an increased risk for developing coronary artery disease. At this point, the client does not need to be referred to a plastic surgeon.
Rationale 2: Document this finding as normal. This is an abnormal finding and the client should be carefully monitored for the development of coronary artery disease.
Rationale 3: Document the finding and notify the healthcare provider. The nurse should document the finding, request information from the client regarding any injuries to the ears, and notify the healthcare provider about the presence of the bilateral earlobe creases.
Rationale 4: Ask the client about any history of injuries to his ears. The nurse should determine if the client has sustained any injuries to the ears that could account for the bilateral earlobe creases.
Rationale 5: Assess the client's risk factors for coronary artery disease. The nurse should assess the client for any other clinical manifestations and risk factors associated with coronary artery disease.
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