230 Exam 3
Which statement by the nurse indicates the best understanding of the purpose of an eye-related health history?
"Broad, open-ended questions provide an opportunity to identify changes in the client's eyes."
When the nurse is obtaining the health history of the nose and sinuses, a client reports symptoms of rhinorrhea. Which question should the nurse ask to determine associated manifestations of this symptom?
"have you had a sore throat?"
Which vision acuity reading indicates blindness?
20/200
A patient in the clinic where you work is considered legally blind. The nurse knows that this means the vision in his better eye, corrected by glasses, is what?
20/200 or less
The nurse notes a tophus of the ear of an older adult. Which assessment data is consistent with a tophus?
A hard nodule composed of uric acid crystals
Where is the temporal artery palpated?
Above the cheek bone near the scalp line
The nurse assesses the frontal sinus where?
Above the eyes
A mother of a small child calls the clinica and asks to schedule an appointment for ear tube removal. The call is transferred to the nurse. What is the nurse's best action?
Ask how long the tubes have been in place
A nurse is preparing to examine a client from Southeast Asia who has been experiencing chronic headaches. Which of the following should the nurse do in light of this client's cultural background?
Ask permission before palpating the head and neck
Which technique by the nurse demonstrates proper use of the ophthalmoscope?
Asks the client to fix the gaze upon an object and look straight ahead
The nurse is assessing the mouth of an older adult and observes that the client appears to have poorly fitting dentures. The nurse should instruct the client that she may be at greater risk for
Aspiration
A 66-year-old woman has come to the clinic with complaints of increasing fatigue over the last several months. She claims to frequently feel lethargic and listless and states that, "I can never seem to get warm, no matter what the thermostat is set at." How should the nurse proceed with assessment?
Assess the woman for hypothyroidism.
A nurse is assessing the mouth of a client and finds that she has a smooth, red, shiny tongue without papillae. The nurse should recognize this as indicative of a loss of which vitamin?
B12
The nurse practitioner notes that the thyroid gland is enlarged and auscultates both lobes of the thyroid. For what is the nurse practitioner listening?
Bruit
The nurse is palpating a client's cervical vertebrae. Which vertebra can be easily palpated when the neck is flexed and should help the nurse locate the other vertebrae?
C7
When inspecting the mouth, the nurse focuses on lateral and vertical surfaces of the tongue and its base, because these are regions where:
Cancers often occur.
During a physical examination the nurse observes the condition shown on a client's hard palate. How should the nurse document this finding?
Candidiasis
A client tells the nurse that his eyes "are not working right." When the nurse asks what the client means, the client states, "It is like one eye is moving faster than the other." What test would be most appropriate for the nurse to use to assess this client?
Cardinal fields
The nurse identifies this as trapping debris and propelling it toward the nasopharynx.
Cilia
The transmission of sound waves through the external ear and the middle ear is known as
Conductive hearing
A light is pointed at a client's pupil, which then contracts. It is also noted that the other pupil contracts as well, though it is not exposed to bright light. Which of the following terms describes this latter phenomenon?
Consensual reaction
While the nurse examines a patient's pupillary response to light in the right eye, the pupil in the left eye is constricted. What does this finding suggest to the nurse?
Consensual reaction (any reflex observed on one side of the body when the other side has been stimulated)
An adult client tells the nurse that his eyes are painful because he left his contact lenses in too long the day before yesterday. The nurse should instruct the client that prolonged wearing of contact lenses can lead to
Corneal damage
A client has been diagnosed with astigmatism. The nurse should be prepared to teach the client about which treatment for this condition?
Corrective lenses
A nurse is working with a client who has an impaired ability to move the tongue. He explains that he was in an automobile accident many years ago and suffered nerve damage that resulted in this condition. Which nerve should the nurse suspect was damaged in this client?
Cranial nerve XII (hypoglossal)
A nurse is assessing a child who got lost on a camping trip in November and was exposed all night to the elements. Which finding about the lips would support a diagnosis of hypoxia in this client?
Cyanotic
A nurse is inspecting the bulbar conjunctiva and sclera of a 67-year-old client, and notices yellowish nodules on the medial side of the iris. Which of the following is the most appropriate nursing action at this time?
Document the finding and proceed with the examination
The nurse selects the chart shown here to assess a client's vision. Which client characteristic caused the nurse to select this chart?
Does not speak English
The nurse is discharging an adult client who received 18 staples for a head laceration received while mountain biking. What can the nurse focus on while doing discharge teaching?
Encourage the use of safety equipment
A nurse is educating a client about the function of the parts of the auditory system. Which is the function of the eustachian tube?
Equalizes the pressure in the middle ear with atmospheric pressure.
The nursing student hopefuls are taking a pre-nursing anatomy and physiology class. What will they learn is the anatomical feature that equalizes air pressure in the middle ear?
Eustachian tube
When performing the cover test, a nurse notices that the client's left eye turns outward. How should the nurse document this finding in the client's record?
Exotropia (a from of strabismus, eyes turn outward)
A client exhibits purulent drainage in the right external ear canal. The client complains of pain that increases when the ear is touched. Which client teaching instructions should the nurse provide?
Finish the course of antibiotic therapy
A six-month old male infant is brought to the emergency department by his parents for inconsolable crying and pulling at his right ear. When assessing this infant the nurse is aware that the tympanic membrane should be what color in a healthy ear?
Gray
Which finding should a nurse recognize as normal when assessing the ears of an elderly client?
High-tone frequency loss
A staff educator from the hospital is providing an event for the hospital staff. The educator is talking about health promotion activities for people with diseases of the nose, mouth, throat, and sinuses. What would the educator include in the presentation?
How to reduce periodontal disease
A client diagnosed with goiter has undergone a thyroidectomy. Which statement from the client indicates understanding of post-operative care teaching?
I must take thyroid hormone replacement medication for the rest of my life.
A child presents to the health care facility with new onset of a foul-smelling, purulent drainage from the right nare. The mother states that no other signs of an upper respiratory tract infection are present. What is an appropriate action by the nurse?
Inspect the nostrils with an otoscope
A client comes into the clinic complaining of hoarseness that has lasted for about a month. What would you suspect?
Laryngeal cancer
An objective assessment of a client's ears reveals small, painless nodules on the left helix. How would the nurse note this finding in the client's medical record?
Left external ear within normal limits
During an oral assessment, the nurse identifies that client has white patches in his mouth. How would this be documented in the medical record?
Leukoplakia
The nurse is presenting an educational event for a local civic group about the risk factors for neck cancer. What would the nurse list? (Select all that apply.)
Male gender Tobacco use Age older than 50 years
A client presents to the emergency department with reports of neck pain and a sudden onset of a headache. Upon examination, the nurse finds that the client has an increased temperature and neck stiffness. The nurse recognizes these findings as most likely to be caused by what condition?
Meningeal inflammation
A nurse is caring for a patient admitted with neck pain. The patient is febrile. What is the most likely medical diagnosis for this patient?
Meningitis
A 38-year-old accountant comes to the clinic for evaluation of a headache. The throbbing sensation is located in the right temporal region, and is an 8 on a pain scale of 1 to 10. It started a few hours ago, and she has noted nausea with sensitivity to light; she has had headaches like this in the past, usually less than one per week, but not as severe. She does not know of any inciting factors. There has been no change in the frequency of her headaches. She usually takes an over-the-counter analgesic, which results in resolution of the headache. Based on this description, what is the most likely diagnosis of the type of headache?
Migraine
A client reports right-sided temporal headache accompanied by nausea and vomiting. A nurse recognizes that which condition is likely to produce these symptoms?
Migraine headache
When teaching a class of school-age children about hygiene, the nurse should include which information about the ears?
Never put anything smaller than your elbow in your ears
Which of the following describes a condition characterized by abnormal spongy bone formation around the stapes?
Otosclerosis
A 73-year-old woman comes to the office for evaluation of new onset of tremors. She is not taking any medications, herbs, or supplements. She has no chronic medical conditions. She does not smoke or drink alcohol. She walks into the examination room with slow, shuffling steps. She has decreased facial mobility with a blunt expression without any changes in hair distribution on her face. Based on this description, what is the most likely reason for the client's symptoms?
Parkinson's disease
Which statement reflects accurate documentation by the nurse of a normal, left tympanic membrane?
Pearly gray, translucent, with cone of light at 7 o'clock position
A client complains of recurring headaches that are worse when first waking in the morning and with coughing or sneezing. What would be the nurse's most appropriate action?
Perform a focused assessment
Which precaution should a nurse take to ensure the safety of a client when performing the Romberg test?
Place arms around the client without touching
The nurse observes a middle-aged colleague fully extending her arm to read the label on a vial of medication. Which of the following age-related changes is the nurse likely to have observed?
Presbyopia (far-sightedness)
Which instructions should the nurse provide to the client taking a sublingual medication?
Put the medication underneath your tongue.
After conducting a health history, the nurse decides to perform the assessment shown. What finding did the nurse use to make this clinical determination?
Reduced hearing in one ear
During a physical examination the nurse performs the action shown. What assessment is the nurse performing?
Rinne test (i think the bone conduction one but check)
A client admitted to the health care facility is diagnosed with vertigo. Which test is appropriate for the nurse to perform to assess for equilibrium in the client?
Romberg
A client presents at the clinic complaining of a loss of balance. What test should the nurse expect the physician to carry out on a client with a loss of balance?
Romberg test
A client is assigned a visual acuity of 20/100 in her left eye. Which of the following is true?
She can see at 20 feet what a normal person could see at 100 feet.
The roof of the oral cavity of the mouth is formed by the anterior hard palate and the
Soft palate
A client is having trouble turning her head to the side. Which of the following muscles should the nurse most suspect as being involved?
Sternocleidomastoid
A 12-year-old presents to the clinic with his father for evaluation of a painful lump in the left eye. It started this morning. The client denies any trauma or injury. There is no visual disturbance. Upon physical examination, there is a red raised area at the margin of the eyelid that is tender to palpation; no tearing occurs with palpation of the lesion. Based on this description, what is the most likely diagnosis?
Stye
Which action by the nurse is consistent with Weber's test?
The nurse activates the tuning fork and places it on the midline of the parietal bone in line with both ears.
Which action by the nurse is consistent with the Rinne test?
The nurse strikes the tuning fork and places it on the patient's mastoid process to measure bone conduction.
The nurse is assessing a client complaining of swelling in the neck. While palpating the neck, the nurse finds a 2-cm lump that is fixed and hard. Why does this finding require emergency investigation?
This could be a sign of cancer
When preparing to examine a patient's sclera and conjunctiva during an eye examination, the nurse should instruct the patient to move both eyes to look in which direction?
Up
A patient is found to have a smooth, glossy tongue. What vitamin deficiency might this indicate?
Vitamin B12 deficiency
The submandibular glands open under the tongue through openings called
Wharton ducts
The nurse is preparing to perform a head and neck assessment of an adult client who has immigrated to the United States from Cambodia. The nurse should first
ask the client if touching the head is permissible.
Before examining the mouth of an adult client, the nurse should first
don clean gloves for the procedure
The nurse observes an inward turning of the lower lid in a 77-year-old patient. The nurse documents
entropion
While assessing the eye of an adult client, the nurse observes an inward turning of the client's left eye. The nurse should document the client's
esotropia.
In order to effectively assess the oral mucosa, the nurse should have which assessment tools available?
gloves, penlight, tongue depressor
A female client visits the clinic and tells the nurse that she wants to "stay healthy." The nurse observes that the client has diffuse neck enlargement, is perspiring, and is quite fidgety. The client tells the nurse that she is "hungry all the time, but I have lost weight." A priority nursing diagnosis for the client is
health-seeking behaviors related to verbalization of wanting to stay healthy and concerns over weight loss.
A patient complains of feeling like he is slowly losing his central vision. The nurse knows this symptom could represent
macular degeneration
Photoreceptors of the eye are located in the eye's
retina
The nurse is preparing to assess the neck of an adult client. To inspect movement of the client's thyroid gland, the nurse should ask the client to
swallow a small sip of water.
A client visits the clinic and tells the nurse that he is depressed because of a recent job loss. He complains of dull, aching, tight, and diffuse headaches that have lasted for several days. The nurse should recognize that these are symptoms of
tension headaches.
When planning care for a client with an inner ear infection, the nurse will need to include interventions for which of the following potential problems?
vertigo
