Assessment Exam 3-Chapters 15, 16, 17, & 18

sublingual gland

a salivary gland on either side of the tongue

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 a. esotropia b. strabismus c. phoria d. exotropia

a. esotropia

The nurse is preparing to examine an adult client's eyes, using a Snellen chart. The nurse should a. position the client 20 ft away from the chart b. ask the client to remove his glasses c. aske the clent to read each line with both eyes open d. instruct the client to begin reading from the bottom of the chart

a. position the client 20 ft away from the chart

A 45 yo client tells the nurse that he occasionally sees spots in from of his eyes. The nurse should a. tell the client that these often occur with aging b. refer the client to an ophthalmologist c. re-examine the client in 2 weeks d. assess the client for signs of diabetes

a. tell the client that these often occur with aging

What the purpose of testing the red reflex? a.Check for cataracts b.Check for ectropion c.Check for glaucoma d.Check for macular degeneration

a.Check for cataracts

What is the name of the test where the nurse covers one eye at a time with an opaque card and quickly removes it? a.Cover-uncover test b.Corneal light reflex test c.Positions test d.Strabismus test

a.Cover-uncover test

What is the appearance of the normal optic disc? a.Creamy color b.Margins of the disc are blurry c.Round with well-defined borders d.Plump and blood-filled

a.Creamy color c.Round with well-defined borders

The functional reflex that allows the eyes to focus on near objects is termed

accomodation

trachea

air passage extending from the throat and larynx to the main bronchi

The meibomian gland secrete

an oily substance to lubricate the eyes

The nurse is caring for a healthy adult client with no history of vision problems. The nurse should tell the client that a thorough eye examination is recommended every a. year b. 2 years c. 3 years d. 4 years

b. 2 years

An adult client visits the clinic and tells the nurse that he has been experiencing double vision for the past few days. The nurse refers the client to a physician for evaluation of possible a. glaucoma b. increased intracranial pressure c. hypertension d. ophthalmic migraine

b. increased intracranial pressure

An adult client tells the nurse that his father had cataracts. He asks the nurse about risk factors for cataracts. The nurse should instruct the client that a potential risk factor is a. lack of vitamin C in the diet b. ultraviolet light exposure c. obesity d. use of antibiotics

b. ultraviolet light exposure

The conjunctiva of the eye is divided into the palpebral portion and the

bulbar portion

The cone of light is located in the... a) inner ear b) middle ear c) external ear d) semicircular ear

c) external ear

What does the confrontation test assess? a.Visual acuity b.Presbyopia c. Peripheral vision d.Pupillary response

c. Peripheral vision

What is the name of the test where the nurse instructs the client to hold his head steady and to follow a pencil or a finger while the pencil or finger moves as if to make a large "X" with a line through it or a large "H"? a. Accommodation test b. Optic disc test c. Positions test for extraocular movement d.Glaucoma test

c. Positions test for extraocular movement

An adult client tell the nurse that he has been experiencing gradual vision loss. The nurse should a. ask about the clients diet b. determine whether thee is a history of glaucoma c. check the clients blood pressure d. ask the client if he has any known allergies

c. check the clients blood pressure

The nurse is examining an adult client's eyes. The nurse has explained the positions test to the client. The nurse determines that the client needs further instructions when the client says that the positions test a. assesses the muscle strength of the eye b. assesses the functioning of the cranial nerves innervating the eye muscles c. requires the covering of each eye separately d. requires the client to focus on an object

c. requires the covering of each eye separately

What does cyanosis of the palpebral conjunctiva suggest? a.Anemia b.Diabetes c.Heart disorder d.Thyroid disorder

c.Heart disorder

vertebra prominens

cervical vertebra that can easily be palpated when the neck is flexed

The middle layer of the eye is known as the

choroid layer

The chambers of the eye contain aqueous humor, which helps to maintain intraocular pressure and

cleanse the cornea of the lens

The ossicles contained in the middle ear include the malleus, the incus, and the... a) pars tensa b) pars flaccida c) umbo d) stapes

d) stapes

An adult client tells the nurse that she frequently experiences burning and itching of both eyes. The nurse should assess the client for a. foreign body b. recent trauma c. blind spots d. allergies

d. allergies

An adult client tells the nurse that his eyes are painful because he left his contact lens in too long the day before yesterday. The nurse should instruct the client that prolonged wearing of contact lenses can lead to a. retinal damage b. cataracts c. myopia d. corneal damage

d. corneal damage

While assessing the eyes of an adult client, the nurse uses a wisp of cotton to stimulate the client's a. eyelid reflexes b. refractory mechanism c. lacrimal reflexes d. corneal reflexes

d. corneal reflexes

An adult client visits the clinic and tells the nurse that he has had excessive tearing in his left eye. The nurse should assess the client's eye for a. viral infection b. double vision c. allergic reactions d. lacrimal obstruction

d. lacrimal obstruction

A client has tested 20/40 on the distant visual acuity test using a Snellen chart. The nurse should a. document the results in the client's record b. ask the client to read a handheld vision chart c. ask the client to return in 2 weeks for another examination d. refer the client to an optometrist

d. refer the client to an optometrist

A client tells the nurse that she has difficulty seeing while driving at night. The nurse should explain to the client that night blindness is often associated with a. retinal deterioration b. head trauma c. migraine headaches d. vitamin A deficiency

d. vitamin A deficiency

When the nurse palpates the lacrimal apparatus, what is the normal finding? a.Clear drainage is seen b. White drainage is seen c.Yellow drainage is seen d.No drainage is seen

d.No drainage is seen

When the nurse is assessing the corneal light reflex, what is being tested? a. The speed with which the light reflex responds b.The speed of the pupillary and corneal response to the light c.When the cornea reacts to light reflected on it d.Where light reflects off of the corneas

d.Where light reflects off of the corneas

thyroid gland

largest of the endocrine glands. situated in the front and sides of neck just below the thyroid cartliage

Parotid gland

largest salivary gland

The optic nerves from each eyeball cross at the

optic chiasma

Trapezius and sternocleidomastoid

paired muscles that allow movement and provide support to the head and neck

The bony orbit and fat cushion of the eye serves as a

protector

Straight movements of the eye are controlled by the

rectus muscles

Photoreceptors of the eye are located in the eye's

retina

cricoid cartliage

ring-like cartliage forming the lower and back part of the larynx

cranial nerve XI

spinal accessory nerve-contractions of trapezius and sternoclediomastoid muscles

An adult client visits the client and tells the nurse that she has had headaches recently that are intense and stabbing and often occur in the late evening. The nurse suspects the presence of a) cluster headaches b)tension headaches c) tumor-related headaches

a) cluster headaches

In the hearing pathway, hair cells of the spiral organ of Corti are stimulated by movement of... a) fluid b) sound c) air d) bone

a) fluid

A female client visits the clinic and tells the nurse that she frequently experiences severe recurring headaches that sometimes last for days and is accompanied by nausea and vomiting. This type of headache is classified as a) migraine headaches b) cluster headaches c) tension headaches

a) migraine headaches

The nurse is assessing the neck of a client and observes their trachea is pulled to the left side, what action should be taken a) refer the client to a physician for further evaluation b) ask the client to flex his neck to the left c) palpate the cricoid cartilage for smoothness

a) refer the client to a physician for further evaluation

An older client visits the clinic accompanied by his daughter. The daughter tells the nurse that her father has been experiencing severe headaches that usually begin in the morning and become worse when he coughs with dizziness. This is a sign of a) tumor headaches b) cluster headaches c) migraine headaches

a) tumor headaches

Sensory receptors in the ear that help maintain both static and dynamic equilibrium are located in the semicircular canals and the... a) vestibule b) tympanic membrane c) cone of light d) eustachian tube

a) vestibule

An adult tells the nurse that her peripheral vision is not what it used to be and she has a blind spot in her left eye. The nurse should refer the client for evaluation of possible a. glaucoma b. increased intracranial pressure c. bacterial infection d. migraine headaches

a. glaucoma

The nurse is preparing to perform a head and neck assessment of an adult client who has immigrated to the US from Cambodia, the nurse should first a) examine the client's lymph nodes b) ask the client if touching their head is permissible c) ask why they can't speak clear english

b) ask the client if touching their head is permissible

A female client tells the nurse 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's hungry all of the time but is loosing weight." A priority nursing diagnosis is a) imbalanced nutrition: less than body requirements related to excessive energy level and nervousness b) health-seeking behaviors related to verbalization of wanting to stay healthy and concerns over weight loss c) thyroid dysfunction related to neck swelling, perspiration, and fidgeting and concern over weight loss

b) health-seeking behaviors related to verbalization of wanting to stay healthy and concerns over weight loss

A client visits an outpatient center with a complaint of sudden head and neck pain with stiffness. The client's oral temperature is 100 degrees Fahrenheit. The nurse suspects the client is experiencing symptoms of... a) migraine headaches b) meningeal irritation c) otitis media

b) meningeal irritation

While assessing a client's head and neck, an asymmetry is observed in front of the ear lobes, the client is referred to a specialist for a) enlarged thyroid b) parotid gland enlargement c) neurological disorder

b) parotid gland enlargement

The nurse has tested the near visual acuity of a 45 yo client. The nurse explains to the client that the client has impaired near vision and discusses a possible reason for the condition. The nurse determines that the client has understood the instructions when the client says that the presbyopia is usually due to a. congenital cataracts b. decreased accommodation c. muscle weakness d. constant misalignment of the eyes

b. decreased accommodation

A client visits the local clinic after experiencing head trauma. The client tells the nurse that he has a consistent blind spot in his right eye. The nurse should a. examine the area of head trauma b. refer the client to a ophthalmologist c. assess the client for double vision d. ask the client if he sees "halos"

b. refer the client to a ophthalmologist

A client reports his 80-year old father is almost deaf, after teaching about hearing loss the nurse determines more coaching is needed when the client says... a) "There is a genetic predisposition to hearing loss." b) "Certain culture groups have a higher rate of hearing loss." c) "It's difficult to prevent hearing loss or worsening of hearing." d) "Chronic otitis media has been associated with hearing loss."

c) "It's difficult to prevent hearing loss or worsening of hearing."

While assessing an adult client's skull, the nurse observes that the skull and facial bones are larger and thicker than usual, this is a sign of a) parotid gland enlargement b) cushing disease c) acromegaly

c) acromegaly

The nurse assesses an adult client's head and neck. While examining the carotid arteries, the nurse assesses each artery individually to prevent a... a) reduction of the blood supply to the brain b) premature ventricular heart sound c) decreased pulse pressure

c) decreased pulse pressure

To inspect movement of a patient's thyroid gland, the nurse should ask the patient to a) inhale deeply b) cough deeply c) swallow a small sip of water

c) swallow a small sip of water

An adult client comes to the doctor complaining of tinnitus, the nurse should ask if the client's been... a) dizzy b) hypertensive c) taking antibiotics d) experiencing ear drainage

c) taking antibiotics

A client visits the clinic and tells the nurse 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 recognizes these are symptoms of a) cluster headaches b) migraine headaches c) tension headaches

c) tension headaches

While assessing the head and neck of an adult client, the client tells the nurse that she has been experiencing sharp shooting facial pains that last from 10-20 seconds but are occurring more frequently. The nurse should refer the client for possible a) cancerous lesions b) arterial occlusion c) trigeminal neuralgia

c) trigeminal neuralgia

Transmission of sound waves in the inner ear is known as... a) conductive hearing b) tympanic hearing c) neuromotor hearing d) perceptive hearing

d) perceptive hearing

What does PERRLA mean? a.Pupil equilibrium retina retention association b.Peripheral pupillary reaction related to accommodation c. Presbyoptic eye reaction retained accentuation d. Pupils equal round reactive to light and accommodation

d. Pupils equal round reactive to light and accommodation

An adult client visits the outpatient clinic and tells the nurse that he has a throbbing aching pain in his right eye. The nurse should assess the client for a. recent exposure to irritants b. increased intracranial pressure c. excessive tearing d. a foreign body in the eye

d. a foreign body in the eye

The nurse has tested an adult client's visual fields and determined that the temporal field is 90 degrees in both eyes. The nurse should a. refer the client for further evaluation b. examine the client for other signs of glaucoma c. ask the client if there is a genetic history of blindness d. document the findings in the client's records

d. document the findings in the client's records

An adult client visits the clinic and tells the nurse that she has had a sudden change in her vision. The nurse should explain to the client that sudden changes in vision are often associated with a. diabetes b. the aging process c. hypertension d. head trauma

d. head trauma

hyoid bone

horseshoe-shaped bone at the base of the tongue; only bone in the body not directly attached to another bone

he tarsal plates of the upper eyelid contain

meibomian glands