Adult Gerontology - ENT Q & A

The nurse practitioner is seeing Millie, a 47-year-old year old school teacher, who comes to the office with complaints of right-side jaw pain, a clicking and popping sound with movement of her jaw, otalgia, and odontalgia. She had dental work done approximately 6 months ago and says the symptoms started after her dental procedure. Your diagnosis is temporomandibular joint (TMJ) dysfunction. All of the following are nonpharmacological therapy except A. starting a liquid diet and continuing it for 6 months. B. applying heat to the affected area for 15 to 20 minutes up to 6 times per day. C. eating a soft diet to rest the muscles of mastication. D. massaging of the masseter and the temporalis muscles.

Answer: A A liquid diet for 6 months would not provide sufficient nutritional value to the patient and may lead to other complications. A soft diet to rest the muscles of mastication, applying heat to the affected areas for 15 to 20 minutes four to six times a day, and massaging the masseter and temporalis muscles are all recommended nonpharmacological therapy for TMJ.

Regular ocular pressure testing is indicated for older adults taking A. high-dose inhaled glucocorticoids. B. NSAIDs. C. angiotensin-converting enzyme (ACE) inhibitors. D. insulin.

Answer: A Although regular ocular pressure testing is indicated for all older adults on a routine basis, it is especially important for clients taking an extended regimen of high-dose inhaled glucocorticoids because prolonged continuous use increases the risk of ocular hypertension or open-angle glaucoma. NSAIDs and ACE inhibitors do not require ocular pressure monitoring. Older adults taking insulin need to have regular eye examinations because they are diabetic and have a risk of diabetic retinopathy, not because they are taking insulin.

You note a completely split uvula in Noi, a 42-year-old Asian. What is your next course of action? A. Do nothing. B. Refer Noi to an ENT specialist. C. Perform a throat culture. D. Order a complete blood count.

Answer: A Bifid uvula, a condition in which the uvula is either partially or completely split, occurs in 18% of Native Americans and 10% of Asians and is rare in whites and blacks. There is no need for treatment.

Sylvia, age 72, has glaucoma and has started taking a medication that acts as a diuretic to reduce the intraocular pressure. Which medication is she taking? A. A carbonic anhydrase inhibitor B. A beta-adrenergic receptor blocker C. A miotic D. A mydriatic

Answer: A Carbonic anhydrase inhibitors, such as acetazolamide (Diamox), act as diuretics to reduce the intraocular pressure in clients with glaucoma. A miotic causes contraction of the pupil, and a mydriatic dilates the pupil. Because of the effect of pupil dilation on aqueous outflow in angle-closure glaucoma, medications such as atropine and other anticholinergics that have a mydriatic effect should be avoided. Miotics such as pilocarpine (Pilocar) may be given to cause contraction of the sphincter of the iris and to contract the ciliary muscle, which promotes accommodation for near vision and facilitates aqueous humor outflow by increasing drainage through the trabecular meshwork in openangle glaucoma. But the question is asking about diuretics, which pilocarpine is not. It is a cholinergic agent.

Which is the most common localized infection of one of the glands of the eyelids? A. Hordeolum B. Chalazion C. Bacterial conjunctivitis D. Herpes simplex

Answer: A Hordeolum (stye) is the most common localized infection of one of the glands of the eyelids. Treatment includes warm compresses for 15 minutes four times a day and topical antibiotics. A chalazion is a chronic swelling of the eyelids not associated with conjunctivitis. Bacterial conjunctivitis does not involve one of the glands of the eyelids. Primary herpes simplex of the eye usually presents as conjunctivitis with a clear, watery discharge; vesicles on the lids; and pre-auricular lymphadenopathy.

In older adults, the most common cause of decreased visual functioning is A. cataract formation. B. glaucoma. C. macular degeneration. D. arcus senilis.

Answer: A In older adults, the most common cause of decreased visual functioning is cataract formation (lens opacity), which should be expected by age 70. Glaucoma (increased ocular pressure) is the secondmost common cause of decreased visual functioning. It increases from age 46 to 60, then levels off. Macular degeneration (loss of central vision), which affects 30% of persons older than age 65, affects a person's ability to read fi ne print and do handiwork. Arcus senilis does not affect vision.

Microtia refers to the size of the A. ears. B. head. C. jaw. D. eyes.

Answer: A Microtia refers to the size of the ears, specifi cally ears smaller than 4 cm vertically. Microcephaly is an abnormally small head due to failure of brain growth. Micrognathia is a term for a lower jaw that is smaller than normal, and microphthalmia is a disorder in which one or both eyes are abnormally small.

The first-line antibiotic therapy for an adult with no known allergies and suspected group A beta-hemolytic streptococcal pharyngitis is A. penicillin. B. erythromycin (E-Mycin). C. azithromycin (Zithromax). D. cephalexin (Kefl ex).

Answer: A Penicillin (PCN) is the fi rst-line antibiotic therapy for an adult with no known allergies and suspected group A beta-hemolytic streptococcus pharyngitis. Erythromycin (E-Mycin) and azithromycin (Zithromax) are macrolide antibiotics and are recommended in individuals who have a penicillin allergy. Cephalexin (Kefl ex) is a cephalosporin antibiotic and has been found to be very effective in the treatment of strep throat and is a reasonable alternative to penicillin.

A 25-year-old client who plays in a band complains that he finds it difficult to understand his fellow musicians at the end of a night of performing, a problem that is compounded by the noisy environment of the club. These symptoms are most characteristic of which of the following? A. Sensorineural loss B. Conductive loss C. Tinnitus D. Vertigo

Answer: A Sensorineural loss comes from exposure to loud noises, inner ear infections, tumors, congenital and familial disorders, and aging. The etiology of conductive loss includes ear infection, presence of a foreign body, perforated drum, and otosclerosis of the ossicles. The results of the Weber and Rinne test will assist in the diagnosis. Tinnitus is ringing in the ears, and vertigo is dizziness associated with inner ear dysfunction. The client does not complain of either of these symptoms.

Mattie, age 64, presents with blurred vision in one eye and states that it felt like "a curtain came down over my eye." She doesn't have any pain or redness. What do you suspect? A. Retinal detachment B. Acute angle-closure glaucoma C. Open-angle glaucoma D. Cataract

Answer: A The classic sign of retinal detachment is a client stating that "a curtain came down over my eye." Typically, the person presents with blurred vision in one eye that becomes progressively worse, with no pain or redness. With acute angle-closure glaucoma, there is a rapid onset in older adults, with severe pain and profound visual loss. The eye is red, with a steamy cornea and a dilated pupil. With open-angle glaucoma, there is an insidious onset in older adults, a gradual loss of peripheral vision over a period of years, and perception of "halos" around lights. With a cataract, there is blurred vision that is progressive over months or years and no pain or redness.

Sally, age 19, presents with pain and pressure over her cheeks and discolored nasal discharge. You cannot transilluminate the sinuses. You suspect which common sinus to be affected? A. Maxillary sinus B. Ethmoid sinus C. Temporal sinus D. Frontal sinus

Answer: A The maxillary sinus is the largest of the paranasal sinuses and is the most commonly affected sinus. There is usually pain and pressure over the cheek. Inability to transilluminate the cavity usually indicates a cavity fi lled with purulent material. Discolored nasal discharge, as well as a poor response to decongestants, may also indicate sinusitis. The ethmoid sinuses are usually nonpalpable and may not be transilluminated. The frontal sinuses are just below the eyebrows. Frontal sinusitis also includes pain and tenderness of the forehead.

The most common offending allergens causing allergic rhinitis are A. pollens of grasses, trees, and weeds. B. fungi. C. animal allergens. D. foods.

Answer: A The most common offending allergens causing allergic rhinitis are, in descending order, pollens of grasses, trees, and weeds; fungi; animal allergens; and dust mites. Rhinitis is the most troublesome allergic problem and affects 20% of the population

Millie, a well-nourished 69-year-old retired widow, presents to the office for her routine physical examination and states that in the past month she has had two nosebleeds. The episodes were mild and self -limiting. Her past medical history is unremarkable. She does not take any anticoagulants, and you have ruled out any coagulopathies. The most likely cause of these nosebleeds is A. local trauma. B. sex hormones. C. a dietary change. D. scurvy.

Answer: A The most common reason for epistaxis is a local irritation or trauma (90%). It would be helpful to ask if the patient bumped her nose or recently had a sinusitis or irritation to the mucosa that may have predisposed her to the nosebleed. Nosebleeds and bruising are common with elderly patients who are taking an anticoagulant; however, this patient is not taking any anticoagulants. Unless the patient diet is severely lacking in vitamin K, there is no need for her to change her diet. Severe vitamin C deficiency (scurvy) can cause bleeding; however, the condition is very rare in the United States.

The most frequent cause of laryngeal obstruction in an adult is A. a piece of meat. B. a tumor. C. mucosal swelling from an allergic reaction. D. inhalation of a carcinogen.

Answer: A The most frequent cause of laryngeal obstruction in an adult is a piece of meat that lodges in the airway. With a tumor, there would be a gradual growth, and treatment would probably be sought before there is a complete obstruction. Mucosal swelling from an allergic reaction may result in an obstruction, but this does not occur as frequently as a laryngeal obstruction from a piece of meat. Inhalation of a carcinogen would result only in an irritation of the mucosa, if anything.

Mrs. Smith, a 70-year-old widow, is seen in the clinic for routine examination. She asks the nurse practitioner if she can donate her corneas when she dies. How do you respond? A. "As long as you don't have any chronic illness, your corneas may be harvested." B. "They will use corneas only from persons younger than age 65." C. "What makes you feel that you are dying?" D. "Don't think about such terrible things now."

Answer: B Corneas are harvested from the cadavers of uninfected persons younger than age 65 who die as the result of an acute trauma or illness. The client's question does not necessarily mean that she is thinking about dying; it is natural for older adults to think about death, and their thoughts and feelings should be explored.

The normal ratio of the artery-to-vein width in the retina as viewed through the ophthalmoscope is A. 2 to 3. B. 3 to 2. C. 1 to 3. D. 3 to 1.

Answer: A The normal artery-to-vein ratio in the retinal vessels is 2:3 or 4:5, with the arterioles being a brighter red than the veins when viewed through the ophthalmoscope. The arterioles have a narrow light reflex from the center line of the vessel. Veins do not normally show a light reflex. Both arterioles and veins show a gradual and regularly diminishing diameter as you look at them from the disc to the periphery. When hypertension is present, the arterioles may be only about half the size of the corresponding vein, and they may appear opaque and lighter. With long-standing hypertension, nicking is present. This occurs when the underlying veins are concealed to some degree by the abnormally opaque arteriole wall at the vessel crossings.

Jill, a 34-year-old bank teller, presents with symptoms of hay fever. She complains of nasal congestion, runny nose with clear mucus, and itchy nose and eyes. On physical assessment, you observe that she has pale nasal turbinates. What is your diagnosis? A. Allergic rhinitis B. Viral rhinitis C. Nasal polyps D. Nasal vestibulitis from folliculitis

Answer: A The symptoms of hay fever, also called allergic rhinitis, are similar to those of viral rhinitis but usually persist and are seasonal in nature. When assessing the nasal mucosa, you will observe that the turbinates are usually pale or violaceous because of venous engorgement with allergic rhinitis. With viral rhinitis, the mucosa is usually erythematous; and with nasal polyps, there are usually yellowish, boggy masses of hypertrophic mucosa. Nasal vestibulitis usually results from folliculitis of the hairs that line the nares.

client comes to the office complaining of pain in the posterior neck with difficulty turning the head to the right for approximately 1 week. What additional history is needed? A. Recent trauma B. Difficulty swallowing C. Stiffness in the right shoulder D. Change in sleeping habits

Answer: A Though a change in sleeping habits (e.g., new bed pillows) is a possibility, in this case the character of the pain should lead the practitioner to inquire about any traumatic event in the past involving her neck, such as a fall or motor vehicle accident or a history of repetitive activity involving the head or neck, such as a change in exercise routine or a new hobby. Spasm of the trapezius will cause difficulty in turning the head to one side or another. Difficulty swallowing, though significant in some clients, doesn't seem related to the presenting complaint.

Which of the following conditions produces sharp, piercing facial pain that lasts for seconds to minutes? A. Trigeminal neuralgia B. TMJ C. Goiter D. Pre-auricular adenitis

Answer: A Trigeminal neuralgia is described as a sharp, piercing, shooting facial pain that is severe but usually lasts only a short time. The origin is the trigeminal nerve (CN V). TMJ is associated with pain on opening and closing the mouth and is also associated with crepitus of that joint. A goiter is generally painless. Pre-auricular adenitis (enlarged and inflamed pre-auricular nodes) would be sustained until the etiological cause is identified and treated.

When you are assessing the internal structure of the eye of your 59-year-old patient, the absence of a red reflex may indicate A. a cataract or a hemorrhage into the vitreous humor. B. acute iritis. C. nothing; this is a normal finding in older adults. D. diabetes or long-standing hypertension.

Answer: A When assessing the internal structure of the eye, absence of a red reflex may indicate the total opacity of the pupil because of a cataract or a hemorrhage into the vitreous humor. It may also be a result of improper positioning of the ophthalmoscope. Acute iritis is noted by constriction of the pupil accompanied by pain and circumcorneal redness (ciliary flush). If areas of hemorrhage, exudate, and white patches are present when the internal structure of the eye is assessed, they are usually a result of diabetes or long-standing hypertension

April, age 50, presents with soft, raised, yellow plaques on her eyelids at the inner canthi. She is concerned that they may be cancerous skin lesions. You tell her that they are probably A. xanthelasmas. B. pingueculae. C. the result of arcus senilis. D. actinic keratoses.

Answer: A Xanthelasmas are soft, raised, yellow plaques on the eyelids at the inner eye canthus. They appear most frequently in women, beginning in the 50s. Xanthelasmas occur with both high and normal lipid levels and have no pathological significance. Pingueculae are yellowish, elevated nodules appearing on the sclera. They are caused by a thickening of the bulbar conjunctiva from prolonged exposure to the sun, wind, and dust. Arcus senilis appears as gray-white arcs or circles around the limbus as a result of deposits of lipid material that make the cornea look cloudy. Actinic keratoses are wartlike growths on the skin that occur in middle-aged or older adults and are caused by excessive exposure to the sun.

Which of the following refractive errors in vision is a result of the natural loss of accommodative capacity with age? A. Presbyopia B. Hyperopia C. Myopia D. Astigmatism

Answer: A Painless, white, slightly raised patches in client's mouth are probably caused by candidiasis (thrush). Aphthous ulcers (canker sores) are extremely painful. Herpes simplex (a viral infection), canker sores, and cancerous lesions are usually discrete and not spread over a large area.

Marty, a 51-year-old banker, has a hordeolum in his right eye. You suspect that the offending organism is A. herpes simplex virus. B. Staphylococcus. C. Candida albicans. D. Escherichia coli.

Answer: B A hordeolum (stye) is an abscess that may occur on the external or internal margin of the eyelid. It is typically caused by Staphylococcus bacteria.

Mary, age 82, presents with several eye problems. She states that her eyes are always dry and look "sunken in." What do you suspect? A. Hypothyroidism B. Normal age-related changes C. Cushing's syndrome D. A detached retina

Answer: B Dryness of the eyes and the appearance of "sunken" eyes are normal age-related changes. With hyperthyroidism, the eyes appear to bulge out (exophthalmos), but in hypothyroidism, the eyes do not appear any different. A moon face is apparent with Cushing's syndrome, and this might make the eyes appear to be sunken in, although on close examination, they are not. With a detached retina, the outward appearance is normal, but the client complains of seeing floaters or spots in the visual field and describes the sensation as like a curtain being drawn across the vision.

Your client, a 72-year-old smoker of 50 years, is at the office today for a routine physical. During your inspection of the oral mucosa, you discover a white lesion on the lateral surface of the tongue that you suspect to be cancerous. You document your finding as A. a superficial, translucent, subepithelial vesicular like lesion in the oral mucosa. B. a white painless firm ulcerated lesion with indurated borders. C. an abnormal white coating of the dorsal surface of the tongue. D. a round, smooth, firm lump on the lateral side of the tongue.

Answer: B A superficial mucocele presents as small, clear vesicle on non-inflamed mucosa. Approximately 90% of oral cancers are squamous cell carcinoma (SCC), which is seen typically on the lip or lateral part of the tongue usually as a lesion that is white, red, or mixed white and red. SSC are characterized by lesions that are painless and fi rm with indurated borders. The term "hairy tongue" is used to describe an abnormal coating on the top (dorsal) surface of the tongue. It is a relatively common, temporary, and harmless condition that occurs in as much as 13% of the population. Hairy tongue can occur at any age but is more frequent in older age. A round, smooth, fi rm lump attached at its base or by a stalk to part of the oral cavity tissue is a called a fibroma. It may occur anywhere in the oral cavity, but most often develops in the inner lining of the cheeks and lips. A fibroma is a common benign oral cavity tumor.

A 65-year-old man presents complaining of a left-side, deep, throbbing headache along with mild fatigue. On examination the client has a tender, tortuous temporal artery. You suspect giant cell arteritis (temporal arteritis). What is the least invasive procedure to help with diagnosis? A. MRI of the head B. Erythrocyte sedimentation rate (ESR) C. EEG D. Otoscopy

Answer: B An elevated ESR—anywhere from 30 to 100 mm/hr—may be seen in giant cell arteritis (temporal arteritis); however, the ESR may also be normal. The temporal artery supplies the optic nerve; if temporal arteritis is suspected due to the age of the client (50 and older) and the location and character of the pain, it is essential that a referral to a surgeon be made for immediate biopsy of the artery before damage to the optic nerve occurs. An MRA, not MRI, can be done to evaluate the blood vessels in the brain, but the blood test is less invasive. EEG and otoscopy are not used in the diagnosis of GCA. A temporal artery biopsy (TAB), an invasive procedure, is the criterion standard for diagnosing temporal arteritis.

When Jillian, age 16, asks you to explain the 20/50 vision in her right eye, you respond, A. "You can see at 20 feet with your left eye what most people can see at 50 feet." B. "You can see at 20 feet with your right eye what most people can see at 50 feet." C. "You can see at 50 feet with your right eye what most people can see at 20 feet." D. "You can see at 50 feet with your left eye what most people can see at 20 feet."

Answer: B An explanation of 20/50 vision in a client's right eye would be: "You can see at 20 ft with your right eye what most people can see at 50 ft." Normal visual acuity is 20/20 on a Snellen eye chart. The larger the denominator, the poorer the vision. If vision is greater than 20/30, refer the client to an ophthalmologist or optometrist.

Mia, a 27-year-old school teacher, has a 2-day history of severe left ear pain that began after one week of URI symptoms. On physical examination, you find that she has AOM. She has severe allergies to penicillin. The most appropriate antimicrobial option for this patient is A. ciprofloxacin (Cipro). B. azithromycin (Zithromax). C. amoxicillin (Amoxil). D. cephalexin (Keflex).

Answer: B Azithromycin is not a perfect option for treating otitis media; however, it is preferred for patients with severe penicillin allergy. Ciprofloxacin, a fluoroquinolone antibiotic, is not recommended for the treatment of acute otitis media; and amoxicillin and cephalexin are penicillin-based antibiotics and should not be given to a patient with a penicillin allergy.

Marlene, a 57-year-old cashier, comes to the clinic because she is unable to differentiate between sharp and dull stimulation on both sides of her face. You suspect A. Bell's palsy. B. a lesion affecting the trigeminal nerve. C. a stroke (brain attack, CVA). D. shingles.

Answer: B Bell's palsy affects the facial nerve, resulting in weakness or paralysis of one side of the face. A stroke and shingles are unilateral in their presentation as well. A lesion affecting the sensory portion of the trigeminal nerve could be manifested by bilateral symptoms

Mark, age 56, has allergic rhinitis and comes to the office requesting medications to relieve his symptoms. He is taking cimetidine (Tagamet) for gastroesophageal reflux disease. As the nurse practitioner caring for Mark, which medication would you not order? A. A first-generation antihistamine B. A second-generation antihistamine C. A decongestant D. A topical nasal corticosteroid

Answer: B Caution needs to be used when ordering a second generation antihistamine for a client taking drugs such as cimetidine (Tagamet), erythromycin (E-Mycin), clarithromycin (Biaxin), and ketoconazole (Nizoral). These drugs are known to block cytochrome P450 metabolism. Also use cautiously in client with renal and hepatic impairment.

Which manifestation is noted with carbon monoxide poisoning? A. Circumoral pallor of the lips B. Cherry-red lips C. Cyanosis of the lips D. Pale pink lips

Answer: B Cherry-red lips are a manifestation of carbon monoxide poisoning. They also occur with acidosis from aspirin poisoning or ketoacidosis. In lightskinned clients, circumoral pallor of the lips occurs with shock and anemia, and cyanosis of the lips occurs with hypoxemia and chilling. Some lips are normally pale pink.

How should the nurse practitioner perform a vision screening for Tommy, age 30 months? A. Using a Snellen letter chart B. Using the Allen test C. Using a Snellen E chart D. Using a Rosenbaum chart

Answer: B Children aged 2.5 to 3 years should have their vision screened using the Allen test, which uses picture cards. The Snellen E chart is used for preschoolers aged 3 to 6, whereas the Snellen letter chart is used for school-aged and older clients. The Rosenbaum chart is used for a gross assessment of near vision by having the client hold reading material 12 to 14 in. away.

Clients with allergic conjunctivitis have which type of discharge? A. Purulent B. Serous or clear C. Stringy and white D. Profuse mucoid or mucopurulent

Answer: B Clients with allergic conjunctivitis have a stringy, white discharge. Clients with bacterial conjunctivitis have a purulent discharge; those with viral conjunctivitis have serous or clear drainage and pre-auricular lymph node enlargement. A profuse mucoid or mucopurulent discharge is indicative of chlamydial conjunctivitis.

Mr. Johnson, age 69, has had Ménière's disease for several years. He has some hearing loss but now has persistent vertigo. What treatment might be instituted to relieve the vertigo? A. A labyrinthectomy B. Pharmacological therapy C. A vestibular neurectomy D. Wearing an earplug in the ear with more hearing loss

Answer: B For a client who has had Ménière's disease for several years with some hearing loss but now has persistent vertigo, treatment by vestibular neurectomy might relieve the vertigo. In vestibular neurectomy, the portion of cranial nerve VIII controlling balance and sensations of vertigo is severed. Vertigo is usually relieved in 90% of the cases. A labyrinthectomy is the surgery of last resort for a client with Ménière's disease because the labyrinth is completely removed and cochlear function destroyed. This procedure is used only when hearing loss is nearly complete. Oral diuretics and a low-sodium diet may aid in maintaining a lower labyrinth pressure, which may help slightly. Wearing an earplug will not help and may aggravate the condition.

Mario, a 17-year-old high school student, came to the office for evaluation. He is complaining of persistent sore throat, fever, and malaise not relieved with penicillin therapy prescribed recently at the urgent care center. As the nurse practitioner, what would you order next? A. A throat culture B. A monospot test C. A rapid antigen test D. A Thayer-Martin plate test

Answer: B If a client has a persistent sore throat, fever, and malaise not relieved with penicillin therapy, a monospot test should be performed to rule out mononucleosis (Epstein-Barr virus). A throat culture and rapid antigen test are performed to help diagnose group A beta-hemolytic streptococcal infection. A Thayer-Martin plate test is performed to diagnose a gonococcal infection.

Kevin, a 56-year-old lawyer, has throbbing pain in the left eye, an irregular pupil shape, marked photophobia, and redness around the iris. What is your initial diagnosis? A. Conjunctivitis B. Iritis C. Subconjunctival hemorrhage D. Acute glaucoma

Answer: B If a client has throbbing pain in the eye, an irregular pupil shape, marked photophobia, and redness (a deep, dull, red halo or ciliary fl ush) around the iris and/or cornea, suspect iritis. An immediate referral is warranted. The client may also have blurred vision. The client with conjunctivitis has redness more prominently at the periphery of the eye, along with tearing and itching. The client may also complain of a scratchy, burning, or gritty sensation but not pain, although photophobia may be present. The client with subconjunctival hemorrhage presents with a sudden onset of a painless, bright-red appearance on the bulbar conjunctiva that usually results from pressure exerted during coughing, sneezing, or Valsalva maneuver. Other conditions that may result in a subconjunctival hemorrhage include uncontrolled hypertension and the use of anticoagulant medication. The client with acute glaucoma presents with circumcorneal redness, with the redness radiating around the iris, and a dilated pupil.

A 62-year-old woman presents to your clinic with a sudden right-side headache that is worse in her right eye. She states that her vision seems blurred, and her right pupil is dilated and slow to react. The right conjunctiva is markedly injected, and the eyeball is firm. You screen her vision and find that she is 20/30 OS and 20/30 OD. She most likely has A. open-angle glaucoma. B. angle-closure glaucoma. C. herpetic conjunctivitis. D. diabetic retinopathy.

Answer: B In angle-closure glaucoma, the patient presents with a sudden onset of symptoms as described in this case. This client has a marked visual deficit and pain as well as a fullness of the affected eye. This is a medical emergency and should be referred immediately because blindness can occur within days without intervention. With open-angle type, the onset is more insidious. Herpetic conjunctivitis is generally associated with a herpetic rash, and the pain is dull in character. Diabetic retinopathy is a complication of diabetes that affects both eyes. It is caused by damage to the blood vessels of the lightsensitive tissue at the back of the eye (retina).

Howard, age 68, has a hearing problem. He tells you he is ready for a drastic solution to the problem because he likes to play bingo but cannot hear the calls. What can you do for him? A. Refer him to a hearing aid specialist. B. Refer him for further testing. C. Perform a gross hearing test in the office, then repeat it in 6 months to determine if there is any further loss. D. Nothing. Tell him that a gradual hearing loss is to be expected with aging.

Answer: B It is important to send the patient for further testing. Approximately 10% of clients with a hearing loss are helped by medical or surgical treatment. If clients are sent for a hearing aid and not correctly identified as having a hearing loss, the underlying problem may not be resolved.

Mrs. Gordon, age 92, presents with dry eyes, redness, and a scratchy feeling in the eyes. You note that this is one of the most common disorders, particularly in older women, and diagnose this as A. viral conjunctivitis. B. keratoconjunctivitis sicca. C. allergic eye disease. D. corneal ulcer.

Answer: B Keratoconjunctivitis sicca is dry eyes, a common disorder among older women. It is associated with dryness, redness, or a scratchy feeling in the eyes. On rare, severe occasions, there is marked discomfort and photophobia. Typically, it is caused by subtle abnormalities of the tear fi lm and a reduced volume of tears. In most cases, tears can be replenished with the aqueous component of tears with over-the-counter artifi cial tears. Occasionally, mucomimetics are indicated when there is mucin deficiency. Viral conjunctivitis is caused by a virus and is associated with pharyngitis, fever, malaise, and pre-auricular lymph node enlargement. Allergic eye disease is benign and usually occurs in late adolescence or early adulthood. It is usually seasonal, and allergy treatment may be effective. A corneal ulcer is most commonly the result of a bacterial, viral, or fungal infection.

Erica, age 39, has a sudden onset of shivering, sweating, headache, aching in the orbits, and general malaise and misery. Her temperature is 102°F. The nurse practitioner diagnosed her with influenza (flu). What is your next course of action? A. Order amoxicillin (Amoxil) 500 mg every 12 hours for 7 days. B. Prescribe rest, fluids, acetaminophen (Tylenol), and possibly a decongestant and an antitussive. C. Order a complete blood count. D. Consult with your collaborating physician

Answer: B Management of influenza (flu) is generally symptomatic and includes rest, fluids, acetaminophen (Tylenol), and possibly a decongestant and an antitussive. The client should be advised to call or return to the clinic in 4 days if symptoms are not improving. Amoxicillin, an antibiotic, is not used in the treatment of influenza, a viral infection. Influenza diagnosis is usually made clinically and does not require a CBC. Consulting with the collaborating physician is unnecessary and will result in the same treatment for influenza.

A 44-year-old banker comes to your office for evaluation of a pulsating headache over the left temporal region, and he rates the pain as an 8 on a scale of 1 to 10. The pain has been constant for the past several hours and is accompanied by nausea and sensitivity to light. He has had frequent headaches for many years but not as severe, and they are usually relieved by over-the-counter medicines. He is unclear as to a precipitating event but notes that he has had visual disturbances before each headache and he has been under a lot of stress in his job. Based on this description, what is the most likely diagnosis of this type of headache? A. Tension B. Migraine C. Cluster D. Temporal arteritis

Answer: B Migraines classically are preceded by an aura and accompanied by nausea, vomiting sometimes, and photophobia. They are usually unilateral. Tension headaches are not associated with photophobia and are usually bilateral and associated with limited neck range of motion (ROM). Tension headaches are not preceded by an aura. Cluster headaches are unilateral, frequently occur at night, and bear some resemblance to migraines; however, cluster headaches are accompanied by tearing, nasal stuffi ness, and sweating on the same side as the headache and they come in clusters. The client is not in the age range (older than 50) for temporal arteritis.

You are performing a physical on your adult patient, and she complains that her nose hurts. Upon inspection, you note a small boil in her left nostril that appears swollen and is painful to the touch. You document your finding as a probable A. allergic rhinitis. B. furuncle. C. nasal polyp. D. carcinoma.

Answer: B Nasal furuncles are typically painful and should be allowed to drain on their own. Avoid trauma when inspecting the patient. Instructing the patient to apply warm soaks may facilitate healing along with an antibiotic to treat the causative agent, which is most often Staphylococcus . Nasal polyps and cancers are usually painless. Allergic rhinitis may cause nasal itching, nasal congestion, and runny nose; but it does not cause pain.

Marjorie, age 37, has asthma and has been told that she has nasal polyps. What do you tell her about them? A. Nasal polyps are usually precancerous. B. Nasal polyps are benign growths. C. The majority of nasal polyps are neoplastic. D. They are probably inflamed turbinates, not polyps, because polyps are infrequent in clients with asthma.

Answer: B Nasal polyps are benign growths that occur frequently in clients with sinus problems, asthma, and allergic rhinitis. Polyps are neither neoplastic growths nor precancerous, but they do have the potential to affect the fl ow of air through the nasal passages. Clients who have asthma and have nasal polyps may have an associated allergy to aspirin, a syndrome that is referred to as Samter's triad.

What condition occurs in almost all persons beginning around age 42 to 46? A. Arcus senilis B. Presbyopia C. Cataracts D. Glaucoma

Answer: B Presbyopia occurs in almost all persons beginning about the mid-40s. The lens loses elasticity and becomes hard and glasslike, decreasing its ability to change shape to accommodate for near vision. Arcus senilis, a gray-white arc or circle around the limbus from deposition of lipid material, does not affect vision. Cataracts and glaucoma may occur around age 50 or older

The most common cause of loss of visual acuity in adults over 45 is A. photopsia. B. presbyopia. C. age-related macular degeneration. D. myopia.

Answer: B Presbyopia, a normal age-related deficit, is the inability to focus on objects in close range. This is common and begins to develop in a person's mid-40s. Photopsia, or seeing fl ashing lights, is a symptom that requires urgent evaluation as it may be associated with a retinal tear of detachment. Myopia, or nearsightedness, is common with younger people and is not associated with advancing age. Age-related macular degeneration is not uncommon and is associated with a loss in central vision.

Which of the following symptom(s) is (are) most indicative of mononucleosis (Epstein-Barr virus)? A. Rapid onset of anterior cervical adenopathy, fatigue, malaise, and headache B. Gradual onset of fatigue, posterior cervical adenopathy, fever, and sore throat C. Gradual and seasonal onset of pharyngeal erythema D. Rapid onset of cough, congestion, and headache

Answer: B Symptoms most indicative of mononucleosis (Epstein-Barr virus) are gradual onset of fatigue, sore throat, fever, posterior cervical adenopathy, palatine petechiae, and hepatosplenomegaly.

Clinical presentation of a client with peritonsillar abscess includes A. occipital lymphadenopathy. B. muffled "hot potato" voice. C. congested cough. D. abdominal pain.

Answer: B Symptoms of a peritonsillar abscess include infection in one or both tonsils, fever or chills, difficulty opening the mouth fully, difficulty swallowing, drooling, headache, muffled "hot potato" voice, sore throat, and foul-smelling breath. The other answer options are not symptoms of peritonsillar abscess.

Cynthia, a 31-year-old woman with a history of depression, is seen in the office today for complaints of headaches. She was recently promoted at her job, which has caused increased stress. She describes the headache as a tightening (viselike) feeling in the temporal and nuchal areas. The pain is bilateral and tends to wax and wane. It started approximately 2 days ago and is still present. What kind of headache is she describing? A. Classic migraine B. Tension headache C. Sinus headache D. Cluster headache

Answer: B Tension headache is the most common type of headache. They are usually bilateral and tend to wax and wane but have a characteristic pressure/tightening (viselike grip) in the forehead, temporal, or nuchal areas and can last from minutes to weeks. Tension headache may be associated with stress, depression, or anxiety disorders. Classic migraine headaches occur after an aura, which may include visual, auditory, or olfactory symptoms. Cluster headaches come in clusters with exquisite pain awakening the client from sleep. They are more common in males than females. Sinus headache would usually be precipitated by allergies or cold symptoms. It is described as pain, pressure, or fullness in the cheeks, brow, or forehead with worsening pain when leaning forward.

How do you test for near vision? A. By using the Snellen eye chart B. By using the Rosenbaum chart C. By asking the client to read from a magazine or newspaper D. By testing the cardinal fields

Answer: B Test for near vision by using the Rosenbaum chart. Hold it 12 to 14 in. from the client's eyes. A gross estimate of near vision may also be assessed by asking the client to read from a magazine or newspaper held 12 to 14 in. away from the eyes. The Snellen eye chart tests vision at a distance of 20 ft. Testing the cardinal fields of gaze does not test for vision but rather for extraocular eye movements.

Catherine, a 56-year-old woman, comes to the office requesting a test for thyroid disease. She has had some weight gain since menopause, and she read on the Internet that all women should have a thyroid test. Based on the recommendations from the U.S. Preventive Services Task Force, which one of the following statements should be considered in this woman's care? A. All adults should be screened for thyroid disease. B. Evidence is insufficient for or against routine screening for thyroid disease in asymptomatic adults. C. All adults older than 50 should be screened for thyroid disease. D. All perimenopausal women should be screened for thyroid disease.

Answer: B The U.S. Preventive Services Task Force (USPSTF) found fair evidence that the thyroid-stimulating hormone test (TSH) can detect subclinical thyroid disease in people without symptoms of thyroid dysfunction, but it found poor evidence that treatment improves clinically important outcomes in adults with screen-detected thyroid disease. The USPSTF concluded that the evidence is insufficient to recommend for or against routine screening for thyroid disease in adults.

The antibiotic of choice for recurrent acute otitis media and/or treatment failure in children is A. amoxicillin (Amoxil). B. amoxicillin and potassium clavulanate (Augmentin). C. azithromycin (Zithromax). D. prednisone (Deltasone)

Answer: B The antibiotic of choice for recurrent acute otitis media (AOM) or treatment failure is amoxicillin and potassium clavulanate (Augmentin). Amoxicillin (Amoxil) is used as the first-line treatment of AOM. However, it is not used in patients with recurrent AOM or treatment failure. Azithromycin (Zithromax) for otitis media is usually reserved for patients with penicillin allergy. Prednisone (Deltasone) is not an antibiotic.

Ellen, a 56-year-old social worker, is seen by the nurse practitioner for complaints of fever, left-side facial pain, moderate amounts of purulent, malodorous nasal discharge, and pain and headache when bending forward. The symptoms have been occurring for approximately 6 days. On physical assessment, there is marked redness and swelling of the nasal passages and tenderness/pain on palpation over the cheekbones. The nurse practitioner should suspect A. dental abscess. B. acute rhinosinusitis. C. chronic rhinosinusitis. D. nasal tumor.

Answer: B The client is exhibiting classic characteristics of acute rhinosinusitis. Chronic rhinosinusitis lasts more than 30 days. Dental abscess and nasal tumor do not cause purulent nasal discharge.

While doing a face, head, and neck examination on a 16-year-old patient, you note that the palpebral fissures are abnormally narrow. What are you examining? A. Nasolabial folds B. The openings between the margins of the upper and lower eyelids C. The thyroid gland in relation to the trachea D. The distance between the trigeminal nerve branches

Answer: B The palpebral fissures are the openings between the margins of the upper and lower eyelids. Someone who appears to be squinting is said to have narrow palpebral fissures. The nasolabial folds are the skin creases that extend from the angle of the nose to the corner of the mouth. The thyroid is a butterfly-shaped gland located in the front of the neck just below the Adam's apple and is wrapped around the trachea. The trigeminal nerve is the fifth cranial nerve located within the brain. It is composed of three branches—the ophthalmic, maxillary, and mandibular—and is primarily responsible for transmitting sensations from the face to the brain. It is also the nerve that controls the muscles used for chewing.

Susan is a 19-year-old college student and avid swimmer. She frequently gets swimmer's ear and asks if there is anything she can do to help prevent it other than wearing earplugs, which do not really work for her. What do you suggest? A. Start using a cotton-tipped applicator to dry the ears after swimming. B. Use eardrops made of a solution of equal parts alcohol and vinegar in each ear after swimming. C. Use a hair dryer on the highest setting to dry the ears. D. Stop swimming.

Answer: B Using ear drops made of a solution of equal parts of alcohol and vinegar in each ear after swimming is effective in drying the ear canal and maintaining an acidic environment, therefore preventing a favorable medium for the growth of bacteria, the cause of swimmer's ear. The adage "You shouldn't put anything smaller than your elbow in your ear" holds true today. A hair dryer on the lowest setting several inches from the ear may be used to dry the canal. There is no reason for the client to stop swimming.

When a practitioner places a vibrating tuning fork in the midline of a client's skull and asks if the tone sounds the same in both ears or is better in one, the examiner is performing A. the Rinne test. B. the Weber test. C. the caloric test. D. a hearing acuity test

Answer: B When a practitioner places a vibrating tuning fork in the midline of a client's skull and asks if the tone sounds the same in both ears or is better in one, the examiner is performing the Weber test. The Weber test is valuable when a client states that hearing is better in one ear than the other. The Rinne test compares air conduction and bone conduction sound. The stem of a vibrating tuning fork is placed on the client's mastoid process, and the client is asked to signal when the sound disappears. The fork is then quickly inverted so that the vibrating end is near the ear canal, at which time the client should still hear a sound. Normally, sound is heard twice as long by air conduction as by bone conduction. The caloric test, or oculovestibular test, assesses cranial nerves III, VI, and VIII. Ice water is instilled into the ear; if nerve function is normal, the eyes will deviate to that side. A hearing acuity test assesses the client's ability to hear the spoken word

Mr. Blair, age 64, presents with a sore throat. Your assessment reveals tonsillar exudate, anterior cervical adenopathy, presence of a fever, and absence of a cough. There is a high probability of which causative agent? A. Haemophilus infl uenzae B. Group A beta-hemolytic streptococcus C. Epstein-Barr virus D. Rhinovirus

Answer: B When the following four symptoms present as a cluster, there is a high probability (43%) that the infection is caused by group A beta-hemolytic streptococcus: throat pain with tonsillar exudate, anterior cervical adenopathy, presence of fever, and absence of cough. These are hallmark symptoms of "strep throat" caused by Group A beta-hemolytic streptococcus. Haemophilus influenzae, Epstein-Barr virus, and rhinovirus are not associated with classic "strep throat."

How would the nasal mucosa appear in a client with chronic allergies? A. Swollen and red B. Swollen, boggy, pale, and gray C. Hard, pale, and inflamed D. Bright pink and inflamed

Answer: B With chronic allergy, a client's mucosa appears swollen, boggy, pale, and gray. Redness indicates an acute process, and the question asks about a chronic allergy.

You are the nurse practitioner caring for Martha, a 47-year-old accountant. You have made a diagnosis of acute sinusitis based on Martha's history and the fact that she complains of pain behind her eye. Which sinuses are affected? A. Maxillary B. Ethmoid C. Frontal D. Sphenoid

Answer: B With ethmoid sinus problems, the pain is behind the eye and high on the nose. Maxillary sinus pain is over the cheek and into the upper teeth; frontal sinus pain is over the lower forehead; and sphenoid sinus pain is in the occiput, vertex, or middle of the head.

When the Weber test is performed with a tuning fork to assess hearing and there is no lateralization, the nurse practitioner should document this finding as A. conductive deafness. B. perceptive deafness. C. a normal finding. D. nerve damage.

Answer: C A Weber test assesses hearing by bone conduction. With normal hearing, sound is heard equally well in both ears, meaning there is no lateralization. With conductive deafness, sound lateralizes to the defective ear because it is transmitted through bone rather than air. With perceptive deafness, sound lateralizes to the better ear. Damage to CN VIII (vestibulocochlear nerve) causes symptoms of hearing loss, vertigo, and loss of equilibrium.

Mr. Cox, age 72, is brought to the office by his son, who states that his father has been unable to see clearly since last night. Mr. Cox reports that his vision is "like looking through a veil." He also sees floaters and flashing lights but is not having any pain. What do you suspect? A. Cataracts B. Glaucoma C. Retinal detachment D. Iritis

Answer: C A client with retinal detachment complains of a sudden change in vision (either blurry vision, flashing lights, or fl oaters) but has no pain. On ophthalmoscopy, the retina appears pale and opaque and folds in and undulates freely as the eye moves. Retinal detachment is an emergency and requires immediate surgery, usually scleral buckling, in which an encircling silicon band is used to keep the choroid in contact with the retina to promote attachment. Iritis is characterized by severe pain. Cataracts and most cases of glaucoma usually present as a gradual change in vision, not a sudden change.

A sexual history of oral-genital contact in a 45-year-old client presenting with pharyngitis is significant when which of the following organisms is suspected? A. Escherichia coli B. Haemophilus infl uenzae C. Neisseria gonorrhoeae D. Streptococcus pneumoniae

Answer: C A sexual history of oral-genital contact in a client presenting with pharyngitis is significant when infection with Neisseria gonorrhoeae is suspected. N. gonorrhoeae pharyngitis is a common sexually transmitted disease

You are assessing a middle-aged woman for a routine annual physical. Your findings include a smooth tongue. This may indicate A. a normal finding. B. alcohol abuse. C. a vitamin deficiency. D. nicotine addiction.

Answer: C A smooth tongue may result from a vitamin deficiency. Normally, the dorsal surface of the tongue is rough because of papillae. The ventral surface near the floor of the mouth is smooth and shows large veins. Although there are no specific symptoms of the tongue related to tobacco and alcohol use, people who smoke and or drink alcohol are at higher risk for oral cavity or oropharyngeal cancer.

James, age 49, comes to the office with a rapid-onset complete paralysis of half of his face. He is unable to raise his eyebrow, close his eye, whistle, or show his teeth. You suspect a lower motor neuron lesion resulting in cranial nerve VII paralysis. What is your working diagnosis? A. Cerebrovascular accident B. Trigeminal neuralgia C. Bell's palsy D. Tic douloureux

Answer: C Bell's palsy should be suspected if a client presents with a rapid-onset, complete paralysis of half of the face and the inability to raise the eyebrow, close the eye, whistle, or show the teeth. Bell's palsy is a lower motor neuron lesion resulting in cranial nerve VII paralysis. It is often a self-limiting condition, lasting a few days or weeks. Occasionally, facial paralysis may result from a tumor or physical trauma compromising the facial nerve. A cerebrovascular accident (CVA, stroke, brain attack) would affect more than just the face. Trigeminal neuralgia, also called tic douloureux, is a painful disorder of the trigeminal nerve. It causes severe pain in the face and forehead on the affected side and is triggered by stimuli such as cold drafts, chewing, and drinking cold liquids.

Cataracts are a common occurrence in the patient over 60 years of age. You counsel your patient that the best cure for cataracts is A. medications. B. dietary supplements. C. corrective lens surgery. D. optical devices.

Answer: C Cataracts cannot be cured by medications, dietary supplements, or optical devices. No proven pharmaceutical treatment exists to date that can delay, prevent, or reverse the development of cataracts. The definitive management for cataract is a surgical approach, one that removes the defective lens and replaces it with an artifi cial one.

Which cranial nerve (CN) is affected in sensorineural or perceptive hearing loss? A. CN II B. CN IV C. CN VIII D. CN XI

Answer: C Cranial nerve (CN) VIII, the vestibulocochlear (acoustic) nerve, is affected by sensorineural or perceptive hearing loss. Both the cochlear and vestibular branches have sensory pathways. CN II, the optic nerve, has sensory pathways. CN IV, the trochlear nerve, has both sensory and motor pathways. CN XI, the accessory nerve, has motor pathways.

How do you respond when Mellissa, age 29, asks why she gets sores on her lips every time she sits out in the sun for an extended period of time? A. "You are allergic to the sun and must wear sunblock on your lips." B. "Your lips are dry to begin with, and you must keep them moist at all times." C. "You have herpes simplex that recurs with sunlight exposure." D. "You're probably allergic to your lip balm."

Answer: C Herpes simplex is associated with vesicular lesions on the lips and oral mucosa. The virus remains latent and may recur with sunlight exposure, stressful times, fever, trauma, and treatment with immunosuppressive drugs. Allergy to the sun, dry lips, and an allergy to lip balm would not cause sores on the lips only when sitting out in the sun for an extended period of time.

Which manifestation of the buccal mucosa is present in a client with mumps? A. Pink, smooth, moist appearance with some patchy hyperpigmentation B. Dappled brown patches C. The orifice of Stensen's duct appearing red D. Koplik's spots

Answer: C In a client with mumps, the orifice of Stensen's duct appears red. The buccal mucosa in a normal client appears pink, smooth, and moist, although there may be some patchy hyperpigmentation in dark-skinned clients. Dappled brown patches are present with Addison's disease. Koplik's spots are a prodromal sign of measles

Which of the following signs of thyroid dysfunction in a 49-year-old patient is a sign of hyperthyroidism? A. Slow pulse B. Decreased systolic BP C. Exophthalmos D. Dry, coarse, cool skin

Answer: C In hyperthyroidism the symptoms of rapid pulse, palpitations, and hypertension due to the excess production of T4 and T3 are common, whereas in hypothyroidism, the opposite symptom complex is common. Velvety, warm, moist skin is a symptom of hyperthyroidism, whereas dry, coarse skin is a symptom of hypothyroidism. Hyperthyroidism is also characterized by exophthalmos, which is the term for the eyeball protruding forward. When it is bilateral, it may signify infiltrative ophthalmopathy of Graves' disease. There may be associated edema and conjunctival injection as well.

What therapy has proved beneficial for long term symptom relief of tinnitus? A. Aspirin B. Lidocaine C. Cognitive behavioral therapy (CBT) D. Corticosporin otic drops

Answer: C Most recently, cognitive behavioral therapy (CBT) has been recognized as an effective treatment for tinnitus. Therapy is focused on reducing the psychological distress associated with tinnitus and developing coping strategies for dealing with the problem. Antidepressants, such as nortriptyline 50 mg PO at bedtime, have proved to be effective especially if the tinnitus disrupts sleep. High doses of aspirin over a sustained period of time may actually cause tinnitus. Lidocaine given intravenously suppresses tinnitus in some individuals but is not suitable for long-term suppression. Corticosporin eardrops have proved to have no effect.

Sharon, age 27, is pregnant for the first time. She complains of nasal stuffiness and occasional epistaxis. What do you do? A. Order lab tests, such as a complete blood count with differential, hemoglobin, and hematocrit. B. Prescribe an antihistamine. C. You do nothing except for client teaching. D. Refer the client to an ear, nose, and throat specialist.

Answer: C Nasal stuffiness and epistaxis may occur during a normal pregnancy because of increased vascularization in the upper respiratory tract. The gums may also be soft and hyperemic and may bleed with normal tooth brushing. Additional laboratory tests are not necessary at this point. No treatment, other than teaching the client what to expect and do, is indicated.

Kevin, age 26, has AIDS and presents to the clinic with complaints of a painful tongue covered with what looks like creamy-white, curdlike patches overlying erythematous mucosa. You are able to scrape off these "curds" with a tongue depressor, which assists you in making which of the following diagnoses? A. Leukoplakia B. Lichen planus C. Oral candidiasis D. Oral cancer

Answer: C Oral candidiasis (thrush) is distinctive because the white areas on the tongue can be rubbed off with a tongue depressor. Leukoplakia cannot be removed by rubbing the mucosal surface; it appears as little white lesions on the tongue. Oral lichen planus is a chronic inflammatory autoimmune disease; it also has white lesions that do not rub off. Oral cancer must be ruled out in any lesion because early detection is the key to successful management and a good prognosis. Thrush may be seen in denture wearers, in debilitated clients, and in those who are immunocompromised or taking corticosteroids or broad-spectrum antibiotics.

Alexandra, age 34, was treated with oral antibiotics 2 weeks ago for a urinary tract infection. She is seen in the office today for a follow-up visit. On physical examination, the nurse practitioner notices that she has some painless, white, slightly raised patches in her mouth. This is probably caused by A. herpes simplex. B. aphthous ulcers. C. candidiasis. D. oral cancer.

Answer: C Painless, white, slightly raised patches in a client's mouth are probably caused by candidiasis (thrush). Aphthous ulcers (canker sores) are extremely painful. Herpes simplex (a viral infection), canker sores, and cancerous lesions are usually discrete and not spread over a large area.

Martin, age 24, presents to the office with an erythematous ear canal and pain on manipulation of the auricle. He is on vacation and has been swimming daily at the resort. What is your diagnosis? A. Acute otitis media B. Chronic otitis media C. External otitis D. Temporomandibular joint syndrome

Answer: C Penicillin (PCN) is the fi rst-line antibiotic therapy for an adult with no known allergies and suspected group A beta-hemolytic streptococcus pharyngitis. Erythromycin (E-Mycin) and azithromycin (Zithromax) are macrolide antibiotics and are recommended in individuals who have a penicillin allergy. Cephalexin (Kefl ex) is a cephalosporin antibiotic and has been found to be very effective in the treatment of strep throat and is a reasonable alternative to penicillin.

A common, age-related, gradual, and progressive hearing loss in adults age 65 and older is called A. noise-induced hearing loss. B. otitis media. C. presbycusis D. otosclerosis

Answer: C Presbycusis is the loss of hearing that gradually occurs in most individuals as they grow older. It is a common hearing disorder associated with aging. It is estimated that approximately 30 to 35 percent of adults age 65 and older have a hearing loss. Noise-induced hearing loss is caused by exposure to loud noise and can affect individuals of all ages. Otitis media (OM) is an infection of the middle ear, usually caused by bacteria. Anyone can get an ear infection, but it is far more common in children. Otosclerosis is caused by abnormal bone remodeling in the middle ear. It is estimated that 10 percent of the adult Caucasian population is affected. It can begin at any time between the ages of 15 and 45 but usually starts in the early twenties.

Kathleen, age 54, has persistent pruritus of the external auditory canal. External otitis and dermatological conditions such as seborrheic dermatitis and psoriasis have been ruled out. What can you advise her to do? A. Use a cotton-tipped applicator daily to remove all moisture and potential bacteria. B. Wash daily with soap and water. C. Apply mineral oil to counteract dryness. D. Avoid topical corticosteroids.

Answer: C Pruritus of the external ear canal is a common problem. In most cases, the pruritus is self-induced from overenthusiastic cleaning or excoriation. The protective cerumen covering must be allowed to regenerate and may be helped to do so by application of a small amount of mineral oil, which helps counteract dryness and reject moisture. The use of soap and water, as well as cotton-tipped swabs, should be avoided. If an infl ammatory component is present, a topical corticosteroid may be applied. Often, isopropyl alcohol may relieve ear canal pruritus.

Which assessment test is a gross measurement of peripheral vision? A. The cover test B. The corneal light reflex test C. The confrontation test D. The Snellen eye-chart test

Answer: C The confrontation test is a gross measure of peripheral vision. It compares the client's peripheral vision with the practitioner's, assuming that the practitioner has normal peripheral vision. The cover test detects small degrees of deviated alignment by interrupting the fusion reflex that normally keeps both eyes parallel. The corneal light reflex test assesses the parallel alignment of the eye axes. The Snellen eye chart test assesses visual acuity.

The leading cause of blindness in persons ages 20 to 60 in the United States is A. macular degeneration. B. glaucoma. C. diabetic retinopathy. D. trauma.

Answer: C The leading cause of blindness in persons aged 20 to 60 in the United States is diabetic retinopathy, a progressive microangiopathy with small-vessel damage and occlusion. Macular degeneration is the leading cause of blindness in persons older than age 60. Glaucoma may eventually lead to loss of vision, but the symptoms have a slow progression, usually leading the client to eventual surgery to correct the problem. Trauma rarely leads to blindness

The trachea deviates toward the unaffected side in all of the following conditions except A. aortic aneurysm. B. unilateral thyroid lobe enlargement. C. large atelectasis. D. pneumothorax

Answer: C The trachea deviates toward the unaffected side with an aortic aneurysm, unilateral thyroid lobe enlargement, and pneumothorax. It deviates toward the affected side with a large atelectasis or fibrosis.

Kimberly, a 17-year-old high school student, was hit in the right eye with a tennis ball. She developed pain in the eye, decreased visual acuity, and injection of the globe. You confirm the diagnosis of hyphema by finding blood in the anterior chamber. Which of the following treatments should the nurse practitioner not recommend while Kimberly is waiting to see the ophthalmologist? A. Apply an eye shield to the affected eye. B. Rest in bed with the HOB elevated. C. Take aspirin 650 mg every 6 hours as needed. D. Avoid strenuous activities.

Answer: C The treatment for hyphema is strict bedrest, with the head elevated at least 20°, application of an eye patch to the affected eye to minimize eye movement, and avoiding strenuous activities. The administration of aspirin is contraindicated to prevent additional bleeding.

Marvin, 76-years-old, has sudden eye redness that occurred after a strenuous coughing episode. You diagnose a subconjunctival hemorrhage. Your next step is to A. refer him to an ophthalmologist. B. order antibiotics. C. do nothing other than provide teaching and reassurance. D. consult with your collaborating physician.

Answer: C There is no treatment for a subconjunctival hemorrhage other than to teach and reassure the client that the blood will be reabsorbed within 2 weeks.

A 64-year-old obese woman comes in complaining of difficulty swallowing for the past 3 weeks. She states that "some foods get stuck" and she has been having "heartburn" at night when she lies down, especially if she has had a heavy meal. Occasionally she awakes at night coughing. She denies weight gain and/ or weight loss, vomiting, or change in bowel movements. She denies alcohol and tobacco use. There is no pertinent family history or findings on review of systems (ROS). Physical examination is normal with no abdominal tenderness, and the stool is OB negative. What is the most likely diagnosis? A. Esophageal varices B. Esophageal cancer C. Gastroesophageal reflux disease (GERD) D. Peptic ulcer disease (PUD)

Answer: C Though the historical data are incomplete, this client has no obvious risk factors for esophageal varices or esophageal cancer. She is a nondrinker and denies weight loss and changes in bowel function or color of stools, which could be a clue to a gastrointestinal bleed. The fact that her worst symptoms occur at night with regurgitation and heartburn is classic for GERD. Dysphagia is frequently a prominent symptom in GERD. She has no abdominal tenderness, and aside from the nighttime symptoms and dysphagia, she reports no symptoms with food or lack of food. Clients with peptic ulcer disease (PUD) frequently complain of clusters of pain separated by periods of no symptoms.

You diagnose 46-year-old Mabel with viral conjunctivitis. Your treatment should include A. gentamycin optic ointment. B. ciprofl oxacin optic gtts. C. supportive measures and lubricating drops (artifi cial tears). D. oral erythromycin for 14 days.

Answer: C Viral conjunctivitis is treated with supportive measures including cold compresses and lubricating eye drops. Preventative measures such as frequent hand washing is important as viral conjunctivitis is highly contagious. Antibiotics should not be used in clients with viral conjunctivitis.

When you are assessing the corneal light reflex, an abnormal finding indicates A. possible use of eye medications. B. a neurological problem C. improper alignment of the eyes. D. strabismus.

Answer: C When assessing the corneal light reflex, an abnormal finding indicates improper alignment of the eyes. It is noted when the reflections of the light are on different sites on the eyes. Some eye medications may cause unequal dilation, constriction, or inequality of pupil size that may be noted when assessing for direct and consensual pupil response. A neurological problem may be suspected if the pupils are unequal in size. Strabismus is noted during the cover-uncover test.

Nystatin (Mycostatin) is ordered for Michael, a 56-year-old banker who has an oral fungal infection. What instructions do you give Michael for taking the medication? A. "Dilute the oral medication with 1 tablespoon of water for easier digestion." B. "Take the medication with meals so that it's absorbed better." C. "Swish and swallow the medication." D. "Apply the medication only to the lesions."

Answer: C When ordering nystatin (Mycostatin) for an oral fungal infection, tell the client to swish the medication in the mouth to coat all the lesions and then to swallow it. The oral medication should not be diluted as that may compromise the absorption, as would taking it with meals. It is almost impossible to apply this liquid medication to only the lesions; swishing it in the mouth coats all the lesions more effectively.

Sharon, a 47-year-old bank teller, is seen by the nurse practitioner in the office for a red eye. You are trying to decide between a diagnosis of conjunctivitis and iritis. One distinguishing characteristic between the two is A. eye discomfort. B. slow progression. C. a ciliary flush. D. no change in or slightly blurred vision.

Answer: C When trying to decide between a diagnosis of conjunctivitis and iritis, one of the distinguishing characteristics is a ciliary flush present in iritis. Photophobia is not usually present in conjunctivitis, but it is always present with iritis. Photophobia occurs with corneal inflammation, iritis, and angle-closure glaucoma. Clients with iritis and those with conjunctivitis both complain of eye discomfort, although in iritis the pain is moderately severe with intermittent stabbing. Both conditions generally produce a slowly progressive redness. Vision is normal with conjunctivitis and blurred with iritis.

Mrs. Glover, age 67, is brought into the office by her daughter for evaluation. She complains of sudden onset impaired vision, severe right eye pain, colored halos around lights, vomiting, and a headache upon entering a dark movie theater. You diagnose the following condition and refer her for urgent treatment. A. Cataracts B. Macular degeneration C. Presbyopia D. Acute angle-closure glaucoma

Answer: D A client with acute angle-closure glaucoma requires urgent treatment and usually presents with sudden onset of impaired vision, severe eye pain, vomiting, and headache, occurring most often in the evening or in a darkened setting. You may assess injected conjunctiva; steamy corneas; a fixed, partially dilated pupil; and a narrow chamber angle. A client with cataracts may present with decreased vision, and you would see an opacity, a cloudy lens, and a decreased view of the fundus. With macular degeneration, there is decreased central vision, and with presbyopia, there may be blurred vision but with a gradual onset. Only acute-angle glaucoma requires urgent treatment.

Which of the following is not a normal sensory deficit associated with aging? A. Gradual decline in sense of taste B. Hearing loss of high-frequency tones C. Decline in sense of proprioception D. Loss of all peripheral vision

Answer: D A narrowed field of vision may be experienced by some older patients, but a complete loss of peripheral vision is not a normal sensory loss in the aging adult. Additional visual deficits common to the aging adult are deficits in reading fine print (presbyopia), an increased sensitivity to light, and decreased night vision. Gradual decline in sense of taste, hearing loss of high-frequency tones, and decline in sense of proprioception are all normal aspects of the aging process.

Max, age 35, states that he thinks he has an ear infection because he just flew back from a business trip and feels unusual pressure in his ear. You diagnose barotrauma. What is your next action? A. Prescribe nasal steroids and oral decongestants. B. Prescribe antibiotic eardrops. C. Prescribe systemic antibiotics. D. Refer Max to an ear, nose, and throat specialist.

Answer: D Barotrauma of the auditory canal causing abnormal middle ear pressure may be relieved by the use of nasal steroids and oral decongestants. With barotrauma, there is no infection, just swelling of the airways, which causes the sensation of abnormal pressure; therefore, antibiotics are not indicated. This is certainly within the practitioner's scope of practice, and a referral is not indicated.

Henry, 64 years old, is having difficulty getting rid of a corneal infection. He asks you why. How do you respond? A. "We can't determine the causative agent." B. "Systemic antibiotics have diffi culty getting to that area of the eye." C. "Because the infection was painless, it was not treated early enough." D. "Because the cornea doesn't have a blood supply, an infection can't be fought off as usual."

Answer: D Because the cornea is an avascular organ, immune defenses have difficulty fighting off infections. "We can't determine the causative agent" is not a satisfactory answer to give a patient. Even if the causative agent were identified, systemic antibiotics would still not be effective in most cases. Earlier treatment would also not increase the rate of healing.

An 80-year-old woman comes into the office with complaints of a rash on the left side of her face that is blistered and painful and accompanied by left-side eye pain. The rash broke out 2 days ago, and she remembers being very tired and feeling feverish for a week before the rash appeared. On examination the rash follows the trigeminal nerve on the left, and she has some scleral injection and tearing. You suspect herpes zoster ophthalmicus. Based on what you know to be complications of this disease, you explain to her that she needs A. antibiotics. B. a biopsy of the rash. C. immediate hospitalization. D. ophthalmological consultation.

Answer: D Because the herpes virus in this case seems to be along the ophthalmic branch of cranial nerve V, there is considerable risk that this client could develop permanent damage in that eye; therefore, an ophthalmological consult needs to be arranged promptly to ascertain damage and prevent any further damage. Antibiotics should not be used in the treatment of viral disease. A biopsy of the rash should not be done in the office at this time. Hospitalization is necessary for patients with disseminated herpes zoster for IV antiviral medications.

Barbara, age 72, states that she was told she had atrophic macular degeneration and asks you if there is any treatment. How do you respond? A. "No, but 5 years from the time of the first symptoms, the process usually stops." B. "Yes, there is a surgical procedure that will cure this." C. "If we start medications now, they may prevent any further damage." D. "Unfortunately, there is no effective treatment, but I can refer you to a rehabilitation agency that can help you adjust to the visual loss."

Answer: D Currently, there is no effective treatment for atrophic macular degeneration. Laser photocoagulation may slow the exudative form of macular degeneration if performed early in the course of the disease. It seals leaking capillaries and stops the exudation. Clients cope with the disease by using large-print books and magazines, magnifying glasses, and high-intensity lighting.

When assessing Patricia, a 57-year-old, who has a sore throat, you note that she has a positive history of diabetes and rheumatic fever. These facts increase the likelihood that which of the following agents caused her sore throat? A. Neisseria gonorrhoeae B. Epstein-Barr virus C. Haemophilus influenzae D. Group A beta-hemolytic streptococcus

Answer: D If a client has a sore throat and a history of diabetes or rheumatic fever, it is very likely that the infection is a result of group A beta-hemolytic streptococcus. Rheumatic fever is an inflammatory disease that may develop as a complication of a streptococcus infection, such as strep throat or scarlet fever (caused by Streptococcus pyogenes or group A betahemolytic streptococcus). Neisseria gonorrhoeae, Epstein-Barr virus, and Haemophilus influenzae are not precursors for rheumatic fever.

Mr. Clark, age 78, is being treated with timolol maleate (Timoptic) drops for his chronic open-angle glaucoma. While performing a new client history and physical, you note that he is taking other medications. Which medication would you be most concerned about? A. Aspirin therapy as prophylaxis for heart attack B. Ranitidine (Zantac) for gastroesophageal reflux disease C. Alprazolam (Xanax), an anxiolytic for anxiety D. Atenolol (Tenormin), a beta blocker for high blood pressure

Answer: D If a client is taking timolol maleate (Timoptic) drops for chronic open-angle glaucoma, you should be most concerned if the client is also taking atenolol (Tenormin), a beta blocker, for high blood pressure. Because timolol maleate drops are beta-adrenergic blockers, additional beta blockers can cause worsening of congestive heart failure or reactive airway disease, as well as acute delirium. Aspirin therapy as prophylaxis for heart attack, ranitidine (Zantac) for gastroesophageal refl ux disease, and alprazolam (Xanax) for anxiety do not interact adversely with eye drops for glaucoma.

Marian, age 79, is at a higher risk than a middle-aged client for developing an eye infection because of which age-related change? A. Increased eyestrain B. Loss of subcutaneous tissue C. Change in pupil size D. A decrease in tear production

Answer: D Older adults are at a higher risk than middle-aged adults for developing an eye infection because of a decrease in tear production, which results in the inability of the tear ducts to wash out infectious organisms. Increased eyestrain, loss of subcutaneous tissues, and change in pupil size do not increase the risk of infection.

Risk factors for oral cancers include A. a family history, poor dental habits, and infrequent use of alcohol. B. obesity, sedentary lifestyle, and chewing tobacco. C. a history of diabetes, smoking, and a high fat intake. D. age greater than 50, heavy alcohol consumption, and smoking and/or chewing tobacco.

Answer: D Risk factors for oral cancers includes age greater than 50, heavy alcohol consumption, and smoking and/or chewing tobacco. Although the other three answer choices may cause oral cancer, they are not as significant risk factors as option D.

Signs and symptoms of acute angle-closure glaucoma include A. painless redness of the eyes. B. loss of peripheral vision. C. translucent corneas. D. halos around lights.

Answer: D Signs and symptoms of acute angle-closure glaucoma include seeing halos around lights, severe eye pain and redness, nausea and vomiting, headache, blurred vision, conjunctival injection, cloudy cornea, mid-dilated pupil, and an increased intraocular pressure. Acute angle-closure glaucoma is less common than primary open-angle glaucoma, accounting for about 10% of all glaucoma cases in the United States. Emergency treatment is indicated, so a prompt referral is necessary when these signs and symptoms occur.

How would you describe the cervical lymphadenopathy associated with asymptomatic HIV infection? A. Movable, discrete, soft, and nontender lymph nodes B. Enlarged, warm, tender, firm, but freely movable lymph nodes C. Hard, unilateral, nontender, and fixed lymph nodes D. Firm but not hard, nontender, and mobile lymph nodes

Answer: D The cervical lymphadenopathy associated with asymptomatic HIV infection may be described as cervical lymph nodes that are firm but not hard, nontender, and mobile. In a healthy person, cervical nodes are often palpable and are movable, discrete, soft, and nontender. In a client with an acute infection, the cervical nodes are bilateral, enlarged, warm, tender, and fi rm but freely movable. Cancerous nodes are hard, unilateral, nontender, and fixed. In a client with a chronic inflammation, such as tuberculosis, the nodes are clumped.

The most common cause of nasopharyngitis (common cold) is A. herpes simplex virus. B. Haemophilus influenzae. C. Streptococcus pneumoniae. D. rhinovirus.

Answer: D The common cold is a minor, self-limiting viral illness of the upper respiratory tract most often caused by rhinoviruses or corona viruses. Herpes simplex virus causes cold sores. Both Haemophilus infl uenzae and Streptococcus pneumoniae are bacterial organisms and do not cause the common cold.

What is the easiest way to differentiate between otitis externa and otitis media? A. With otitis media, tender swelling is usually visible. B. With otitis media, there is usually bilateral pain in the ears. C. With otitis media, there is usually tenderness on palpation over the mastoid process. D. With otitis externa, movement or pressure on the pinna is extremely painful.

Answer: D The easiest way to differentiate between otitis externa and otitis media is that with otitis externa, movement or pressure on the pinna is extremely painful. With otitis externa, there may also be tender swelling of the outer ear canal. Bilateral pain in the ears is more suggestive of otitis externa. Clients with acute mastoiditis present with severe pain in, and, especially behind, the ear.

The most common cause of sensorineural hearing loss is A. trauma. B. tympanic membrane sclerosis and scarring. C. otosclerosis. D. presbycusis.

Answer: D The most common cause of sensorineural hearing loss is presbycusis, a gradual decrease in cochlear function that occurs in most persons with advancing age. Otosclerosis (stapes fi xation) and tympanic membrane sclerosis and scarring both result in a conductive hearing loss. Trauma would also result in a conductive hearing loss.

Mandy, 44, was given a diagnosis of fl u 1 day ago and wants to start on the "new flu medicine" right away. What do you tell her? A. "The medication is effective only if started within the first 72 hours after symptoms begin." B. "If you treat a cold, it goes away in 7 days; if you don't treat it, it goes away in 1 week." C. "The medicine has not proven its effectiveness." D. "I'll start you on oseltamivir (Tamifl u) today. It may shorten the course of the disease and perhaps lessen the severity of your symptoms."

Answer: D Two antiviral drugs, oseltamivir (Tamifl u), a pill taken by mouth, and zanamivir (Relenza), an inhaled medication, are particularly effective against the influenza viruses that cause the flu. If the virus causing the flu is type A influenza, the client may benefit from either one of these drugs. They are most effective if started early in the course of the disease (within 48 hours after symptoms begin. The flu is not a cold (rhinovirus).

Jonathan, age 19, has just been given a diagnosis of mononucleosis. Which of the following statements is true? A. The offending organism is bacteria and should be treated with antibiotics. B. Convalescence is usually only a few days, and Jonathan should be back to normal in a week. C. Mononucleosis is rarely contagious. D. Jonathan should avoid contact sports and heavy lifting.

Answer: D When teaching clients about mononucleosis (EBV), tell them to avoid contact sports and heavy lifting, because of splenomegaly and a threat of rupture. Also instruct the patient to avoid stress and advise that convalescence may take several weeks. Antibiotic therapy is not indicated for EBV. The virus that causes mononucleosis is transmitted through the saliva, hence the nickname the "kissing disease." It is contagious and can be transmitted through kissing or sharing utensils. Bedrest is necessary only in severe cases.

Mrs. Johnson, a 54-year-old accountant, presents to the office with a painful red eye without discharge. You should suspect A. bacterial conjunctivitis. B. viral conjunctivitis. C. allergic conjunctivitis. D. iritis.

Answer: D With bacterial conjunctivitis, there is purulent, thick discharge; with allergic conjunctivitis, a stringy mucoid discharge; and with viral conjunctivitis, usually a watery discharge. In a client with iritis, there is rarely a discharge.

Tonsils Grading

Grade1 indicates that the tonsils are visible; Grade 2 indicates that the tonsils are halfway between the tonsillar pillars and uvula; Grade 3: Tonsils that touch the uvula Grade 4 indicates that the tonsils touch each other. Tonsils are enlarged to 2, 3, or 4 with an acute infection.