Exam 2 HEENT & Respiratory :(
When doing an examination of the thyroid gland, the suggested sequence of examination for a posterior approach is:
1. Have the patient sip and swallow 2. Place the fingers of both hands on ither side of the thyroid 3. Flex the neck forward 4. Displace the trachea right then left, evaluating the margins of the lobes
Identify the location where vesicular, broncho-vesicular, bronchial, and tracheal lung sounds are heard (in that order).
1. Over most of both lungs 2. Between the scapulae 3. Over the manubrium 4. Over the trachea in the neck
When performing a Rinne test, the nurse would perform the steps in what order?
1. Place the base of a vibrating tuning fork on the mastoid bone until the patient says she cannot hear the sound. 2. Place the tuning fork in front of the ear and ask the patient if she can hear the sound.
The nurse does a health history. The patient states he has lost 30lbs in the last couple months without trying. The patient states he feels warm all the time and sometimes feels like he has heart palpitations. The nurse would anticipate orders to evauate the patient for: A. Hyperthyroidism B. Hyperbilirubinemia C. Hypernatremia D. Hyperproteinemia
Answer A
A patient with hypothyroidism is admitted to the medical unit. The nurse would expect to assess which sign/symptoms? Select all that apply A. Lower systolic blood pressure B. Lethargy C. Constipation D. Cool skin E. Weight loss
Answer A, B, C, D: S/s for HYPOthyroidism is lower systolic blood pressure, lethargy, constipation, cool skin...Remember HYPO= LOW and Slow
When providing client education on hearing, the nurse should remind clients to utilize ear plugs when they are what? (select all that apply) A. At concerts B. Using lawnmowers C. Cleaning their homes D. Working with children E. At train stations
Answer A, B, E: At concerts, using lawnmowers, and At concerts.
Your patient is complaining of nasal stuffiness. what drugs should you ask if she is taking? (select all that apply) A. Oral contraceptives B. Alcohol C. Nicotine D. Guaifenesin E. Guanethidine
Answer A, B, E: Oral contraceptives, Alcohol, and Guanethidine.
What systemic disease may cause nodular episcleritis? (Select all that apply) A. Rheumatoid arthritis B. Systemic lupus erythematosus C. Muscular dystrophy D. Fibromyalgia E. Multiple sclerosis
Answer A, B: Rheumatoid arthritis & Systemic lupus erythematosus
The nurse should ask about or assess which associated factors when a patient complains of cluster headaches? Select all that apply A. Miosis B. Photophobia C. Ptosis D. Rhinorrhea E. Lacrimation
Answer A, C, D, E: Miosis, ptosis, rhinorrhea, lacrimation
What are the bordering landmarks of the anterior triangle of the neck? (select all that apply) A. The mandible B. The omohyoid muscle C. The sternomastoid D. The midline of the neck E. The clavicle
Answer A, C, D: The sternomastoid, mandible, and midline of the neck are the bordering landmarks of the anterior triangle of the neck.
What are associated manifestations of a headache caused by traumatic head injury? (select all that apply) A. Seizures B. Changes in appetite C. Apathy D. Gait changes E. Attention span deficit
Answer A, D, E: Seizures, Gait changes, Attention span deficit
What does the nurse assess the face for? (Select all that apply) A. Edema B. Affect C. Hair color D. Involuntary movements E. Asymmetry
Answer A, D, E: The nurse assess for edema, involuntary movements, and asymmetry.
What associated symptoms might a patient with a history of chronic bronchitis have? (select all that apply) A. Wheezing B. Paroxysmal nocturnal dyspnea C. Orthopnea D. Recurrent respiratory infections E. Chronic productive cough
Answer A, D, E: Wheezing, Recurrent respiratory infections, Chronic productive cough.
The nurse notes thrush on the palate of a patient. The most appropriate question the nurse should ask is: A. "Have you been on antibiotics recently?" B. "Have you traveled out of the country in the last month?" C. "Do you smoke?" D. "Have you been tested for HIV?"
Answer A: "Have you been on antibiotics recently?"
When assessing the posterior chest, what is a starting point for counting ribs and interspaces? A. 12th rib B. 6th rib C. 8th rib D. 10th rib
Answer A: 12th rib
The nurse examines the pharynx of a patient and records that the tonsils are touching the uvula. The nurse would grade the tonsils as: A. 3+ B. 4+ C. 2+ D. 1+
Answer A: 3+
A 55-year-old smoker complains of chest pain and gestures with a closed fist over her sternum to describe it. Which of the following diagnoses are diagnoses are consistent with her gesture? A. Angina pectoris B. Pericarditis C. Bronchitis D. Costochondritis
Answer A: Angina pectoris
An alternate pathway that bypasses the external and middle ear is called what? A. Bone conduction B. Sensory conduction C. Neuro conduction D. Air conduction
Answer A: Bone conduction
A client presents at the clinic with a chief complaint of right ear pain. The nurse notes a rash in the right ear canal. What should the nurse know is a possible cause of these symptoms? A. Chronic otitis media B. Chronic otosclerosis C. Acute mastoiditis D. Acute ossiculo-mastitis
Answer A: Chronic otitis media
You are teaching a health class on a college campus. What would you teach students to use during oral sex to help reduce the transmission of STDs? A. Dental dams B. Oral barriers C. Dental prophylactic D. Oral condoms
Answer A: Dental Dams
The nurse documents vesicular lung sounds upon auscultation. The nurse heard what type of sound? A. Sound heard throughout inspiration and two thirds of expiration. B. Inspiratory and expiratory sounds equal in length. C. Expiratory sounds lasting longer than inspiratory. D. Short silence between inspiration and expiration.
Answer A: Sound heard throughout inspiration and two thirds of expiration
When assessing posteriorly, where would the trachea bifurcate into its mainstem bronchi? A. T4 spinous process B. Midaxillary line C. Suprasternal notch D. Sternal angle
Answer A: T4 spinous process
It has become apparent that there is not a lifetime immunity to pertussis for those who received the childhood DPT vaccine. True False
Answer A: True
When visualizing the structures of the nose, the nurse recalls that air travels from the anterior nares to the trachea through the: A. Vestibule, nasal passages, and nasopharynx B. Turbinates, ethmoid sinuses, and nasal passages C. Ala nasi, turbinates, and nasopharynx D. Ala nasi, vestibule, and ethmoid sinuses
Answer A: Vestibules, nasal passages, and nasopharynx
A patient appears in the clinic with a cough that began 24 hours prior to coming to this visit. The nurse evaluates the patient based on the most common cause of an acute cough, which is...... A. Viral respiratory infection B. Asthma C. Pneumonia D. Chronic bronchitis
Answer A: Viral respiratory infection
A young toddler is brought to the emergency room by his parents. The mother reports no recent illnesses. The nurse suspects that the most likely cause of the wheezing is: A. a foreign body obstruction B. a severe cold C. increased secretions D. exercise-induced asthma
Answer A: a foreign body obstruction
The nurse would expect to assess which symptoms in a patient complaining of migraine headaches? Select all that apply A. Muscle tension B. Throbbing C. Continuous D. Recurrent E. Photophobia
Answer B,D,E: Symptoms in a patient complaining of migraine headaches are throbbing, recurrent, and photohobia
Upon examination of the ear with an otoscope, the nurse documents the skin of the ear canal as thickened, red, and itchy. The nurse would expect this finding with a diagnosis of: A. Acute otitis media B. Chronic otitis media C. Otitis media with serous effusion D. Purulent otitis media
Answer B: Chronic otitis media
The nurse percusses the lungs of a patient with pneumonia. What percussion note would the nurse expect to document? A. tympany B. dullness C. flatness D. hyperresonance
Answer B: Dullness
What is a characteristic symptom of Graves hyperthyroidism? A. Pinguecula B. Exophthalmos C. Episcleritis D. Pterygium
Answer B: Exophthalmos
When examining the eye with an opthalmoscope, where would the nurse look to visualize the optic disc? A. Upward toward the forehead B. Medially toward the nose C. Laterally toward the ear D. Downward toward the chin
Answer B: Medially toward the nose
You note anterior bulging of the physiologic cup when performing a funduscopic examination of your patient's eyes. What would you document? A. Hyperopia B. Papilledema C. Positive axoplasmic sign D. Ateriovenous crossings
Answer B: Papilledema
The nurse is caring for a client who is 48 hours postop from the repair of a fractured hip. She has a sudden onset of dyspnea without pain. What disease process would the nurse suspect? A. Asthma B. Pulmonary embolism C. Chronic lung disease D. Left ventricular failure
Answer B: Pulmonary embolism
The nursing instructor is discussing assessment of the head and neck with the class. What identifying characteristic would the instructor use for the thyroid cartilage. A. Its relation to the cricoid cartilage B. The notch on its superior edge C. Its position just below the mandible D. The curve on its inferior edge
Answer B: The notch on its superior edge
A client presents at the clinic for a routine check-up. The nurse notes that she is dressed in warm clothing even though the temperature outside is 73*F. the nurse also notes that the patient has gained 10lbs since her last visit 9 months ago. What might the nurse suspect? (select all that apply) A. Hypothyroidism B. Effects of age-related changes C. Hyperthyroidism D. Brain tumor
Answer B: effects of age-related changes
When assessing a patient with Graves disease, how would you expect the thyroid gland to be? A. Nodular B. Soft C. Tender D. Firm
Answer B: soft
A patient in the clinic where you work is considered legally blind. The nurse knows that this means the vision in his better eye, corrected by glasses, is what? A. 20/400 or less B. 20/100 or less C. 20/200 or less D. 20/300 or less
Answer C: 20/200 or less
Functionally, the most important range for hearing is the range of human speech. What is the range of human speech? A. 400Hz to 2000Hz B. 350Hz to 1500Hz C. 500Hz to 3000Hz D. 450Hz to 2500Hz
Answer C: 500Hz to 3000Hz
Dyspnea, an uncomfortable awareness of breathing that is inappropriate to the level of exertion, is what? A. Painful breathing B. Prolonged inspiration C. Air hunger D. Audible breathing
Answer C: Air hunger
What lines the cheeks? A. Alveolar mucosa B. Labial mucosa C. Buccal mucosa D. Lingual mucosa
Answer C: Buccal Mucosa
What are you testing when you ask the patient to follow your finger or pencil as you move it in toward the bridge of the nose? A. Accommodation B. EOM C. Convergence D. Visual Fields
Answer C: Convergence
A 16-year-old white female is brought to the clinic by her mother with a chief complaint of a severe headache lasting more than 24 hours. The mother states, "just before the headache started my daughter was craving food. i couldn't feed her enough." What is this called? A. Aura B. Neurologic onset C. Prodrome D. Aberrant sign
Answer C: Prodrome
When assessing a patient the nurse notes that the tonsils are touching the uvula. How would the nurse document the tonsils? A. Tonsils are T4 B. Tonsils are T2 C. Tonsils are T3 D. Tonsils are T1
Answer C: Tonsils are T3
The nurse observes an inward turning of the lower lid in a 77 year old patient. The nurse documents: A. ectropion B. ptosis c. entropion d. exophthalmos
Answer C: entropion
A patient has conjunctivitis. The nurses understand that conjunctivitis differs from conjunctival hemorrhage in that conjunctivitis: A. is not painful B. can result from a cough c. has a watery, mucoid discharge d. usually follows trauma
Answer C: has a watery, mucoid discharge
A patient complains of feeling like he is slowly losing his central vision. The nurse knows this symptom could represent: A. hemianopsia B. retinal detachment C. macular degeneration D. open-angle glaucoma
Answer C: macular degeneration
When assessing the breath sounds of a newly admitted patient, the nurse notes increased transmission of voice sounds over the right lung. What would this indicate to the nurse? A. The lung is overinflated B. The lung has an embolus C. The lung has become airless D. The lung is full of fluid
Answer C: the lung has become airless
What is the primary purpose of the health history in relation to the eyes? A. To identify if problems are unilateral or bilateral B. To test the acuity of central vision C. To identify changes D. To identify a family history of ocular disease
Answer C: to identify changes
During your physical examination of the patient you note an enlarged tender tonsillar lymph node. What would you do? A. Assess for meningitis B. Look for involvement of other regions of the body C. Assess for dietary changes D. Look for a source such as infection in the area that it drains
Answer D
Which ribs are considered "floating ribs"? A. 10th and 11th B. 9th and 10th C. 8th and 9th D. 11th and 12th
Answer D: 11th and 12th
You are assessing visual fields on a patient newly admitted for eye surgery. The patient's left eye repeatedly does not see your fingers until they have crossed the line of gaze. you would document that the patient has what? A. A homonymous hemianopsia B. A bitemporal hemianopsia C. A quadrantic defect D. A left temporal hemianopsia
Answer D: A left temporal hemianopsia
The nurse is performing a physical examination and notes an enlarged left supraclavicular lymph node. The nurse understands that this could be indicative of: A. Tonsillitis B. Nasopharyngitis C. A goiter D. A metastasis
Answer D: A metastasis
What activity is known to aggravate a tension headache? A. Exercise B. Listening to music C. Prolonged sleep D. Driving
Answer D: Driving
What replaces resonance when fluid or solid tissue replaces air-containing lung or occupies the pleural space? A. Hyperresonance B. Tympany C. Chief complaint D. Dullness
Answer D: Dullness
What is vital in maintaining vision and a healthy outlook for clients: A. Physical exercise B. Emotional support C. Monthly eye exams D. Health education
Answer D: Health education
A patient presents to the clinic with "sores around the mouth." The nurse notes vesicular lesions on the upper lip and right corner of the lips. The patient describes these as painful. The nurse suspects what condition? A. Actinic cheilitis B. Syphilis C. Angioedema D. Herpes simplex
Answer D: Herpes simplex
What are the glands that are located on the tarsal plates and open on the lid margins? A. Levator glands B. Pterygium glands C. Chalazion glands D. Meibomian glands
Answer D: Meibomian glands
A client arrives in the emergency department by ambulance after falling down his front steps. The nurse notes two soft lumps, approximately 3 cm in diameter, on the side of his head. What would the nurse identifying these as? A. Pigmented nevi B. Edema from fall C. Signs of abuse D. Pilar cysts
Answer D: Pilar cysts
A client is brought to the emergency department by ambulance after being involved in a motor vehicle accident. The nurse finds that he has decreased breath sounds over the left lung fields. Whayt might the nurse suspect is the cause? A. Asthma B. Atelectasis C. Muscular weakness D. Pneumothorax
Answer D: Pneumothorax
A patient tells the nurse that he is constantly congested despite using a decongestant at least twice daily. The nurse understands the patient may be experiencing: A. Vasomotor rhinitis B. Rhinorrhea C. Allergic rhinitis D. Rhinitis medicamentosa
Answer D: Rhinitis medicamentosa
What is the best guide to make vertical locations on the chest? A. 5th intercostal space B. Midclavicular line C. Angle of Henri D. Sternal angle
Answer D: Sternal angle
What structure in the inner ear senses the position and movement of the head and helps maintain balance? A. The umbo B. The cochlea C. The ossicle D. The labryinth
Answer D: The labyrinth
The nurse notes that the ophthalmologist suspects death of the optic nerve. When looking into the eye, the nurse would expect to see what color if the disc is dead? A. Black B. Red C. Yellow D. White
Answer D: White
The thyroid gland is usually larger in women than in men: True False
Answer True
A patient with lobar pneumonia would have muffled and indistinct spoken voice sounds True False
Answer: False
The frontal sinuses are the only ones readily accessible to clinical examination: True False
Answer: False
A parent is very upset because she is told her child has a refractive error. The nurse reassures the parent that refractive errors are the most common visual change in childre. True False
Answer: True
Lung tissue has no pain fibers True False
Answer: True
The nurse tests the six cardinal directions to test extraocular movement of the eye. True False
Answer: True
When assessing a patient with asthma, the nurse would expect to hear wheezing. True False
Answer: True
Primary headaches are more worrisome than secondary headaches. True False
False
Tonsils are T1:______ Tonsils are T2:_______ Tonsils are T3:________ Tonsils are T4:_________
T1: tonsils are visible T2: tonsils are between the tonsillar pillars and the uvula T3: Tonsils are touching the uvula T4: Tonsils are touching each other