Health Assessment eyes heart

The nurse is preparing to teach a woman about breast self-examination (BSE). Which statement by the nurse is correct?

"BSE on a monthly basis will help you feel familiar with your own breasts and their normal variations."

A woman is in the family planning clinic seeking birth control information. She states that her breasts "change all month long" and that she is worried that this is unusual. What is the nurse's best response?

Tell her that, because of the changing hormones during the monthly menstrual cycle, cyclic breast changes are common.

A 17-year-old student is a swimmer on her high school's swim team. She has had three bouts of otitis externa so far this season and wants to know what to do to prevent it. The nurse instructs her to:

use rubbing alcohol or 2% acetic acid eardrops after every swim.

. The nurse is palpating a female patient's breasts during an examination. Which of these positions is most likely to make significant lumps more distinct during breast palpation?

Supine with arms raised over her head

When a light is directed across the iris of a patient's eye from the temporal side, the nurse is assessing for:

the presence of shadows, which may indicate glaucoma.

When a breastfeeding mother is diagnosed with a breast abscess, which of these instructions from the nurse is correct? The mother needs to:

temporarily discontinue nursing on affected breast and manually express milk and discard it.

The nurse is assessing color vision of a male child. Which statement is correct? The nurse should:

test for color vision once between the ages of 4 and 8.

The nurse is performing an eye-screening clinic at a daycare center. When examining a 2-year-old child, the nurse suspects that the child has "lazy eye" and should:

test for strabismus by performing the corneal light reflex test.

During an interview, the patient states he has the sensation that "everything around him is spinning." The nurse recognizes that the portion of the ear responsible for this sensation is:

the labyrinth.

In performing a breast examination, the nurse knows that it is especially important to examine the upper outer quadrant of the breast. The reason for this is that the upper outer quadrant is:

the location of most breast tumors.

A patient's vision is recorded as 20/30 when the Snellen eye chart is used. The nurse interprets these results to indicate that:

the patient can read at 20 feet what a person with normal vision can read at 30 feet.

The nurse is discussing breast self-examination with a postmenopausal woman. The best time for postmenopausal women to perform breast self-examination is:

the same day every month.

The nurse has palpated a lump in a female patient's right breast. The nurse documents this as a small, round, firm, distinct, lump located at 2 o'clock, 2 cm from the nipple. It is nontender and fixed. There is no associated retraction of skin or nipple, no erythema, and no axillary lymphadenopathy. Which of these statements reveals the information that is missing from the documentation? It is missing information about:

the size of the lump.

When performing an otoscopic examination of a 5-year-old child with a history of chronic ear infections, the nurse sees that his right tympanic membrane is amber-yellow in color and that there are air bubbles behind the tympanic membrane. The child reports occasional hearing loss and a popping sound with swallowing. The preliminary analysis based on this information is that:

this is most likely a serous otitis media.

The mother of a 2-year-old is concerned about the upcoming placement of tympanostomy tubes in her son's ears. The nurse would include which of these statements in the teaching plan?

The purpose of the tubes is to decrease the pressure and allow for drainage.

Which of the following statements is true regarding the internal structures of the breast? The breast is:

composed of fibrous, glandular, and adipose tissue.

A patient with a middle ear infection asks the nurse, "What does the middle ear do?" The nurse responds by telling the patient that the middle ear functions to:

conduct vibrations of sounds to the inner ear.

While inspecting a patient's breasts, the nurse finds that the left breast is slightly larger than the right with the presence of Montgomery's glands bilaterally. The nurse should:

consider these normal findings and proceed with the examination.

A patient has a normal pupillary light reflex. The nurse recognizes that this reflex indicates that:

constriction of both pupils occurs in response to bright light.

The nurse is performing an assessment on a 65-year-old male patient. He reports a crusty nodule behind the pinna. It bleeds intermittently and has not healed over the past 6 months. On physical assessment, the nurse finds an ulcerated crusted nodule with an indurated base. The preliminary analysis in this situation is that this:

could be a potential carcinoma and should be referred.

A patient comes into the clinic complaining of pain in her right eye. On examination, the nurse sees apustule at the lid margin that is painful to touch, red, and swollen. The nurse recognizes that this is

dacryocystitis.

When examining a patient's eyes, the nurse recalls that stimulation of the sympathetic branch of the autonomic nervous system:

elevates the eyelid and dilates the pupil.

A patient's vision is recorded as 20/80 in each eye. The nurse interprets this finding to mean that the patient:

has poor vision.

During a physical education class, a student is hit in the eye with the end of a baseball bat. When examined in the emergency department, the nurse notices the presence of blood in the anterior chamber of the eye. This finding indicates the presence of:

hyphema.

The nurse is reviewing the structures of the ear. Which of these statements concerning the Eustachian tube is true?

it helps equalize air pressure on both sides of the tympanic membrane.

A 52-year-old patient describes the presence of occasional "floaters" or "spots" moving in front of his eyes. The nurse should:

know that floaters are usually not significant and are caused by condensed vitreous fibers.

A patient is newly diagnosed with benign breast disease. The nurse recognizes that which statement about benign breast disease is true? The presence of benign breast disease:

makes it harder to examine the breasts.

The nurse is conducting a visual examination. Which of these statements regarding visual pathways and visual fields is true?

The image formed on the retina is upside down and reversed from its actual appearance in the outside world.

The nurse assesses the hearing of a 7-month-old by clapping hands. What is the expected response?

The infant turns the head to localize sound.

Which of these assessment findings would the nurse expect to see when examining the eyes of a black patient?

A dark retinal background

The nurse is performing an ear examination of an 80-year-old patient. Which of these would be considered a normal finding?

A high-tone frequency loss

During an assessment of the sclera of an African-American patient, the nurse would consider which of these an expected finding?

The presence of small brown macules on the sclera

A patient comes into the emergency department after an accident at work. A machine blew dust into his eyes and he was not wearing safety glasses. The nurse examines his corneas by shining a light from the side across the cornea. What findings would suggest that he has suffered a corneal abrasion?

A shattered look to the light rays reflecting off the cornea

The nurse is reviewing causes of increased intraocular pressure. Which of these factors determines intraocular pressure?

Amount of aqueous produced and resistance to its outflow at the angle of the anterior chamber

The nurse is reviewing risk factors for breast cancer. Which of these women have risk factors that place them at a higher risk for breast cancer?

65 year old whose mother had breast cancer

During an examination, the patient states he is hearing a buzzing sound and says that it is "driving me crazy!" The nurse recognizes that this symptom indicates:

tinnitus.

A 43-year-old woman is at the clinic for a routine examination. She reports that she has had a breast lump in her right breast for years. Recently, it has begun to change in consistency and is becoming harder. She reports that 5 years ago her physician evaluated the lump and determined that it "was nothing to worry about." The examination validates the presence of a mass in the right upper outer quadrant at 1 o'clock, approximately 5 cm from the nipple. It is firm, mobile, nontender, with borders that are not well defined. The nurse's recommendation to her is:

"Because of the change in consistency of the lump, it should be further evaluated by a physician."

During an interview, a patient reveals that she is pregnant. She states that she is not sure whether she will breastfeed her baby and asks for some information about this. Which of these statements by the nurse is accurate with regard to breastfeeding?

"Breastfeeding provides the perfect food and antibodies for your baby."

A mother asks when her newborn infant's eyesight will be developed. The nurse should reply:

"By about 3 months, infants develop more coordinated eye movements and can fixate on an object."

A 55-year-old postmenopausal woman is being seen in the clinic for a yearly examination. She is concerned about changes in her breasts that she has noticed over the past 5 years. She states that her breasts have decreased in size and that the elasticity has changed so that her breasts seem "flat and flabby." The nurse's best reply would be:

"Decreases in hormones after menopause causes atrophy of the glandular tissue in the breast. This is a normal process of aging."

While discussing the history of a 6-month-old infant, the mother tells the nurse that she took a great deal of aspirin while she was pregnant. What question would the nurse want to include in the history?

"Does your baby seem to startle with loud noise?"

During a discussion about breast self-examination with a 30-year-old woman, which of these statements by the nurse is most appropriate?

"Examine your breasts shortly after your menstrual period each month."

A 9-year-old girl is in the clinic for a sports physical. After some initial shyness she finally asks,"Am I normal? I don't seem to need a bra yet, but I have some friends who do. What if I never get breasts?" The nurse's best response would be:

"I understand that it is hard to feel different from your friends. Breasts usually develop between 8 and 10 years of age."

During a breast health interview, a patient states that she has noticed pain in her left breast. The nurse's most appropriate response to this would be:

"I would like some more information about the pain in your left breast."

The nurse is taking the history of a patient who may have a perforated eardrum. What would be an important question in this situation?

"Was there any relationship between the ear pain and the discharge you mentioned?"

The nurse is teaching a pregnant woman about breast milk. Which statement by the nurse is correct?

"You may notice a thick, yellow fluid expressed from your breasts as early as the fourth month of pregnancy."

The mother of a 2-year-old is concerned because her son has had three ear infections in the past year. What would be an appropriate response by the nurse?

"Your son's eustachian tube is shorter and wider than yours because of his age, which allows for infections to develop more easily."

Which of these clinical situations would the nurse consider to be outside normal limits?

A patient has had two pregnancies and she breastfed both of her children. Her youngest child is now 10 years old. Her breast examination reveals breast tissue that is somewhat soft and she has a small amount of thick yellow discharge from both nipples.

During an examination of a 7-year-old girl, the nurse notices that the girl is showing breast budding. What should the nurse do next?

Assess the girl's weight and body mass index (BMI).

The nurse is reviewing statistics regarding breast cancer. Which woman, aged 40 years in the United States, has the highest risk for development of breast cancer?

African-American

The nurse is preparing for a class in early detection of breast cancer. Which statement is true with regard to breast cancer in African-American women in the United States?

African-American women are more likely to die of breast cancer at any age.

A 65-year-old patient remarks that she just can't believe that her breasts sag so much. She states it must be from lack of exercise. What explanation should the nurse offer her?

After menopause, the glandular and fat tissue atrophies, causing breast size and elasticity to diminish, resulting in breasts that sag.

The nurse is examining a patient's retina with an ophthalmoscope. Which finding is considered normal?

An optic disc that is a yellow-orange color

An assessment of a 23-year-old patient reveals the following: an auricle that is tender and reddishblue in color with small vesicles. Additional information the nurse would need to know includes which of these?

Any prolonged exposure to extreme cold

During a history interview, a female patient states that she has noticed a few drops of clear discharge from her right nipple. What should the nurse do next?

Ask her some additional questions about the medications she is taking.

During an assessment the nurse notices that an elderly patient has tears rolling down his face from his left eye. Closer examination shows that the lower lid is loose and rolling outward. The patient complains of his eye feeling "dry and itchy." Which action by the nurse is correct?

Assess for other signs of ectropion.

During an annual physical exam, a 43-year-old patient states that she doesn't perform monthly breast self-examinations (BSE). She tells the nurse that she believes that mammograms "do a much better job than I ever could to find a lump." The nurse should explain to her that:

BSEs may detect lumps that appear between mammograms.

The nurse is assessing a 16-year-old patient who has suffered head injuries from a recent motor vehicle accident. Which of these statements indicates the most important reason for assessing for any drainage from the ear canal?

Bloody or clear watery drainage can indicate a basal skull fracture.

The nurse is reviewing the function of the cranial nerves. Which of the cranial nerves is responsible for conducting nerve impulses to the brain from the organ of Corti?

CN VIII

In performing an assessment of a woman's axillary lymph system, the nurse should assess which of these nodes?

Central, lateral, pectoral, and subscapular nodes

The nurse is assessing a patient's eyes for the accommodation response and would expect to see which normal finding?

Convergence of the axes of the eyes

During an ophthalmoscopic examination of the eye, the nurse notices areas of exudate that look like "cotton wool" or fluffy gray -white cumulus clouds. This finding indicates which possible problem?

Diabetes

In an individual with otitis externa, which of these signs would the nurse expect to find on assessment?

Enlarged superficial cervical nodes

In examining a 70-year-old male patient, the nurse notices that he has bilateral gynecomastia. Which of the following describes the nurse's best course of action?

Explain that this condition may be the result of hormonal changes and recommend that he see his physician.

The nurse suspects that a patient has otitis media. Early signs of otitis media include which of these findings of the tympanic membrane?

Hypomobility

During an examination, the nurse notes a supernumerary nipple just under the patient's left breast. The patient tells the nurse that she always thought it was a mole. Which statement about this finding is correct?

It is a normal variation and not a significant finding.

The nurse is assessing a patient who may have hearing loss. Which of these statements is true concerning air conduction?

It is the normal pathway for hearing.

During the physical examination, the nurse notices that a female patient has an inverted left nipple. Which statement regarding this is most accurate?

It should be determined whether the inversion is a recent change.

The nurse is reviewing for a class in age-related changes in the eye. Which of these physiological changes is responsible for presbyopia?

Loss of lens elasticity

A new mother calls the clinic to report that part of her left breast is red, swollen, tender, very hot, and hard. She has a fever of 101 F. She has also had symptoms of the flu, such as chills, sweating, and feeling tired. The nurse notices that she has been breastfeeding for 1 month. From her description, what condition does the nurse suspect?

Mastitis

A 70-year-old patient tells the nurse that he has noticed that he is having trouble hearing, especially in large groups. He says he "can't always tell where the sound is coming from" and the words often sound "mixed up." What might the nurse suspect as the cause for this change?

Nerve degeneration in the inner ear

A patient has been admitted after an accident at work. During the assessment, the patient is having trouble hearing and states, "I don't know what the matter is. All of a sudden, I can't hear you out of my left ear!" What should the nurse do next?

Notify the patient's health care provider.

A 60-year-old man is at the clinic for an eye examination. The nurse suspects that he has ptosis of one eye. How should the nurse check for this?

Observe the distance between the palpebral fissures.

A 54-year-old man comes to the clinic with a "horrible problem." He tells the nurse that he has just discovered a lump on his breast and is fearful of cancer. The nurse knows that which statement about breast cancer in males is true?

One percent of all breast cancer occurs in men.

The nurse is testing a patient's visual accommodation, which refers to which action?

Papillary constriction when looking at a near object

The nurse is performing the diagnostic positions test. Normal findings would be which of these results?

Parallel movement of both eyes

The nurse is conducting a child safety class for new mothers. Which of these is a risk factor for ear infections in young children?

Passive cigarette smoke

The nurse is preparing to do an otoscopic examination on a 2-year-old child. Which of these reflects correct procedure?

Pull the pinna down.

The nurse is performing an otoscopic examination on an adult. Which of these actions is correct?

Pull the pinna up and back before inserting the speculum.

A patient in her first trimester of pregnancy is diagnosed with rubella. Which of these statements is correct regarding the significance of this in relation to the infant's hearing?

Rubella can damage the infant's organ of Corti, which will impair hearing.

A woman has just learned that she is pregnant. What are some things the nurse should teach her about her breasts?

She can expect her areolae to become larger and darker in color.

When assessing the pupillary light reflex, the nurse should use which technique?

Shine a light across the pupil from the side and observe for direct and consensual pupillary constriction.

A patient is unable to read even the largest letters on the Snellen chart. The nurse should take which action next?

Shorten the distance between the patient and the chart until it is seen and record that distance.

A patient contacts the office and tells the nurse that she is worried about her 10-year-old daughter having breast cancer. She describes a unilateral enlargement of the right breast with associated tenderness. She is worried because the left breast is not enlarged. What would be the nurse's best response?

Tell the mother that, although an examination of her daughter would rule out a problem, it is most likely normal breast development.

During an examination of the eye, the nurse would expect what normal finding when assessing the lacrimal apparatus?

The absence of drainage from the puncta when pressing against the inner orbital rim

The nurse is conducting a class about breast self-examination (BSE). Which of these statements indicates proper BSE technique?

The best time to perform BSE is 4 to 7 days after the first day of the menstrual period.

The nurse is preparing to perform an otoscopic examination of a newborn infant. Which statement is true regarding this examination?

The normal membrane may appear thick and opaque.

The nurse is performing an external eye examination. Which statement regarding the outer layer of the eye is true?

The outer layer of the eye is very sensitive to touch.

The nurse is examining a patient's ears and notices cerumen in the external canal. Which of these statements about cerumen is correct?

The purpose of cerumen is to protect and lubricate the ear.

During an examination of a woman, the nurse notices that her left breast is slightly larger than her right breast. Which of these statements is true about this finding?

This finding is not unusual, but the nurse should verify that this change is not new.

During an assessment of a 20-year-old Asian patient, the nurse notices that he has dry, flaky cerumen in his canal. What is the significance of this finding?

This is a normal finding and no further follow-up is necessary.

A colleague is assessing an 80-year-old patient who has ear pain and asks him to hold his nose and swallow. The nurse knows that which of the following is true concerning this technique?

This should not be used in an 80-year-old patient.

The nurse is performing an eye assessment on an 80-year-old patient. Which of these findings is considered abnormal?

Unequal pupillary constriction in response to light

The nurse is preparing to assess the visual acuity of a 16-year-old patient. How should the nurse proceed?

Use the Snellen chart positioned 20 feet away from the patient.

During a physical examination, a 45-year-old woman states that she has had a crusty, itchy rash on her breast for about 2 weeks. In trying to find the cause of the rash, which of these would be important for the nurse to determine?

Where did it first appear—on the nipple, the areola, or the surrounding skin?

In performing a voice test to assess hearing, which of these actions would the nurse do?

Whisper a set of random numbers and letters and ask the patient to repeat them.

The nurse is assisting with a self-breast examination clinic. Which of these women reflect abnormal findings during the inspection phase of breast examination?

Woman whose nipples are in different planes (deviated)

During an otoscopic examination, the nurse notices an area of black and white dots on the tympanic membrane and ear canal wall. What does this finding suggest?

Yeast or fungal infection

During a breast examination on a female patient, the nurse notices that the nipple is flat, broad, and fixed. The patient states it "started doing that a few months ago." This finding suggests:

a retracted nipple.

While performing the otoscopic examination of a 3-year-old boy who has been pulling on his left ear, the nurse finds that his left tympanic membrane is bright red and that the light reflex is not visible. The nurse interprets these findings to indicate:

acute otitis media.

The nurse notices the presence of periorbital edema when performing an eye assessment on a 70-year-old patient. The nurse should:

ask the patient if he or she has a history of heart failure.

A patient has been shown to have a sensorineural hearing loss. During the assessment, it would be important for the nurse to:

ask the patient what medications he is currently taking.

The nurse needs to pull the portion of the ear that consists of movable cartilage and skin down and back when administering eardrops. This portion of the ear is called the:

auricle.

A 2-week-old infant can fixate on an object but cannot follow a light or bright toy. The nurse would:

consider this a normal finding.

When performing the corneal light reflex assessment, the nurse notes that the light is reflected at 2 o'clock in each eye. The nurse should:

consider this a normal finding.

In using the ophthalmoscope to assess a patient's eyes, the nurse notices a red glow in the patient's pupils. On the basis of this finding, the nurse would:

consider this a normal reflection of the ophthalmoscope light off the inner retina.

An ophthalmic examination reveals papilledema. The nurse is aware that this finding indicates:

increased intracranial pressure.

If a patient reports a recent breast infection, then the nurse should expect to find _____ node enlargement.

ipsilateral axillary

A 31-year-old patient tells the nurse that he has noticed pain in his left ear when people speak loudly to him. The nurse knows that this finding:

is a characteristic of recruitment.

When examining the eye, the nurse notices that the patient's eyelid margins approximate completely. The nurse recognizes that this assessment finding:

is expected.

The nurse is performing a middle ear assessment on a 15-year-old patient who has a history of chronic ear infections. When examining the right tympanic membrane, the nurse sees the presence of dense white patches. The tympanic membrane is otherwise unremarkable. It is pearly, with the light reflex at 5 o'clock and landmarks visible. The nurse should:

know that these are scars caused from frequent ear infections.

During an examination, the nurse notices that the patient stumbles a bit while walking, and, when she sits down, she holds on to the sides of the chair. The patient states, "It feels like the room is spinning!" The nurse notices that the patient is experiencing:

objective vertigo.

A 31-year-old patient tells the nurse that he has noticed a progressive loss in his hearing. He says that it does seem to help when people speak louder or if he turns up the volume. The most likely cause of his hearing loss is:

otosclerosis.

A patient states during the interview that she noticed a new lump in the shower a few days ago. It was on her left breast near her axilla. The nurse should plan to:

palpate the unaffected breast first.

When examining the ear with an otoscope, the nurse notes that the tympanic membrane should appear:

pearly gray and slightly concave.

While examining a 75-year-old woman, the nurse notices that the skin over her right breast is thickened and the hair follicles are exaggerated. This condition is known as:

peau d'orange.

In performing an examination of a 3 year old with a suspected ear infection, the nurse would:

perform the otoscopic examination at the end of the assessment.

In a patient who has anisocoria, the nurse would expect to observe:

pupils of unequal size.

A patient comes to the emergency department after a boxing match, and his left eye is swollen almost shut. He has bruises on his face and neck. He says he is worried because he "can't see well" from his left eye. The physician suspects retinal damage. The nurse recognizes that signs of retinal detachment include:

shadow or diminished vision in one quadrant or one half of the visual field.

A 14-year-old girl is anxious about not having reached menarche. When taking the history, the nurse should ascertain which of the following? The age:

she began to develop breasts

A 68-year-old woman is in the eye clinic for a checkup. She tells the nurse that she has been having trouble with reading the paper, sewing, and even seeing the faces of her grandchildren. On examination, the nurse notes that she has some loss of central vision but her peripheral vision is normal. These findings suggest that:

she may have macular degeneration.

The nurse is performing a breast examination. Which of these statements best describes the correct procedure to use when screening for nipple and skin retraction during a breast examination? Have the woman:

slowly lift her arms above her head and note any retraction or lag in movement.

During ocular examinations, the nurse keeps in mind that movement of the extraocular muscles is:

stimulated by cranial nerves III, IV, and VI.