Health Assessment Test 3

A client presents to the health care facility for a routine health checkup. The nurse learns that the client has a long history of cardiovascular disease, including hypertension and carotid artery disease. When assessing this client for potential problems in the nervous system, which question by the nurse is appropriate?

"Are you having any dizziness or lightheadedness?" Clients with carotid artery disease may experience dizziness or lightheadedness, especially with ambulation because of the increased difficulty in circulating enough blood and oxygen to the brain. Trouble hearing and changes in vision may signal cranial nerve dysfunction. Weakness in the muscles of the extremities is an indication of a CVA or nerve injury.

A nurse is interviewing a client as part of a routine examination of his ears and hearing. The nurse notes that this client has high blood pressure. Which of the following questions regarding his hearing should the nurse ask that is associated with his high blood pressure?

"Do you experience any ringing, roaring, or crackling in your ears?" Ringing in the ears (tinnitus) may be associated with excessive ear wax buildup, high blood pressure, or certain ototoxic medications. None of the other questions pertains to conditions related to high blood pressure. Ear pain is associated with ear infections, cerumen blockage, sinus infections, teeth and gum problems, and swimmer's ear. Drainage usually indicates infection. Hearing loss may be related to any number of causes but is not associated with high blood pressure.

A 61-year-old man has visited the clinic at the prompting of his wife, who states that his hearing is becoming less acute. Which of the following assessment questions is most useful in determining whether the man's hearing loss is sensorineural or conductive?

"Do you find that you have particular difficulty understanding people's speech?" A hallmark of sensorineural hearing loss is difficulty in understanding speech. It would be prudent to assess for loss of balance and vertigo and to identify any pitch-dependent characteristics, but these would be less useful in differentiating between conductive and sensorineural hearing loss. Hearing loss is not noted to correlate with other sensory losses.

The mother of a small child with tubes in both eardrums asks the nurse if it is okay if the child travels by airplane. What is the nurse's best response?

"It's safe to fly because the tubes will equalize pressure." Pressure equalization tubes equalize pressure on either sides of the eardrum; so it's a great time to fly if one has tubes in the ears. The child should wear ear plugs to keep water out of the ears when swimming. Wearing ear plugs while flying may diminish the pressure equalization advantage of the tubes. Clients do not have to avoid flying for any period of time after tube placement. Ear tubes do not have an effect on immunocompromised clients.

A client recently diagnosed with Grave's diseases exhibits protruded eyeballs. Which eye care instruction should the nurse discuss with this client?

"Wear an eyepatch and use moisturizing eye drops." Exopthalmos, or protruding eyeballs, is commonly caused by Grave's disease. Untreated exopthalmos can impair the ability of the eye to close properly and can increased dryness. The client should have regular eye exams and can wear an eyepatch and use moisturizing eye drops for dryness. Eyes should be cleaned from the inner to outer canthus as needed. Wearing UV blocking glasses does not affect the progression of this condition, but does help with cataracts. Sympathomimetic eye drops are used to dilate pupils for eye exams. These drops are not commonly prescribed for exopthalmos.

Which factor, if present in a client's lifestyle and health practices assessment, would alert the nurse to the need for performing a more thorough head and neck assessment? Select all that apply.

-Alcohol abuse -Recreational drug use -Smokeless tobacco use -Multiple sex partners Tobacco and alcohol use increases the risk of head and neck cancer. A more recently identified cause of head and neck cancer is exposure to human papillomavirus (HPV). People with multiple sexual partners and those who engage in oral sex are at increased risk of developing oral HPV-related cancer. For these reasons the nurse would need to perform a thorough head and neck examination.

A nurse practitioner is assessing a client in the ED following a motor vehicle accident. The client complains of ear pain. The nurse practitioner is performing an otoscopic examination. What would demonstrate the correct technique for using the otoscope?

-Holding the otoscope so that the thumb is by the window -Holding the client's ear at the helix -Rotating the otoscope slightly The examiner should hold the otoscope so that the thumb is by the window and the fingers are bracing the shaft along the client's cheek. The examiner should hold the client's ear at the helix and lift up and back to align the canal for best visualization of the tympanic membrane. After visualization of the canal, the examiner should rotate the otoscope slightly to visualize the entire tympanic membrane, including portions of the malleus, umbo, manubrium, and short process.

An older adult client presents at the clinic, reporting otalgia in the right ear. Physical assessment reveals cerumen impacted in the client's ear. Removing this mechanical blockage may do what for this client? (Select all that apply.)

-Improve hearing -Enhance socialization -Prevent injury Removing a mechanical blockage can improve hearing and enhance socialization. It also helps to prevent injury by preserving the sense of hearing. Removing the mechanical blockage will not increase the size of the ear canal or provide less rigidity in the outer ear.

A nurse is examining a client's goiter and explaining the characteristics and functions of the thyroid gland. Which of the following should the nurse mention? Select all that apply.

-Largest endocrine gland in the body -Produces hormones that increase the metabolic rate of most body cells -Consists of two lateral lobes -Covered mostly by the sternomastoid muscles The thyroid gland is the largest endocrine gland in the body. It produces thyroid hormones that increase the metabolic rate of most body cells. The thyroid gland consists of two lateral lobes that curve posteriorly on both sides of the trachea and esophagus and are mostly covered by the sternomastoid muscles. The parotid glands, not the thyroid, are located on each side of the face, anterior and inferior to the ears and behind the mandible. The submandibular glands, not the thyroid, produce saliva.

Which of these factors should a nurse include when teaching about risk reduction for cerebrovascular accidents (CVA) to a group of middle-aged adults within the community? Select all that apply.

-Limit alcohol to 1 drink per day for women and 2 for men -Lower blood pressure Risk reduction for a CVA includes controlling blood pressure, stopping smoking (not just reducing it), limiting alcohol to no more than 1 drink per day for women and 2 drinks for men, exercising, lowering cholesterol and fat intake, controlling blood sugar, and avoiding drugs such as cocaine. Increasing estrogen levels and protein intake are not associated with reducing risk for CVAs.

The nurse is presenting an educational event for a local civic group about the risk factors for neck cancer. What would the nurse list? (Select all that apply.)

-Male gender -Tobacco use -Age older than 50 years Risk factors for neck cancers include male gender, age older than 50 years, tobacco use, and alcohol consumption. For clients with such risk factors, nurses should especially emphasize teaching related to smoking prevention or cessation. Risk factors do not include female gender or being a coffee drinker.

The nursing instructor is discussing the eye with the nursing students. What would the instructor cite as part of the lacrimal apparatus? (Select all that apply.)

-Punctum -Lacrimal gland -Nasolacrimal duct The lacrimal apparatus, which consists of the lacrimal gland, punctum, lacrimal sac, and nasolacrimal duct, protects and lubricates the cornea and conjunctiva by producing and draining tears. The palpebral fissure is the open space between the eyelids. The limbus is the border between the cornea and the sclera.

What are the openings to the middle ear? Select all that apply.

-The tympanic membrane -The round window -The oval window -The eustachian tube There are four openings to the middle ear chamber: tympanic membrane; cochlear window, also known as the round window; oval window; and eustachian tube. The square window is a distracter for the question.

The nurse is conducting a physical examination of a client who reports finding a lump in the neck. Which of the following questions should be included in when the nurse is collecting subjective data? (Select all that apply).

-When did you first notice the lump? -How recently have you consumed alcohol? -Has the lump changed? Asking the client when the lump was first noticed is included in the subjective data set in the onset section. Asking the client if alcohol has recently been consumed is included in the subjective data set in associated manifestations section. Asking the client whether the lump has changed is included in the subjective data set in the characteristic symptoms section. Assessing for familial experience with the client's chief complaint would be included in health history. The objective examination would provide the nurse with information regarding the experience of pain from the lump.

The nurse assesses a client with noisy breathing including a gasping sound with respiration. The nurse notes tracheal deviation from the usual midline position. Which conditions should the nurse assess for further? Select all that apply.

-mediastinal mass -atelectasis -pneumothorax -goiter A mediastinal mass is any large mass of the lung, bronchi or pleural cavity, benign or malignant, that can cause a shift of the trachea from the normal midline position. Atelectasis refers to the diminished lung volume from either a blockage or inability to inflate the lungs fully. The decreased pressure associated with this problem could shift the trachea. Pneumothorax is a part or complete collapse of the lung due to abnormal air entry to the pleural space causing lung compression. This leads to little or no expansion of the lungs on inspiration. As a result, the trachea shifts. A goiter is an enlargement of the thyroid gland. The enlargement can impede upon the trachea shifting it from the midline position. The preauricular node is located in the front of the ear. Its location is not near the trachea.

Upon assessment of the tonsils, the nurse finds them to be obstructing 30% of midline. This nurse would document this as what?

1+ When tonsils obstruct 25-50% of midline, it would be documented as 2+. A 1+ is an obstruction of up to 25% of midline. A 3+ is an obstruction of 50-75% of midline. If the tonsils obstruct 75-100% of midline, it is a 4+.

On palpating a client's scrotum and testes, the nurse notes that the testes appear to be of normal shape and size. Which of the following would indicate a normal length for testes?

4.5 cm Testes are ovoid, approximately 3.5 to 5 cm long, 2.5 cm wide, and 2.5 cm deep, and equal bilaterally in size and shape.

A 55-year-old male client has just been diagnosed with presbycusis. In the interview with the client, the nurse should most expect the client to complain of having trouble hearing which of the following in the initial stages of this condition?

A story his wife is telling him Presbycusis often begins with a loss of high-frequency sounds (woman's voice) followed later by the loss of low-frequency sounds. The bass speakers, his son's voice, and the engine starting would all have lower-frequency sounds than his wife's voice.

Which of the following clients is most likely to be diagnosed with migraine headaches?

A woman whose headaches come on suddenly and are somewhat relieved by a quiet, dark room The hallmarks of migraine headaches include a rapid onset, nausea, and relief by the removal of light and sound stimuli. Sustained muscle activity associated with typing and driving often precedes tension headaches. Cluster headaches, not migraines, are episodic over the course of a day.

A nurse palpates an enlarged and tender left sided supraclavicular lymph node in a client. Where should the nurse focus the physical assessment to obtain more data about this finding?

Abdomen and thoracic area for changes associated with malignancy The supraclavicular lymph nodes are located by hooking the fingers over the clavicles and feeling deeply between the clavicles and the sternomastoid muscles. Normally, these lymph nodes should not be palpable. An enlarged, hard, nontender, left-sided supraclavicular node may be an indication of malignancy of the abdomen or thorax. Lymph nodes enlarged because of infection or inflammation and do not affect sensation, movement, or range of motion. Infection or inflammation in the head and neck region most often enlarge the nodes closest to the site affected, such as preauricular or postauricular with ear infections. Degeneration within the spinal cord does not effect lymph nodes.

What do retinal abnormalities include?

Age-related macular degeneration Age-related macular degeneration gradually causes loss of sharp central vision, needed for common daily tasks (eg, driving, reading). The macula degenerates (dry) or abnormal blood vessels behind the retina grow under the macula (wet). Mydriasis, Argyll Robertson syndrome, and Horner's syndrome all affect the pupils, not the retina.

The nurse is assessing a new client in the obstetric clinic. What is the most likely question that the nurse would ask this client when assessing the upper respiratory tract?

Are you having nosebleeds? Hormonal fluctuations often result in increased nasal congestion and may exacerbate allergies. Epistaxis may be secondary to engorged nasal vessels. When assessing the upper respiratory tract, the questions the nurse would ask are pertinent to the upper respiratory tract. Asking about lesions anywhere is not specific to the upper respiratory tract. Asking about being a smoker is not specific to the upper respiratory tract. The nurse would be sure to ask if the client is having nasal congestion, but exploring use of medications would depend on the client's answer to that question first.

A nurse assesses a client's pupils for the reaction to light and observes that the pupils are of unequal size. What should the nurse do next in relation to this finding?

Ask the client about previous trauma to the eyes Unequal pupil size is termed anisocoria. Often it is a normal finding but it can indicate trauma to the parasympathetic nerve supply to the iris. The nurse should ask the client about previous trauma to the eye to determine if this is a new finding or this is new onset. All other options the nurse can do after this is determined.

How should a nurse proceed with palpation of the anus to best facilitate the exam without causing the client undo discomfort?

Ask the client to bear down and place the lubricated finger on the anal opening The nurse should lubricate the index finger of the gloved hand and ask the client to bear down. As the client bears down, place the pad of the index finger on the anal opening. When the sphincter relaxes, insert the finger with the pad facing down. Do not use the fingertip because this may cause the sphincter to tighten and this will cause pain when placed into the rectum. Spread the gluteal folds with the hands and attempt to visualize the anal opening is necessary if the client reports severe pain in order to see if there is a lesion present.

The nurse suspects an enlarged thyroid in a patient during the physical examination of the head and neck. What should the nurse first?

Ask the patient to sip and swallow water. In order to determine if the thyroid gland is enlarged, the first step in the physical assessment is to ask the client to sip some water, extend the neck and swallow. By doing so, the nurse can watch for upward movement of the thyroid gland and determine if the gland is enlarged. Once it confirmed that the thyroid gland is enlarged, it would be the next step for the nurse to listen over the lateral lobes with a stethoscope to detect a bruit. Displacing the trachea would not be part of the assessment; however, the nurse would need to inspect the trachea for deviations that may push it to one side. Assessment of the thyroid gland can be done while the client is sitting up from either an anterior or posterior approach. The assessment cannot be effectively done with the client lying down.

Upon inspection of an elderly client's ears using an otoscope, the nurse observes a cloudy appearance to the tympanic membranes with prominent landmarks. What action should the nurse perform first?

Ask whether the client is experiencing ear pain or pressure The older client's eardrums may appear cloudy with prominent landmarks due to the atrophy of the tympanic membranes associated with normal aging. The nurse should ask the client about ear pain because prominent landmarks can also be a sign of negative pressure associated with obstructed eustachian tubes. An ear infection should be ruled out and problems with hearing and balance assessed before making a clinical judgment that this is a normal finding. All objective information should be documented by the nurse.

A client with a cervical spine injury has chronic pain. What would be the most appropriate initial nursing intervention for this client?

Assess characteristics The first step would be for the nurse to assess characteristics of the pain. Surgery or pharmacologic interventions would be considered by the whole health care team after more information was gathered. Option C represents a nursing diagnosis, not an intervention.

When palpating the neck, performing which of the following techniques will help differentiate lymph nodes from a band of muscles?

Attempting to roll the structure up and down and side to side While lymph nodes may be rolled both up and down and side to side, muscles will not move in this manner. The other cited techniques do not differentiate between lymph nodes and muscles.

The nurse explains the parts of a female pelvic examination to a young adult female client. What should the nurse explain is being examined in this diagram?

Bimanual palpation of the cervix This diagram demonstrates the bimanual palpation of the cervix. The non-examining hand is located midway between the symphysis pubis and the umbilicus. Palpation of the bladder can be performed externally. The non-examining hand is placed lateral to the midline of the abdomen when palpating the ovaries. A finger is inserted in the rectum when determining the integrity of the wall between the uterus and the rectum.

A diabetes educator is teaching a group of adults about the risks to vision that result from poorly controlled blood glucose levels. Which of the following pathophysiologic processes underlies the vision loss associated with diabetes mellitus?

Blood vessels supplying the retina become weak and bleeding occurs. In diabetic retinopathy, the vessels that feed the retina change and weaken. Eventually, they may become blocked and cause bleeding into the eye, which blocks vision. Diabetes does not directly cause an increase in pressure in the eye, osmotic changes in the aqueous humor or corneal infection.

The nurse is palpating a client's cervical vertebrae. Which vertebra can be easily palpated when the neck is flexed and should help the nurse locate the other vertebrae?

C7 The cervical vertebrae (C1 through C7) are located in the posterior neck and support the cranium. The vertebra prominens is C7, which can easily be palpated when the neck is flexed. Using C7 as a landmark will help you to locate other vertebrae.

Which of the following is inconsistent with a digital rectal examination?

Can reveal a hydrocele The DRE is recommended as part of the regular health checkup for every man older than 40 years of age. It is a screening for cancer of the prostate gland. It enables the examiner to assess the size, shape, and constistency of the prostate gland.

A nurse observes a client's gait and notes it to be wide-based and staggering. The Romberg test results were positive. The nurse recognizes this as what type of abnormal gait?

Cerebellar ataxia Cerebellar ataxia is recognized by the wide-based and staggering gait. The Romberg test will be positive. This gait can be seen in persons with cerebellar disease or alcohol or drug intoxication. The characteristic abnormality in Parkinson's disease is the shuffling gait with a stooped over posture and flexion of the hips and knees. Spastic hemiparesis presents with the arm flexed and held close to the body while the client drags toe and circles the leg outward and forward. Steppage gait (footddrop) is seen when the client lifts the foot and knee high with each step, then slaps the foot hard to the ground.

The nurse is assessing the client's coordination and finds that her movements are clumsy, unsteady, and inappropriately varying in their speed, force, and direction. The nurse notes that patient has dysmetria. What would the nurse know this patient has?

Cerebellar disease In cerebellar disease, movements are clumsy, unsteady, and inappropriately varying in their speed, force, and direction. The finger may initially overshoot its mark, but finally reaches it fairly well, termed dysmetria. An intention tremor may appear toward the end of the movement.

A male college student presents to the student health clinic with reports of night-time headaches for the past 2 weeks. He denies nausea or photosensitivity but states that he has noticed his eyes are tearing and his nose runs a lot. He is stressed because of final exams and confesses to drinking more alcohol than normal. The nurse recognizes these findings as indicative of what type of headache?

Cluster Cluster headaches occur more often in young males, have a sudden onset, and may be precipitated by ingestion of alcohol. The headaches typically occur in the evening and are localized to the eyes, with radiation into the facial and temporal areas. The person may report tearing of the eye or runny nose. Migraine headaches are accompanied by nausea, vomiting, and sensitivity to light and sound. Tension headaches occur more frequently in females and are usually a result of stress, anxiety, or depression.

A nurse is examining the eyes of a client who has complained of having a feeling of a foreign body in his eye. The nurse examines the thin, transparent, continuous membrane that lines the inside of the eyelids and covers most of the anterior eye. The nurse recognizes this membrane as which of the following?

Conjunctiva The conjunctiva is a thin, transparent, continuous membrane that is divided into two portions: a palpebral and a bulbar portion. The palpebral conjunctiva lines the inside of the eyelids, and the bulbar conjunctiva covers most of the anterior eye, merging with the cornea at the limbus. The innermost layer, the retina, extends only to the ciliary body anteriorly. It receives visual stimuli and sends them to the brain. The sclera is a dense, protective, white covering that physically supports the internal structures of the eye. The transparent cornea permits the entrance of light, which passes through the lens to the retina.

When palpating the lymph nodes of the neck, the nurse assesses for which of the following characteristics?

Consistency, delineation, mobility, tenderness Parameters of lymph node assessment include size, shape, delinitation, mobility, consistency, and tenderness.

What activity is known to aggravate a tension headache?

Driving Factors that aggravate or provoke: sustained muscle tension, as in driving or typing.

An anatomy and physiology instructor is discussing the lymphatic system of the head and neck. Why would the instructor emphasize the importance of the drainage pattern of the lymph?

Enlargement of a node may be a sign of pathology that is distant from that node. It is important to understand the drainage patterns of the lymphatics because enlargement of a node may be a sign of pathology that is not directly adjacent to that node.

Primary headaches are more worrisome than secondary headaches.

False

The nurse selects the diagram shown to use when teaching a female client. What health problem is the nurse reviewing with this client?

Fibroids Uterine fibroids appear as single or multiple tumors within the wall of the uterus, often extending from it on stalks or pedunculations. Manifestations of cancer include abnormal bleeding, pain, and alterations in other body systems. Endometrial tissue is found outside the uterus because of a retrograde fl ow of menstrual fluid into the peritoneal cavity. This tissue adheres to other organs and causes pelvic pain, dyspareunia, dysmenorrhea, and possibly infertility. In an ectopic pregnancy, a fertilized ovum implants in a site other than the uterine endometrium.

A nurse needs to examine a client's thyroid as part of the head and neck assessment. How should the nurse instruct the client to position the head in order to best facilitate this exam?

Flex the head toward the side being examined To correctly examine the thyroid, the nurse should stand behind the client and ask him to lower the chin and turn the head toward the side being examined. This action helps to relax the client's neck muscles.

A nurse assesses the parallel alignment of a client's eyes by testing the corneal light reflex. Where should the nurse shine the penlight to obtain an accurate result?

Focused on the bridge of the nose When testing the corneal reflex, the nurse should shine the light toward the bridge of the nose. At the same time, the client is instructed to stare straight ahead. This facilitates a parallel image on the cornea. The eye response upon shining the light toward the eye may interfere with the assessment. The light should not be shined toward the forehead or on an object on the wall.

A client has been receiving intravenous antibiotics for several weeks. Which prevention strategy would be best for the nurse to recommend for this client?

Formal hearing test One group at risk for developing a hearing loss is those who are receiving intravenous antibiotics. The prevention strategy that would be applicable for this client would be a formal hearing test. Although the other tests including whisper hearing test, rubbing fingers test and tuning fork test can be used to test hearing, these are not considered the gold standard. These tests would not be the best prevention strategy to rule out hearing loss in this case.

A 7-year-old child comes to the clinic with her mother, who states that her daughter is doing poorly in school because she has some kind of "ADD" (attention deficit disorder). The nurse asks the mother what makes her think the child has ADD. The mother says that both at home and at school her daughter just zones out for several seconds and licks her lips. She states it happens at least four to six times an hour. She says this has been happening for about 1 year. After several seconds of lip licking, her daughter seems normal again. She states her daughter has been generally healthy with just normal childhood colds and ear infections. The client's parents are both healthy; no other family members have had these symptoms. What type of seizure disorder is most likely?

Generalized absence seizure In an absence seizure there is no tonic-clonic activity. There is a sudden brief lapse of consciousness with blinking, staring, lip smacking, or hand movements that resolve quickly to full consciousness. It is easily mistaken for daydreaming or ADD. Some will try to induce these episodes with hyperventilation.

A male client is complaining of pain with urination, rectal pain and urethral discharge. The nurse suspects this is what?

Gonorrhea Gonorrhea symptoms include pain with urination, rectal pain and urethral discharge. Chlamydia is generally asymptomatic. Scabies is associated with papules, vesicles, pustules and itching. Syphilis has five stages but is exhibited by a genital lesion.

The nurse is assessing a 5-month-old Asian American infant whose mother has brought him to the clinic with reports that the baby is pulling at the ear and is sleepless and crying at night. When assessing the infant's ears, what color cerumen would the nurse expect to find?

Grey Grey to white cerumen is often flakey and misdiagnosed as eczema. This type of cerumen, called dry cerumen, is most prevalent in Asians and Native Americans. Dark brown, light yellow, or gold cerumen is less common in Asian Americans.

When documenting the findings from a physical examination of the head and neck, what will the nurse include when describing the client's head?

Hair color When describing a client's head, the nurse should include 2 categories of findings, the client's hair color and the presence or absence of abnormalities of the skull. Sclera color is included in documentation of the eyes. Nasal mucosa color is included in documentation regarding the nose. Facial skin color is best included when documenting data regarding the skin.

When inspecting the tympanic membrane, which of the following structures does the nurse expect to identify?

Handle of malleus, short process of malleus, cone of light Visualization of the tympanic membrane using an otoscope includes inspection of the cone of light, the short process of the malleus, and the handle of the maleus. The cochlea, vestibule, and stapes (part of the ossicles) are not normally visualizable.

A client presents to the health care clinic with reports of a stiff neck for the past 3 days. What objective information can the nurse obtain during the health history using inspection?

Head position While collecting history, the nurse would be able to inspect the client to see in what position the head was being held. Range of motion would require the nurse to give the client commands and would be performed during the physical assessment. Neck tenderness and thyroid size would require the use of palpation, not inspection, and would also be covered in the physical assessment portion of the examination.

The nurse is documenting an objective assessment of the client's ears. Which of the following would be the most appropriate documentation?

Hearing intact bilaterally on whisper test Documentation of the whisper test should be "hearing intact bilaterally on whisper test." Documentation of the Rinne and Weber test results usually validates normal findings (e.g., "No unexpected findings on Weber and Rinne tests."). The report from the client is a subjective assessment finding.

When assessing a client's deep tendon reflexes, which technique would be most appropriate for the nurse to use?

Hold the reflex hammer between the thumb and the index finger When eliciting deep tendon reflexes, the nurse should hold the reflex hammer between the thumb and the index finger so that it swings freely. The nurse should use the pointed end to strike smaller areas and the blunt end to strike a wider area. The nurse should palpate the tendon to be used to elicit the reflex and use a rapid wrist movement to briskly strike the tendon.

When providing client teaching about the ears, what should the nurse be sure to include?

How the client cleans the ears It is important to address how the client cleans the ears. Many people associate cerumen in the ear canal with lack of hygiene and therefore clean their ears routinely. Often, patients think that cotton-tipped applicators are for this purpose. This self-care behavior is unsafe, placing clients at risk for cerumen impaction. Nurses should reinforce proper cleaning techniques. Since cleaning with cotton-tipped applicators is not correct, the nurse would not teach the client how to use the applicators to clear the ears. The nurse would not teach the client about basic anatomy and physiology of the ears. The option of potential infection from self-cleaning of ears is not correct.

What structure is found midline in the tracheal area just beneath the mandible?

Hyoid bone Important landmarks for the head and neck region are in the tracheal area. The usually palpable U-shaped hyoid bone is located midline just beneath the mandible. The large thyroid cartilage consists of two flat, plate-like structures joined together at an angle and with a small, sometimes palpable notch at the superior edge. Usually more prominent in males, the thyroid cartilage is also called the "Adam's apple." The palpable cricoid cartilage is a ringed structure just inferior to the thyroid cartilage.

Impaired dilation of the eye is evaluated with an assessment of which cranial nerve (CN)?

III (oculomotor) Fibers traveling in the oculomotor nerve (CN III) and producing pupillary constriction are part of the parasympathetic nervous system. The iris is also supplied by sympathetic fibers. When these are stimulated, the pupil dilates, and the upper eyelid rises a little, as if from fear. The sympathetic pathway starts in the hypothalamus and passes down through the brainstem and cervical cord into the neck. From there, it follows the carotid artery or its branches into the orbit. A lesion anywhere along this pathway may impair sympathetic effects that dilate the pupil. CN II conveys visual information to the brain; CN IV and VI are involved in moving the eye in its cardinal directions.

A nurse assesses the distant vision acuity of a client using the Snellen chart. Which action should the nurse implement to perform the test with accuracy?

Instruct the client to read without reading glasses The nurse should instruct the client to read without reading glasses to accurately test the distant vision acuity with a Snellen chart. Reading glasses blur the vision when reading in the distance, so they can interfere with the assessment. The nurse should position the client 20 feet, not 12 feet, away from the Snellen chart. The nurse should ensure that the client does not lean forward and read because it may be an unconscious attempt to see well. The client's eye should be covered with an opaque card. Covering the eye with the hand may encourage the client to peek through the fingers.

A normal assessment of the neck would include palpation of the thyroid isthmus. Where would the nurse find the isthmus?

Just below the cricoid cartilage Just below the cricoid cartilage, the isthmus of the thyroid should be palpable as a smooth rubbery band that rises and falls with swallowing. the other three options are distracters for the question.

The nurse is caring for an adult client who suffers from a spinal cord hemisection due to a tumor. The client is unable to feel pain or temperature changes below the level of the tumor. What other symptoms should the nurse teach the family to expect the client to experience?

Loss of position sense, vibration, and motor function on same side of the body Following a spinal cord hemisection, pain and temperature sensation, are lost below the level of the injury or lesion on the opposite side of the body. Position sense, vibration, and motor function are affected on the same side of the body.

A nurse observes a think, white, cheesy discharge at the vaginal opening with irritation and swelling of the labia. The nurse recognizes this finding as most likely indicating what type vaginal infection?

Moniliasis Candidal vaginitis (Moniliasis) is caused by an overgrowth of yeast in the vagina. It causes a thick, white, cheesy discharge. Trichomoniasis vaginal infection is caused by a protozoan organism and is sexually transmitted. The discharge is typically yellow-green, frothy, and foul smelling. Chlamydia produces a mucopurulent yellowish discharge from the cervical os and is not always visible on the external genitalia. Bacterial vaginosis produces a thin, gray-white discharge that has a positive amine (fishy smell) and coats the vaginal walls and ectocervix.

The client presents at the clinic with a complaint of weakness that is made worse with repeated effort and improves with rest. The client's complaint is consistent with what health problem?

Myasthenia gravis Weakness made worse with repeated effort and improved with rest suggests myasthenia gravis.

A nurse observes a few small, yellow nodules on the cervix of a client during the speculum exam. They are not painful or odorous, and a thin, clear discharge is present. The nurse recognizes that these are most indicative of what type of condition?

Nabothian cysts Nabothian cysts are normal findings on the cervix after childbirth. They are small retention cysts, yellow, translucent, odorless, nonirritating, with clear to cloudy, thin to thick discharge. Chlamydia infection causes a mucopurulent, yellowish discharge that is irritating to the cervix and may cause bleeding and redness of the cervical opening. Cervical eversion is a normal finding after childbirth. The columnar epithelium from within the cervical canal is everted and appears as a deep red, rough ring round the cervical os, surrounded by the normal pink color of the cervix.

A nurse is performing a head and neck assessment on a client. Which area should the nurse inspect for facial symmetry?

Nasolabial folds The nasolabial folds are ideal places to check facial features for symmetry. Inspection of the temporomandibular joint cannot elicit facial symmetry. Preauricular nodes are common head and neck lymph nodes that are not inspected but palpated. Earlobes are not an appropriate feature to use to determine facial symmetry.

A client complains of a unilateral headache near the scalp line and double vision. The nurse palpates the space above the cheekbone near the scalp line on the affected side, and the client complains of tenderness on palpation. What is the nurse's next action?

Notify the healthcare provider immediately. Temporal arteritis is a painful inflammation of the temporal artery. Clients report severe unilateral headache sometimes accompanied by visual disturbances. This condition needs immediate care. A biopsy may be necessary for diagnosis; however the healthcare provider immediately. The temporal artery pulse can be palpated; but the carotid artery pulses should never be palpated simultaneously so that the client does not pass out from lack of blood flow to the brain.

Where should a nurse place the hands to palpate the submandibular lymph nodes?

On the medial border of the mandible The submandibular lymph nodes can be palpated on the medial border of the mandibular bone. Tonsillar nodes are found at the angle of the mandible on the anterior edge of the sternomastoid muscle. The occipital nodes can be palpated at the posterior base of the skull bone. Submental lymph nodes can be palpated a few centimeters behind the tip of the mandible.

What is the common channel for the respiratory and digestive systems?

Oropharynx The oropharynx is the common channel for the respiratory and digestive systems. The frenulum is part of the tongue. The nares are part of the nose.

A nurse inspects the cervix of a 52-year-old client during a routine assessment. Which coloration of the cervix may indicate that the woman is postmenopausal?

Pale Redness of the cervix may indicate inflammation. The surface of the cervix is normally smooth, pink, and even. In a nonpregnant client, a bluish cervix may indicate cyanosis. In pregnant clients, the cervix appears blue; this is also referred to as Chadwick's sign. In a nonmenopausal client, a pale cervix may indicate anemia; in older clients the cervix may appear pale after menopause.

A 73-year-old woman comes to the office for evaluation of new onset of tremors. She is not taking any medications, herbs, or supplements. She has no chronic medical conditions. She does not smoke or drink alcohol. She walks into the examination room with slow, shuffling steps. She has decreased facial mobility with a blunt expression without any changes in hair distribution on her face. Based on this description, what is the most likely reason for the client's symptoms?

Parkinson's disease This is a typical description for a client with Parkinson's disease. Facial mobility is decreased, which results in a blunt expression or a "masked" appearance. The client also has decreased blinking and a characteristic stare with an upward gaze. Combined with the findings of slow movements and a shuffling gait, the diagnosis of Parkinson's is highly likely.

Upon inspection of a client with reports of a fever, the nurse notices that the client's earlobes are asymmetrical in appearance. The nurse recognizes that the most common cause for the asymmetry of the earlobes is what condition?

Parotid enlargement Earlobe asymmetry can be due to parotid gland enlargement. In this case, the client may have mumps as parotid enlargement is accompanied by fever. It can also be due to an abscess or tumor. Bell's palsy is a neurologic condition that may cause drooping of one side of the face. Acute pharyngitis causes swelling in the throat which is not usually visible on the outside of the face. Thyroid enlargement affects the neck and has no effect on the symmetry of the earlobes.

A nurse assesses the pupillary reaction to light for a client who has lost vision in one eye. Which precaution should the nurse follow to get an accurate result of consensual response?

Place an opaque card in between the eyes of the client The nurse should place an opaque card in between the eyes of the client when assessing the client for consensual response to avoid inaccurate results. The light should not be focused directly into the eye to be tested; it should be focused obliquely into one eye, and the response should be checked in the other eye. The client should not be instructed to close the other eye not focused with light because the response is checked in the other eye.

An adult farm worker presents at the ED after falling out of a hay loft. The client states falling approximately 4 hours ago and did not lose consciousness. The client is experiencing only a mild headache. When asked why the client came to the ED, the patient states that he had a clear discharge from the right ear ever since the accident. What should this finding indicate to the nurse?

Possible basilar skull fracture Hemotympanum, otorrhea, or tympanic membrane rupture may indicate barotrauma from pressure changes or a basilar skull fracture. Otitis externa is a outer ear infection. Otitis media is an inner ear infection. The drainage from the ear is a classic sign of a possible basilar skull fracture. Possible mass in the ear is a distracter to the question.

The nurse is assessing a client exhibiting dystonic movements. The nurse should review the client's medications from home to check whether he is taking which medications that may cause the dystonia?

Psychiatric medications Dystonia is commonly due to the use of psychiatric medications, resulting in slow, involuntary movement of the trunk and larger muscles. These movements may also be accompanied by twisted postures.

The nurse is conducting an examination of an adult male's genitalia during his annual physical examination. The client has an erection and the nurse reassures him that this is a normal physiologic response and continues the examination. Why would the nurse continue with the examination at this time?

Stopping could cause further embarrassment If the client has an erection during the physical examination, reassure him that this is a normal physiologic response to touch that he could not have prevented. Do not stop the examination as doing so could cause further embarrassment. This makes options A, C, and D incorrect.

On inspection of a client's penis, the nurse observes a small, silvery-white papule. Which of the following conditions should the nurse suspect in this client?

Syphilitic chancre Syphilitic chancre initially is a small, silvery-white papule that develops a red, oval ulceration. Herpes progenitalis is characterized by clusters of pimple-like, clear vesicles that erupt and become ulcers. Cancer of the glans penis appears as a hardened nodule or ulcer on the glans. Hypospadias is a condition in which the urethral meatus is located underneath the glans (ventral side).

The nursing instructor is discussing ear problems. What would the instructor indicate is an abnormal finding?

Tenderness of the mastoid process Normal ear findings on physical assessment are firm auricles without lumps, nonpalpable lymph tissue, nontender ears, and no pain elicited during palpation or manipulation of the auricle. No pain should occur with palpation of the mastoid process. Enlarged lymph nodes indicate pathology or inflammation. Pain with auricle movement or tragus palpation indicates otitis externa or furuncle. Sclerosis of the tympanic membrane is a variation of normal ear findings. Atrophied lymph nodes and tenderness of the apex are distracters for this question.

A 29-year-old computer programmer comes to the office for evaluation of a headache. The tightening sensation of moderate intensity is located all over the head. It used to last minutes, but this time it has lasted for 5 days. He denies photophobia and nausea. He spends several hours at a computer monitor/keyboard. He has tried over-the-counter medication; it has dulled the pain, but not taken it away. Based on this description, what is the most likely diagnosis?

Tension This is a description of a typical tension headache.

A nurse is admitting a client to the hospital. When reviewing the client's medical record, the nurse notes that this client had abnormal findings during the Weber test. What would the nurse know this means?

The client has unilateral hearing loss The whisper test evaluates loss of high-frequency sounds. The Weber test helps to differentiate the cause of unilateral hearing loss. In the Rinne test, use of a tuning fork helps the nurse determine if hearing is equal in both ears and if there is either a conductive or a sensorineural hearing loss by allowing the nurse to compare the difference in bone conduction (BC) versus air conduction (AC). Remember AC has less resistance than BC. Option D is a distracter for this question.

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?

The notch on its superior edge The thyroid cartilage is readily identified by the notch on its superior edge.

The open space between the eyelids is called what?

The palpebral fissure The palpebral fissure is the almond-shaped open space between the eyelids. The limbus is the border of the cornea and the sclera. Eyeball and lacrimal fissure are distracters for the question.

After positioning a 34-year-old woman for examination of the anal region, the nurse notes a small opening above the client's gluteal crease that contains a tuft of hair. How should the nurse interpret this assessment finding?

The pilonidal cyst and sinus are usually benign, but can occasionally become infected or develop further sinuses. A pilonidal cyst is a congenital, and usually asymptomatic, tract that can become a problem if infection or sinus formation results. It alone does not indicate infection.

An nurse practitioner is assessing the tympanic membrane of a client who has come to the clinic. What would the nurse practitioner expect to visualize if the client has a normal otoscopic evaluation?

The short process of the malleus During visualization of the normal tympanic membrane, it is intact and translucent and the short process of the malleus is visible. The nurse practitioner would not expect to see the stapes or the head of the incus.

The nursing instructor is discussing the difference between sesorineural and conductive hearing loss with his class. The discussion turns to evaluation for determining what kind of hearing loss a client has. What Weber test results would indicate the presence of a sensorineural loss?

The sound is better in the ear in which he has better hearing. A client with sensorineural hearing loss hears the sound better in the ear in which he has better hearing. The Weber test assesses bone conduction of sound and is used for assessing unilateral hearing loss. A tuning fork is used. A client with normal hearing hears the sound equally in both ears or describes the sound as centered in the middle of the head. A client whose hearing loss is conductive hears the sound better in the affected ear.

When examining the head, the nurse remembers that the anatomic regions of the cranium take their names from which of the following sources?

The underlying bones Regions of the head take their names from the underlying bones of the skull, not from the names of anatomists, anatomical positions, or vasculature.

During the physical examination of a client, a nurse detects a thick and tender temporal artery. Which additional assessment should the nurse perform to rule out the possibility of temporal arteritis?

Vision acuity The nurse should assess the client for vision acuity. If the temporal artery is hard, thick, and tender with inflammation, it may be due to temporal arteritis. Temporal arteritis may lead to blindness. Inspecting for facial symmetry, palpation of the lymph nodes, the temporomandibular joint are unrelated to the involvement of the temporal arteries.

The nurse is planning to assess an adult client's thyroid gland. The nurse should plan to

approach the client posteriorly. To palpate the thyroid, use a posterior approach. Stand behind the client and ask the client to lower the chin to the chest and turn the neck slightly to the right.

An adult client tells the nurse that he has been experiencing gradual vision loss. The nurse should

check the client's blood pressure. Hypertension narrows blood vessels in the retina affecting vision.

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

chronic otitis media

An adult client visits the clinic and tells the nurse that she has had headaches recently that are intense and stabbing and often occur in the late evening. The nurse should suspect the presence of

cluster headaches. Other vascular headaches may be caused by fever or high blood pressure ("cluster headaches").

The nurse has performed the Rinne test on an older adult client. After the test, the client reports that her bone conduction sound was heard longer than the air conduction sound. The nurse determines that the client is most likely experiencing

conductive hearing loss. With conductive hearing loss, bone conduction (BC) sound is heard longer than or equally as long as air conduction (AC) sound (BC ? AC).

The nurse is preparing to assess a client's thyroid gland using the posterior approach. What direction should the nurse provide regarding the client's head?

flex the neck forward When assessing the thyroid gland from the posterior approach the client should flex the neck forward to relax the neck muscles. Tilting the head back would be used if assessing the thyroid gland using the anterior approach. Turning the head to the right or left shoulder would be done later in order to further assess the individual thyroid gland lobes.

While assessing the ears of an adult client, the nurse observes that the tympanic membrane is completely immobile. The nurse should further assess the client for signs and symptoms of

infection. With otitis media, the membrane does not move or flutter when the bulb is inflated.

A client is newly diagnosed with myasthenia gravis. What should the nurse expect to assess in this client?

intact deep tendon reflexes The client with myasthenia gravis will have intact deep tendon reflexes. Muscle fasciculations do not occur. The muscles are not paralyzed or atrophied in myasthenia gravis.

An older client asks why vision is not as sharp as it used to be when the eyes are focused forward. What should the nurse realize this client is describing?

macular degeneration Macular degeneration causes a loss of central vision. Risk factors for macular degeneration are age, smoking history, obesity, family history, and female gender. Cataracts are characterized by cloudiness of the eye lenses. Glaucoma is an increase in intraocular pressure that places pressure on eye structures and affecting vision. A detached retina is the sudden loss of vision in one eye. This health problem may be precipitated by the appearance of blind spots.

The nurse is planning to perform an ear examination on an adult client. After explaining the procedures to the client, the nurse should

observe the client's response to the explanations. As you prepare the client for the ear examination, carefully note how the client responds to your explanations.

The nurse is preparing to inspect the nose of an adult client with an otoscope. The nurse plans to

position the handle of the otoscope to one side. Position the otoscope's handle to the side to improve your view of the structures. If an otoscope is unavailable, use a penlight and hold the tip of the nose slightly up. A nasal speculum with a penlight also facilitates good visualization.

The nurse is planning to assess a client's lymph nodes. Which set of nodes should the nurse assess first?

preauricular The lymph nodes in front of the ear, or preauricular, are usually palpated first. The submental nodes are under the chin. The supraclavicular nodes are located near the clavicle and sternocleidomastoid muscle. The superficial cervical nodes are located superficial to the sternocleidomastoid muscle.

The nurse conducts the physical examination of a client with a diagnosis of chronic obstructive pulmonary disease. The nurse observes the point of maximal impulse (PMI) is located in the epigastric region. What condition explains this finding?

right ventricular hypertrophy Hypertrophy can cause an anatomical shift of the right ventricle, leading the PMI to be palpable in the epigastric region. Aortic stenosis denotes a narrowed valvular orifice, which obstructs blood flow. Aortic insufficiency is caused by a valve that fails to fully close, allowing blood to leak backward, creating a regurgitant murmur. Orthopnea describes shortness of breath that occurs when the client is lying down. This would not be the reason the PMI would shift to be heard in the epigastric region.

The hypothalamus is responsible for regulating

sleep cycles. The hypothalamus (part of the autonomic nervous system, which is a part of the peripheral nervous system) is responsible for regulating many body functions including water balance, appetite, vital signs (temperature, blood pressure, pulse, and respiratory rate), sleep cycles, pain perception, and emotional status.

A client complains of a headache over both temporal areas. What type of headache should the nurse suspect the client is experiencing?

tension Tension headaches often arise in the temporal areas. Cluster headaches typically occur behind the eyes. A throbbing, severe, unilateral headache that lasts 6-24 hours and is associated with photophobia, nausea, and vomiting suggests a migraine headache. Hypertensive is not a type of headache although individuals with hypertension may experience a headache upon arising in the morning.

An adult client tells the nurse that his father had cataracts. He asks the nurse about risk factors for cataracts. The nurse should instruct the client that a potential risk factor is

ultraviolet light exposure. Exposure to ultraviolet radiation puts the client at risk for the development of cataracts (opacities of the lenses of the eyes). Consistent use of sunglasses during exposure minimizes the client's risk.

A nurse performs a hearing test on an elderly client. Which result should the nurse recognize as an indication that presbycusis is present? An inability to hear:

whispered sounds The inability of the client to hear whispered sounds indicates presbycusis, which is a gradual sensorineural hearing loss due to degeneration of the cochlea or vestibulocochlear nerve, common in older clients. The inability to hear the calling bell may indicate deafness. The inability to hear the tuning fork may indicate sensorineural or conductive hearing loss.