BOARD PRACTICE QUESTIONS - HEAD, EYES, EARS, NOSE, AND THROAT REVIEW

The nurse practitioner is assessing the hearing of a preschool-age child. Place in order the normal pathway of sound wave transmission (hearing) through the ear. 1. 2. 3. 4. 5. A. Vibrations are transmitted to the cerebral cortex auditory center B. Nerve impulses are stimulated in the inner ear C. Sound waves are collected in the pinna D. Transmission of vibrations through the hammer, anvil, and stirrup E. Sound is interpreted by the cerebral cortex

C1, D2, B3, A4, E5. The normal transmission of sound through the ear is as follows: Sound waves are collected in the pinna → transmission of vibrations through the hammer, anvil, and stirrup → nerve impulses are stimulated in the inner ear → vibrations are transmitted to the cerebral cortex auditory center → sound is interpreted by the cerebral cortex.

A 28-year-old male nurse of Hispanic descent reports a history of a cold that resolved 2 weeks ago except for a dry cough and pain over his right cheek that worsens when he bends down. The patient denies fever. He tells the employee health nurse practitioner that he is very allergic to both cephalexin (Keflex) and erythromycin. The patient's vital signs are temperature of 99.2°F, pulse of 72 beats/min, and respirations of 12 breaths/min. Which condition is most likely? A. Acute sinusitis B. Acute bronchitis C. Fever secondary to the previous viral upper respiratory infection (URI) D. Hay fever

Solution: A Acute sinusitis. Acute sinusitis symptoms include cough, facial pain, and low-grade fever.

The nurse practitioner notices a gray ring on the edge of both irises of an 80-year-old woman. The patient denies visual changes or pain. She reports that she has had the "ring" for many years. Question Which of the following causes is most likely? A. Arcus senilis B. Pinguecula C. Peripheral cataracts D. Macular degeneration

Solution: A Arcus senilis. Arcus senilis (arcus senilis corneae) is a white, gray, or blue opaque ring in the corneal margin (peripheral corneal opacity) or white ring in front of the periphery of the iris. It is present at birth, but it then fades; however, it is commonly present in older adults. It can also appear earlier in life as a result of hypercholesterolemia. It does not affect vision. Unilateral arcus is a sign of decreased blood flow to the unaffected eye due to carotid artery disease or ocular hypotony.

A 13-year-old girl has a throat culture that is positive for strep throat. She reports that her younger brother was recently diagnosed with strep throat and treated. The patient has a severe allergy to penicillin and reports that erythromycin makes her very nauseated. Which of the following antibiotics is the best choice? A. Azithromycin (Zithromax) B. Cephalexin (Keflex) C. Cefuroxime axetil (Ceftin) D. Levofloxacin (Levaquin)

Solution: A Azithromycin (Zithromax). If the patient has a severe penicillin allergy, there is a 10% chance of cross-reactivity to cephalosporins (especially first generation). Because the patient is a child, the levofloxacin is contraindicated. Nausea is a common adverse reaction to erythromycin (it is not an allergic reaction). The best option is to use azithromycin because of its minimal gastrointestinal (GI) adverse effects. Azithromycin has fewer drug interactions compared with other macrolides.

A middle-aged adult presents as a "walk-in" patient. He is anxious and wants to be seen today. He complains that when he woke up and got out of bed that morning, he had severe dizziness and almost fell on the floor because "the room was spinning so much." His gait is unstable with some swaying noted. He reports that if he moves his head quickly, he gets very dizzy and has problems with balance. He denies trauma, hypertension, tinnitus, hearing loss, and fever. The Romberg test is positive. Question Which of the following conditions is most likely? A. BPPV (benign paroxysmal positional vertigo) B. Ménière's disease C. Acoustic neuroma D. Cerebrovascular accident (CVA)

Solution: A BPPV (benign paroxysmal positional vertigo) BPPV is the most common cause of vertigo in the United States. It is caused by calcium carbonate crystals in the semicircular canals. An initial treatment is the Epley maneuver, in which the head is turned sequentially, which helps to move the crystals in the semicircular canals by gravity. May need several repositioning maneuvers at the same visit; recurrences can occur. It is not Ménière's disease or an acoustic neuroma, since there is no tinnitus and hearing loss. There is no limb weakness or slurred speech, so rule out a stroke (CVA).

While performing a newborn assessment, the nurse practitioner notes discharge, swelling, and redness on one of the infant's lacrimal ducts. The mother reports crusting on the infant's eyes. Which diagnosis is most likely? A. Dacryostenosis B. Jaundice C. Red reflex abnormality D. Myopia

Solution: A Dacryostenosis. Dacryostenosis is an obstruction of the lacrimal duct(s). Any discharge should be cultured and treated with an appropriate antibiotic. Newborn jaundice is a yellowing of an infant's skin and eyes. Newborn jaundice is very common and can occur when infants have a high level of bilirubin, a yellow pigment produced during normal breakdown of red blood cells. Red reflex testing is vital for early detection of vision and potentially life-threatening abnormalities in infants, such as cataracts, glaucoma, retinoblastoma, retinal abnormalities, systemic diseases with ocular manifestations, and high refractive errors. Dark spots in the red reflex, a markedly diminished reflex, the presence of a white reflex, or asymmetry of the reflexes require referral to an ophthalmologist. Myopia or nearsightedness is when the eyeball is slightly longer than normal from front to back. Light rays focus in front of the retina.

In the majority of children, the first permanent teeth start to erupt at the age of 6 years. Which of the following are the first permanent teeth to erupt in this time period? A. First molars B. Second molars C. Lower or upper incisors D. Canines

Solution: A First molars. The first molars are the first permanent teeth to develop; they appear at approximately 6 years of age.

An elderly adult complains that his central vision appears to be blurred and he cannot see when driving. Which condition is most likely? A. Macular degeneration B. Central vision inflammation C. Blepharitis D. Conjunctival hemorrhage

Solution: A Macular degeneration. Age-related macular degeneration affects the area of central vision. It creates a blurring or loss of central vision. It is associated with advanced age. Central vision inflammation is a generic term. Blepharitis is a chronic condition caused by inflammation of the eyelids. It creates itching and irritation and eye redness but does not create blurred vision. Conjunctival hemorrhage is caused by blood trapped underneath the conjunctiva and sclera secondary to broken arterioles and is identified by a red patch in the white of the eye.

Visual fields by confrontation is used to evaluate for: A. Peripheral vision B. Central distance vision C. Narrow-angle glaucoma D. Accommodation

Solution: A Peripheral vision. The visual fields by confrontation test is used to evaluate peripheral vision. The Snellen chart is used to measure central distance vision. A tonometer is used to assess for glaucoma. The ophthalmoscope is used to assess for cataracts.

An elderly man is diagnosed with conductive hearing loss in the left ear by the nurse practitioner. Which of the following is the expected result when performing a Rinne test on this patient? A. AC (air conduction) > BC (bone conduction) B. Lateralization to the bad ear C. BC > AC D. Lateralization to the good ear

Solution: C BC > AC. A normal result in the Rinne test is AC > BC. When there is a conductive hearing loss (e.g., ceruminosis, otitis media), the result will be BC > AC. The reason is that the sound waves are blocked (e.g., cerumen, fluid in middle ear). Therefore, the patient cannot hear them as well as through BC.

A patient presents with fever, severe throat pain, difficulty swallowing, a "hot potato" voice, and trismus. On examination, there is unilateral swelling of the peritonsillar and soft palate area. The uvula is deviated to the left. Which diagnosis is most likely? A. Peritonsillar abscess B. Infectious mononucleosis C. Pharyngitis D. Aphthous stomatitis

Solution: A Peritonsillar abscess. The most likely diagnosis is peritonsillar abscess. Peritonsillar abscess is classically associated with severe sore throat, difficulty swallowing, trismus, and a muffled "hot potato" voice. The abscess displaces the uvula. Infectious mononucleosis refers to a group of symptoms usually caused by the Epstein-Barr virus. Symptoms include fatigue, fever, rash, and swollen glands. Pharyngitis is the inflammation of the back of the throat, known as the pharynx. It typically results in a sore throat and fever. Other symptoms may include a runny nose, cough, headache, and a hoarse voice. Aphthous stomatitis is a common condition characterized by the repeated formation of benign and noncontagious mouth ulcers.

Which of the following conditions is classified as sensorineural hearing loss? A. Presbycusis B. Otitis media C. Ceruminosis D. Otitis externa

Solution: A Presbycusis Presbycusis is a type of sensorineural hearing loss that is caused by normal aging of the auditory system. It initially affects the ability to hear higher-pitched sounds of speech (or high frequency). It has a gradual onset, and over time it affects lower frequencies. An example of higher frequency sounds is speech or speaking. A common symptom is setting the volume of TVs or radio high and difficulty hearing in noisy environments. A hearing aid can help. Otitis media, ceruminosis, and otitis externa are some of the causes of conductive hearing loss.

When assessing a patient using a Snellen chart, the nurse practitioner records the visual acuity as 20/80. What does this assessment mean? A. The patient can see at 20 feet what a person with normal vision sees at 80 feet B. The patient can see at 80 feet what a person with normal vision sees at 20 feet C. The patient has experienced a 20% decrease in acuity in one eye and an 80% decrease in the opposite eye D. The patient has presbyopia

Solution: A The patient can see at 20 feet what a person with normal vision sees at 80 feet. The top number is the patient's distance in feet from the chart. The bottom number is the distance at which a person with normal eyesight can read the same line. A patient with 20/80 vision can see at 20 feet what a person with normal vision sees at 80 feet. Presbyopia is caused by loss of elasticity of the lenses, which makes it difficult to focus on close objects.

A 75-year-old patient with a 25-year history of diabetes is at the primary care clinic for an annual exam. Which finding would prompt the nurse practitioner to refer the patient to the ED? A. Tonometer reading of 28 mmHg B. Retinal hemorrhages C. Cotton-wool spots on the retina D. Reports of difficulty driving at night

Solution: A Tonometer reading of 28 mmHg. A tonometer is used to measure intraocular pressure (IOP). A normal range for IOP is 8 to 21 mmHg. A reading of 28 mmHg could be indicative of primary open-angle glaucoma. Retinal hemorrhages in a 75-year-old patient with a 25-year history of diabetes would likely be the result of systemic vascular conditions such as hypertension and carotid artery stenosis. They represent a long-standing disease and are not a medical emergency; however, if the patient presented with sudden black spots or floaters in the vision, the retinal hemorrhage could represent a more emergent issue such as retinal tear/retinal detachment. Cotton-wool spots on the retina indicate diabetic retinopathy, which is not a medical emergency. Cataract symptoms include difficulty driving at night due to glare, halos around lights, and blurred vision.

What is the most common sign or symptom of allergic rhinitis? A. Transverse nasal crease B. Yellow nasal discharge C. Under-eye circles D. Inability to sleep through the night

Solution: A Transverse nasal crease. The classic sign of allergic rhinitis is a transverse nasal crease (allergic salute) from frequent rubbing and wiping away of nasal discharge. Allergic rhinitis generally produces clear nasal discharge unless there is also sinusitis. It may also cause under-eye circles from vasodilation or lack of sleep from sneezing and itchiness.

A 10-year-old child presents with external ear pain, swelling, and decreased hearing in the left ear. The child is on a swim team and practices daily. Upon physical examination, the child does not want the left ear touched. There are no other abnormal findings. The nurse practitioner will advise the patient to: (Select all that apply.) A. Use aluminum acetate solution PRN B. Keep water out of the ear during treatment C. Apply polymyxin B-neomycin-hydrocortisone suspension drops QID × 7 days D. Apply steroid nasal spray BID × 1 week E. Apply ofloxacin otic drops BID × 7 days

Solution: A, B, C, E Use aluminum acetate solution PRN; Advise the patient to keep water out of the ear during treatment; apply polymyxin B-neomycin-hydrocortisone suspension drops QID × 7 days; apply ofloxacin otic drops BID × 7 days. The symptoms and history of the patient make otitis externa the most likely diagnosis. Otitis externa, also called swimmer's ear, is inflammation of the ear canal. A recommended treatment plan includes the use of aluminum acetate solution prophylactically and as needed. Aluminum acetate solution provides soothing, effective relief of minor skin irritations and inflammation. The patient should be advised to keep water out of the ear during treatment, so swimming activities should be adjusted. Recommended treatment includes the application of polymyxin B-neomycin-hydrocortisone suspension drops QID × 7 days and/or ofloxacin otic drops BID × 7 days. A steroid nasal spray would not be included in the treatment of otitis externa.

Which medication will the nurse practitioner include in the treatment plan for a 7-year-old child with acute otitis media? A. Cefaclor B. Amoxicillin C. Erythromycin D. Azithromycin

Solution: B Amoxicillin. Amoxicillin is the first line of therapy for the treatment of acute otitis media. Cefaclor is a second-generation cephalosporin and is not the first line of treatment for acute otitis media unless the infection is caused by gram-positive cocci and gram-negative rods. Erythromycin is not prescribed as the first line of treatment for acute otitis media. Azithromycin can be administered as the first line of treatment for acute otitis media if amoxicillin is contraindicated.

In a Rinne test, what is considered a normal finding? A. Vibration is louder in the "good" ear B. Sound is heard equally in both ears C. Frequency is heard higher in the "bad" ear D. Air conduction (AC) is heard longer than bone conduction (BC)

Solution: D Air conduction (AC) is longer than bone conduction (BC). A normal finding for a Rinne test is AC heard longer than BC. In the Weber test, a normal finding is when there is no lateralization, where sound is heard equally in both ears when a tuning fork is placed on the midline of the forehead. If vibrations are louder in the "good" ear with a Weber test, that is a normal finding.

A school-age child presents with low-grade fever and suspected hearing loss. Upon examination, the nurse practitioner notes erythema and bullae on the bulging tympanic membrane. There is decreased motility of the tympanic membrane on insufflation. Which diagnosis is most likely? A. Otitis externa B. Bullous myringitis C. Purulent otitis media D. Serous otitis media

Solution: B Bullous myringitis. Bullous myringitis is an ear infection in which small, fluid-filled blisters form on the eardrum. This finding distinguishes the diagnosis of the condition. Otitis externa, also called swimmer's ear, is inflammation of the ear canal. Purulent otitis media is an inflammation of the middle ear in which there is fluid in the middle ear accompanied by signs or symptoms of ear infection: a bulging eardrum usually accompanied by pain or a perforated eardrum, often with drainage of purulent material. In serous otitis media, sterile serous fluid is trapped inside the middle ear.

Which of the following is considered an objective finding in patients who have a case of suppurative otitis media? A. Erythema of the tympanic membrane B. Decreased mobility of the tympanic membrane as measured by tympanogram C. Displacement of the light reflex D. Bulging of the tympanic membrane

Solution: B Decreased mobility of the tympanic membrane as measured by tympanogram. Acute suppurative otitis media is an acute infection affecting the mucosal lining of the middle ear and the mastoid air system. Suppurative stage: The tympanic membrane bulges and ruptures spontaneously through a small perforation in the pars tensa. Ear discharge is usually present. Diagnosis is usually made simply by looking at the eardrum through an otoscope. The eardrum will appear red and swollen, and may appear either abnormally drawn inward or bulging outward. Using the tympanogram with the otoscope allows a puff of air to be blown lightly into the ear. Normally, this should cause movement of the eardrum. In an infection, or when there is fluid behind the eardrum, this movement may be decreased or absent.

A middle-aged adult presents as a "walk-in" patient. He is anxious and wants to be seen today. He complains that when he woke up and got out of bed that morning, he had severe dizziness and almost fell on the floor because "the room was spinning so much." His gait is unstable with some swaying noted. He reports that if he moves his head quickly, he gets very dizzy and has problems with balance. He denies trauma, hypertension, tinnitus, hearing loss, and fever. The Romberg test is positive. Question Which of the following tests will help to correctly diagnose this patient? A. Lachman B. Dix-Hallpike C. Obturator D. Finklestein

Solution: B Dix-Hallpike The patient has benign paroxysmal positional vertigo (BPPV). The Dix-Hallpike test or maneuver is the gold-standard test for benign paroxysmal positional vertigo (BPPV). Positive if classic rotary nystagmus seen with latency (limited duration). The Lachman maneuver is a test for the anterior cruciate ligament (ACL) of the knee. The Obturator test is used for acute appendicitis. The Finklestein test is used to assess for De Quervain's tenosynovitis.

An 8-year-old child is seen as a walk-in appointment by the nurse practitioner. The mother reports that her child has been febrile for 2 days and is not eating well because of painful sores inside the mouth. The child's temperature is 101°F, pulse is 88 beats/min, and respirations are 14 breaths/min. During the physical exam, the nurse practitioner notices several small blisters and shallow ulcers on the child's pharynx and oral mucosa. The child has small, round red rashes on both palms and soles. Which of the following conditions is most likely? A. Herpes simplex infection B. Hand, foot, and mouth disease (HFMD) C. Varicella infection D. Secondary syphilis infection

Solution: B Hand, foot, and mouth disease (HFMD). HFMD is caused by the coxsackievirus. The virus is found in the saliva, sputum, nasal mucus, feces, and blister fluid. It is transmitted through direct contact of the secretion or in fomites (e.g., preschool toys). Treatment is symptomatic.

The nurse practitioner is performing a vision assessment on a 10-week-old infant. All of the following assessment findings require a referral to a pediatric ophthalmologist, except: A. Pseudostrabismus B. Intermittent esotropia C. White reflex D. Positive Hirschberg test

Solution: B Intermittent esotropia. Abnormal vision screenings that require a referral to a pediatric ophthalmologist include pseudostrabismus (epicanthal folds appear "crossed-eyed"); white reflex, which could indicate cataracts, leukocoria, or retinoblastoma; and a positive Hirschberg test. Intermittent esotropia is common in infants younger than 20 weeks and usually resolves spontaneously. Refer if esotropia is still present after age 20 weeks.

The nurse practitioner diagnoses a child with measles after observing which signs? A. Hairy leukoplakia B. Koplik's spots C. Boggy turbinates D. Enlarged parotid gland

Solution: B Koplik's spots. One of the classic symptoms of measles is Koplik's spots, groups of small-sized red papules with white centers in the cheeks. The other signs include fever, rash, red eyes, and sneezing. Oral hairy leukoplakia is related to secondary infections from HIV and is caused by the Epstein-Barr virus (EBV). Boggy turbinates would be found in allergic rhinitis, in addition to an itchy nose and congestion. An enlarged parotid gland is more indicative of mumps.

A kindergarten teacher is diagnosed with acute streptococcal pharyngitis. On exam, her throat is a bright-red color with no tonsillar exudate, and clear mucus is seen on the lower nasal turbinates. The urinalysis shows a large amount of white blood cells and is positive for nitrites. The patient has a sulfa allergy and thinks she is also allergic to penicillins. Which of the following is the best treatment choice? A. Amoxicillin-clavulanic acid (Augmentin) 500 mg PO BID B. Levofloxacin (Levaquin) 250 mg PO daily C. Trimethoprim-sulfamethoxazole (Bactrim DS) 1 tablet PO BID D. Clarithromycin (Biaxin) 500 mg PO BID

Solution: B Levofloxacin (Levaquin) 250 mg PO daily. Streptococcal pharyngitis and urinary tract infection are both covered by using Levaquin, which is a fluoroquinolone. Amoxicillin-clavulanic acid (Augmentin) and trimethoprim-sulfamethoxazole (Bactrim) would not be used because of the patient's allergies. Fluoroquinolones can be used in patients age 18 years or older.

A toddler who was born prematurely is being assessed for hearing loss. Which assessment finding is a high-risk factor for hearing loss? A. Hypobilirubinemia B. Low Apgar scores C. Ear infection D. Exposure to chlamydia in utero

Solution: B Low Apgar scores. The mnemonic for high-risk factors for hearing loss is HEARS: hyperbilirubinemia; ear infection frequency; low Apgar scores; exposure to rubella, cytomegalovirus (CMV), or toxoplasmosis; and seizures. Exposure to chlamydia in utero is not a risk factor for hearing loss.

A 4-year-old boy diagnosed with acute otitis media returns in 48 hours with a possible rupture of the tympanic membrane (TM) of the right ear. The mother reports seeing pus and a small amount of blood on the pillow that morning. The child states that his ear is no longer painful. During the ear exam, the otoscope is used to visualize the TM, which has a perforation on the lower edge that is draining a small amount of purulent discharge. All of the following topical ear medications should be avoided in patients with perforation of the TM, except: A. Gentamycin ear drops B. Ofloxacin ear drops C. Tobramycin ear drops D. Neomycin sulfate ear drops

Solution: B Ofloxacin ear drops. Ofloxacin ear drops are not considered to be ototoxic. Aminoglycoside otic drops (gentamycin, tobramycin) are ototoxic and should not be used to treat otitis media or perforation of the TM. In addition, ear drops with alcohol, benzocaine, or olive oil should be avoided in patients with TM perforation. Swimming or water inside the ear should be avoided until the TM is healed. Topical therapy with topical quinolone drops may be equivalent to oral therapy, but some experts prefer oral antibiotic therapy, such as amoxicillin or amoxicillin-clavulanate (Augmentin) for 10 days, to treat TM perforations.

A 68-year-old male presents with a sudden onset of headache with right-sided eye pain and blurred vision. He states he is seeing halos around lights. On examination, the nurse practitioner notes the right eye is fixed with a mid-dilated, cloudy pupil that reacts slowly to light. Which diagnosis is most likely? A. Subconjunctival hemorrhage B. Primary angle-closure glaucoma C. Pterygium D. Pinguecula

Solution: B Primary angle-closure glaucoma. The symptoms are consistent with those of primary angle-closure glaucoma, which is a sudden blockage of the aqueous humor. Primary angle-closure glaucoma causes marked increase of intraocular pressure and can cause permanent damage to the optic nerve. A subconjunctival hemorrhage occurs when blood is trapped under the conjunctiva and sclera. It is painless. A pterygium is a painless, yellow, triangular thickening of the conjunctiva that extends across the cornea on the nasal side. A pinguecula is a painless, yellowish, raised growth on the conjunctiva next to the cornea.

An 80-year-old female with a history of hypertension, atrial fibrillation, and type 2 diabetes presents to the clinic with a complaint of painless bright-red blood on the right eye that she noticed on awakening. She denies falling, visual changes, visual loss, eye pain, headache, coryza, and fever. The visual exam is normal, and both pupils are equal and reactive to light and accommodation. The funduscopic exam does not show bleeding. Which of the following conditions is most likely? A. Hyphema B. Subconjunctival hemorrhage C. Ectropion D. Blepharitis

Solution: B Subconjunctival hemorrhage A subconjunctival hemorrhage is caused by blood that is trapped between the sclera and conjunctiva. The patient's history of atrial fibrillation is highly suggestive of anticoagulation therapy, which increases her risk of bleeding. In addition, hypertension and diabetes are also risk factors. A hyphema is blood that is trapped in the anterior chamber of the eye (space between the cornea and the iris); it is usually painful. An ectropion is the eversion of the lower eyelids, which can cause irritation but no bleeding. Blepharitis presents on the edge of an eyelid as a painful abscess.

The nurse practitioner notices a gray ring on the edge of both irises of an 80-year-old woman. The patient denies visual changes or pain. She reports that she has had the "ring" for many years. Question What is the clinical significance of this finding in a 35-year-old patient? A. The patient has a higher risk of blindness B. The patient should be evaluated for hyperlipidemia C. The patient should be evaluated by an ophthalmologist D. The patient should be evaluated for acute glaucoma

Solution: B The patient should be evaluated for hyperlipidemia. Arcus senilis is caused by lipid deposits deep in the edge of the cornea and is quite commonly present in the elderly. However, it can also appear earlier in life as a result of hypercholesterolemia.

During a sports participation exam, a 16-year-old patient is noted to have a few beats of horizontal nystagmus on extreme lateral gaze that disappear when the eyes move back toward midline. Which statement best describes this clinical finding? A.It is caused by occult bleeding of the retinal artery B. This is a normal finding C. It is a sign of a possible brain mass D. This is a borderline result and requires further evaluation

Solution: B This is a normal finding. Horizontal nystagmus is a normal variation on physical exam. Full movement of the eyes is controlled by the integrated function of cranial nerves III (oculomotor), IV (trochlear), and VI (abducens). Holding the patient's chin to prevent movement of the head, ask the patient to watch your finger as it moves through the six cardinal fields of gaze. Then ask the patient to look to the extreme lateral (temporal) positions. A few horizontal nystagmic beats are within normal limits (WNL).

A 40-year-old male who is building a house presents with a 2-day history of foreign body sensation and excessive tearing of the right eye. What type of exam is recommended initially? A. Cardiac exam B. Visual exam C. Neurologic exam D. Cerebellar exam

Solution: B Visual exam Any patient who is complaining of new onset of eye symptoms should have a visual exam first. Distance vision can be checked by using the Snellen chart. Near vision is tested by asking a patient to read a paragraph of a book or newspaper. The eye exam also includes an inspection of the surface of the eye, pupillary reflex, and red reflex. A fluorescein exam is performed to look for a corneal abrasion, which appears as pooling of the dye that is visualized using a blue light in a darkened room.

A 12-year-old girl is complaining of a 2-week history of facial pressure that worsens when she bends over. She complains of tooth pain in her upper molars on the right side of her face. On physical exam, her lung and heart sounds are normal. Which diagnosis is most likely? A. An acute dental abscess B. Chronic sinusitis C. Acute sinusitis D. Severe allergic rhinitis

Solution: C Acute sinusitis. Signs and symptoms of acute sinusitis include headache, facial pain that worsens with bending over, eye/ear pressure and pain, aching in upper jaw/teeth, reduced smell and taste, cough (especially at night due to the nasal drainage), sore throat, bad breath, and fatigue.

A 70-year-old male patient complains of a bright-red-colored spot in his left eye for 2 days. He denies eye pain, visual changes, or headaches. He has a new-onset cough from a recent viral upper respiratory infection. The only medicine he is taking is Bayer aspirin one tablet daily. Which of the following actions is appropriate follow-up for this 70-year-old patient? A. Refer the patient to an optometrist B. Refer the patient to an ophthalmologist C. Advise the patient that the condition is benign and will resolve spontaneously D. Prescribe an ophthalmic antibiotic solution

Solution: C Advise the patient that the condition is benign and will resolve spontaneously. Subconjunctival hemorrhages do not require any treatment. The blood in the eye will be absorbed within 10 to 14 days.

A nurse practitioner assesses a child who is experiencing severe otalgia and has a temperature of 100.7°F. The Rinne test result shows BC > AC, and the Weber exam shows lateralization in the affected ear. The nurse practitioner notes blisters on an erythematic tympanic membrane (TM). Which of the following conditions is most likely? A. Acute otitis media (AOM) B. Otitis media with effusion C. Bullous myringitis D. Otitis externa

Solution: C Bullous myringitis. Bullous myringitis is a severe type of AOM with painful blisters (bullae) on a reddened TM. The patient may exhibit conductive hearing loss, otalgia, muffled hearing, and a low-grade fever. With otitis media with effusion, the TM may bulge or retract, but it is not red. It may follow AOM and be caused by chronic allergic rhinitis. Otitis externa (swimmer's ear) is more common in the warm and humid seasons. There is external otalgia, swelling, discharge, pruritus, and hearing loss if the canal is blocked with pus.

A cauliflower-like growth with foul-smelling discharge is seen during an otoscopic exam of the left ear of an 8-year-old boy with a history of chronic otitis media. The tympanic membrane and ossicles are not visible, and the patient seems to have difficulty hearing the nurse practitioner's instructions. Which condition is most likely? A. Chronic perforation of the tympanic membrane with secondary bacterial infection B. Chronic mastoiditis C. Cholesteatoma D. Cancer of the middle ear

Solution: C Cholesteatoma. An abnormal skin growth in the middle ear behind the eardrum is called cholesteatoma. Repeated infections and/or a tear or pulling inward of the eardrum can allow skin into the middle ear. Cholesteatomas often develop as cysts or pouches that shed layers of old skin, which build up inside the middle ear. Over time, the cholesteatoma can increase in size and destroy the surrounding delicate bones of the middle ear, leading to hearing loss that surgery can often improve. Permanent hearing loss, dizziness, and facial muscle paralysis are rare, but they can result from continued cholesteatoma growth.

A 69-year-old patient presents with acute hearing loss. Upon physical examination, the nurse practitioner finds a cerumen impaction. Which type of hearing loss is expected? A. Central hearing loss B. Sensorineural hearing loss C. Conductive hearing loss D. Lateral hearing loss

Solution: C Conductive hearing loss. Cerumen (ear wax) is obstructive to the middle and/or outer ear and is a common condition in geriatric patients. Any type of obstruction to sound waves will cause conductive hearing loss. Sensorineural hearing loss occurs when there is damage to vital ear structures such as the cochlea, vestibule, and/or auditory nerve pathways. Trauma, disease, or ototoxic drugs can cause sensorineural hearing loss. A lesion in the central auditory pathway or the auditory cortex causes central hearing loss. The auditory cortex processes and interprets the sounds amplified and received by the ossicles and cochlear hair cells. Lateral hearing loss occurs when one has difficulty hearing or deafness that affects only one ear.

A middle-aged male presents with right eyelid pain for 24 hours. He denies vision changes or discharge from the eye. Upon physical examination, the nurse practitioner notes a painful, swollen red abscess on the upper right eyelid. The nurse practitioner will: A. Start incision and drainage of the abscess B. Begin intravenous (IV) antibiotic of ampicillin C. Initiate hot compresses TID D. Apply bacitracin ophthalmic ointment

Solution: C Initiate hot compresses TID. The patient has a hordeolum, or stye. The treatment plan should begin with hot compresses to the affected eye until the abscess drains. Many hordeolums will spontaneously drain within the first 48 hours. If infection spreads, the result would be preseptal cellulitis, and antibiotic therapy would be initiated. Incision and drainage would require a referral to an ophthalmologist, which is not indicated at this time.

A 4-year-old child presents with a high fever and enlarged lymph nodes in the neck area. The nurse practitioner notes dry, cracked lips and a "strawberry tongue" upon a physical assessment. Which diagnosis is most likely? A. Pharyngitis B. Allergic rhinitis C. Kawasaki disease D. Tonsillitis

Solution: C Kawasaki disease. Kawasaki disease classically presents with high fever; enlarged lymph nodes in the neck; conjunctivitis; dry, cracked lips; and a "strawberry" (bright-red) tongue. Most cases occur in children under 5 years of age. Pharyngitis is an acute infection of the pharynx and presents with a stuffy nose, rhinitis with clear mucus, and watery eyes. Allergic rhinitis is inflammatory changes of the nasal mucosa due to an allergy response. Tonsillitis is inflammation of the tonsils, which are two oval-shaped pads of tissue at the back of the throat. Signs and symptoms of tonsillitis include swollen tonsils, sore throat, difficulty swallowing, and tender lymph nodes on the sides of the neck.

The nurse practitioner is performing a vision screening on a newborn. Which finding would prompt a referral to a pediatric ophthalmologist? A. Inability to produce tears B. Fixation on mother's face C. One eye turned inward D. Bluish-gray eyes

Solution: C One eye turned inward. During the first 2 months of life, a newborn's eyes may appear crossed or wander at times (normal). If one eye is turned in or out consistently, the newborn should be referred to a pediatric ophthalmologist for further evaluation. The lacrimal ducts are immature at birth, but typically a newborn can shed tears by 2 weeks. It is normal for Caucasian newborns to be born with bluish-gray eyes, which change as they mature. A newborn will often fixate on their mother's face.

Upon examination of a 26-year-old patient, the nurse practitioner finds elongated papilla of the lateral aspects on the patient's tongue. How will the nurse practitioner document this finding? A. Koplik's spots B. Geographic tongue C. Oral hairy leukoplakia D. Cheilosis

Solution: C Oral hairy leukoplakia. Oral hairy leukoplakia presents as elongated papilla of the lateral aspects on the tongue. The Epstein-Barr virus is the causative agent of oral hairy leukoplakia. Koplik's spots present as clusters of small red papules with white centers located on the buccal mucosa by the lower molars. Koplik's spots are a prodromic viral enanthem of measles manifesting 2 to 3 days before the measles rash itself. Geographic tongue is an inflammatory disorder that usually appears on the top and sides of the tongue. Typically, affected tongues have a bald, red area of varying sizes that is surrounded by an irregular white border that resembles a map. Cheilosis is a painful inflammation and cracking of the corners of the mouth.

A 10-year-old child presents with external pain, swelling, and decreased hearing in the left ear. The child is on a swimming team and practices daily. Upon physical examination, the child flinches when the affected ear is touched. There are no other abnormal findings. Which diagnosis is most likely? A. Otitis media B. Rhinosinusitis C. Otitis externa D. Bullous myringitis

Solution: C Otitis externa. The symptoms and history of the patient make otitis externa the most likely diagnosis. Otitis externa, also called swimmer's ear, is inflammation of the ear canal. It often presents with ear pain, swelling of the ear canal, and, occasionally, decreased hearing. Typically, there is pain with movement of the outer ear. Otitis media is inflammation or infection located in the middle ear. Otitis media can occur because of a cold, sore throat, or respiratory infection. Rhinosinusitis is defined as inflammation of the sinuses and nasal cavity. Bullous myringitis is a type of ear infection in which small, fluid-filled blisters form on the eardrum. These blisters usually cause severe pain. The infection is caused by the same viruses or bacteria that lead to other ear infections.

A 6-year-old girl who attends preschool part time is brought to the clinic by her mother as a walk-in patient. The mother reports that her daughter has recently begun swim lessons. The symptoms began as redness on the left eye and spread to the second eye within 2 days. The child's eyes are watery and crusted in the morning when she wakes up. Her vital signs are temperature of 98.8°F, pulse of 90 beats/min, and respirations of 16 breaths/min. The eye exam reveals bilateral injected conjunctivae. When the lower eyelid is examined, the nurse practitioner notes that it is pink with a cobblestone appearance. There is ipsilateral preauricular adenopathy. All of the following treatment measures are appropriate, except: A. Prescribe a topical ophthalmic vasoconstrictor to be used two times per day as needed for up to 3 days to reduce redness B. Write a note excusing the child from school because she should not attend until the symptoms resolve C. Prescribe ophthalmic topical antibiotic eye drops, two or three drops to be applied in each eye QID for 7 days D. Advise use of cool compress over closed eyes as needed for comfort, washing hands often

Solution: C Prescribe ophthalmic topical antibiotic eye drops, two or three drops to be applied in each eye QID for 7 days. Treatment for viral keratoconjunctivitis (pink eye) is symptomatic. Cold compresses and slightly chilled artificial tears may help with the itching. Educate the parent and/or child to avoid touching the eyes with hands, avoid sharing towels, perform frequent handwashing, and use tissues if touching the eyes. Viral keratoconjunctivitis is usually caused by an adenovirus (but other viruses can also cause it). It is contagious for 10 to 12 days after the onset of symptoms and is a self-limiting condition. It can be transmitted through swimming pools, fomites, and hands. Children should not attend school until symptoms resolve.

While checking for the red reflex on a 3-year-old boy during a well-child visit, the nurse practitioner notes a white reflection on the child's left pupil. Which of the following conditions should be ruled out? A. Unilateral strabismus B. Unilateral cataracts C. Retinoblastoma of the left eye D. Color blindness of the left eye

Solution: C Retinoblastoma of the left eye Retinoblastoma is a congenital tumor of the retina. It usually affects only one eye (rarely both eyes are involved). During infancy, the tumor is a small size, and it continues to grow with the child. This rare cancer is diagnosed by noting a pupil that appears white or has white spots on it. One or both eyes may be affected. It is often first noted in photographs, because a white glow is present in the eye instead of the usual "red eye" that results from the flash.

All of the following are risk factors that could lead to hearing loss in an infant who was premature at birth, except: A. Hyperbilirubinemia B. Low Apgar scores C. Rubeola D. Seizures

Solution: C Rubeola. Use the HEARS mnemonic for risk factors that may lead to hearing loss: Hyperbilirubinemia; Ear infections that are frequent; low Apgar scores; Rubella/cytomegalovirus (CMV), not rubeola; and Seizures. Sickle cell disease is not a risk factor for hearing loss.

Where is Kiesselbach's plexus located? A. The posterior area of the pharynx B. The superior lateral area of the maxillary sinus C. The anterior inferior area of the nasal septum D. The submandibular area of the mouth

Solution: C The anterior inferior area of the nasal septum Kiesselbach's plexus is a vascular network of four arteries that supply the nasal septum. It is located on the anterior inferior area of the nasal septum (lower one-third of the nose). When there is trauma to this area (e.g., picking the nose), it can cause rupture of some tiny blood vessels, which causes an anterior epistaxis or a nosebleed.

A mother brings her 4-year-old daughter, who just started attending preschool, to the health clinic. She tells the nurse practitioner that her child is complaining of burning and itching that started in the left eye. Within 2 days it involved both eyes, and the child developed a runny nose and sore throat. During the physical exam, the child's eyes appear injected bilaterally with no purulent discharge. The throat is red, the inferior nasal turbinates are swollen, and lymph nodes are palpable in front of each ear. Which diagnosis is most likely? A. Herpes keratitis B. Corneal ulcer C. Viral conjunctivitis D. Bacterial conjunctivitis

Solution: C Viral conjunctivitis. The causative organisms of viral conjunctivitis (pink eye) include adenovirus and other virus types. It can present with or without cold symptoms. Patient complains of itchy red eyes and may have clear discharge accompanied by preauricular lymphadenopathy. The condition does not affect vision. If a contact lens wearer, assume bacterial infection and obtain culture of eye discharge.

An elderly patient has been taking digoxin, metformin, atenolol, and aspirin for several months. During an office visit, the patient reports dark areas in the central vision fields. The patient's digoxin level is 1.3 ng/mL. Which of the following is the most likely cause? A. Acute angle-closure glaucoma B. Herpes keratitis C. Retinal detachment D. Age-related macular degeneration

Solution: D The patient is experiencing symptoms of macular degeneration (changes in central vision), which can be attributed to atenolol use. The patient's digoxin level is within normal range (0.7 to 1.5 ng/mL). Additionally, the patient's vision changes are not typical of digoxin toxicity, which include yellowish-green halos. Metformin and aspirin do not cause macular degeneration.

When a domestic dog is suspected of being infected with the rabies virus, it can either be killed for a brain biopsy or be quarantined. What is the minimum number of days a dog suspected of rabies must be quarantined? A. 4 weeks B. 21 days C. 14 days D. 10 days

Solution: D 10 days. The minimum number of days to quarantine an animal suspected of rabies is 10 days. If the animal is healthy and has no symptoms of rabies at 10 days, it is not infected with the rabies virus and can be returned to the owner.

An elderly patient presents with right-sided hearing loss. On physical examination, there is lateralization to the right ear. The Rinne test shows BC>AC. Which diagnosis is most likely? A. Ménière's disease B. Labyrinthitis C. Acoustic neuroma D. Cerumen impaction

Solution: D Cerumen impaction. Cerumen (ear wax) is obstructive to the middle and/or outer ear. Any type of obstruction to sound waves will cause conductive hearing loss. Sensorineural hearing loss occurs when there is damage to vital ear structures such as the cochlea/vestibule and/or to the auditory nerve pathways. Ménière's disease, labyrinthitis, and acoustic neuroma are associated with sensorineural hearing loss.

A middle-aged male presents with right eyelid pain for 24 hours. He denies vision changes or discharge from the eye. Upon physical examination, the nurse practitioner notes a painful, swollen red abscess on the upper right eyelid. How will the nurse practitioner document this finding? A. Cholesteatoma B. Papilledema C. Pinguecula D. Hordeolum

Solution: D Hordeolum. The patient has a hordeolum or stye, which is an abscess of a hair follicle and sebaceous gland on the eyelid. A cholesteatoma is an abnormal, noncancerous skin growth that can develop in the middle section of the ear, behind the eardrum. Papilledema is a condition in which increased pressure in or around the brain causes the part of the optic nerve inside the eye to swell. Pinguecula is a yellowish, raised growth on the conjunctiva.

Which is the most effective chart or test to screen for color blindness? A. Snellen chart B. Confrontation exam C. Extraocular movement test D. Ishihara chart

Solution: D Ishihara chart. The Ishihara chart is the most appropriate method for screening a patient for color blindness. The Snellen chart is used to evaluate central distance vision, while the confrontation exam evaluates peripheral vision. The extraocular movement test reveals whether the eyes move together when following an object.

A 70-year-old man with open-angle glaucoma is prescribed timolol (Betimol) ophthalmic drops. All of the following are contraindications to Betimol ophthalmic drops, except: A. Overt heart failure or sinus bradycardia B. History of asthma C. Second- or third-degree atrioventricular (AV) block D. Migraine headaches

Solution: D Migraine headaches. Migraines are not a contraindication to Betimol (timolol). Contraindications include bronchial asthma, asthma history, severe chronic obstructive pulmonary disorder (COPD), uncompensated heart failure, second- or third-degree AV block, sinus bradycardia, and cardiogenic shock. Caution should be used if the following conditions are present: closed-angle glaucoma, peripheral vascular disease, bronchospastic disease, diabetes, hyperthyroidism, and myasthenia gravis.

A 68-year-old male patient arrives at the clinic reporting a sudden, erupting rash on his forehead and temple area, with a swollen eye on the same side. The patient is experiencing photophobia, eye pain, and blurred vision. To which specialist will the nurse practitioner refer the patient? A. Neurologist B. Dermatologist C. Oncologist D. Ophthalmologist

Solution: D Ophthalmologist. Probable diagnosis is herpes zoster ophthalmicus, a shingles infection of the trigeminal nerve, which is a vision-threatening condition caused by reactivation of the herpes zoster virus on the ophthalmic branch of the trigeminal nerve (CN V). It is imperative that the patient be seen and treated by an ophthalmologist as soon as possible. The other specialist referrals are not specific for this condition, because there is no indication of cancer or neurologic damage at this point. A dermatologist would be needed if the rash does not respond to treatment.

A woman at 32 weeks' gestation has a positive throat culture for Streptococcus pyogenes (strep throat). She denies allergies but becomes very nauseated with erythromycin. Which of the following is the best choice for this pregnant patient? A. Clarithromycin (Biaxin) B. Trimethoprim-sulfamethoxazole (Bactrim DS) C. Ofloxacin (Floxin) D. Penicillin (Pen VK)

Solution: D Penicillin (Pen VK). Pen VK is safe to use for strep throat during pregnancy and is the best choice for a pregnant patient with the presented symptoms.

A patient presents with a wedge-shaped, superficial, yellow, triangular mass on the nasal side of the left eye. The patient denies pain or vision changes. PERRLA is normal. Which diagnosis is most likely? A. Pinguecula B. Chalazion C. Hordeolum D. Pterygium

Solution: D Pterygium. The patient has a pterygium, which is a yellow, triangular thickening of the conjunctiva that extends across the cornea on the nasal side. Pinguecula is a yellowish, raised growth on the conjunctiva next to the cornea. A chalazion is a chronic inflammation of the meibomian gland. A hordeolum, or stye, is an abscess of a hair follicle and sebaceous gland on the eyelid.

A 74-year-old patient diagnosed with streptococcal pharyngitis was treated with oral penicillin V 500 mg BID × 10 days. During a follow-up visit, the patient presents with tonsillar exudate and a low-grade fever. The nurse practitioner will: A. Prescribe a 5-day course of azithromycin B. Refer patient to an ENT specialist C. Prescribe another course of penicillin V D. Repeat culture and sensitivity (C&S)

Solution: D Repeat culture and sensitivity (C&S). If a patient returns post strep-pharyngitis and has completed a course of treatment, a throat C&S should be repeated. It is not necessary to refer the patient to an ENT specialist. Another round of penicillin V may not be clinically appropriate without a repeat C&S first. Once the C&S report is back, it may or may not be appropriate to begin a new antibiotic such as azithromycin.

A 70-year-old male patient complains of a bright-red-colored spot in his left eye for 2 days. He denies eye pain, visual changes, or headaches. He has a new-onset cough from a recent viral upper respiratory infection. The only medicine he is taking is Bayer aspirin one tablet daily. Which of the following is most likely? A. Corneal abrasion B. Acute bacterial conjunctivitis C. Acute uveitis D. Subconjunctival hemorrhage

Solution: D Subconjunctival hemorrhage. Bright-red blood in a sharply defined area surrounded by normal-appearing conjunctiva indicates subconjunctival hemorrhage. The blood stays red because of direct diffusion of oxygen through the conjunctiva. Risk factors include diabetes, hypertension, illnesses that cause severe coughing or sneezing, blood-thinning medications and aspirin, and herbal supplements such as ginkgo.

A 16-year-old female patient who wears contact lenses presents to the clinic with eye pain, redness, and excessive tearing in the right eye. She tells the nurse practitioner that she frequently sleeps with her contact lenses because she forgets to take them out. During slit-lamp testing, the nurse practitioner notes there is an oval-shaped lesion in the right cornea. Which treatment will the nurse practitioner prescribe? A. Oral steroid B. Oral antibiotic C. Topical steroid D. Topical antibiotic

Solution: D Topical antibiotic. Sleeping with contact lenses is an unhygienic practice that may result in contact lens keratitis. Symptoms include eye pain, redness, excessive tearing, and a lesion on the cornea. Topical antibiotics are the first line of treatment for the condition. Oral steroids, antibiotics, and topical steroids are not used as the first line of treatment for contact lens keratitis.

Which initial treatment will the nurse practitioner recommend for a patient experiencing mild allergic conjunctivitis? A. Nonsteroidal anti-inflammatory drugs (NSAIDs) B. Oral antihistamines C. Topical corticosteroids D. Topical antihistamines/mast cell stabilizers

Solution: D Topical antihistamines/mast cell stabilizers. Mild allergic conjunctivitis occurs because of a mast cell response to an allergen. An over-the-counter topical antihistamine/mast cell stabilizer can be used to treat the initial symptoms of mild allergic conjunctivitis. NSAIDs are not the first line of treatment for mild allergic conjunctivitis. Patients with allergic conjunctivitis often produce an inadequate amount of tears, which results in dryness of the eyes. Although oral antihistamines can be used for mild allergic conjunctivitis, they may induce dry eye syndrome, which impairs the protective barrier of tears and worsens allergic conjunctivitis. Artificial tears may be needed if oral antihistamines are prescribed. Topical corticosteroids are not the first line of treatment for mild allergic conjunctivitis.

What is the first-line treatment for allergic rhinitis? A. Saline nasal spray B. Oral antihistamine C. Topical nasal decongestant spray D. Topical nasal steroid spray

Solution: D Topical nasal steroid spray The first-line treatment for allergic rhinitis is a topical nasal steroid spray, which is used once or twice per day. Allergic rhinitis can be seasonal (e.g., ragweed, mold, pollens), or it can be due to an indoor allergen, such as dust mites. If it is severe or accompanied by asthma, referral to an allergist for allergy testing is helpful. Topical nasal decongestant spray (e.g., Afrin) is for short-term use only because it can result in a rebound effect with worsening of symptoms (rhinitis medicamentosa).

A 16-year-old male athlete has recently been diagnosed with infectious mononucleosis. During the abdominal exam, the nurse practitioner identifies an enlarged spleen. Abdominal ultrasound confirms this finding. The patient wants to know when he can go back to playing football. Which of the following responses by the nurse practitioner is the most appropriate? A. You may return to play contact sports when your sore throat is gone B. You should avoid all sports and exercise for the next 2 weeks C. You may not play contact sports for 4 to 6 months D. You may return to exercise and sports in 4 to 6 weeks after a follow-up visit to confirm that your splenomegaly has resolved

Solution: D You may return to exercise and sports in 4 to 6 weeks after a follow-up visit to confirm that your splenomegaly has resolved Most reported cases of splenic rupture occurred in athletes who returned to play within 3 weeks of the illness. Many sports medicine physicians will restrict all exercise for the first 3 weeks of reported symptoms. After 3 weeks when the fever is gone and the athlete feels better, they can gradually return to exercise and athletics. Therefore, the time of about 4 to 6 weeks of avoiding exercise or athletics after illness onset (and patient feeling better) is probably based on this. But the best test to confirm that the spleen and/or liver size is back to normal is the abdominal ultrasound.