HA exam 2

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A 68-year-old woman is in the eye clinic for a checkup. She tells the nurse that she has been having trouble reading the paper, sewing, and even seeing the faces of her grandchildren. On examination, the nurse notes that she has some loss of central vision but her peripheral vision is normal. What do these findings suggest? a. Macular degeneration b. Vision that is normal for someone her age c. The beginning stages of cataract formation d. Increased intraocular pressure or glaucoma

18. A patient is newly diagnosed with benign breast disease. The nurse recognizes which statement about benign breast disease to be true? a. It makes it more difficult to examine the breasts. b. It is easily reduced with hormone replacement therapy. c. It frequently turns into cancer in a woman's later years. d. It is usually diagnosed before a woman reaches childbearing age

1. When examining the eye, the nurse notices that the patient's eyelid margins approximate completely. What does the nurse understand about this assessment finding? a. It is expected. b. It may result in problems with tearing. c. It indicates increased intraocular pressure. d. It may indicate a problem with extraocular muscles.

1. A physician tells the nurse that a patient's vertebra prominens is tender and asks the nurse to reevaluate the area in 1 hour. What area of the body will the nurse assess? a. At the level of the C7 vertebra b. At the level of the T11 vertebra c. At the level of the L5 vertebra d. At the level of the S3 vertebra

1. Which of the following statements is true regarding the internal structures of the breast? a. Fibrous, glandular, and adipose tissues b. Primarily muscle with very little fibrous tissue c. Primarily milk ducts, known as lactiferous ducts d. Glandular tissue, which supports the breast by attaching to the chest wall

11. A 75-year-old woman who has a history of diabetes and peripheral vascular disease has been trying to remove a corn on the bottom of her foot with a pair of scissors. Why is it important that the nurse encourage her to stop trying to remove the corn with scissors? a. The woman could be at increased risk for infection and lesions because of her chronic disease. b. With her diabetes, she has increased circulation to her foot, and it could cause severe bleeding. c. She is 75 years old and is unable to see; consequently, she places herself at greater risk for self-injury with the scissors. d. With her peripheral vascular disease, her range of motion is limited and she may not be able to reach the corn safely.

13. The nurse is using an otoscope to assess the nasal cavity. Which of these techniques is correct? a. Avoiding touching the nasal septum with the speculum b. Inserting the speculum at least 3 cm into the vestibule c. Gently displacing the nose to the side that is being examined d. Keeping the speculum tip medial to avoid touching the floor of the nares

16. A patient tells the nurse that he has noticed that one of his moles has started to burn and bleed. When assessing his skin, the nurse pays special attention to the danger signs for pigmented lesions and is concerned with which additional finding? a. Color variation b. Border regularity c. Symmetry of lesions d. Diameter of less than 6 mm

17. During an assessment of a 20-year-old patient with a 3-day history of nausea and vomiting, the nurse notices dry mucosa and deep vertical fissures in the tongue. What do these findings indicate? a. Dehydration b. A normal oral assessment c. Irritation from gastric juices d. Side effects from nausea medication

19. During an annual physical examination, a 43-year-old patient states that she does not perform monthly breast self-examinations (BSEs). She tells the nurse that she believes that mammograms "do a much better job than I ever could to find a lump." What should the nurse include in his or her response to this patient? a. BSEs may detect lumps that appear between mammograms. b. She is correct—mammography is a good replacement for BSE. c. The American Cancer Society recommends women over 40 years old perform a monthly BSE. d. She does not need to perform BSEs as long as a physician checks her breasts annually.

23. The nurse is assisting with a BSE clinic. Which of these women reflects abnormal findings during the inspection phase of breast examination? a. Woman whose nipples are in different planes (deviated) b. Woman whose left breast is slightly larger than her right c. Nonpregnant woman whose skin is marked with linear striae d. Pregnant woman whose breasts have a fine blue network of veins visible under the skin

26. A 40-year-old patient who has just finished chemotherapy for breast cancer tells the nurse that she is concerned about her mouth. During the assessment the nurse finds areas of buccal mucosa that are raw and red with some bleeding, as well as other areas that have a white, cheesy coating. What do these findings indicate? a. Candidiasis b. Leukoplakia c. Koplik spots d. Aphthous ulcers

26. The nurse is palpating a female patient's breasts during an examination. Which of these positions is most likely to make significant lumps more distinct during breast palpation? a. Supine with the arms raised over her head b. Sitting with the arms relaxed at her sides c. Supine with the arms relaxed at her sides d. Sitting with the arms flexed and fingertips touching her shoulders

26. When examining children affected with Down syndrome (trisomy 21), what should the nurse look for r/t this disorder? a. Ear dysplasia b. Long, thin neck c. Protruding thin tongue d. Narrow and raised nasal bridge

28. The nurse just noted from the medical record that the patient has a lesion that is confluent in nature. What should the nurse expect to find upon examination? a. Lesions that run together b. Annular lesions that have grown together c. Lesions arranged in a line along a nerve route d. Lesions that are grouped or clustered together

3. The nurse is examining a patient who tells the nurse, "I sure sweat a lot, especially on my face and feet but it doesn't have an odor." The nurse knows that this is likely r/t a disorder with what part of the body? a. Eccrine glands b. Apocrine glands c. Disorder of the stratum corneum d. Disorder of the stratum germinativum

32. A 43-year-old woman is at the clinic for a routine examination. She reports that she has had a lump in her right breast for years. Recently, it has begun to change in consistency and is becoming harder. She reports that 5 years ago her physician evaluated the lump and determined that it was "nothing to worry about." The nurse's examination validates the presence of a mass in the right upper outer quadrant at 1 o'clock, approximately 5 cm from the nipple. It is firm, mobile, and nontender, with borders that are not well defined. What is the best response by the nurse? a. "Because of the change in consistency of the lump, it should be further evaluated by a physician." b. "The changes could be r/t your menstrual cycles. Keep track of the changes in the mass each month." c. "The lump is probably nothing to worry about because it has been present for years and was determined to be noncancerous 5 years ago." d. "Because you are experiencing no pain and the size has not changed, you should continue to monitor the lump and return to the clinic in 3 months"

32. The nurse is performing an assessment on a 7-year-old child who has symptoms of chronic watery eyes, sneezing, and clear nasal drainage. The nurse notices the presence of a transverse line across the bridge of the nose, dark blue shadows below the eyes, and a double crease on the lower eyelids. What does the nurse suspect is the cause of these signs and symptoms? a. Chronic allergies b. Lymphadenopathy C. . Nasal congestion d. Upper respiratory infection

33. When assessing the tongue of an adult, what finding would be considered abnormal? a. Smooth glossy dorsal surface b. Thin white coating over the tongue c. Raised papillae on the dorsal surface d. Visible venous patterns on the ventral surface

34. During an examination, the nurse notes a supernumerary nipple just under the patient's left breast. The patient tells the nurse that she always thought it was a mole. Which statement about this finding is correct? a. This variation is normal and not a significant finding. b. This finding is significant and needs further investigation. c. A supernumerary nipple also contains glandular tissue and may leak milk during pregnancy and lactation. d. The patient is correct—a supernumerary nipple is actually a mole that happens to be located under the breast.

36. A new mother calls the clinic to report that part of her left breast is red, swollen, tender, very hot, and hard. She has a fever of 38.3° C. She also has had symptoms of influenza, such as chills, sweating, and feeling tired. The nurse notices that she has been breastfeeding for 1 month. From her description, what condition does the nurse suspect? a. Mastitis b. Paget disease c. Plugged milk duct d. Mammary duct ectasia

36. During an examination, the nurse knows that the best way to palpate the lymph nodes in the neck is described by which statement? a. Using gentle pressure, palpate with both hands to compare the two sides. b. Using strong pressure, palpate with both hands to compare the two sides. c. Gently pinch each node between one's thumb and forefinger, and then move down the neck muscle. d. Using the index and middle fingers, gently palpate by applying pressure in a rotating pattern.

37. During a breast examination on a female patient, the nurse notices that the nipple is flat, broad, and fixed. The patient states it "started doing that a few months ago." What does this finding suggest? a. Dimpling b. Retracted nipple c. Nipple inversion d. Deviation in nipple pointing

37. During a well-baby checkup, a mother is concerned because her 2-month-old infant cannot hold her head up when she is pulled to a sitting position. Which response by the nurse is appropriate? a. "Head control is usually achieved by 4 months of age." b. "You shouldn't be trying to pull your baby up like that until she is older." c. "Head control should be achieved by this time." d. "This inability indicates possible nerve damage to the neck muscles."

37. During an oral examination of a 4-year-old American-Indian child, the nurse notices that her uvula is partially split. Which of these statements is accurate? a. A bifid uvula may occur in some American-Indian groups. b. This condition is a cleft palate and is common in American Indians. c. A bifid uvula is torus palatinus, which frequently occurs in American Indians. d. This condition is due to an injury and should be reported to the authorities.

37. While performing an assessment of a 65-year-old man with a history of hypertension and coronary artery disease, the nurse notices the presence of bilateral pitting edema in the lower legs. The skin is puffy and tight but normal in color. No increased redness or tenderness is observed over his lower legs, and the peripheral pulses are equal and strong. In this situation, the nurse suspects that the likely cause of the edema is which condition? a. Heart failure b. Venous stasis c. Local inflammation d. Peripheral arterial insufficiency

38. A 54-year-old man comes to the clinic with a "horrible problem." He tells the nurse that he has just discovered a lump on his breast and is fearful of cancer. The nurse knows which statement about breast cancer in men is true? a. Breast cancer in men rarely spreads to the lymph nodes. b. Less than one percent of all breast cancers occurs in men. c. Most breast masses in men are diagnosed as gynecomastia. d. Breast masses in men are difficult to detect because of minimal breast tissue.

46. A patient has been admitted for severe psoriasis. The nurse expects to see what finding in the patient's fingernails? a. Pitting b. Paronychia c. Beau lines d. Splinter hemorrhages

7. During an examination, the nurse finds that a patient has excessive dryness of the skin. How should the nurse document this finding? a. Xerosis b. Pruritus c. Alopecia d. Seborrhea

7. When examining a patient's CN function, what muscles should the nurse assess to assess the function of CN XI? a. Sternomastoid and trapezius b. Spinal accessory and omohyoid c. Trapezius and sternomandibular d. Sternomandibular and spinal accessory

8. A 22-year-old woman comes to the clinic because of severe sunburn and states, "I was out in the sun for just a couple of minutes." The nurse begins a medication review with her, paying special attention to which medication class? a. Tetracyclines for acne b. Proton pump inhibitors for heartburn c. Nonsteroidal anti-inflammatory drugs for pain d. Thyroid replacement hormone for hypothyroidism

8. A patient's laboratory data reveal an elevated thyroxine (T4) level. What gland should the nurse assess? a. Thyroid b. Parotid c. Adrenal d. Parathyroid

A 2-week-old infant can fixate on an object but cannot follow a light or bright toy. What should the nurse do? a. Consider this a normal finding. b. Continue with the examination, and assess visual fields. c. Assess the pupillary light reflex for possible blindness. d. Expect that a 2-week-old infant should be able to fixate and follow an object

A woman has just learned that she is pregnant. What should the nurse teach this patient about changes in her breasts? a. She can expect her areolae to become larger and darker in color. b. Breasts may begin secreting milk after the fourth month of pregnancy. c. She should inspect her breasts for visible veins and immediately report these. D. During pregnancy, breast changes are fairly uncommon; most of the changes occur after the birth.

The nurse has palpated a lump in a female patient's right breast. The nurse documents this as a small, round, firm, distinct, lump located at 2 o'clock, 2 cm from the nipple. It is nontender and fixed. No associated retraction of the skin or nipple, no erythema, and no axillary lymphadenopathy are observed. What information is missing from the documentation? a. Size of the lump b. Shape of the lump c. Consistency of the lump d. Whether the lump is solitary or multiple

The nurse is assessing a patient who may have hearing loss. Which of these statements is true concerning air conduction? a. Air conduction is the normal pathway for hearing. b. Amplitude of sound determines the pitch that is heard. c. Vibrations of the bones in the skull cause air conduction. d. Loss of air conduction is called a conductive hearing loss.

The nurse is examining a patient's retina with an ophthalmoscope. Which finding is considered normal? a. Optic disc that is a yellow-orange color. b. Presence of pigmented crescents in the macular area. c. Optic disc margins that are blurred around the edges. d. Presence of the macula located on the nasal side of the retina.

The nurse is performing an ear examination of an 80-year-old patient. Which of these findings would be considered normal? a. High-tone frequency loss b. Thin, translucent membrane c. Shiny, pink tympanic membrane d. Increased elasticity of the pinna

The nurse is performing an external eye examination. Which statement regarding the outer layer of the eye is true? a. The outer layer of the eye is very sensitive to touch. b. The outer layer of the eye is darkly pigmented to prevent light from reflecting internally. c. The trigeminal nerve (CN V) and the trochlear nerve (CN IV) are stimulated when the outer surface of the eye is stimulated. d. The visual receptive layer of the eye in which light waves are changed into nerve impulses is located in the outer layer of the eye.

The nurse is performing an oral assessment on a 40-year-old black patient and notices the presence of a 1-cm, nontender, grayish-white lesion on the left buccal mucosa. Which one of these statements is true about this lesion? a. It is leukoedema which is common in dark-pigmented people. b. It is indicative of cancer and should be immediately tested. c. It is the result of hyperpigmentation and is a normal finding. d. It is torus palatinus and would normally be found only in smokers.

The nurse is preparing to do an otoscopic examination on a 2-year-old child. Which one of these reflects the correct procedure? a. Pulling the pinna down b. Pulling the pinna up and back c. Slightly tilting the child's head toward the examiner d. Instructing the child to touch their chin to their chest

The nurse is reviewing the age-related changes in the eye for a class. Which of these physiologic changes is responsible for presbyopia? a. Loss of lens elasticity b. Degeneration of the cornea c. Decreased adaptation to darkness d. Decreased distance vision abilities

The nurse suspects that a patient has otitis media. Early signs of otitis media include which of these findings of the tympanic membrane? a. Hypomobility b. Fiery red and bulging of entire eardrum c. Retraction with landmarks clearly visible d. Flat, slightly pulled in at the center, and moves with insufflation

When performing the corneal light reflex assessment, the nurse notes that the light is reflected at 2 o'clock in each eye. What should the nurse do regarding this finding? a. Record this as a normal finding. b. Refer the individual for further evaluation. c. Document this finding as an asymmetric light reflex. d. Perform the confrontation test to validate the findings.

While discussing the history of a 6-month-old infant, the mother tells the nurse that she took a significant amount of aspirin while she was pregnant. What question would the nurse want to include in the history? a. "Does your baby seem to startle with loud noises?" b. "Has your baby had any surgeries on her ears?" c. "Have you noticed any drainage from her ears?" d. "How many ear infections has your baby had since birth?"

35. While examining a 75-year-old woman, the nurse notices that the skin over her right breast is thickened and the hair follicles are exaggerated. What is this condition called? a. Dimpling b. Retraction c. Peau d'orange D. Benign breast disease

1. During an assessment, a patient mentions that "I just can't smell like I used to. I can barely smell the roses in my garden. Why is that?" For which possible causes of changes in the sense of smell will the nurse assess? (Select all that apply.) a. Aging b. Chronic allergies c. Cigarette smoking d. Chronic alcohol use e. Herpes simplex virus I f. Frequent episodes of strep throat

A,B,C

The nurse is testing the hearing of a 78-year-old man and is reminded of the changes in hearing that occur with aging that include which of the following? (Select all that apply.) a. Progression of hearing loss is slow. b. The aging person has low-frequency tone loss. c. Sounds may be garbled and difficult to localize. d. Hearing loss r/t aging begins in the mid-40s. e. Hearing loss reflects nerve degeneration of the middle ear. f. The aging person may find it harder to hear consonants than vowels.

A,C,F

1. The nurse is assessing the breasts of a 68-year-old woman and discovers a mass in the upper outer quadrant of the left breast. When assessing this mass, the nurse is aware that characteristics of a cancerous mass include which of the following? (Select all that apply.) a. Nontender mass b. Regular border c. Hard, dense, and immobile d. Rubbery texture and mobile e. Dull, heavy pain on palpation f. Irregular, poorly delineated border

A,F

36. The nurse has discovered decreased skin turgor in a patient and knows that this finding is expected in which condition? a. Severe obesity b. Severe dehydration c. Childhood growth spurts d. Connective tissue disorders such as scleroderma

3. The nurse notices that a patient's palpebral fissures are not symmetric. On examination, the nurse may find that damage has occurred to which cranial nerve (CN)? a. V b. VII c. XI d. XIII

12. A mother brings her newborn in for an assessment and asks, "Is there something wrong with my baby? His head seems so big." Which statement is true regarding the relative proportions of the head and trunk of the newborn? a. At birth, the head is one fifth the total length. b. Head circumference should be greater than chest circumference at birth. c. The head size reaches 90% of its final size when the child is 3 years old. d. When the anterior fontanel closes at 2 months, the head will be more proportioned to the body.

12. The nurse keeps in mind that a thorough skin assessment is extremely important. What can the skin provide important information about? a. Support systems b. Circulatory status c. Socioeconomic status d. Psychological wellness

14. A patient reports excruciating headache pain on one side of his head, especially around his eye, forehead, and cheek that has lasted approximately to 2 hours, occurring once or twice each day. What should the nurse suspect? a. Hypertension b. Cluster headaches c. Tension headaches d. Migraine headaches

14. The nurse is preparing for a class on breast cancer. Which statement is true with regard to cultural differences in breast cancer in the United States? a. Black women have a lower incidence of aggressive, triple negative breast cancer. b. The relative 5-year survival rate for black women is lower than that for Caucasian women. c. For every stage of breast cancer, Asian/Pacific Islander women have the lowest rate of survival. d. Ashkenazi Jewish women have a significantly lower prevalence of BRCA1 and BRCA2 gene mutations.

15. During a breast health interview, a patient states that she has noticed pain in her left breast. Which statement by the nurse is most appropriate? a. "Don't worry about the pain; breast cancer is not painful." b. "I would like some more information about the pain in your left breast." c. "Oh, I had pain like that after my son was born; it turned out to be a blocked milk duct." d. "Breast pain is almost always the result of benign breast disease

18. During a skin assessment, the nurse notices that a Mexican-American patient has skin that is yellowish-brown; however, the skin on the hard and soft palate is pink and the patient's scleras are white. From these findings, what can the nurse rule out? a. Pallor b. Jaundice c. Cyanosis d. Iron deficiency

19. A 10-year-old is at the clinic for "a sore throat that has lasted 6 days." Which of these findings would be consistent with an acute infection? a. Tonsils 3+/1-4+ with pale coloring b. Tonsils 3+/1-4+ with large white spots c. Tonsils 2+/1-4+ with small plugs of white debris d. Tonsils 1+/1-4+ and pink; the same color as the oral mucosa

19. A patient has come in for an examination and states, "I have this spot in front of my ear lobe on my cheek that seems to be getting bigger and is tender. What do you think it is?" The nurse notes swelling below the angle of the jaw. What does the nurse suspect? a. Inflammation of the thyroid gland b. Inflammation of the parotid gland c. Infection in the occipital lymph node d. Infection in the submental lymph node

2. In performing a breast examination, the nurse knows that examining the upper outer quadrant of the breast is especially important. What is the reason for this? a. It is the largest quadrant of the breast. b. It is the most common location of breast tumors. c. It is where the majority of suspensory ligaments attach. d. It is more prone to injury and calcifications than other locations in the breast

20. A male patient with a history of acquired immunodeficiency syndrome (AIDS) has come in for an examination and states, "I think that I have the mumps." What should the nurse examine first? a. Thyroid gland b. Parotid gland c. Cervical lymph nodes d. Mouth and skin for lesions

21. The nurse suspects that a patient has hyperthyroidism, and the laboratory data indicate that the patient's T4 and T3 hormone levels are elevated. Which of these findings would the nurse most likely find on examination? a. Dyspnea b. Tachycardia c. Constipation D. Atrophied nodular thyroid gland

22. During an examination of a woman, the nurse notices that her left breast is slightly larger than her right breast. Which of these statements is true about this finding? a. Asymmetry of the breasts is unusual and the patient should be referred to physician. b. Asymmetry of the breasts is common, but the nurse should verify that this finding is not new. c. Asymmetry of breast size and shape is very unusual and means she may have an inflammation or growth. d. Asymmetry of breast size and shape is probably due to breastfeeding and is nothing to worry about.

23. A patient's thyroid gland is enlarged, and the nurse is preparing to auscultate the thyroid gland for the presence of a bruit. What technique should the nurse use to assess for a bruit. a. Palpate the thyroid while the patient is swallowing. b. Auscultate the thyroid with the bell of the stethoscope. c. Palpate the thyroid while the patient holds their breath. d. Auscultate the thyroid with the diaphragm of the stethoscope.

24. A 35-year-old pregnant woman comes to the clinic for a monthly appointment. During the assessment, the nurse notices that she has a brown patch of hyperpigmentation on her face. The nurse continues the skin assessment. What other finding should the nurse expect? a. Xerosis b. Chloasma c. Keratoses d. Acrochordons

24. While performing an assessment of the mouth, the nurse notices that the patient has a 1-cm ulceration that is crusted with an elevated border and located on the outer third of the lower lip. What other information would be most important for the nurse to assess? a. Nutritional status b. When the patient first noticed the lesion c. Whether the patient has had a recent cold d. Whether the patient has had any recent exposure to sick animals

25. A man has come in to the clinic for a skin assessment because he is worried he might have skin cancer. During the skin assessment the nurse notices several areas of pigmentation that look greasy, dark, and "stuck on" his skin. Which is the best description of these? a. Senile lentigines, which do not become cancerous b. Seborrheic keratoses, which do not become cancerous c. Acrochordons, which are precursors to squamous cell carcinoma d. Actinic keratoses, which are precursors to basal cell carcinoma

28. A patient states during the interview that she noticed a new lump in the shower a few days ago. It was on her left breast near her axilla. How should the nurse proceed? a. Palpate the lump first. b. Palpate the unaffected breast first. c. Avoid palpating the lump because it could be a cyst, which might rupture. d. Palpate the breast with the lump first but plan to palpate the axilla last.

28. A woman comes to the clinic and states, "I've been sick for so long! My eyes have gotten so puffy, and my eyebrows and hair have become coarse and dry." For what condition should the nurse assess for other signs and symptoms? a. Cachexia b. Myxedema c. Graves disease d. Parkinson syndrome

31. A 55-year-old postmenopausal woman is being seen in the clinic for her annual examination. She is concerned about changes in her breasts that she has noticed over the past 5 years. She states that her breasts have decreased in size and that the elasticity has changed so that her breasts seem "flat and flabby." Which is the best reply by the nurse? a. "This change occurs most often because of long-term use of bras that do not provide enough support to the breast tissues." b. "Decreases in hormones after menopause causes atrophy of the glandular tissue in the breast and is a normal process of aging." c. "This is a normal change that occurs as women get older and is due to the increased levels of progesterone during the aging process." d. "Postural changes in the spine make it appear that your breasts have changed in shape. Exercises to strengthen the muscles of the upper back and chest wall will help prevent the changes in elasticity and size"

31. A mother has noticed that her son, who has been to a new babysitter, has some blisters and scabs on his face and buttocks. On examination, the nurse notices moist, thin-roofed vesicles with a thin erythematous base. What does the nurse suspect? a. Eczema b. Impetigo c. Herpes zoster d. Diaper dermatitis

31. During an assessment of an infant, the nurse notes that the fontanels are depressed and sunken. The nurse suspects which condition? a. Rickets b. Dehydration c. Mental retardation d. Increased intracranial pressure

33. While inspecting a patient's breasts, the nurse finds that the left breast is slightly larger than the right with the bilateral presence of Montgomery glands. How should the nurse proceed? a. Palpate over the Montgomery glands, checking for drainage. b. Consider these findings as normal, and proceed with the examination. c. Ask extensive health history questions regarding the woman's breast asymmetry. d. Continue with the examination, and then refer the patient for further evaluation of the Montgomery glands.

34. A 45-year-old farmer comes in for a skin evaluation and complains of hair loss on his head. His hair seems to be breaking off in patches, and he notices some scaling on his head. What does the nurse suspect? a. Folliculitis b. Tinea capitis c. Toxic alopecia d. Seborrheic dermatitis

34. The nurse has just completed a lymph node assessment on a 60-year-old healthy female patient. When palpating the nodes on this healthy 60-year-old adult, how did the lymph nodes feel? a. Fixed b. Nonpalpable c. Rubbery, discrete, and mobile d. Large, firm, and fixed to the tissue

38. A 40-year-old woman reports a change in mole size, accompanied by color changes, itching, burning, and bleeding over the past month. She has a dark complexion and has no family history of skin cancer, but she has had many blistering sunburns in the past. What is the best response by the nurse? a. Tell the patient to watch the lesion and report back in 2 months. b. Refer the patient because of the suggestion of melanoma on the basis of her symptoms. c. Ask additional questions regarding environmental irritants that may have caused this condition. d. Tell the patient that these signs suggest a compound nevus, which is very common in young to middle-aged adults.

4. If a patient reports a recent breast infection, then the nurse should expect to find what type of node enlargement? A. . Nonspecific b. Ipsilateral axillary c. Inguinal and cervical d. Contralateral axillary

40. The nurse is assessing a patient with liver disease for jaundice. Which of these assessment findings is indicative of true jaundice? a. Yellow patches in the outer sclera b. Yellow color of the sclera that extends up to the iris c. Skin that appears yellow when examined under low light d. Yellow deposits on the palms and soles of the feet where jaundice first appears

41. The nurse is assessing for inflammation in a dark-skinned person. Which technique is the best? a. Assessing the skin for cyanosis and swelling b. Palpating the skin for edema and increased warmth c. Assessing the oral mucosa for generalized erythema d. Palpating for tenderness and local areas of ecchymosis

5. When examining the face of a patient, what are the two pairs of salivary glands that are accessible for examination? a. Occipital; submental b. Parotid; submandibular c. Submandibular; occipital d. Sublingual; parotid

9. A patient says that she has recently noticed a lump in the front of her neck below her "Adam's apple" that seems to be getting bigger. During the assessment, what finding would lead the nurse to suspect that this may not be a cancerous thyroid nodule? a. It is tender. b. It is mobile and soft. c. It disappears when the patient smiles. D. It is hard and fixed to the surrounding structures.

9. A woman is leaving on a trip to Hawaii and has come in for a checkup. During the examination the nurse learns that she has diabetes and is prescribed oral hypoglycemic agents. What should the nurse include in this patient's teaching? a. Increased possibility of bruising b. Importance of sunscreen and avoiding direct sunlight c. Lack of availability of glucose-monitoring equipment d. Skin sensitivity as a result of exposure to salt water

A 17-year-old student is a swimmer on her high school's swim team. She has had three bouts of otitis externa this season and wants to know what to do to prevent it. What should the nurse include in the instructions? a. Use a cotton-tipped swab to dry ear canals thoroughly after each swim. B. Use rubbing alcohol or 2% acetic acid eardrops after every swim c. Irrigate the ears with warm water and a bulb syringe after each swim. d. Rinse the ears with a warmed solution of mineral oil and hydrogen peroxide.

A 31-year-old patient tells the nurse that he has noticed a progressive loss in his hearing. He says that it does seem to help when people speak louder or if he turns up the volume of a television or radio. What is the most likely cause of this hearing loss? a. Presbycusis b. Otosclerosis c. Trauma to the bones d. Frequent ear infections

A mother is concerned because her 18-month-old toddler has 12 teeth. She is wondering if this is normal for a child of this age. Which is the best response by the nurse? a. "How many teeth did you have at this age?" b. "This is a normal number of teeth for an 18 month old." c. "Normally, by age 2 years, 16 deciduous teeth are expected." d. "All 20 deciduous teeth are expected to erupt by age 4 years."

A patient comes into the clinic reporting pain in her O.D. On examination, the nurse sees a pustule at the lid margin that is painful to touch, red, and swollen. What is the correct term for this finding? a. Chalazion b. Hordeolum c. Blepharitis d. Dacryocystitis

A patient has been admitted after an accident at work. During the assessment, the patient is having trouble hearing and states, "I don't know what is the matter. All of a sudden I can't hear you out of my left ear!" What should the nurse do next? a. Irrigate the ear with rubbing alcohol. b. Notify the patient's health care provider. c. Prepare to remove cerumen from the patient's ear. d. Make note of this finding for the report to the next shift

A patient in her first trimester of pregnancy is diagnosed with rubella. Which of these statements is correct regarding the significance of this in relation to the infant's hearing? a. Rubella may affect the mother's hearing but not the infant's b. Rubella can damage the infant's organ of Corti, which will impair hearing. c. Rubella can impair the development of cranial nerve VIII and thus affect hearing. d. Rubella is especially dangerous to the infant's hearing in the second trimester of pregnancy.

A patient's vision is recorded as 20/30 when the Snellen eye chart is used. How should the nurse interpret these results? a. At 30 feet the patient can read the entire chart. b. The patient can read at 20 feet what a person with normal vision can read at 30 feet. c. The patient can read the chart from 20 feet in the O.S. and 30 feet in the O.D. d. The patient can read from 30 feet what a person with normal vision can read from 20 feet.

A patient's vision is recorded as 20/80 in each eye. How does the nurse interpret this finding? a. Patient has presbyopia. b. Patient as poor vision. c. Patient has acute vision. d. Patient has normal vision.

During a physical education class, a student is hit in the eye with the end of a baseball bat. When examined in the emergency department, the nurse notices the presence of blood in the anterior chamber of the eye. What does this finding indicate? a. Hypopyon b. Hyphema c. Pterygium d. A corneal abrasion

During an assessment of the sclera of a black patient, the nurse would consider which of these an expected finding? a. Yellow fatty deposits over the cornea b. Presence of small brown macules on the sclera c. Pallor near the outer canthus of the lower lid d. Yellow color of the sclera that extends up to the iris

During an assessment, the nurse notices that an older adult patient has tears rolling down his face from his O.S. Closer examination shows that the lower lid is loose and rolling outward. The patient complains of his eye feeling "dry and itchy." Which action by the nurse is correct? a. Documenting the finding as ptosis b. Assessing for other signs of ectropion c. Assessing the eye for a possible foreign body d. Contacting the prescriber; these are signs of basal cell carcinoma

During ocular examinations, what should the nurse keep in mind regarding the movement of the extraocular muscles? a. Is decreased in the older adult. b. Is stimulated by CNs III, IV, and VI. c. Is impaired in a patient with cataracts. d. Is stimulated by cranial nerves (CNs) I and II.

In assessing the tonsils of a 30-year-old, the nurse notices that they are involuted, granular in appearance, and appear to have deep crypts. What is the correct response to these findings? a. Refer the patient to a throat specialist. b. No response is needed; this appearance is normal for the tonsils. c. Continue with the assessment, looking for any other abnormal findings. d. Obtain a throat culture on the patient for possible streptococcal (strep) infection.

In performing a voice test to assess hearing, which of these actions would the nurse perform? a. Shield the lips so that the sound is muffled. b. Whisper a set of random numbers and letters, and then ask the patient to repeat them. c. Ask the patient to place his or her finger in their ear to occlude outside noise. d. Stand approximately 4 feet away to ensure that the patient can really hear at this distance.

The nurse is palpating the sinus areas. If the findings are normal, then the patient should report which sensation? a. No sensation b. Firm pressure c. Pain during palpation d. Pain sensation behind eyes

The nurse is performing a middle ear assessment on a 15-year-old patient who has had a history of chronic ear infections. When examining the right tympanic membrane, the nurse sees the presence of dense white patches. The tympanic membrane is otherwise unremarkable. It is pearly, with the light reflex at 5 o'clock and landmarks visible. What should the nurse do? a. Refer the patient for the possibility of a fungal infection. b. Recognize that these are scars caused from frequent ear infections. c. Consider that these findings may represent the presence of blood in the middle ear. d. Be concerned about the ability to hear because of this abnormality on the tympanic membrane.

The nurse is performing an eye assessment on an 80-year-old patient. Which of these findings is considered abnormal? a. Decrease in tear production b. Unequal pupillary constriction in response to light c. Presence of arcus senilis observed around the cornea d. Loss of the outer hair on the eyebrows attributable to a decrease in hair follicles

The nurse is performing the diagnostic positions test. Which result is a normal finding? a. Convergence of the eyes b. Parallel movement of both eyes c. Nystagmus in extreme superior gaze d. Slight amount of lid lag when moving the eyes from a superior to an inferior

When examining the ear with an otoscope, how should the tympanic membrane look? a. Light pink with a slight bulge b. Pearly gray and slightly concave c. Whitish with black flecks or dots d. Pulled in at the base of the cone of light

When examining the mouth of an older patient, the nurse recognizes which finding is due to the aging process? a. Teeth appearing shorter b. Tongue that looks smoother in appearance c. Buccal mucosa that is beefy red in appearance d. Small, painless lump on the dorsum of the tongue

When performing an otoscopic examination of a 5-year-old child with a history of chronic ear infections, the nurse sees that his right tympanic membrane is amber-yellow in color and that air bubbles are visible behind the tympanic membrane. The child reports occasional hearing loss and a popping sound with swallowing. Based on this data, what does the nurse conclude? a. An acute purulent otitis externa b. Most likely a serous otitis media c. Evidence of a resolving cholesteatoma d. Experiencing the early stages of perforation

Which of these assessment findings would the nurse expect to see when examining the eyes of a black patient? a. Increased night vision b. Dark retinal background c. Increased photosensitivity d. Narrowed palpebral fissures

Which of these statements regarding visual pathways and visual fields is true? a. The right side of the brain interprets the vision for the O.D. B. The image formed on the retina is upside down and reversed from its actual appearance in the outside world. c. Light rays are refracted through the transparent media of the eye before striking the pupil. d. Light impulses are conducted through the optic nerve to the temporal lobes of the brain.

While obtaining a health history, a patient tells the nurse that he has frequent nosebleeds and asks the best way to get them to stop. What would be the nurse's best response? a. "While sitting up, place a cold compress over your nose." b. "Sit up with your head tilted forward and pinch your nose." c. "Allow the bleeding to stop on its own, but don't blow your nose." d. "Lie on your back with your head tilted back and pinch your nose."

2. The nurse is examining a 62-year-old man and notes that he has bilateral gynecomastia. The nurse should explore his health history for which related conditions? (Select all that apply.) a. Malnutrition b. Liver disease c. Hyperthyroidism d. Type 2 diabetes mellitus e. History of alcohol abuse

B,C,E

During an examination, a patient states that she was diagnosed with open-angle glaucoma 2 years ago. The nurse assesses for characteristics of open-angle glaucoma. Which of these are characteristics of open-angle glaucoma? (Select all that apply.) a. Immediate treatment is needed. b. Virtually no symptoms are exhibited. c. Vision loss begins with peripheral vision. d. Patient may experience sensitivity to light, nausea, and halos around lights. e. Patient experiences tunnel vision in the late stages. f. Open-angle glaucoma causes sudden attacks of increased pressure that cause blurred vision.

B,C,E

1. The nurse is assessing a 1-month-old infant at his well-baby checkup. Which assessment findings are appropriate for this age? (Select all that apply.) a. Absent tonic neck reflex b. Nonpalpable cervical lymph nodes c. Fontanels firm and slightly concave d. Head circumference equal to chest circumference e. Head circumference less than chest circumference f. Head circumference greater than chest circumference

B,C,F

1. The nurse is preparing for a certification course on skin care and needs to be familiar with the various lesions that may be identified on assessment of the skin. Which of the following definitions are correct? (Select all that apply.) a. Papule: Hypertrophic scar. b. Vesicle: Known as a friction blister. c. Bulla: Elevated, circumscribed lesion filled with turbid fluid (pus). d. Nodule: Solid, elevated, and hard or soft growth that is larger than 1 cm. e. Petechiae: Tiny punctate hemorrhages, 1 to 3 mm, round and discrete, dark red, purple, or brown in color.

B,D,E

. The nurse is examining a patient's ears and notices cerumen in the external canal. Which of these statements about cerumen is correct? a. Wet, honey-colored cerumen is a sign of infection. b. The presence of cerumen is indicative of poor hygiene. c. The purpose of cerumen is to protect and lubricate the ear. d. Cerumen is necessary for transmitting sound through the auditory canal.

10. A 13-year-old girl is interested in obtaining information about the cause of her acne. What should the nurse include in the information about acne? a. It is contagious. b. It has no known cause. c. It is caused by increased sebum production. d. It has been found to be r/t poor hygiene.

13. A patient comes in for a physical examination in late July and states that she was "freezing to death" while waiting for her examination. The nurse notes that her skin is pale and cool. What should the nurse understand is the likely cause? a. Venous pooling b. Peripheral vasodilation c. Peripheral vasoconstriction d. Decreased arterial perfusion

19. A black patient is in the intensive care unit because of impending shock after an accident. The nurse expects to find what characteristics in this patient's skin? a. Ruddy blue b. Generalized pallor c. Ashen, gray, or dull d. Patchy areas of pallor

13. A patient, an 85-year-old woman, is complaining about the fact that the bones in her face have become more noticeable. What explanation should the nurse give her? a. Diets low in protein and high in carbohydrates may cause enhanced facial bones. b. Bones can become more noticeable if the person does not use a dermatologically approved moisturizer. c. More noticeable facial bones are probably due to a combination of factors r/t aging, such as decreased elasticity, subcutaneous fat, and moisture in her skin. d. Facial skin becomes more elastic with age. This increased elasticity causes the skin to be more taught, drawing attention to the facial bones.

14. A patient comes to the clinic and tells the nurse that he has been confined to his recliner chair for approximately 3 days with his feet down and he asks the nurse to evaluate his feet. What should the nurse expect to find during the assessment? a. Pallor b. Coolness c. Distended veins d. Prolonged capillary filling time

15. A patient is especially worried about an area of skin on her feet that has turned white. The health care provider has told her that her condition is vitiligo. What should the nurse include in the teaching of vitiligo? a. It is associated with an excess of melanin pigment. b. It is a result of excess apocrine glands in her feet. c. It is caused by the complete absence of melanin pigment in an area. d. It is r/t impetigo and can be treated with a prescription ointment

16. During an oral assessment of a 30-year-old black patient, the nurse notices bluish lips and a dark line along the gingival margin. What action would the nurse perform in response to this finding? a. Check the patient's Hb for anemia. b. Assess for other signs of insufficient oxygen supply. c. Proceed with the assessment, this appearance is a normal finding. d. Ask if he has been exposed to an excessive amount of carbon monoxide.

17. During a physical examination, a 45-year-old woman states that she has had a crusty, itchy rash on her breast for approximately 2 weeks. In trying to find the cause of the rash, which question would be important for the nurse to ask? a. "Is the rash raised and red?" b. "Does it appear to be cyclic?" c. "Where did the rash first appear—on the nipple, the areola, or the surrounding skin?" d. "What was she doing when she first noticed the rash, and do her actions make it worse?"

17. During a well-baby checkup, the nurse notices that a 1-week-old infant's face looks small compared with his cranium, which seems enlarged. On further examination, the nurse also notices dilated scalp veins and downcast or "setting sun" eyes. The nurse suspects which condition? a. Craniotabes b. Microcephaly c. Hydrocephalus d. Caput succedaneum

18. The nurse needs to palpate the temporomandibular joint for crepitation. Where is this joint located? a. Just below the hyoid bone and posterior to the tragus b. Just below the vagus nerve and posterior to the mandible c. Just below the temporal artery and anterior to the tragus d. Just below the temporal artery and anterior to the mandible

20. An older adult woman is brought to the emergency department after being found lying on the kitchen floor for 2 days; she is extremely dehydrated. What would the nurse expect to see during the examination? a. Pale mucous membranes b. Smooth mucous membranes and lips c. White patches on the mucous membranes d. Dry mucous membranes and cracked lips

20. Immediately after birth, the nurse is unable to suction the nares of a crying newborn. An attempt is made to pass a catheter through both nasal cavities with no success. What should the nurse do next? a. Attempt to suction again with a bulb syringe. b. Wait a few minutes, and try again once the infant stops crying. c. Recognize that this situation requires immediate intervention. d. Contact the physician to schedule an appointment for the infant at his or her next hospital visit.

21. A 42-year-old woman states that she has noticed several small, slightly raised, bright red dots on her chest. On examination, the nurse confirms the presence of these "dots." How should the nurse document these findings? a. Anasarca b. Scleroderma c. Senile angiomas d. Latent myeloma

21. The nurse notices that the mother of a 2-year-old boy brings him into the clinic quite frequently for various injuries and suspects there may be some child abuse involved. What should the nurse look for during an inspection of this child's mouth? a. Swollen, red tonsils b. Ulcerations on the hard palate c. Bruising on the buccal mucosa or gums d. Small yellow papules along the hard palate

22. A visitor from Poland who does not speak English seems to be somewhat apprehensive about the nurse examining his neck. How should the nurse proceed that would allow the patient to feel more comfortable with the nurse examining his thyroid gland? a. Behind with the nurse's hands placed firmly around his neck b. The side with the nurse's eyes averted toward the ceiling and thumbs on his neck c. The front with the nurse's thumbs placed on either side of his trachea and his head tilted forward d. The front with the nurse's thumbs placed on either side of his trachea and his head tilted backward

22. The nurse is assessing a 3-year-old for "drainage from the nose." On assessment, a purulent drainage that has a very foul odor is noted from the left naris and no drainage is observed from the right naris. The child is afebrile with no other symptoms. What should the nurse do next? a. Refer to the physician for an antibiotic order. b. Have the mother bring the child back in 1 week. c. Perform an otoscopic examination of the left nares. d. Tell the mother that this drainage is normal for a child of this age.

What is the primary purpose of the ciliated mucous membrane in the nose? a. To warm the inhaled air b. To filter out dust and bacteria c. To filter coarse particles from inhaled air d. To facilitate the movement of air through the nares

23. During an assessment of a 26-year-old for "a spot on my lip I think is cancer," the clinic nurse notices a group of clear vesicles with an erythematous base around them located at the lip-skin border. The patient mentions that she just returned from Hawaii. What is the most appropriate action by the nurse? a. Tell the patient she needs to see a skin specialist. b. Discuss the benefits of having a biopsy performed on any unusual lesion. c. Tell the patient that these vesicles are indicative of herpes simplex I or cold sores and that they will heal in 4 to 10 days. d. Tell the patient that these vesicles are most likely the result of a riboflavin deficiency and discuss nutrition.

24. During the physical examination, the nurse notices that a female patient has an inverted left nipple. Which statement regarding this is most accurate? a. Normal nipple inversion is usually bilateral. b. Unilateral inversion of a nipple is always a serious sign. c. Whether the inversion is a recent change should be determined. d. Nipple inversion is not significant unless accompanied by an underlying palpable mass.

24. The nurse notices that an infant has a large, soft lump on the side of his head and that his mother is very concerned. The mother tells the nurse that she noticed the lump approximately 8 hours after her baby's birth and that it seems to be getting bigger. What is a possible explanation for this? a. Hydrocephalus b. Craniosynostosis c. Cephalhematoma d. Caput succedaneum

26. A 70-year-old woman who loves to garden has small, flat, brown macules over her arms and hands. She asks, "What causes these liver spots?" Which is the best response by the nurse? a. "They are signs of decreased hematocrit r/t anemia." b. "Those are due to the destruction of melanin in your skin from exposure to the sun." c. "They are clusters of melanocytes that appear after extensive exposure to sunlight." d. "Those are areas of hyperpigmentation r/t decreased perfusion and vasoconstriction"

35. During an examination of a patient in her third trimester of pregnancy, the nurse notices that the patient's thyroid gland is slightly enlarged. No enlargement had been previously noticed. What does the nurse suspect? a. An iodine deficiency b. Early signs of goiter c. A normal enlargement of the thyroid gland during pregnancy d. Possible thyroid cancer and the need for further evaluation

29. During an examination of a female patient, the nurse notes lymphadenopathy and suspects an acute infection. How do acutely infected lymph nodes typically appear? a. Clumped b. Unilateral c. Firm but freely movable d. Soft and nontender

3. In performing an assessment of a woman's axillary lymph system, the nurse should assess which of these nodes? a. Central, axillary, lateral, and sternal b. Pectoral, lateral, anterior, and sternal c. Central, lateral, pectoral, and subscapular d. Lateral, pectoral, axillary, and suprascapular

30. A physician has diagnosed a patient with purpura. After leaving the room, a nursing student asks the nurse what the physician saw that led to that diagnosis. What is the best response by the nurse? a. "Blue dilation of blood vessels in a star-shaped linear pattern on the legs." b. "Fiery red, star-shaped marking on the cheek that has a solid circular center." c. "Confluent and extensive patch of petechiae and ecchymoses on the feet." d. "Tiny areas of hemorrhage that are less than 2 mm, round, discrete, and dark red in color."

30. The nurse is conducting a class on BSE. Which of these statements indicates the proper BSE technique? a. The best time to perform BSE is in the middle of the menstrual cycle. b. A woman should perform BSEs bimonthly unless she has fibrocystic breast tissue. c. The best time to perform a BSE is 4 to 7 days after the first day of the menstrual period. d. If she suspects that she is pregnant, then the woman should not perform a BSE until after her baby is born

30. The physician reports that a patient with a neck tumor has a tracheal shift. The nurse should understand that what is occurring to the patient's trachea? a. Pushed downward b. Pulled to the affected side c. Pushed to the unaffected side d. Pulled downward in a rhythmic pattern

33. While performing a well-child assessment on a 5 year old, the nurse notes the presence of palpable, bilateral, cervical, and inguinal lymph nodes. They are approximately 0.5 cm in size, round, mobile, and nontender. What do these findings lead the nurse to conclude? a. The child has chronic allergies. b. The child likely has an infection. c. These are normal findings for a well child of this age. d. These findings indicate a need for additional evaluation.

38. During an examination of a 3-year-old child, the nurse notices a bruit over the left temporal area. What should the nurse do? a. Check for the bruit again in 1 hour. b. Stop the examination, and notify the physician. c. Continue the examination because a bruit is a normal finding for this age. d. Notify the parents that a bruit has been detected in their child and requires further evaluation.

4. A newborn infant is in the clinic for a well-baby checkup. The nurse observes the infant for the possibility of fluid loss because of which of these factors? a. Subcutaneous fat deposits are high in the newborn. b. Sebaceous glands are overproductive in the newborn. c. The newborn's skin is more permeable than that of the adult. d. The amount of vernix caseosa dramatically rises in the newborn.

4. A patient is unable to differentiate between sharp and dull stimulation to both sides of her face. What does the nurse suspect? a. Bell palsy b. Scleroderma c. Damage to the trigeminal nerve d. Frostbite with resultant paresthesia to the cheeks

42. A few days after a summer hiking trip, a 25-year-old man comes to the clinic with a rash. On examination, the nurse notes that the rash is red, macular, with a bull's eye pattern across his midriff and behind his knees. What does the nurse suspect? a. Eczema b. Rubeola c. Lyme disease d. Medication allergy

43. A 52-year-old woman has a papule on her nose that has rounded, pearly borders and a central red ulcer. She said she first noticed it several months ago and that it has slowly grown larger. The nurse suspects which condition? a. Acne b. Melanoma c. Basal cell carcinoma d. Squamous cell carcinoma

6. A patient comes to the clinic complaining of neck and shoulder pain and is unable to turn her head. Which nerve does the nurse suspect is damaged and how should the nurse proceed with the examination? a. XII; assess for a positive Romberg sign. b. XI; palpate the anterior and posterior triangles. c. XI; have patient shrug their shoulders against resistance. d. XII; percuss the sternomastoid and submandibular neck muscles.

6. A patient contacts the office and tells the nurse that she is worried about her 10-year-old daughter having breast cancer. She describes a unilateral enlargement of the right breast with associated tenderness. She is worried because the left breast is not enlarged. Which response by the nurse to the mother is best? a. "Breast development is usually fairly symmetric your daughter should be examined right away." b. "You should bring in your daughter right away because breast cancer is fairly common in preadolescent girls." c. "Although an examination of your daughter would rule out a problem, her breast development is most likely normal." d. "It is unusual for breasts that are first developing to feel tender because they haven't developed much fibrous tissue

8. A woman is in the family planning clinic seeking birth control information. She states that her breasts "change all month long" and that she is worried that this is unusual. What is the best response by the nurse? a. "Continual changes in your breasts are unusual. The breasts of nonpregnant women usually stay pretty much the same all month long." b. "Breast changes in response to stress are very common and you should assess your life for stressful events." c. "Because of the changing hormones during the monthly menstrual cycle, cyclic breast changes are common." d. "Breast changes normally occur only during pregnancy. You should get a pregnancy test done as soon as possible

A 60-year-old man is at the clinic for an eye examination. The nurse suspects that he has ptosis of one eye. How should the nurse check for this? a. Perform the confrontation test. b. Assess the individual's near vision. c. Observe the distance between the palpebral fissures. d. Perform the corneal light test, and look for symmetry of the light reflex.

A 70-year-old patient tells the nurse that he has noticed that he is having trouble hearing, especially in large groups. He says "I can't always tell where the sound is coming from" and that the words often sound "mixed up." What might the nurse suspect as the cause for this change? a. Atrophy of the apocrine glands b. Cilia becoming coarse and stiff c. Nerve degeneration in the inner ear d. Scar tissue in the tympanic membrane

A 92-year-old patient has had a stroke. The right side of his face is drooping. The nurse might also suspect which of these assessment findings? a. Epistaxis b. Rhinorrhea c. Dysphagia d. Xerostomia

A mother asks when her newborn infant's eyesight will be developed. What is the best response by the nurse? a. "Vision is not totally developed until 2 years of age." b. "Infants develop the ability to focus on an object at approximately 8 months of age." c. "By approximately 3 months of age, infants develop more coordinated eye movements and can fixate on an object." d. "Most infants have uncoordinated eye movements for the first year of life."

A patient has been identified as having a sensorineural hearing loss. What would be important for the nurse to do during the assessment of this patient? a. Speak loudly so the patient can hear the questions. b. Assess for middle ear infection as a possible cause. c. Ask the patient what medications he is currently taking. d. Look for the source of the obstruction in the external ear.

A patient with a middle ear infection asks the nurse, "What does the middle ear do?" Which is the best response by the nurse? a. It helps maintain balance. b. It interprets sounds as they enter the ear. c. It conducts vibrations of sounds to the inner ear. d. It increases the amplitude of sound for the inner ear to function.

During an assessment of a 20-year-old Asian patient, the nurse notices that he has dry, flaky, white cerumen in his canal. What is the significance of this finding? a. It represents poor hygiene. b. It is probably the result of lesions from eczema in his ear. c. It is a normal finding, and no further follow-up is necessary. d. It could be indicative of change in cilia; the nurse should assess for hearing loss.

During an examination of a 7-year-old girl, the nurse notices that the girl is showing breast budding. What should the nurse do next? a. Nothing; breast budding is a normal finding. b. Ask the young girl if her periods have started. c. Assess the girl's weight and body mass index (BMI). d. Ask the girl's mother at what age she started to develop breasts.

During an examination of the eye, the nurse would expect what normal finding when assessing the lacrimal apparatus? a. Presence of tears along the inner canthus b. Blocked nasolacrimal duct in a newborn infant c. Absence of drainage from the puncta when pressing against the inner orbital rim d. Slight swelling over the upper lid and along the bony orbit if the individual has a cold

During an examination, the nurse notices that the patient stumbles a little while walking, and, when she sits down, she holds on to the sides of the chair. The patient states, "It feels like the room is spinning!" What do this signs and symptoms indicate? a. Tinnitus b. Dizziness c. Objective vertigo d. Subjective vertigo

During an examination, the patient states he is hearing a buzzing sound and says that it is "driving me crazy!" What does this indicate? a. Vertigo b. Pruritus c. Tinnitus d. Cholesteatoma

During an interview, the patient states he has the sensation that "everything around him is spinning." What part of the ear should the nurse recognize is responsible for this sensation? a. Cochlea b. CN VIII c. Labyrinth d. Organ of Corti

In a patient who has anisocoria, what would the nurse expect to observe? a. Dilated pupils b. Excessive tearing c. Pupils of unequal size d. Uneven curvature of the lens

In examining a 70-year-old male patient, the nurse notices that he has bilateral gynecomastia. Which of the following describes the nurse's best course of action? a. Recommend that he make an appointment with his physician for a mammogram. b. Acknowledge it as benign breast enlargement which is not unusual in men. c. Explain that this condition may be the result of hormonal changes, and recommend that he see his physician. d. Explain that gynecomastia in men is usually associated with prostate enlargement and recommend that he be thoroughly screened.

In using the ophthalmoscope to assess a patient's eyes, the nurse notices a red glow in the patient's pupils. Based on this finding, what should the nurse do? a. Suspect that an opacity is present in the lens or cornea. b. Check the light source of the ophthalmoscope to verify that it is functioning. c. Consider the red glow a normal reflection of the ophthalmoscope light off the inner retina. d. Continue with the ophthalmoscopic examination, and refer the patient for further evaluation.

The nurse assesses the hearing of a 7-month-old by clapping hands. What is the expected response? a. The infant shows no obvious response to the noise. b. The infant shows a startle and acoustic blink reflex. c. The infant turns his or her head to localize the sound. d. The infant stops any movement, and appears to listen for the sound.

The nurse is assessing a 16-year-old patient who has suffered head injuries from a recent motor vehicle accident. Which of these statements indicates the most important reason for assessing for any drainage from the ear canal? a. The auditory canal may be occluded from increased cerumen. b. If the drum has ruptured, then purulent drainage will result. c. Bloody or clear watery drainage can indicate a basal skull fracture. d. Foreign bodies from the accident may cause occlusion of the ear cana

The nurse is assessing a patient in the hospital who has received numerous antibiotics for a lung infection and notices that his tongue appears to be black and hairy. In response to his concern, what would the nurse say? a. "We will need to get a biopsy to determine the cause." b. "This is an overgrowth of hair and will go away in a few days." c. "Black, hairy tongue is a fungal infection caused by all the antibiotics you have received." d. "This is probably caused by the same bacteria you had in your lungs."

The nurse is assessing an 80-year-old patient. Which of these findings would be expected for this patient? a. Hypertrophy of the gums b. Increased production of saliva c. Decreased ability to identify odors d. Finer and less prominent nasal hair

The nurse is performing an assessment on a 21-year-old patient and notices that his nasal mucosa appears pale, gray, and swollen. What would be the most appropriate question to ask the patient? a. "Have you had any symptoms of a cold?" b. "Do you have an elevated temperature?" c. "Are you aware of having any allergies?" d. "Have you been having frequent nosebleeds?"

The nurse is performing an assessment on a 65-year-old man. He reports a crusty nodule behind the pinna. It intermittently bleeds and has not healed over the past 6 months. On physical assessment, the nurse finds an ulcerated crusted nodule with an indurated base. Based on these findings, what does the nurse suspect? a. Most likely a keloid b. Probably a benign sebaceous cyst c. Could be a potential carcinoma, and the patient should be referred for a biopsy d. A tophus, which is common in the older adult and is a sign of gout

The nurse is performing an otoscopic examination on an adult. Which of these actions is correct? a. Tilt the person's head forward during the examination. b. Once the speculum is in the ear, releasing the traction. c. Pulling the pinna up and back before inserting the speculum. d. Using the smallest speculum to decrease the amount of discomfort.

The nurse is preparing to assess the visual acuity of a 16-year-old patient. How should the nurse proceed? a. Perform the confrontation test. b. Ask the patient to read the print on a handheld Jaeger card. c. Use the Snellen chart positioned 20 feet away from the patient. d. Determine the patient's ability to read newsprint at a distance of 12 to 14 inches.

The nurse is preparing to perform an otoscopic examination of a newborn infant. Which statement is true regarding this examination? a. An injected membrane may indicate an infection. b. The eardrum will appear in the oblique position. c. The normal membrane may appear thick and opaque. d. The appearance of the membrane is identical to that of an adult

The nurse is reviewing the function of the cranial nerves (CNs). Which CN is responsible for conducting nerve impulses to the brain from the organ of Corti? a. I b. III c. VIII d. XI

The nurse is testing a patient's visual accommodation. How is accommodation assessed? a. Pupillary dilation when looking at a distant object b. Involuntary blinking in the presence of bright light c. Pupillary constriction when looking at a near object d. Changes in peripheral vision in response to bright light

The nurse notices the presence of periorbital edema when performing an eye assessment on a 70-year-old patient. What should the nurse do next? a. Check for the presence of exophthalmos. b. Suspect that the patient has hyperthyroidism. c. Ask the patient if he or she has a history of heart failure. d. Assess for blepharitis, which is often associated with periorbital edema.

What are the projections in the nasal cavity that increase the surface area are called? a. Meatus b. Septum c. Turbinates d. Kiesselbach plexus

When assessing the pupillary light reflex, the nurse should use which technique? a. Shine a penlight from directly in front of the patient, and inspect for pupillary constriction. b. Ask the patient to follow the penlight in eight directions, and observe for bilateral pupil constriction. c. Shine a light across the pupil from the side, and observe for direct and consensual pupillary constriction. d. Ask the patient to focus on a distant object. Then ask the patient to follow the penlight to approximately 7 cm from the nose.

While performing the otoscopic examination of a 3-year-old boy who has been pulling on his left ear, the nurse finds that his left tympanic membrane is bright red and that the light reflex is not visible. What do these findings indicate? a. Cholesteatoma b. A fungal infection c. An acute otitis media d. A perforation of the eardrum

11. The nurse is explaining to a student nurse the four areas in the body where lymph nodes are accessible. Which areas should the nurse include in her explanation to the student? a. Head, breasts, groin, and abdomen b. Arms, breasts, inguinal area, and legs c. Head and neck, arms, breasts, and axillae d. Head and neck, arms, inguinal area, and axillae

1. The nurse educator is preparing an education module on skin, hair, and nails for the nursing staff. Which of these statements about the epidermal layer of the skin should be included in the module? a. Highly vascular b. Thick and tough c. Thin and nonstratified d. Replaced every 4 weeks

10. The nurse notices that a patient's submental lymph nodes are enlarged. In an effort to identify the cause of the node enlargement, what should the nurse assess? a. Infraclavicular area b. Supraclavicular area c. Area distal to the enlarged node d. Area proximal to the enlarged node

15. A patient complains that while studying for an examination he began to notice a severe headache in the frontotemporal area of his head that is throbbing and is somewhat relieved when he lies down. He tells the nurse that his mother also had these headaches. What should the nurse suspect? a. Hypertension b. Cluster headaches c. Tension headaches D. Migraine headaches

16. A 19-year-old college student is brought to the emergency department with a severe headache he describes as, "Like nothing I've ever had before." His temperature is 40° C, and he has a stiff neck. The nurse looks for other signs and symptoms of which problem? a. Head injury b. Cluster headache c. Migraine headache d. Meningeal inflammation

16. During a health history interview, a female patient states that she has noticed a few drops of clear discharge from her right nipple. What should the nurse do next? a. Ask her if she is possibly pregnant. b. Immediately contact the physician to report the discharge. c. Immediately obtain a sample for culture and sensitivity testing. d. Ask the patient some additional questions about the medications she is taking.

17. A patient comes to the clinic and states that he has noticed that his skin is redder than normal. The nurse understands that this condition is erythema. What is the likely cause? a. Decreased amounts of bilirubin in the blood b. Excess blood in the underlying blood vessels c. Decreased perfusion to the surrounding tissues d. Excess blood in the dilated superficial capillaries

18. A 32-year-old woman is at the clinic for "little white bumps in my mouth." During the assessment, the nurse notes that she has a 0.5-cm white, nontender papule under her tongue and one on the mucosa of her right cheek. What would the nurse tell the patient? a. "These spots indicate an infection such as strep throat." b. "These bumps could be indicative of a serious lesion, so I will refer you to a specialist" c. "This condition is called leukoplakia and can be caused by chronic irritation such as with smoking." d. "These bumps are Fordyce granules, which are sebaceous cysts and are not a serious condition"

2. A mother brings her 2-month-old daughter in for an examination and says, "My daughter rolled over against the wall, and now I have noticed that she has this spot that is soft on the top of her head. Is something terribly wrong?" How should the nurse respond? a. "Perhaps that could be a result of your dietary intake during pregnancy." b. "Your baby may have craniosynostosis, a disease of the sutures of the skull." c. "That 'soft spot' may be an indication of cretinism or congenital hypothyroidism." d. "That 'soft spot' is normal, and actually allows for growth of the brain during the first year of your baby's life"

2. The nurse educator is preparing an education module on skin, hair, and nails for the nursing staff. Which of these statements about the dermal layer of the skin should be included in the module? a. Contains mostly fat cells b. Consists mostly of keratin c. Is replaced every 4 weeks d. Contains sensory receptors

20. During an interview, a patient reveals that she is pregnant. She states that she is not sure whether she will breastfeed her baby and asks for some information about this. Which of these statements by the nurse is accurate? a. "Breastfed babies tend to be more colicky." b. "Breastfed babies eat more often than infants on formula." c. "Breastfeeding is second nature, and every woman can do it." d. "Breastfeeding provides the perfect food and antibodies for your baby

21. The nurse is reviewing risk factors for breast cancer. Which of these women have risk factors that place them at a higher risk for breast cancer? a. 37-year-old who is slightly overweight b. 42-year-old who has had ovarian cancer c. 45-year-old who has never been pregnant d. 66-year-old whose mother had breast cancer

22. A 65-year-old man with emphysema and bronchitis has come to the clinic for a follow-up appointment. On assessment, the nurse might expect to see which finding? a. Anasarca b. Scleroderma c. Pedal erythema d. Clubbing of the nails

23. A newborn infant has Down syndrome. During the skin assessment, the nurse notices a transient mottling in the trunk and extremities in response to the cool temperature in the examination room. The infant's mother also notices the mottling and asks what it is. What should the nurse tell the mother that this mottling is called? a. Carotenemia b. Acrocyanosis c. Café au lait d. Cutis marmorata

25. A pregnant woman states that she is concerned about her gums because she has noticed they are swollen and have started to bleed. What would be an appropriate response by the nurse? a. "Your condition is probably due to a vitamin C deficiency." b. "I'm not sure what causes swollen and bleeding gums, but let me know if it's not better in a few weeks." c. "You need to make an appointment with your dentist as soon as possible to have this checked." d. "Swollen and bleeding gums can be caused by a change in hormonal balance during pregnancy."

25. During an admission assessment, the nurse notices that a male patient has an enlarged and rather thick skull. The nurse suspects acromegaly. What additional finding would the nurse assess for to confirm this suspicion? a. Exophthalmos b. Bowed long bones c. Acorn-shaped cranium d. Coarse facial features

25. The nurse is performing a breast examination. Which of these statements best describes the correct procedure to use when screening for nipple and skin retraction during a breast examination? a. Have the patient bend over and touch her toes. b. Have the patient lie down on her left side and observe for any retraction. c. Have the patient shift from a supine position to a standing position, and note any lag or retraction. d. Have the patient slowly lift her arms above her head, and note any retraction or lag in movement

27. A patient visits the clinic because he has recently noticed that the left side of his mouth is paralyzed. He states that he cannot whistle but the nurse notes he can still raise his eyebrows. What does the nurse suspect? a. Bell palsy b. Cushing syndrome c. Parkinson syndrome d. Experienced a cerebrovascular accident (CVA) or stroke

27. The nurse notices that a patient has a solid, elevated, circumscribed lesion that is less than 1 cm in diameter. How should the nurse document this finding? a. A bulla b. A wheal c. A nodule d. A papule

27. Which of these clinical situations would the nurse consider to be outside normal limits? a. A patient has had one pregnancy and states that she believes she may be entering menopause. Her breast examination reveals breasts that are soft and slightly sagging. b. A patient has never been pregnant. Her breast examination reveals large pendulous breasts that have a firm, transverse ridge along the lower quadrant in both breasts. c. A patient has never been pregnant and reports that she should begin her period tomorrow. Her breast examination reveals breast tissue that is nodular and somewhat engorged. She states that the examination was slightly painful. d. A patient has had two pregnancies, and she breastfed both of her children. Her youngest child is now 10 years old. Her breast examination reveals breast tissue that is somewhat soft, and she has a small amount of thick yellow discharge from both nipples.

28. The nurse is assessing a patient with a history of intravenous drug abuse. In assessing his mouth, the nurse notices a dark red confluent macule on the hard palate. This could be an early sign of what disease or disorder? a. Measles b. Leukemia c. A carcinoma d. Acquired immunodeficiency syndrome (AIDS)

29. A mother brings her 4-month-old infant to the clinic with concerns regarding a small pad in the middle of the upper lip that has been there since 1 month of age. The infant has no health problems. On physical examination, the nurse notices a 0.5-cm, fleshy, elevated area in the middle of the upper lip. No evidence of inflammation or drainage is observed. What would the nurse tell this mother? a. "This area of irritation is caused from teething and is nothing to worry about." b. "This finding is abnormal and should be evaluated by another health care provider." c. "This area of irritation is the result of chronic drooling and should resolve within the next month or two." d. "This elevated area is a sucking tubercle caused from the friction of breastfeeding or bottle-feeding and is normal."

29. A patient has had a "terrible itch" for several months that he has been continuously scratching. What might the nurse expect to find upon physical examination? a. A keloid b. A fissure c. Keratosis D. Lichenification

32. The nurse notices that a school-aged child has bluish-white, red-based spots in her mouth that are elevated approximately 1 to 3 mm. What other signs would the nurse expect to find in this patient? a. Pink, papular rash on the face and neck b. Pruritic vesicles over her trunk and neck c. Hyperpigmentation on the chest, abdomen, and back of the arms d. Red-purple, maculopapular, blotchy rash behind the ears and on the face

33. The nurse is assessing the skin of a patient who has acquired immunodeficiency syndrome (AIDS) and notices multiple patchlike lesions on the temple and beard area that are faint pink in color. What does the nurse suspect? a. Angiomas b. Herpes zoster c. Measles (rubeola) d. Kaposi's sarcoma

35. A mother brings her 10-year-old daughter into the clinic for an examination of the scalp and hair. She states that the child has developed irregularly shaped patches with broken-off, stublike hair in some places; she is worried that this condition could be some form of premature baldness. What is the best response by the nurse? a. "This looks like folliculitis which can be treated with an antibiotic." b. "This sounds like traumatic alopecia which can be treated with antifungal medications." c. "This appears to be tinea capitis which is highly contagious and needs immediate attention." d. "This appears to be trichotillomania. Does your daughter have a habit of absentmindedly twirling her hair?"

35. A patient has been diagnosed with strep throat. The nurse is aware that without treatment, which complication may occur? a. Rubella b. Leukoplakia c. Scarlet fever d. Rheumatic fever

36. During a checkup, a 22-year-old woman tells the nurse that she uses an over-the-counter nasal spray because of her allergies. She also states that it does not work as well as it used to when she first started using it. Which is the best response by the nurse? a. "You should never use over-the-counter nasal sprays because of the risk for addiction." b. "You should try switching to another brand of medication to prevent this problem." c. "Continuing to use this spray is important to keep your allergies under control." d. "Frequent use of these nasal medications irritates the lining of the nose and may cause rebound swelling."

38. A patient comes into the clinic complaining of facial pain, fever, and malaise. On examination, the nurse notes swollen turbinates and purulent discharge from the nose. The patient also complains of a dull, throbbing pain in his cheeks and teeth on the right side and pain when the nurse palpates the areas. What do these findings indicate? a. Nasal polyps b. Frontal sinusitis c. Posterior epistaxis d. Maxillary sinusitis

39. A woman who is in the second trimester of pregnancy mentions that she has had "more nosebleeds than ever" since she became pregnant. What is the likely reason for this? a. Inappropriate use of nasal sprays b. A problem with the patient's coagulation system c. Increased susceptibility to colds and nasal irritation d. Increased vascularity in the upper respiratory tract as a result of the pregnancy

39. During an examination, the nurse finds that a patient's left temporal artery is tortuous and feels hardened and tender, compared with the right temporal artery. The nurse suspects which condition? a. Bell palsy b. Crepitation c. Mastoiditis d. Temporal arteritis

39. The nurse is assessing for clubbing of the fingernails. Which is the best description of clubbing? a. Nail bases that are firm and slightly tender b. Curved nails with a convex profile and ridges across the nails c. Nail bases that feel spongy with an angle of the nail base of 150 degrees d. Nail bases with an angle of 180 degrees or greater and nail bases that feel spongy

44. A father brings in his 2-month-old infant to the clinic because the infant has had diarrhea for the last 24 hours. He says his baby has not been able to keep any formula down and that the diarrhea has been at least every 2 hours. The nurse suspects dehydration. Where should the nurse test for skin mobility and turgor? a. Over the sternum b. On the forehead c. On the forearms d. Over the abdomen

45. A semiconscious woman is brought to the emergency department after she was found on the floor in her kitchen. Her face, nail beds, lips, and oral mucosa are a bright cherry-red color. What should the nurse suspect is the likely cause of these findings? a. Uremia b. Carotenemia c. Polycythemia d. Carbon monoxide poisoning

5. A 9-year-old girl is in the clinic for a sport physical examination. After some initial shyness she finally asks, "Am I normal? I don't seem to need a bra yet, but I have some friends who do. What if I never get breasts?" Which response by the nurse is best? a. "Don't worry, you still have plenty of time to develop." b. "I know just how you feel, I was a late bloomer myself. Just be patient, and they will grow." c. "You will probably get your periods before you notice any significant growth in your breasts." d. "I understand that it is hard to feel different from your friends. Breasts usually develop between 8 and 10 years of age."

5. The nurse is bathing an 80-year-old man and notices that his skin is wrinkled, thin, lax, and dry. This finding would be r/t which factor in the older adult? a. Increased vascularity of the skin b. Increased numbers of sweat and sebaceous glands c. An increase in elastin and a decrease in subcutaneous fat d. An increased loss of elastin and a decrease in subcutaneous fat

6. During the aging process, the hair can look gray or white and begin to feel thin and fine. What should the nurse understand causes this? a. Increased adipose tissue b. Increase in the vascularity of the scalp c. Decrease in the number of functioning phagocytes d. Decrease in the number of functioning melanocytes

A 14-year-old girl is anxious about not having reached menarche. When taking the health history, the nurse should ascertain which of the following? a. The age her mother developed breasts b. The age she began to develop pubic hair c. The age she began developing axillary hair d. The age the girl began to develop breasts

A 31-year-old patient tells the nurse that he has noticed pain in his left ear when people speak loudly to him. What does this finding indicate? a. A cerumen impaction b. Normal for people of his age c. Possible middle ear infection d. A characteristic of recruitment

A 52-year-old patient describes the presence of occasional floaters or spots moving in front of his eyes. How should the nurse proceed? a. Examine the retina to determine the number of floaters. b. Presume the patient has glaucoma and refer him for further testing. c. Consider these to be abnormal findings, and refer him to an ophthalmologist. d. Understand that floaters are usually insignificant and are caused by condensed vitreous fibers.

A 65-year-old patient remarks that she just cannot believe that her breasts "sag so much." She states it must be from a lack of exercise. What explanation should the nurse offer her? a. After menopause, only women with large breasts experience sagging. b. After menopause, sagging is usually due to decreased muscle mass within the breast. c. After menopause, a diet that is high in protein will help maintain muscle mass, which keeps the breasts from sagging. d. After menopause, the glandular and fat tissue atrophies, causing breast size and elasticity to diminish, resulting in breasts that sag.

A 72-year-old patient has a history of hypertension and chronic lung disease. Which is an important question for the nurse to include in this patient's health history? a. "Do you use a fluoride supplement?" b. "Have you had tonsillitis in the last year?" c. "At what age did you get your first tooth?" d. "Have you noticed any dryness in your mouth?"

A patient comes into the emergency department after an accident at work. A machine blew dust into his eyes, and he was not wearing safety glasses. The nurse examines his corneas by shining a light from the side across the cornea. What findings would suggest that he has suffered a corneal abrasion? a. Smooth and clear corneas b. Opacity of the lens behind the cornea c. Bleeding from the areas across the cornea d. Shattered look to the light rays reflecting off the cornea

A patient comes to the emergency department after a boxing match, and his O.S. is almost swollen shut. He has bruises on his face and neck. He says he is worried because he "can't see well" from his O.S. The physician suspects retinal detachment. What finding would support this suspicion? a. Loss of central vision b. Loss of peripheral vision c. Sudden loss of pupillary constriction and accommodation d. Shadow or diminished vision in one quadrant or one half of the visual field

A patient is unable to read even the largest letters on the Snellen chart. The nurse should take which action next? a. Refer the patient to an ophthalmologist or optometrist for further evaluation. b. Assess whether the patient can count the nurse's fingers when they are placed in front of his or her eyes. c. Ask the patient to put on his or her reading glasses and attempt to read the Snellen chart again. d. Shorten the distance between the patient and the chart until the letters are seen, and record that distance.

An assessment of a 23-year-old patient reveals the following: an auricle that is tender and reddish-blue in color with small vesicles. The nurse would need to know additional information that includes which of these? a. Any change in ability to hear b. Any recent drainage from the ear c. Recent history of trauma to the ear d. Any prolonged exposure to extreme cold

An ophthalmic examination reveals papilledema. What does this finding indicate? a. Retinal detachment b. Diabetic retinopathy c. Acute-angle glaucoma d. Increased intracranial pressure

During an otoscopic examination, the nurse notices an area of black and white dots on the tympanic membrane and the ear canal wall. What does this finding suggest? a. Malignancy b. Viral infection c. Blood in the middle ear d. Yeast or fungal infection

How should the nurse perform an examination of a 2-year-old child with a suspected ear infection? a. Pull the ear up and back before inserting the speculum. b. Omit the otoscopic examination if the child has a fever. c. Ask the mother to leave the room while examining the child. d. Perform the otoscopic examination at the end of the assessment

In an individual with otitis externa, which of these signs would the nurse expect to find on assessment? a. Rhinorrhea b. Periorbital edema c. Pain over the maxillary sinuses d. Enlarged superficial cervical nodes

MSC: Client Needs: Physiological Integrity: Physiological Adaptation 20. An older adult woman is brought to the emergency department after being found lying on the kitchen floor for 2 days; she is extremely dehydrated. What would the nurse expect to see during the examination? a. Pale mucous membranes b. Smooth mucous membranes and lips c. White patches on the mucous membranes d. Dry mucous membranes and cracked lips

The mother of a 2-year-old is concerned because her son has had three ear infections in the past year. What would be an appropriate response by the nurse? a. "It is unusual for a small child to have frequent ear infections unless something else is wrong." b. "We need to check the immune system of your son to determine why he is having so many ear infections." c. "Ear infections are not uncommon in infants and toddlers because they tend to have more cerumen in the external ear." d. "Your son's eustachian tube is shorter and wider than yours because of his age, which allows for infections to develop more easily."

The mother of a 2-year-old toddler is concerned about the upcoming placement of tympanostomy tubes in her son's ears. The nurse would include which of these statements in the teaching plan? a. The tubes are placed in the inner ear. b. The tubes are used in children with sensorineural loss. c. The tubes are permanently inserted during a surgical procedure. d. The purpose of the tubes is to decrease the pressure and allow for drainage

The nurse is assessing a patient's eyes for the accommodation response and would expect to see which normal finding? a. Dilation of the pupils b. Consensual light reflex c. Disconjugate movement of the eyes d. Convergence of the axes of the eyes

The nurse is assessing color vision of a male child. Which statement is correct? a. Color vision should be checked annually until the age of 18 years. b. Color vision screening should begin at the child's 2-year checkup. c. The nurse should ask the child to identify the color of his or her clothing. d. Testing for color vision should be done once between the ages of 4 and 8 years.

The nurse is conducting a child safety class for new mothers. Which factor places young children at risk for ear infections? a. Family history b. Air conditioning c. Excessive cerumen d. Passive cigarette smoke

The nurse is obtaining a health history on a 3-month-old infant. During the interview, the mother states, "I think she is getting her first tooth because she has started drooling a lot." What is the best response by the nurse? a. "You're right, drooling is usually a sign of the first tooth." b. "It would be unusual for a 3-month-old to be getting her first tooth." c. "This could be the sign of a problem with the salivary glands." d. "She is just starting to salivate and hasn't learned to swallow the saliva."

The nurse is performing an assessment. Which of these findings would cause the greatest concern? a. A painful vesicle inside the cheek for 2 days b. The presence of moist, nontender Stensen's ducts c. Stippled gingival margins that snugly adhere to the teeth d. An ulceration on the side of the tongue with rolled edges

The nurse is performing an eye-screening clinic at a daycare center. When examining a 2-year-old child, the nurse suspects that the child has a "lazy eye". What should the nurse do next? a. Examine the external structures of the eye. b. Assess visual acuity with the Snellen eye chart. c. Assess the child's visual fields with the confrontation test. d. Test for strabismus by performing the corneal light reflex test

The nurse is reviewing causes of increased intraocular pressure. Which of these factors determines intraocular pressure? a. Thickness or bulging of the lens b. Posterior chamber as it accommodates increased fluid c. Contraction of the ciliary body in response to the aqueous within the eye d. Amount of aqueous produced and resistance to its outflow at the angle of the anterior chamber

The nurse is reviewing the development of the newborn infant. Regarding the sinuses, which statement is true in relation to a newborn infant? a. Sphenoid sinuses are full size at birth. b. Maxillary sinuses reach full size after puberty. c. Frontal sinuses are fairly well developed at birth. d. Maxillary and ethmoid sinuses are the only sinuses present at birth.

The nurse is taking the history of a patient who may have a perforated eardrum. What would be an important question in this situation? a. "Do you ever notice ringing or crackling in your ears?" b. "When was the last time you had your hearing checked?" c. "Have you ever been told that you have any type of hearing loss?" d. "Is there any relationship between the ear pain and the discharge you mentioned?"

The nurse is teaching a pregnant woman about breast milk. Which statement by the nurse is correct? a. "Your breast milk is immediately present after the delivery of your baby." b. "Breast milk is rich in protein and sugars (lactose) but has very little fat." c. "The colostrum, which is present right after birth, does not contain the same nutrients as breast milk." d. "You may notice a thick, yellow fluid expressed from your breasts as early as the fourth month of pregnancy."

What is the nurse assessing for when he or she directs a light across the iris of a patient's eye from the temporal side? a. Drainage from dacryocystitis b. Presence of conjunctivitis over the iris c. Presence of shadows, which may indicate glaucoma d. Scattered light reflex, which may be indicative of cataracts

What is the tissue that connects the tongue to the floor of the mouth called? a. Uvula b. Palate c. Papillae d. Frenulum

When examining a patient's eyes, what should the nurse be aware that stimulation of the sympathetic branch of the autonomic nervous system causes? a. Pupillary constriction b. Adjusts the eye for near vision c. Causes contraction of the ciliary body d. Elevates the eyelid and dilates the pupil

When examining the nares of a 45-year-old patient who is experiencing rhinorrhea, itching of the nose and eyes, and sneezing, the nurse notices the following: pale turbinates, swelling of the turbinates, and clear rhinorrhea. Which of these conditions is most likely the cause? a. Nasal polyps b. Acute rhinitis c. Acute sinusitis d. Allergic rhinitis

While obtaining a health history from the mother of a 1-year-old child, the nurse notices that the baby has had a bottle in his mouth the entire time. The mother states, "It makes a great pacifier." What is the best response by the nurse? a. "You're right. Bottles make very good pacifiers." b. "Using a bottle as a pacifier is better for the teeth than thumb-sucking." c. "It's okay to use a bottle as long as it contains milk and not juice." d. "Prolonged use of a bottle can increase the risk for tooth decay and ear infections."

2. A patient has been admitted to a hospital after the staff in the nursing home noticed a pressure ulcer in his sacral area. The nurse examines the pressure ulcer and determines that it is a stage II ulcer. Which of these findings are characteristic of a stage II pressure ulcer? (Select all that apply.) a. Intact skin appears red but is not broken. b. Patches of eschar cover parts of the wound. c. Ulcer extends into the subcutaneous tissue. d. Open blister areas have a red-pink wound bed. e. Localized redness in light skin will blanch with fingertip pressure. f. Partial thickness skin erosion is observed with a loss of epidermis or dermis.

D,F

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