Health: Chapter 10: Head, Eyes, Ears, Nose, and Throat

Which patient in the eye clinic should the nurse assess first? a. The patient who reports a gradual clouding of vision b. The patient who complains of sudden loss of vision c. The patient who complains of double vision d. The patient who complains of poor night vision

Feedback A A gradual clouding of vision is a symptom of cataracts that develop slowly and do not require immediate assessment. B Sudden vision loss may indicate a detached retina and requires immediate referral. C Double vision is a symptom of cataracts that develop slowly and do not require immediate assessment. D Poor night vision is a symptom of cataracts that develop slowly and do not require immediate assessment.

Which finding on assessment of a patient's eyes should the nurse document as abnormal? a. An Asian American patient with an upward slant to the palpebral fissure b. A Caucasian American patient whose sclerae are visible between the upper and lower lids and the iris c. An African American patient who has off-white sclerae with tiny black dots of pigmentation near the limbus d. An American Indian patient whose pupillary diameters are 5 mm bilaterally

Feedback A An Asian American patient with an upward slant to the palpebral fissure has an expected racial variation. B A Caucasian American patient whose sclerae are visible between the upper and lower lids and the iris has eyeball protrusion beyond the supraorbital ridge, which indicates exophthalmos caused by hyperthyroidism. C An African American patient who has off-white sclerae with tiny black dots of pigmentation near the limbus has an expected racial variation. D An American Indian whose pupils are 5 mm bilaterally is an expected finding.

How does a nurse recognize a patient's mydriasis? a. The lens of each of the patient's eyes is opaque. b. There is involuntary rhythmical, horizontal movement of the patient's eyes. c. There is a white opaque ring encircling the patient's limbus. d. The patient's pupils are 7 mm and do not constrict.

Feedback A An opaque lens is an abnormality that occurs when cataracts are present. B An involuntary rhythmical, horizontal movement of the patient's eyes is a description of nystagmus. C A white opaque ring encircling the patient's limbus is a description of corneal arcus seen in patients older than 60 years of age. D Mydriasis is pupil size greater than 6 mm and the pupil fails to constrict.

A nurse examines a patient's auditory canal and tympanic membrane with an otoscope and observes which finding as normal? a. Clear fluid lining the auditory canal b. A firm tympanic membrane without fluctuation with puffs of air c. A small hole within the cone of light d. A shiny, translucent tympanic membrane

Feedback A Clear fluid or bloody drainage following a head injury may indicate a basilar skull fracture. B An expected response is that the tympanic membrane slightly fluctuates with puffs of air. C A cone of light is expected, but a hole indicates perforation. D A shiny, translucent tympanic membrane is an expected finding.

When inspecting a patient's eyes, the nurse assesses the presence of cranial nerve III (oculomotor nerve) by observing the eyelids open and close bilaterally. What other technique does a nurse use to test the function of this cranial nerve? a. Pupillary constriction to light b. Visual acuity c. Peripheral vision d. Presence of the red reflex

Feedback A Cranial nerve III (oculomotor) controls pupillary dilation and constriction, as well as eyelid movement. Pupil dilation and ptosis may occur when CN III is impaired. B Cranial nerve II (optic) provides vision. C Cranial nerve II (optic) provides peripheral vision. D The red reflex is not controlled by cranial nerve III, but is created by a light illuminating the retina.

A patient reports a history of snorting cocaine and is concerned about his bloody nasal drainage. What does the nurse expect to see on inspection of his nose? a. Deviated septum b. Pale turbinates c. Perforated nasal septum d. Localized erythema and edema

Feedback A Deviated septum may be from birth or trauma to the nose, but not from cocaine use. B Pale turbinates are an indication of allergies. C Perforated nasal septum develops from cocaine use. D Localized erythema and edema are nonspecific and indicate inflammation somewhere in the nose.

Which finding warrants a referral for additional evaluation? a. Earlobes hanging freely from the base of the pinna b. Ears having painless nodules less than 1 cm in diameter at the helix c. Ears measuring 8 cm in length d. Pinna is 20 degrees lower than the outer canthus of the eye

Feedback A Earlobes hanging freely from the base of the pinna is an expected finding. B This is called a Darwin tubercle. It is a normal deviation and may be noted at the helix of the ear. C A length of 8 cm is an expected finding. D The pinna of the ear should align directly with the outer canthus of the eye and be angled no more than 10 degrees from a vertical position.

During the history, a patient reports watery nasal drainage from allergies. Based on this information, what does the nurse expect to find on inspection of the nares? a. Enlarged and pale turbinates b. Polyps within the nares c. High vascularity of the turbinates d. Dry and dull turbinates

Feedback A Enlarged and pale turbinates are expected findings for allergic rhinitis. B Polyps within the nares is not an expected finding. C High vascularity of the turbinates is not an expected finding. D Dry and dull turbinates is not an expected finding.

A patient complains of nasal drainage and sinus headache. The nurse suspects a nasal infection and anticipates observing which finding during examination? a. Foul-smelling drainage b. Purulent green-yellow drainage c. Bloody drainage d. Watery drainage

Feedback A Foul-smelling drainage is consistent with a foreign object in the nose. B Purulent green-yellow drainage is consistent with a nasal or sinus infection. C Bloody drainage is consistent with trauma to the nose. D Watery drainage is consistent with a nasal allergy.

A patient complains of a lesion in his nose. Which technique does a nurse use to inspect the nasal mucosa? a. Inserts a nasal speculum horizontally into the patient's affected nares b. Inserts a nasal speculum obliquely into the patient's affected nares c. Uses a light source from the ophthalmoscope d. Inserts a nasal speculum vertically into the patient's affected nares

Feedback A Horizontal insertion puts pressure on the nasal septum, which is painful. B This is the appropriate technique for inspecting the nares. C The alternate light source is from an otoscope, rather than an ophthalmoscope. The otoscope has an ear speculum that can be used when a nasal speculum is unavailable. D Vertical insertion obstructs the nurse's view of the internal nares.

Which finding indicates that this patient has a sensorineural hearing loss? a. The patient hears sound by air conduction longer than by bone conduction. b. The patient hears sound from a vibrating tuning fork in the affected ear only. c. The patient hears normal conversation at 40 dB and a whisper at 20 dB. d. The patient hears the rubbing of fingers together from a distance of 4 inches from each ear.

Feedback A In the Rinne test, hearing sound from a vibrating tuning fork longer by air conduction than by bone conduction is consistent with a sensorineural hearing loss. B This finding from the Weber test is consistent with a conduction hearing loss. C This is an expected finding using audiometry. D This is an expected finding using the finger rubbing screening hearing test.

How does a nurse recognize normal accommodation? a. The patient has peripheral vision of 90 degrees left and right. b. The patient's eyes move up and down, side to side, and obliquely. c. The right pupil constricts when a light is shown in the left pupil. d. The patient's pupils dilate when looking toward a distant object.

Feedback A Normally a patient has 90 degrees peripheral vision temporally, but only 60 degrees nasally. B This is an expected finding, but is not a test for accommodation. It is a test of extraocular muscle function in the six cardinal fields of gaze. C This is an expected finding for consensual reaction, rather than accommodation. D This is an indication of accommodation.

What instructions does the nurse give the patient before using the Snellen visual acuity chart? a. "Remove your eyeglasses before attempting to read the lowest line." b. "Stand 10 feet from the chart and read the first line aloud." c. "Hold a white card over one eye and read the smallest possible line." d. "Squint if necessary to improve the ability to read the largest letters."

Feedback A Patients should wear their glasses when visual acuity is tested. B The patient should stand 20 feet from the Snellen chart. C This is the appropriate technique for using the Snellen chart. D The patient should not squint to see the chart.

A patient complains of right ear pain. What findings does the nurse anticipate on inspecting the patient's ears? a. Redness and edema of the pinna of the right ear b. Report of pain when the nurse manipulates the right ear c. Bulging and red tympanic membrane in the right ear d. Increased cerumen in the right ear canal

Feedback A Redness and edema of the pinna of the right ear is consistent with external ear pain that may be associated with otitis externa or swimmer's ear. B Report of pain when the nurse manipulates the right ear is consistent with external ear pain that may be associated with otitis externa or swimmer's ear. C Bulging and red tympanic membrane in the right ear is consistent with internal ear pain that may be associated with otitis media. D Increased cerumen in the right ear canal is not consistent with internal ear pain.

During the history, a patient reports blurred vision, seeing double at times, and a glare from headlights from oncoming cars at night. Based on this information, what finding does the nurse expect to find on assessment of this patient's eyes? a. Anterior chamber depth is shallow. b. Red reflex is absent. c. Extraocular muscle movement is asymmetric. d. Retinal arteries are wider than retinal veins.

Feedback A Shallow anterior chamber depth occurs in glaucoma. B The symptoms suggest cataracts. The red reflex cannot be seen because the light cannot penetrate the opacity of the lens. C Extraocular muscle movement is asymmetric. Cataracts affect the lens rather than the eye muscles. D Retinal arteries are wider than retinal veins. Cataracts affect the lens rather than the retinal vessels.

During an eye assessment, a nurse asks the patient to cover one eye with a card as the nurse covers his or her eye directly opposite the patient's covered eye. The nurse moves an object into the field of vision and asks the patient to tell when the object can be seen. This assessment technique collects what data about the patient's eyes? a. Symmetry of extraocular muscles b. Visual acuity in the uncovered eye c. Peripheral vision of the uncovered eye d. Consensual reaction of the uncovered eye

Feedback A Symmetry is tested by the corneal light reflex. B Visual acuity is tested using the Snellen chart. C This describes the confrontation test, which assesses peripheral vision. D Consensual reaction is tested by noticing the pupillary constriction of one eye when a light is being shown into the other eye.

When using an ophthalmoscope to examine the internal eye, how does the nurse distinguish the retinal arteries from the retinal veins? a. The arteries are narrower than veins. b. The arteries are a darker red than veins. c. The arteries have no light reflex and the veins have a narrow band of light in the center. d. The arteries have prominent pulsations and veins have no pulsations.

Feedback A The artery-to-vein width should be 2:3 to 4:5. B Arteries are lighter red than veins. C Arteries have a narrow band of light in the center and veins have no light reflex. D Arteries show little to no pulsations and venous pulsations may be visible.

A nurse shines a light toward the bridge of the patient's nose and notices that the light reflection in the right cornea is at the 2 o'clock position and in the left cornea at the 10 o'clock position. Based on these data, the nurse should take what action? a. Document these findings as normal. b. Perform the cover-uncover test. c. Perform the confrontation test. d. Document these findings as abnormal.

Feedback A The findings are abnormal. The light should appear in the same location in each cornea. B The nurse is performing the corneal light reflex test and the findings are abnormal. Thus, when the corneal light reflex is asymmetric, the cover-uncover test is performed to determine which eye has the weak extraocular muscle(s). C The confrontation test is used to assess peripheral visual fields and is not appropriate to perform when the corneal light reflex is asymmetric. D The asymmetric corneal light reflex is abnormal, but the cover-uncover test should follow the abnormal finding to determine which eye has the weak extraocular muscle(s).

Which cranial nerve is assessed by using the Snellen visual acuity chart? a. Optic cranial nerve (CN II) b. Oculomotor cranial nerve (CN III) c. Abducens cranial nerve (CN IV) d. Trochlear cranial nerve (CN VI)

Feedback A The optic cranial nerve (CN II) provides vision tested by the Snellen visual acuity chart. B CN III controls pupillary constriction, eyelid movement, and eyeball movement. C CN IV controls eyeball movement. D CN VI controls eyeball movement.

A patient complains of itching, swelling, and drainage from the eyes with a postnasal drip and sneezing. What type of nasal drainage does the nurse anticipate seeing during inspection of this patient's nares? a. Clear b. Malodorous c. Yellow d. Green

Feedback A The patient has allergic rhinitis, which produces clear drainage. B Malodorous drainage is associated with bacterial infection, which is not consistent with the history given by this patient. C Yellow drainage is associated with bacterial infection, which is not consistent with the history given by this patient. D Green drainage is associated with bacterial infection, which is not consistent with the history given by this patient.

A nurse shines a light toward the bridge of the patient's nose and notices that the light reflection in the right cornea is at the 9 o'clock position and in the left cornea at the 9 o'clock position. What is the interpretation of this finding? a. The extraocular muscles of both eyes are intact. b. The cornea of each eye is transparent. c. The sclera of each eye is clear. d. The consensual reaction of both eyes is intact.

Feedback A The reflection of the light in both eyes in the same location indicates muscles holding the eyes are symmetric. B The reflection of the light in both eyes in the same location indicates muscles holding the eyes are symmetric. C The reflection of the light in both eyes in the same location indicates muscles holding the eyes are symmetric. D Consensual reaction involves constriction of pupils.

A nurse is assessing a patient who was hit at the base of the skull with a blunt instrument causing a skull fracture. What assessment finding does this nurse anticipate during the inspection? a. Tinnitus, vertigo, and dizziness b. Clear drainage from the ear and nose c. Loss of hearing and smell d. Purulent drainage from the ear and bloody drainage from the nose

Feedback A These are subjective and gathered during the history rather than inspection. Although the patient may report having dizziness or vertigo, the finding of tinnitus is inconsistent with a basilar skull fracture. B This may occur after a basilar skull fracture. The clear drainage may be cerebrospinal fluid. C This is inconsistent with a basilar skull fracture. D Purulent drainage is inconsistent with a basilar skull fracture, and bloody drainage usually does not come from the nose, but may be seen from the ear.

A nurse assessing the hearing of a patient with presbycusis expects which finding on a test for hearing? a. Bone conduction will be longer than air conduction on the Rinne test (BC > AC). b. Air conduction will be longer than bone conduction on the Rinne test (AC > BC). c. Sound lateralizes to the affected ear on the Weber test. d. Sound lateralizes to both ears equally on the Weber test.

Feedback A This finding indicates a conduction hearing loss, rather than a sensorineural hearing loss. B This finding indicates a sensorineural health loss, the most common cause of presbycusis. C This finding indicates a conduction hearing loss, rather than a sensorineural hearing loss. D This is a normal finding on this test.

A nurse reads in the history that a patient has a new onset of acute otitis media. Based on this information, how does the nurse expect this patient's tympanic membrane to appear? a. Dull b. Shiny c. Red d. Blue to deep red

Feedback A This indicates fibrosis or scarring. B This is normal for the tympanic membrane. C This indicates infection in the middle ear, such as otitis media. D This indicates blood behind the tympanic membrane, which may have occurred secondary to injury.

A nurse shines a light in the right pupil to test constriction and notices that the left pupil constricts as well. Based on these data, the nurse should take what action? a. Document this finding as an abnormal finding. b. Assess the patient for accommodation. c. Document this finding as a consensual reaction. d. Assess the patient's corneal light reflex.

Feedback A This is a description of an expected finding—consensual reaction. B Accommodation is not assessed in response to consensual reaction; it tests the function of the oculomotor cranial nerve (CN III). C This is a description of expected consensual reaction. D This item describes a consensual reaction rather than a corneal light reflex.

During symptom analysis, the nurse helps the patient distinguish between dizziness and vertigo. Which description by the patient indicates vertigo? a. "I felt faint, like I was going to pass out." b. "I just could not keep my balance when I sat up." c. "It seemed that the room was spinning around." d. "I was afraid that I was going to lose consciousness."

Feedback A This is a description of lightheadedness, a form of dizziness. B This is a description of disequilibrium, a form of dizziness. C This is consistent with vertigo because it includes a sensation of motion. D This is a description of syncope, a form of dizziness.

During symptom analysis, the nurse helps the patient distinguish between dizziness and vertigo. Which description by the patient indicates dizziness? a. "I felt faint, like I was going to pass out." b. "It felt like I was on a merry-go-round." c. "The room seemed to be spinning around." d. "My body felt like it was revolving and could not stop."

Feedback A This is a description of lightheadedness, a form of dizziness. B This is consistent with objective vertigo because it includes a sensation of motion. C This is consistent with objective vertigo because it includes a sensation of motion. D This is consistent with subjective vertigo because it includes a sensation of one's body rotating in space.

During a Weber test, a patient with right ear hearing loss reports hearing sound longer in the right ear than the left ear. What results should the nurse expect to find from this patient during a Rinne test? a. Air conduction will be twice as long as bone conduction (2:1 ratio). b. Air conduction will be 1.5 times as long as bone conduction (1.5:1 ratio). c. Bone conduction will be longer than air conduction. d. Bone conduction will be equal to air conduction.

Feedback A This is an expected finding. B This finding is consistent with a sensorineural hearing loss, but this patient has a conduction hearing loss based on the results of the Weber test. C This finding from the Rinne test indicates a conduction hearing loss, which is consistent with the finding from the Weber test described in the question. D This finding is not consistent with the conductive hearing loss described.

A patient is being seen in the clinic for suspected nasal obstruction from a foreign body. The nurse recognizes which finding as most consistent with this diagnosis? a. Unilateral foul-smelling drainage b. Bilateral purulent green-yellow discharge c. Bilateral bloody discharge d. Unilateral watery discharge

Feedback A This is consistent with presence of a foreign object in one side of the nose. B This is consistent with a nasal or sinus infection. C This is consistent with localized trauma, such as a nasal fracture. D This is consistent with a history of head injury and may indicate skull fracture.

During an eye examination of an Asian patient, a nurse notices an involuntary rhythmical, horizontal movement of the patient's eyes. How does a nurse document this finding? a. An expected racial variation b. Nystagmus c. Exophthalmus d. Myopia

Feedback A This is not a racial variation. B An involuntary rhythmical, horizontal movement of the patient's eyes is a description of nystagmus. C Exophthalmus is the bulging of the eyeball forward, seen in patients with hyperthyroidism. D Myopia is an elongated eyeball found in patients who are nearsighted.

An adult patient comes to the clinic complaining of right ear pain. What technique does the nurse use to inspect this patient's auditory canal? a. Position the otoscope speculum 1.0 to 1.5 cm (about 0.5 inches) into the ear canal. b. Remove cerumen from each canal before inserting otoscope. c. Choose the smallest otoscope speculum that will fit the patient's ear comfortably. d. Pull the pinna slightly downward and backward before inserting the otoscope speculum.

Feedback A This is the correct technique. B Removing cerumen is not necessary. C The largest speculum that comfortably fits in the ear canal is the one that should be chosen. D For adults, the pinna is pulled up and backward to straighten the ear canal.

A nurse observes a student using the whisper test to screen a patient with hearing loss. Which behavior by the student requires a corrective comment from the nurse? a. Instructing the patient to cover the ear not being tested b. Standing beside the patient on the side of the ear being tested c. Shielding the mouth to prevent the patient from reading lips d. Whispering one or two syllable words and ask the patient to repeat what is heard

Feedback A This is the correct technique. B The student nurse should stand 1 to 2 feet in front or to the side of the patient. C This is the correct technique. D This is the correct technique.

During the Rinne test, a nurse determines that the patient hears the tuning fork held on the mastoid process for 15 seconds and hears the tuning fork held in front of the ear for 30 seconds. The same results are found in both ears. Based on this finding, what is the most appropriate response of the nurse? a. Repeat the test again using a 2000 Hz tuning fork. b. Tell the patient that this represents an expected finding. c. Refer the patient for additional testing to detect hearing abnormality. d. Perform a Weber test to confirm the findings of the Rinne test.

Feedback A This is unnecessary because the finding of the Rinne test was normal. B This is a normal finding. Air conduction (30 seconds) is twice as long as bone conduction (15 seconds). C This is unnecessary because the finding of the Rinne test was normal. D This is unnecessary because the finding of the Rinne test was normal.

On inspection of the external eye structures of an African American patient, the nurse notices the sclerae are not white, but appear a darker shade with tiny black dots of pigmentation near the limbus. How does the nurse document this finding? a. As an indication of a type of anemia b. As a hordeolum or sty c. As jaundice d. As an expected racial variation

Feedback A This may cause a pale conjunctiva. B This is an acute infection originating in the sebaceous gland of the eyelid. C Jaundice is a yellow color of the sclera associated with liver or gallbladder disease. D This as an expected racial variation.

What changes in using the ophthalmoscope should the nurse need to make when inspecting the eye of a patient who is nearsighted? a. Holding the ophthalmoscope in the right hand when inspecting the patient's right eye b. Using the grid light of the lens aperture to visualize the internal structures of the eye c. Rotating the diopter to the red (minus) numbers d. Asking the patient to look directly into the ophthalmoscope light

Feedback A This procedure is performed with all patients having an internal eye examination. B The grid is used to estimate the size of lesions. C This compensates for the longer eyeball of a myopic patient. D This is an instruction given to the patient to visualize the macula.

the nurse locate the optic disc? a. By rotating the diopter to the block (positive) numbers until the optic disc comes into focus b. By following the retinal vessels inward toward the nose until optic disc is seen c. By using the green beam light while looking outward toward the ear until the disc is seen d. By locating the macula and then looking temporally (toward the ear) until the disc is seen

Feedback A This procedure is used for patients who are myopic. B This procedure locates the optic disc. C The green beam is used to identify retinal hemorrhages. D The macula lies temporal to the optic disc; thus the optic disc is in the opposite direction.

While taking a history, the nurse observes that the patient's facial cranial nerves (CN VII) are intact based on which behaviors of the patient? a. The patient's eyes move to the left, right, up, down, and obliquely during conversation. b. The patient moistens the lips with the tongue. c. The sides of the mouth are symmetric when the patient smiles. d. The patient's eyelids blink periodically.

Feedback A This represents movement of the extraocular muscles, which are controlled by the oculomotor, trochlear, and abducens cranial nerves (CN III, IV, and VI, respectively). B This represents movement of the tongue, which is controlled by the hypoglossal cranial nerve (CN XII). C This represents facial symmetry, which is controlled by the facial cranial nerve (CN VII). D This represents function of the oculomotor cranial nerve (CN III).

How does the nurse perform a Weber test to assess hearing function? a. Whispers three to four words into the patient's ear and asks him to repeat the words heard b. Places a vibrating tuning fork in the middle of the head and asks the patient if the sound is heard the same in both ears c. Places a set of headphones over both ears, plays several tones, and asks the patient to identify the sounds d. Places a vibrating tuning fork on the mastoid process and asks the patient to signal when he can no longer hear the sound

Feedback A This technique describes the whisper test. B This technique describes the Weber test. C This technique describes the use of an audiometer. D This technique describes part of the Rinne test.

How does the nurse perform a Rinne test of hearing function? a. Whispers several words to the patient and requests that the patient repeat the words heard b. Places a vibrating tuning fork in the middle of the head and asks the patient if the sound is heard the same in both ears or if it is louder in one ear than the other c. Places a set of headphones over both ears, plays several tones, and asks the patient to identify the sounds d. Places a vibrating tuning fork on the mastoid process until the patient no longer hears it, and then moves it in front of the ear until the patient no longer hears it

Feedback A This technique describes the whisper test. B This technique describes the Weber test. C This technique describes the use of an audiometer. D This technique describes the Rinne test.

A nurse uses which technique to assess a patient's peripheral vision? a. The nurse asks the patient to keep the head still and by moving the eyes only, follow the nurse's finger as it moves side to side, up and down, and obliquely. b. The nurse covers one of the patient's eyes with a card and observes the uncovered eye for movement, then removes the card and observes the just uncovered eye for movement. c. With the patient and nurse facing each other and a card covering their corresponding eyes, the nurse moves an object into the visual field and the patient reports when the object is seen. d. The nurse shines a light on both corneas at the same time and notes the location of the reflection in each eye.

Feedback A This technique tests extraocular muscle symmetry. B This cover-uncover technique is performed when the corneal light reflex is asymmetric. C This is the confrontation test that tests peripheral vision. D This describes the corneal light reflex that tests the symmetry of the eye muscles.

How does a nurse assess movements of the eyes? a. By assessing peripheral vision b. By noting the symmetry of the corneal light reflex c. By assessing the cardinal fields of gaze d. By performing the cover-uncover test

Feedback A This tests the function of cranial nerve I (optic). B This indicates symmetry of eye muscles. C This tests the movement of the eye in all directions, which assesses the functions of the cranial nerves III (oculomotor), IV (abducens), and VI (trochlear). D This is performed after the corneal light reflex is abnormal, indicating asymmetric eye muscles.