EENT HNTL Health Assessment

A client presents to the health care clinic with reports of inability to concentrate at work and daily frontal headaches for the past two weeks. What additional information should the nurse ask this client?

"Are you experiencing sinus pressure and congestion?' The client has a recent onset of a frontal headache and the nurse should collect information on additional findings of a sinus infection. Family history of headaches will not provide information about the current headache. High blood pressure causes a headache in the occipital area. A previous injury will not explain the recent acute onset of headache that the client is now experiencing.

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

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

The nurse examines the pharynx of a client and records that the tonsils are touching the uvula. The nurse would grade the tonsils as

3+

The nurse notes a tophus of the ear of an older adult. Which assessment data is consistent with a tophus?

A hard nodule composed of uric acid crystals

What do retinal abnormalities include?

Age-related macular degeneration gradually causes loss of sharp central vision, needed for common daily tasks (e.g., driving, reading). The macula degenerates (dry) or abnormal blood vessels behind the retina grow under the macula (wet).

Dyspnea, an uncomfortable awareness of breathing that is inappropriate to the level of exertion, is what?

Air hunger

Which of the following statements most accurately describes the maintenance of normal intraocular pressure?

Aqueous humor is continuously circulating through the eye with production equaling drainage.

During the health history of the nose and sinuses, a client complains of having rhinorrhea. What question would the nurse ask to determine associated manifestations of this symptom?

Are there any other symptoms?

The nurse is auscultating a client's breath sounds. What should the nurse do first after hearing an unusual sound?

Ask the client to cough

A nurse palpates an elderly client's thyroid and detects an enlargement over the right lateral lobe. What action should the nurse take first?

Auscultate with the bell over the lateral lobes

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

Blood vessels supplying the retina become weak and bleeding occurs.

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

Conjunctiva

During assessment of the oral cavity, the nurse examines the salivary glands. Which area of the mouth should the nurse assess to inspect for the Wharton's ducts?

Either side of the frenulum on the floor of the mouth

What muscles control the eye movement and hold the eye in place in the socket?

Extraocular

A nurse examines a client's retina during the ophthalmic examination and notices light-colored spots on the retinal background. The nurse should ask the client about a history of what disease process?

Exudates appear as light-colored spots on the retinal background and occur in individuals with diabetes or hypertension.

A client diagnosed with Sjogren syndrome should be given which instructions?

Eye drops and sucking on hard candy may used to relieve dryness.

A client comes to the clinic and states, "I have a bad cold and am having trouble breathing." The nurse checks the client's breath sounds and hears bilateral fine crackles at the base. Of what is this finding indicative?

Fluid in the alveoli

The nurse assess the client for common upper respiratory symptoms which may include what? Select all that apply

Hoarseness Pharyngitis Nasal congestion

A nurse inspects the anterior thorax of a client with emphysema. Which change in the thorax should the nurse recognize as normal for this client?

Horizontal position to the ribs with a costal angle of greater than 90 degrees

A client presents to the emergency department after being hit in the head with a baseball bat during a game. The nurse should assess for which condition?

Hyphema Hyphema is blood in the anterior chamber of the eye, usually caused by blunt trauma.

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

III (oculomotor)

A nurse is testing a client's pupillary reaction to light, noting that the pupil constricts when shining light obliquely into it. The nurse understands that muscles in which of the following structures adjust to control the amount of light entering the eye through the aperture of the pupil?

Iris

Which of the following conditions would produce a hyperresonant percussion note?

Large pneumothorax There is a great deal of free air in the chest with a large pneumothorax, which produces a hyperresonant note. The other three conditions produce dullness by dampening the percussion note with fluid.

An older adult client who wears dentures reports having soreness of the gums. Which intervention should the nurse recommend to the client to alleviate this problem?

Massage the gums daily.

How should a nurse position a client to accurately auscultate the right middle lobe of the lung?

Move the right arm away from the body

The nurse observes a young client holding a newspaper up close to read. Which condition does the nurse suspect this client suffers from?

Myopia Myopia is nearsightedness, meaning the client can see objects better up close.

Which statement reflects accurate documentation by the nurse of a normal, left tympanic membrane?

Pearly gray, translucent, with cone of light at 7 o'clock position

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

Possible basilar skull fracture

A nurse examines the ear of a client diagnosed with an obstructed eustachian tube. What finding should the nurse anticipate upon assessment?

Prominent landmarks on the tympanic membrane

A 67-year-old lawyer comes to the clinic for an annual examination. He denies any history of eye trauma or recent visual changes. Inspection of his eyes reveals a triangular thickening of the bulbar conjunctiva across the outer surface of the cornea. He has a normal pupillary reaction to light and accommodation. Based on this description, what is the most likely diagnosis?

Pterygium A pterygium is a triangular thickening of the bulbar conjunctiva that grows slowly across the outer surface of the cornea, usually from the nasal side. Reddening may occur, and it may interfere with vision as it encroaches on the pupil. Otherwise treatment is unnecessary.

When percussing the anterior chest for tone, a nurse should anticipate what tone over the majority of the lung fields?

Resonance

A nurse is assessing a client with acute asthma. Which adventitious breath sound should the nurse expect to hear in this client?

Sibilant wheezes heard primarily during expiration but may also be heard on inspiration

A client is admitted to the health care facility after sustaining a crushing injury to the right eye. The nurse should anticipate abnormal results for which vision test?

Six cardinal positions of gaze

A 52-year-old client fails the Romberg test. The nurse explains that this might indicate a dysfunction in what part of the ear?

The vestibular portion of the inner ear

The nurse is preparing to auscultate the lung sounds of a young adult. Which sound will the nurse expect to hear over most of the client's lungs?

Vesicular

When visualizing the structures of the nose, the nurse recalls that air travels from the anterior nares to the trachea through the:

Vestibule, nasal passages, and nasopharyn

The nurse notes that the ophthalmologist suspects death of the optic nerve. When looking into the eye, the nurse would expect to see what color if the disc is dead?

White

cochlea

a coiled, bony, fluid-filled tube in the inner ear through which sound waves trigger nerve impulses (amplitude

The middle layer of the eye is known as the

choroid layer

The nurse assesses an adult client and observes that the client's breathing pattern is very labored and noisy, with occasional coughing. The nurse should refer the client to a physician for possible

chronic bronchitis.

Eardrum

composed of the hammer, incus, and stirrup. They transmit sounds to the cochlea

The nurse has assessed the respiratory pattern of an adult client. The nurse determines that the client is exhibiting Kussmaul respirations with hyperventilation. The nurse should contact the client's physician because this type of respiratory pattern usually indicates

diabetic ketoacidosis.

The nurse percusses the lungs of a client with pneumonia. What percussion note would the nurse expect to document?

dullness

auricle

external portion of the ear

Under normal circumstances, the strongest stimulus to breathe is

hypercapnia.

A client has a history of emphysema. The nurse percussing the client's chest expects to hear what characteristic sound?

hyperresonance

After percussing a client's lung fields the nurse suspects a client has a chronic lung disease. What sound did the nurse hear to make this clinical determination?

hyperresonance

Presbyopia

impaired vision as a result of aging, usually near vision

The client reports severe pain when breathing in deeply. The description suggests to the nurse that the client is experiencing which respiratory condition?

inflammation of the parietal pleura

A nurse is palpating the sternum of a client. If the client is healthy, which of the following would characterize his costal angle?

less than 90 degrees

A client complains of feeling like he is slowly losing his central vision. The nurse knows this symptom could represent what?

macular degeneration

What is the open space between the eyelids called?

palpebral fissure

The nurse documents vesicular lung sounds upon auscultation. The nurse heard what type of sound?

sound heard throughout inspiration and two thirds of expiration

auditory canal

the area that sound waves pass through to reach the eardrum

Conjuctiva

thin, transparent, continuous membrane that is divided into two portions: a palpebral and a bulbar portion.

The nurse auscultates very loud, high-pitched lung sounds that are equal in length over a client's anterior chest. Which area did the nurse most likely hear these sounds?

trachea Tracheal sounds are very loud and harsh with inspiratory and expiratory sounds equal in length, over the trachea in the neck. Bronchial sounds are louder and higher in pitch and are heard over the manubrium. Bronchovesicular sounds are heard between the scapula. Vesicular sounds are heard over most of the lung fields.

A client tells the nurse that she has difficulty seeing while driving at night. The nurse should explain to the client that night blindness is often associated with

vitamin A deficiency. Night blindness is associated with optic atrophy, glaucoma, and vitamin A deficiency.

A nurse is examining the eyes of a 7-year-old boy. The boy asks the nurse, "What's inside my eyeball?" The nurse explains that the biggest space inside the eyeball contains a clear, gelatinous substance that light passes through. Which of the following is the technical name for this gelatinous substance?

vitreous humor Vitreous humor is the clear and gelatinous substance that fills the vitreous chamber, the largest chamber of the eye, which is located in the area behind the lens to the retina. Aqueous humor is a clear liquid substance produced by the ciliary body that fills the anterior and posterior chambers of the eye.