Health Assessment Prep U's

Photoreceptors of the eye are located in the eye's A. Pupil B. Retina C. Lens

B. Retina

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? A. Aqueous humor B. Vitreous humor C. Lacrimal humor D. Meibomian humor

B. Vitreous humor

Upon inspection of a client's chest, a nurse observes an increase in the ratio of anteroposterior to transverse diameter. The nurse recognizes this as a finding in which disease process?

COPD

Which of the following is a symptom of the eye? A. Tinnitus B. Dysphagia C. Rhinorrhea D. Scotomas

D. Scotomas

A client frequently experiences dry, irritated eyes. These findings are consistent with a problem in what part of the eye?

Lacrimal apparatus

A client calls the clinic and tells the nurse that the doctor told her that she has "otalgia." The client cannot remember what the doctor explained this to be. How would the nurse most appropriately respond?

Otalgia is the pain of the ear

What part of the eye receives and transmits visual stimuli to the brain for processing?

Retina

How can a nurse accurately assess the distant visual acuity of a client who is non-English speaking?

Use a Snellen E chart to perform the examination

A young toddler is brought to the emergency room by his parents. The mother states that the child was playing on the floor with toys and suddenly began to wheeze. The mother reports no recent illnesses. The nurse suspects that the most likely cause of the wheezing is a. a foreign body obstruction b. increased secretions c. a severe cold d. exercise-induced asthma

a foreign body obstruction

A 52-year-old client with documented myopia presents to the emergency department because of "spots" floating in their line of vision. What should the nurse respond to the client about this symptom? a. "This is a normal change in the eye associated with aging." b. "A cataract is forming and cannot be treated until it ripens." c. "You have a detached retina and need to lie down immediately." d. "This means you have glaucoma and need to have your eye pressure checked."

a. "This is a normal change in the eye associated with aging."

What is a characteristic symptom of Graves hyperthyroidism? A. Exophthalmos B. Episcleritis C. Pinguecula D. Pterygium

a. Exophthalmos

Which characteristic associated with respiratory effort should be considered when planning care for a client diagnosed with a brainstem injury? a. There is loss of involuntary respiratory control. b. The client will respond negatively to increased stimuli. c. There is an increased level of carbon dioxide in the blood. d. The client's oxygen levels in the blood will be increased.

a. There is loss of involuntary respiratory control.

After examining the client's tympanic membranes, the nurse documents "Right tympanic membrane, red and bulging with no light reflex." The nurse recognizes that these are signs of a. acute otitis media. b. serous otitis media. c. skull trauma. d. trauma from infection.

a. acute otitis media

A client complains of feeling like he is slowly losing his central vision. The nurse knows this symptom could represent a. macular degeneration b. open-angle glaucoma c. hemianopsia d. retinal detachment

a. macular degeneration

Which of the following assessment findings suggests a problem with the client's cranial nerves? a. A client states that he has recently begun seeing lights flashing in his field of vision. b. A client's extraocular movements are asymmetrical and she complains of diplopia. c. Fundoscopic examination reveals intraocular bleeding. d. A client's lens appears cloudy and she claims that her visual acuity has recently declined.

b. A client's extraocular movements are asymmetrical and she complains of diplopia.

An avid swimmer presents with ear pain. Her history includes pain and drainage from the left ear. On examination, she has pain when the ear, including the tragus, is manipulated. The canal is narrowed and erythematous with some white debris in the canal. The rest of the examination is normal. What diagnosis would be most appropriate for this client? a. Otitis media b. External otitis c. Perforation of the tympanum d. Cholesteatoma

b. External otitis

A nurse is educating a client about the function of the parts of the auditory system. Which is the function of the eustachian tube? a. Transmits vibration to the fluid filled inner ear at the oval window. b. Separates the external from the middle ear. c. Sends sensory information to the cerebellum and midbrain. d. Equalizes the pressure in the middle ear with atmospheric pressure.

d. Equalizes the pressure in the middle ear with atmospheric pressure.

The nurse is planning to perform an ear examination on an adult client. After explaining the procedures to the client, the nurse should a. ask the client to remain standing. b. show the client the otoscope. c. ask the client to remove his contact lenses. d. observe the client's response to the explanations.

d. observe the client's response to the explanations.

A 6-year-old boy has come to the clinic with his mother because of recent eye redness and discharge. The nurse's assessment has suggested a diagnosis of conjunctivitis. What should the nurse tell the mother about her son's eye? a. "In children, this problem is usually caused by an increase in pressure within the eye." b. "I'll prescribe some analgesics because your son is likely to have quite severe pain while his eye heals." c. "Antibiotics will clear this up, but you need to make sure he gets them as ordered to avoid vision damage." d."This might have been the result of an allergy, but most likely it was caused by a bacteria or virus."

d."This might have been the result of an allergy, but most likely it was caused by a bacteria or virus."

What would the nurse expect to hear when auscultating the lungs of a client diagnosed with pleuritis? a. Friction rub b. Decreased breath sounds c. Sibilant wheeze d. Stridor

friction rub