N314 Exam 4

To assist in the examination of the soft palate of a young child, what question should the nurse ask the patient? -"Do you brush your own teeth?" -"Can you pant like a puppy?" -"Can you take a deep breath?" -"Did you have any surgeries on your mouth when you were a baby?"

"Can you pant like a puppy?"

The nursing instructor is talking with a nursing student about the superficial nodes of the lymphatic system that are accessible to inspection and palpation. Which statement by the nursing student indicates effective learning? -"Cervical nodes drain the head and neck." -"Axillary nodes drain the hand and lower arm." -"Inguinal nodes drain the posterior abdominal wall." -"Epitrochlear nodes drain the breast and upper arm."

"Cervical nodes drain the head and neck."

A nurse is teaching a class on the pathophysiology of the eyes. Which statement by a student would indicate a need for further teaching? -"Glaucoma is a common disease in children." -"Diabetic retinopathy is an important cause of blindness." -"Cataracts are caused by the clouding of the crystalline lens." -"Age-related macular degeneration (AMD) is caused by drusen."

"Glaucoma is a common disease in children."

The examiner is teaching a class on anatomy and physiology of the human eye. Which statement by a student indicates effective learning? -"The sclera is a thin layer sensitive to touch." -"The bulbar conjunctiva lines the lids and is clear." -"The spinal nerves control the movement of extraocular muscles." -"The iris controls the amount of light reaching the retina."

"The iris controls the amount of light reaching the retina."

The examiner is describing the process of palpating the lymph nodes with a student examiner. Which statement, if made by the examiner is accurate? -"Trap the lymph nodes between the thumb and second finger." -"Use the dorsal surface of the hand to locate the lymph nodes." -"Move the fingertips lightly over the skin to find the lymph nodes." -"Use a gentle circular motion of the finger pads to feel the lymph nodes."

"Use a gentle circular motion of the finger pads to feel the lymph nodes."

As part of the history of present illness, which questions should the nurse ask a patient presenting with a nosebleed to learn more about the potential predisposing factors? (Select all that apply.) -"Are you experiencing any nasal congestion or fever?" -"Have you been struck in the nose recently?" -"Have you noticed your nasal passages feeling dry?" -"When did the nosebleed start?" -"How long do the nosebleeds last when you have them?"

-"Are you experiencing any nasal congestion or fever?" -"Have you been struck in the nose recently?" -"Have you noticed your nasal passages feeling dry?"

Choose which medical-surgical history questions to ask a patient presenting with ear pain. (Select all that apply.) -"Did your parents have tubes put in their ears as children?" -"Did you experience frequent ear infections during childhood?" -"Have you ever been diagnosed with labyrinthitis?" -"Do you clean your ears with cotton-tipped applicators?" -"Do you use ear drops for the pain?"

-"Did you experience frequent ear infections during childhood?" -"Have you ever been diagnosed with labyrinthitis?"

The nurse should ask a patient with a red eye which questions about associated symptoms as part of the history of present illness? (Select all that apply.) -"Do you have pain in or around the eye?" -"Have you tried using eye drops?" -"Do you have any vision loss?" -"Do you have seasonal allergies?" -"Do you wear contact lenses?"

-"Do you have pain in or around the eye?" -"Do you have any vision loss?"

The nurse should ask a patient who reports halos around lights which questions as part of the past medical history? (Select all that apply.) -"Do you have pain in or around the eye?" -"Have you been treated for glaucoma?" -"Do you have seasonal allergies?" -"How long has this been going on?"

-"Have you been treated for glaucoma?" -"Do you have seasonal allergies?"

Which questions should the nurse ask a patient who has difficulty swallowing as part of the history of present illness? (Select all that apply.) -"When did you first notice the difficulty swallowing?" -"When you try to swallow liquid, does it come out of your nose?" -"Do you cough or have a choking sensation when you swallow?" -"Have you ever been diagnosed with acid reflux or esophageal problems?" -"How many cigarettes do you smoke daily?"

-"When did you first notice the difficulty swallowing?" -"When you try to swallow liquid, does it come out of your nose?" -"Do you cough or have a choking sensation when you swallow?"

The nurse develops a teaching plan for a patient with newly diagnosed migraine headaches. Which key items should be included in the teaching plan? (Select all that apply.) -Continue taking estrogen as prescribed by your physician. -Avoid drugs such as Tagamet, nitroglycerin, and Nifedipine. -One potential side effect of medications is rebound headache. -Abortive therapy is aimed at eliminating the pain during the aura. -Avoid foods that contain tyramine, such as alcohol and aged cheeses. -Complementary therapies such as relaxation and stress management may be helpful.

-Avoid drugs such as Tagamet, nitroglycerin, and Nifedipine. -One potential side effect of medications is rebound headache. -Abortive therapy is aimed at eliminating the pain during the aura. -Avoid foods that contain tyramine, such as alcohol and aged cheeses. -Complementary therapies such as relaxation and stress management may be helpful.

What findings are expected when assessing the iris and pupils of the eyes? (Select all that apply.) -Both pupils constrict when a light is shone directly into one eye. -When testing accommodation, the pupils constrict when looking at the far object. -Both pupils are the same size. -One pupil constricts more rapidly than the other. -Both pupils have notched edges.

-Both pupils constrict when a light is shone directly into one eye. -Both pupils are the same size.

Which features of the buccal mucosa should be inspected as part of a thorough ears, nose, and throat examination? (Select all that apply.) -Color -Masses -Swelling -Symmetry -Ulcerations

-Color -Swelling -Symmetry -Ulcerations

For which features should the nurse inspect during assessment of the sclera? (Select all that apply.) -Visual acuity -Corneal abrasions -Color of the sclera -Eyelid fasciculations -Presence of senile hyaline plaque

-Color of the sclera -Presence of senile hyaline plaque

When inspecting the nasal septum, which features should the nurse assess? (Select all that apply.) -Crusting -Bleeding -Alignment -Perforation -Tenderness

-Crusting -Bleeding -Alignment -Perforation

Which mouth and oropharynx assessment finding is expected for the child? -Mottled teeth -Deciduous teeth -Black or grey teeth -Caries on upper incisors

-Deciduous teeth

Match the external eye structure with the relevant function. -Distributes tears over the eye surface -Protects from foreign bodies and desiccation -Produces tears that moisten the eye -Lacrimal gland -Conjunctiva -Eyelid

-Distributes tears over the eye surface: Conjunctiva -Protects from foreign bodies and desiccation: Eyelid -Produces tears that moisten the eye: Lacrimal gland

Which are possible abnormal findings that may be encountered during a physical exam of visible lymph nodes and their surrounding areas? (Select all that apply.) -Edema -Mobility -Coolness -Erythema -Red streaks

-Edema -Erythema -Red streaks

For which features should the nurse inspect the orbital area? (Select all that apply.) -Edema -Puffiness -Tenderness -Temperature -Sagging tissue

-Edema -Puffiness -Sagging tissue

Match the conditions with the associated abnormal mouth and throat assessment findings. -Enlarged anterior cervical lymph nodes; swollen tonsils -Displaced tonsil and uvula associated with sore throat radiating to the ear -Firm, nonmobile mass with cervical lymphadenopathy -Deep pockets between the teeth and gingiva -Oral cancer -Peritonsillar abscess -Periodontal disease -Acute pharyngitis

-Enlarged anterior cervical lymph nodes; swollen tonsils: acute pharyngitis -Displaced tonsil and uvula associated with sore throat radiating to the ear: peritonsillar abscess -Firm, nonmobile mass with cervical lymphadenopathy: oral cancer -Deep pockets between the teeth and gingiva: periodontal disease

Which are systems of deep and superficial collecting ducts, carrying lymph from the upper extremity to the subclavian lymphatic trunk? (Select all that apply.) -Epitrochlear nodes -Brachial (axillary) nodes -Radial lymphatic vessels -Ulnar lymphatic vessels -Inferior superficial inguinal nodes -Small saphenous lymphatic vessels

-Epitrochlear nodes -Brachial (axillary) nodes -Radial lymphatic vessels -Ulnar lymphatic vessels

A patient with a history of hypertension complains of impaired vision and eye discomfort. The nurse notes hemorrhages in the eye and increased ocular pressure. Which information related to the eye assessment should the nurse document as objective data? (Select all that apply.) -Hypertension -Impaired vision -Eye discomfort -Eye hemorrhages -Increased ocular pressure

-Eye hemorrhages -Increased ocular pressure

A patient with a history of hypertension complains of diplopia and halos. The nurse notes eye redness and irritation and a blood pressure of 136/82 mm Hg. Which finding should the nurse document as history of present illness related to the eye assessment? (Select all that apply.) -Halos -Diplopia -Eye redness -Blood pressure of 136/82 mm Hg -Patient's history of hypertension

-Halos -Diplopia -Eye redness

The nurse is caring for a patient with complaints of hoarseness, sore throat, and difficulty swallowing. The nurse notes redness in the oropharynx and swollen tonsils. Which information suggestive of tonsillitis should the nurse document as history of present illness? (Select all that apply.) -Hoarseness -Sore throat -Swollen tonsils -Difficulty swallowing -Redness of the oropharynx

-Hoarseness -Sore throat -Difficulty swallowing

Which nasal assessment findings, suggestive of inhaled cocaine abuse, are considered abnormal? (Select all that apply.) -Hyperemia -Polyps -Rhinorrhea -Clear nasal discharge -Edema of the nasal mucosa

-Hyperemia -Rhinorrhea -Edema of the nasal mucosa

The nurse inspecting a patient's head and neck observes palpable, tender, hard lymph nodes. What are the most likely causes of this condition? (Select all that apply.) -Infection -Tuberculosis -Hypertension -Malignancies -Acquired immune deficiency syndrome (AIDS)

-Infection -Tuberculosis -Malignancies -Acquired immune deficiency syndrome (AIDS)

Match the nerve with the relevant function in the eye. -Innervates the lateral rectus muscle -Innervates the superior oblique muscle -Elevates and retracts the eyelid -Trochlear nerve -Oculomotor nerve -Abducens nerve

-Innervates the lateral rectus muscle: Abducens nerve -Innervates the superior oblique muscle: Trochlear nerve -Elevates and retracts the eyelid: Oculomotor nerve

Which anatomical components form the neck and provide its support and movement? (Select all that apply.) -Ligaments -Trapezius muscle -Cervical vertebrae -Vastus lateralis muscle -Sternocleidomastoid muscle

-Ligaments -Trapezius muscle -Cervical vertebrae -Sternocleidomastoid muscle

Which organs are part of the lymphatic system? (Select all that apply.) -Liver -Lungs -Spleen -Kidneys -Thymus -Gallbladder

-Liver -Spleen -Thymus -Gallbladder

The nurse assesses a child diagnosed with Down syndrome. What findings does the nurse expect when examining the child's head and neck? (Select all that apply.) -Low-seat ears -Epicanthal folds -Corneal clouding -Depressed nasal bridge -Mongoloid slant of eyes

-Low-seat ears -Epicanthal folds -Depressed nasal bridge -Mongoloid slant of eyes

The ossicles of the inner ear include which small bones? (Select all that apply.) -Tympanic -Malleus -Stapes -Incus -Maxilla

-Malleus -Stapes -Incus

A pregnant patient will frequently have which changes as a result of pregnancy? (Select all that apply.) -Dry eyes -Mild corneal edema -Tears that feel greasier -Less significant diabetic retinopathy -Lower intraocular pressure during the latter half of the pregnancy

-Mild corneal edema -Tears that feel greasier -Lower intraocular pressure during the latter half of the pregnancy

Match the examination with the type of vision it tests. -Near vision -Peripheral vision -Central vision -Confrontation -Rosenbaum pocket screener -Snellen chart

-Near vision: Rosenbaum pocket screener -Peripheral vision: Confrontation test -Central vision: Snellen chart

A patient complains of hoarseness, throat pain, and difficulty swallowing. The nurse notes a bruit over the thyroid and neck swelling. Which information should the nurse document as objective data? (Select all that apply.) -Hoarseness -Throat pain -Neck swelling -Difficulty swallowing -Bruit over the thyroid

-Neck swelling -Bruit over the thyroid

Which nose assessment findings should be considered abnormal? (Select all that apply.) -Noisy breathing or occlusion -Patient unable to smell -Perforated or deviated septum -Deviation of uvula -Hyperemia, rhinorrhea, and edema of mucosa

-Noisy breathing or occlusion -Perforated or deviated septum -Hyperemia, rhinorrhea, and edema of mucosa

A patient presents with a complaint of impaired smell and nasal stuffiness. The patient reports use of intranasal cocaine and oral tobacco products. The nurse notes inflamed oral and nasal mucosa. Which subjective information should the nurse document as a part of the personal/social history related to the ear, nose, and throat (ENT) assessment? (Select all that apply.) -Nasal stuffiness -Oral tobacco use -Impaired smell -Intranasal cocaine use -Inflamed oral mucosa

-Oral tobacco use -Intranasal cocaine use

When the sinuses are palpated, which findings should be considered abnormal? (Select all that apply.) -Pain -Swelling -Tenderness -Opaque glow on transillumination -Dim red glow on transillumination

-Pain -Swelling -Tenderness -Opaque glow on transillumination

Which lymph nodes are in the "necklace of nodes"? (Select all that apply.) -Parotid -Axillary -Occipital -Submental -Epitrochlear -Retropharyngeal

-Parotid -Occipital -Submental -Retropharyngeal

Which are functions of the spleen? (Select all that apply.) -Producing antibodies -Storing red blood cells -Producing T lymphocytes -Destroying old red blood cells -Filtering microorganisms from the blood -Producing cells responsible for cell-mediated immunity reactions

-Producing antibodies -Storing red blood cells -Destroying old red blood cells -Filtering microorganisms from the blood

What are the different functions of the eyelids? (Select all that apply.) -Secretion of tears -Provision of oil to tears -Protection from dust -Protection from bright light -Filtering out dust and dirt

-Provision of oil to tears -Protection from dust -Protection from bright light

When gathering medical-surgical history about a patient who presents with postnasal drip, which conditions should the nurse ask about? (Select all that apply.) -Headaches -Thyroid disease -Seasonal allergies -Recurrent sinusitis -Chronic postnasal drip

-Seasonal allergies -Recurrent sinusitis -Chronic postnasal drip

Which head and neck characteristics does the nurse expect to observe when examining a child with fetal alcohol syndrome? (Select all that apply.) -Short nose -Thin upper lip -Widespread eyes -Maxillary hypoplasia -Inner epicanthal folds -Poorly formed philtrum

-Short nose -Thin upper lip -Widespread eyes -Inner epicanthal folds -Poorly formed philtrum

During a physical exam, the nurse palpates the superficial lymph nodes and compares them side to side to determine which qualities? (Select all that apply.) -Size -Pulse -Mobility -Consistency -Tenderness -Discrete borders

-Size -Mobility -Consistency -Tenderness -Discrete borders

Which lymph nodes are involved with the tongue? (Select all that apply.) -Submental -Suprahyoid -Preauricular -Thyrolinguofacial -Retropharyngeal

-Submental -Suprahyoid -Thyrolinguofacial

Which information should the nurse document as history of present illness related to strabismus? (Select all that apply.) -Sudden onset of double vision -Eye surgery to correct double vision -Patient reports that eyes cross -Nurse notes that one eye deviates inward -Use of a protective eye device

-Sudden onset of double vision -Patient reports that eyes cross

The nurse assesses an older adult patient who reports lack of access to food and poor intake over the past month. The nurse notes sunken eyes and loose, wrinkled eyelids. Which information suggestive of poor nutrition should the nurse document as objective data? (Select all that apply.) -Sunken -Loose -Poor food intake -Wrinkled eyelids -Lack of access to food

-Sunken -Loose -Wrinkled eyelids

The nurse assesses an older adult patient admitted for an elective surgery. What does the nurse expect to find as normal changes of aging? (Select all that apply.) -Sunken eyes -Fibrotic thyroid gland -Enlarged lymph nodes -Altered facial symmetry -Decreased range of motion

-Sunken eyes -Fibrotic thyroid gland -Altered facial symmetry -Decreased range of motion

Which statements are true of the tonsils? (Select all that apply.) -They have Peyer patches on them. -They contain white pulp and red pulp. -They are composed principally of lymphoid tissue. -They can obstruct the nasopharyngeal passageway when enlarged. -They are set between the palatine arches on each side of the pharynx below the base of the tongue.

-They are composed principally of lymphoid tissue. -They can obstruct the nasopharyngeal passageway when enlarged. -They are set between the palatine arches on each side of the pharynx below the base of the tongue.

Which statements are true regarding B lymphocytes? (Select all that apply.) -They produce antibodies. -They have a lifespan of 100 to 200 days. -They are involved in the humoral immune response. -They are able to discriminate between healthy and abnormal cells. -They are characterized by the various arrangements of immunoglobulins on their surfaces.

-They produce antibodies. -They are involved in the humoral immune response. -They are characterized by the various arrangements of immunoglobulins on their surfaces.

Which ear assessment findings would be considered abnormal? (Select all that apply.) -Vertigo -Tinnitus -Darwin tubercle -Preauricular pits -Hearing loss

-Vertigo -Tinnitus -Hearing loss

In which ways should the nurse evaluate a young child's hearing? (Select all that apply.) -Use the Snellen E chart or HOVT chart. -Whisper words with meaning to the child. -Have the child repeat phrases the nurse yells. -Inspect the tympanic membrane for perforations. -Ask the child to perform tasks using a soft voice.

-Whisper words with meaning to the child. -Ask the child to perform tasks using a soft voice.

Which eye finding is normal for a 3-year-old child? -White reflex -20/40 visual acuity -Different visual acuity in each eye -Bleeding of retinal blood vessels

20/40 visual acuity

At which age is the mass of lymphoid tissue most plentiful? -0-3 years -6-9 years -11-14 years -18-21 years

6-9 years

The nurse assesses a patient with enlargement of the head and bony facial structures caused by excessive secretion of growth hormone. Which best describes the patient's condition? -Craniotabes -Acromegaly -Craniosynostosis -Hydrocephalus

Acromegaly

Which is the priority nursing diagnosis for the patient experiencing a migraine headache? -Risk for side effects related to medical therapy -Acute pain related to biologic and chemical factors -Anxiety related to change in or threat to health status -Hopelessness related to deteriorating physiological condition

Acute pain related to biologic and chemical factors

The examiner is preparing a 4-year-old child and parent for a well child visit. While the examiner explains the purpose of vision screening, the parent asks when the child will have adult visual acuity. Which answer should the examiner provide? -Age 6 months -Age 18 months -Age 48 months -Age 60 months

Age 48 months

The registered examiner teaches a student examiner how to palpate the thyroid gland of a patient. Which action by the student examiner would indicate a need for further teaching? -Asking the patient to lie in the side lying position. -Giving a glass of water to the patient during palpation. -Tilting the head back to stretch the skin against the thyroid. -Using the fingers of the left hand to push the trachea slightly to the right.

Asking the patient to lie in the side lying position.

The nurse provides care for a patient diagnosed with Bell palsy. Which is a clinical manifestation of this condition? -Asymmetry of the mouth -Asymmetry of the lower face -Involuntary movements of the face -Asymmetry of the entire side of the face

Asymmetry of the entire side of the face

During the eye assessment, the nurse notes a visual acuity of 20/70 and periorbital swelling. The patient complains of blurred vision and has had recent eye surgery. Which history of present illness information should the nurse document as a part of the eye assessment? -Eye surgery -Blurred vision -Periorbital swelling -20/70 visual acuity

Blurred vision

Where are the majority of lymphocytes in the body produced? -Spleen -Adenoids -Bone marrow -Lymph nodes

Bone marrow

Which finding is expected when both eyes are examined for light reactivity? -Slow bilateral reactivity -No reaction in either eye -Brisk bilateral reactivity -Reactivity in the illuminated eye only

Brisk bilateral reactivity

What is the term for blotchy, brownish hyperpigmentation in a symmetrical pattern on both sides of the face, particularly the forehead, cheeks, and above the upper lip that occurs during pregnancy? -Acne -Measle -Chloasma -Melanoma

Chloasma

When examining the eyes, which finding is indicative of cataracts? -In the affected eye the pupil dilates more slowly than the unaffected eye -Shallow anterior chamber in the affected eye -Cobblestone appearance of the conjunctivae in the affected eye -Cloudiness of the lens in the affected eye

Cloudiness of the lens in the affected eye

Which suture is present in between the frontal and parietal lobes? -Sagittal -Coronal -Squamosal -Lambdoidal

Coronal

Which cranial nerve is responsible for elevation of the eyelid? -Cranial nerve III -Cranial nerve V -Cranial nerve IV -Cranial nerve X

Cranial nerve III

Which finding is expected when assessing the tonsils? -Dark red tonsils -Hypertrophied tonsils -Exudate on the tonsils -Crypts with food particles

Crypts with food particles

When performing the ophthalmoscopic examination, which finding of the optic discs is abnormal? -Sharp well-defined disc margin -About 1.5 mm in diameter -Cupping of the disc -Yellow to creamy pink in color

Cupping of the disc

Which age-related finding is expected in a 55-year-old patient? -Hearing loss -Loss of vision -Loss of sense of smell -Decrease in sense of taste

Decrease in sense of taste

Which symptom is typical of a tension headache? -Possible warning aura -Exacerbated by alcohol -Dull, bandlike constricting pain -Sudden onset that reaches peak in minutes

Dull, bandlike constricting pain

A patient who has undergone radiation therapy for cancer of the right breast has significant edema in the right arm. The examiner suspects the patient will be diagnosed with which condition? -Early lymphedema -Chronic hypotension -Deep vein thrombosis -Superficial varicose veins

Early lymphedema

The nurse assesses a newborn infant with a visible sac of tissue protruding through the back of the skull. What is the best description for this condition? -Torticollis -Microcephaly -Encephalocele -Craniosynostosis

Encephalocele

What structure prevents food from entering the lungs? -Uvula -Hard palate -Palatine tonsils -Epiglottis

Epiglottis

Which finding should the nurse note as normal when assessing the mouth and throat of an infant? -Adherent white patches on the buccal mucosa -Epstein pearls -Persistent drooling after age 6 months not associated with teething -Presence of natal teeth

Epstein pearls

Which eye assessment finding is associated with hyperthyroidism? -Episcleritis -Strabismus -Nystagmus -Exophthalmos

Exophthalmos

Which question related to family history should a nurse ask a patient with a red eye? -"Do you have pain in or around the eye?" -"Have you had eye surgery?" -"Do you have any vision loss?" -"Do you have seasonal allergies?" -"Has anyone in your family had glaucoma?"

Has anyone in your family had glaucoma?

During ear assessment of a 62-year-old patient, the nurse notes a buildup of cerumen and irritation in the ear canal. The patient reports a family history of Meniere disease and complains of muffled hearing. Which subjective assessment information should be documented as a part of the family history related to the ear assessment? -Muffled hearing -Buildup of cerumen -Irritation of the ear canal -History of Meniere disease

History of Meniere disease

Which are expected changes in the thyroid gland of a pregnant female patient? -Goiter -Hypotrophy -Decreased vascularity -Hypertrophy and palpability

Hypertrophy and palpability

The examiner is conducting an eye examination for an older adult. Which finding is considered a common finding for an older adult? -Multiple drusen bodies -Increased tear production -Involuted lacrimal glands -Bilateral lens cloudiness

Involuted lacrimal glands

A neonate has been diagnosed with caput succedaneum. Which statement about this condition is most accurate? -It usually resolves in three to six weeks. -It doesn't cross the cranial suture line. -It's a collection of blood between the skull and the periosteum. -It involves swelling of tissue over the presenting part of the presenting head.

It involves swelling of tissue over the presenting part of the presenting head.

Which question about environmental exposure should the nurse ask a patient presenting with hearing loss as part of the personal/social history? -Hot, dry air -Air pollutants -Dust and allergens -Loud, continuous noises

Loud, continuous noises

What does the white pulp of the spleen consist of? -Peyer patches -Venus sinusoids -Connective tissue and a few elastic fibrils -Lymphatic nodules and diffuse lymphatic tissue

Lymphatic nodules and diffuse lymphatic tissue

The nurse assesses a newborn infant with a much smaller than normal head for gestational age because the brain has most likely not developed properly or stopped growing. Which is the best description of this condition? -Torticollis -Microencephaly -Encephalocele -Craniosynostosis

Microcephaly

Which type of headache is usually described as throbbing or pounding, is sudden in onset, and is frequently associated with nausea, photophobia, and visual problems? -Sinus -Tension -Migraine -Hypertension

Migraine

When is the thymus at its larges and most active? -Older age -Middle age -Adolescence -Neonatal period

Neonatal period

When examining the eyes, which finding is indicative of extraocular muscle weakness? -Nystagmus -Red reflex -Pupillary dilation -Pupillary constriction

Nystagmus

Which pathologic condition leads to the accumulation of lymph in the breasts and upper arms? -Obstruction of the cervical nodes. -Obstruction of the axillary nodes. -Obstruction of the inguinal nodes. -Obstruction of the epitrochlear nodes.

Obstruction of the axillary nodes.

The nurse in a newborn nursery assesses a newborn. What is the most appropriate method for measuring the head circumference of the infant? -Wrap the tape measure around the infant's head, and measure just above the eyebrows. -Place the tape measure under the infant's head, wrap around the occiput, and measure just above the eyes. -Place the tape measure under the infant's head at the base of the skull and wrap around to the front just above the eyes. -Place the tape measure at the back of the infant's head, wrap around across the ears, and measure across the infant's mouth.

Place the tape measure under the infant's head, wrap around the occiput, and measure just above the eyes.

When examining the eyes, which finding describes abnormal findings of the eyelid? -Drusen bodies -Sclera yellow, dark green, or rust-colored -Pterygium -Ptosis

Ptosis

Which eye structure is known as the "white" of the eye? -Iris -Sclera -Cornea -Conjunctiva

Sclera

While assessing a patient, a light shined tangentially at the limbus does not light a portion of the iris. Which eye defect does the examiner suspect? -Pterygium -Hypopyon -Corneal abrasion -Shallow anterior chamber

Shallow anterior chamber

Which finding indicates that a patient has a normal and healthy optic disc? -The color of the optic disc is gray. -The color of the optic disc is red. -The color of the optic disc is black. -The color of the optic disc is yellow-orange.

The color of the optic disc is yellow-orange.

The examiner is assessing a patient who has an acute infection and enlarged lymph nodes. Which assessment finding would the examiner expect? -The lymph nodes are painless, rubbery, and discrete. -The lymph nodes are enlarged, firm, contender, and mobile. -The lymph nodes are warm, tender, and firm, but freely movable. -The lymph nodes are hard, longer than 3 cm, contender, and fixed.

The lymph nodes are warm, tender, and firm, but freely movable.

The examiner is examining the palpebral fissures of a patient with Down syndrome. Which part of the patient's face is the examiner examining? -The creases in the lips -The folds in the forehead just above the eyebrows -The openings between the margins of the upper and lower eyelids -The creases in the skin extending from the angle of the nose to the corner of the mouth

The openings between the margins of the upper and lower eyelids

The examiner is evaluating a student examiner who is palpating a patient's cervical lymph nodes. Which action, if performed by the student examiner, should be corrected by the examiner? -The student examiner palpates the submittal gland with one hand. -The student examiner uses firm pressure for assessing lymphatic glands. -The student examiner palpates the lymph nodes by using a circular motion. -The student examiner assesses for parotid tenderness starting from the preauricular lymph nodes.

The student examiner uses firm pressure for assessing lymphatic glands.

Which condition may cause mitosis in a patient? -Use of opioids -Damage to the optic disk -Damage to the cerebral cortex -Damage to the trochlear nerve IV

Use of opioids

During the eye assessment, the nurse notes discoloration of the sclera and red conjunctiva. The patient reports poor vision and eye pain and wears protective eye devices for work. Which subjective information would the nurse document as a part of the personal/social history related to the eye examination? -Eye pain -Poor vision -Red conjunctiva -Discoloration of the sclera -Use of a protective eye device

Use of protective eye device

The examiner is screening an older adult for risk factors for cataract formation. Which is a potential risk factor for cataract formation? -Use of steroids -Trauma to the eyes -Overusing eyes in dim light -Exposure to chemicals in the workplace

Use of steroids

The examiner is assessing the function of cranial nerve V (CN V). Which assessment technique should be used? -Observing for nystagmus when the patient looks upwards -Having the patient follow a penlight to the temporal sides of the face -Using a piece of cotton to touch the cones to determine the presence of a blink -Having the patient follow a penlight to the lateral and to the medial parts of the face

Using a piece of cotton to touch the cones to determine the presence of a blink

When performing the ophthalmoscopic examination, which finding of the blood vessels is abnormal? -Venules smaller than arterioles -Branching of vessels away from the optic disc -Smooth crossing of the vessels -Possible venous pulsations

Venules smaller than arterioles

Which age-related color change is expected on assessment of the sclera of an older adult? -Red -White -Blue -Yellow

Yellow