prepU: nose, ears, eyes, mouth, and throat
A client has been diagnosed with astigmatism. The nurse should be prepared to teach the client about which treatment for this condition? Surgery Daily use of eye drops Corrective lenses No night driving
Corrective lenses Astigmatism is corrected with a cylindrical lens that has more focusing power in one access than the other. These corrective lenses can and should be worn while driving at night. Eye drops and surgery are not usual treatments for this condition.
A nurse has completed the assessment of an older adult client's head and neck and is now analyzing the assessment findings. Which finding should the nurse attribute to age-related physiological changes? Increased size of a single thyroid nodule A nonpalpable carotid pulse Decreased strength of temporal artery pulsations Tenderness of lymph nodes on palpation
Decreased strength of temporal artery pulsations Explanation: The strength of the pulsation of the temporal artery may be decreased in the older client. Enlargement of a single thyroid nodule suggests a malignancy and must be evaluated further. Carotid pulses should always be palpable in healthy clients, and tender lymph nodes are a pathologic finding in clients of any age.
When doing a risk assessment of the nose, sinuses, mouth, and throat, what finding might indicate an allergy? Low-grade fever History of macular rash Frequent childhood infections Family history of diabetes
Frequent childhood infections Explanation: Frequent upper respiratory infections in childhood should raise the nurse's suspicion of allergy. Chronic inflammation of the respiratory tract may lead to mucosal damage with resultant chronic infections (eg, sinusitis). The findings of low-grade fever, history of macular rash, or family history of diabetes would not necessarily raise the suspicion of allergy. p 293
A client shares that a first-degree relative has an eye problem, but they not sure what the diagnosis is. What major eye problem will the nurse suggest screening the client for? Retinoblastoma Strabismus Retinitis pigmentosa Glaucoma
Glaucoma Glaucoma in a first-degree relative increases the client's risk for the same problem two to three times. Retinoblastoma can be inherited from either parent but does not have increased incidence if a first-degree relative has the disease. Retinitis pigmentosa is also a genetic disease, but a client's risk of the disease is not increased if a first-degree relative is affected. Strabismus is not genetic in nature.
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 Blepharitis Chalazion Iris nevus
Hyphema Explanation: Hyphema is blood in the anterior chamber of the eye, usually caused by blunt trauma. Blepharitis is inflammation of the margin of the eyelid. Chalazion is a cyst in the eyelid. Iris nevus is a rare condition affecting one eye. The latter 3 conditions are not commonly attributed to blunt force trauma to the head as hyphema is.
A nurse assesses a client for pupillary response of the eyes and finds a unilateral dilated pupil that is unresponsive to light or accommodation. The nurse recognizes that which cranial nerve is responsible for the damage of pupillary response? I III V II
III Explanation: Cranial nerve III is responsible for the damage to pupillary response. Cranial nerve I disorders cause damage to sense of smell. Cranial nerve V is responsible for the function of masseter muscle contraction. Cranial nerve II disorders damage vision due to retinal detachment or due to a lesion in the nerve.
The nurse has placed her hands behind the client's head and flexed the client's neck forward as far as the client can tolerate. During the test, the client experiences leg pain and bends his knees. This assessment finding is suggestive of what health problem? Ischemic stroke Meningitis Bell's palsy Brain stem lesion
Meningitis Explanation: Pain and flexion of the hips and knees during neck flexion are positive Brudzinski's signs, suggesting meningeal inflammation. This finding is not suggestive of stroke, Bell's palsy, or a brain stem lesion.
A client complains of a unilateral headache near the scalp line and double vision. The nurse palpates the space above the cheekbone near the scalp line on the affected side, and the client complains of tenderness on palpation. What is the nurse's next action? Notify the healthcare provider immediately. Administer intravenous pain medication. Palpate the carotid pulses bilaterally at the same time. Prepare the client for a temporal artery biopsy.
Notify the healthcare provider immediately. Explanation: Temporal arteritis is a painful inflammation of the temporal artery. Clients report severe unilateral headache sometimes accompanied by visual disturbances. This condition needs immediate care. A biopsy may be necessary for diagnosis; however the healthcare provider immediately. The temporal artery pulse can be palpated; but the carotid artery pulses should never be palpated simultaneously so that the client does not pass out from lack of blood flow to the brain.
A nurse is performing an eye and vision assessment on a client who has an inner ear disorder. This disorder may contribute to what finding during the client's eye positions test? Strabismus Phoria Tropia Nystagmus
Nystagmus Nystagmus may be associated with an inner ear disorder. Strabismus or tropia would refer to a constant misalignment of the eyes due to a muscle weakness detected with the corneal light reflex test. Phoria describes a drifting of the eyes due to a mild muscle weakness and is detected only with the cover test.
A nursing educator is evaluating a colleague's examination of a client's thyroid gland. The educator would determine that the nurse needs additional instruction when the nurse demonstrates which technique? Inspection Auscultation Palpation Percussion
Percussion Explanation: When examining the thyroid gland, the nurse inspects for enlargement and asymmetry; auscultates for bruits; and palpates for tumors, masses, size, and tenderness. Percussion does not provide meaningful data.
A nurse is providing care at an inner-city shelter, and a man who frequents the shelter presents with a significant frontal growth that is located midline at the base of his neck. The nurse should recognize the need for what referral? Referral for further assessment of thyroid function Referral for assessment of cranial nerve function Referral for assessment of lymphatic system function Referral for further assessment of swallowing ability
Referral for further assessment of thyroid function A goiter (an enlarged thyroid gland) may appear as a large swelling at the base of the neck. This growth is not suggestive of impaired cranial nerve or lymphatic function, and it does not normally impair swallowing ability.
Which of the following is a symptom of the eye? Scotomas Tinnitus Dysphagia Rhinorrhea
Scotomas Explanation: Scotomas are specks in the vision or areas where the client cannot see; therefore, this is a common and concerning symptom of the eye. Tinnitus is a ringing in the ears, dysphagia is difficulty swallowing, and rhinorrhea is a "runny nose."
A community health nurse is attending a seminar on headaches. What would this nurse learn is a red flag for headaches? Stiff neck Pain centered behind the eyes Pain that is temporary Pain without new symptomatology
Stiff neck Explanation: Limitation of neck mobility may be from muscle tension/strain or cervical vertebral joint dysfunction.
The nursing instructor is discussing assessment of the head and neck with the class. What identifying characteristic would the instructor use for the thyroid cartilage? Its position just below the mandible The curve on its inferior edge Its relation to the cricoid cartilage The notch on its superior edge
The notch on its superior edge Explanation: The thyroid cartilage is readily identified by the notch on its superior edge.
During the health history, a client describes recent episodes of intermittent facial pain lasting several minutes. The nurse should recognize that this complaint is suggestive of what health problem? Trigeminal neuralgia Migraine headache Meningitis Temporomandibular joint dysfunction
Trigeminal neuralgia Explanation: Trigeminal neuralgia is manifested by sharp, shooting, piercing facial pain that lasts from seconds to minutes. Migraine headache is characterized by pain around the eyes, temples, cheeks, or forehead. Meningitis would be manifested by sudden head and neck pain, with fever and neck stiffness. Temporomandibular joint dysfunction is manifested by limited range of motion, swelling, tenderness, or crepitation in the jaw area. Chapter 10: The Head and Neck - Page 230
The meibomian glands secrete an oily substance to lubricate the eyes. sweat. hormones. clear liquid tears.
an oily substance to lubricate the eyes.
An adult client tells the nurse that his eyes are painful because he left his contact lenses in too long the day before yesterday. The nurse should instruct the client that prolonged wearing of contact lenses can lead to retinal damage. cataracts. myopia. corneal damage.
corneal damage. Improper cleaning or prolonged wearing of contact lenses can lead to infection and corneal damage.
An adult client visits the clinic and tells the nurse that she has had a sudden change in her vision. The nurse should explain to the client that sudden changes in vision are often associated with diabetes. the aging process. hypertension. head trauma.
head trauma. Sudden changes in vision are associated with acute problems such as head trauma or increased intracranial pressure.
A patient complains of feeling like he is slowly losing his central vision. The nurse knows this symptom could represent macular degeneration open-angle glaucoma hemianopsia retinal detachment
macular degeneration
The optic nerves from each eyeball cross at the optic chiasma. vitreous humor. optic disc. visual cortex.
optic chiasma. Explanation: At the point where the optic nerves from each eyeball cross—the optic chiasma—the nerve fibers from the nasal quadrant of each retina (from both temporal visual fields) cross over to the opposite side.
The nurse observes a middle-aged colleague fully extending her arm to read the label on a vial of medication. Which of the following age-related changes is the nurse likely to have observed? Presbyopia Cataract formation Loss of convergence Macular degeneration
presbyopia Explanation: Prebyopia denotes an age-related deficit in close vision. It is less likely that cataracts, macular degeneration, or loss of convergence underlie the colleague's visual changes. Chapter 11: The Eyes - Page 243
A client complains of a headache over both temporal areas. What type of headache should the nurse suspect the client is experiencing? cluster tension migraine hypertensive
tension Tension headaches often arise in the temporal areas. Cluster headaches typically occur behind the eyes. A throbbing, severe, unilateral headache that lasts 6-24 hours and is associated with photophobia, nausea, and vomiting suggests a migraine headache. Hypertensive is not a type of headache although individuals with hypertension may experience a headache upon arising in the morning.
An adult client tells the nurse that his father had cataracts. He asks the nurse about risk factors for cataracts. The nurse should instruct the client that a potential risk factor is lack of vitamin C in the diet. ultraviolet light exposure. obesity. use of antibiotics.
ultraviolet light exposure. Explanation: Exposure to ultraviolet radiation puts the client at risk for the development of cataracts (opacities of the lenses of the eyes). Consistent use of sunglasses during exposure minimizes the client's risk.
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? "In children, this problem is usually caused by an increase in pressure within the eye." "I'll prescribe some analgesics because your son is likely to have quite severe pain while his eye heals." "Antibiotics will clear this up, but you need to make sure he gets them as ordered to avoid vision damage." "This might have been the result of an allergy, but most likely it was caused by a bacteria or virus."
"This might have been the result of an allergy, but most likely it was caused by a bacteria or virus." Explanation: Conjunctivitis usually has an infectious etiology. Severe pain and vision damage are not common consequences.
A nurse examines a client with complaints of a sore throat and finds that the tonsils are just visible. Using a grading scale of 1+ to 4+, how should the nurse appropriately document the tonsils? 1+ 2+ 3+ 4+
1+ The nurse should document the tonsillar grading as 1+ because the tonsils are just visible. Grade 2 tonsils are midway between the tonsillar pillars and the uvula. Tonsils that touch the uvula are graded 3+, and tonsils that are so enlarged that they touch each other are graded 4+. Chapter 12: Ears, Nose, Mouth, and Throat - Page 305
Which vision acuity reading indicates blindness? 20/20 20/200 20/40 20/100
20/200 Explanation: The reading of 20/200 on a vision acuity test indicates blindness. The reading of 20/20 is considered normal vision. This means that the client being tested can distinguish what a person with normal vision can distinguish from 20 feet away. The top or first number is always 20, indicating the distance from the client to the chart. The bottom or second number refers to the last full line the client could read. The higher the second number, the poorer the vision. 20/40 and 20/100 also denote poor vision.
A nurse is assessing a small child who has lead poisoning. Which characteristic of the gums should the nurse expect this client? Pink, moist, firm Red, bleeding Enlarged, reddened A grey-white line
A grey-white line Explanation: A grey-white line along the gum line is seen in cases of lead poisoning. The nurse may find enlarged, reddened gums as an adverse effect of phenytoin treatment. Pink, moist, firm gums are normal findings of the gums. Red, swollen, bleeding gums are seen in gingivitis, scurvy, and leukemia. p. 302.
While assessing the ears of an 8-year-old client, the nurse observes white spots on the tympanic membrane with no redness present. Which action would be most appropriate? Assess the client for trauma to the skull. Determine whether impacted cerumen is present. Ask the mother whether the child has had numerous ear infections. Assess the child for further symptoms of acute otitis media.
Ask the mother whether the child has had numerous ear infections. Explanation: White spots on the tympanic membrane indicate scarring from previous infections. Therefore the nurse would ask the mother about a history of previous ear infections. A bluish or dark red color to the membrane would suggest skull trauma. Impacted cerumen would prevent the nurse from viewing the tympanic membrane. A red, bulging eardrum and a distorted, diminished, or absent light reflex would suggest acute otitis media.
Which technique by the nurse demonstrates proper use of the ophthalmoscope? Uses right eye to examine the client's left eye Moves the scope around so the entire optic disk may be seen Approaches the client directly in front of the pupil Asks the client to fix the gaze upon an object and look straight ahead
Asks the client to fix the gaze upon an object and look straight ahead Explanation: After turning on the ophthalmoscope, the nurse should ask the client to gaze straight ahead and slightly upward. Ask the client to remove glasses but keep contact lens in place. The nurse should use the right eye to examine the right eye & left eye to examine the client's left eye. This allows the nurse to get as close as possible to the client's eye. Begin about 10-15 inches from the client at a 15 degree angle. The nurse should keep the ophthalmoscope still & ask the client to look into the light to view the fovea and macula.
A nurse has performed the corneal light reflex test during a client's eye examination. During this test, the nurse appraised the client's eye alignment in which way? By comparing the reflection of the light on the client's eye surface By comparing the speed of pupillary constriction By comparing how quickly the client blinks each eyelid By comparing the relative color of the sclerae before and after light exposure
By comparing the reflection of the light on the client's eye surface During the corneal light reflex test, the reflection of light on the corneas is assessed and should be in the exact same spot on each eye, indicating parallel alignment. Constriction, color of the sclerae, and blinking are not appraised.
While the nurse is assessing a client for an unrelated health concern, the client experiences a sudden, severe headache with no known cause. He also complains of dizziness and trouble seeing out of one eye. What associated condition should the nurse suspect in this client? Diabetes Brain tumor Impending stroke Hyperthyroidism
Impending stroke Explanation: A sudden, severe headache with no known cause may be a sign of impending stroke, particularly if accompanied by sudden trouble seeing in one or both eyes or sudden trouble walking, dizziness, and loss of balance or coordination. Only impending stroke is associated with all of these symptoms. Diabetes is not associated with headache or the other symptoms. A tumor-related headache is aching and steady and not necessarily associated with sudden onset. Hyperthyroidism is associated with goiter, bruit, and sudden weight loss, but not with any of the symptoms listed. Chapter 10: The Head and Neck - Page 213
What part of the eye receives and transmits visual stimuli to the brain for processing? Retina Optic disc Posterior chamber Vitreous chamber
Retina Explanation: The retina, which is the innermost layer of the eye, receives and transmits visual stimuli to the brain for processing. The posterior and vitreous chambers of the eye contain aqueous and vitreous humor of the eye. The optic disc, a well-defined round or oval area, is the opening for the optic nerve head.
On examination of a client, the nurse detects a fecal odor to the breath. The nurse recognizes this finding as characteristic of what disease process? End-stage liver disease Small bowel obstruction Diabetic ketoacidosis Respiratory infection
Small bowel obstruction Explanation: Clients with small bowel obstructions have a fecal smell to their breath. The nurse should suspect the client of having diabetic ketoacidosis if there is a fruity smell on the breath. Clients with end-stage liver disease have a sulfur odor in their breath. Clients with respiratory infection have foul odors in their breath. Chapter 12: Ears, Nose, Mouth, and Throat - Page 303
A 12-year-old presents to the clinic with his father for evaluation of a painful lump in the left eye. It started this morning. The client denies any trauma or injury. There is no visual disturbance. Upon physical examination, there is a red raised area at the margin of the eyelid that is tender to palpation; no tearing occurs with palpation of the lesion. Based on this description, what is the most likely diagnosis? Dacryocystitis Chalazion Stye Xanthelasma
Stye A hordeolum or stye is a painful, tender, erythematous infection in a gland at the margin of the eyelid. Chalazion is a subacute nontender and usually painless nodule involving a meibomian gland. May become acutely inflamed but, unlike a sty, usually points inside the lid rather than on the lid margin. p267
A 15-year-old high school student presents to the emergency department with his mother for evaluation of an area of blood in the left eye. He denies trauma or injury but has been coughing forcefully with a recent cold. He denies visual disturbances, eye pain, or discharge from the eye. On physical examination, the pupils are equal, round, and reactive to light with a visual acuity of 20/20 in each eye and 20/20 bilaterally. There is a homogeneous, sharply demarcated area at the lateral aspect of the base of the left eye. The cornea is clear. Based on this description, what is the most likely diagnosis? Conjunctivitis Acute iritis Corneal abrasion Subconjunctival hemorrhage
Subconjunctival hemorrhage A subconjunctival hemorrhage is a leakage of blood outside of the vessels, which produces a homogenous, sharply demarcated bright red area; it fades over several days, turns yellow, then disappears. There is no associated eye pain, ocular discharge, or changes in visual acuity; the cornea is clear. Many times it is associated with severe cough, choking, or vomiting, which increase venous pressure. It is rare for a serious condition to cause it, so reassurance is usually the only treatment necessary.
A client seeks medical attention for sharp, shooting facial pain that lasts for several minutes at a time. For which health problem should the nurse assess this client? Cluster headache Tension headache Migraine headache Trigeminal neuralgia
Trigeminal neuralgia Explanation: Trigeminal neuralgia is manifested by sharp, shooting, piercing facial pain that lasts from seconds to minutes. The pain occurs over the divisions of the fifth trigeminal cranial nerve. A headache associated with a fever or high blood pressure is a cluster headache. Tension headaches are caused by tightening of facial and neck muscles. Migraine headaches are provoked by hormone fluctuations. Chapter 10: The Head and Neck - Page 230
A parent is very upset because she is told her child has a refractive error. The nurse reassures the parent that refractive errors are the most common visual change in children. True False
True Strabismus is eye misalignment; these are found most frequently in infants and children up to 5 years old. Screening tests for detecting strabismus and amblyopia include simple inspection, the cover-uncover test, corneal light reflex, and visual acuity tests. The most common visual change in school-age children, adolescents, and young adults is refractive errors. Most school-age children are screened in school, and young adults present to their health care provider when they have changes in vision or are tested for driving examinations, employment, or physicals. The Snellen vision chart is used for the screening examination. p263
