assessment exam 2 - questions

When examining a patient's CN function, what muscles should the nurse assess to assess the function of CN XI? (A) Sternomastoid and trapezius (B) Spinal accessory and omohyoid (C) Trapezius and sternomandibular (D) Sternomandibular and spinal accessory

(A) Sternomastoid and trapezius The muscles innervated by CN XI are the sternomastoid and the trapezius muscles in the neck. Options B, C, and D are incorrect because the spinal accessory is not a muscle but the name of CN XI and there is no sternomandibular muscle.

During an examination of a female patient, the nurse notes lymphadenopathy and suspects an acute infection. How do acutely infected lymph nodes typically appear? (A) Clumped (B) Unilateral (C) Firm but freely movable (D) Soft and nontender

(C) Firm but freely movable Acutely infected lymph nodes are bilateral, enlarged, warm, tender, and firm but freely movable. Unilaterally enlarged nodes that are firm and nontender may indicate cancer.

A patient comes into the clinic reporting pain in her O.D. On examination, the nurse sees a pustule at the lid margin that is painful to touch, red, and swollen. What is the correct term for this finding? (A) Chalazion (B) Hordeolum (C) Blepharitis (D) Dacryocystitis

(B) Hordeolum A hordeolum, or stye, is a painful, red, and swollen pustule at the lid margin. A chalazion is a nodule protruding on the lid, toward the inside, and is nontender, firm, with discrete swelling. Dacryocystitis is an inflammation of the lacrimal sac. Blepharitis is inflammation of the eyelids. The painful, red, swollen pustule at the lid margin on this patient's eyelid is a hordeolum or stye.

The nurse is testing a patient's visual accommodation. How is accommodation assessed? (A) Pupillary dilation when looking at a distant object (B) Involuntary blinking in the presence of bright light (C) Pupillary constriction when looking at a near object (D) Changes in peripheral vision in response to bright light

(C) Pupillary constriction when looking at a near object The muscle fibers of the iris contract the pupil in bright light and accommodate for near vision, which also results in pupil constriction. The other responses are not correct.

While discussing the history of a 6-month-old infant, the mother tells the nurse that she took a significant amount of aspirin while she was pregnant. What question would the nurse want to include in the history? (A) "Does your baby seem to startle with loud noises?" (B) "Has your baby had any surgeries on her ears?" (C) "Have you noticed any drainage from her ears?" (D) "How many ear infections has your baby had since birth?"

(A) "Does your baby seem to startle with loud noises?" Children exposed in utero to a variety of conditions, such as maternal rubella or to maternal ototoxic drugs are at risk for hearing deficits. Aspirin can be ototoxic, so the nurse should ask if the baby seems to startle with loud noises.

During a well-baby checkup, a mother is concerned because her 2-month-old infant cannot hold her head up when she is pulled to a sitting position. Which response by the nurse is appropriate? (A) "Head control is usually achieved by 4 months of age." (B) "You shouldn't be trying to pull your baby up like that until she is older." (C) "Head control should be achieved by this time." (D) "This inability indicates possible nerve damage to the neck muscles."

(A) "Head control is usually achieved by 4 months of age." Head control is achieved by 4 months when the baby can hold the head erect and steady when pulled to a vertical position. The other responses are not appropriate.

The nurse is assessing a patient who may have hearing loss. Which of these statements is true concerning air conduction? (A) Air conduction is the normal pathway for hearing. (B) Amplitude of sound determines the pitch that is heard. (C) Vibrations of the bones in the skull cause air conduction. (D) Loss of air conduction is called a conductive hearing loss.

(A) Air conduction is the normal pathway for hearing. The normal pathway of hearing is air conduction, which starts when sound waves produce vibrations on the tympanic membrane. Conductive hearing loss results from a mechanical dysfunction of the external or middle ear. The other statements are not true concerning air conduction. The frequency of sound waves is what determines pitch, not the amplitude. Vibrations of the bones in the skull are bone conduction, not air conduction. Conductive hearing loss involves mechanical dysfunction of the external or middle ear and is caused by impacted cerumen, foreign bodies, a perforated tympanic membrane, pus or serum in the middle ear, and otosclerosis, not loss of air conduction.

A physician tells the nurse that a patient's vertebra prominens is tender and asks the nurse to reevaluate the area in 1 hour. What area of the body will the nurse assess? (A) At the level of the C7 vertebra (B) At the level of the T11 vertebra (C) At the level of the L5 vertebra (D) At the level of the S3 vertebra

(A) At the level of the C7 vertebra The C7 vertebra has a long spinous process, called the vertebra prominens, which is palpable when the head is flexed.

A mother brings her newborn in for an assessment and asks, "Is there something wrong with my baby? His head seems so big." Which statement is true regarding the relative proportions of the head and trunk of the newborn? (A) At birth, the head is one fifth the total length. (B) Head circumference should be greater than chest circumference at birth. (C) The head size reaches 90% of its final size when the child is 3 years old. (D) When the anterior fontanel closes at 2 months, the head will be more proportioned to the body.

(B) Head circumference should be greater than chest The nurse recognizes that during the fetal period, head growth predominates. Head size is greater than chest circumference at birth, and the head size grows during childhood, reaching 90% of its final size when the child is age 6 years.

The nurse is performing an assessment on a 7-year-old child who has symptoms of chronic watery eyes, sneezing, and clear nasal drainage. The nurse notices the presence of a transverse line across the bridge of the nose, dark blue shadows below the eyes, and a double crease on the lower eyelids. What does the nurse suspect is the cause of these signs and symptoms? (A) Chronic allergies (B) Lymphadenopathy (C) Nasal congestion (D) Upper respiratory infection

(A) Chronic allergies Chronic allergies often develop chronic facial characteristics and include blue shadows below the eyes, a double or single crease on the lower eyelids, open-mouth breathing, and a transverse line on the nose. Lymphadenopathy means enlargement of lymph nodes from infection, allergy, or neoplasm, it is a sign of allergies, not a cause. Although nasal congestion and upper respiratory infections may present with watery eyes and sneezing, people with nasal congestion usually state congestion or a pressure feeling in their head and people with upper respiratory infections often have a cough and/or sore throat and don't have a transverse line across the bridge of the nose, dark blue shadows under the eyes, or a double crease on the lower eyelids. The signs and symptoms of this patient are likely from chronic allergies.

A 2-week-old infant can fixate on an object but cannot follow a light or bright toy. What should the nurse do? (A) Consider this a normal finding. (B) Continue with the examination, and assess visual fields. (C) Assess the pupillary light reflex for possible blindness. (D) Expect that a 2-week-old infant should be able to fixate and follow an object.

(A) Consider this a normal finding. This is a normal finding. By 2 to 4 weeks an infant can fixate on an object. By the age of 1 month, the infant should fixate and follow a bright light or toy. This is a normal finding. The nurse cannot assess visual fields as the infant cannot follow instructions; assessing the pupillary light reflex does not assess for blindness; and the nurse should not expect the infant to be able follow an object. An infant can fixate on an object by 2 to 4 weeks and by the age of 1 month, should be able to fixate and follow a bright light or toy.

When examining children affected with Down syndrome (trisomy 21), what should the nurse look for r/t this disorder? (A) Ear dysplasia (B) Long, thin neck (C) Protruding thin tongue (D) Narrow and raised nasal bridge

(A) Ear dysplasia With the chromosomal aberration trisomy 21, also known as Down syndrome, head and face characteristics may include upslanting eyes with inner epicanthal folds, a flat nasal bridge, a small broad flat nose, a protruding thick tongue, ear dysplasia, a short broad neck with webbing, and small hands with a single palmar crease. A short broad neck with webbing, rather than a long, thin neck; a protruding thick tongue, not a thin tongue; and a flat nasal bridge, not a raised nasal bridge are associated with Down syndrome.

When examining the eye, the nurse notices that the patient's eyelid margins approximate completely. What does the nurse understand about this assessment finding? (A) It is expected. (B) It may result in problems with tearing. (C) It indicates increased intraocular pressure. (D) It may indicate a problem with extraocular muscles.

(A) It is expected. The palpebral fissure is the elliptical open space between the eyelids, and, when closed, the lid margins approximate completely, which is a normal finding. This is a normal finding and does not result in problems with tearing or indicate problems with increase intraocular pressure or extraocular muscles.

The nurse is reviewing the age-related changes in the eye for a class. Which of these physiologic changes is responsible for presbyopia? (A) Loss of lens elasticity (B) Degeneration of the cornea (C) Decreased adaptation to darkness (D) Decreased distance vision abilities

(A) Loss of lens elasticity The lens loses elasticity and decreases its ability to change shape to accommodate for near vision. This condition is called presbyopia.

A 68-year-old woman is in the eye clinic for a checkup. She tells the nurse that she has been having trouble reading the paper, sewing, and even seeing the faces of her grandchildren. On examination, the nurse notes that she has some loss of central vision but her peripheral vision is normal. What do these findings suggest? (A) Macular degeneration (B) Vision that is normal for someone her age (C) The beginning stages of cataract formation (D) Increased intraocular pressure or glaucoma

(A) Macular degeneration Macular degeneration is characterized by the loss of central vision and is the most common cause of blindness. Cataracts would show lens opacity. Chronic open-angle glaucoma, the most common type of glaucoma, involves a gradual loss of peripheral vision. These findings are not consistent with normal vision at this, or any, age. These findings are not consistent with normal vision at this, or any, age. The increased intraocular pressure of chronic open-angle glaucoma, the most common type of glaucoma, involves a gradual loss of peripheral vision but not central vision. The symptoms this patient has suggest macular degeneration. Macular degeneration is characterized by the loss of central vision and is the most common cause of blindness.

The nurse is examining a patient's retina with an ophthalmoscope. Which finding is considered normal? (A) Optic disc that is a yellow-orange color. (B) Presence of pigmented crescents in the macular area. (C) Optic disc margins that are blurred around the edges. (D) Presence of the macula located on the nasal side of the retina.

(A) Optic disc that is a yellow-orange color. The optic disc is located on the nasal side of the retina. Its color is a creamy yellow-orange to a pink, and the edges are distinct and sharply demarcated, not blurred. A pigmented crescent is black and is due to the accumulation of pigment in the choroid. Presence of pigmented crescents in the macular area is an abnormal finding. A pigmented crescent is black and is due to the accumulation of pigment in the choroid. The optic dish margins are normally distinct and sharply demarcated, not blurred around the edges. The macula is located on the temporal side of the fundus of the eye, not on the nasal side of the retina. The correct answer of a normal finding is that the optic disc is a yellow-orange color.

When performing the corneal light reflex assessment, the nurse notes that the light is reflected at 2 o'clock in each eye. What should the nurse do regarding this finding? (A) Record this as a normal finding. (B) Refer the individual for further evaluation. (C) Document this finding as an asymmetric light reflex. (D) Perform the confrontation test to validate the findings.

(A) Record this as a normal finding. Reflection of the light on the corneas should be in exactly the same spot on each eye, or symmetric. If asymmetry is noted, then the nurse should administer the cover test.

The nurse is performing an external eye examination. Which statement regarding the outer layer of the eye is true? (A) The outer layer of the eye is very sensitive to touch. (B) The outer layer of the eye is darkly pigmented to prevent light from reflecting internally. (C) The trigeminal nerve (CN V) and the trochlear nerve (CN IV) are stimulated when the outer surface of the eye is stimulated. (D) The visual receptive layer of the eye in which light waves are changed into nerve impulses is located in the outer layer of the eye.

(A) The outer layer of the eye is very sensitive to touch. The cornea and the sclera make up the outer layer of the eye. The cornea is very sensitive to touch. The middle layer, the choroid, has dark pigmentation to prevent light from reflecting internally. The trigeminal nerve (CN V) and the facial nerve (CN VII), not the trochlear nerve (IV), are stimulated when the outer surface of the eye is stimulated. The retina, in the inner layer of the eye, is where light waves are changed into nerve impulses. The outer layer of the eye is not darkly pigmented, the sclera is white and the cornea is transparent. It is the middle layer, the choroid, that has dark pigmentation to prevent light from reflecting internally. The true statement about the outlayer of the eye is that it is made up of the cornea and the sclera.

A patient's laboratory data reveal an elevated thyroxine (T4) level. What gland should the nurse assess? (A) Thyroid (B) Parotid (C) Adrenal (D) Parathyroid

(A) Thyroid The thyroid gland is a highly vascular endocrine gland that secretes T4 and triiodothyronine (T3). The other glands do not secrete T4. The parotid glands are salivary glands and secrete saliva. The adrenal glands secrete corticosteroids, not T4, and the parathyroid glands control the body's calcium. The gland that secretes thyroxine, or T4, is the thyroid gland. The thyroid gland is a highly vascular endocrine gland that secretes thyroxine (T4) and triiodothyronine (T3).

During an examination, the nurse knows that the best way to palpate the lymph nodes in the neck is described by which statement? (A) Using gentle pressure, palpate with both hands to compare the two sides. (B) Using strong pressure, palpate with both hands to compare the two sides. (C) Gently pinch each node between one's thumb and forefinger, and then move down the neck muscle. (D) Using the index and middle fingers, gently palpate by applying pressure in a rotating pattern.

(A) Using gentle pressure, palpate with both hands to compare the two sides. Using gentle pressure is recommended because strong pressure can push the nodes into the neck muscles. Palpating with both hands to compare the two sides symmetrically is usually most efficient.

A mother is concerned because her 18-month-old toddler has 12 teeth. She is wondering if this is normal for a child of this age. Which is the best response by the nurse? (A) "How many teeth did you have at this age?" (B) "This is a normal number of teeth for an 18 month old." (C) "Normally, by age 2 1/2 years, 16 deciduous teeth are expected." (D) "All 20 deciduous teeth are expected to erupt by age 4 years."

(B) "This is a normal number of teeth for an 18 month old." The guidelines for the number of teeth for children younger than 2 years old are as follows: the child's age in months minus the number 6 should be equal to the expected number of deciduous teeth. Normally all 20 teeth are in by 2 1/2 years old. In this instance, the child is 18 months old, minus 6, equals 12 deciduous teeth expected.

During an assessment, the nurse notices that an older adult patient has tears rolling down his face from his O.S. Closer examination shows that the lower lid is loose and rolling outward. The patient complains of his eye feeling "dry and itchy." Which action by the nurse is correct? (A) Documenting the finding as ptosis (B) Assessing for other signs of ectropion (C) Assessing the eye for a possible foreign body (D) Contacting the prescriber; these are signs of basal cell carcinoma

(B) Assessing for other signs of ectropion The condition described is known as ectropion, and it occurs in older adults and is attributable to atrophy of the elastic and fibrous tissues. The lower lid does not approximate to the eyeball, and, as a result, the puncta cannot effectively siphon tears; excessive tearing results. Ptosis is a drooping of the upper eyelid. These signs do not suggest the presence of a foreign body in the eye or basal cell carcinoma

A patient's thyroid gland is enlarged, and the nurse is preparing to auscultate the thyroid gland for the presence of a bruit. What technique should the nurse use to assess for a bruit? (A) Palpate the thyroid while the patient is swallowing. (B) Auscultate the thyroid with the bell of the stethoscope. (C) Palpate the thyroid while the patient holds their breath. (D) Auscultate the thyroid with the diaphragm of the stethoscope.

(B) Auscultate the thyroid with the bell of the stethoscope. If the thyroid gland is enlarged, then the nurse should auscultate it for the presence of a bruit, which is a soft, pulsatile, whooshing, blowing sound heard best with the bell of the stethoscope. A bruit is a soft, pulsatile, whooshing, blowing sound. A bruit occurs with accelerated or turbulent blood flow. It is not able to be palpated. A bruit is heard best with the bell, not the diaphragm of the stethoscope.

A patient reports excruciating headache pain on one side of his head, especially around his eye, forehead, and cheek that has lasted approximately 1 2 to 2 hours, occurring once or twice each day. What should the nurse suspect? (A) Hypertension (B) Cluster headaches (C) Tension headaches (D) Migraine headaches

(B) Cluster headaches Cluster headaches produce pain around the eye, temple, forehead, and cheek and are unilateral and always on the same side of the head. They are excruciating and occur once or twice per day and last 1/2 to 2 hours each. Although hypertension may cause headaches, the blood pressure needs to be severely elevated and would likely not occur once or twice a day and last for 1/2 to 2 hours. Tension headaches are occipital, frontal, or with bandlike tightness. Migraine headaches are supraorbital, retro-orbital, or frontotemporal.

Which of these assessment findings would the nurse expect to see when examining the eyes of a black patient? (A) Increased night vision (B) Dark retinal background (C) Increased photosensitivity (D) Narrowed palpebral fissures

(B) Dark retinal background An ethnically based variability in the color of the iris and in retinal pigmentation exists, with darker irides having darker retinas behind them.

During an assessment of an infant, the nurse notes that the fontanels are depressed and sunken. The nurse suspects which condition? (A) Rickets (B) Dehydration (C) Mental retardation (D) Increased intracranial pressure

(B) Dehydration Depressed and sunken fontanels occur with dehydration or malnutrition. Mental retardation and rickets have no effect on the fontanels. Increased intracranial pressure would cause tense or bulging and possibly pulsating fontanels.

During a physical education class, a student is hit in the eye with the end of a baseball bat. When examined in the emergency department, the nurse notices the presence of blood in the anterior chamber of the eye. What does this finding indicate? (A) Hypopyon (B) Hyphema (C) Pterygium (D) A corneal abrasion

(B) Hyphema Hyphema is the term for blood in the anterior chamber and is a serious result of blunt trauma (a fist or a baseball) or spontaneous hemorrhage and may indicate scleral rupture or major intraocular trauma. Hypopyon is the term for lager of white blood cells in the anterior chamber and often cause pain, red eye, and possibly decreased vision. Pterygium is the term for a triangular opaque wing of bulbar conjunctive overgrows toward the center of the cornea. It looks membranous, translucent, and yellow to white. A corneal abrasion is the term for damage or removal of the top layer of corneal epithelium, usually a result of scratches or poorly fitting or overworn contact lenses. The person with a corneal abrasion usually feels intense pain; a foreign body sensation; and lacrimation, redness, and photophobia. The presence of blood in the anterior chamber that this patient has is hyphema.

A patient has come in for an examination and states, "I have this spot in front of my ear lobe on my cheek that seems to be getting bigger and is tender. What do you think it is?" The nurse notes swelling below the angle of the jaw. What does the nurse suspect? (A) Inflammation of the thyroid gland (B) Inflammation of the parotid gland (C) Infection in the occipital lymph node (D) Infection in the submental lymph node

(B) Inflammation of the parotid gland Swelling of the parotid gland is evident below the angle of the jaw and is most visible when the head is extended. Painful inflammation occurs with mumps, and swelling also occurs with abscesses or tumors. Swelling occurs anterior to the lower ear lobe.

During ocular examinations, what should the nurse keep in mind regarding the movement of the extraocular muscles? (A) Is decreased in the older adult. (B) Is stimulated by CNs III, IV, and VI. (C) Is impaired in a patient with cataracts. (D) Is stimulated by cranial nerves (CNs) I and II.

(B) Is stimulated by CNs III, IV, and VI. Movement of the extraocular muscles is stimulated by three CNs: III, IV, and VI. Aging and cataracts do not affect the extraocular movements. Movement of the extraocular muscles is not stimulated by CNs I and II but by CNs III, IV, and VI.

A patient says that she has recently noticed a lump in the front of her neck below her "Adam's apple" that seems to be getting bigger. During the assessment, what finding would lead the nurse to suspect that this may not be a cancerous thyroid nodule? (A) It is tender. (B) It is mobile and soft. (C) It disappears when the patient smiles. (D) It is hard and fixed to the surrounding structures.

(B) It is mobile and soft. Painless, rapidly growing nodules may be cancerous, especially the appearance of a single nodule in a young person. However, cancerous nodules tend to be hard and fixed to surrounding structures, not mobile.

A woman comes to the clinic and states, "I've been sick for so long! My eyes have gotten so puffy, and my eyebrows and hair have become coarse and dry." For what condition should the nurse assess for other signs and symptoms? (A) Cachexia (B) Myxedema (C) Graves disease (D) Parkinson syndrome

(B) Myxedema Myxedema (hypothyroidism) is a deficiency of thyroid hormone that, when severe, causes a nonpitting edema or myxedema. The patient will have a puffy edematous face, especially around the eyes (periorbital edema); coarse facial features; dry skin; and dry, coarse hair and eyebrows. Cachexia, or cachectic appearance, accompanies chronic wasting diseases such as cancer, dehydration, and starvation. Features included sunken eyes, hollow cheeks, and exhausted, defeated expression. Graves disease is an autoimmune disease with increased production of thyroid hormones which is manifested by goiter, eyelid retraction, and exophthalmos (bulging eyeballs) and other symptoms. The facial features characteristic of Parkinson syndrome are a flat and expressionless, "masklike," with elevated eyebrows, staring gaze, oily skin, and drooling. The signs and symptoms of this patient are characteristic of myxedema, or hypothyroidism.

The nurse has just completed a lymph node assessment on a 60-year-old healthy female patient. When palpating the nodes on this healthy 60-year-old adult, how did the lymph nodes feel? (A) Fixed (B) Nonpalpable (C) Rubbery, discrete, and mobile (D) Large, firm, and fixed to the tissue

(B) Nonpalpable Most lymph nodes are nonpalpable in adults. The palpability of lymph nodes decreases with age. Normal nodes feel movable, discrete, soft, and nontender.

The nurse is assessing a 1-month-old infant at his well-baby checkup. Which assessment findings are appropriate for this age? (Select all that apply.) (A) Absent tonic neck reflex (B) Nonpalpable cervical lymph nodes (C) Fontanels firm and slightly concave (D) Head circumference equal to chest circumference (E) Head circumference less than chest circumference (F) Head circumference greater than chest circumference

(B) Nonpalpable cervical lymph nodes (C) Fontanels firm and slightly concave (F) Head circumference greater than chest circumference An infant's head circumference is larger than the chest circumference. At age 2 years, both measurements are the same. During childhood, the chest circumference grows to exceed the head circumference by 5 to 7 cm. The fontanels should feel firm and slightly concave in the infant, and they should close by age 9 months. The tonic neck reflex is present until between 3 and 4 months of age, and cervical lymph nodes are normally nonpalpable in an infant.

A 31-year-old patient tells the nurse that he has noticed a progressive loss in his hearing. He says that it does seem to help when people speak louder or if he turns up the volume of a television or radio. What is the most likely cause of this hearing loss? (A) Presbycusis (B) Otosclerosis (C) Trauma to the bones (D) Frequent ear infections

(B) Otosclerosis Otosclerosis is a common cause of conductive hearing loss in young adults between the ages of 20 and 40 years. Presbycusis is a type of hearing loss that occurs with aging. Trauma and frequent ear infections are not a likely cause of his hearing loss. Instead, a common cause of conductive hearing loss (mechanical dysfunction of the external or middle ear which causes partial hearing loss that can be compensated for with an increase in amplitude) in young adults between the ages of 20 and 40 years is otosclerosis.

In a patient who has anisocoria, what would the nurse expect to observe? (A) Dilated pupils (B) Excessive tearing (C) Pupils of unequal size (D) Uneven curvature of the lens

(C) Pupils of unequal size Unequal pupil size is termed anisocoria. It normally exists in 5% of the population but may also be indicative of central nervous system disease. Dilated pupils, excessive tearing, and uneven curvature of the lens are not associated with anisocoria. Anisocoria is the term for unequal pupil size. It exists in about 5% of the population but may also be indicative of central nervous system disease.

The nurse is performing the diagnostic positions test. Which result is a normal finding? (A) Convergence of the eyes (B) Parallel movement of both eyes (C) Nystagmus in extreme superior gaze (D) Slight amount of lid lag when moving the eyes from a superior to an inferior position

(B) Parallel movement of both eyes A normal response for the diagnostic positions test is parallel tracking of the object with both eyes. Eye movement that is not parallel indicates a weakness of an extraocular muscle or dysfunction of the CN that innervates it. The diagnostic positions test assesses for any muscle weakness during movement of the eye by leading the eyes through the six cardinal positions of gaze. It is not assessing the ability of the eyes to converge, or move toward each other. Nystagmus with an extreme superior gaze is normal, but not in any other position and lid lag is not normal.

A male patient with a history of acquired immunodeficiency syndrome (AIDS) has come in for an examination and states, "I think that I have the mumps." What should the nurse examine first? (A) Thyroid gland (B) Parotid gland (C) Cervical lymph nodes (D) Mouth and skin for lesions

(B) Parotid gland The parotid gland may become swollen with the onset of mumps, and parotid enlargement has been found with HIV.

When examining the face of a patient, what are the two pairs of salivary glands that are accessible for examination? (A) Occipital; submental (B) Parotid; submandibular (C) Submandibular; occipital (D) Sublingual; parotid

(B) Parotid; submandibular The two pairs of salivary glands accessible to examination on the face are the parotid glands, which are in the cheeks over the mandible, anterior to and below the ear; and the submandibular glands, which are beneath the mandible at the angle of the jaw. The parotid glands are normally nonpalpable. The occipital and submental are lymph nodes, not glands and the sublingual glands lie on the floor of the mouth, so are not readily accessible for examination. The two pairs of salivary glands that are accessible for examination on the face are the parotid glands, which are in the cheeks over the mandible, anterior to and below the ear; and the submandibular glands, which are beneath the mandible at the angle of the jaw.

A patient's vision is recorded as 20/80 in each eye. How does the nurse interpret this finding? (A) Patient has presbyopia. (B) Patient as poor vision. (C) Patient has acute vision. (D) Patient has normal vision.

(B) Patient as poor vision. Normal visual acuity is 20/20 in each eye; the larger the denominator, the poorer the vision. Presbyopia is a decrease in accommodation which is observed by convergence (motion toward) of the axes of the eyeballs and pupillary constriction and is tested by having the person focus on a distant object.

When examining the ear with an otoscope, how should the tympanic membrane look? (A) Light pink with a slight bulge (B) Pearly gray and slightly concave (C) Whitish with black flecks or dots (D) Pulled in at the base of the cone of light

(B) Pearly gray and slightly concave The tympanic membrane is a translucent membrane with a pearly gray color and a prominent cone of light in the anteroinferior quadrant, which is the reflection of the otoscope light. The tympanic membrane is oval and slightly concave, pulled in at its center by the malleus, which is one of the middle ear ossicles. A light pink color and a slight bulge of the tympanic membrane indicate otitis media. It should not look white and if there are tiny black flecks or dots, that is indicative of a fungal infection, or otomycosis. The tympanic membrane does not appear pulled in at the base of the cone of light, but should instead appear flat and slightly pulled in at the center. A normal tympanic membrane should appear a pearly gray color and have a prominent cone of light in the anteroinferior quadrant, which is the reflection of the otoscope light. The tympanic membrane is oval and slightly concave, pulled in at its center by the malleus, which is one of the middle ear ossicles.

During an assessment of the sclera of a black patient, the nurse would consider which of these an expected finding? (A) Yellow fatty deposits over the cornea (B) Presence of small brown macules on the sclera (C) Pallor near the outer canthus of the lower lid (D) Yellow color of the sclera that extends up to the iris

(B) Presence of small brown macules on the sclera Normally in dark-skinned people, small brown macules may be observed in the sclera. Blacks may have yellowish fatty deposits beneath the eyelids, away from the cornea, not over the cornea or extending up to the iris. Pallor near the outer canthus is not normal, but may indicate anemia.

A patient in her first trimester of pregnancy is diagnosed with rubella. Which of these statements is correct regarding the significance of this in relation to the infant's hearing? (A) Rubella may affect the mother's hearing but not the infant's. (B) Rubella can damage the infant's organ of Corti, which will impair hearing. (C) Rubella can impair the development of cranial nerve VIII and thus affect hearing. (D) Rubella is especially dangerous to the infant's hearing in the second trimester of pregnancy.

(B) Rubella can damage the infant's organ of Corti, which will impair hearing. If maternal rubella infection occurs during the first trimester, then it can damage the organ of Corti and impair hearing. Maternal rubella can affect the infant's hearing, not the mother's hearing, if it occurs in the first trimester of pregnancy. Hearing is impaired due to damage to the organ of Corti, not cranial nerve VIII. Rubella does not impair the development of cranial nerve VIII.

The nurse suspects that a patient has hyperthyroidism, and the laboratory data indicate that the patient's T4 and T3 hormone levels are elevated. Which of these findings would the nurse most likely find on examination? (A) Dyspnea (B) Tachycardia (C) Constipation (D) Atrophied nodular thyroid gland

(B) Tachycardia T4 and T3 are thyroid hormones that stimulate the rate of cellular metabolism, resulting in tachycardia. With an enlarged thyroid gland as in hyperthyroidism, the nurse might expect to find diffuse enlargement (goiter) or a nodular lump but not an atrophied gland. Dyspnea and constipation are not findings associated with hyperthyroidism.

The nurse is conducting a visual examination. Which of these statements regarding visual pathways and visual fields is true? (A) The right side of the brain interprets the vision for the O.D. (B) The image formed on the retina is upside down and reversed from its actual appearance in the outside world. (C) Light rays are refracted through the transparent media of the eye before striking the pupil. (D) Light impulses are conducted through the optic nerve to the temporal lobes of the brain.

(B) The image formed on the retina is upside down and reversed from its actual appearance in the outside world. The image formed on the retina is upside down and reversed from its actual appearance in the outside world. The light rays are refracted through the transparent media of the eye before striking the retina, and the nerve impulses are conducted through the optic nerve tract to the visual cortex of the occipital lobe of the brain. The left side of the brain interprets vision for the O.D.

A patient's vision is recorded as 20/30 when the Snellen eye chart is used. How should the nurse interpret these results? (A) At 30 feet the patient can read the entire chart. (B) The patient can read at 20 feet what a person with normal vision can read at 30 feet. (C) The patient can read the chart from 20 feet in the O.S. and 30 feet in the O.D. (D) The patient can read from 30 feet what a person with normal vision can read from 20 feet.

(B) The patient can read at 20 feet what a person with normal vision can read at 30 feet. The top number indicates the distance the person is standing from the chart; the denominator gives the distance at which a normal eye can see.

The nurse is performing an eye assessment on an 80-year-old patient. Which of these findings is considered abnormal? (A) Decrease in tear production (B) Unequal pupillary constriction in response to light (C) Presence of arcus senilis observed around the cornea (D) Loss of the outer hair on the eyebrows attributable to a decrease in hair follicles

(B) Unequal pupillary constriction in response to light Pupils are small in the older adult, and the pupillary light reflex may be slowed, but pupillary constriction should be symmetric. The assessment findings in the other responses are considered normal in older people. Decrease in tear production, presence of arcus senilis around the cornea, and loss of outer hair on the eyebrows are normal findings in the aging adult. Although pupils are small in the older adult, and the pupillary light reflex may be slowed, the pupillary constriction should be symmetric. Therefore, unequal pupillary constriction in response to light is an abnormal finding.

The nurse notices that a patient's palpebral fissures are not symmetric. On examination, the nurse may find that damage has occurred to which cranial nerve (CN)? (A) V (B) VII (C) XI (D) XIII

(B) VII Facial muscles are mediated by CN VII; asymmetry of palpebral fissures may be attributable to damage to CN VII (Bell palsy). Cranial nerve V, the trigeminal nerve, mediates facial sensations of pain and touch. Cranial nerve XI is the spinal accessory nerve that innervates the sternomastoid and trapezius muscles of the neck. There is no cranial nerve XIII (only 12 cranial nerves).

During an examination, a patient states that she was diagnosed with open-angle glaucoma 2 years ago. The nurse assesses for characteristics of open-angle glaucoma. Which of these are characteristics of open-angle glaucoma? (Select all that apply.) (A) Immediate treatment is needed. (B) Virtually no symptoms are exhibited. (C) Vision loss begins with peripheral vision. (D) Patient may experience sensitivity to light, nausea, and halos around lights. (E) Patient experiences tunnel vision in the late stages. (F) Open-angle glaucoma causes sudden attacks of increased pressure that cause blurred vision.

(B) Virtually no symptoms are exhibited. (C) Vision loss begins with peripheral vision. (E) Patient experiences tunnel vision in the late stages. Open-angle glaucoma is the most common type of glaucoma; virtually no symptoms are exhibited. Vision loss begins with the peripheral vision, which often goes unnoticed because individuals learn to compensate intuitively by turning their heads. The other characteristics are those of closed angle glaucoma.

In performing a voice test to assess hearing, which of these actions would the nurse perform? (A) Shield the lips so that the sound is muffled. (B) Whisper a set of random numbers and letters, and then ask the patient to repeat them. (C) Ask the patient to place his or her finger in their ear to occlude outside noise. (D) Stand approximately 4 feet away to ensure that the patient can really hear at this distance.

(B) Whisper a set of random numbers and letters, and then ask the patient to repeat them. With the examiner's head 30 to 60 cm (1 to 2 feet) from the patient's ear, have the patient place one finger on the tragus of the ear and push it in and out of the auditory meatus. While the patient is doing this, the examiner exhales and slowly whispers a set of random numbers and letters, such as "5, B, 6." Normally the patient is asked to repeat each number and letter correctly after hearing the examiner say them. Shielding the lips to muffle the sound, asking the patient to place a finger in their ear to occlude outside noise, and the examiner standing 4 feet away from the patient are not techniques used to perform the voice test. The voice test is performed with the examiner's head 30 to 60 cm (1 to 2 feet) from the patient's ear and having the patient place one finger on the tragus of the ear and push it in and out of the auditory meatus. While the patient is doing this, the examiner exhales and slowly whispers a set of random numbers and letters, such as "5, B, 6." Normally, the patient is asked to repeat each number and letter correctly after hearing the examiner say them and then exhaling and slowly whispering a set of random numbers and letters, such as "5, B, 6." Normally the patient is asked to repeat each number and letter correctly after hearing the examiner say them.

A mother asks when her newborn infant's eyesight will be developed. What is the best response by the nurse? (A) "Vision is not totally developed until 2 years of age." (B) "Infants develop the ability to focus on an object at approximately 8 months of age." (C) "By approximately 3 months of age, infants develop more coordinated eye movements and can fixate on an object." (D) "Most infants have uncoordinated eye movements for the first year of life."

(C) "By approximately 3 months of age, infants develop more coordinated eye movements and can fixate on an object." Eye movements may be poorly coordinated at birth, but by 3 to 4 months of age, the infant should establish binocularity and should be able to fixate simultaneously on a single image with both eyes.

During an examination of a patient in her third trimester of pregnancy, the nurse notices that the patient's thyroid gland is slightly enlarged. No enlargement had been previously noticed. What does the nurse suspect? (A) An iodine deficiency (B) Early signs of goiter (C) A normal enlargement of the thyroid gland during pregnancy (D) Possible thyroid cancer and the need for further evaluation

(C) A normal enlargement of the thyroid gland during pregnancy The thyroid gland enlarges slightly during pregnancy because of hyperplasia of the tissue and increased vascularity.

During an examination of the eye, the nurse would expect what normal finding when assessing the lacrimal apparatus? (A) Presence of tears along the inner canthus (B) Blocked nasolacrimal duct in a newborn infant (C) Absence of drainage from the puncta when pressing against the inner orbital rim (D) Slight swelling over the upper lid and along the bony orbit if the individual has a cold

(C) Absence of drainage from the puncta when pressing against the inner orbital rim No swelling, redness, or drainage from the puncta should be observed when it is pressed. Regurgitation of fluid from the puncta, when pressed, indicates duct blockage. The lacrimal glands are not functional at birth.

The nurse notices the presence of periorbital edema when performing an eye assessment on a 70-year-old patient. What should the nurse do next? (A) Check for the presence of exophthalmos. (B) Suspect that the patient has hyperthyroidism. (C) Ask the patient if he or she has a history of heart failure. (D) Assess for blepharitis, which is often associated with periorbital edema.

(C) Ask the patient if he or she has a history of heart failure. Periorbital edema occurs with local infections, crying, and systemic conditions such as heart failure, renal failure, allergy, and hypothyroidism. Periorbital edema is not associated with blepharitis. Exophthalmos is associated with hyperthyroidism or thyrotoxicosis and hyperthyroidism is not associated with periorbital edema (although hypothyroidism is). Periorbital edema is not associated with blepharitis, either. Thus, the nurse should ask about these conditions.

A patient has been identified as having a sensorineural hearing loss. What would be important for the nurse to do during the assessment of this patient? (A) Speak loudly so the patient can hear the questions. (B) Assess for middle ear infection as a possible cause. (C) Ask the patient what medications he is currently taking. (D) Look for the source of the obstruction in the external ear.

(C) Ask the patient what medications he is currently taking. Sensorineural hearing loss may be caused by presbycusis, which is a gradual nerve degeneration that occurs with aging and by ototoxic drugs, which affect the hair cells in the cochlea. So the nurse should ask the patients about the medications they have been taking. A simple increase in amplitude may not enable the person to understand spoken words. The middle ear and obstruction of the external ear are not associated with sensorineural hearing loss so the nurse should not assess for a middle ear infection or external ear obstruction.

The nurse is assessing a 16-year-old patient who has suffered head injuries from a recent motor vehicle accident. Which of these statements indicates the most important reason for assessing for any drainage from the ear canal? (A) The auditory canal may be occluded from increased cerumen. (B) If the drum has ruptured, then purulent drainage will result. (C) Bloody or clear watery drainage can indicate a basal skull fracture. (D) Foreign bodies from the accident may cause occlusion of the ear canal.

(C) Bloody or clear watery drainage can indicate a basal skull fracture. Frank blood or clear watery drainage (cerebrospinal fluid) after a trauma suggests a basal skull fracture and warrants immediate referral. Purulent drainage indicates otitis externa or otitis media. An ear canal occluded from cerumen would not be draining, purulent drainage indicates otitis externa or otitis media, and it is not likely a foreign body from an accident would cause occlusion of the ear canal.

The nurse notices that an infant has a large, soft lump on the side of his head and that his mother is very concerned. The mother tells the nurse that she noticed the lump approximately 8 hours after her baby's birth and that it seems to be getting bigger. What is a possible explanation for this? (A) Hydrocephalus (B) Craniosynostosis (C) Cephalhematoma (D) Caput succedaneum

(C) Cephalhematoma A cephalhematoma is a subperiosteal hemorrhage that is the result of birth trauma. It is soft, fluctuant, and well defined over one cranial bone. It appears several hours after birth and gradually increases in size. Hydrocephalus is enlarged head due to increased cerebral spinal fluid. Craniosynostosis is a severe deformity of the head with marked asymmetry caused by premature closure of the sutures. Caput succedaneum is edematous swelling and ecchymosis of the presenting part of the head caused by birth trauma that usually causes the skull to look markedly asymmetric.

In using the ophthalmoscope to assess a patient's eyes, the nurse notices a red glow in the patient's pupils. Based on this finding, what should the nurse do? (A) Suspect that an opacity is present in the lens or cornea. (B) Check the light source of the ophthalmoscope to verify that it is functioning. (C) Consider the red glow a normal reflection of the ophthalmoscope light off the inner retina. (D) Continue with the ophthalmoscopic examination, and refer the patient for further evaluation.

(C) Consider the red glow a normal reflection of the ophthalmoscope light off the inner retina. The red glow filling the person's pupil is the red reflex and is a normal finding caused by the reflection of the ophthalmoscope light off the inner retina, so there is no need to check the light source of the ophthalmoscope or referral of the patient, and the interruption or absence, not the presence, of the red reflex would indicate an opacity. The other responses are not correct.

During an examination of a 3-year-old child, the nurse notices a bruit over the left temporal area. What should the nurse do? (A) Check for the bruit again in 1 hour. (B) Stop the examination, and notify the physician. (C) Continue the examination because a bruit is a normal finding for this age. (D) Notify the parents that a bruit has been detected in their child and requires further evaluation.

(C) Continue the examination because a bruit is a normal finding for this age. Bruits are common in the skull in children under 4 or 5 years of age and in children with anemia. They are systolic or continuous and are heard over the temporal area. There is no need to stop the examination and notify the physician, check the bruit in an hour, or further evaluation as bruits are common in the skull in children under 4 or 5 years of age and in children with anemia. They are systolic or continuous and are heard over the temporal area.

A patient is unable to differentiate between sharp and dull stimulation to both sides of her face. What does the nurse suspect? (A) Bell palsy (B) Scleroderma (C) Damage to the trigeminal nerve (D) Frostbite with resultant paresthesia to the cheeks

(C) Damage to the trigeminal nerve Facial sensations of pain or touch are mediated by CN V, which is the trigeminal nerve. Bell palsy is associated with CN VII damage. Frostbite and scleroderma are not associated with this problem.

During a well-baby checkup, the nurse notices that a 1-week-old infant's face looks small compared with his cranium, which seems enlarged. On further examination, the nurse also notices dilated scalp veins and downcast or "setting sun" eyes. The nurse suspects which condition? (A) Craniotabes (B) Microcephaly (C) Hydrocephalus (D) Caput succedaneum

(C) Hydrocephalus Hydrocephalus occurs with the obstruction of drainage of cerebrospinal fluid that results in excessive accumulation, increasing intracranial pressure, and an enlargement of the head. The face looks small, compared with the enlarged cranium, and dilated scalp veins and downcast or "setting sun" eyes are noted. Craniotabes is a softening of the skull's outer layer. Microcephaly is an abnormally small head. A caput succedaneum is edematous swelling and ecchymosis of the presenting part of the head caused by birth trauma. The signs and symptoms of the infant in this question are those of hydrocephalus.

A patient with a middle ear infection asks the nurse, "What does the middle ear do?" Which is the best response by the nurse? (A) It helps maintain balance. (B) It interprets sounds as they enter the ear. (C) It conducts vibrations of sounds to the inner ear. (D) It increases the amplitude of sound for the inner ear to function.

(C) It conducts vibrations of sounds to the inner ear. Among its other functions, the middle ear conducts sound vibrations from the outer ear to the central hearing apparatus in the inner ear. The other responses are not functions of the middle ear. The inner ear, not the middle ear, helps with balance. Sound is interpreted in the cerebral cortex, not the middle ear. The middle ear reduces the amplitude of loud sounds, not increase them, to protect the inner year. The functions of the middle ear are to conduct sound vibrations from the outer ear to the central hearing apparatus in the inner ear; protect the inner ear by reducing the amplitude of loud sounds; and allow equalization of air pressure on each side of the tympanic membrane via the eustachian tubes so that the membrane does not rupture.

During an assessment of a 20-year-old Asian patient, the nurse notices that he has dry, flaky, white cerumen in his canal. What is the significance of this finding? (A) It represents poor hygiene. (B) It is probably the result of lesions from eczema in his ear. (C) It is a normal finding, and no further follow-up is necessary. (D) It could be indicative of change in cilia; the nurse should assess for hearing loss.

(C) It is a normal finding, and no further follow-up is necessary. Asians and American Indians are more likely to have dry cerumen, which appears white and flaky, whereas blacks and whites usually have wet cerumen that appears honey-brown. Dry, flaky cerumen in an Asian patient is not a result of poor hygiene, lesions from eczema, or change in cilia.

The nurse needs to palpate the temporomandibular joint for crepitation. Where is this joint located? (A) Just below the hyoid bone and posterior to the tragus (B) Just below the vagus nerve and posterior to the mandible (C) Just below the temporal artery and anterior to the tragus (D) Just below the temporal artery and anterior to the mandible

(C) Just below the temporal artery and anterior to the tragus

During an interview, the patient states he has the sensation that "everything around him is spinning." What part of the ear should the nurse recognize is responsible for this sensation? (A) Cochlea (B) CN VIII (C) Labyrinth (D) Organ of Corti

(C) Labyrinth If the labyrinth of the ear becomes inflamed, it feeds the wrong information to the brain, creating a staggering gait and a strong, pinning, whirling sensation called vertigo. The cochlea, which contains the central hearing apparatus, and cranial nerve VIII, the vestibulocochlear nerve, which conducts nerve impulses from the organ of Corti to the brain, are all involved with hearing. The spinning sensation that this patient is experiencing is from the labyrinth of the ear.

A patient, an 85-year-old woman, is complaining about the fact that the bones in her face have become more noticeable. What explanation should the nurse give her? (A) Diets low in protein and high in carbohydrates may cause enhanced facial bones. (B) Bones can become more noticeable if the person does not use a dermatologically approved moisturizer. (C) More noticeable facial bones are probably due to a combination of factors r/t aging, such as decreased elasticity, subcutaneous fat, and moisture in her skin. (D) Facial skin becomes more elastic with age. This increased elasticity causes the skin to be more taught, drawing attention to the facial bones.

(C) More noticeable facial bones are probably due to a combination of factors r/t aging, such as decreased elasticity, subcutaneous fat, and moisture in her skin. A low protein, high carbohydrate diet do not enhance facial bones; although aging adults have diminished moisture in their skin, the bones do not become more noticeable; and the elasticity of the skin decreases, not increases, with aging. The facial bones and orbits appear more prominent in the aging adult and the facial skin sags, which is attributable to decreased elasticity, decreased subcutaneous fat, and decreased moisture in the skin.

A 70-year-old patient tells the nurse that he has noticed that he is having trouble hearing, especially in large groups. He says "I can't always tell where the sound is coming from" and that the words often sound "mixed up." What might the nurse suspect as the cause for this change? (A) Atrophy of the apocrine glands (B) Cilia becoming coarse and stiff (C) Nerve degeneration in the inner ear (D) Scar tissue in the tympanic membrane

(C) Nerve degeneration in the inner ear Presbycusis is a type of hearing loss that occurs in 60% of those older than 65 years of age, even in those living in a quiet environment. This sensorineural loss is gradual and caused by nerve degeneration in the inner ear. Words sound garbled, and the ability to localize sound is also impaired. This communication dysfunction is accentuated when background noise is present. Atrophy of the apocrine glands causes cerumen to be more dry and cilia becoming coarse and stiff may cause cerumen to accumulate and oxidize and reduce hearing but they do cause this patient's symptoms of not being able to locate the source of sounds or sounds being mixed up. Scarring of the tympanic eardrum are sequelae of repeated ear infections but do not necessarily affect hearing.

What is the nurse assessing for when he or she directs a light across the iris of a patient's eye from the temporal side? (A) Drainage from dacryocystitis (B) Presence of conjunctivitis over the iris (C) Presence of shadows, which may indicate glaucoma (D) Scattered light reflex, which may be indicative of cataracts

(C) Presence of shadows, which may indicate glaucoma The presence of shadows in the anterior chamber may be a sign of acute angle-closure glaucoma. The normal iris is flat and creates no shadows. This technique (directing a light across the iris of a patient's eye from the temporal side) is not the technique to assess for dacryocystitis, conjunctivitis, or cataracts.

The nurse is performing an otoscopic examination on an adult. Which of these actions is correct? (A) Tilt the person's head forward during the examination. (B) Once the speculum is in the ear, releasing the traction. (C) Pulling the pinna up and back before inserting the speculum. (D) Using the smallest speculum to decrease the amount of discomfort.

(C) Pulling the pinna up and back before inserting the speculum. The pinna is pulled up and back on an adult or older child, which helps straighten the S-shape of the canal. Traction should not be released on the ear until the examination is completed and the otoscope is removed. The nurse should tilt the patient's head slightly away from them and toward the opposite shoulder, not forward. The traction on the pinna of the ear should not be released until the examination is finished and the otoscope has been removed. The largest speculum that fits comfortably in the ear, not the smallest, should be used. The correct action is to pull the pinna up and back on an adult or older child (down and back on an infant or child under the age of 3), which helps straighten the S-shape of the canal.

The physician reports that a patient with a neck tumor has a tracheal shift. The nurse should understand that what is occurring to the patient's trachea? (A) Pushed downward (B) Pulled to the affected side (C) Pushed to the unaffected side (D) Pulled downward in a rhythmic pattern

(C) Pushed to the unaffected side The trachea is pushed to the unaffected side with an aortic aneurysm, a tumor, unilateral thyroid lobe enlargement, or a pneumothorax. The trachea is pulled to the affected side with large atelectasis, pleural adhesions, or fibrosis. Tracheal tug is a rhythmic downward pull that is synchronous with systole and occurs with aortic arch aneurysm. The trachea is pulled to the affected side with large atelectasis, pleural adhesions, or fibrosis. Tracheal tug is a rhythmic downward pull that is synchronous with systole and occurs with aortic arch aneurysm. The trachea is pushed to the unaffected side with an aortic aneurysm, a tumor, unilateral thyroid lobe enlargement, or a pneumothorax.

When assessing the pupillary light reflex, the nurse should use which technique? (A) Shine a penlight from directly in front of the patient, and inspect for pupillary constriction. (B) Ask the patient to follow the penlight in eight directions, and observe for bilateral pupil constriction. (C) Shine a light across the pupil from the side, and observe for direct and consensual pupillary constriction. (D) Ask the patient to focus on a distant object. Then ask the patient to follow the penlight to approximately 7 cm from the nose.

(C) Shine a light across the pupil from the side, and observe for direct and consensual pupillary constriction. To test the pupillary light reflex, the nurse should advance a light in from the side and note the direct and consensual pupillary constriction.

A visitor from Poland who does not speak English seems to be somewhat apprehensive about the nurse examining his neck. How should the nurse proceed that would allow the patient to feel more comfortable with the nurse examining his thyroid gland? (A) Behind with the nurse's hands placed firmly around his neck (B) The side with the nurse's eyes averted toward the ceiling and thumbs on his neck (C) The front with the nurse's thumbs placed on either side of his trachea and his head tilted forward (D) The front with the nurse's thumbs placed on either side of his trachea and his head tilted backward

(C) The front with the nurse's thumbs placed on either side of his trachea and his head tilted forward Examining this patient's thyroid gland from the back may be unsettling for him. It would be best to examine his thyroid gland using the anterior approach, asking him to tip his head forward and to the right and then to the left.

The nurse is preparing to perform an otoscopic examination of a newborn infant. Which statement is true regarding this examination? (A) An injected membrane may indicate an infection. (B) The eardrum will appear in the oblique position. (C) The normal membrane may appear thick and opaque. (D) The appearance of the membrane is identical to that of an adult.

(C) The normal membrane may appear thick and opaque. During the first few days after the birth, the tympanic membrane of a newborn often appears thickened and opaque. It may look injected and have a mild redness from increased vascularity. The eardrum of a neonated is more horizontal, making it more difficult to see completely. By one month of age the drum is in the oblique (more vertical) position as in the adult. During the first few days after the birth, the tympanic membrane of a newborn often appears thickened and opaque. It may look injected and have a mild redness from increased vascularity, but it is not due to infection. The eardrum of a neonated is more horizontal (not oblique), making it more difficult to see completely. By one month of age the drum is in the oblique (more vertical) position as in the adult.

The nurse is examining a patient's ears and notices cerumen in the external canal. Which of these statements about cerumen is correct? (A) Wet, honey-colored cerumen is a sign of infection. (B) The presence of cerumen is indicative of poor hygiene. (C) The purpose of cerumen is to protect and lubricate the ear. (D) Cerumen is necessary for transmitting sound through the auditory canal.

(C) The purpose of cerumen is to protect and lubricate the ear. The ear is lined with glands that secrete cerumen. Cerumen is genetically determined, with two distinct types. Wet, honey-brown occurs in Caucasians and African Americans, and a dry, flaky white is found in East Asians and American Indians. Cerumen is supposed to be present-to lubricate, waterproof, and clean the external auditory canal. It also is antibacterial, and traps foreign bodies. Wet, honey-colored cerumen is not a sign of infection. Cerumen is not a sign of poor hygiene. It is supposed to be present-to lubricate, waterproof, and clean the external auditory canal. It also is antibacterial, and traps foreign bodies. It is not necessary for transmitting sound through the auditory canal and too much cerumen can impair hearing.

While performing a well-child assessment on a 5 year old, the nurse notes the presence of palpable, bilateral, cervical, and inguinal lymph nodes. They are approximately 0.5 cm in size, round, mobile, and nontender. What do these findings lead the nurse to conclude? (A) The child has chronic allergies. (B) The child likely has an infection. (C) These are normal findings for a well child of this age. (D) These findings indicate a need for additional evaluation.

(C) These are normal findings for a well child of this age. These are not signs of chronic allergies or an infection and do not require additional evaluation. Palpable lymph nodes are normal in children until puberty when the lymphoid tissue begins to atrophy. Lymph nodes may be up to 1 cm in size in the cervical and inguinal areas but are discrete, movable, and nontender.

The nurse is preparing to assess the visual acuity of a 16-year-old patient. How should the nurse proceed? (A) Perform the confrontation test. (B) Ask the patient to read the print on a handheld Jaeger card. (C) Use the Snellen chart positioned 20 feet away from the patient. (D) Determine the patient's ability to read newsprint at a distance of 12 to 14 inches.

(C) Use the Snellen chart positioned 20 feet away from the patient. The Snellen alphabet chart is the most commonly used and most accurate measure of visual acuity. The confrontation test is a gross measure of peripheral vision. The Jaeger card or newspaper tests are used to test near vision.

The nurse is reviewing the function of the cranial nerves (CNs). Which CN is responsible for conducting nerve impulses to the brain from the organ of Corti? (A) I (B) III (C) VIII (D) XI

(C) VIII The nerve impulses are conducted by the auditory portion of CN VIII to the brain. Cranial nerve I, the olfactory nerve, is responsible for the sense of smell. Cranial nerve III, the oculomotor, innervates the superior, inferior, and medial rectus and the inferior oblique muscles of the eye. Cranial nerve XI, the accessory nerve, controls the muscles of the neck. The nerve that conducts nerve impulses from the organ of Corti to the brain is CN VIII, the vestibulocochlear nerve.

A patient comes to the clinic complaining of neck and shoulder pain and is unable to turn her head. Which nerve does the nurse suspect is damaged and how should the nurse proceed with the examination? (A) XII; assess for a positive Romberg sign. (B) XI; palpate the anterior and posterior triangles. (C) XI; have patient shrug their shoulders against resistance. (D) XII; percuss the sternomastoid and submandibular neck muscles.

(C) XI; have patient shrug their shoulders against resistance. The major neck muscles are the sternomastoid and the trapezius. They are innervated by CN XI, the spinal accessory. The innervated muscles assist with head rotation and head flexion, movement of the shoulders, and extension and turning of the head. To assess the function of cranial nerve XI the nurse should have the patient shrug their shoulders against resistance. Cranial nerve XII is the hypoglossal nerve which innervates the muscles of the tongue involved with speech and swallowing and is not involved in head movement. Identifying the anterior and posterior triangles are helpful guidelines when describing findings in the neck but palpating them does not assess any cranial nerves.

The nurse is taking the history of a patient who may have a perforated eardrum. What would be an important question in this situation? (A) "Do you ever notice ringing or crackling in your ears?" (B) "When was the last time you had your hearing checked?" (C) "Have you ever been told that you have any type of hearing loss?" (D) "Is there any relationship between the ear pain and the discharge you mentioned?"

(D) "Is there any relationship between the ear pain and the discharge you mentioned?" Typically with perforation, ear pain occurs first and resolves after a popping sensation, then drainage occurs.

A mother brings her 2-month-old daughter in for an examination and says, "My daughter rolled over against the wall, and now I have noticed that she has this spot that is soft on the top of her head. Is something terribly wrong?" How should the nurse respond? (A) "Perhaps that could be a result of your dietary intake during pregnancy." (B) "Your baby may have craniosynostosis, a disease of the sutures of the skull." (C) "That 'soft spot' may be an indication of cretinism or congenital hypothyroidism." (D) "That 'soft spot' is normal, and actually allows for growth of the brain during the first year of your baby's life."

(D) "That 'soft spot' is normal, and actually allows for growth of the brain during the first year of your baby's life." Membrane-covered "soft spots" allow for growth of the brain during the first year of life. They gradually ossify; the triangular-shaped posterior fontanel is closed by 1 to 2 months, and the diamond-shaped anterior fontanel closes between 9 months and 2 years.

The mother of a 2-year-old is concerned because her son has had three ear infections in the past year. What would be an appropriate response by the nurse? (A) "It is unusual for a small child to have frequent ear infections unless something else is wrong." (B) "We need to check the immune system of your son to determine why he is having so many ear infections." (C) "Ear infections are not uncommon in infants and toddlers because they tend to have more cerumen in the external ear." (D) "Your son's eustachian tube is shorter and wider than yours because of his age, which allows for infections to develop more easily."

(D) "Your son's eustachian tube is shorter and wider than yours because of his age, which allows for infections to develop more easily." The infant's eustachian tube is relatively shorter and wider than the adult's eustachian tube, and its position is more horizontal; consequently, pathogens from the nasopharynx can more easily migrate through to the middle ear. The other responses are not appropriate. It is not unusual for a small child to have frequent ear infections, thus, it is not necessary to check the immune system. The reason that ear infections in infants and toddlers is not uncommon is not due to more cerumen but because the infant's eustachian tubes are relatively shorter and wider than the adult's eustachian tube, and its position is more horizontal; consequently, pathogens from the nasopharynx can more easily migrate through to the middle ear.

A 31-year-old patient tells the nurse that he has noticed pain in his left ear when people speak loudly to him. What does this finding indicate? (A) A cerumen impaction (B) Normal for people of his age (C) Possible middle ear infection (D) A characteristic of recruitment

(D) A characteristic of recruitment Recruitment is significant hearing loss occurring when speech is at low intensity, but sound actually becomes painful when the speaker repeats at a louder volume. The other responses are not correct. A cerumen impaction and ear infection do not cause these symptoms and these are not normal findings. Instead, this patient's symptoms are a characteristic of recruitment.

The nurse is reviewing causes of increased intraocular pressure. Which of these factors determines intraocular pressure? (A) Thickness or bulging of the lens (B) Posterior chamber as it accommodates increased fluid (C) Contraction of the ciliary body in response to the aqueous within the eye (D) Amount of aqueous produced and resistance to its outflow at the angle of the anterior chamber

(D) Amount of aqueous produced and resistance to its outflow at the angle of the anterior chamber Intraocular pressure is determined by a balance between the amount of aqueous produced and the resistance to its outflow at the angle of the anterior chamber. The other responses are incorrect.

The nurse notices that a patient's submental lymph nodes are enlarged. In an effort to identify the cause of the node enlargement, what should the nurse assess? (A) Infraclavicular area (B) Supraclavicular area (C) Area distal to the enlarged node (D) Area proximal to the enlarged node

(D) Area proximal to the enlarged node When nodes are abnormal, the nurse should check the area into which they drain for the source of the problem. The area proximal (upstream) to the location of the abnormal node should be explored.

During an admission assessment, the nurse notices that a male patient has an enlarged and rather thick skull. The nurse suspects acromegaly. What additional finding would the nurse assess for to confirm this suspicion? (A) Exophthalmos (B) Bowed long bones (C) Acorn-shaped cranium (D) Coarse facial features

(D) Coarse facial features Acromegaly is the excessive secretion of growth hormone that creates an enlarged skull and thickened cranial bones. Patients will have elongated heads, massive faces, prominent noses and lower jaws, heavy eyebrow ridges, and coarse facial features. Exophthalmos is associated with hyperthyroidism. Bowed long bones and an acorn-shaped cranium result from Paget disease.

The nurse is assessing a patient's eyes for the accommodation response and would expect to see which normal finding? (A) Dilation of the pupils (B) Consensual light reflex (C) Disconjugate movement of the eyes (D) Convergence of the axes of the eyes

(D) Convergence of the axes of the eyes The accommodation reaction includes pupillary constriction and convergence of the axes of the eyes. The other responses are not correct. Dilation of the pupil occurs with dimming the lights and having the person look in the distance, not when assessing for accommodation. Consensual light reflex is simultaneous constriction of the pupil opposite the pupil that light is being shined on. Conjugate, not disconjugate, movement of the eye (the axes of both eyes remains parallel while moving) is a normal finding.

When examining a patient's eyes, what should the nurse be aware that stimulation of the sympathetic branch of the autonomic nervous system causes? (A) Pupillary constriction (B) Adjusts the eye for near vision (C) Causes contraction of the ciliary body (D) Elevates the eyelid and dilates the pupil

(D) Elevates the eyelid and dilates the pupil Stimulation of the sympathetic branch of the autonomic nervous system dilates the pupil and elevates the eyelid. Parasympathetic nervous system stimulation causes the pupil to constrict. The muscle fibers of the iris contract the pupil in bright light to accommodate for near vision. The ciliary body controls the thickness of the lens. Parasympathetic nervous system stimulation, not sympathetic nervous system, causes the pupil to constrict. The muscle fibers of the iris contract the pupil in bright light to accommodate for near vision, not sympathetic nervous system stimulation.

A patient visits the clinic because he has recently noticed that the left side of his mouth is paralyzed. He states that he cannot whistle but the nurse notes he can still raise his eyebrows. What does the nurse suspect? (A) Bell palsy (B) Cushing syndrome (C) Parkinson syndrome (D) Experienced a cerebrovascular accident (CVA) or stroke

(D) Experienced a cerebrovascular accident (CVA) or stroke With an upper motor neuron lesion, as with a CVA, the patient will have paralysis of lower facial muscles, but the upper half of the face will not be affected owing to the intact nerve from the unaffected hemisphere. The person is still able to wrinkle the forehead and close the eyes. Bell palsy presents as complete paralysis of one side of the face. The person cannot wrinkle forehead, raise eyebrows, close eyelids, whistle, or show teeth on the affected side. With Cushing syndrome the person develops a rounded, "moonlike" face, prominent jowls, red cheeks, hirsutism on the upper lip, lower cheeks, and chin, and acneiform rash on the chest. The facial features characteristic of Parkinson syndrome are a flat and expressionless, "masklike," with elevated eyebrows, staring gaze, oily skin, and drooling. This patient who cannot whistle but can still raise his eyebrows has probably experienced a cerebrovascular accident.

The nurse is explaining to a student nurse the four areas in the body where lymph nodes are accessible. Which areas should the nurse include in her explanation to the student? (A) Head, breasts, groin, and abdomen (B) Arms, breasts, inguinal area, and legs (C) Head and neck, arms, breasts, and axillae (D) Head and neck, arms, inguinal area, and axillae

(D) Head and neck, arms, inguinal area, and axillae Nodes are located throughout the body, but they are accessible to examination only in four areas: head and neck, arms, inguinal region, and axillae.

An ophthalmic examination reveals papilledema. What does this finding indicate? (A) Retinal detachment (B) Diabetic retinopathy (C) Acute-angle glaucoma (D) Increased intracranial pressure

(D) Increased intracranial pressure Papilledema, or choked disk, is a serious sign of increased intracranial pressure, which is caused by a space-occupying mass such as a brain tumor or hematoma. This pressure causes venous stasis in the globe, showing redness, congestion, and elevation of the optic disc, blurred margins, hemorrhages, and absent venous pulsations. Papilledema is not associated with the conditions in the other responses. Papilledema is not associated with retinal detachment, diabetic retinopathy, or acute-angle glaucoma.

A 19-year-old college student is brought to the emergency department with a severe headache he describes as, "Like nothing I've ever had before." His temperature is 40° C, and he has a stiff neck. The nurse looks for other signs and symptoms of which problem? (A) Head injury (B) Cluster headache (C) Migraine headache (D) Meningeal inflammation

(D) Meningeal inflammation The acute onset of neck stiffness and pain along with headache and fever occurs with meningeal inflammation. A severe headache in an adult or child who has never had it before is a red flag. Head injury and cluster or migraine headaches are not associated with a fever or stiff neck.

A patient complains that while studying for an examination he began to notice a severe headache in the frontotemporal area of his head that is throbbing and is somewhat relieved when he lies down. He tells the nurse that his mother also had these headaches. What should the nurse suspect? (A) Hypertension (B) Cluster headaches (C) Tension headaches (D) Migraine headaches

(D) Migraine headaches Migraine headaches tend to be supraorbital, retro-orbital, or frontotemporal with a throbbing quality. They are severe in quality and are relieved by lying down. Migraines are associated with a family history of migraine headaches. Although hypertension may cause headaches, the blood pressure needs to be severely elevated and would likely not be relieved with lying down. Cluster headaches produce pain around the eye, temple, forehead, and cheek and are unilateral and always on the same side of the head. They are excruciating and occur once or twice per day and last 1 2 to 2 hours each. Tension headaches are occipital, frontal, or with bandlike tightness.

How should the nurse perform an examination of a 2-year-old child with a suspected ear infection? (A) Pull the ear up and back before inserting the speculum. (B) Omit the otoscopic examination if the child has a fever. (C) Ask the mother to leave the room while examining the child. (D) Perform the otoscopic examination at the end of the assessment.

(D) Perform the otoscopic examination at the end of the assessment. In addition to its place in the complete examination, eardrum assessment is mandatory for any infant or child requiring care for an illness or fever. For the infant or young child, the timing of the otoscopic examination is best toward the end of the complete examination because many young children protest vigorously during this procedure and it is difficult to re-establish cooperation afterward. When performing an ear examination on a 2-year-old child, with or without a suspected ear infection, the pinna should be pulled down (not up) and back. In addition to its place in the complete examination, eardrum assessment is mandatory for any infant or child requiring care for an illness or fever, so should not be omitted. Rather than asking the parent to leave the room, the nurse should enlist the parent's help in holding the child to protect the eardrum from injury.

A patient comes to the emergency department after a boxing match, and his O.S. is almost swollen shut. He has bruises on his face and neck. He says he is worried because he "can't see well" from his O.S. The physician suspects retinal detachment. What finding would support this suspicion? (A) Loss of central vision (B) Loss of peripheral vision (C) Sudden loss of pupillary constriction and accommodation (D) Shadow or diminished vision in one quadrant or one half of the visual field

(D) Shadow or diminished vision in one quadrant or one half of the visual field With retinal detachment, the person has shadows or diminished vision in one quadrant or one half of the visual field. The other responses are not signs of retinal detachment. Loss of central or peripheral vision or sudden loss of pupillary constriction and accommodation are not signs of retinal detachment.

A patient comes into the emergency department after an accident at work. A machine blew dust into his eyes, and he was not wearing safety glasses. The nurse examines his corneas by shining a light from the side across the cornea. What findings would suggest that he has suffered a corneal abrasion? (A) Smooth and clear corneas (B) Opacity of the lens behind the cornea (C) Bleeding from the areas across the cornea (D) Shattered look to the light rays reflecting off the cornea

(D) Shattered look to the light rays reflecting off the cornea A corneal abrasion causes irregular ridges in reflected light, which produce a shattered appearance to light rays. No opacities should be observed in the cornea. The other responses are not correct.

A patient is unable to read even the largest letters on the Snellen chart. The nurse should take which action next? (A) Refer the patient to an ophthalmologist or optometrist for further evaluation. (B) Assess whether the patient can count the nurse's fingers when they are placed in front of his or her eyes. (C) Ask the patient to put on his or her reading glasses and attempt to read the Snellen chart again. (D) Shorten the distance between the patient and the chart until the letters are seen, and record that distance.

(D) Shorten the distance between the patient and the chart until the letters are seen, and record that distance. If the person is unable to see even the largest letters when standing 20 feet from the chart, then the nurse should shorten the distance to the chart until the letters are seen, and record that distance (e.g., "10/200"). If visual acuity is even lower, then the nurse should assess whether the person can count fingers when they are spread in front of the eyes or can distinguish light perception from a penlight. If vision is poorer than 20/30, then a referral to an ophthalmologist or optometrist is necessary, but the nurse must first assess the visual acuity. The nurse should assess whether the person can count fingers when they are spread in front of the eyes or can distinguish light perception from a penlight only if unable to see the letters on the Snellen chart when the distance is shortened. Applying reading glasses will not help with reading the Snellen chart as that is assessing far vision, not near vision.

During an examination, the nurse finds that a patient's left temporal artery is tortuous and feels hardened and tender, compared with the right temporal artery. The nurse suspects which condition? (A) Bell palsy (B) Crepitation (C) Mastoiditis (D) Temporal arteritis

(D) Temporal arteritis With temporal arteritis, the artery appears more tortuous and feels hardened and tender. These assessment findings are not consistent with the other responses. Bell palsy presents as complete paralysis of one side of the face. The person cannot wrinkle forehead, raise eyebrows, close eyelids, whistle, or show teeth on the affected side. Crepitation is a crackling sound. Mastoiditis is an inflammation of the mastoid process which is behind the ears. The signs and symptoms this patient has are consistent with temporal arteritis. With temporal arteritis, the artery appears more tortuous and feels hardened and tender.

The nurse is performing an eye-screening clinic at a daycare center. When examining a 2-year-old child, the nurse suspects that the child has a "lazy eye". What should the nurse do next? (A) Examine the external structures of the eye. (B) Assess visual acuity with the Snellen eye chart. (C) Assess the child's visual fields with the confrontation test. (D) Test for strabismus by performing the corneal light reflex test.

(D) Test for strabismus by performing the corneal light reflex test. Testing for strabismus is done by performing the corneal light reflex test and the cover test. The Snellen eye chart and confrontation test are not used to test for strabismus. Examining the external structures of the eye, assessing visual acuity with the Snellen eye chart, and assessing for confrontation are not used to test for strabismus.

The nurse is assessing color vision of a male child. Which statement is correct? (A) Color vision should be checked annually until the age of 18 years. (B) Color vision screening should begin at the child's 2-year checkup. (C) The nurse should ask the child to identify the color of his or her clothing. (D) Testing for color vision should be done once between the ages of 4 and 8 years.

(D) Testing for color vision should be done once between the ages of 4 and 8 years. Boys should be tested only once for color vision between the ages of 4 and 8 years. Color vision is not tested in girls because it is rare in girls. Testing is performed with the Ishihara test, which is a series of polychromatic cards.

A 52-year-old patient describes the presence of occasional floaters or spots moving in front of his eyes. How should the nurse proceed? (A) Examine the retina to determine the number of floaters. (B) Presume the patient has glaucoma and refer him for further testing. (C) Consider these to be abnormal findings, and refer him to an ophthalmologist. (D) Understand that floaters are usually insignificant and are caused by condensed vitreous fibers.

(D) Understand that floaters are usually insignificant and are caused by condensed vitreous fibers. Floaters are a common sensation with myopia or after middle age and are attributable to condensed vitreous fibers. Floaters or spots are not usually significant, but the acute onset of floaters may occur with retinal detachment. The floaters or spots would not be visible for the nurse to see or count. A decrease in peripheral vision is a symptom of glaucoma, not floaters.

A 60-year-old man is at the clinic for an eye examination. The nurse suspects that he has ptosis of one eye. How should the nurse check for this? a. Perform the confrontation test. b. Assess the individual's near vision. c. Observe the distance between the palpebral fissures. d. Perform the corneal light test, and look for symmetry of the light reflex.

c. Observe the distance between the palpebral fissures. Ptosis is a drooping of the upper eyelid that would be apparent by observing the distance between the upper and lower eyelids. The confrontation test measures peripheral vision, not ptosis. Measuring near vision or the corneal light test does not check for ptosis.