Exam 4- Eyes- Ears-Head, Neck, and neurological ATI

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?

Bloody or clear watery drainage can indicate a basal skull fracture.

A nurse is assessing a client who has a lump on their neck. Which of the following questions should the nurse ask the client? (select all that apply) 1. "Are you experiencing difficulty breathing?" 2."How long has the lump been on your neck?" 3."Is the lump causing you discomfort?" 4."Are you having difficulty swallowing?" 5."Have you started taking a new medication?"

1. "Are you experiencing difficulty breathing?" 2."How long has the lump been on your neck?" 3."Is the lump causing you discomfort?" 4."Are you having difficulty swallowing?"

A nurse is preparing to assess a client's conjunctiva. Identify the sequence the nurse should follow when taking the following actions

1. Apply examination gloves 2. Instruct the client to look up 3.Place the thumbs below each of the client's lower eyelids. 4. Gently pull the client's skin down to the top edge of the bony orbital rim 5. Inspect the color and condition of the conductive and sclera, noting any color change, swelling, drainage, or lesions

A nurse is obtaining a client's health history. Which of the following questions should the nurse ask the client to obtain a focused history of the ears? (select all that apply) 1. Have you had trouble hearing? 2. Do you ever lose your balance? 3. Have you ever used hearing aids? 4. Do you have ringing in your ears? 5. Do you have a problems with nasal drainage?

1. Have you had trouble hearing? 2. Do you ever lose your balance? 3. Have you ever used hearing aids? 4. Do you have ringing in your ears?

A nurse is preparing to palpate a client's sinuses. Identify the sequence the nurse should follow when taking the following actions.

1. Position the thumbs on the supra orbital ridge just below the client's eyebrows to assess the clients frontal sinuses is the first step 2. Firmly press upward on the ridge and make sure not to apply pressure to the client's eyes is the second step 3. Ask the client if they detect tenderness or pain is the third step 4. Position the thumbs below the client's cheekbones with fingers alongside the client's head to assess the client's maxillary sinuses. 5. Apply firm, upward pressure and ask the client if hey detect tenderness or pain

A nurse is teaching an older adult client about health promotion. The nurse should instruct the client to have which of the following examinations preformed on a regular basis? (Select all that apply) 1.Vision screening every year 2.Hearing test every 5 years 3.Dental examination every 6 months 4.Skin cancer screening every 2 years 5.Neurological check every 3 months

1.Vision screening every year 3.Dental examination every 6 months

. During an oral examination of a 4-year-old Native-American child, the nurse notices that her uvula is partially split. Which of these statements is accurate?

A bifid uvula may occur in some Native-American groups. rational: Bifid uvula, a condition in which the uvula is split either completely or partially, occurs in some Native-American groups.

During an examination of the eye, the nurse would expect what normal finding when assessing the lacrimal apparatus?

Absence of drainage from the puncta when pressing against the inner orbital rim

A nurse is assessing the mouth of a client who has a vitamin B12 insufficiency. Which of the following findings should the nurse expect? 1. White patches not he tongue 2. Bleeding of the gums 3. Beefy red tongue 4. Petechiae of the hard palate

Beefy red tongue

The nurse is assessing a patient in the hospital who has received numerous antibiotics and notices that his tongue appears to be black and hairy. In response to his concern, what would the nurse say?

Black, hairy tongue is a fungal infection caused by all the antibiotics you have received. rational: A black, hairy tongue is not really hair but the elongation of filiform papillae and painless overgrowth of mycelial threads of fungus infection on the tongue. It occurs after the use of antibiotics, which inhibit normal bacteria and allow a proliferation of fungus.

A nurse is preparing to inspect the outer ears of a client who has been in a motor-vehicle crash. The nurse should identify that which of t the following findings indicates the client might have. Skull fracture? 1. Edema 2. Bloody drainage 3. yellow drainage 4. crushed skin

Bloody drainage

The nurse notices that the mother of a 2-year-old boy brings him into the clinic quite frequently for various injuries and suspects there may be some child abuse involved. During an inspection of his mouth, the nurse should look for:

Bruising on the buccal mucosa or gums. rational: The nurse should notice any bruising or laceration on the buccal mucosa or gums of an infant or young child. Trauma may indicate child abuse from a forced feeding of a bottle or spoon.

In using the ophthalmoscope to assess a patients eyes, the nurse notices a red glow in the patients pupils. On the basis of this finding, the nurse would:

Consider the red glow a normal reflection of the ophthalmoscope light off the inner retina.

A 2-week-old infant can fixate on an object but cannot follow a light or bright toy. The nurse would:

Consider this a normal finding.

Which of these assessment findings would the nurse expect to see when examining the eyes of a black patient?

Dark retinal background

A nurse is assessing an older adult client's mouth. The nurse should identify that which of the following is an expected variation for this client? 1.Yellowing of the hard palate 2. Red spots on the hard palate 3. White patches not he Tonge 4. Darkening of the mucosa

Darkening of the mucosa

The nurse is assessing an 80-year-old patient. Which of these findings would be expected for this patient?

Decreased ability to identify odors rational: The sense of smell may be reduced because of a decrease in the number of olfactory nerve fibers.

In an individual with otitis externa, which of these signs would the nurse expect to find on assessment?

Enlarged superficial cervical nodes

The nurse is palpating the sinus areas. If the findings are normal, then the patient should report which sensation?

Firm pressure

The nurse is performing an ear examination of an 80-year-old patient. Which of these findings would be considered normal?

High-tone frequency loss

An ophthalmic examination reveals papilledema. The nurse is aware that this finding indicates:

Increased intracranial pressure.

During an assessment of a 20-year-old Asian patient, the nurse notices that he has dry, flaky cerumen in his canal. What is the significance of this finding? This finding:

Is a normal finding, and no further follow-up is necessary.

A 52-year-old patient describes the presence of occasional floaters or spots moving in front of his eyes. The nurse should:

Know that floaters are usually insignificant and are caused by condensed vitreous fibers.

A 70-year-old patient tells the nurse that he has noticed that he is having trouble hearing, especially in large groups. He says that he can't always tell where the sound is coming from and the words often sound mixed up. What might the nurse suspect as the cause for this change?

Nerve degeneration in the inner ear

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. The most likely cause of his hearing loss is:

Otosclerosis. rational: 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.

The nurse is performing the diagnostic positions test. Normal findings would be which of these results?

Parallel movement of both eyes

The salivary gland that is the largest and located in the cheek in front of the ear is the _________ gland.

Parotid rational: The mouth contains three pairs of salivary glands. The largest, the parotid gland, lies within the cheeks in front of the ear extending from the zygomatic arch down to the angle of the jaw

During ocular examinations, the nurse keeps in mind that movement of the extraocular muscles is:

Stimulated by CNs III, IV, and VI.

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 and should:

Test for strabismus by performing the corneal light reflex test.

In performing a voice test to assess hearing, which of these actions would the nurse perform?

Whisper a set of random numbers and letters, and then ask the patient to repeat them. rational: With the head 30 to 60 cm (1 to 2 feet) from the patients ear, 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

A nurse is assessing the mouth of a client who has candidiasis, an oral fungal infection. Which of the following findings should the nurse expect? 1. White patches on the tongue 2. Beefy red tongue 3. Petechiae on hard palate 4. Overgroth og gum tissue

White patches on the tongue

During an otoscopic examination, the nurse notices an area of black and white dots on the tympanic membrane and the ear canal wall. What does this finding suggest?

Yeast or fungal infection rational: A colony of black or white dots on the drum or canal wall suggests a yeast or fungal infection (otomycosis).

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?

Your sons eustachian tube is shorter and wider than yours because of his age, which allows for infections to develop more easily.

A nurse is preforming a focused assessment on a client who reports having difficulty swallowing and a continuous headache. The nurse should identify that these findings can indicate which of the following conditions? 1. Chest disorder 2. Thyroid disorder 3. Musculoskeletal disorder 4. Central nervous system disorder

central nervous system disorders

A nurse is assessing the eye of a client who experienced a subconjunctival hemorrhage as a result of vomiting. Which of the following findings should the nurse expect? 1. Defined reddened area of the sclera 2. Dropping of the eyelid 3. Cloudy pupil 4. Bulging eyes

defined reddened area of the sclera

A nurse is preforming a head and neck assessment on a client. After checking the client's vision, the nurse notes the client has a difficulty reading fine print. In which of the following sections of the client's electronic health record should the nurse document this finding? 1. Vital signs 2. Review of system 3. Allergies and home medications 4. Patient information

review of systems

A nurse is preforming a head-to-toe assessment on a client and notes a lump on the anterior portion of their neck. The nurse should identify that this finding can indicate which of the following conditions? 1. Infection 2. Cancer 3. Thyroid disorder 4. Chest disorder

thyroid disorder

A nurse is preforming an eye assessment on a client. Which of the following should the nurse identify as the cornea of the eye? 1. Outer layer of the eyeball 2. Mucous membrane that lines the eyeball 3. Transparent layer that covers the iris and pupil 4. Colored portion in the center of the eye

transparent layer that covers the iris and pupil

The nurse is assessing a patient with a history of intravenous drug abuse. In assessing his mouth, the nurse notices a dark red confluent macule on the hard palate. This could be an early sign of:

Acquired immunodeficiency syndrome (AIDS). Rational: Oral Kaposis sarcoma is a bruiselike, dark red or violet, confluent macule that usually occurs on the hard palate. It may appear on the soft palate or gingival margin. Oral lesions may be among the earliest lesions to develop with AIDS.

While performing the otoscopic examination of a 3-year-old boy who has been pulling on his left ear, the nurse finds that his left tympanic membrane is bright red and that the light reflex is not visible. The nurse interprets these findings to indicate a(n):

Acute otitis media. rational: Absent or distorted light reflex and a bright red color of the eardrum are indicative of acute otitis media

The nurse is assessing a patient who may have hearing loss. Which of these statements is true concerning air conduction?

Air conduction is the normal pathway for hearing

When examining the nares of a 45-year-old patient who has complaints of rhinorrhea, itching of the nose and eyes, and sneezing, the nurse notices the following: pale turbinates, swelling of the turbinates, and clear rhinorrhea. Which of these conditions is most likely the cause?

Allergic rhinitis

The nurse is performing an assessment on a 21-year-old patient and notices that his nasal mucosa appears pale, gray, and swollen. What would be the most appropriate question to ask the patient?

Are you aware of having any allergies? rational: With chronic allergies, the mucosa looks swollen, boggy, pale, and gray.

The nurse notices the presence of periorbital edema when performing an eye assessment on a 70-year-old patient. The nurse should:

Ask the patient if he or she has a history of heart failure.

A patient has been shown to have a sensorineural hearing loss. During the assessment, it would be important for the nurse to:

Ask the patient what medications he is currently taking.

During an assessment, the nurse notices that an older adult patient has tears rolling down his face from his left eye. 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?

Assessing for other signs of ectropion

The nurse needs to pull the portion of the ear that consists of movable cartilage and skin down and back when administering eardrops. This portion of the ear is called the:

Auricle. or pinna

The nurse is using an otoscope to assess the nasal cavity. Which of these techniques is correct?

Avoiding touching the nasal septum with the speculum

A 40-year-old patient who has just finished chemotherapy for breast cancer tells the nurse that she is concerned about her mouth. During the assessment the nurse finds areas of buccal mucosa that are raw and red with some bleeding, as well as other areas that have a white, cheesy coating. The nurse recognizes that this abnormality is:

Candidiasis.

A patient with a middle ear infection asks the nurse, What does the middle ear do? The nurse responds by telling the patient that the middle ear functions to:

Conduct vibrations of sounds to the inner ear.

When performing the corneal light reflex assessment, the nurse notes that the light is reflected at 2 o'clock in each eye. The nurse should:

Consider this a normal finding.

A patient has a normal pupillary light reflex. The nurse recognizes that this reflex indicates that:

Constriction of both pupils occurs in response to bright light. Rational: The pupillary light reflex is the normal constriction of the pupils when bright light shines on the retina. The other responses are not correct.

The nurse is assessing a patient's eyes for the accommodation response and would expect to see which normal finding?

Convergence of the axes of the eyes

During an assessment of a 20-year-old patient with a 3-day history of nausea and vomiting, the nurse notices dry mucosa and deep vertical fissures in the tongue. These findings are reflective of:

Dehydration rational: Dry mouth occurs with dehydration or fever. The tongue has deep vertical fissures.

When examining a patient's eyes, the nurse recalls that stimulation of the sympathetic branch of the autonomic nervous system:

Elevates the eyelid and dilates the pupil. Rational: Stimulation of the sympathetic branch of the autonomic nervous system dilates the pupil and elevates the eyelid.

A nurse is performing a head and neck assessment on a client. The client reports a high-pitched ringing in their ears. In which of the following sections of the client's electronic health record (EHR) should the nurse document this finding? 1. Encounter 2. Vital signs 3. Patient information 4. Allergies and home medications

Encounter

The tissue that connects the tongue to the floor of the mouth is the:

Frenulum. rational: The frenulum is a midline fold of tissue that connects the tongue to the floor of the mouth.

A 72-year-old patient has a history of hypertension and chronic lung disease. An important question for the nurse to include in the health history would be:

Have you noticed any dryness in your mouth? rational: Xerostomia (dry mouth) is a side effect of many drugs taken by older people, including antidepressants, anticholinergics, antispasmodics, antihypertensives, antipsychotics, and bronchodilators

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. This finding indicates the presence of:

Hyphema.

The nurse suspects that a patient has otitis media. Early signs of otitis media include which of these findings of the tympanic membrane?

Hypomobility rational: An early sign of otitis media is hypomobility of the tympanic membrane. As pressure increases, the tympanic membrane begins to bulge.

A woman who is in the second trimester of pregnancy mentions that she has had more nosebleeds than ever since she became pregnant. The nurse recognizes that this is a result of:

Increased vascularity in the upper respiratory tract as a result of the pregnancy. rational: Nasal stuffiness and epistaxis may occur during pregnancy as a result of increased vascularity in the upper respiratory tract.

A 31-year-old patient tells the nurse that he has noticed pain in his left ear when people speak loudly to him. The nurse knows that this finding:

Is a characteristic of recruitment. Rational: 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.

During an interview, the patient states he has the sensation that everything around him is spinning. The nurse recognizes that the portion of the ear responsible for this sensation is the:

Labyrinth. rational: If the labyrinth ever becomes inflamed, then it feeds the wrong information to the brain, creating a staggering gait and a strong, spinning, whirling sensation called vertigo.

The nurse is performing an oral assessment on a 40-year-old Black patient and notices the presence of a 1 cm, nontender, grayish-white lesion on the left buccal mucosa. Which one of these statements is true? This lesion is:

Leukoedema and is common in dark-pigmented persons. rational: Leukoedema, a grayish-white benign lesion occurring on the buccal mucosa, is most often observed in Blacks.

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. These findings suggest that she may have:

Macular degeneration.

A patient comes into the clinic complaining of facial pain, fever, and malaise. On examination, the nurse notes swollen turbinates and purulent discharge from the nose. The patient also complains of a dull, throbbing pain in his cheeks and teeth on the right side and pain when the nurse palpates the areas. The nurse recognizes that this patient has:

Maxillary sinusitis.

When performing an otoscopic examination of a 5-year-old child with a history of chronic ear infections, the nurse sees that his right tympanic membrane is amber-yellow in color and that air bubbles are visible behind the tympanic membrane. The child reports occasional hearing loss and a popping sound with swallowing. The preliminary analysis based on this information is that the child:

Most likely has serous otitis media. rational: An amber-yellow color to the tympanic membrane suggests serum or pus in the middle ear. Air or fluid or bubbles behind the tympanic membrane are often visible. The patient may have feelings of fullness, transient hearing loss, and a popping sound with swallowing. These findings most likely suggest that the child has serous otitis media.

In assessing the tonsils of a 30 year old, the nurse notices that they are involuted, granular in appearance, and appear to have deep crypts. What is correct response to these findings?

No response is needed; this appearance is normal for the tonsils

A patient has been admitted after an accident at work. During the assessment, the patient is having trouble hearing and states, I dont know what the matter is. All of a sudden, I cant hear you out of my left ear! What should the nurse do next?

Notify the patients health care provider. rational: Any sudden loss of hearing in one or both ears that is not associated with an upper respiratory infection needs to be reported at once to the patients health care provider. Hearing loss associated with trauma is often sudden.

During an examination, the nurse notices that the patient stumbles a little while walking, and, when she sits down, she holds on to the sides of the chair. The patient states, It feels like the room is spinning! The nurse notices that the patient is experiencing:

Objective vertigo. rational: With objective vertigo, the patient feels like the room spins; with subjective vertigo, the person feels like he or she is spinning.

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?

Observe the distance between the palpebral fissures.

The nurse is examining a patients retina with an ophthalmoscope. Which finding is considered normal?

Optic disc that is a yellow-orange color

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.

Patient experiences tunnel vision in the late stages. Vision loss begins with peripheral vision. Virtually no symptoms are exhibited.

The nurse is assessing a 3 year old for drainage from the nose. On assessment, a purulent drainage that has a very foul odor is noted from the left naris and no drainage is observed from the right naris. The child is afebrile with no other symptoms. What should the nurse do next?

Perform an otoscopic examination of the left nares. rational: Children are prone to put an object up the nose, producing unilateral purulent drainage with a foul odor. Because some risk for aspiration exists, removal should be prompt.

In performing an examination of a 3-year-old child with a suspected ear infection, the nurse would:

Perform the otoscopic examination at the end of the assessment.

When a light is directed across the iris of a patient's eye from the temporal side, the nurse is assessing for:

Presence of shadows, which may indicate glaucoma.

During an assessment of the sclera of a black patient, the nurse would consider which of these an expected finding?

Presence of small brown macules on the sclera

During an oral assessment of a 30-year-old Black patient, the nurse notices bluish lips and a dark line along the gingival margin. What action would the nurse perform in response to this finding?

Proceed with the assessment, knowing that this appearance is a normal finding. rational: Some Blacks may have bluish lips and a dark line on the gingival margin; this appearance is a normal finding.

The nurse is testing the hearing of a 78-year-old man and is reminded of the changes in hearing that occur with aging that include which of the following? Select all that apply.

Progression of hearing loss is slow. The aging person may find it harder to hear consonants than vowels. Sounds may be garbled and difficult to localize.

While obtaining a health history from the mother of a 1-year-old child, the nurse notices that the baby has had a bottle in his mouth the entire time. The mother states, It makes a great pacifier. The best response by the nurse would be:

Prolonged use of a bottle can increase the risk for tooth decay and ear infections

The nurse is performing an otoscopic examination on an adult. Which of these actions is correct?

Pulling the pinna up and back before inserting the speculum

The nurse is testing a patient's visual accommodation, which refers to which action?

Pupillary constriction when looking at a near object Rational: The muscle fibers of the iris contract the pupil in bright light and accommodate for near vision, which also results in pupil constriction.

In a patient who has anisocoria, the nurse would expect to observe:

Pupils of unequal size.

Immediately after birth, the nurse is unable to suction the nares of a newborn. An attempt is made to pass a catheter through both nasal cavities with no success. What should the nurse do next?

Recognize that this situation requires immediate intervention. rational: Determining the patency of the nares in the immediate newborn period is essential because most newborns are obligate nose breathers. Nares blocked with amniotic fluid are gently suctioned with a bulb syringe. If obstruction is suspected, then a small lumen (5 to 10 Fr) catheter is passed down each naris to confirm patency. The inability to pass a catheter through the nasal cavity indicates choanal atresia, which requires immediate intervention

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 infants hearing?

Rubella can damage the infants organ of Corti, which will impair hearing. rational: If maternal rubella infection occurs during the first trimester, then it can damage the organ of Corti and impair hearing.

A patient comes to the emergency department after a boxing match, and his left eye is swollen almost shut. He has bruises on his face and neck. He says he is worried because he cant see well from his left eye. The physician suspects retinal damage. The nurse recognizes that signs of retinal detachment include:

Shadow or diminished vision in one quadrant or one half of the visual field.

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?

Shattered look to the light rays reflecting off the cornea

The nurse is obtaining a health history on a 3-month-old infant. During the interview, the mother states, I think she is getting her first tooth because she has started drooling a lot. The nurse's best response would be:

She is just starting to salivate and hasnt learned to swallow the saliva. rational: In the infant, salivation starts at 3 months. The baby will drool for a few months before learning to swallow the saliva. This drooling does not herald the eruption of the first tooth, although many parents think it does.

When assessing the pupillary light reflex, the nurse should use which technique?

Shine a light across the pupil from the side, and observe for direct and consensual pupillary constriction.

A patient is unable to read even the largest letters on the Snellen chart. The nurse should take which action next?

Shorten the distance between the patient and the chart until the letters are seen, and record that distance.

While obtaining a health history, a patient tells the nurse that he has frequent nosebleeds and asks the best way to get them to stop. What would be the nurse's best response?

Sit up with your head tilted forward and pinch your nose. rational: With a nosebleed, the person should sit up with the head tilted forward and pinch the nose between the thumb and forefinger for 5 to 15 minutes.

A pregnant woman states that she is concerned about her gums because she has noticed they are swollen and have started bleeding. What would be an appropriate response by the nurse?

Swollen and bleeding gums can be caused by the change in hormonal balance in your system during pregnancy. rational: Gum margins are red and swollen and easily bleed with gingivitis. A changing hormonal balance may cause this condition to occur in pregnancy and puberty.

The nurse is conducting a visual examination. Which of these statements regarding visual pathways and visual fields is true?

The image formed on the retina is upside down and reversed from its actual appearance in the outside world.

The nurse is preparing to perform an otoscopic examination of a newborn infant. Which statement is true regarding this examination?

The normal membrane may appear thick and opaque.

The nurse is performing an external eye examination. Which statement regarding the outer layer of the eye is true?

The outer layer of the eye is very sensitive to touch. Rational: The cornea and the sclera make up the outer layer of the eye. The cornea is very sensitive to touch.

A patients vision is recorded as 20/30 when the Snellen eye chart is used. The nurse interprets these results to indicate that:

The patient can read at 20 feet what a person with normal vision can read at 30 feet.

The nurse is examining a patients ears and notices cerumen in the external canal. Which of these statements about cerumen is correct?

The purpose of cerumen is to protect and lubricate the ear.

The mother of a 2-year-old toddler is concerned about the upcoming placement of tympanostomy tubes in her sons ears. The nurse would include which of these statements in the teaching plan?

The purpose of the tubes is to decrease the pressure and allow for drainage.

A 32-year-old woman is at the clinic for little white bumps in the mouth. During the assessment, the nurse notes that she has a 0.5 cm white, nontender papule under her tongue and one on the mucosa of her right cheek. What would the nurse tell the patient?

These bumps are Fordyce granules, which are sebaceous cysts and are not a serious condition. rational: Fordyce granules are small, isolated white or yellow papules on the mucosa of the cheek, tongue, and lips. These little sebaceous cysts are painless and are not significant.

A mother brings her 4-month-old infant to the clinic with concerns regarding a small pad in the middle of the upper lip that has been there since 1 month of age. The infant has no health problems. On physical examination, the nurse notices a 0.5-cm, fleshy, elevated area in the middle of the upper lip. No evidence of inflammation or drainage is observed. What would the nurse tell this mother?

This elevated area is a sucking tubercle caused from the friction of breastfeeding or bottle-feeding and is normal. rational: A normal finding in infants is the sucking tubercle, a small pad in the middle of the upper lip from the friction of breastfeeding or bottle-feeding.

During an examination, the patient states he is hearing a buzzing sound and says that it is driving me crazy! The nurse recognizes that this symptom indicates:

Tinnitus. rational: Tinnitus is a sound that comes from within a person; it can be a ringing, crackling, or buzzing sound. It accompanies some hearing or ear disorders.

When examining the mouth of an older patient, the nurse recognizes which finding is due to the aging process?

Tongue that looks smoother in appearance rational: In the aging adult, the tongue looks smoother because of papillary atrophy. The teeth are slightly yellowed and appear longer because of the recession of gingival margins.

A 10 year old is at the clinic for a sore throat that has lasted 6 days. Which of these findings would be consistent with an acute infection?

Tonsils 3+/1-4+ with large white spots rational: With an acute infection, tonsils are bright red and swollen and may have exudate or large white spots. Tonsils are enlarged to 2+, 3+, or 4+ with an acute infection.

The nurse assesses the hearing of a 7-month-old by clapping hands. What is the expected response? The infant:

Turns his or her head to localize the sound.

During a checkup, a 22-year-old woman tells the nurse that she uses an over-the-counter nasal spray because of her allergies. She also states that it does not work as well as it used to when she first started using it. The best response by the nurse would be:

Using these nasal medications irritates the lining of the nose and may cause rebound swelling

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?

VIII rational: The nerve impulses are conducted by the auditory portion of CN VIII to the brain.

While performing an assessment of the mouth, the nurse notices that the patient has a 1-cm ulceration that is crusted with an elevated border and located on the outer third of the lower lip. What other information would be most important for the nurse to assess?

When the patient first noticed the lesion rational: With carcinoma, the initial lesion is round and indurated, but then it becomes crusted and ulcerated with an elevated border. Most cancers occur between the outer and middle thirds of the lip. Any lesion that is still unhealed after 2 weeks should be referred.

A nurse is preparing to assess the eyes of a client who has liver disease. Which of the following findings should the nurse expect? 1. Ptosis of an eyelid 2.Yellow sclera 3.Edema of the eyelids 4.Reddened conjunctiva

Yellow sclera

A nurse is inspecting the sinuses of a client who has allergies. Which of the following findings should the nurse expect? 1. Pale mucosa 2. Bright red mucosa 3. Green discharge 4. Yellow discharge

pale mucosa

The primary purpose of the ciliated mucous membrane in the nose is to:

Filter out dust and bacteria.

The nurse is reviewing in age-related changes in the eye for a class. Which of these physiologic changes is responsible for presbyopia?

Loss of lens elasticity

. A patient has been diagnosed with strep throat. The nurse is aware that without treatment, which complication may occur?

Rheumatic fever

When assessing the tongue of an adult, the nurse knows that an abnormal finding would be:

Smooth glossy dorsal surface.

The nurse is performing an assessment. Which of these findings would cause the greatest concern?

Ulceration on the side of the tongue with rolled edges rational: Ulceration on the side or base of the tongue or under the tongue raises the suspicion of cancer and must be investigated. The risk of early metastasis is present because of rich lymphatic drainage.

The nurse is performing an eye assessment on an 80-year-old patient. Which of these findings is considered abnormal?

Unequal pupillary constriction in response to light

A 17-year-old student is a swimmer on her high schools swim team. She has had three bouts of otitis externa this season and wants to know what to do to prevent it. The nurse instructs her to:

Use rubbing alcohol or 2% acetic acid ear drops after every swim.

The nurse is preparing to assess the visual acuity of a 16-year-old patient. How should the nurse proceed?

Use the Snellen chart positioned 20 feet away from the patient.

A patient comes into the clinic complaining of pain in her right eye. On examination, the nurse sees a pustule at the lid margin that is painful to touch, red, and swollen. The nurse recognizes that this is a:

Hordeolum (stye).

The nurse is reviewing causes of increased intraocular pressure. Which of these factors determines intraocular pressure?

Amount of aqueous produced and resistance to its outflow at the angle of the anterior chamber

An assessment of a 23-year-old patient reveals the following: an auricle that is tender and reddish-blue in color with small vesicles. The nurse would need to know additional information that includes which of these?

Any prolonged exposure to extreme cold rational: Frostbite causes reddish-blue discoloration and swelling of the auricle after exposure to extreme cold. Vesicles or bullae may develop, and the person feels pain and tenderness.

The nurse is performing an assessment on a 65-year-old man. He reports a crusty nodule behind the pinna. It intermittently bleeds and has not healed over the past 6 months. On physical assessment, the nurse finds an ulcerated crusted nodule with an indurated base. The preliminary analysis in this situation is that this:

Could be a potential carcinoma, and the patient should be referred for a biopsy.

. 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?

Does your baby seem to startle with loud noises? rational: Children at risk for a hearing deficit include those exposed in utero to a variety of conditions, such as maternal rubella or to maternal ototoxic drugs.

A 92-year-old patient has had a stroke. The right side of his face is drooping. The nurse might also suspect which of these assessment findings?

Dysphagia

When examining the eye, the nurse notices that the patient's eyelid margins approximate completely. The nurse recognizes that this assessment finding:

Is expected. Rational: The palpebral fissure is the elliptical open space between the eyelids, and, when closed, the lid margins approximate completely, which is a normal finding.

The nurse is reviewing the structures of the ear. Which of these statements concerning the eustachian tube is true?

It helps equalize air pressure on both sides of the tympanic membrane.

When examining the ear with an otoscope, the nurse notes that the tympanic membrane should appear:

Pearly gray and slightly concave.

The nurse is taking the history of a patient who may have a perforated eardrum. What would be an important question in this situation?

Is there any relationship between the ear pain and the discharge you mentioned? rational: Typically with perforation, ear pain occurs first, stopping with a popping sensation, and then drainage occurs.

A mother asks when her newborn infants eyesight will be developed. The nurse should reply:

By approximately 3 months of age, infants develop more coordinated eye movements and can fixate on an object. Rational: 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.

A patients vision is recorded as 20/80 in each eye. The nurse interprets this finding to mean that the patient:

Has poor vision.

The nurse is performing a middle ear assessment on a 15-year-old patient who has had a history of chronic ear infections. When examining the right tympanic membrane, the nurse sees the presence of dense white patches. The tympanic membrane is otherwise unremarkable. It is pearly, with the light reflex at 5 o'clock and landmarks visible. The nurse should:

Know that these are scars caused from frequent ear infections. rational: Dense white patches on the tympanic membrane are sequelae of repeated ear infections. They do not necessarily affect hearing.

The nurse is reviewing the development of the newborn infant. Regarding the sinuses, which statement is true in relation to a newborn infant?

Maxillary and ethmoid sinuses are the only sinuses present at birth. rational: Only the maxillary and ethmoid sinuses are present at birth. The sphenoid sinuses are minute at birth and develop after puberty. The frontal sinuses are absent at birth, are fairly well developed at age 7 to 8 years, and reach full size after puberty.

The nurse is preparing to do an otoscopic examination on a 2-year-old child. Which one of these reflects the correct procedure?

Pulling the pinna down

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. The nurses best response would be:

This is a normal number of teeth for an 18 month old.

The nurse is conducting a child safety class for new mothers. Which factor places young children at risk for ear infections?

Passive cigarette smoke

The projections in the nasal cavity that increase the surface area are called the:

Turbinates.

During an assessment of a 26 year old at the clinic for a spot on my lip I think is cancer, the nurse notices a group of clear vesicles with an erythematous base around them located at the lip-skin border. The patient mentions that she just returned from Hawaii. What would be the most appropriate response by the nurse?

Tell the patient that these vesicles are indicative of herpes simplex I or cold sores and that they will heal in 4 to 10 days.

The nurse is assessing color vision of a male child. Which statement is correct? The nurse should:

Test for color vision once between the ages of 4 and 8 years.