Health Assessment Exam 2
A client is diagnosed with a scotoma. What question is appropriate for the nurse to ask to obtain more data about this condition?
"Are the blind spots constant or intermittent?"
A nurse inspects the gums and teeth of a middle aged adult and notices the presence of small brown spots on the chewing surfaces of several of the molar teeth. What question should the nurse ask the client to determine the cause of this finding?
"Are you experiencing any tooth pain?"
While the nurse is obtaining a client's health history regarding the head and neck, the client tells the nurse about having a lump in the neck. In order to assess for associated manifestations of this problem, which of the following questions should the nurse ask next?
"Do you have difficulty swallowing?
The nurse notes that a client's nasal mucosa is pale pink. What question should the nurse ask the client based upon this finding?
"Have you been told you have allergies?"
A female client asks a nurse why it seems like her headaches are more severe and longer in duration than male friends who also have migraines. What is the best response by the nurse?
"Hormones affect the severity of migraine headaches."
A nurse is teaching nursing students about the risks associated with developing head and neck cancers. The nurse determines student understanding when the students make which of the following statements?
"Most head and neck cancers are linked to smoking."
An adolescent wrestler has been diagnosed with herpes simplex virus with weeping lesions on the face, nose, and lips. The client asks the nurse when he can resume competition wrestling. What is the nurse's best response?
"You can wrestle after the lesions stop weeping and have crusted over."
A client in the clinic where you work is considered legally blind. The nurse knows that this means the vision in his better eye, corrected by glasses, is what?
20/200 or less
A nurse assesses a client who is reporting a sore throat and difficult, painful swallowing. The nurse observes that the client's tonsils are touching each other. What ranking (grade scale) should the nurse document for tonsillitis?
4+
A nurse is assessing a small child who has lead poisoning. Which characteristic of the gums should the nurse expect this client?
A grey-white line
The nurse notes a tophus of the ear of an older adult. Which assessment data is consistent with a tophus?
A hard nodule composed of uric acid crystals
Which of the following clients is most likely to be diagnosed with migraine headaches?
A woman whose headaches come on suddenly and are somewhat relieved by a quiet, dark room
Where is the temporal artery palpated?
Above the cheek bone near the scalp line STRUCTURE AND FUNCTION
Upon examination of the head and neck of a client, a nurse notes that the submandibular nodes are tender and enlarged. The nurse should assess the client for further findings related to what condition?
Acute infection
The nurse is inspecting the cornea and lens of an elderly client and notices a white arc around the limbus of the client's eye. The nurse recognizes this condition, common in older adults, as which of the following?
Arcus senilis
A 82 year old female presents with neck pain, decreased strength and sensation of the upper extremities. The nurse identifies that this could be related to what?
Arthritic changes of the cervical spine
An 81-year-old client complains of neck pain and demonstrates decreased range of motion on examination. Which of the following causes should the nurse most suspect in this client?
Arthritis
The nurse suspects an enlarged thyroid in a client during the physical examination of the head and neck. What should the nurse do first?
Ask the client to sip and swallow water.
A client with a cervical spine injury reports chronic pain. What would be the most appropriate initial nursing intervention for this client?
Assess the client regarding characteristics of the pain.
A 57-year-old client reports, "I am having the worst headache I have ever experienced." Which action should the nurse perform next?
Assess the client's blood pressure.
When palpating the neck, performing which of the following techniques will help differentiate lymph nodes from a band of muscles?
Attempting to roll the structure up and down and side to side
A nurse palpates an elderly client's thyroid and detects an enlargement over the right lateral lobe. What action should the nurse take first?
Auscultate with the bell over the lateral lobes
A nurse is assessing a client with hyperthyroidism for the presence of a bruit. Which assessment technique should the nurse use?
Auscultation
A client is being assessed following a motor vehicle accident. The client's right eye is swollen shut and very painful. Why does this require further assessment?
Blunt-force trauma often results in fracture of the orbit
A client reports a 20 pack per year history of cigarette smoking. To assess this client for cancer, where should the nurse inspect the tongue?
Both sides
A client presents to a primary care office with a complaint of double vision (diplopia). On questioning, the client claims to have not suffered any head injuries. Which of the following underlying conditions should the nurse most suspect in this client?
Brain tumor
The nurse practitioner auscultates both lobes of a client's enlarged thyroid gland. Identification of what sound would tend to confirm a diagnosis of a toxic goiter?
Bruit
When inspecting the mouth, the nurse focuses on lateral and vertical surfaces of the tongue and its base, because these are regions where:
Cancers often occur.
A nurse is working with a client from Asia who has just been diagnosed with oropharyngeal cancer. Which culture-related risk factor should the nurse most suspect in this client?
Chewing betel nuts
The thin mucous membrane that lines the inner eyelid and covers the sclera is known as what?
Conjunctiva
Which action by a nurse is appropriate to prevent the gag reflex during observation of the uvula?
Depress the tongue slightly off center
The nurse is planning a presentation to a group of high school students about the risk factors for oral cancer. Which of the following should be included in the nurse's plan?
Diets low in fruits and vegetables are a possible risk factor for oral cancer.
The nurse selects the chart shown here to assess a client's vision. Which client characteristic caused the nurse to select this chart?
Does not speak English
On examining a client, the nurse detects a sulfur odor to the breath. The nurse recognizes this finding as a characteristic of which disease process?
End-stage liver disease
A 29-year-old physical therapist presents for evaluation of an eyelid problem. On observation, the right eyeball appears to be protruding forward. Based on this description, what is the most likely diagnosis?
Exophthalmos
When performing the cover test, a nurse notices that the client's left eye turns outward. How should the nurse document this finding in the client's record?
Exotropia
During a comprehensive assessment, a client reports difficulty moving their tongue and jaw. What is the first action of the nurse?
Further assess the client for signs and symptoms of cancer.
During an assessment the nurse observes the condition shown in the client's mouth. What should the nurse suspect is occurring with this client?
Gingival hyperplasia
A client shares that a first-degree relative has an eye problem, but they not sure what the diagnosis is. What major eye problem will the nurse suggest screening the client for?
Glaucoma
What is the most common type of hyperthyroidism?
Graves' disease
A six-month old male infant is brought to the emergency department by his parents for inconsolable crying and pulling at his right ear. When assessing this infant the nurse is aware that the tympanic membrane should be what color in a healthy ear?
Gray
A nurse begins the eye examination on a client who presents to the health care clinic for a routine examination. What is the correct action by the nurse to perform the test for near visual acuity?
Have the client hold the Jaeger card 14 inches from the face and read with one eye at a time
You are caring for a client in the outpatient clinic with suspicion of cancer due to recent weight losses for unidentifiable reasons. The client a 25-year history of smoking. You perform an assessment and ask the client about symptoms related to laryngeal cancer. What is an early symptom associated with laryngeal cancer?
Hoarseness
A staff educator from the hospital is providing an event for the hospital staff. The educator is talking about health promotion activities for people with diseases of the nose, mouth, throat, and sinuses. What would the educator include in the presentation?
How to reduce periodontal disease
When identifying the midline structures of the neck from the mandible to the sternal notch, the nurse notes the structures in what order?
Hyoid bone, thyroid cartilage, cricoid cartilage, isthmus of the thyroid
A client presents to the emergency department after being hit in the head with a baseball bat during a game. The nurse should assess for which condition? a. Hyphema b. Blepharitis c. Chalazion d. Iris nevus
Hyphema
While the nurse is assessing a client for an unrelated health concern, the client experiences a sudden, severe headache with no known cause. He also complains of dizziness and trouble seeing out of one eye. What associated condition should the nurse suspect in this client?
Impending stroke
A client is diagnosed with an obstruction of the canal of Schlemm affecting the left eye. What assessment data concerning the left eye noted in the client's medical record supports this diagnosis?
Increased intraocular pressure
A child presents to the health care facility with new onset of a foul-smelling, purulent drainage from the right nare. The mother states that no other signs of an upper respiratory tract infection are present. What is an appropriate action by the nurse?
Inspect the nostrils with an otoscope
In addition to noting the physical characteristics of the thyroid gland, which of the following signs would be most important to consider in determining if the client has hypothyroidism?
Laboratory tests
A client frequently experiences dry, irritated eyes. These findings are consistent with a problem in what part of the eye?
Lacrimal apparatus
A client comes into the clinic complaining of hoarseness that has lasted for about a month. What would you suspect?
Laryngeal cancer
During an oral assessment, the nurse identifies that client has white patches in his mouth. How would this be documented in the medical record?
Leukoplakia
During your physical examination of the client you note an enlarged tender tonsillar lymph node. What would you do?
Look for a source such as infection in the area that it drains
An older adult client who wears dentures reports having soreness of the gums. Which intervention should the nurse recommend to the client to alleviate this problem?
Massage the gums daily.
A nurse is examining a client who is complaining of sinus pressure in his face and congestion. The nurse discovers tenderness on palpation of the sinuses and a large amount of exudate. Over which sinuses should the nurse expect to feel crepitus in this client?
Maxillary
When examining the eye with an ophthalmoscope, where would the nurse look to visualize the optic disc?
Medially toward the nose
What are the glands that are located on the tarsal plates and open on the lid margins?
Meibomian glands
A nurse is caring for a client admitted with neck pain. The client is febrile. What is the most likely medical diagnosis for this client?
Meningitis
A client reports right-sided temporal headache accompanied by nausea and vomiting. A nurse recognizes that which condition is likely to produce these symptoms?
Migraine headache
When preparing to provide education regarding the prevention of head injuries from motor vehicle accidents, the nurse should be sure to include which point?
Mobile phones should only be used if there is a hands-free option available.
Which area should the nurse inspect for facial symmetry when performing a head and neck assessment?
Nasolabial folds
A client reports sudden head and neck pain with stiffness, a new sensitivity to light, and has developed a fever. What is a priority action of the nurse?
Notify the health care provider.
A client complains of a unilateral headache near the scalp line and double vision. The nurse palpates the space above the cheekbone near the scalp line on the affected side, and the client complains of tenderness on palpation. What is the nurse's next action?
Notify the healthcare provider immediately.
A nurse has completed the assessment of a client's direct pupillary response and is now assessing consensual response. This aspect of assessment should include which action?
Observing the eye's reaction when a light is shone into the opposite eye
The nurse performs the action shown when assessing a client's eyes. What is the nurse assessing?
Ocular alignment
Which instruction to the client will help facilitate examination of the temporomandibular joint by the nurse?
Open the mouth
Which of the following describes a condition characterized by abnormal spongy bone formation around the stapes?
Otosclerosis
The nursing instructor is discussing the administration of nasal spray with the nursing students. What information is most important to include in this discussion?
Overuse of nasal spray may cause rebound congestion.
A client has been brought to the emergency unit of a health care facility following an automobile accident. Which finding about the lips supports the diagnosis of anemia and shock?
Pallor
You note anterior bulging of the physiologic cup when performing a funduscopic examination of your client's eyes. What would you document?
Papilledema
On assessing a client's mouth, the nurse finds that the uvula is deviated and the palate fails to rise. Which of the following conditions should the nurse most suspect in this client?
Paralysis of cranial nerve X (vagus)
Which characteristic of the gums should a nurse expect to assess in a client who is healthy?
Pink, moist, firm
A nurse assesses the pupillary reaction to light for a client. Which precaution should the nurse follow to get an accurate result of consensual response?
Place an opaque card in between the eyes of the client
A nurse notices a middle-aged client in the waiting room pick up a magazine to read while she waits to be seen. She opens the magazine and then extends her arms to move it further from her eyes. Which condition does the nurse most suspect in this client?
Presbyopia
Which technique should the nurse use to examine the sinuses of a client with a sinus infection?
Press up on the brow on each side of the nose to palpate the frontal sinus.
When testing the near reaction, an expected finding includes which of the following?
Pupillary constriction on near gaze; dilation on distant gaze
A young adult client has just had X-rays and computed tomography scanning of the head and neck following a mountain bicycling accident. All results are negative. What should the nurse assess for next?
Range of motion of the neck
A nurse is assessing the mouth of an older client. Which of the following findings is common among older adults?
Receding and ischemic gums
Which assessment of the tongue should a nurse recognize as abnormal?
Red with loss of papillae
While conducting a comprehensive assessment on a new client, the client states, "I've had these mouth and tongue sores for a few weeks that do not seem to heal." The nurse assesses the client's mouth and finds thickened lumpy areas with a rough and crusty appearance. What is the best action of the nurse?
Refer the client for further evaluation of the sores.
What part of the eye receives and transmits visual stimuli to the brain for processing?
Retina
A client admitted to the health care facility is diagnosed with vertigo. Which test is appropriate for the nurse to perform to assess for equilibrium in the client?
Romberg
A client is admitted to the health care facility after sustaining a crushing injury to the right eye. The nurse should anticipate abnormal results for which vision test?
Six cardinal positions of gaze
In examining a client's mouth with a penlight, the nurse notices salivary ducts that are visible on the buccal mucosa across from the second upper molars. The nurse recognizes these as which of the following?
Stenson's ducts
A 29-year-old computer programmer comes to the office for evaluation of a headache. The tightening sensation of moderate intensity is located all over the head. It used to last minutes, but this time it has lasted for 5 days. He denies photophobia and nausea. He spends several hours at a computer monitor/keyboard. He has tried over-the-counter medication; it has dulled the pain, but not taken it away. Based on this description, what is the most likely diagnosis?
Tension
A nurse performs the Snellen test on a client and obtains these results: OD 20/40, OS 20/30. What conclusion can the nurse make in regards to the client's vision based on these results?
The larger the bottom number, the worse the visual acuity.
What is the open space between the eyelids called?
The palpebral fissure
When examining the head, the nurse remembers that the anatomic regions of the cranium take their names from which of the following sources?
The underlying bones
Palpation of a 15-year-old boy's submandibular lymph nodes reveals them to be enlarged and tender. What is the nurse's most reasonable interpretation of this assessment finding?
There is an infection in the area that these nodes drain.
A nurse assesses the vision of an older adult client with a long history of uncontrolled type 2 diabetes. The nurse determines the client's vision with corrective lenses is 20/200. How should the nurse interpret these findings?
These findings indicate the client is legally blind.
A 58-year-old man who is HIV-positive has presented with thick, white plaques on his oral mucosa. What diagnosis would the nurse first suspect?
Thrush
What is the primary purpose of the health history in relation to the eyes?
To identify changes
Which of the following assessment findings of the mouth, nose, and throat of an older adult client would the nurse attribute to the aging process?
Tongue fissures
A young man is concerned about a hard mass in the midline of his palate that he has just noticed. Examination reveals that it is indeed hard and in the midline. No mucosal abnormalities are associated with this lesion. The client has no other symptoms. What is the most likely diagnosis?
Torus palatinus
A nurse is inspecting a client's eyes to assess for the possibility of detached retinas. The nurse is aware that which of the following is the function of the retina?
Transforms light rays into nerve impulses that are conducted to the brain STRUCTURE AND FUNCTION
When preparing to examine a client's sclera and conjunctiva during an eye examination, the nurse should instruct the client to move both eyes to look in which direction?
Up
Which food is most appropriate for the nurse to recommend for a client who suffers frequent nosebleeds due to hereditary hemorrhagic telangiectasia?
Vegetable omelet
A client is found to have a smooth, glossy tongue. What vitamin deficiency might this indicate?
Vitamin B12 deficiency
The submandibular glands open under the tongue through openings called
Wharton ducts.
The nurse should make it a priority to assess which client for papilledema?
a 45-year-old suspected of experiencing a subarachnoid hemorrhage
What do retinal abnormalities include? a. Age-related macular degeneration b. Mydriasis c. Argyll Robertson syndrome d. Horner's syndrome
a. Age-related macular degeneration
Which factor, if present in a client's lifestyle and health practices assessment, would alert the nurse to the need for performing a more thorough head and neck assessment? Select all that apply. a. Alcohol abuse b. Recreational drug use c. Smokeless tobacco use d. Multiple sex partners
a. Alcohol abuse b. Recreational drug use c. Smokeless tobacco use d. Multiple sex partners
When providing client education on hearing, the nurse should remind clients to utilize ear plugs when they are what? (Select all that apply.) a. At train stations b. Cleaning their homes c. Using lawnmowers d. Working with children e. At concerts
a. At train stations c. Using lawnmowers e. At concerts
A client asks a nurse if any foods promote eye health. What food would the nurse include as a response? a. Deep-water fish b. Low-fat meat c. Foods that contain lots of water d. Multigrain foods
a. Deep-water fish
A 60-year-old client is concerned about developing cataracts in her eyes. She asks the nurse whether there is anything she can do to reduce her risk. Consumption of which of the following foods should the nurse recommend to the client for this purpose? Select all that apply. a. Kale b. Red wine c. Eggs d. Turkey e. Oranges f. Skim milk
a. Kale c. Eggs e. Oranges
Which statement regarding oral cancer is correct? Select all that apply. a. Oral cancer occurs more frequently in males. b. Oral cancer occurs more frequently in females. c. Risk factors for oral cancer includes oral sex. d. Smoking is a risk factor for oral cancer. e. African Americans have a higher incidence of oral cancer.
a. Oral cancer occurs more frequently in males. c. Risk factors for oral cancer includes oral sex. d. Smoking is a risk factor for oral cancer.
Equipment used for objective data collection involving the eyes includes which of the following? Select all that apply. a. Penlight b. Protective mask c. Occlusive covers d. Ophthalmoscope c. Snellen chart
a. Penlight d. Ophthalmoscope c. Snellen chart
The nurse observes a middle-aged colleague fully extending her arm to read the label on a vial of medication. Which of the following age-related changes is the nurse likely to have observed? a. Presbyopia b. Cataract formation c. Loss of convergence d. Macular degeneration
a. Presbyopia
A client is experiencing sinus tenderness associated with a head cold. What techniques should the nurse use to assess this client's symptom? (Select all that apply.) a. Press up on the frontal sinuses from under the bony brows. b. Press down on the head. c. Press up on the area next to the ear. d. Press up on the maxillary sinuses. e. Press down on the lower jaw.
a. Press up on the frontal sinuses from under the bony brows. d. Press up on the maxillary sinuses.
What action should the nurse implement using an otoscope when assessing the ear of an adult client? a. Pull the auricle out, up, and back b. Choose the smallest speculum for client comfort c. Hold the speculum in the nondominant hand. d. Insert the speculum gently down and backward
a. Pull the auricle out, up, and back
During a physical examination the nurse performs the action shown. What assessment is the nurse performing? a. Rinne test b. Weber test c. Auditory acuity d. Vestibular function
a. Rinne test
Which glands are responsible for mouth drainage? Select all that apply. a. Sublingual b. Submandibular c. Parotid d. Lacrimal e. Sebaceous
a. Sublingual b. Submandibular c. Parotid
The meibomian gland secrete a. an oily substance to lubricate the eyes b. sweat c. hormones d. clear liquid tears
a. an oily substance to lubricate the eyes
While assessing the eye of an adult client, the nurse observes an inward turning of the client's left eye. The nurse should document the client's a. esotropia b. strabismus c. phoria d. exotropia
a. esotropia
An adult client tells the nurse that her peripheral vision is not what it used to be and she has a blind spot in her left eye. The nurse should refer the client for evaluation of possible a. glaucoma b. increased intracranial pressure c. bacterial infection d. migraine headaces
a. glaucoma
In order to effectively assess the oral mucosa, the nurse should have which assessment tools available? a. gloves b. penlight c. tongue depressor d. speculum e. tuning fork
a. gloves b. penlight c. tongue depressor
A client with hypothyroidism is admitted to the medical unit. The nurse would expect to assess which signs/symptoms? Select all that apply. a. lethargy b. constipation c. cool skin d. lower systolic blood pressure e. weight loss
a. lethargy b. constipation c. cool skin d. lower systolic blood pressure
The tarsal plates of the upper eyelid contain a. meibomian glands b. sebacious glands c. tear ducts d. ocular muscles
a. meibomian glands.
The optic nerves from each eyeball cross at the a. optic chiasma b. vitreous humor c. optic disc d. visual cortex
a. optic chiasma
The nurse is preparing to examine an adult client's eyes, using a Snellen chart. The nurse should a. position the client 20 ft away from the chart b. ask the client to remove his glasses c. ask the clent to read each line with both eyes open d. instruct the client to begin reading from the bottom of the chart
a. position the client 609.6 cm (20 ft) away from the chart.
The nurse is preparing to collect a client's past history related to the nose and sinuses. Which topic(s) should the nurse explore? Select all that apply. a. sinus infections b. upper respiratory infections (URIs) c. allergies d. traumas or injuries e. history of syphilis, rubella, meningitis
a. sinus infections b. upper respiratory infections (URIs) c. allergies d. traumas or injuries
A 45 yo client tells the nurse that he occasionally sees spots in from of his eyes. The nurse should a. tell the client that these often occur with aging b. refer the client to an opthalmologist c. re-examine the client in 2 weeks d. assiss the client for signs of diabetes
a. tell the client that these often occur with aging
A nurse performs a comprehensive assessment on a client. The nurse observes the following findings: enlarged hands, feet, and facial features (nose, ears). Which of the following disorders do these findings indicate?
acromegaly
A client reports experiencing chronic headache after a recent upper respiratory tract infection. On physical examination, the nurse notes tenderness when palpating over the sinuses. Which condition is likely?
acute bacterial sinusitis
The meibomian glands secrete
an oily substance to lubricate the eyes.
The nurse is assessing an adult client's oral cavity for possible oral cancer. The nurse should explain to the client that the most common site of oral cancer is the
area underneath the tongue.
A client calls the clinic and tells the nurse that the doctor told her that she has "otalgia." The client cannot remember what the doctor explained this to be. How would the nurse most appropriately respond? a. "Otalgia is discoloration of the ear." b. "Otalgia is pain in the ear." c. "Otalgia is the beginning of hearing loss." d. "Otalgia is a disease of the inner ear."
b. "Otalgia is pain in the ear."
The nurse is caring for a healthy adult client with no history of vision problems. The nurse should tell the client that a thorough eye examination is recommended every a. year b. 2 years c. 3years d. 4 years
b. 2 years
Which of the following assessment findings suggests a problem with the client's cranial nerves? a. A client states that he has recently begun seeing lights flashing in his field of vision. b. A client's extraocular movements are asymmetrical and she complains of diplopia. c. Fundoscopic examination reveals intraocular bleeding. d. A client's lens appears cloudy and she claims that her visual acuity has recently declined.
b. A client's extraocular movements are asymmetrical and she complains of diplopia.
What does the nurse assess the face for? (Select all that apply.) a. Hair color b. Asymmetry c. Affect d. Edema e. Involuntary movements
b. Asymmetry d. Edema e. Involuntary movements
What risk factors should the nurse include in a discussion on the occurrence of neck cancer? (Select all that apply.) a. Female gender b. Male gender c. Coffee drinker d. Tobacco use e. Age older than 50 years
b. Male gender d. Tobacco use e. Age older than 50 years
The functional reflex that allows the eyes to focus on near objects is termed a. pupillary reflex b. accommodation c. refraction d. indirect reflex
b. accommodation
A 12-year-old presents to the clinic with his father for evaluation of a painful lump in the left eye. It started this morning. The client denies any trauma or injury. There is no visual disturbance. Upon physical examination, there is a red raised area at the margin of the eyelid that is tender to palpation; no tearing occurs with palpation of the lesion. Based on this description, what is the most likely diagnosis? a. Dacryocystitis b. Chalazion c. Stye d. Xanthelasma
c. Stye
An adult client visits the outpatient clinic and tells the nurse that he has a throbbing aching pain in his right eye. The nurse should assess the client for a. increased intracranial pressure. b. excessive tearing. c. a foreign body in the eye. d. recent exposure to irritants.
c. a foreign body in the eye.
The nurse notes that the pupil of a client's left eye constricts when a light is shined into the right eye. How should the nurse document this finding? a. direct light response present in left eye b. pupils equal and react to accommodation-consensual light response present in left eye c.consensual light response present in right eye
c. consensual light response present in left eye
When assessing the fundus of the eye, the nurse recognizes which normal characteristic represented in dark-skinned individuals? a. slightly darker fovea is just discernible b. no light reflex is visible c. fundus is grayish brown with a purplish cast d. the lower field of the fundus has characteristic stripes
c. fundus is grayish brown with a purplish cast
The bony orbit and fat cushion of the eye serves as a a. caruncle b. channel c. protector d. filter
c. protector
The nurse is examining an adlt client's eyes. The nurse has explained the positions test to the client. The nurse determines that the client needs further instructions when the client says that the positions test a. assesses the muscle strength of the eye b. assesses the functioning of the cranial nerves innervating the eye muscles c. requires the covering of each eye separately d. requires the client to focus on an object
c. requires the covering of each eye separately
Photoreceptors of the eye are located in the eye's a. ciliary body b. lens c. retinal layer d. optic layer
c. retinal layer
A client is brought to the emergency department via ambulance after experiencing difficulty speaking and weakness in the left arm and leg. The nurse understands that the client is most likely experiencing which of the following disorders?
cerebrovascular accident
The middle layer of the eye is known as the a. choroid layer b. scleral layer c. retinal layer d. optic layer
choroid layer.
A client comes to the clinic reporting pain, tenderness, swelling, and pressure around the eyes, cheeks, nose, and forehead for the past 12 weeks. Based on these findings, which of the following disorders is the client most likely experiencing?
chronic sinusitis
A 52-year-old client with myopia calls the ophthalmology clinic very upset. She tells the nurse, "I keep seeing semi-clear spots floating across my vision. What is wrong with me?" What would be the most appropriate response by the nurse? a. "Because it is almost 5 o'clock, please go to the emergency department right away. This sounds very serious." b. "Please come into the clinic right away so we can see what is wrong." c. "I have an opening tomorrow at 2 in the afternoon. Can you come in then?" d. "It is not an uncommon finding in people older than 40 years for this to happen. They are called 'floaters'."
d. "It is not an uncommon finding in people older than 40 years for this to happen. They are called 'floaters'."
A 6-year-old boy has come to the clinic with his mother because of recent eye redness and discharge. The nurse's assessment has suggested a diagnosis of conjunctivitis. What should the nurse tell the mother about her son's eye? a. "In children, this problem is usually caused by an increase in pressure within the eye." b. "I'll prescribe some analgesics because your son is likely to have quite severe pain while his eye heals." c. "Antibiotics will clear this up, but you need to make sure he gets them as ordered to avoid vision damage." d. "This might have been the result of an allergy, but most likely it was caused by a bacteria or virus."
d. "This might have been the result of an allergy, but most likely it was caused by a bacteria or virus."
A nurse is educating a client about the function of the parts of the auditory system. Which is the function of the eustachian tube? a. Transmits vibration to the fluid filled inner ear at the oval window. b. Separates the external from the middle ear. c. Sends sensory information to the cerebellum and midbrain. d. Equalizes the pressure in the middle ear with atmospheric pressure.
d. Equalizes the pressure in the middle ear with atmospheric pressure.
Which characteristic feature of the tympanic membrane should a nurse anticipate finding in a client with acute otitis media? a. Pearly, translucent, with no bulging b. Yellowish, bulging, with fluid bubbles c. Gray, translucent, with no retraction d. Red, bulging, with an absent light reflex
d. Red, bulging, with an absent light reflex
A client reports recent dizziness and feeling unsteady on their feet. Which of the following tests should the nurse perform? a. Rinne b. Weber c. whisper d. Romberg
d. Romberg
As part of a physical assessment, the nurse performs the confrontation test to assess the client's peripheral vision. Which test result should a nurse recognize as indicating normal peripheral vision for a client using the confrontation test? a. Client's consensual pupil constricts in response to indirect light. b. Eyes converge on an object as it is moved towards the nose. c. Direct light shown into the client's pupils results in constriction. d. The client and the examiner see the examiner's finger at the same time.
d. The client and the examiner see the examiner's finger at the same time.
The conjunctiva of the eye is divided into the palpebral portion and the a. canthus portion b. intraocular portion c. nasolacrimal portion d. bulbar portion
d. bulbar portion
The chambers of the eye contain aqueous humor, which helps to maintain intraocular pressure and a. trasmit light rays b. maintain the retinal vessels c. change refractory of the lens d. cleanse the cornea and the lens
d. cleanse the cornea and the lens
The nurse is preparing to examine the ears of an adult client with an otoscope. The nurse should plan to a. ask the client to tilt the head slightly forward. b. release the auricle during the examination. c. use a speculum that measures 10 mm in diameter. d. firmly pull the auricle out, up, and back.
d. firmly pull the auricle out, up, and back.
An adult client visits the clinic and tells the nurse that he has had excessive tearing in his left eye. The nurse should assess the client's eye for a. viral infection b. double vision c. allergic reactions d. lacrimal obstruction
d. lacrimal obstruction
Straight movements of the eye are controlled by the a. lacrimal muscles b. oblique muscles c. corneal muscles d. rectus muscles
d. rectus muscles STRUCTURE AND FUNCTION
A client has tested 20/40 on the distant visual acuity test using a Snellen chart. The nurse should a. document the results in the client's record b. ask the client to read a handheld vision chart c. ask the client to return in 2 weeks for another examination d. refer the client to an optometrist
d. refer the client to an optometrist
A client tells the nurse that she has difficulty seeing while driving at night. The nurse should explain to the client that night blindness is often associated with a. retinal deterioration b. head trauma c. migraine headaches d. vitamin A deficiency
d. vitamin A deficiency
The nurse has tested the near visual acuity of a 45-year-old client. The nurse explains to the client that the client has impaired near vision and discusses a possible reason for the condition. The nurse determines that the client has understood the instructions when the client says that presbyopia is usually due to
decreased accommodation.
A client reports having had difficulty breathing through their right nostril for years. The client denies any other symptoms except for unrestful sleep. The nurse suspects that the client may have which of the following conditions?
deviated septum
The nurse has tested an adult client's visual fields and determined that the temporal field is 90 degrees in both eyes. The nurse should
document the findings in the client's records.
Before examining the mouth of an adult client, the nurse should first
don clean gloves for the procedure.
The nurse observes an inward turning of the lower lid in a 77-year-old client. The nurse documents
entropion
The nurse is using the ophthalmoscope to examine the client's eyes. The nurse holds the scope
in the right hand for the right eye and in the left hand for the left eye
As the nurse palpates the lymph nodes of the neck, hard and fixed nodes are noted in the supra-clavicular region. This finding is consistent with which condition?
malignancy
The nurse is preparing to examine the sinuses of an adult client. After examining the frontal sinuses, the nurse should proceed to examine the
maxillary sinuses.
While assessing an adult client's head and neck, the nurse observes asymmetry in front of the client's ear lobes. The nurse refers the client to the physician because the nurse suspects the client is most likely experiencing a/an
parotid gland enlargement.
The nurse is preparing to inspect the nose of an adult client with an otoscope. The nurse plans to
position the handle of the otoscope to one side.
A nurse assesses the mouth of an adult male client and observes a rough, crusty, eroded area. The nurse should
refer the client for further evaluation.
While assessing an older adult client's neck, the nurse observes that the client's trachea is pulled to the left side. The nurse should
refer the client to a physician for further evaluation.
The nurse is preparing to assess the neck of an adult client. To inspect movement of the client's thyroid gland, the nurse should ask the client to
swallow a small sip of water.
A client visits the clinic and tells the nurse that he is depressed because of a recent job loss. He complains of dull, aching, tight, and diffuse headaches that have lasted for several days. The nurse should recognize that these are symptoms of
tension headaches.
A client reports sharp, shooting, piercing facial pains that last from seconds to minutes. The nurse identifies these as signs and symptoms of which of the following disorders?
tic douloureux
What is the largest chamber of the eye?
vitreous
