PrepU Chapter Quizzes 15-18
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? "This might have been the result of an allergy, but most likely it was caused by a bacteria or virus." "I'll prescribe some analgesics because your son is likely to have quite severe pain while his eye heals." "In children, this problem is usually caused by an increase in pressure within the eye." "Antibiotics will clear this up, but you need to make sure he gets them as ordered to avoid vision damage."
"This might have been the result of an allergy, but most likely it was caused by a bacteria or virus."
Which vision acuity reading indicates blindness? 20/40 20/100 20/20 20/200
20/200
Which of the following assessment findings suggests a problem with the client's cranial nerves? A client's lens appears cloudy and she claims that her visual acuity has recently declined. A client states that he has recently begun seeing lights flashing in his field of vision. A client's extraocular movements are asymmetrical and she complains of diplopia. Fundoscopic examination reveals intraocular bleeding.
A client's extraocular movements are asymmetrical and she complains of diplopia.
While performing an examination of the head and neck, a nurse notices left-sided facial drooping. The nurse recognizes this as what condition? Trigeminal neuralgia Preauricular adenitis Temporomandibular joint syndrome Bell's palsy
Bell's palsy
A nurse is providing care for a client who experienced a head injury and who just moved to the United States from Southeast Asia. What cultural nursing consideration should the nurse take into account when performing an assessment on clients from different cultures? Follow hospital policy. Treat all clients the same despite culture. Consider cultural norms. Explain U.S. norms because they are in the United States.
Consider cultural norms
Teenagers doing community service following arrest for driving under the influence and are working at the rehabilitation hospital with clients who have paraplegia. These clients have been paralyzed by drunk drivers. How would the nurses who care for these clients best use the time spent with these teenagers? Fulfilling the court requirements Teaching them how to turn these clients every 2 hours Educating them about not drinking and driving Keeping the shelves restocked
Educating them about not drinking and driving
A client has anisocoria on examination. Pathological causes of this include which of the following? Differing light intensities for each eye Eye prosthesis Horner's syndrome Benign anisocoria
Horner's syndrome
A client reports right-sided temporal headache accompanied by nausea and vomiting. A nurse recognizes that which condition is likely to produce these symptoms? Bell's palsy Tension headache Migraine headache Temporal arteritis
Migraine headache
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? Shortness of breath Range of motion of the arms and shoulders Range of motion of the neck Headache
Range of motion of the neck
A student nurse asks the nursing instructor what blood vessels go to the eye. What would be the instructor's best answer? The coronal vein The optic vein The choroids The optic plexus
The choroids
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. The client must have developed macular degeneration. This is normal vision for a client over 65. The client will need a new pair of glasses.
These findings indicate the client is legally blind
While assessing an adult client's skull, the nurse observes that the client's skull and facial bones are larger and thicker than usual. The nurse should assess the client for Cushing syndrome. acromegaly. parotid gland enlargement. Paget disease.
acromegaly
The nurse is preparing to perform a head and neck assessment of an adult client who has immigrated to the United States from Cambodia. The nurse should first determine whether the client desires a family member present. explain to the client why the assessment is necessary. examine the lymph nodes of the neck before examining the head. ask the client if touching the head is permissible.
ask the client if touching the head is permissible.
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. refer the client for further evaluation. ask the client if there is a genetic history of blindness. examine the client for other signs of glaucoma.
document the findings in the client's records.
The nurses assesses the thyroid gland of a client with recent weight loss. On auscultation, a low, soft, rushing sound is heard over the lateral lobes. Which condition is most likely? benign tumor Hashimoto thyroiditis thyroid cyst hyperthyroidism
hyperthyroidism
The nurses assesses the thyroid gland of a client with recent weight loss. On auscultation, a low, soft, rushing sound is heard over the lateral lobes. Which condition is most likely? hyperthyroidism Hashimoto thyroiditis thyroid cyst benign tumor
hyperthyroidism
The nurse assesses a client's submental lymph nodes. In which area of the client's head should the nurse palpate these lymph nodes? At the angle of the mandible In front of the ear Superficial to the sternomastoid In the midline, a few centimeters behind the tip of the mandible
in the midline, a few centimeters behind the tip of the mandible
A client reports having a headache. The nurse performs a specialized focused assessment and notes the following: client rates pain 10 on a scale of 1 to 10 (10 being the worst), nauseated and vomited, reporting sensitivity to noise and light. The nurse determines that the client is most likely experiencing which of the following types of headache? cluster sinus migraine tension
migraine
A client reports using pain medication and sitting in a dark room on the onset of a migraine headache. In which part of the subjective section of the physical examination should the nurse document this information? relieving factors location onset treatment
relieving factors
The nurse is assessing cranial nerves III, IV, and VI. Which instructions should the nurse provide to the client in order to perform this assessment? "Stand very still with your eyes closed." "Follow my finger with only your eyes." "Shrug your shoulders as I push down on them." "Rotate your head from side to side."
"Follow my finger with only your eyes."
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? "It is not an uncommon finding in people older than 40 years for this to happen. They are called 'floaters'." "Please come into the clinic right away so we can see what is wrong." "I have an opening tomorrow at 2 in the afternoon. Can you come in then?" "Because it is almost 5 o'clock, please go to the emergency department right away. This sounds very serious."
"It is not an uncommon finding in people older than 40 years for this to happen. They are called 'floaters'."
The nurse is planning to instruct a group of adolescents on ways to prevent traumatic brain injuries. What should be included in these instructions? Wear nonslip shoes in the house. Use of guns should be supervised by an adult. Avoid risky activities such as snowboarding. Always use seat belts.
Always use seat belts.
A nurse is preparing to examine a client from Southeast Asia who has been experiencing chronic headaches. Which of the following should the nurse do in light of this client's cultural background? Have a nurse who is the same sex as the client perform the examination Palpate the client's feet before palpating the head Avoid asking the client to remove her clothes for the examination Ask permission before palpating the head and neck
Ask permission before palpating the head and neck
A client with a cervical spine injury reports chronic pain. What would be the most appropriate initial nursing intervention for this client? Discuss pharmacologic interventions. Educate the client regarding cervical spine pain. Assess the client regarding characteristics of the pain. Work with medical team to evaluate possible surgery.
Assess the client regarding characteristics of the pain
A client performs the test for distant visual acuity and scores 20/50. How should the nurse most accurately interpret this finding? When 50 feet from the chart, the client can see better than a person standing at 20 feet. Client did not wear his glasses for this test and therefore it is not accurate. At 20 feet from the chart, the client sees what a person with good vision can see at 50 feet. Client can read the 20/50 line correctly and two other letters on the line above.
At 20 feet from the chart, the client sees what a person with good vision can see at 50 feet.
A nurse is assessing a client with hyperthyroidism for the presence of a bruit. Which assessment technique should the nurse use? Inspection Percussion Auscultation Palpation
Auscultation
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 Gurgle Murmur Rush
Bruit
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? Murmur Gurgle Bruit Rush
Bruit
The nurse is palpating a client's neck as part of a physical assessment. Which of the following blood vessels should the nurse be especially careful to avoid bilaterally compressing during the assessment? External jugular vein Temporal artery Internal jugular vein Carotid artery
Carotid artery
When palpating the lymph nodes of the neck, the nurse assesses for which of the following characteristics? Configuration, discreteness, temperature, color Consistency, delineation, mobility, tenderness Congruency, induration, size, turgor Delineation, integrity, shape, color
Consistency, delineation, mobility, tenderness
The nurse is discharging an adult client who received 18 staples for a head laceration received while mountain biking. What can the nurse focus on while doing discharge teaching? Encourage the client to take a safety course Encourage the use of safety equipment Teach proper posture, bending, and lifting Encourage proper nutrition to promote healing
Encourage the use of safety equipment
What is a characteristic symptom of Graves hyperthyroidism? Episcleritis Pinguecula Pterygium Exophthalmos
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 Presbyopia Strabismus Esotropia
Exotropia
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? Strabismus Retinitis pigmentosa Glaucoma Retinoblastoma
Glaucoma
What is the most common type of hyperthyroidism? Graves' disease Moon face Cushing's syndrome Thyroid cancer
Graves' disease
A client frequently experiences dry, irritated eyes. These findings are consistent with a problem in what part of the eye? Sinus Aqueous chamber Vitreous chamber Lacrimal apparatus
Lacrimal apparatus
The nurse feels a small mass in the neck of a client. It is mobile in both the up-and-down and side-to-side directions. Which of the following is the nurse most likely feeling? Deep scar Muscle Lymph node Cancer
Lymph node
A client presents to the emergency department with reports of neck pain and a sudden onset of a headache. Upon examination, the nurse finds that the client has an increased temperature and neck stiffness. The nurse recognizes these findings as most likely to be caused by what condition? Parkinson's disease Meningeal inflammation Migraine headache Trigeminal neuralgia
Meningeal inflammation
A 38-year-old accountant comes to the clinic for evaluation of a headache. The throbbing sensation is located in the right temporal region, and is an 8 on a pain scale of 1 to 10. It started a few hours ago, and she has noted nausea with sensitivity to light; she has had headaches like this in the past, usually less than one per week, but not as severe. She does not know of any inciting factors. There has been no change in the frequency of her headaches. She usually takes an over-the-counter analgesic, which results in resolution of the headache. Based on this description, what is the most likely diagnosis of the type of headache? Tension Cluster Analgesic rebound Migraine
Migraine
A 73-year-old woman comes to the office for evaluation of new onset of tremors. She is not taking any medications, herbs, or supplements. She has no chronic medical conditions. She does not smoke or drink alcohol. She walks into the examination room with slow, shuffling steps. She has decreased facial mobility with a blunt expression without any changes in hair distribution on her face. Based on this description, what is the most likely reason for the client's symptoms? Nephrotic syndrome Myxedema Parkinson's disease Cushing's syndrome
Parkinson's disease
On a health history, a client reports no visual disturbances, last eye exam being 2 years ago, and not wearing glasses. The nurse notices that the client squints when signing the consent for treatment form and holds the paper close to the face. What should the nurse do next? Perform both the distant and near visual acuity tests Document the findings in the client's record Obtain a referral to the ophthalmologist for a complete eye exam Test the pupils for direct and consensual reaction to light
Perform both the distant and near visual acuity tests
A client reports severe pain in the posterior region of the neck and difficulty turning the head to the right. What additional information should the nurse collect? Changes in sleeping habits Difficulty with swallowing Stiffness in the right shoulder Previous injuries to the head and neck
Previous injuries to the head and neck
When testing the near reaction, an expected finding includes which of the following? Pupillary dilation on near gaze; dilation on distant gaze Pupillary constriction on near gaze; constriction on distant gaze Pupillary constriction on near gaze; dilation on distant gaze Pupillary dilation on near gaze; constriction on distant gaze
Pupillary constriction on near gaze; dilation on distant gaze
A client is having trouble turning her head to the side. Which of the following muscles should the nurse most suspect as being involved? Sternocleidomastoid Trapezius Temporalis Masseter
Sternocleidomastoid
A client is having trouble turning her head to the side. Which of the following muscles should the nurse most suspect as being involved? Trapezius Temporalis Masseter Sternocleidomastoid
Sternocleidomastoid
The nurse is assessing a client complaining of swelling in the neck. While palpating the neck, the nurse finds a 2-cm lump that is fixed and hard. Why does this finding require emergency investigation? This could be a sign of a parotid stone This could be a sign of an embolus This could be a sign of cancer This could be a sign of pneumothorax
This could be a sign of cancer
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? Down To the left Up To the right
Up
Which of the following assessment findings suggests a problem with the client's cranial nerves? A client's lens appears cloudy and she claims that her visual acuity has recently declined. Fundoscopic examination reveals intraocular bleeding. A client states that he has recently begun seeing lights flashing in his field of vision. A client's extraocular movements are asymmetrical and she complains of diplopia.
a client's extraocular movements are asymmetrical and she complains of diplopia.
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? temporal arteritis Bell palsy trigeminal neuralgia cerebrovascular accident
cerebrovascular accident
A nurse is about to receive a report on a 50-year-old female client diagnosed with Cushing syndrome. Which sign(s) and symptom(s) should the nurse expect? Select all that apply. round, puffy face increased facial hair thin extremities increased fat on the upper back hypoglycemia
increased fat on the upper back increased facial hair round, puffy face thin extremities
A client complains of feeling like he is slowly losing his central vision. The nurse knows this symptom could represent retinal detachment hemianopsia macular degeneration open-angle glaucoma
macular degeneration
A client reports using pain medication and sitting in a dark room on the onset of a migraine headache. In which part of the subjective section of the physical examination should the nurse document this information? location onset treatment relieving factors
relieving factors
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. inhale deeply. cough deeply. flex the neck to each side.
swallow a small sip of water.
The nurse is conducting discharge teaching to the caregiver of an older adult who was hospitalized following a fall at home. Which statement by the caregiver indicates a need for additional teaching by the nurse? "Loss of sensation in the toes is an age-related change." "Changes in vision such as decreased accommodation happen with aging." "Standing up slowly is important because dizziness can cause falls." "Certain medications can cause muscle weakness."
"Loss of sensation in the toes is an age-related change."
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 Temporal arteritis Tension headache Bell's palsy
Migraine headache
A client presents at the emergency room reporting "the worst headache I have ever had." What are the critical initial nursing interventions for this client? (Select all that apply.) Scheduling a computerized tomography (CT) scan Conducting a focused history interview Physical examination for neurologic changes Scheduling a magnetic resonance imaging (MRI) scan Scheduling an electroencephalography (EEG)
Physical examination for neurologic changes Conducting a focused history interview
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? Esotropia Exotropia Strabismus Presbyopia
Presbyopia
The nurse is assessing a client complaining of swelling in the neck. While palpating the neck, the nurse finds a 2-cm lump that is fixed and hard. Why does this finding require an emergency investigation? This could be a sign of pneumothorax This could be a sign of a parotid stone This could be a sign of an embolus This could be a sign of cancer
This could be a sign of cancer
An older client asks why vision is not as sharp as it used to be when the eyes are focused forward. What should the nurse realize this client is describing? detached retina macular degeneration glaucoma cataracts
macular degeneration
A female client visits the clinic and tells the nurse that she frequently experiences severe recurring headaches that sometimes last for several days and are accompanied by nausea and vomiting. The nurse determines that the type of headache the client is describing is a migraine headache. cluster headache. tension headache. tumor-related headache.
migraine headache
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 Shining a light into one eye while covering the other eye with an opaque card Comparing the difference between the client's dilated pupil and a constricted pupil Have the client state when they see the nurse's finger enter their peripheral vision field.
observing the eye's reaction when a light is shone into the opposite eye
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? Observe the response in the eye focused with light Place an opaque card in between the eyes of the client Instruct the client to close the eye not focused with light Shine a bright light directly into the eye to be tested
place an opaque card in between the eyes of the client
The nurse is preparing to examine an adult client's eyes, using a Snellen chart. The nurse should ask the client to remove his glasses. ask the client to read each line with both eyes open. instruct the client to begin reading from the bottom of the chart. position the client 609.6 cm (20 ft) away from the chart.
position the client 609.6 cm (20 ft) away from the chart.
