Quiz 3 (Ch 14,15,16,17)
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 client reports the onset of tinnitus. What question should the nurse ask the client to further assess this condition?
"Have you taken any antibiotics in the past few weeks?"
The mother of a small child with tubes in both eardrums asks the nurse if it is okay if the child travels by airplane. What is the nurse's best response?
"It's safe to fly because the tubes will equalize pressure."
There is normally a_____ degree angle between the nail base and the skin.
160
What do retinal abnormalities include?
Age-related macular degeneration
When reviewing ear assessment, a student nurse would learn that the cone of light should be visible where on the tympanic membrane?
Anterior inferior quadrant
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.
Upon inspection of an elderly client's ears using an otoscope, the nurse observes a cloudy appearance to the tympanic membranes with prominent landmarks. What action should the nurse perform first?
Ask whether the client is experiencing ear pain or pressure
_______ conveys visual information to the brain
CN II
__________ involved in moving the eye in its cardinal directions.
CN IV and VI
A female client visits the health care clinic with reports of hair falling out in clumps and a butterfly rash on her face. She begins to cry and states: "I am so ugly with this rash!" Which nursing diagnoses can the nurse confirm with this data?
Disturbed Body Image Ineffective Individual Coping Anxiety
The nurse is performing a focused assessment on a 45-year-old client of African descent. The nurse observes the following: nail beds have pigmented streaks, 160-degree angle between the nail base and the skin. What action should the nurse take?
Document the findings as normal.
An avid swimmer presents with ear pain. Her history includes pain and drainage from the left ear. On examination, she has pain when the ear, including the tragus, is manipulated. The canal is narrowed and erythematous with some white debris in the canal. The rest of the examination is normal. What diagnosis would be most appropriate for this client?
External otitis
A nurse performs palpation of a client's lymph nodes. Which finding should be reported to the health care provider?
Fixed to underlying tissue
The muscles of the ciliary body control the thickness of the lens, allowing the eye to:
Focus on near or distant objects
The nurse is documenting an objective assessment of the client's ears. Which of the following would be the most appropriate documentation?
Hearing intact bilaterally on whisper test
A client presents to the emergency department after being hit in the head with a baseball bat during a game. The nurse should assess for which condition?
Hyphema
Impaired dilation of the eye is evaluated with an assessment of which cranial nerve (CN)?
III (oculomotor)
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
What features would most likely be noted on fundoscopic examination of someone with glaucoma?
Increased cup-to-disc ratio
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
The client asks the nurse why the nurse put the tuning fork on the bone behind the ear. Which is the best response by the nurse?
It identifies a problem with the normal pathways for sound to travel to your inner ear.
What are the glands that are located on the tarsal plates and open on the lid margins?
Meibomian glands
Which area should the nurse inspect for facial symmetry when performing a head and neck assessment?
Nasolabial folds
The nurse palpates a client's auricles and notes an enlarged lymph node on one ear. No redness is observed, and the client denies pain or tenderness. What is the nurse's best action?
Notify the healthcare provider about the finding.
A nurse obtains an objective assessment on a child who presents to the clinic with reports of right ear pain. The nurse observes the following: painful movement of the pinna and tragus; ear canal is red and swollen with presence of purulent discharge from the external canal; temperature 101.8°F. The mother states that the family was on vacation at the beach last week. The nurse recognizes these findings as an indication of what acute ear condition?
Otitis externa
Which statement reflects accurate documentation by the nurse of a normal, left tympanic membrane?
Pearly gray, translucent, with cone of light at 7 o'clock position
An adult farm worker presents at the ED after falling out of a hay loft. The client states falling approximately 4 hours ago and did not lose consciousness. The client is experiencing only a mild headache. When asked why the client came to the ED, the client states that he had a clear discharge from the right ear ever since the accident. What should this finding indicate to the nurse?
Possible basilar skull fracture
A nurse performs a Rinne test on a client who relates a history of decreased hearing in the right ear. The test demonstrates that the client has conductive hearing loss in the right ear. What is the correct documentation of this test by the nurse?
Right: BC greater than AC; left AC greater than BC
Which of the following tests use a tuning fork between two positions to assess hearing?
Rinne
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
A 23-year-old woman has presented to the clinician to follow up her recent diagnosis of psoriasis. Which of the following assessments of the client's nails would be consistent with the client's diagnosis?
Small pits in the surfaces of the nails
A client is diagnosed with otosclerosis, a condition in which the auditory ossicles develop a spongy consistency, which results in conductive hearing loss. It appears that the worst site is the inner most bone, which transmits sound waves through the oval window. Which bone is this?
Stapes
A client comes to the trauma unit in respiratory distress following a motor vehicle accident. On examination, the nurse notices that the trachea is deviated from the midline. What does this finding indicate?
Tension pneumothorax
A client is being assessed for indications of a possible obstructed nasolacrimal duct in the right eye. Under what circumstances should the nurse avoid compressing the lacrimal sac?
The area around the sac is inflamed.
The analysis of a client's arterial blood indicates a normal level of arterial oxygen, but the client's skin is cyanotic. What is a likely cause of this condition?
The cyanosis may be a result of a prolonged period of exposure to the cold
A nurse is assessing a client's tympanic membrane. The nurse suspects that the client may have otitis media. Which of the following findings would confirm this suspicion?
The membrane does not flutter upon pneumatic otoscopy with a bulb insufflator
What is the open space between the eyelids called
The palpebral fissure
A nurse practitioner is assessing the tympanic membrane of a client who has come to the clinic. What would the nurse practitioner expect to visualize if the client has a normal otoscopic evaluation?
The short process of the malleus
A 4-year-old child presents to the health care clinic with circular lesions. Which of the following conditions should the nurse most suspect in this client, based on the configuration of the lesions?
Tinea corporis
What is the primary purpose of the health history in relation to the eyes?
To identify changes
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
Which portion of the middle ear equalizes pressure?
Tympanic membrane
While performing an otoscopic examination of a client's ear, the nurse finds white patches on the tympanic membrane. How would the nurse note this finding in the chart?
Tympanic membrane visualized with areas of sclerosis noted
A client tells the nurse that it is difficult to hear normal conversation when in a room with a lot of noise. Which test should the nurse perform to assess the hearing ability of the client?
Weber
The nurse assessing for unilateral hearing loss by using a tuning fork. What test is the nurse performing?
Weber's test
A client seeks medical attention for the skin lesion shown. What should the nurse document as this type of lesion?
Wheal
The nurse should make it a priority to assess which client for papilledema? -a 45-year-old suspected of experiencing a subarachnoid hemorrhage -an 80-year-old diagnosed with chronic open-angle glaucoma -a 12-year-old demonstrating a deviated left eye -a 56-year-old reporting double vision
a 45-year-old suspected of experiencing a subarachnoid hemorrhage
The nurse is performing a physical examination and notes an enlarged left supraclavicular lymph node. The nurse understands that this could be indicative of
a metastasis
While assessing the nails of an adult client, the nurse observes Beau lines. The nurse should ask the client if he has had
a recent illness
With hearing loss, bone conduction becomes longer than or equal to
air conduction
While assessing an adult client's feet for fungal disease using a Wood light, the nurse documents the presence of a fungus when the fluorescence is
blue
With normal hearing, air conduction should be heard longer than
bone conduction.
The conjunctiva of the eye is divided into the palpebral portion and the
bulbar portion.
The middle layer of the eye is known as the
choroid layer
The chambers of the eye contain aqueous humor, which helps to maintain intraocular pressure and
cleanse the cornea and the lens
The transmission of sound waves through the external ear and the middle ear is known as
conductive hearing
While assessing the eyes of an adult client, the nurse uses a wisp of cotton to stimulate the client's
corneal reflexes
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
Microaneurysms are seen in
diabetes
A nurse examines a client's retina during the ophthalmic examination and notices light-colored spots on the retinal background. The nurse should ask the client about a history of what disease process?
diabetes or hypertension
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
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
examine the client for other signs of glaucoma
Dark-skinned clients may have ______________ in their nails
freckles or pigmented streaks
A 48-year-old client reports a recent loss of peripheral vision and eye pain. Based on these findings, the nurse determines these signs and symptoms may be the result of which of the following eye disorders?
glaucoma
While assessing the ears of an adult client, the nurse observes that the tympanic membrane is completely immobile. The nurse should further assess the client for signs and symptoms of
infection
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
lacrimal obstruction
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 optic nerves from each eyeball cross at the
optic chiasma
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 cochlea is a winding, snail-shaped bony tube that forms a
portion of the inner ear and contains the organ of Corti; the transducer of hearing.
You are using the Braden Scale to measure risk factors for pressure sores. What risk factors will you assess? Select all that apply.
sensory perception, moisture, activity, mobility, nutrition, and friction and shear
A 45-year-old client tells the nurse that he occasionally sees spots in front of his eyes. The nurse should
tell the client that these often occur with aging
The nursing instructor is discussing ear problems. What would the instructor indicate is an abnormal finding?
tenderness of the mastoid process
The cone of light will be located at
the 5 o'clock position in the right ear.
The lacrimal apparatus protects and lubricates____________ by producing and draining tears.
the cornea and conjunctiva
he limbus is the border of
the cornea and the sclera.
The auricle collects the sound waves and directs vibrations into
the external auditory canal.
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
A client diagnosed with arthritis has been taking aspirin and now reports experiencing adverse effects. What adverse effect indicates that a decrease in dose may be necessary?
tinittus
Ossicles, which are held in place by joints, muscles, and ligaments, assist in the
transmission of sound.
Upon examination of a client, the nurse finds a circumscribed elevated, palpable mass containing serous fluid. How should the nurse properly document this finding?
vesiscle
What is the largest chamber of the eye?
vitreous
A nurse assesses a client's pupils for the reaction to light and observes that the pupils are of unequal size. What should the nurse do next in relation to this finding?
Ask the client about previous trauma to the eyes
A nurse obtains a tonometer reading of 23 mm Hg on a client. What is the best response of the nurse?
Ask the client if they have experienced any pain or changes in vision
__________ is only needed if the thyroid gland appears enlarged.
Auscultation
Safety tips for ear care ___ seek medical evaluation if have symptoms of hearing loss, ear fullness, or ear pain. _____ask provider about ways to treat cerumen impaction. ____ seek medical attention with ear pain, drainage, or bleeding.
DO
Act FAST for Stroke
F- face look uneven? A- one Arm hanging down? S- slurred speech? T- Time to call 911
If drooping is noted on one side of the face, the nurse should continue assessing the client for possible Bell palsy
FALSE The priority should be to immediately assess for a possible stroke and alert the registered nurse or health care provider as this is a medical emergency. A tool that can be used is the FAST tool. If the assessment indicates the client has not suffered a stroke, then Bell palsy would be a possibility but would need further assessment.
_______ is fluid filled and made up of the bony labyrinth and an inner membranous labyrinth.
The inner ear
_____ is a small, air-filled chamber in the temporal bone.
The middle ear
__________ is the nutrient that can help lower (but not prevent) the risk of skin cancer.
Vitamin B3 (niacin)
The lens _______ to focus on close objects and flattens to focus on far objects. This is possible due to the refractive ability of the lens
bulges
If the eyes cannot look down when turned inward, it indicates
fourth nerve paralysis.
Exposure to ultraviolet radiation________the risk for the development of cataracts
increases
Asians and Native Americans have ___________________ because of decreased sweat production.
mild to no body odor
The axis is the ______ of the seven cervical vertebrae.
second
With___________ hearing loss, air conduction sound is heard longer than bone conduction sound (AC > BC) if anything is heard at all.
sensorineural
In the third nerve paralysis, the eye looks
straight ahead.
Whites and African Americans tend to have a _____________________
strong body odor.
Exposure to __________ increases the risk for the development of cataracts.
ultraviolet radiation
Asking specific questions about the client's past medical history may
uncover a potential risk factor that the client may have forgotten about.
The nurse is conducting a skin assessment on a client and notices the client has bilateral patches on tops of both feet with no color. The nurse should document this finding as:
vitiligo
A client reports, "There is something in my left eye that is causing me considerable discomfort." What initial step should the nurse take when everting the client's upper eyelid in order to search for the foreign body?
Ask the client to look down toward the left cheek.
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
Is the following statement true or false? The inner ear is an air-filled cavity.
False The inner ear is fluid filled and made up of the bony labyrinth and an inner membranous labyrinth. The middle ear is a small, air-filled chamber in the temporal bone.
When providing client teaching about the ears, what should the nurse be sure to include?
How the client cleans the ears
When testing the near reaction, an expected finding includes which of the following?
Pupillary constriction on near gaze; dilation on distant gaze
An adult client visits the clinic and tells the nurse that she has had headaches recently that are intense and stabbing and often occur in the late evening. The nurse should suspect the presence of
cluster headache
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
Presbycusis often begins with a loss of the ability to hear
high-frequency sounds.
AV nicking and cotton wool spots are seen in
hypertension
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
A nurse is providing care to a female client with a history of Cushing's disease. What findings should the nurse expect with this client?
increased body and facial hair
A nurse is examining the eyes of a client who has complained of having a feeling of a foreign body in his eye. The nurse examines the thin, transparent, continuous membrane that lines the inside of the eyelids and covers most of the anterior eye. The nurse recognizes this membrane as which of the following?
Conjunctiva
Safety tips for ear care: ______ overclean ears. ______put anything smaller than your elbow in your ears. ______use ear candles.
DON'T
The client should be cautioned about inserting anything smaller than _____________into the external auditory canal. There is a danger of causing an impaction of the cerumen and/or actually puncturing the TM, which can lead to hearing loss.
the elbow
A nurse assesses the parallel alignment of a client's eyes by testing the corneal light reflex. Where should the nurse shine the penlight to obtain an accurate result?
Focused on the bridge of the nose
The nurse observes a middle-aged colleague fully extending her arm to read the label on a vial of medication. Which of the following age-related changes is the nurse likely to have observed?
Presbyopia
Parents should be aware that a potential sign of otitis media in toddlers is
pulling at the ear
