Health Assessment Final Exam Spring 2022
A physician tells the nurse that a patient’s vertebra prominens is tender and asks the nurse
to reevaluate
... [Show More] the area in 1 hour. The area of the body the nurse will assess is:
a. Just above the diaphragm.
b. Just lateral to the knee cap.
c. At the level of the C7 vertebra.
d. At the level of the T11 vertebra. - C
A mother brings her 2-month-old daughter in for an examination and says, my daughter
rolled over against the wall, and now I have noticed that she has this spot that is soft on the
top of her head. Is something terribly wrong? The nurse’s best response would be:
a. Perhaps that could be a result of your dietary intake during pregnancy.
b. Your baby may have craniosynostosis, a disease of the sutures of the brain.
c. That soft spot may be an indication of cretinism or congenital hypothyroidism.
d. That soft spot is normal, and actually allows for growth of the brain during the first year
of your babys life - D
The nurse notices that a patients palpebral fissures are not symmetric. On examination, the
nurse may find that damage has occurred to which cranial nerve (CN)?
a. III
b. V
c. VII
d. VIII - C
A patient is unable to differentiate between sharp and dull stimulation to both sides of her
face. The nurse suspects:
a. Bell palsy.
b. Damage to the trigeminal nerve.
c. Frostbite with resultant paresthesia to the cheeks.
d. Scleroderma. - B
When examining the face of a patient, the nurse is aware that the two pairs of salivary
glands that are accessible to examination are the ___________ and ___________ glands.
a. Occipital; sub mental
b. Parotid; jugulodigastric
c. Parotid; submandibular
d. Submandibular; occipital - C
A patient comes to the clinic complaining of neck and shoulder pain and is unable to turn
her head. The nurse suspects damage to CN ______ and proceeds with the examination by
_____________.
a. XI; palpating the anterior and posterior triangles
b. XI; asking the patient to shrug her shoulders against resistance
c. XII; percussing the sternomastoid and submandibular neck muscles
d. XII; assessing for a positive Romberg sign - B
When examining a patient’s CN function, the nurse remembers that the muscles in the neck
that are innervated by CN XI are the:
a. Sternomastoid and trapezius.
b. Spinal accessory and omohyoid.
c. Trapezius and sternomandibular.
d. Sternomandibular and spinal accessory. - A
A patient’s laboratory data reveal an elevated thyroxine (T4) level. The nurse would
proceed with an examination of the _____ gland.
a. Thyroid
b. Parotid
c. Adrenal
d. Parathyroid - A
A patient says that she has recently noticed a lump in the front of her neck below her
Adams apple that seems to be getting bigger. During the assessment, the finding that leads
the nurse to suspect that this may not be a cancerous thyroid nodule is that the lump
(nodule):
a. Is tender.
b. Is mobile and not hard.
c. Disappears when the patient smiles.
d. Is hard and fixed to the surrounding structures. - B
The nurse notices that a patient’s sub mental lymph nodes are enlarged. In an effort to
identify the cause of the node enlargement, the nurse would assess the patients:
a. Infraclavicular area.
b. Supraclavicular area.
c. Area distal to the enlarged node.
d. Area proximal to the enlarged node. - D
The nurse is aware that the four areas in the body where lymph nodes are accessible are
the:
a. Head, breasts, groin, and abdomen.
b. Arms, breasts, inguinal area, and legs.
c. Head and neck, arms, breasts, and axillae.
d. Head and neck, arms, inguinal area, and axillae. - D
A mother brings her newborn in for an assessment and asks, Is there something wrong with
my baby? His head seems so big. Which statement is true regarding the relative proportions
of the head and trunk of the newborn?
a. At birth, the head is one fifth the total length.
b. Head circumference should be greater than chest circumference at birth.
c. The head size reaches 90% of its final size when the child is 3 years old.
d. When the anterior fontanel closes at 2 months, the head will be more proportioned to the
body. - B
A patient, an 85-year-old woman, is complaining about the fact that the bones in her face
have become more noticeable. What explanation should the nurse give her?
a. Diets low in protein and high in carbohydrates may cause enhanced facial bones.
b. Bones can become more noticeable if the person does not use a dermatologically
approved moisturizer.
c. More noticeable facial bones are probably due to a combination of factors related to
aging, such as decreased elasticity, subcutaneous fat, and moisture in her skin.
d. Facial skin becomes more elastic with age. This increased elasticity causes the skin to be
more taught, drawing attention to the facial bones. - C
A patient reports excruciating headache pain on one side of his head, especially around his
eye, forehead, and cheek that has lasted approximately to 2 hours, occurring once or twice
each day. The nurse should suspect:
a. Hypertension.
b. Cluster headaches.
c. Tension headaches.
d. Migraine headaches. - B
A patient complains that while studying for an examination he began to notice a severe
headache in the frontotemporal area of his head that is throbbing and is somewhat relieved
when he lies down. He tells the nurse that his mother also had these headaches. The nurse
suspects that he may be suffering from:
a. Hypertension.
b. Cluster headaches.
c. Tension headaches.
d. Migraine headaches. - D
A 19-year-old college student is brought to the emergency department with a severe
headache he describes as, like nothing I’ve ever had before. His temperature is 40 C, and he
has a stiff neck. The nurse looks for other signs and symptoms of which problem?
a. Head injury
b. Cluster headache
c. Migraine headache
d. Meningeal inflammation - D
During a well-baby checkup, the nurse notices that a 1-week-old infants face looks small
compared with his cranium, which seems enlarged. On further examination, the nurse also
notices dilated scalp veins and downcast or setting sun eyes. The nurse suspects which
condition?
a. Craniotabes
b. Microcephaly
c. Hydrocephalus
d. Caput succedaneum - C
The nurse needs to palpate the temporomandibular joint for crepitation. This joint is
located just below the temporal artery and anterior to the:
a. Hyoid bone.
b. Vagus nerve.
c. Tragus.
d. Mandible. - C
A patient has come in for an examination and states, I have this spot in front of my ear lobe
on my cheek that seems to be getting bigger and is tender. What do you think it is? The
nurse notes swelling below the angle of the jaw and suspects that it could be an
inflammation of his:
a. Thyroid gland.
b. Parotid gland.
c. Occipital lymph node.
d. Sub mental lymph node. - B
A male patient with a history of acquired immunodeficiency syndrome (AIDS) has come in
for an examination and he states, I think that I have the mumps. The nurse would begin by
examining the:
a. Thyroid gland.
b. Parotid gland.
c. Cervical lymph nodes.
d. Mouth and skin for lesions. - B
The nurse suspects that a patient has hyperthyroidism, and the laboratory data indicate
that the patients T4 and T3 hormone levels are elevated. Which of these findings would the
nurse most likely find on examination?
a. Tachycardia
b. Constipation
c. Rapid dyspnea
d. Atrophied nodular thyroid gland - A
A visitor from Poland who does not speak English seems to be somewhat apprehensive
about the nurse examining his neck. He would probably be more comfortable with the
nurse examining his thyroid gland from:
a. Behind with the nurse’s hands placed firmly around his neck.
b. The side with the nurse’s eyes averted toward the ceiling and thumbs on his neck.
c. The front with the nurse’s thumbs placed on either side of his trachea and his head tilted
forward.
d. The front with the nurse’s thumbs placed on either side of his trachea and his head tilted
backward. - C
A patient’s thyroid gland is enlarged, and the nurse is preparing to auscultate the thyroid
gland for the presence of a bruit. A bruit is a __________ sound that is heard best with the
__________ of the stethoscope.
a. Low gurgling; diaphragm
b. Loud, whooshing, blowing; bell
c. Soft, whooshing, pulsatile; bell
d. High-pitched tinkling; diaphragm - C
The nurse notices that an infant has a large, soft lump on the side of his head and that his
mother is very concerned. She tells the nurse that she noticed the lump approximately 8
hours after her baby’s birth and that it seems to be getting bigger. One possible explanation
for this is:
a. Hydrocephalus.
b. Craniosynostosis.
c. Cephalhematoma.
d. Caput succedaneum - C
A mother brings in her newborn infant for an assessment and tells the nurse that she has
noticed that whenever her newborns head is turned to the right side, she straightens out
the arm and leg on the same side and flexes the opposite arm and leg. After observing this
on examination, the nurse tells her that this reflex is:
a. Abnormal and is called the atonic neck reflex.
b. Normal and should disappear by the first year of life.
c. Normal and is called the tonic neck reflex, which should disappear between 3 and 4
months of age.
d. Abnormal. The baby should be flexing the arm and leg on the right side of his body when
the head is turned to the right. - C
During an admission assessment, the nurse notices that a male patient has an enlarged and
rather thick skull. The nurse suspects acromegaly and would further assess for:
a. Exophthalmos.
b. Bowed long bones.
c. Coarse facial features.
d. Acorn-shaped cranium. - C
When examining children affected with Down syndrome (trisomy 21), the nurse looks for
the possible presence of:
a. Ear dysplasia.
b. Long, thin neck.
c. Protruding thin tongue.
d. Narrow and raised nasal bridge. - A
A patient visits the clinic because he has recently noticed that the left side of his mouth is
paralyzed. He states that he cannot raise his eyebrow or whistle. The nurse suspects that he
has:
a. Cushing syndrome.
b. Parkinson disease.
c. Bell palsy.
d. Experienced a cerebrovascular accident (CVA) or stroke. - D
A woman comes to the clinic and states, I’ve been sick for so long! My eyes have gotten so
puffy, and my eyebrows and hair have become coarse and dry. The nurse will assess for
other signs and symptoms of:
a. Cachexia.
b. Parkinson syndrome.
c. Myxedema.
d. Scleroderma. - C
During an examination of a female patient, the nurse notes lymphadenopathy and suspects
an acute infection. Acutely infected lymph nodes would be:
a. Clumped.
b. Unilateral.
c. Firm but freely movable.
d. Firm and nontender. - C
The physician reports that a patient with a neck tumor has a tracheal shift. The nurse is
aware that this means that the patient’s trachea is:
a. Pulled to the affected side.
b. Pushed to the unaffected side.
c. Pulled downward.
d. Pulled downward in a rhythmic pattern. - B
During an assessment of an infant, the nurse notes that the fontanels are depressed and
sunken. The nurse suspects which condition?
a. Rickets
b. Dehydration
c. Mental retardation
d. Increased intracranial pressure - B
The nurse is performing an assessment on a 7-year-old child who has symptoms of chronic
watery eyes, sneezing, and clear nasal drainage. The nurse notices the presence of a
transverse line across the bridge of the nose, dark blue shadows below the eyes, and a
double crease on the lower eyelids. These findings are characteristic of:
a. Allergies.
b. Sinus infection.
c. Nasal congestion.
d. Upper respiratory infection. - A
While performing a well-child assessment on a 5 year old, the nurse notes the presence of
palpable, bilateral, cervical, and inguinal lymph nodes. They are approximately 0.5 cm in
size, round, mobile, and nontender. The nurse suspects that this child:
a. Has chronic allergies.
b. May have an infection.
c. Is exhibiting a normal finding for a well-child of this age.
d. Should be referred for additional evaluation. - C
The nurse has just completed a lymph node assessment on a 60-year-old healthy female
patient. The nurse knows that most lymph nodes in healthy adults are normally:
a. Shotty.
b. Nonpalpable.
c. Large, firm, and fixed to the tissue.
d. Rubbery, discrete, and mobile. - B
During an examination of a patient in her third trimester of pregnancy, the nurse notices
that the patient’s thyroid gland is slightly enlarged. No enlargement had been previously
noticed. The nurse suspects that the patient:
a. Has an iodine deficiency.
b. Is exhibiting early signs of goiter.
c. Is exhibiting a normal enlargement of the thyroid gland during pregnancy.
d. Needs further testing for possible thyroid cancer. - C
During an examination, the nurse knows that the best way to palpate the lymph nodes in
the neck is described by which statement?
a. Using gentle pressure, palpate with both hands to compare the two sides.
b. Using strong pressure, palpate with both hands to compare the two sides.
c. Gently pinch each node between ones thumb and forefinger, and then move down the
neck muscle.
d. Using the index and middle fingers, gently palpate by applying pressure in a rotating
pattern. - A
During a well-baby checkup, a mother is concerned because her 2-month-old infant cannot
hold her head up when she is pulled to a sitting position. Which response by the nurse is
appropriate?
a. Head control is usually achieved by 4 months of age.
b. You shouldnt be trying to pull your baby up like that until she is older.
c. Head control should be achieved by this time.
d. This inability indicates possible nerve damage to the neck muscles. - A
During an examination of a 3-year-old child, the nurse notices a bruit over the left temporal
area. The nurse should:
a. Continue the examination because a bruit is a normal finding for this age.
b. Check for the bruit again in 1 hour.
c. Notify the parents that a bruit has been detected in their child.
d. Stop the examination, and notify the physician. - A
During an examination, the nurse finds that a patients left temporal artery is tortuous and
feels hardened and tender, compared with the right temporal artery. The nurse suspects
which condition?
a. Crepitation
b. Mastoiditis
c. Temporal arteritis
d. Bell palsy - C
The nurse is assessing a 1-month-old infant at his well-baby checkup. Which assessment
findings are appropriate for this age? Select all that apply.
a. Head circumference equal to chest circumference
b. Head circumference greater than chest circumference
c. Head circumference less than chest circumference
d. Fontanels firm and slightly concave
e. Absent tonic neck reflex
f. Nonpalpable cervical lymph nodes - B, D, F
When examining the eye, the nurse notices that the patients eyelid margins approximate
completely. The nurse recognizes that this assessment finding:
a. Is expected.
b. May indicate a problem with extraocular muscles.
c. May result in problems with tearing.
d. Indicates increased intraocular pressure. - A
During ocular examinations, the nurse keeps in mind that movement of the extraocular
muscles is:
a. Decreased in the older adult.
b. Impaired in a patient with cataracts.
c. Stimulated by cranial nerves (CNs) I and II.
d. Stimulated by CNs III, IV, and VI. - D
The nurse is performing an external eye examination. Which statement regarding the outer
layer of the eye is true?
a. The outer layer of the eye is very sensitive to touch.
b. The outer layer of the eye is darkly pigmented to prevent light from reflecting internally.
c. The trigeminal nerve (CN V) and the trochlear nerve (CN IV) are stimulated when the
outer surface of the eye is stimulated.
d. The visual receptive layer of the eye in which light waves are changed into nerve
impulses is located in the outer layer of the eye. - A
When examining a patients eyes, the nurse recalls that stimulation of the sympathetic
branch of the autonomic nervous system:
a. Causes pupillary constriction.
b. Adjusts the eye for near vision.
c. Elevates the eyelid and dilates the pupil.
d. Causes contraction of the ciliary body. - C
The nurse is reviewing causes of increased intraocular pressure. Which of these factors
determines intraocular pressure?
a. Thickness or bulging of the lens
b. Posterior chamber as it accommodates increased fluid
c. Contraction of the ciliary body in response to the aqueous within the eye
d. Amount of aqueous produced and resistance to its outflow at the angle of the anterior
chamber - D
The nurse is conducting a visual examination. Which of these statements regarding visual
pathways and visual fields is true?
a. The right side of the brain interprets the vision for the right eye.
b. The image formed on the retina is upside down and reversed from its actual appearance
in the outside world.
c. Light rays are refracted through the transparent media of the eye before striking the
pupil.
d. Light impulses are conducted through the optic nerve to the temporal lobes of the brain. -
B
The nurse is testing a patients visual accommodation, which refers to which action?
a. Pupillary constriction when looking at a near object
b. Pupillary dilation when looking at a far object
c. Changes in peripheral vision in response to light
d. Involuntary blinking in the presence of bright light - A
A patient has a normal pupillary light reflex. The nurse recognizes that this reflex indicates
that:
a. The eyes converge to focus on the light.
b. Light is reflected at the same spot in both eyes.
c. The eye focuses the image in the center of the pupil.
d. Constriction of both pupils occurs in response to bright light. - D
A mother asks when her newborn infants eyesight will be developed. The nurse should
reply:
a. Vision is not totally developed until 2 years of age.
b. Infants develop the ability to focus on an object at approximately 8 months of age.
c. By approximately 3 months of age, infants develop more coordinated eye movements and
can fixate on an object.
d. Most infants have uncoordinated eye movements for the first year of life. - C
The nurse is reviewing in age-related changes in the eye for a class. Which of these
physiologic changes is responsible for presbyopia?
a. Degeneration of the cornea
b. Loss of lens elasticity
c. Decreased adaptation to darkness
d. Decreased distance vision abilities - B
Which of these assessment findings would the nurse expect to see when examining the eyes
of a black patient?
a. Increased night vision
b. Dark retinal background
c. Increased photosensitivity
d. Narrowed palpebral fissures - B
A 52-year-old patient describes the presence of occasional floaters or spots moving in front
of his eyes. The nurse should:
a. Examine the retina to determine the number of floaters.
b. Presume the patient has glaucoma and refer him for further testing.
c. Consider these to be abnormal findings, and refer him to an ophthalmologist.
d. Know that floaters are usually insignificant and are caused by condensed vitreous fibers.
- D
The nurse is preparing to assess the visual acuity of a 16-year-old patient. How should the
nurse proceed?
a. Perform the confrontation test.
b. Ask the patient to read the print on a handheld Jaeger card.
c. Use the Snellen chart positioned 20 feet away from the patient.
d. Determine the patients ability to read newsprint at a distance of 12 to 14 inches. - C
A patients vision is recorded as 20/30 when the Snellen eye chart is used. The nurse
interprets these results to indicate that:
a. At 30 feet the patient can read the entire chart.
b. The patient can read at 20 feet what a person with normal vision can read at 30 feet.
c. The patient can read the chart from 20 feet in the left eye and 30 feet in the right eye.
d. The patient can read from 30 feet what a person with normal vision can read from 20
feet. - B
A patient is unable to read even the largest letters on the Snellen chart. The nurse should
take which action next?
a. Refer the patient to an ophthalmologist or optometrist for further evaluation.
b. Assess whether the patient can count the nurses fingers when they are placed in front of
his or her eyes.
c. Ask the patient to put on his or her reading glasses and attempt to read the Snellen chart
again.
d.Shorten the distance between the patient and the chart until the letters are seen, and
record that distance. - D
A patients vision is recorded as 20/80 in each eye. The nurse interprets this finding to mean
that the patient:
a. Has poor vision.
b. Has acute vision.
c. Has normal vision.
d. Is presbyopic. - A
When performing the corneal light reflex assessment, the nurse notes that the light is
reflected at 2 oclock in each eye. The nurse should:
a. Consider this a normal finding.
b. Refer the individual for further evaluation.
c. Document this finding as an asymmetric light reflex.
d. Perform the confrontation test to validate the findings. - A
The nurse is performing the diagnostic positions test. Normal findings would be which of
these results?
a. Convergence of the eyes
b. Parallel movement of both eyes
c. Nystagmus in extreme superior gaze
d. Slight amount of lid lag when moving the eyes from a superior to an inferior position - B
During an assessment of the sclera of a black patient, the nurse would consider which of
these an expected finding?
a. Yellow fatty deposits over the cornea
b. Pallor near the outer canthus of the lower lid
c. Yellow color of the sclera that extends up to the iris
d. Presence of small brown macules on the sclera - D
A 60-year-old man is at the clinic for an eye examination. The nurse suspects that he has
ptosis of one eye. How should the nurse check for this?
a. Perform the confrontation test.
b. Assess the individuals near vision.
c. Observe the distance between the palpebral fissures.
d. Perform the corneal light test, and look for symmetry of the light reflex. - C
During an examination of the eye, the nurse would expect what normal finding when
assessing the lacrimal apparatus?
a. Presence of tears along the inner canthus
b. Blocked nasolacrimal duct in a newborn infant
c. Slight swelling over the upper lid and along the bony orbit if the individual has a cold
d. Absence of drainage from the puncta when pressing against the inner orbital rim - D
When assessing the pupillary light reflex, the nurse should use which technique?
a. Shine a penlight from directly in front of the patient, and inspect for pupillary constriction.
b. Ask the patient to follow the penlight in eight directions, and observe for bilateral pupil
constriction.
c. Shine a light across the pupil from the side, and observe for direct and consensual pupillary
constriction.
d. Ask the patient to focus on a distant object. Then ask the patient to follow the penlight to
approximately 7 cm from the nose. - C
The nurse is assessing a patients eyes for the accommodation response and would expect to
see which normal finding?
a. Dilation of the pupils
b. Consensual light reflex
c. Conjugate movement of the eyes
d. Convergence of the axes of the eyes - D
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:
a. Suspect that an opacity is present in the lens or cornea.
b. Check the light source of the ophthalmoscope to verify that it is functioning.
c. Consider the red glow a normal reflection of the ophthalmoscope light off the inner
retina.
d. Continue with the ophthalmoscopic examination, and refer the patient for further
evaluation. - C
The nurse is examining a patients retina with an ophthalmoscope. Which finding is
considered normal?
a. Optic disc that is a yellow-orange color
b. Optic disc margins that are blurred around the edges
c. Presence of pigmented crescents in the macular area
d. Presence of the macula located on the nasal side of the retina - A
A 2-week-old infant can fixate on an object but cannot follow a light or bright toy. The nurse
would:
a. Consider this a normal finding.
b. Assess the pupillary light reflex for possible blindness.
c. Continue with the examination, and assess visual fields.
d. Expect that a 2-week-old infant should be able to fixate and follow an object. - A
The nurse is assessing color vision of a male child. Which statement is correct? The nurse
should:
a. Check color vision annually until the age of 18 years.
b. Ask the child to identify the color of his or her clothing.
c. Test for color vision once between the ages of 4 and 8 years.
d. Begin color vision screening at the childs 2-year checkup. - C
The nurse is performing an eye-screening clinic at a daycare center. When examining a
2year-old child, the nurse suspects that the child has a lazy eye and should:
a. Examine the external structures of the eye.
b. Assess visual acuity with the Snellen eye chart.
c. Assess the childs visual fields with the confrontation test.
d. Test for strabismus by performing the corneal light reflex test. - D
The nurse is performing an eye assessment on an 80-year-old patient. Which of these
findings is considered abnormal?
a. Decrease in tear production
b. Unequal pupillary constriction in response to light
c. Presence of arcus senilis observed around the cornea
d. Loss of the outer hair on the eyebrows attributable to a decrease in hair follicles - B
The nurse notices the presence of periorbital edema when performing an eye assessment
on a 70-year-old patient. The nurse should:
a. Check for the presence of exophthalmos.
b. Suspect that the patient has hyperthyroidism.
c. Ask the patient if he or she has a history of heart failure.
d. Assess for blepharitis, which is often associated with periorbital edema. - C
When a light is directed across the iris of a patients eye from the temporal side, the nurse is
assessing for:
a. Drainage from dacryocystitis.
b. Presence of conjunctivitis over the iris.
c. Presence of shadows, which may indicate glaucoma.
d. Scattered light reflex, which may be indicative of cataracts. - C
In a patient who has anisocoria, the nurse would expect to observe:
a. Dilated pupils.
b. Excessive tearing.
c. Pupils of unequal size.
d. Uneven curvature of the lens. - C
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:
a. Loss of central vision.
b. Shadow or diminished vision in one quadrant or one half of the visual field.
c. Loss of peripheral vision.
d. Sudden loss of pupillary constriction and accommodation. - B
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:
a. Chalazion.
b. Hordeolum (stye).
c. Dacryocystitis.
d. Blepharitis. - B
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:
a. Macular degeneration.
b. Vision that is normal for someone her age.
c. The beginning stages of cataract formation.
d. Increased intraocular pressure or glaucoma. - A
A patient comes into the emergency department after an accident at work. A machine blew
dust into his eyes, and he was not wearing safety glasses. The nurse examines his corneas
by shining a light from the side across the cornea. What findings would suggest that he has
suffered a corneal abrasion?
a. Smooth and clear corneas
b. Opacity of the lens behind the cornea
c. Bleeding from the areas across the cornea
d. Shattered look to the light rays reflecting off the cornea - D
An ophthalmic examination reveals papilledema. The nurse is aware that this finding
indicates:
a. Retinal detachment.
b. Diabetic retinopathy.
c. Acute-angle glaucoma.
d. Increased intracranial pressure. - D
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:
a. Hypopyon.
b. Hyphema.
c. Corneal abrasion.
d. Pterygium. - B
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?
a. Assessing the eye for a possible foreign body
b. Documenting the finding as ptosis
c. Assessing for other signs of ectropion
d. Contacting the prescriber; these are signs of basal cell carcinoma - C
During an examination, a patient states that she was diagnosed with open-angle glaucoma 2
years ago. The nurse assesses for characteristics of open-angle glaucoma. Which of these
are characteristics of open-angle glaucoma?Select all that apply.
a. Patient may experience sensitivity to light, nausea, and halos around lights.
b. Patient experiences tunnel vision in the late stages.
c. Immediate treatment is needed.
d. Vision loss begins with peripheral vision.
e. Open-angle glaucoma causes sudden attacks of increased pressure that cause blurred
vision.
f. Virtually no symptoms are exhibited. - B, D, F
The nurse is examining a patients ears and notices cerumen in the external canal. Which of
these statements about cerumen is correct?
a. Sticky honey-colored cerumen is a sign of infection.
b. The presence of cerumen is indicative of poor hygiene.
c. The purpose of cerumen is to protect and lubricate the ear.
d. Cerumen is necessary for transmitting sound through the auditory canal. - C
When examining the ear with an otoscope, the nurse notes that the tympanic membrane
should appear:
a. Light pink with a slight bulge.
b. Pearly gray and slightly concave.
c. Pulled in at the base of the cone of light.
d. Whitish with a small fleck of light in the superior portion. - B
The nurse is reviewing the structures of the ear. Which of these statements concerning the
eustachian tube is true?
a. The eustachian tube is responsible for the production of cerumen.
b. It remains open except when swallowing or yawning.
c. The eustachian tube allows passage of air between the middle and outer ear.
d. It helps equalize air pressure on both sides of the tympanic membrane. - D
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:
a. Maintain balance.
b. Interpret sounds as they enter the ear.
c. Conduct vibrations of sounds to the inner ear.
d. Increase amplitude of sound for the inner ear to function. - C
The nurse is reviewing the function of the cranial nerves (CNs). Which CN is responsible for
conducting nerve impulses to the brain from the organ of Corti?
a. I
b. III
c. VIII
d. XI - C
The nurse is assessing a patient who may have hearing loss. Which of these statements is
true concerning air conduction?
a. Air conduction is the normal pathway for hearing.
b. Vibrations of the bones in the skull cause air conduction.
c. Amplitude of sound determines the pitch that is heard.
d. Loss of air conduction is called a conductive hearing loss - A
A patient has been shown to have a sensorineural hearing loss. During the assessment, it
would be important for the nurse to:
a. Speak loudly so the patient can hear the questions.
b. Assess for middle ear infection as a possible cause.
c. Ask the patient what medications he is currently taking.
d. Look for the source of the obstruction in the external ear. - C
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:
a. Cochlea.
b. CN VIII.
c. Organ of Corti.
d. Labyrinth. - D
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?
a. Rubella may affect the mothers hearing but not the infants.
b. Rubella can damage the infants organ of Corti, which will impair hearing.
c. Rubella is only dangerous to the infant in the second trimester of pregnancy.
d. Rubella can impair the development of CN VIII and thus affect hearing. - B
The mother of a 2-year-old is concerned because her son has had three ear infections in the
past year. What would be an appropriate response by the nurse?
a. It is unusual for a small child to have frequent ear infections unless something else is
wrong.
b. We need to check the immune system of your son to determine why he is having so many
ear infections.
c. Ear infections are not uncommon in infants and toddlers because they tend to have more
cerumen in the external ear.
d. Your sons eustachian tube is shorter and wider than yours because of his age, which allows
for infections to develop more easily. - D
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:
a. Otosclerosis.
b. Presbycusis.
c. Trauma to the bones.
d. Frequent ear infections. - A
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 cant 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?
a. Atrophy of the apocrine glands
b. Cilia becoming coarse and stiff
c. Nerve degeneration in the inner ear
d. Scarring of the tympanic membrane - C
The nurse is taking the history of a patient who may have a perforated eardrum. What
would be an important question in this situation?
a. Do you ever notice ringing or crackling in your ears?
b. When was the last time you had your hearing checked?
c. Have you ever been told that you have any type of hearing loss?
d. Is there any relationship between the ear pain and the discharge you mentioned? - D
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:
a. Is normal for people of his age.
b. Is a characteristic of recruitment.
c. May indicate a middle ear infection.
d. Indicates that the patient has a cerumen impaction. - B
While discussing the history of a 6-month-old infant, the mother tells the nurse that she
took a significant amount of aspirin while she was pregnant. What question would the
nurse want to include in the history?
a. Does your baby seem to startle with loud noises?
b. Has your baby had any surgeries on her ears?
c. Have you noticed any drainage from her ears?
d. How many ear infections has your baby had since birth? - A [Show Less]