CHAPTER 05- Head, Ears, Nose, Throat, and Eye

Question 1

The most common cause of bacterial pharyngitis is:

1. Gonorrhea.
2. Group C Streptococcus.
3. Mycoplasma.
4. Group A Streptococcus.

Answer 1

4. Group A Streptococcus.

Streptococcus A is by far the most common cause of acute pharyngitis.

Question 2

Risk factors for acute pharyngitis include all of the following EXCEPT:

1. Age (older people are more vulnerable).
2. Attendance at day care.
3. Smoking.
4. Allergies.

Answer 2

1. Age (older people are more vulnerable).

Younger patients are more vulnerable due to immature immune systems.

Question 3

A new patient, aged 11 years, is suspected of having acute tonsillitis. The FNP would expect her to have which of the following symptoms?

1. Oral lesions
2. Tonsillar ulcers
3. Dry cough
4. Comorbid pulmonary disease

Answer 3

2. Tonsillar ulcers

There will be ulcers and/or exudate prominent on the affected tonsils. Pulmonary symptoms are common with RSV or mycoplasma pneumonia and oral lesions with acute stomatitis.

Question 4

Treatment of the patient with acute tonsillitis will include all of the following EXCEPT:

1. Assessment of airway obstruction.
2. Judicious use of antibacterial mouthwash.
3. Ofloxacin in appropriate dose.
4. Warm salt water gargles.

Answer 4

3. Ofloxacin in appropriate dose.

Ofloxacin is a quinolone and should never be used in pediatric cases.

Question 5

The most common etiology for enlarged cervical lymph nodes is:

1. Human immunodeficiency virus.
2. Common viral and bacterial infections.
3. Dental abscess.
4. Rheumatoid arthritis and other autoimmune diseases.

Answer 5

2. Common viral and bacterial infections.

Although all of the answers can cause cervical lymphadenopathy, viral and bacterial infections account for the majority of infections.

Question 6

Infectious mononucleosis is found most often in which age group?

1. Pediatric
2. Adolescent
3. Adult
4. Geriatric

Answer 6

2. Adolescent

The highest recurrence rate is in those aged 15–25 years; 1–3% of college students experience IM annually.

Question 7

After history and the physical exam, the FNP suspects a 22-year-old female has infectious mononucleosis. Of the following diagnostic studies that provide the most specific test, the result will be:

1. A positive heterophile antibody test.
2. A modest elevation of the white blood count.
3. An elevated bilirubin.
4. A decreased lymphocyte count.

Answer 7

1. A positive heterophile antibody test.

The heterophile antibody test is the confirming test in IM. It is present in 40–60% patients in the first week and 78–90% of cases by weeks 3–4.

Question 8

The management plan for the patient with infectious mononucleosis will include:

1. A course of systemic corticosteroids.
2. Bed rest for 3–5 days.
3. Avoidance of contact sports for 3–5 days.
4. Increased clear fluids.

Answer 8

4. Increased clear fluids.

Increased fluids are an important supportive measure during the acute phase of IM. Increased activity levels increase the possibility of splenic rupture, and sports should be avoided for at least 4–6 weeks. Systemic corticosteroids are only used with complicated cases because they can affect cell-mediated immune response and may increase the risk of secondary bacterial infection.

Question 9

A 67-year-old male presents with a 72-hour history of sore throat associated with nasal congestion, clear rhinorrhea, and slight cough. This is most likely:

1. Epstein-Barr virus.
2. RSV.
3. Bacterial pharyngitis.
4. Viral pharyngitis.

Answer 9

4. Viral pharyngitis.

Viral pharyngitis usually presents with associated respiratory symptoms. Patient is in the wrong age group for EB virus or RSV.

Question 10

A 10-year-old male presents with a 2-week history of nosebleeds from both sides of his nose. They usually stop with pressure but have been becoming more frequent. They generally last about 5 minutes. The mother is concerned that her son might have a significant health problem. The exam will most probably reveal:

1. Hemoptysis.
2. Hematemesis.
3. Small sites of bleeding on the anterior nasal septum bilaterally.
4. Dripping blood in the posterior pharynx.

Answer 10

3. Small sites of bleeding on the anterior nasal septum bilaterally.

This is most likely an anterior bleed (90%) in children. The other answers are indicative of a posterior bleed.

Question 11

A 72-year-old male presents with the acute onset of unilateral epistaxis. He has been unable to stop the bleeding, which is a steady drip from his right naris. He has been coughing up bright red blood. He has hypertension and no history of previous episodes. This is most likely caused by:

1. A foreign body.
2. A posterior bleed.
3. An anterior bleed.
4. Cocaine abuse.

Answer 11

2. A posterior bleed.

This is most likely a posterior bleed because he has been coughing up bright red blood. A foreign body is unusual in this age group, as is cocaine abuse.

Question 12

The most common cause of an upper respiratory infection is:

1. Streptococcus.
2. Rhinovirus.
3. RSV.
4. Enterovirus.

Answer 12

2. Rhinovirus.

Rhinovirus is the most common cause of a URI. Bacteria can be a complication but is never the primary offending agent.

Question 13

Which of the following is NOT true about allergic rhinitis?

1. Poor sleep quality
2. Peaks during young adulthood
3. Results in decreased school concentration
4. May exacerbate asthma

Answer 13

2. Peaks during young adulthood

Allergic rhinitis peaks during adolescence.

Question 14

After evaluating a 22-year-old female, the FNP diagnoses allergic rhinitis. What testing could be performed?

1. Sinus films
2. Sinus CT
3. Blood testing for allergies
4. Blood chemistries

Answer 14

3. Blood testing for allergies

Imaging is not recommended for the diagnosis of allergies. A RAST or ELISA test could be done to see what allergies are present.

Question 15

After the test is performed on the 22-year-old female from the previous question, what treatment will initially be prescribed?

1. Oral antihistamine
2. Leukotriene receptor antagonist
3. Oral corticosteroid
4. Topical decongestant

Answer 15

1. Oral antihistamine

Oral antihistamines are always the drug of choice to begin therapy.

Question 16

Upon evaluating a 73-year-old male for nasal congestion, a “bad smell” is noted in his nose. This patient may have:

1. Allergic rhinitis.
2. Vasomotor rhinitis.
3. Atrophic rhinitis.
4. An upper respiratory infection.

Answer 16

3. Atrophic rhinitis.

Atrophic rhinitis is usually found in the elderly and is distinctive by its foul odor.

Question 17

All of the following are risk factors for acute stomatitis EXCEPT:

1. Day care attendance.
2. Vitamin deficiency.
3. Poverty.
4. Intact dentures.

Answer 17

4. Intact dentures.

Only poorly fitting dentures increase the risk for acute stomatitis.

Question 18

Oral apthous ulcers appear as:

1. Vesicles that break down to grayish ulcers.
2. Small vesicles or ulcers only on the posterior pharyngeal wall.
3. Small round or ovoid ulcers with circumscribed margins.
4. Erythema of lips and oral mucosa.

Answer 18

3. Small round or ovoid ulcers with circumscribed margins.

Vesicles that break down to grayish ulcers are usually herpes simplex. Small vesicles on the posterior pharyngeal wall are usually indicative of herpangina. Erythema of the lips and oral mucosa is found in Kawasaki disease.

Question 19

First-line treatment for the patient with aphthous ulcers would include:

1. Oral corticosteroids.
2. Thalidomide.
3. Valacyclovir.
4. Amlexanox.

Answer 19

3. Valacyclovir.

Valtrex may be used for RAU as an initial systemic treatment. The other medications must be reserved for severe cases.

Question 20

The following is true of acute rhinosinusitis:

1. An antibiotic is the only treatment.
2. It is most common in adolescents and young adults.
3. It is considered chronic if it lasts more than 2 months.
4. The most common microbe involved is S. Pneumoniae.

Answer 20

4. The most common microbe involved is S. Pneumoniae.

All rhinosinusitis begins as a virus and only a small amount become infected with bacteria. It is most common in women between 45 and 64 years of age. It is considered chronic after 12 weeks of symptoms.

Question 21

Predictive symptoms that a viral rhinosinusitis has become infected with bacteria include:

1. Worsening symptoms > 5–7 days.
2. Bilateral dental pain.
3. Persistent hyposmia.
4. Persistent symptoms for > 7 days.

Answer 21

1. Worsening symptoms > 5–7 days.

Dental pain is usually unilateral, and hyposmia is not a cardinal symptom for a bacterial super infection. Persistent symptoms should last >10 days before bacterial infection is suspected.

Question 22

A 47-year-old female presents to the office with 3 days of nasal congestion with mucoid drainage, a dull frontal headache, and post nasal drip. She is concerned that she has a sinus infection. Treatment will include:

1. High-dose Amoxicillin for 10 days.
2. Watchful waiting with a backup of antibiotics if her symptoms worsen.
3. Oral corticosteroids to decrease inflammation.
4. Referral to a neurologist for a headache evaluation.

Answer 22

2. Watchful waiting with a backup of antibiotics if her symptoms worsen.

Watchful waiting is the best treatment plan at this stage because she has not been sick long enough to establish a bacterial diagnosis, and antibiotics are not necessary with her history.

Question 23

A patient that was seen a week ago and diagnosed with a common cold returns today with worsening nasal congestion and headaches and purulent post nasal drip. She has a low-grade fever. Her exam reveals purulent drainage in the posterior pharynx and an edematous erythematous nasal chamber. Treatment will include:

1. High-dose Amoxicillin for 10–14 days.
2. Referral to otolaryngology.
3. Ordering a CT scan of the sinuses.
4. Avelox 400 mg for 14 days.

Answer 23

1. High-dose Amoxicillin for 10–14 days.

Amoxicillin is an initial choice for uncomplicated bacterial rhinosinusitis. It is too early to order a CT scan or make a referral.

Question 24

The FNP is performing a risk assessment on a 9-month-old female infant with a history of two previous episodes of AOM. Which of the following is NOT a risk factor?

1. Second-hand smoke
2. Bottle feeding in upright position
3. Day care with seven children
4. Pacifier use

Answer 24

2. Bottle feeding in upright position

Bottle feeding in the SUPINE position presents a risk for AOM.

Question 25

The tympanic membrane of a child with an otitis media with effusion will appear:

1. Bulging.
2. Erythematous.
3. Retracted.
4. With increased vascular markings.

Answer 25

3. Retracted.

A bulging erythematous tympanic membrane with hyperemia are signs of acute otitis media.

Question 26

A 5-month-old male infant has a documented acute otitis media. He appears ill with a fever of 103.2 degrees F. The mother is a reliable witness. The treatment plan would include:

1. Observation of the patient to see if he improves over the next 24–48 hours.
2. Sending him to the emergency room because he is so ill.
3. Placing him on amoxicillin suspension at the appropriate dose if he has no known allergy.
4. Explaining to the mother that no treatment is needed but he should be followed up in 2 weeks.

Answer 26

3. Placing him on amoxicillin suspension at the appropriate dose if he has no known allergy.

An infant under the age of 5 months should be treated with an antibiotic but does not need emergency care. The mother can report his progress by phone in 24–48 hours to ascertain efficacy of the antibiotic.

Question 27

A 4-year-old female patient has otitis media with effusion following an initial episode of acute otitis media 2 months ago. She is experiencing no hearing loss and has no speech problems. Which of the following is the best next step?

1. Tell the patient’s parents that this is within normal limits for resolution and to make a follow-up appointment in 4 weeks.
2. Refer her to an otolaryngologist.
3. Place the patient on a decongestant or antihistamine.
4. Use Augmentin in appropriate doses.

Answer 27

1. Tell the patient’s parents that this is within normal limits for resolution and to make a follow-up appointment in 4 weeks.

It is too soon to refer this patient because there is a 40% presence of effusion at 4 weeks. Decongestants, antihistamines, and antibiotics are not effective in OME.

Question 28

Prevention measures for AOM/OME include:

1. Choosing a day care with at least 20 children.
2. Making sure that an antibiotic is used with each episode.
3. Allowing infants to bottle feed in the supine position only.
4. Preventing exposure to second-hand smoke.

Answer 28

4. Preventing exposure to second-hand smoke.

The smaller the day care center, the less the risk; 20 children is too great a number. Antibiotics are not indicated in OME and infants should always be bottle-fed in the upright position.

Question 29

During examination of a 4-year-old male child, it is noted that the left tympanic membrane is dull and immobile. The FNP suspects that he has an associated hearing loss. This type of hearing loss is most likely:

1. Sensorineural.
2. Conductive.
3. Congenital.
4. Mixed.

Answer 29

2. Conductive.

Conductive hearing loss is most prevalent in children. The presence of a dull and immobile tympanic membrane suggests the presence of fluid behind the TM, which is associated with conductive hearing loss.

Question 30

A 7-year-old female child is doing poorly in school and her grades are falling. She is having problems concentrating and her mother is concerned about her ability to hear the teacher. She has a long history of acute and chronic ear infections. A conductive hearing loss is suspected. The FNP expects to find the following:

1. A Weber test that lateralizes to the unaffected ear
2. A Rinne test where air conduction = bone conduction
3. An audiometric test from school showing an “air-bone gap”
4. A tympanometry test showing no negative pressure

Answer 30

3. An audiometric test from school showing an “air-bone gap”

In conductive hearing loss, the Weber test lateralizes to the affected ear, and the Rinne test will show bone conduction greater than air conduction. The tympanogram will show negative pressure or immobility.

Question 31

A 76-year-old male patient presents with a suspected hearing loss in both ears. He notes that it is impossible for him to hear anyone when dining in a restaurant and he is sure that his wife mumbles all the time. The most likely diagnosis is:

1. Mixed hearing loss.
2. Sensorineural hearing loss.
3. Conductive hearing loss.
4. Sudden SNHL.

Answer 31

2. Sensorineural hearing loss.

Presbycusis occurs in the elderly with bilateral SNHL and problems with ambient noise. Physical examination of the ear will be completely normal. If SNHL is sudden, the patient will complain of a sudden loss of hearing, usually unilateral, and often accompanied by tinnitus.

Question 32

A 29-year-old female patient presents with a 10-hour history of sudden hearing loss in her right ear, accompanied by tinnitus and an echo sensation in the affected ear. The FNP suspects a sudden SNHL. The most appropriate next step is to:

1. Order a CT scan of her head.
2. Reassure her that this is temporary and will respond to steroid ear drops.
3. Immediately refer her to otolaryngology.
4. Begin her on Amoxicillin because this is probably a conductive hearing loss with an effusion of the middle ear.

Answer 32

3. Immediately refer her to otolaryngology.

Sudden SNHL is an emergency and should be immediately referred to ENT. A conductive hearing loss is seldom sudden and may be bilateral.

Question 33

A 32-year-old male patient is being seen for the first time in the office. He states he has a new job on a construction site. The treatment plan for his hearing will include:

1. Discussing the need for yearly hearing tests and daily ear protection.
2. Referring him for a hearing aid evaluation.
3. Discussing the need for him to stay away from the noisiest machines.
4. Referring him for genetic counseling.

Answer 33

1. Discussing the need for yearly hearing tests and daily ear protection.

Having a job in a noisy environment heightens the risk for SNHL. He should always be tested annually for changes in hearing. Many employers offer this as a benefit for their workers.

Question 34

Presyncope is defined as:

1. A sensation of uneasiness.
2. A sense of spinning.
3. A sense of pending loss of consciousness.
4. A sense of impaired balance.

Answer 34

3. A sense of pending loss of consciousness.

Vertigo is a sense of spinning. Disequilibrium is a sense of impaired balance. Lightheadedness is a sense of uneasiness.

Question 35

An adolescent male patient is being evaluated for “dizziness” following a concussion. The FNP suspects:

1. BPPV.
2. Ménière’s disease.
3. Labyrinthitis.
4. A central vertigo secondary to the concussion.

Answer 35

4. A central vertigo secondary to the concussion.

Any complaint of dizziness following head trauma must be considered central until the evaluation is completed.

Question 36

Ms. Hamilton, a 23-year-old female patient, presents with an acute onset of vertigo worsened by head movement and changes in position. She has severe nausea and vomiting and is acutely ill. The most likely diagnosis is:

1. BPPV.
2. Ménière’s disease.
3. Labyrinthitis.
4. Neuritis.

Answer 36

1. BPPV.

BPPV begins suddenly and is always exacerbated by head movements and position changes. In labyrinthitis, head motion is not usually a positive symptom. Ménière’s disease must have the four symptoms of vertigo, aural pressure, roaring tinnitus, and hearing loss.

Question 37

The diagnosis of BPPV will be aided by:

1. A CBC with differential.
2. The Dix–Hallpike Maneuver.
3. A CT of the head.
4. An MRI of the brain.

Answer 37

2. The Dix–Hallpike Maneuver.

The Dix–Hallpike is a diagnostic for BPPV. No radiology is necessary in the acute phase.

Question 38

Treatment measures for BPPV include all of the following EXCEPT:

1. No driving.
2. Clear fluids for hydration with nausea and vomiting.
3. An immediate return to daily activities with periods of rest.
4. The Epley maneuver.

Answer 38

3. An immediate return to daily activities with periods of rest.

The patient with BPPV must rest until symptoms begin to resolve.

Question 39

Risk factors for oral candidiasis include all of the following EXCEPT:

1. Hyperthyroidism.
2. Denture use.
3. Birth control pills.
4. Stress.

Answer 39

1. Hyperthyroidism.

Patients with hypothyroidism are at higher risk for oral candidiasis.

Question 40

A 45-year-old female patient has been on Nystatin Oral Rinse for oral candidiasis for 2 weeks without any symptom relief. She is now having increasing dysphagia and losing weight. The FNP will:

1. Change the medication to Clotrimazole trouches.
2. Repeat the Nystatin regime for another course.
3. Refer the patient to infectious disease.
4. Begin an antibiotic.

Answer 40

3. Refer the patient to infectious disease.

This patient is likely having a spread of fungal disease into the esophagus and needs a referral for specific testing.

Question 41

Risk factors for developing acute otitis externa include all the following EXCEPT:

1. Swimming in chlorinated pools.
2. Swimming in lakes.
3. Excessive ear cleaning with Q-tips.
4. Frequent upper respiratory infections.

Answer 41

4. Frequent upper respiratory infections.

Otitis externa occurs only in the ear canal itself. Upper respiratory infections occur in the nasal chamber and Eustachian tubes. These are separated from the external ear canal by the tympanic membrane.

Question 42

The bacteria most responsible for acute otitis externa is:

1. Staphylococcus Aureus.
2. Aspergillus.
3. Pseudomonas Aeruginosa.
4. Proteus Mirabilis.

Answer 42

3. Pseudomonas Aeruginosa.

Pseudomonas Aeruginosa is the offensive agent in 67% of cases.

Question 43

The patient with acute otitis externa will complain of which of the following?

1. Nasal congestion
2. Intense pain in the occipital area
3. Severe sore throat
4. Intense pain and pruritus from the affected ear

Answer 43

4. Intense pain and pruritus from the affected ear

The external ear canal inflammation will cause LOCAL pain. There may be a comorbid upper respiratory infection, but this is coincidental. A sore throat can cause ear pain, but it is usually a dull aching rather than a severe pain with and without palpation.

Question 44

Management of the patient with acute otitis externa includes:

1. Application of a hot water bottle to relieve pain.
2. Irrigation of the ear canal.
3. To continue swimming and showering and making sure to dry the ear thoroughly afterward.
4. Oral antibiotics for 10 days.

Answer 44

1. Application of a hot water bottle to relieve pain.

Pain relief is an important supportive measure in the acute phase, and intermittent heat will relieve some of the discomfort. NO water should be inserted into the external ear canal, and antibiotic drops are now the drug of choice for otitis externa.

Question 45

Indications for referral for acute otitis externa include:

1. Green drainage from the ear.
2. Presence of facial paralysis.
3. Wick has become loose, resulting in it falling out of the ear canal.
4. Fever and otalgia.

Answer 45

2. Presence of facial paralysis.

The presence of facial paralysis indicates the possibility of neurological involvement and should be referred immediately. Drainage and pruritus are symptoms of an acute infection that can be managed in primary care. A loose wick usually means that the ear canal edema is lessening and it does not have to be replaced.

Question 46

A 4-year-old boy is at the office for a pre-school physical exam. The FNP performs the cover/uncover test to evaluate for:

1. Strabismus.
2. Presbyopia.
3. Chalazion.
4. Butler’s sign.

Answer 46

1. Strabismus.

The cover/uncover test will detect any ocular deviation such as occurs in strabismus.

Question 47

A 42-year-old female is at the clinic with a complaint of having difficulty focusing on the words in newspapers. The FNP will most likely find that this patient has:

1. Presbyopia.
2. Strabismus.
3. Cataract.
4. Macular degeneration.

Answer 47

1. Presbyopia.

Presbyopia typically occurs between the ages of 40–50. Patients complain of difficulty focusing on near objects and fine print.

Question 48

A 19-year-old male presents to the health center with complaints of “really itchy eyes, and my eyes were like they were glued shut this morning. I had to use a lot of warm water to clear them.” The FNP suspects:

1. Viral conjunctivitis.
2. Bacterial conjunctivitis.
3. Allergic conjunctivitis.
4. Blepharitis.

Answer 48

2. Bacterial conjunctivitis.

Bacterial conjunctivitis typically causes redness and pyogenic exudate, which causes crusting and a scratchy or gritty sensation that feels “itchy.”

Question 49

The FNP is performing a physical examination in a 65-year-old female. Arcus senilis is noted during the examination. The FNP is aware that this finding requires:

1. Referral to an ophthalmologist for possible surgical intervention.
2. Referral to a cardiologist for cardiac workup.
3. No referral because this is a normal finding in this age group.
4. No referral; however, this finding by itself indicates a need for a lipid profile.

Answer 49

3. No referral because this is a normal finding in this age group.

Arcus senilis is a common finding in the elderly, caused by lipid deposits. However, it is not caused by high cholesterol. No referral is required.

Question 50

A 22-year-old male presents to the walk-in center with the chief complaint of “painful eye swelling.” Upon examination, the FNP notes the right eye has a hordeolum. The FNP treats this patient’s problem by:

1. Writing a prescription for Tobrex eye drops.
2. Encouraging the patient to use clean warm soaks to the affected area for 15 minutes four times per day.
3. Referring the patient to an eye surgeon for incision and drainage of the hordeolum.
4. Applying a patch to keep the eye covered and avoid further irritation to the eyelid.

Answer 50

2. Encouraging the patient to use clean warm soaks to the affected area for 15 minutes four times per day.

Unless the stye persists, no treatment other than cleansing with mild soap and water, and warm soaks to reduce discomfort are required. If it does not go away on its own, other treatments, including antibiotics, may be needed.