CHP 15,16,17

Question 1

When examining the eye, the nurse notices that the patients eyelid margins approximate completely. The nurse recognizes that this assessment finding:

Answer 1

Is expected.

The palpebral fissure is the elliptical open space between the eyelids, and, when closed, the lid margins
approximate completely, which is a normal finding

Question 2

During ocular examinations, the nurse keeps in mind that movement of the extraocular muscles is:

Answer 2

Stimulated by CNs III, IV, and VI.

Movement of the extraocular muscles is stimulated by three CNs: III, IV, and VI

Question 3

The nurse is performing an external eye examination. Which statement regarding the outer layer of the eye is true?

Answer 3

The outer layer of the eye is very sensitive to touch.

The cornea and the sclera make up the outer layer of the eye. The cornea is very sensitive to touch. The middle layer, the choroid, has dark pigmentation to prevent light from reflecting internally. The trigeminal nerve (CN V) and the facial nerve (CN VII) are stimulated when the outer surface of the eye is stimulated. The retina, in the inner layer of the eye, is where light waves are changed into nerve impulses.

Question 4

When examining a patients eyes, the nurse recalls that stimulation of the sympathetic branch of the
autonomic nervous system:

Answer 4

Elevates the eyelid and dilates the pupil.

Stimulation of the sympathetic branch of the autonomic nervous system dilates the pupil and elevates the eyelid. Parasympathetic nervous system stimulation causes the pupil to constrict. The muscle fibers of the iris contract the pupil in bright light to accommodate for near vision. The ciliary body controls the thickness of the lens.

Question 5

The nurse is reviewing causes of increased intraocular pressure. Which of these factors determines
intraocular pressure?

Answer 5

Amount of aqueous produced and resistance to its outflow at the angle of the anterior chamber

Intraocular pressure is determined by a balance between the amount of aqueous produced and the resistance to its outflow at the angle of the anterior chamber.

Question 6

The nurse is conducting a visual examination. Which of these statements regarding visual pathways and visual fields is true?

Answer 6

The image formed on the retina is upside down and reversed from its actual appearance in the
outside world.

The image formed on the retina is upside down and reversed from its actual appearance in the outside world. The light rays are refracted through the transparent media of the eye before striking the retina, and the nerve impulses are conducted through the optic nerve tract to the visual cortex of the occipital lobe of the brain. The left side of the brain interprets vision for the right eye

Question 7

The nurse is testing a patients visual accommodation, which refers to which action?

Answer 7

Pupillary constriction when looking at a near object

The muscle fibers of the iris contract the pupil in bright light and accommodate for near vision, which also results in pupil constriction.

Question 8

A patient has a normal pupillary light reflex. The nurse recognizes that this reflex indicates that:

Answer 8

Constriction of both pupils occurs in response to bright light.

The pupillary light reflex is the normal constriction of the pupils when bright light shines on the retina

Question 9

A mother asks when her newborn infants eyesight will be developed. The nurse should reply:

Answer 9

By approximately 3 months of age, infants develop more coordinated eye movements and can
fixate on an object.

Eye movements may be poorly coordinated at birth, but by 3 to 4 months of age, the infant should establish binocularity and should be able to fixate simultaneously on a single image with both eyes.

Question 10

The nurse is reviewing in age-related changes in the eye for a class. Which of these physiologic changes is
responsible for presbyopia?

Answer 10

Loss of lens elasticity

The lens loses elasticity and decreases its ability to change shape to accommodate for near vision. This
condition is called presbyopia

Question 11

Which of these assessment findings would the nurse expect to see when examining the eyes of a black
patient?

Answer 11

Dark retinal background

An ethnically based variability in the color of the iris and in retinal pigmentation exists, with darker irides having darker retinas behind them

Question 12

A 52-year-old patient describes the presence of occasional floaters or spots moving in front of his eyes. The nurse should

Answer 12

Know that floaters are usually insignificant and are caused by condensed vitreous fibers

Floaters are a common sensation with myopia or after middle age and are attributable to condensed vitreous fibers. Floaters or spots are not usually significant, but the acute onset of floaters may occur with retinal detachment.

Question 13

The nurse is preparing to assess the visual acuity of a 16-year-old patient. How should the nurse proceed?

Answer 13

Use the Snellen chart positioned 20 feet away from the patient.

The Snellen alphabet chart is the most commonly used and most accurate measure of visual acuity. The confrontation test is a gross measure of peripheral vision. The Jaeger card or newspaper tests are used to test near vision.

Question 14

A patients vision is recorded as 20/30 when the Snellen eye chart is used. The nurse interprets these results to indicate that:

Answer 14

The patient can read at 20 feet what a person with normal vision can read at 30 feet.

The top number indicates the distance the person is standing from the chart; the denominator gives the distance at which a normal eye can see

Question 15

A patient is unable to read even the largest letters on the Snellen chart. The nurse should take which action next?

Answer 15

Shorten the distance between the patient and the chart until the letters are seen, and record that distance

If the person is unable to see even the largest letters when standing 20 feet from the chart, then the nurse
should shorten the distance to the chart until the letters are seen, and record that distance (e.g., 10/200). If
visual acuity is even lower, then the nurse should assess whether the person can count fingers when they are spread in front of the eyes or can distinguish light perception from a penlight. If vision is poorer than 20/30, then a referral to an ophthalmologist or optometrist is necessary, but the nurse must first assess the visual acuity.

Question 16

A patients vision is recorded as 20/80 in each eye. The nurse interprets this finding to mean that the patient:

Answer 16

Has poor vision.

Normal visual acuity is 20/20 in each eye; the larger the denominator, the poorer the vision.

Question 17

When performing the corneal light reflex assessment, the nurse notes that the light is reflected at 2 oclock in each eye. The nurse should:

Answer 17

Consider this a normal finding.

Reflection of the light on the corneas should be in exactly the same spot on each eye, or symmetric. If asymmetry is noted, then the nurse should administer the cover test.

Question 18

The nurse is performing the diagnostic positions test. Normal findings would be which of these results?

Answer 18

Parallel movement of both eyes

A normal response for the diagnostic positions test is parallel tracking of the object with both eyes. Eye
movement that is not parallel indicates a weakness of an extraocular muscle or dysfunction of the CN that
innervates it

Question 19

During an assessment of the sclera of a black patient, the nurse would consider which of these an expected finding?

Answer 19

Presence of small brown macules on the sclera

Normally in dark-skinned people, small brown macules may be observed in the sclera

Question 20

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?

Answer 20

Observe the distance between the palpebral fissures.

Ptosis is a drooping of the upper eyelid that would be apparent by observing the distance between the upper and lower eyelids. The confrontation test measures peripheral vision. Measuring near vision or the corneal light test does not check ptosis.

Question 20

During an examination of the eye, the nurse would expect what normal finding when assessing the lacrimal
apparatus?

Answer 20

Absence of drainage from the puncta when pressing against the inner orbital rim

No swelling, redness, or drainage from the puncta should be observed when it is pressed. Regurgitation of fluid
from the puncta, when pressed, indicates duct blockage. The lacrimal glands are not functional at birth.

Question 21

When assessing the pupillary light reflex, the nurse should use which technique?

Answer 21

Shine a light across the pupil from the side, and observe for direct and consensual pupillary constriction.

To test the pupillary light reflex, the nurse should advance a light in from the side and note the direct and
consensual pupillary constriction.

Question 21

The nurse is assessing a patients eyes for the accommodation response and would expect to see which
normal finding?

Answer 21

Convergence of the axes of the eyes

The accommodation reaction includes pupillary constriction and convergence of the axes of the eyes

Question 21

24. 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:

Answer 21

c. Consider the red glow a normal reflection of the ophthalmoscope light off the inner retina.

The red glow filling the persons pupil is the red reflex and is a normal finding caused by the reflection of the
ophthalmoscope light off the inner retina

Question 22

25. The nurse is examining a patients retina with an ophthalmoscope. Which finding is considered normal?

Answer 22

a. Optic disc that is a yellow-orange color

The optic disc is located on the nasal side of the retina. Its color is a creamy yellow-orange to a pink, and the
edges are distinct and sharply demarcated, not blurred. A pigmented crescent is black and is due to the
accumulation of pigment in the choroid.

Question 22

A 2-week-old infant can fixate on an object but cannot follow a light or bright toy. The nurse would:

Answer 22

Consider this a normal finding.

By 2 to 4 weeks an infant can fixate on an object. By the age of 1 month, the infant should fixate and follow a
bright light or toy.

Question 22

The nurse is assessing color vision of a male child. Which statement is correct? The nurse should:

Answer 22

Test for color vision once between the ages of 4 and 8 years.

Test boys only once for color vision between the ages of 4 and 8 years. Color vision is not tested in girls
because it is rare in girls. Testing is performed with the Ishihara test, which is a series of polychromatic cards

Question 23

The nurse is performing an eye-screening clinic at a daycare center. When examining a 2-year-old child,
the nurse suspects that the child has a lazy eye and should:

Answer 23

Test for strabismus by performing the corneal light reflex test.

Testing for strabismus is done by performing the corneal light reflex test and the cover test. The Snellen eye
chart and confrontation test are not used to test for strabismus.

Question 24

The nurse notices the presence of periorbital edema when performing an eye assessment on a 70-year-old
patient. The nurse should:

Answer 24

Ask the patient if he or she has a history of heart failure.

Periorbital edema occurs with local infections, crying, and systemic conditions such as heart failure, renal
failure, allergy, and hypothyroidism. Periorbital edema is not associated with blepharitis.

Question 24

When a light is directed across the iris of a patients eye from the temporal side, the nurse is assessing for:

Answer 24

Presence of shadows, which may indicate glaucoma.

The presence of shadows in the anterior chamber may be a sign of acute angle-closure glaucoma. The normal iris is flat and creates no shadows. This method is not correct for the assessment of dacryocystitis, conjunctivitis, or cataracts

Question 24

In a patient who has anisocoria, the nurse would expect to observe:

Answer 24

Pupils of unequal size.

Unequal pupil size is termed anisocoria. It normally exists in 5% of the population but may also be indicative of central nervous system disease.

Question 25

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:

Answer 25

Shadow or diminished vision in one quadrant or one half of the visual field.

With retinal detachment, the person has shadows or diminished vision in one quadrant or one half of the visual
field. The other responses are not signs of retinal detachment.

Question 26

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:

Answer 26

Hordeolum (stye).

A hordeolum, or stye, is a painful, red, and swollen pustule at the lid margin. A chalazion is a nodule
protruding on the lid, toward the inside, and is nontender, firm, with discrete swelling. Dacryocystitis is an
inflammation of the lacrimal sac. Blepharitis is inflammation of the eyelids.

Question 26

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:

Answer 26

Macular degeneration.

Macular degeneration is the most common cause of blindness. It is characterized by the loss of central vision. Cataracts would show lens opacity. Chronic open-angle glaucoma, the most common type of glaucoma, involves a gradual loss of peripheral vision. These findings are not consistent with vision that is considered normal at any age.

Question 27

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?

Answer 27

Shattered look to the light rays reflecting off the cornea

A corneal abrasion causes irregular ridges in reflected light, which produce a shattered appearance to light rays. No opacities should be observed in the cornea.

Question 28

An ophthalmic examination reveals papilledema. The nurse is aware that this finding indicates:

Answer 28

Increased intracranial pressure.

Papilledema, or choked disk, is a serious sign of increased intracranial pressure, which is caused by a space- occupying mass such as a brain tumor or hematoma. This pressure causes venous stasis in the globe, showing redness, congestion, and elevation of the optic disc, blurred margins, hemorrhages, and absent venous pulsations.

Question 28

38. 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:

Answer 28

b. Hyphema.

Hyphema is the term for blood in the anterior chamber and is a serious result of blunt trauma (a fist or a
baseball) or spontaneous hemorrhage and may indicate scleral rupture or major intraocular trauma

Question 29

39. 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?

Answer 29

c. Assessing for other signs of ectropion

The condition described is known as ectropion, and it occurs in older adults and is attributable to atrophy of the
elastic and fibrous tissues. The lower lid does not approximate to the eyeball, and, as a result, the puncta cannot effectively siphon tears; excessive tearing results. Ptosis is a drooping of the upper eyelid. These signs do not suggest the presence of a foreign body in the eye or basal cell carcinoma.

Question 29

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.

Answer 29

1. Patient experiences tunnel vision in the late stages.
2. Vision loss begins with peripheral vision.
3. Virtually no symptoms are exhibited.

Open-angle glaucoma is the most common type of glaucoma; virtually no symptoms are exhibited. Vision loss begins with the peripheral vision, which often goes unnoticed because individuals learn to compensate
intuitively by turning their heads. The other characteristics are those of closed-angle glaucoma.

Question 30

Chp 16

Question 30

The nurse needs to pull the portion of the ear that consists of movable cartilage and skin down and back
when administering eardrops. This portion of the ear is called the:

Answer 30

Auricle.

The external ear is called the auricle or pinna and consists of movable cartilage and skin.

Question 30

2. The nurse is examining a patients ears and notices cerumen in the external canal. Which of these statements about cerumen is correct?

Answer 30

The purpose of cerumen is to protect and lubricate the ear.

The ear is lined with glands that secrete cerumen, which is a yellow waxy material that lubricates and protects the ear.

Question 31

When examining the ear with an otoscope, the nurse notes that the tympanic membrane should appear:

Answer 31

Pearly gray and slightly concave.

The tympanic membrane is a translucent membrane with a pearly gray color and a prominent cone of light in the anteroinferior quadrant, which is the reflection of the otoscope light. The tympanic membrane is oval and slightly concave, pulled in at its center by the malleus, which is one of the middle ear ossicles.

Question 32

The nurse is reviewing the structures of the ear. Which of these statements concerning the eustachian tube is true?

Answer 32

It helps equalize air pressure on both sides of the tympanic membrane.

The eustachian tube allows an equalization of air pressure on each side of the tympanic membrane so that the membrane does not rupture during, for example, altitude changes in an airplane. The tube is normally closed, but it opens with swallowing or yawning.

Question 33

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:

Answer 33

Conduct vibrations of sounds to the inner ear.

Among its other functions, the middle ear conducts sound vibrations from the outer ear to the central hearing apparatus in the inner ear. The other responses are not functions of the middle ear.

Question 34

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?

Answer 34

c. VIII

Question 34

The nurse is assessing a patient who may have hearing loss. Which of these statements is true concerning air conduction?

Answer 34

Air conduction is the normal pathway for hearing.

The normal pathway of hearing is air conduction, which starts when sound waves produce vibrations on the tympanic membrane. Conductive hearing loss results from a mechanical dysfunction of the external or middle ear. The other statements are not true concerning air conduction.

Question 35

A patient has been shown to have a sensorineural hearing loss. During the assessment, it would be important for the nurse to:

Answer 35

Ask the patient what medications he is currently taking.

A simple increase in amplitude may not enable the person to understand spoken words. Sensorineural hearing loss may be caused by presbycusis, which is a gradual nerve degeneration that occurs with aging and by ototoxic drugs, which affect the hair cells in the cochlea.

Question 35

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:

Answer 35

Labyrinth.

If the labyrinth ever becomes inflamed, then it feeds the wrong information to the brain, creating a staggering gait and a strong, spinning, whirling sensation called vertigo.

Question 35

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?

Answer 35

Rubella can damage the infants organ of Corti, which will impair hearing.

If maternal rubella infection occurs during the first trimester, then it can damage the organ of Corti and impair hearing.

Question 36

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?

Answer 36

Your sons eustachian tube is shorter and wider than yours because of his age, which allows for infections to develop more easily.

The infants eustachian tube is relatively shorter and wider than the adults eustachian tube, and its position is more horizontal; consequently, pathogens from the nasopharynx can more easily migrate through to the middle ear. The other responses are not appropriate.

Question 37

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:

Answer 37

Otosclerosis.

Otosclerosis is a common cause of conductive hearing loss in young adults between the ages of 20 and 40 years. Presbycusis is a type of hearing loss that occurs with aging. Trauma and frequent ear infections are not a likely cause of his hearing loss

Question 37

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?

Answer 37

Nerve degeneration in the inner ear

Presbycusis is a type of hearing loss that occurs in 60% of those older than 65 years of age, even in those living in a quiet environment. This sensorineural loss is gradual and caused by nerve degeneration in the inner ear. Words sound garbled, and the ability to localize sound is also impaired. This communication dysfunction is accentuated when background noise is present.

Question 37

During an assessment of a 20-year-old Asian patient, the nurse notices that he has dry, flaky cerumen in his canal. What is the significance of this finding? This finding:

Answer 37

Is a normal finding, and no further follow-up is necessary.

Asians and Native Americans are more likely to have dry cerumen, whereas Blacks and Whites usually have wet cerumen.

Question 38

The nurse is taking the history of a patient who may have a perforated eardrum. What would be an important question in this situation?

Answer 38

Is there any relationship between the ear pain and the discharge you mentioned?

Typically with perforation, ear pain occurs first, stopping with a popping sensation, and then drainage occurs.

Question 39

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:

Answer 39

Is a characteristic of recruitment.

Recruitment is significant hearing loss occurring when speech is at low intensity, but sound actually becomes painful when the speaker repeats at a louder volume. The other responses are not correct.

Question 40

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?

Answer 40

Does your baby seem to startle with loud noises?

Children at risk for a hearing deficit include those exposed in utero to a variety of conditions, such as maternal rubella or to maternal ototoxic drugs.

Question 41

The nurse is performing an otoscopic examination on an adult. Which of these actions is correct?

Answer 41

Pulling the pinna up and back before inserting the speculum

The pinna is pulled up and back on an adult or older child, which helps straighten the S-shape of the canal. Traction should not be released on the ear until the examination is completed and the otoscope is removed.

Question 42

The nurse is assessing a 16-year-old patient who has suffered head injuries from a recent motor vehicle accident. Which of these statements indicates the most important reason for assessing for any drainage from the ear canal?

Answer 42

Bloody or clear watery drainage can indicate a basal skull fracture.

Frank blood or clear watery drainage (cerebrospinal leak) after a trauma suggests a basal skull fracture and warrants immediate referral. Purulent drainage indicates otitis externa or otitis media.

Question 43

In performing an examination of a 3-year-old child with a suspected ear infection, the nurse would:

Answer 43

Perform the otoscopic examination at the end of the assessment.

In addition to its place in the complete examination, eardrum assessment is mandatory for any infant or child requiring care for an illness or fever. For the infant or young child, the timing of the otoscopic examination is best toward the end of the complete examination

Question 43

In performing a voice test to assess hearing, which of these actions would the nurse perform?

Answer 43

Whisper a set of random numbers and letters, and then ask the patient to repeat them.

With the head 30 to 60 cm (1 to 2 feet) from the patients ear, the examiner exhales and slowly whispers a set of random numbers and letters, such as 5, B, 6. Normally, the patient is asked to repeat each number and letter correctly after hearing the examiner say them.

Question 44

The nurse is preparing to perform an otoscopic examination of a newborn infant. Which statement is true regarding this examination?

Answer 44

The normal membrane may appear thick and opaque.

During the first few days after the birth, the tympanic membrane of a newborn often appears thickened and opaque. It may look injected and have a mild redness from increased vascularity.

Question 44

The nurse assesses the hearing of a 7-month-old by clapping hands. What is the expected response? The infant:

Answer 44

Turns his or her head to localize the sound.

With a loud sudden noise, the nurse should notice the infant turning his or her head to localize the sound and to respond to his or her own name. A startle reflex and acoustic blink reflex is expected in newborns; at age 3 to 4 months, the infant stops any movement and appears to listen.

Question 45

The nurse is performing an ear examination of an 80-year-old patient. Which of these findings would be considered normal?

Answer 45

High-tone frequency loss

A high-tone frequency hearing loss is apparent for those affected with presbycusis, the hearing loss that occurs with aging. The pinna loses elasticity, causing earlobes to be pendulous. The eardrum may be whiter in color and more opaque and duller in the older person than in the younger adult.

Question 46

An assessment of a 23-year-old patient reveals the following: an auricle that is tender and reddish-blue in color with small vesicles. The nurse would need to know additional information that includes which of these?

Answer 46

Any prolonged exposure to extreme cold

Frostbite causes reddish-blue discoloration and swelling of the auricle after exposure to extreme cold. Vesicles or bullae may develop, and the person feels pain and tenderness.

Question 47

While performing the otoscopic examination of a 3-year-old boy who has been pulling on his left ear, the nurse finds that his left tympanic membrane is bright red and that the light reflex is not visible. The nurse interprets these findings to indicate a(n):

Answer 47

Acute otitis media.

Absent or distorted light reflex and a bright red color of the eardrum are indicative of acute otitis media

Question 47

The mother of a 2-year-old toddler is concerned about the upcoming placement of tympanostomy tubes in her sons ears. The nurse would include which of these statements in the teaching plan?

Answer 47

The purpose of the tubes is to decrease the pressure and allow for drainage.

Polyethylene tubes are surgically inserted into the eardrum to relieve middle ear pressure and to promote
drainage of chronic or recurrent middle ear infections. Tubes spontaneously extrude in 6 months to 1 year.

Question 48

In an individual with otitis externa, which of these signs would the nurse expect to find on assessment?

Answer 48

Enlarged superficial cervical nodes

The lymphatic drainage of the external ear flows to the parotid, mastoid, and superficial cervical nodes. The signs are severe swelling of the canal, inflammation, and tenderness. Rhinorrhea, periorbital edema, and pain over the maxillary sinuses do not occur with otitis externa.

Question 49

When performing an otoscopic examination of a 5-year-old child with a history of chronic ear infections, the nurse sees that his right tympanic membrane is amber-yellow in color and that air bubbles are visible behind the tympanic membrane. The child reports occasional hearing loss and a popping sound with swallowing. The preliminary analysis based on this information is that the child:

Answer 49

Most likely has serous otitis media.

An amber-yellow color to the tympanic membrane suggests serum or pus in the middle ear. Air or fluid or
bubbles behind the tympanic membrane are often visible. The patient may have feelings of fullness, transient hearing loss, and a popping sound with swallowing. These findings most likely suggest that the child has serous otitis media.

Question 50

The nurse is performing an assessment on a 65-year-old man. He reports a crusty nodule behind the pinna. It intermittently bleeds and has not healed over the past 6 months. On physical assessment, the nurse finds an ulcerated crusted nodule with an indurated base. The preliminary analysis in this situation is that this:

Answer 50

Could be a potential carcinoma, and the patient should be referred for a biopsy.

An ulcerated crusted nodule with an indurated base that fails to heal is characteristic of a carcinoma. These lesions fail to heal and intermittently bleed. Individuals with such symptoms should be referred for a biopsy. The other responses are not correct.

Question 50

The nurse suspects that a patient has otitis media. Early signs of otitis media include which of these findings of the tympanic membrane?

Answer 50

Hypomobility

An early sign of otitis media is hypomobility of the tympanic membrane. As pressure increases, the tympanic membrane begins to bulge.

Question 51

The nurse is performing a middle ear assessment on a 15-year-old patient who has had a history of chronic ear infections. When examining the right tympanic membrane, the nurse sees the presence of dense white patches. The tympanic membrane is otherwise unremarkable. It is pearly, with the light reflex at 5 oclock and landmarks visible. The nurse should:

Answer 51

Know that these are scars caused from frequent ear infections.

Dense white patches on the tympanic membrane are sequelae of repeated ear infections. They do not
necessarily affect hearing

Question 52

The nurse is preparing to do an otoscopic examination on a 2-year-old child. Which one of these reflects the correct procedure?

Answer 52

Pulling the pinna down

For an otoscopic examination on an infant or on a child under 3 years of age, the pinna is pulled down. The other responses are not part of the correct procedure.

Question 53

A 17-year-old student is a swimmer on her high schools swim team. She has had three bouts of otitis externa this season and wants to know what to do to prevent it. The nurse instructs her to:

Answer 53

Use rubbing alcohol or 2% acetic acid eardrops after every swim.

With otitis externa (swimmers ear), swimming causes the external canal to become waterlogged and swell; skinfolds are set up for infection. Otitis externa can be prevented by using rubbing alcohol or 2% acetic acid eardrops after every swim.

Question 53

During an otoscopic examination, the nurse notices an area of black and white dots on the tympanic membrane and the ear canal wall. What does this finding suggest?

Answer 53

Yeast or fungal infection

A colony of black or white dots on the drum or canal wall suggests a yeast or fungal infection (otomycosis).

Question 53

The nurse is conducting a child safety class for new mothers. Which factor places young children at risk for ear infections?

Answer 53

Passive cigarette smoke

Exposure to passive and gestational smoke is a risk factor for ear infections in infants and children.

Question 54

A patient has been admitted after an accident at work. During the assessment, the patient is having trouble hearing and states, I dont know what the matter is. All of a sudden, I cant hear you out of my left ear! What should the nurse do next?

Answer 54

Notify the patients health care provider.

Any sudden loss of hearing in one or both ears that is not associated with an upper respiratory infection needs to be reported at once to the patients health care provider. Hearing loss associated with trauma is often sudden. Irrigating the ear or removing cerumen is not appropriate at this time.

Question 54

During an examination, the patient states he is hearing a buzzing sound and says that it is driving me crazy! The nurse recognizes that this symptom indicates:

Answer 54

Tinnitus.

Tinnitus is a sound that comes from within a person; it can be a ringing, crackling, or buzzing sound. It
accompanies some hearing or ear disorders.

Question 55

During an examination, the nurse notices that the patient stumbles a little while walking, and, when she sits down, she holds on to the sides of the chair. The patient states, It feels like the room is spinning! The nurse notices that the patient is experiencing:

Answer 55

Objective vertigo.

With objective vertigo, the patient feels like the room spins; with subjective vertigo, the person feels like he or she is spinning. Tinnitus is a sound that comes from within a person; it can be a ringing, crackling, or buzzing sound. It accompanies some hearing or ear disorders. Dizziness is not the same as true vertigo; the person who is dizzy may feel unsteady and lightheaded.

Question 56

The nurse is testing the hearing of a 78-year-old man and is reminded of the changes in hearing that occur with aging that include which of the following? Select all that apply.

Answer 56

-Progression of hearing loss is slow.
-The aging person may find it harder to hear consonants than vowels.
-Sounds may be garbled and difficult to localize.

Presbycusis is a type of hearing loss that occurs with aging and is found in 60% of those older than 65 years. It is a gradual sensorineural loss caused by nerve degeneration in the inner ear or auditory nerve, and it slowly progresses after the age of 50 years. The person first notices a high-frequency tone loss; it is harder to hear consonants (high-pitched components of speech) than vowels, which makes words sound garbled. The ability to localize sound is also impaired.

Question 57

Chapter 17

Question 57

The primary purpose of the ciliated mucous membrane in the nose is to:

Answer 57

Filter out dust and bacteria.

The nasal hairs filter the coarsest matter from inhaled air, whereas the mucous blanket filters out dust and bacteria. The rich blood supply of the nasal mucosa warms the inhaled air.

Question 58

The nurse is reviewing the development of the newborn infant. Regarding the sinuses, which statement is true in relation to a newborn infant?

Answer 58

Maxillary and ethmoid sinuses are the only sinuses present at birth.

Only the maxillary and ethmoid sinuses are present at birth. The sphenoid sinuses are minute at birth and develop after puberty. The frontal sinuses are absent at birth, are fairly well developed at age 7 to 8 years, and reach full size after puberty.

Question 59

The projections in the nasal cavity that increase the surface area are called the:

Answer 59

Turbinates.

The lateral walls of each nasal cavity contain three parallel bony projections: the superior, middle, and inferior turbinates. These increase the surface area, making more blood vessels and mucous membrane available to warm, humidify, and filter the inhaled air.

Question 60

The tissue that connects the tongue to the floor of the mouth is the:

Answer 60

Frenulum.

The frenulum is a midline fold of tissue that connects the tongue to the floor of the mouth. The uvula is the free projection hanging down from the middle of the soft palate. The palate is the arching roof of the mouth. Papillae are the rough, bumpy elevations on the tongues dorsal surface.

Question 61

In assessing the tonsils of a 30 year old, the nurse notices that they are involuted, granular in appearance, and appear to have deep crypts. What is correct response to these findings?

Answer 61

No response is needed; this appearance is normal for the tonsils.

The tonsils are the same color as the surrounding mucous membrane, although they look more granular and their surface shows deep crypts. Tonsillar tissue enlarges during childhood until puberty and then involutes.

Question 61

The salivary gland that is the largest and located in the cheek in front of the ear is the _________ gland.

Answer 61

Parotid

The mouth contains three pairs of salivary glands. The largest, the parotid gland, lies within the cheeks in front of the ear extending from the zygomatic arch down to the angle of the jaw. The Stensens duct (not gland) drains the parotid gland onto the buccal mucosa opposite the second molar. The sublingual gland is located within the floor of the mouth under the tongue. The submandibular gland lies beneath the mandible at the angle of the jaw.

Question 62

The nurse is obtaining a health history on a 3-month-old infant. During the interview, the mother states, I think she is getting her first tooth because she has started drooling a lot. The nurses best response would be:

Answer 62

She is just starting to salivate and hasnt learned to swallow the saliva.

In the infant, salivation starts at 3 months. The baby will drool for a few months before learning to swallow the saliva. This drooling does not herald the eruption of the first tooth, although many parents think it does.

Question 62

The nurse is assessing an 80-year-old patient. Which of these findings would be expected for this patient?

Answer 62

Decreased ability to identify odors

The sense of smell may be reduced because of a decrease in the number of olfactory nerve fibers. Nasal hairs grow coarser and stiffer with aging. The gums may recede with aging, not hypertrophy, and saliva production Decreases.

Question 63

The nurse is performing an oral assessment on a 40-year-old Black patient and notices the presence of a 1 cm, nontender, grayish-white lesion on the left buccal mucosa. Which one of these statements is true? This lesion is:

Answer 63

Leukoedema and is common in dark-pigmented persons.

Leukoedema, a grayish-white benign lesion occurring on the buccal mucosa, is most often observed in Blacks.

Question 64

While obtaining a health history from the mother of a 1-year-old child, the nurse notices that the baby has had a bottle in his mouth the entire time. The mother states, It makes a great pacifier. The best response by the nurse would be:

Answer 64

Prolonged use of a bottle can increase the risk for tooth decay and ear infections.

Prolonged bottle use during the day or when going to sleep places the infant at risk for tooth decay and middle ear infections.

Question 64

A 92-year-old patient has had a stroke. The right side of his face is drooping. The nurse might also suspect which of these assessment findings?

Answer 64

Dysphagia

Dysphagia is difficulty with swallowing and may occur with a variety of disorders, including stroke and other neurologic diseases. Rhinorrhea is a runny nose, epistaxis is a bloody nose, and xerostomia is a dry mouth.

Question 65

While obtaining a health history, a patient tells the nurse that he has frequent nosebleeds and asks the best way to get them to stop. What would be the nurses best response?

Answer 65

Sit up with your head tilted forward and pinch your nose.

With a nosebleed, the person should sit up with the head tilted forward and pinch the nose between the thumb and forefinger for 5 to 15 minutes.

Question 66

A 72-year-old patient has a history of hypertension and chronic lung disease. An important question for the nurse to include in the health history would be:

Answer 66

Have you noticed any dryness in your mouth?

Xerostomia (dry mouth) is a side effect of many drugs taken by older people, including antidepressants, anticholinergics, antispasmodics, antihypertensives, antipsychotics, and bronchodilators.

Question 66

The nurse is using an otoscope to assess the nasal cavity. Which of these techniques is correct?

Answer 66

Avoiding touching the nasal septum with the speculum

The correct technique for using an otoscope is to insert the apparatus into the nasal vestibule, avoiding pressure on the sensitive nasal septum. The tip of the nose should be lifted up before inserting the speculum.

Question 67

The nurse is performing an assessment on a 21-year-old patient and notices that his nasal mucosa appears pale, gray, and swollen. What would be the most appropriate question to ask the patient?

Answer 67

Are you aware of having any allergies?

With chronic allergies, the mucosa looks swollen, boggy, pale, and gray. Elevated body temperature, colds, and nosebleeds do not cause these mucosal changes.

Question 68

During an assessment of a 20-year-old patient with a 3-day history of nausea and vomiting, the nurse notices dry mucosa and deep vertical fissures in the tongue. These findings are reflective of:

Answer 68

Dehydration.

Dry mouth occurs with dehydration or fever. The tongue has deep vertical fissures.

Question 68

During an oral assessment of a 30-year-old Black patient, the nurse notices bluish lips and a dark line along the gingival margin. What action would the nurse perform in response to this finding?

Answer 68

Proceed with the assessment, knowing that this appearance is a normal finding.

Some Blacks may have bluish lips and a dark line on the gingival margin; this appearance is a normal finding.

Question 68

The nurse is palpating the sinus areas. If the findings are normal, then the patient should report which sensation?

Answer 68

Firm pressure

The person should feel firm pressure but no pain. Sinus areas are tender to palpation in persons with chronic allergies or an acute infection (sinusitis).

Question 69

Immediately after birth, the nurse is unable to suction the nares of a newborn. An attempt is made to pass a catheter through both nasal cavities with no success. What should the nurse do next?

Answer 69

Recognize that this situation requires immediate intervention.

Determining the patency of the nares in the immediate newborn period is essential because most newborns are obligate nose breathers. Nares blocked with amniotic fluid are gently suctioned with a bulb syringe. If obstruction is suspected, then a small lumen (5 to 10 Fr) catheter is passed down each naris to confirm patency. The inability to pass a catheter through the nasal cavity indicates choanal atresia, which requires immediate

Question 69

A 10 year old is at the clinic for a sore throat that has lasted 6 days. Which of these findings would be
consistent with an acute infection?

Answer 69

Tonsils 3+/1-4+ with large white spots

With an acute infection, tonsils are bright red and swollen and may have exudate or large white spots. Tonsils are enlarged to 2+, 3+, or 4+ with an acute infection.

Question 69

A 32-year-old woman is at the clinic for little white bumps in my mouth. During the assessment, the nurse notes that she has a 0.5 cm white, nontender papule under her tongue and one on the mucosa of her right cheek. What would the nurse tell the patient?

Answer 69

These bumps are Fordyce granules, which are sebaceous cysts and are not a serious condition.

Fordyce granules are small, isolated white or yellow papules on the mucosa of the cheek, tongue, and lips. These little sebaceous cysts are painless and are not significant. Chalky, white raised patches would indicate leukoplakia. In strep throat, the examiner would see tonsils that are bright red, swollen, and may have exudates or white spots.

Question 70

The nurse notices that the mother of a 2-year-old boy brings him into the clinic quite frequently for various injuries and suspects there may be some child abuse involved. During an inspection of his mouth, the nurse should look for:

Answer 70

Bruising on the buccal mucosa or gums.

The nurse should notice any bruising or laceration on the buccal mucosa or gums of an infant or young child. Trauma may indicate child abuse from a forced feeding of a bottle or spoon.

Question 71

The nurse is assessing a 3 year old for drainage from the nose. On assessment, a purulent drainage that has a very foul odor is noted from the left naris and no drainage is observed from the right naris. The child is
afebrile with no other symptoms. What should the nurse do next?

Answer 71

Perform an otoscopic examination of the left nares.

Children are prone to put an object up the nose, producing unilateral purulent drainage with a foul odor. Because some risk for aspiration exists, removal should be prompt.

Question 72

During an assessment of a 26 year old at the clinic for a spot on my lip I think is cancer, the nurse notices a group of clear vesicles with an erythematous base around them located at the lip-skin border. The patient mentions that she just returned from Hawaii. What would be the most appropriate response by the nurse?

Answer 72

Tell the patient that these vesicles are indicative of herpes simplex I or cold sores and that they will
heal in 4 to 10 days.

Cold sores are groups of clear vesicles with a surrounding erythematous base. These evolve into pustules or crusts and heal in 4 to 10 days. The most likely site is the lip-skin junction. Infection often recurs in the same site. Recurrent herpes infections may be precipitated by sunlight, fever, colds, or allergy.

Question 73

A 40-year-old patient who has just finished chemotherapy for breast cancer tells the nurse that she is
concerned about her mouth. During the assessment the nurse finds areas of buccal mucosa that are raw and red with some bleeding, as well as other areas that have a white, cheesy coating. The nurse recognizes that this abnormality is:

Answer 73

Candidiasis.

Candidiasis is a white, cheesy, curdlike patch on the buccal mucosa and tongue. It scrapes off, leaving a raw, red surface that easily bleeds. It also occurs after the use of antibiotics or corticosteroids and in persons who are immunosuppressed.

Question 73

While performing an assessment of the mouth, the nurse notices that the patient has a 1-cm ulceration that is crusted with an elevated border and located on the outer third of the lower lip. What other information would be most important for the nurse to assess?

Answer 73

When the patient first noticed the lesion

With carcinoma, the initial lesion is round and indurated, but then it becomes crusted and ulcerated with an elevated border. Most cancers occur between the outer and middle thirds of the lip. Any lesion that is still unhealed after 2 weeks should be referred.

Question 74

A pregnant woman states that she is concerned about her gums because she has noticed they are swollen and have started bleeding. What would be an appropriate response by the nurse?

Answer 74

Swollen and bleeding gums can be caused by the change in hormonal balance in your system
during pregnancy.

Gum margins are red and swollen and easily bleed with gingivitis. A changing hormonal balance may cause this condition to occur in pregnancy and puberty.

Question 75

The nurse is assessing a patient in the hospital who has received numerous antibiotics and notices that his tongue appears to be black and hairy. In response to his concern, what would the nurse say?

Answer 75

Black, hairy tongue is a fungal infection caused by all the antibiotics you have received.

A black, hairy tongue is not really hair but the elongation of filiform papillae and painless overgrowth of
mycelial threads of fungus infection on the tongue. It occurs after the use of antibiotics, which inhibit normal bacteria and allow a proliferation of fungus.

Question 76

The nurse is assessing a patient with a history of intravenous drug abuse. In assessing his mouth, the nurse notices a dark red confluent macule on the hard palate. This could be an early sign of:

Answer 76

Acquired immunodeficiency syndrome (AIDS).

Oral Kaposis sarcoma is a bruiselike, dark red or violet, confluent macule that usually occurs on the hard
palate. It may appear on the soft palate or gingival margin. Oral lesions may be among the earliest lesions to develop with AIDS.

Question 77

A mother brings her 4-month-old infant to the clinic with concerns regarding a small pad in the middle of the upper lip that has been there since 1 month of age. The infant has no health problems. On physical
examination, the nurse notices a 0.5-cm, fleshy, elevated area in the middle of the upper lip. No evidence of inflammation or drainage is observed. What would the nurse tell this mother?

Answer 77

This elevated area is a sucking tubercle caused from the friction of breastfeeding or bottle-feeding
and is normal.

A normal finding in infants is the sucking tubercle, a small pad in the middle of the upper lip from the friction of breastfeeding or bottle-feeding. This condition is not caused by irritation, teething, or excessive drooling, and evaluation by another health care provider is not warranted

Question 78

When examining the mouth of an older patient, the nurse recognizes which finding is due to the aging
process?

Answer 78

Tongue that looks smoother in appearance

In the aging adult, the tongue looks smoother because of papillary atrophy. The teeth are slightly yellowed and appear longer because of the recession of gingival margins.

Question 79

A mother is concerned because her 18-month-old toddler has 12 teeth. She is wondering if this is normal for a child of this age. The nurses best response would be:

Answer 79

This is a normal number of teeth for an 18 month old.

The guidelines for the number of teeth for children younger than 2 years old are as follows: the childs age in months minus the number 6 should be equal to the expected number of deciduous teeth. Normally, all 20 teeth are in by 2 years old. In this instance, the child is 18 months old, minus 6, equals 12 deciduous teeth expected.

Question 79

When examining the nares of a 45-year-old patient who has complaints of rhinorrhea, itching of the nose and eyes, and sneezing, the nurse notices the following: pale turbinates, swelling of the turbinates, and clear rhinorrhea. Which of these conditions is most likely the cause?

Answer 79

Allergic rhinitis

Rhinorrhea, itching of the nose and eyes, and sneezing are present with allergic rhinitis. On physical
examination, serous edema is noted, and the turbinates usually appear pale with a smooth, glistening surface.

Question 80

The nurse is performing an assessment. Which of these findings would cause the greatest concern?

Answer 80

Ulceration on the side of the tongue with rolled edges

Ulceration on the side or base of the tongue or under the tongue raises the suspicion of cancer and must be investigated. The risk of early metastasis is present because of rich lymphatic drainage. The vesicle may be an aphthous ulcer, which is painful but not dangerous.

Question 80

When assessing the tongue of an adult, the nurse knows that an abnormal finding would be:

Answer 80

Smooth glossy dorsal surface.

The dorsal surface of the tongue is normally roughened from papillae. A thin white coating may be present. The ventral surface may show veins. Smooth, glossy areas may indicate atrophic glossitis.

Question 81

A patient has been diagnosed with strep throat. The nurse is aware that without treatment, which
complication may occur?

Answer 81

Rheumatic fever

Untreated strep throat may lead to rheumatic fever. When performing a health history, the patient should be asked whether his or her sore throat has been documented as streptococcal.

Question 82

A patient comes into the clinic complaining of facial pain, fever, and malaise. On examination, the nurse notes swollen turbinates and purulent discharge from the nose. The patient also complains of a dull, throbbing pain in his cheeks and teeth on the right side and pain when the nurse palpates the areas. The nurse recognizes that this patient has:

Answer 82

Maxillary sinusitis.

Signs of maxillary sinusitis include facial pain after upper respiratory infection, red swollen nasal mucosa, swollen turbinates, and purulent discharge. The person also has fever, chills, and malaise. With maxillary sinusitis, dull throbbing pain occurs in the cheeks and teeth on the same side, and pain with palpation is present. With frontal sinusitis, pain is above the supraorbital ridge.

Question 82

During an oral examination of a 4-year-old Native-American child, the nurse notices that her uvula is
partially split. Which of these statements is accurate?

Answer 82

A bifid uvula may occur in some Native-American groups.

Bifid uvula, a condition in which the uvula is split either completely or partially, occurs in some Native- American groups.

Question 82

During a checkup, a 22-year-old woman tells the nurse that she uses an over-the-counter nasal spray
because of her allergies. She also states that it does not work as well as it used to when she first started using it. The best response by the nurse would be:

Answer 82

Using these nasal medications irritates the lining of the nose and may cause rebound swelling.

The misuse of over-the-counter nasal medications irritates the mucosa, causing rebound swelling, which is a common problem.

Question 83

During an assessment, a patient mentions that I just cant smell like I used to. I can barely smell the roses in my garden. Why is that? For which possible causes of changes in the sense of smell will the nurse assess?
Select all that apply.

Answer 83

• Cigarette smoking
• Chronic allergies
• Aging

The sense of smell diminishes with cigarette smoking, chronic allergies, and aging. Chronic alcohol use, a history of strep throat, and herpes simplex virus I are not associated with changes in the sense of smell.

Question 83

The nurse is teaching a health class to high-school boys. When discussing the topic of using smokeless tobacco (SLT), which of these statements are accurate? Select all that apply.

Answer 83

• Using SLT has been associated with a greater risk of oral cancer than smoking.
• Pain is rarely an early sign of oral cancer.
• Tooth decay is another risk of SLT because of the use of sugar as a sweetener.

One pinch of SLT in the mouth for 30 minutes delivers the equivalent of three cigarettes. Pain is rarely an early sign of oral cancer. Many brands of SLT are sweetened with sugars, which promotes tooth decay. SLT is not considered a healthy alternative to smoking, and the use of SLT has been associated with a greater risk of oral cancer than smoking.

Question 83

A woman who is in the second trimester of pregnancy mentions that she has had more nosebleeds than ever since she became pregnant. The nurse recognizes that this is a result of:

Answer 83

Increased vascularity in the upper respiratory tract as a result of the pregnancy.

Nasal stuffiness and epistaxis may occur during pregnancy as a result of increased vascularity in the upper respiratory tract.