Deck 10: Head, Eyes, Ears, Nose, and Throat

Question 1

Which patient in the eye clinic should the nurse assess first?

A) The patient who reports a gradual clouding of vision
B) The patient who complains of sudden loss of vision
C) The patient who complains of double vision
D) The patient who complains of poor night vision

Answer 1

The patient who complains of sudden loss of vision

Question 2

Which finding on assessment of a patient's eyes should the nurse document as abnormal?

A) An Asian American patient with an upward slant to the palpebral fissure
B) A Caucasian American patient whose sclerae are visible between the upper and lower lids and the iris
C) An African-American patient who has off-white sclerae with tiny black dots of pigmentation near the limbus
D) An American Indian patient whose pupillary diameters are 5 mm bilaterally

Answer 2

A Caucasian American patient whose sclerae are visible between the upper and lower lids and the iris

Question 3

A patient is admitted with edema of the occipital lobe following a head injury. The nurse correlates which finding with damage to this area?

A) Ipsilateral ptosis
B) Impaired vision
C) Pupillary constriction
D) Increased intraocular pressure

Answer 3

Impaired vision

Question 4

While taking a history, the nurse observes that the patient's facial cranial nerves (CN VII) are intact based on which behaviors of the patient?

A) The patient's eyes move to the left, right, up, down, and obliquely during conversation.
B) The patient moistens the lips with the tongue.
C) The sides of the mouth are symmetric when the patient smiles.
D) The patient's eyelids blink periodically.

Question 5

A patient reports having migraine headaches on one side of the head that often start with an aura and last 1 to 3 days. As a part of the symptom analysis, the patient reports which associated symptoms of migraine headaches?

A) Nausea, vomiting, or visual disturbances
B) Nasal stuffiness or discharge
C) Ringing in the ears or dizziness
D) Red, watery eyes or drooping eyelids

Question 6

What instructions does the nurse give the patient before using the Snellen visual acuity chart?

A) "Remove your eyeglasses before attempting to read the lowest line."
B) "Stand 10 feet from the chart and read the first line aloud."
C) "Hold a white card over one eye and read the smallest possible line."
D) "Squint if necessary to improve the ability to read the largest letters."

Question 7

During symptom analysis, the nurse helps the patient distinguish between dizziness and vertigo. Which description by the patient indicates dizziness?

A) "I felt faint, like I was going to pass out."
B) "It felt like I was on a merry-go-round."
C) "The room seemed to be spinning around."
D) "My body felt like it was revolving and could not stop."

Question 8

The nurse is taking a health history on a patient who reports frequent headaches with pain in the front of the head, but sometimes felt in the back of the head. Which statement by the patient is most indicative of tension headaches?

A) "I usually have nausea and vomiting with my headaches."
B) "My whole head is constantly throbbing."
C) "It feels like my head is in a vice."
D) "The pain is on the left side over my eye, forehead, and cheek."

Question 9

A patient complains of nasal drainage and sinus headache. The nurse suspects a nasal infection and anticipates observing which finding during examination?

A) Foul-smelling drainage
B) Purulent green-yellow drainage
C) Bloody drainage
D) Watery drainage

Question 10

Which cranial nerve is assessed by using the Snellen visual acuity chart?

A) Optic cranial nerve (CN II)
B) Oculomotor cranial nerve (CN III)
C) Abducens cranial nerve (CN IV)
D) Trochlear cranial nerve (CN VI)

Question 11

To assess jaw movement of an adult patient, the nurse uses which technique?

A) Asking the patient to open the mouth and then passively moving the patient's open jaw from side to side
B) Placing two fingers in front of each ear and asking the patient to slowly open and close the mouth
C) Asking the patient to open the mouth and to resist the nurse's attempt to close the mouth
D) Using the pads of all fingers to feel along the mandible for tenderness and nodules

Question 12

The nurse palpates the patient's jaw movement, placing two fingers in front of each ear and asking the patient to slowly open and close the mouth. What additional request does the nurse ask the patient to do to assess the jaw?

A) Clinch the jaws together as tightly as possible.
B) Move the lower jaw from side to side.
C) Open the mouth as wide as possible, like a yawn.
D) Move the lower jaw forward and backward several times.

Question 13

A patient complains of itching, swelling, and drainage from the eyes with a postnasal drip and sneezing. What type of nasal drainage does the nurse anticipate seeing during inspection of this patient's nares?

A) Clear
B) Malodorous
C) Yellow
D) Green

Question 14

A patient reports a history of snorting cocaine and is concerned about his bloody nasal drainage. What does the nurse expect to see on inspection of his nose?

A) Deviated septum
B) Pale turbinates
C) Perforated nasal septum
D) Localized erythema and edema

Question 15

A patient is in a sitting position as the nurse palpates the temporal arteries and feels smooth, bilateral pulsations. What is the appropriate action for the nurse at this time?

A) Auscultate the temporal arteries for bruits.
B) Palpate the arteries with the patient in supine position.
C) Document this as an expected finding.
D) Measure the patient's blood pressure.

Question 16

A patient complains of right ear pain. What findings does the nurse anticipate on inspecting the patient's ears?

A) Redness and edema of the pinna of the right ear
B) Report of pain when the nurse manipulates the right ear
C) Bulging and red tympanic membrane in the right ear
D) Increased cerumen in the right ear canal

Question 17

During the history, a patient reports watery nasal drainage from allergies. Based on this information, what does the nurse expect to find on inspection of the nares?

A) Enlarged and pale turbinates
B) Polyps within the nares
C) High vascularity of the turbinates
D) Dry and dull turbinates

Question 18

A nurse shines a light toward the bridge of the patient's nose and notices that the light reflection in the right cornea is at the 9 o'clock position and in the left cornea at the 9 o'clock position. What is the interpretation of this finding?

A) The extraocular muscles of both eyes are intact.
B) The cornea of each eye is transparent.
C) The sclera of each eye is clear.
D) The consensual reaction of both eyes is intact.

Question 19

The nurse is taking a health history on a patient who reports frequent stabbing headaches occurring once a day lasting about an hour. Which statement by the patient is most indicative of cluster headaches?

A) "I usually have nausea and vomiting with my headaches."
B) "My whole head is constantly throbbing."
C) "It feels like my head is in a vice."
D) "The pain is on the left side over my eye, forehead, and cheek."

Question 20

During symptom analysis, the nurse helps the patient distinguish between dizziness and vertigo. Which description by the patient indicates vertigo?

A) "I felt faint, like I was going to pass out."
B) "I just could not keep my balance when I sat up."
C) "It seemed that the room was spinning around."
D) "I was afraid that I was going to lose consciousness."

Question 21

How does a nurse assess movements of the eyes?

A) By assessing peripheral vision
B) By noting the symmetry of the corneal light reflex
C) By assessing the cardinal fields of gaze
D) By performing the cover-uncover test

Question 22

A nurse reads in the history that a patient has a new onset of acute otitis media. Based on this information, how does the nurse expect this patient's tympanic membrane to appear?

A) Dull
B) Shiny
C) Red
D) Blue to deep red

Question 23

After seeing the red reflex and retinal vessels through the ophthalmoscope, how does the nurse locate the optic disc?

A) By rotating the diopter to the block (positive) numbers until the optic disc comes into focus
B) By following the retinal vessels inward toward the nose until optic disc is seen
C) By using the green beam light while looking outward toward the ear until the disc is seen
D) By locating the macula and then looking temporally (toward the ear) until the disc is seen

Question 24

An adult patient comes to the clinic complaining of right ear pain. What technique does the nurse use to inspect this patient's auditory canal?

A) Position the otoscope speculum 1.0 to 1.5 cm (about 0.5 inches) into the ear canal.
B) Remove cerumen from each canal before inserting otoscope.
C) Choose the smallest otoscope speculum that will fit the patient's ear comfortably.
D) Pull the pinna slightly downward and backward before inserting the otoscope speculum.

Question 25

What changes in using the ophthalmoscope should the nurse need to make when inspecting the eye of a patient who is nearsighted?

A) Holding the ophthalmoscope in the right hand when inspecting the patient's right eye
B) Using the grid light of the lens aperture to visualize the internal structures of the eye
C) Rotating the diopter to the red (minus) numbers
D) Asking the patient to look directly into the ophthalmoscope light

Question 26

During an eye assessment, a nurse asks the patient to cover one eye with a card as the nurse covers his or her eye directly opposite the patient's covered eye. The nurse moves an object into the field of vision and asks the patient to tell when the object can be seen. This assessment technique collects what data about the patient's eyes?

A) Symmetry of extraocular muscles
B) Visual acuity in the uncovered eye
C) Peripheral vision of the uncovered eye
D) Consensual reaction of the uncovered eye

Question 27

A nurse examines a patient's auditory canal and tympanic membrane with an otoscope and observes which finding as normal?

A) Clear fluid lining the auditory canal
B) A firm tympanic membrane without fluctuation with puffs of air
C) A small hole within the cone of light
D) A shiny, translucent tympanic membrane

Question 28

During an eye examination of an Asian patient, a nurse notices an involuntary rhythmical, horizontal movement of the patient's eyes. How does a nurse document this finding?

A) An expected racial variation
B) Nystagmus
C) Exophthalmus
D) Myopia

Question 29

Which finding warrants a referral for additional evaluation?

A) Earlobes hanging freely from the base of the pinna
B) Ears having painless nodules less than 1 cm in diameter at the helix
C) Ears measuring 8 cm in length
D) Pinna is 20 degrees lower than the outer canthus of the eye

Question 30

On inspection of the external eye structures of an African-American patient, the nurse notices the sclerae are not white, but appear a darker shade with tiny black dots of pigmentation near the limbus. How does the nurse document this finding?

A) As an indication of a type of anemia
B) As a hordeolum or sty
C) As jaundice
D) As an expected racial variation

Question 31

How does a nurse recognize normal accommodation?

A) The patient has peripheral vision of 90 degrees left and right.
B) The patient's eyes move up and down, side to side, and obliquely.
C) The right pupil constricts when a light is shown in the left pupil.
D) The patient's pupils dilate when looking toward a distant object.

Question 32

A nurse is assessing a patient who was hit at the base of the skull with a blunt instrument causing a skull fracture. What assessment finding does this nurse anticipate during the inspection?

A) Tinnitus, vertigo, and dizziness
B) Clear drainage from the ear and nose
C) Loss of hearing and smell
D) Purulent drainage from the ear and bloody drainage from the nose

Question 33

During the history, a patient reports blurred vision, seeing double at times, and a glare from headlights from oncoming cars at night. Based on this information, what finding does the nurse expect to find on assessment of this patient's eyes?

A) Anterior chamber depth is shallow.
B) Red reflex is absent.
C) Extraocular muscle movement is asymmetric.
D) Retinal arteries are wider than retinal veins.

Question 34

A nurse uses which technique to assess a patient's peripheral vision?

A) The nurse asks the patient to keep the head still and by moving the eyes only, follow the nurse's finger as it moves side to side, up and down, and obliquely.
B) The nurse covers one of the patient's eyes with a card and observes the uncovered eye for movement, then removes the card and observes the just uncovered eye for movement.
C) With the patient and nurse facing each other and a card covering their corresponding eyes, the nurse moves an object into the visual field and the patient reports when the object is seen.
D) The nurse shines a light on both corneas at the same time and notes the location of the reflection in each eye.

Question 35

A nurse shines a light in the right pupil to test constriction and notices that the left pupil constricts as well. Based on these data, the nurse should take what action?

A) Document this finding as an abnormal finding.
B) Assess the patient for accommodation.
C) Document this finding as a consensual reaction.
D) Assess the patient's corneal light reflex.

Question 36

A nurse observes a student using the whisper test to screen a patient with hearing loss. Which behavior by the student requires a corrective comment from the nurse?

A) Instructing the patient to cover the ear not being tested
B) Standing beside the patient on the side of the ear being tested
C) Shielding the mouth to prevent the patient from reading lips
D) Whispering one or two syllable words and ask the patient to repeat what is heard

Question 37

When using an ophthalmoscope to examine the internal eye, how does the nurse distinguish the retinal arteries from the retinal veins?

A) The arteries are narrower than veins.
B) The arteries are a darker red than veins.
C) The arteries have no light reflex and the veins have a narrow band of light in the center.
D) The arteries have prominent pulsations and veins have no pulsations.

Question 38

When inspecting a patient's eyes, the nurse assesses the presence of cranial nerve III (oculomotor nerve) by observing the eyelids open and close bilaterally. What other technique does a nurse use to test the function of this cranial nerve?

A) Pupillary constriction to light
B) Visual acuity
C) Peripheral vision
D) Presence of the red reflex

Question 39

How does a nurse recognize a patient's mydriasis?

A) The lens of each of the patient's eyes is opaque.
B) There is involuntary rhythmical, horizontal movement of the patient's eyes.
C) There is a white opaque ring encircling the patient's limbus.
D) The patient's pupils are 7 mm and do not constrict.

Question 40

A nurse shines a light toward the bridge of the patient's nose and notices that the light reflection in the right cornea is at the 2 o'clock position and in the left cornea at the 10 o'clock position. Based on these data, the nurse should take what action?

A) Document these findings as normal.
B) Perform the cover-uncover test.
C) Perform the confrontation test.
D) Document these findings as abnormal.

Question 41

A patient complains of a lesion in his nose. Which technique does a nurse use to inspect the nasal mucosa?

A) Inserts a nasal speculum horizontally into the patient's affected nares
B) Inserts a nasal speculum obliquely into the patient's affected nares
C) Uses a light source from the ophthalmoscope
D) Inserts a nasal speculum vertically into the patient's affected nares

Question 42

Wearing gloves, the nurse grasps the patient's tongue with a gauze pad and palpates a small, firm nodule on the left side of the tongue. Based upon this finding, what is the nurse's appropriate response?

A) Document that the patient's tongue is normal on palpation.
B) Inspect the left submandibular salivary glands for redness.
C) Ask the patient to move the tongue in all directions.
D) Palpate cervical and submental lymph nodes for enlargement.

Question 43

How does the nurse perform a Rinne test of hearing function?

A) Whispers several words to the patient and requests that the patient repeat the words heard
B) Places a vibrating tuning fork in the middle of the head and asks the patient if the sound is heard the same in both ears or if it is louder in one ear than the other
C) Places a set of headphones over both ears, plays several tones, and asks the patient to identify the sounds
D) Places a vibrating tuning fork on the mastoid process until the patient no longer hears it, and then moves it in front of the ear until the patient no longer hears it

Question 44

Which finding indicates that this patient has a sensorineural hearing loss?

A) The patient hears sound by air conduction longer than by bone conduction.
B) The patient hears sound from a vibrating tuning fork in the affected ear only.
C) The patient hears normal conversation at 40 dB and a whisper at 20 dB.
D) The patient hears the rubbing of fingers together from a distance of 4 inches from each ear.

Question 45

In assessing a patient with head injury, the nurse should be most concerned with which finding?

A) Pain on palpation of the scalp
B) Unilateral clear, watery nasal discharge
C) A scalp laceration at the sight of injury
D) Complaints of dizziness

Question 46

After assessment of the nose and paranasal sinuses, which finding requires further investigation by the nurse?

A) Nasal septum off the midline
B) Nose in the midline of the face
C) Middle turbinates deep pink in color
D) Noiseless exchange of air from each naris

Question 47

When inspecting a patient's posterior wall of the pharynx and tonsils, a nurse documents which finding as abnormal?

A) Both tonsils have a smooth surface.
B) Left and right tonsils meet at the midline.
C) Left and right tonsils extend beyond the posterior pillars.
D) Both tonsils have a glistening appearance.

Question 48

What instruction does a nurse give a patient to facilitate palpation of the right lobe of the thyroid gland?

A) "Swallow for me one time."
B) "Flex your head down and to the left."
C) "Rotate your head to the right for me."
D) "Hold your breath for a few seconds."

Question 49

During the Rinne test, a nurse determines that the patient hears the tuning fork held on the mastoid process for 15 seconds and hears the tuning fork held in front of the ear for 30 seconds. The same results are found in both ears. Based on this finding, what is the most appropriate response of the nurse?

A) Repeat the test again using a 2000 Hz tuning fork.
B) Tell the patient that this represents an expected finding.
C) Refer the patient for additional testing to detect hearing abnormality.
D) Perform a Weber test to confirm the findings of the Rinne test.

Question 50

How does the nurse perform a Weber test to assess hearing function?

A) Whispers three to four words into the patient's ear and asks him to repeat the words heard
B) Places a vibrating tuning fork in the middle of the head and asks the patient if the sound is heard the same in both ears
C) Places a set of headphones over both ears, plays several tones, and asks the patient to identify the sounds
D) Places a vibrating tuning fork on the mastoid process and asks the patient to signal when he can no longer hear the sound

Question 51

A nurse assesses neck range of movement of several adults. Which patient has an expected range of motion of the neck?

A) Patient A is unable to resist the nurse's attempt to move the head upright.
B) Patient B bends the head to the right and left (ear to shoulder) 15 degrees.
C) Patient C flexes chin toward the chest 45 degrees.
D) Patient D hyperextends the head 30 degrees from midline.

Question 52

During a Weber test, a patient with right ear hearing loss reports hearing sound louder in the right ear than the left ear. What results should the nurse expect to find from this patient during a Rinne test?

A) Air conduction will be twice as long as bone conduction (2:1 ratio).
B) Air conduction will be 1.5 times as long as bone conduction (1.5:1 ratio).
C) Bone conduction will be longer than air conduction.
D) Bone conduction will be equal to air conduction.

Question 53

A patient is being seen in the clinic for suspected nasal obstruction from a foreign body. The nurse recognizes which finding as most consistent with this diagnosis?

A) Unilateral foul-smelling drainage
B) Bilateral purulent green-yellow discharge
C) Bilateral bloody discharge
D) Unilateral watery discharge

Question 54

What technique does a nurse use when palpating the right lobe of a patient's thyroid gland using the posterior approach?

A) Pushes the cricoid process to the left with the right thumb and feels the right lobe with the left hand
B) Uses the left hand to push the sternocleidomastoid muscle to the right and feels the lobe with the right hand
C) Pushes the trachea to the right with the left hand and feels the right lobe with the right hand
D) Places the fingers on either side of the trachea above the cricoid cartilage and feels the right lobe

Question 55

A nurse assessing the hearing of a patient with presbycusis expects which finding on a test for hearing?

A) Bone conduction will be longer than air conduction on the Rinne test (BC > AC).
B) Air conduction will be longer than bone conduction on the Rinne test (AC > BC).
C) Sound lateralizes to the affected ear on the Weber test.
D) Sound lateralizes to both ears equally on the Weber test.

Question 56

What technique does a nurse use when palpating the right lobe of a patient's thyroid gland using the anterior approach?

A) Pushes the cricoid process to the left with the right thumb
B) Displaces the trachea to the right with the left thumb
C) Manipulates the thyroid between the thumb and index finger
D) Moves the sternocleidomastoid muscle to the right with the left thumb

Question 57

A nurse suspects the patient has an infection of the maxillary sinuses. How can this suspicion be confirmed?

A) Using a flashlight to illuminate the floor of the mouth
B) Pressing gently with both thumbs into the eyebrow ridges
C) Applying firm pressure with the thumbs below the cheekbones
D) Standing behind the patient and asking him or her to slowly rotate the head

Question 58

A patient comes to the clinic for evaluation after a sinus infection. To evaluate the therapy, the nurse uses transillumination to assess the sinuses and notes which finding indicating recovery from a frontal sinus infection?

A) The soft palate illuminates brightly when the light source is placed against the lateral nose.
B) No illumination is noted when the light source is placed firmly against the lateral nose.
C) A bright glow illuminates the hard palate when the light source is placed against each temporal bone.
D) A reddish light is noted above the eyebrows when the light is placed against each supraorbital rim.

Question 59

When inspecting a patient's nasal mucous membrane, which finding does the nurse expect to see?

A) Deep pink turbinates
B) Red, edematous mucous membranes
C) Septum that angles to the left
D) Clear exudate

Question 60

While taking a history, the nurse notices that the patient's family member repeats most of the questions to the patient in a loud voice. Based on this information, what finding does the nurse anticipate when assessing this patient's hearing using an audioscope?

A) 5 dB hearing loss at all frequencies
B) 10 dB hearing loss at all frequencies
C) 20 dB hearing loss at all frequencies
D) 40 dB hearing loss at all frequencies

Question 61

What findings does the nurse expect when assessing the ears of a healthy adult? (Select all that apply.)

A) Cerumen noted in the outer ear canal
B) Pinna located below the external corner of the eye
C) Cone of light located in the 5 o'clock position in the left ear
D) Ratio of air conduction to bone conduction 2:1
E) Tympanic membrane pearly gray
F) Whispered words repeated accurately

Question 62

How does the nurse test the function of the patient's spinal accessory nerve (CN XI)?

A) Ask the patient to stick out the tongue and move it side to side.
B) Ask the patient to shrug the shoulders against the resistance of the nurse's hands.
C) Ask the patient to open the mouth and observe the uvula rise when he says "ah."
D) Ask the patient to move the chin to the chest and then up toward the ceiling.

Question 63

Which findings does the nurse expect when assessing the mouth of a healthy adult? (Select all that apply.)

A) Lips appear pink, smooth, moist, and symmetric.
B) Teeth are white, yellow, or gray, with smooth edges.
C) Exposed tooth neck and brown spots between teeth
D) Slight roughness on the dorsum of the tongue
E) Hard palate appears smooth, pale, and immovable.
F) Mucous membranes are dry and intact.

Question 64

What instructions does the nurse give the patient before palpating the right supraclavicular lymph nodes?

A) "Lean your head backward and toward the right as far as comfortably possible."
B) "Lie supine and turn your head away from the right side."
C) "Draw up your shoulders forward, and flex your chin toward the right side."
D) "Sit up, raise both arms over your head, and flex your chin away from the right side."

Question 65

During an eye assessment, the nurse asks the patient to keep the head stationary and by moving the eyes only follow the nurse's finger as it moves side to side, up and down, and obliquely. This assessment technique collects what data about which cranial nerves? (Select all that apply.)

A) Cranial nerve II (optic)
B) Cranial nerve III (oculomotor)
C) Cranial nerve IV (trochlear)
D) Cranial nerve VI (abducens)
E) Cranial nerve V (trigeminal)

Question 66

When palpating the right lobe of the patient's thyroid gland using the anterior approach, the nurse feels the tissue between which two structures?

A) Sternocleidomastoid and the trapezius muscles
B) Trapezius muscle and the trachea
C) Cricoid process and the trachea
D) Sternocleidomastoid muscle and the trachea

Question 67

A nurse's presentation to patients on risk factors for oral cancer includes which fact?

A) The peak incidence of oral cancer is before 40 years of age.
B) Women have a higher risk than men.
C) Excessive alcohol consumption is a risk factor.
D) Eating a low fiber diet is a risk factor.

Question 68

During an examination of the head and neck of a healthy adult, the nurse expects which findings? (Select all that apply.)

A) Small red lesions with white flakes scattered on the scalp.
B) The head and facial bones are proportional for the size of the body.
C) Depressions palpated on the right and left sides over the parietal bones.
D) Head held flexed 15 degrees to the left.
E) Face and jaw are symmetric and proportional.
F) Temporomandibular joint moves smoothly.

Question 69

A patient complains of sore throat, pain with swallowing, fever, and chills. The nurse suspects tonsillitis and plans to palpate the anterior cervical lymph nodes. Where does the nurse place his fingers to palpate these nodes?

A) In front of the ears
B) Under the mandibles
C) Along the angle of the mandibles
D) Adjacent to the sternocleidomastoid muscles

Question 70

Nurses inquire about lifestyle behaviors in those patients with specific risk factors for cataracts. Which characteristics are associated with risk factors for cataracts? (Select all that apply.)

A) Smoking more than 20 cigarettes a day
B) Having parents with cataracts
C) Chronic consumption of alcohol
D) Having a chronic disease, such as diabetes mellitus
E) Being Asian
F) Being a man

Question 71

A teenager comes to the clinic complaining about the whiteheads and blackhead on his face interfering with his social life. During the examination the nurse palpates an enlarged submental lymph node. Where is this lymph node located?

A) In front of the ear
B) Under the mandible
C) At the base of the skull
D) Along the angle of the jaw

Question 72

During the history, a 65-year-old male patient reports smoking two packs of cigarettes a day for more than 40 years. With this knowledge, what does the nurse expect during the examination of this patient's mouth?

A) Cracks and erythema in the corners of the mouth
B) Slightly rough papillae on the dorsal surface of the tongue
C) Smooth or beefy, red-colored, edematous tongue
D) Painless, nonhealing mouth ulcers

Question 73

A nurse is assessing the eyes of a healthy 72-year-old adult. What findings does the nurse expect? (Select all that apply.)

A) Bulbar conjunctiva pink and clear, with small red vessels noted
B) Sclera yellow and moist, cornea transparent
C) Extraocular movement tracking parallel with peripheral vision noted
D) Newspaper held at 18 inches to see clearly
E) Sclera visible between upper lid and iris
F) Gray to white circle noted where the sclera merges with the cornea
G) Light reflects on the cornea at 12 o'clock in each eye

Question 74

A patient has had an infected facial wound for more than 3 months. How does the nurse expect the patient's enlarged lymph nodes to feel?

A) Soft, edematous, and tender
B) Round, tender, and movable
C) Hard, nontender, and nonmobile
D) Irregularly shaped, tender, and firm

Question 75

On palpation the nurse determines that the patient's left thyroid lobe is larger than the right thyroid lobe. What is the nurse's most appropriate action at this time?

A) Refer the patient to the health care provider for further evaluation.
B) Document that the patient's thyroid is normal on palpation.
C) Palpate the left thyroid lobe again using very firm pressure.
D) Ask the patient to flex the chin toward his chest and palpate again.