Question 1

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

Accepted Answer

Sudden vision loss may indicate a detached retina and requires immediate referral. A gradual clouding of vision is a symptom of cataracts that develop slowly and do not require immediate assessment. Double vision is a symptom of cataracts that develop slowly and do not require immediate assessment. Poor night vision is a symptom of cataracts that develop slowly and do not require immediate assessment.

Question 2

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

Accepted Answer

A Caucasian American patient whose sclerae are visible between the upper and lower lids and the iris has eyeball protrusion beyond the supraorbital ridge, which indicates exophthalmos caused by hyperthyroidism. An Asian American patient with an upward slant to the palpebral fissure has an expected racial variation. An African-American patient who has off-white sclerae with tiny black dots of pigmentation near the limbus has an expected racial variation. An American Indian whose pupils are 5 mm bilaterally is an expected finding.

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?

Accepted Answer

The occipital lobe contains the visual context. Ipsilateral ptosis (drooping of the eye lid) is controlled by the oculomotor cranial nerve (CN III) that is located in the midbrain. The nurse must correlate anatomy with function and assessment. Pupillary constriction is controlled by the oculomotor cranial nerve (CN III) that is located in the midbrain. This abnormality is associated with glaucoma rather than injury to the occipital lobe.

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?

Accepted Answer

Option C represents facial symmetry, which is controlled by the facial cranial nerve (CN VII). Option A represents movement of the extraocular muscles, which are controlled by the oculomotor, trochlear, and abducens cranial nerves (CN III, IV, and VI, respectively). Option B represents movement of the tongue, which is controlled by the hypoglossal cranial nerve (CN XII). Option D represents function of the oculomotor cranial nerve (CN III).

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?

Accepted Answer

Nausea, vomiting, or visual disturbances are symptoms associated with migraine headaches. Nasal stuffiness or discharge is a symptom associated with cluster headaches rather than migraine headaches. Ringing in the ears or dizziness is a symptom not associated with migraine headaches. Red, watery eyes or drooping eyelids are symptoms associated with cluster headaches rather than migraine headaches.

Question 6

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

Accepted Answer

Option C is the appropriate technique for using the Snellen chart. Patients should wear their glasses when visual acuity is tested. The patient should stand 20 feet from the Snellen chart. The patient should not squint to see the chart.

Question 7

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

Accepted Answer

Option A is a description of lightheadedness, a form of dizziness. Option B is consistent with objective vertigo because it includes a sensation of motion. Option C is consistent with objective vertigo because it includes a sensation of motion. Option D is consistent with subjective vertigo because it includes a sensation of one's body rotating in space.

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?

Accepted Answer

Option C is descriptive of tension headaches, which is consistent with the rest of the data reported by the patient. Option A is descriptive of migraines rather than tension headaches. Option B is descriptive of migraines rather than tension headaches. Option D is consistent with cluster headaches rather than tension headaches.

Question 9

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

Accepted Answer

Purulent green-yellow drainage is consistent with a nasal or sinus infection. Foul-smelling drainage is consistent with a foreign object in the nose. Bloody drainage is consistent with trauma to the nose. Watery drainage is consistent with a nasal allergy.

Question 10

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

Accepted Answer

The optic cranial nerve (CN II) provides vision tested by the Snellen visual acuity chart. CN III controls pupillary constriction, eyelid movement, and eyeball movement. CN IV controls eyeball movement. CN VI controls eyeball movement.

Question 11

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

Accepted Answer

Option B is the correct technique for palpating the jaw. The patient's jaw movement should be active, not passive. Option C assesses strength of the jaw, which is not typically evaluated. Palpating under the middle of the mandible may reveal the submental lymph node.

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?

Accepted Answer

Option B is the technique to complete assessment of the motion of the jaw. Option A is not an assessment technique for the jaw. Option C was completed when the nurse asked the patient to open and close the mouth. Option D is not an assessment technique for the jaw.

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?

Accepted Answer

The patient has allergic rhinitis, which produces clear drainage. Malodorous drainage is associated with bacterial infection, which is not consistent with the history given by this patient. Yellow drainage is associated with bacterial infection, which is not consistent with the history given by this patient. Green drainage is associated with bacterial infection, which is not consistent with the history given by this patient.

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?

Accepted Answer

Perforated nasal septum develops from cocaine use. Deviated septum may be from birth or trauma to the nose, but not from cocaine use. Pale turbinates are an indication of allergies. Localized erythema and edema are nonspecific and indicate inflammation somewhere in the nose.

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?

Accepted Answer

Option C is consistent with expected assessment. Option A is not necessary for this patient at this time. Option B is not necessary for this patient at this time. Option D will be done as a part of the assessment, but does not relate to the expected palpation of this patient's temporal arteries.

Question 16

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

Accepted Answer

Bulging and red tympanic membrane in the right ear is consistent with internal ear pain that may be associated with otitis media. Redness and edema of the pinna of the right ear is consistent with external ear pain that may be associated with otitis externa or swimmer's ear. Report of pain when the nurse manipulates the right ear is consistent with external ear pain that may be associated with otitis externa or swimmer's ear. Increased cerumen in the right ear canal is not consistent with internal ear pain.

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?

Accepted Answer

Enlarged and pale turbinates are expected findings for allergic rhinitis. Polyps within the nares is not an expected finding. High vascularity of the turbinates is not an expected finding. Dry and dull turbinates is not an expected finding.

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?

Accepted Answer

The reflection of the light in both eyes in the same location indicates muscles holding the eyes are symmetric. The reflection of the light in both eyes in the same location indicates muscles holding the eyes are symmetric. The reflection of the light in both eyes in the same location indicates muscles holding the eyes are symmetric. Consensual reaction involves constriction of pupils.

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?

Accepted Answer

The description mentioned in option D is consistent with cluster headaches. Option A is descriptive of migraines rather than cluster headaches. Option B is descriptive of migraines rather than cluster headaches. Option C is descriptive of tension rather than cluster headaches.

Question 20

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

Accepted Answer

Option C is consistent with vertigo because it includes a sensation of motion. Option A is a description of lightheadedness, a form of dizziness. Option B is a description of disequilibrium, a form of dizziness. Option D is a description of syncope, a form of dizziness.

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