Question 1

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

Accepted Answer

Options A, D, E, and F are all expected findings from an assessment of the ears of a healthy adult. The pinna should align with the outer canthus of the eye. Cone of light should be located in the 7 o'clock position in the left ear and the 5 o'clock position in the right ear.

Question 2

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

Accepted Answer

Option B is the correct technique for assessing the spinal accessory cranial nerve (XI). Option A is a test of the hypoglossal cranial nerve (XII). Option C is a test for cranial nerves IX (glossopharyngeal) and X (vagus). Option D assesses the range motion of the neck.

Question 3

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

Accepted Answer

Options A, B, D, and E are all expected findings from a mouth assessment of a healthy adult. Receding gums expose tooth neck and may indicate gingival disease. Brown spots may indicate caries. Dry and intact mucous membranes may indicate dehydration.

Question 4

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

Accepted Answer

Option C is the technique for palpating the supraclavicular nodes. Option A is incorrect. The patient should draw up (hunch) the shoulders forward rather than leaning back. The patient should be sitting, rather than lying down. The shoulders should be drawn up (hunched) forward, rather than raising the arms.

Question 5

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.)

Accepted Answer

Cranial nerve III (oculomotor), cranial nerve IV (trochlear), and cranial nerve VI (abducens) provide muscle movement for the eyes. Cranial nerve II (optic) provides vision. Cranial nerve V (trigeminal) provides movement for the jaw and sensation for cornea, conjunctive, eyelids, teeth, tongue, and mouth.

Question 6

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

Accepted Answer

Option D is the correct location for palpating the thyroid gland using the anterior approach. Option A is not the correct location for palpating the thyroid gland using the anterior approach. Option B is not the correct location for palpating the thyroid gland using the anterior approach. Option C is not the correct location for palpating the thyroid gland using the anterior approach.

Question 7

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

Accepted Answer

Seventy-five to eighty percent of individuals who develop oral cancer consume excessive amounts of alcohol. There is increased incidence after age 40 with peak incidence between ages 64 and 74. There is a 2:1 men-to-women incidence. A low fiber diet increases the risk for colon cancer, but not oral cancer.

Question 8

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

Accepted Answer

Option B, E, and F are expected findings from an assessment of the head of a healthy adult. Small red lesions with white flakes scattered on the scalp is an abnormal finding. The scalp should be intact without lesion or flakes. Depressions palpated on the right and left sides over the parietal bones is an abnormal finding. Perhaps this patient had skull tongs from cervical traction at one time. Head held flexed 15 degrees to the left is an abnormal finding. The head should be erect.

Question 9

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?

Accepted Answer

Option D is the location of the anterior cervical lymph nodes. Option A is the location of the preauricular lymph nodes. Option B is the location of the submental and submandibular lymph nodes. Option C is the location of the parotid lymph nodes.

Question 10

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.)

Accepted Answer

Options A, C, and D are all risk factors for cataracts. Having parents with cataracts is not a genetic or familial disorder. Being Asian or a man are not risk factors, but being an African-American or being a woman are risk factors.

Question 11

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?

Accepted Answer

Option B is the location of the submental lymph node. Option A is the location of the preauricular lymph nodes. Option C is the location of the occipital lymph nodes. Option D is the location of the parotid lymph nodes.

Question 12

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?

Accepted Answer

Option D may indicate oral cancer. Option A may be caused by vitamin B deficiencies. Option B is an expected finding on the tongue. Option C may be an indication of anemia.

Question 13

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

Accepted Answer

Options A, C, and G are expected findings from an assessment of the eyes of a healthy adult. Sclera should be white and moist. Newspaper held at 18 inches to see clearly is due to presbyopia due to the patient's age. Patient must hold paper further away to see clearly. The upper lid should cover the upper part of the iris. Sclera is visible in hyperthyroidism. A gray to white circle is arcus senilis, which is an abnormal finding in older adults.

Question 14

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?

Accepted Answer

Option B is a characteristic of enlarged lymph nodes associated with inflammation. Option A is not a characteristic of lymph nodes associated with inflammation. Option C is a characteristic of enlarged lymph nodes associated with a malignancy. Option D is not a characteristic of lymph nodes associated with inflammation.

Question 15

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?

Accepted Answer

The nurse found an abnormality that needs referral for follow-up. Option B is not an appropriate action because the nurse found an abnormality. Repeating the examination will yield the same abnormal finding.

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