Chapter 14 15 16 PDF

Chapter 14: Eyes
Chapter 14: Eyes

Jarvis: Physical Examination & Health Assessment, 7th Edition
MULTIPLE CHOICE
1. When examining the eye, the nurse notices that the patients eyelid margins
approximate completely. The nurse recognizes that this assessment finding:

a. Is expected.
b. May indicate a problem with extraocular muscles.
c. May result in problems with tearing.
d. Indicates increased intraocular pressure.

ANS: A
The palpebral fissure is the elliptical open space between the eyelids, and, when
closed, the lid margins approximate completely, which is a normal finding.
DIF: Cognitive Level: Understanding (Comprehension) REF: p. 281
MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation
2. During ocular examinations, the nurse keeps in mind that movement of the
extraocular muscles is:

a. Decreased in the older adult.
b. Impaired in a patient with cataracts.
c. Stimulated by cranial nerves (CNs) I and II.
d. Stimulated by CNs III, IV, and VI.

ANS: D
Movement of the extraocular muscles is stimulated by three CNs: III, IV, and VI.
DIF: Cognitive Level: Remembering (Knowledge) REF: p. 283
3. The nurse is performing an external eye examination. Which statement regarding
the outer layer of the eye is true?

a. The outer layer of the eye is very sensitive to touch.
b. The outer layer of the eye is darkly pigmented to prevent light from reflecting
internally.
c. The trigeminal nerve (CN V) and the trochlear nerve (CN IV) are stimulated when
the outer surface of the eye is stimulated.

d. The visual receptive layer of the eye in which light waves are changed into nerve
impulses is located in the outer layer of the eye.

ANS: A
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.

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

a. Causes pupillary constriction.
b. Adjusts the eye for near vision.
c. Elevates the eyelid and dilates the pupil.
d. Causes contraction of the ciliary body.

ANS: C
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.
5. The nurse is reviewing causes of increased intraocular pressure. Which of these
factors determines intraocular pressure?

a. Thickness or bulging of the lens
b. Posterior chamber as it accommodates increased fluid
c. Contraction of the ciliary body in response to the aqueous within the eye
d. Amount of aqueous produced and resistance to its outflow at the angle of the
anterior chamber
ANS: D
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. The
other responses are incorrect.
6. The nurse is conducting a visual examination. Which of these statements regarding
visual pathways and visual fields is true?

a. The right side of the brain interprets the vision for the right eye.
b. The image formed on the retina is upside down and reversed from its actual
appearance in the outside world.

c. Light rays are refracted through the transparent media of the eye before striking
the pupil.
d. Light impulses are conducted through the optic nerve to the temporal lobes of the
brain.
ANS: B
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.

7. The nurse is testing a patients visual accommodation, which refers to which
action?
a. Pupillary constriction when looking at a near object
b. Pupillary dilation when looking at a far object
c. Changes in peripheral vision in response to light
d. Involuntary blinking in the presence of bright light

ANS: A
The muscle fibers of the iris contract the pupil in bright light and accommodate for
near vision, which also results in pupil constriction. The other responses are not
correct.
8. A patient has a normal pupillary light reflex. The nurse recognizes that this reflex
indicates that:
a. The eyes converge to focus on the light.
b. Light is reflected at the same spot in both eyes.
c. The eye focuses the image in the center of the pupil.
d. Constriction of both pupils occurs in response to bright light.
ANS: D
The pupillary light reflex is the normal constriction of the pupils when bright light
shines on the retina. The other responses are not correct.
9. A mother asks when her newborn infants eyesight will be developed. The nurse
should reply:
a.
Vision
is not totally developed until 2 years of age.
b.
Infants
develop the ability to focus on an object at approximately 8 months of
age.
c.
By
d.
Most
approximately 3 months of age, infants develop more coordinated eye

movements and can fixate on an object.
infants have uncoordinated eye movements for the first year of life.
ANS: C
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.
DIF: Cognitive Level: Applying (Application) REF: p. 302
MSC: Client Needs: Health Promotion and Maintenance
10. The nurse is reviewing in age-related changes in the eye for a class. Which of these
physiologic changes is responsible for presbyopia?
a. Degeneration of the cornea
b. Loss of lens elasticity
c. Decreased adaptation to darkness
d. Decreased distance vision abilities

ANS: B
The lens loses elasticity and decreases its ability to change shape to accommodate for
near vision. This condition is called presbyopia.
11. Which of these assessment findings would the nurse expect to see when examining
the eyes of a black patient?

a. Increased night vision
b. Dark retinal background
c. Increased photosensitivity
d. Narrowed palpebral fissures

ANS: B
An ethnically based variability in the color of the iris and in retinal pigmentation
exists, with darker irides having darker retinas behind them.
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
12. A 52-year-old patient describes the presence of occasional floaters or spots
moving in front of his eyes. The nurse should:

a. Examine the retina to determine the number of floaters.
b. Presume the patient has glaucoma and refer him for further testing.
c. Consider these to be abnormal findings, and refer him to an ophthalmologist.
d. Know that floaters are usually insignificant and are caused by condensed vitreous
fibers.
ANS: D
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.
DIF: Cognitive Level: Analyzing (Analysis) REF: p. 287
13. The nurse is preparing to assess the visual acuity of a 16-year-old patient. How
should the nurse proceed?

a. Perform the confrontation test.
b. Ask the patient to read the print on a handheld Jaeger card.
c. Use the Snellen chart positioned 20 feet away from the patient.
d. Determine the patients ability to read newsprint at a distance of 12 to 14 inches.

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

a. At 30 feet the patient can read the entire chart.
b. The patient can read at 20 feet what a person with normal vision can read at 30
feet.
c. The patient can read the chart from 20 feet in the left eye and 30 feet in the right
eye.
d. The patient can read from 30 feet what a person with normal vision can read from
20 feet.
ANS: B
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.
15. A patient is unable to read even the largest letters on the Snellen chart. The nurse
should take which action next?

a. Refer the patient to an ophthalmologist or optometrist for further evaluation.
b. Assess whether the patient can count the nurses fingers when they are placed in
front of his or her eyes.

c. Ask the patient to put on his or her reading glasses and attempt to read the Snellen
chart again.
d. Shorten the distance between the patient and the chart until the letters are seen, and
record that distance.

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

a. Has poor vision.
b. Has acute vision.
c. Has normal vision.
d. Is presbyopic.
ANS: A
Normal visual acuity is 20/20 in each eye; the larger the denominator, the poorer the
vision.
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:

a. Consider this a normal finding.
b. Refer the individual for further evaluation.
c. Document this finding as an asymmetric light reflex.
d. Perform the confrontation test to validate the findings.

ANS: A
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.
18. The nurse is performing the diagnostic positions test. Normal findings would be
which of these results?
a. Convergence of the eyes
b. Parallel movement of both eyes
c. Nystagmus in extreme superior gaze
d. Slight amount of lid lag when moving the eyes from a superior to an inferior
position
ANS: B
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.
19. During an assessment of the sclera of a black patient, the nurse would consider
which of these an expected finding?

a. Yellow fatty deposits over the cornea
b. Pallor near the outer canthus of the lower lid
c. Yellow color of the sclera that extends up to the iris
d. Presence of small brown macules on the sclera

ANS: D
Normally in dark-skinned people, small brown macules may be observed in the sclera.

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?
a. Perform the confrontation test.
b. Assess the individuals near vision.
c. Observe the distance between the palpebral fissures.
d. Perform the corneal light test, and look for symmetry of the light reflex.
ANS: C
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 for
ptosis.
21. During an examination of the eye, the nurse would expect what normal finding
when assessing the lacrimal apparatus?

a. Presence of tears along the inner canthus
b. Blocked nasolacrimal duct in a newborn infant
c. Slight swelling over the upper lid and along the bony orbit if the individual has a
cold
d. Absence of drainage from the puncta when pressing against the inner orbital rim
ANS: D
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.
22. When assessing the pupillary light reflex, the nurse should use which technique?
a. Shine a penlight from directly in front of the patient, and inspect for pupillary
constriction.
b. Ask the patient to follow the penlight in eight directions, and observe for bilateral
pupil constriction.
c. Shine a light across the pupil from the side, and observe for direct and consensual
pupillary constriction.
d. Ask the patient to focus on a distant object. Then ask the patient to follow the
penlight to approximately 7 cm from the nose.

ANS: C
To test the pupillary light reflex, the nurse should advance a light in from the side and
note the direct and consensual pupillary constriction.
23. The nurse is assessing a patients eyes for the accommodation response and would
expect to see which normal finding?

a. Dilation of the pupils
b. Consensual light reflex
c. Conjugate movement of the eyes
d. Convergence of the axes of the eyes

ANS: D
The accommodation reaction includes pupillary constriction and convergence of the

axes of the eyes. The other responses are not correct.
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:
a. Suspect that an opacity is present in the lens or cornea.
b. Check the light source of the ophthalmoscope to verify that it is functioning.
c. Consider the red glow a normal reflection of the ophthalmoscope light off the
inner retina.
d. Continue with the ophthalmoscopic examination, and refer the patient for further
evaluation.
ANS: C
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. The other responses
are not correct.
25. The nurse is examining a patients retina with an ophthalmoscope. Which finding
is considered normal?
a. Optic disc that is a yellow-orange color
b. Optic disc margins that are blurred around the edges
c. Presence of pigmented crescents in the macular area
d. Presence of the macula located on the nasal side of the retina

ANS: A
The optic disc is located on the nasal side of the retina. Its color is a creamy yelloworange 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.
26. A 2-week-old infant can fixate on an object but cannot follow a light or bright toy.
The nurse would:

a. Consider this a normal finding.
b. Assess the pupillary light reflex for possible blindness.
c. Continue with the examination, and assess visual fields.
d. Expect that a 2-week-old infant should be able to fixate and follow an object.
ANS: A
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.
27. The nurse is assessing color vision of a male child. Which statement is correct?
The nurse should:

a. Check color vision annually until the age of 18 years.
b. Ask the child to identify the color of his or her clothing.
c. Test for color vision once between the ages of 4 and 8 years.
d. Begin color vision screening at the childs 2-year checkup.
ANS: C
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.
28. 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:
a. Examine the external structures of the eye.
b. Assess visual acuity with the Snellen eye chart.

c. Assess the childs visual fields with the confrontation test.
d. Test for strabismus by performing the corneal light reflex test.

ANS: D
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.
29. The nurse is performing an eye assessment on an 80-year-old patient. Which of
these findings is considered abnormal?

a. Decrease in tear production
b. Unequal pupillary constriction in response to light
c. Presence of arcus senilis observed around the cornea
d. Loss of the outer hair on the eyebrows attributable to a decrease in hair follicles
ANS: B
Pupils are small in the older adult, and the pupillary light reflex may be slowed, but
pupillary constriction should be symmetric. The assessment findings in the other
responses are considered normal in older persons.
30. The nurse notices the presence of periorbital edema when performing an eye
assessment on a 70-year-old patient. The nurse should:

a. Check for the presence of exophthalmos.
b. Suspect that the patient has hyperthyroidism.
c. Ask the patient if he or she has a history of heart failure.
d. Assess for blepharitis, which is often associated with periorbital edema.

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

a. Drainage from dacryocystitis.
b. Presence of conjunctivitis over the iris.
c. Presence of shadows, which may indicate glaucoma.
d. Scattered light reflex, which may be indicative of cataracts.

ANS: C
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.
32. In a patient who has anisocoria, the nurse would expect to observe:
a. Dilated pupils.
b. Excessive tearing.
c. Pupils of unequal size.
d. Uneven curvature of the lens.

ANS: C
Unequal pupil size is termed anisocoria. It normally exists in 5% of the population

but may also be indicative of central nervous system disease.
33. 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:
a. Loss of central vision.
b. Shadow or diminished vision in one quadrant or one half of the visual field.
c. Loss of peripheral vision.
d. Sudden loss of pupillary constriction and accommodation.

ANS: B
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.
34. 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:
a. Chalazion.
b. Hordeolum (stye).
c. Dacryocystitis.
d. Blepharitis.
ANS: B
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 (see Table 14-3).
35. 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:
a. Macular degeneration.
b. Vision that is normal for someone her age.
c. The beginning stages of cataract formation.
d. Increased intraocular pressure or glaucoma.

ANS: A
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.
36. 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?
a. Smooth and clear corneas
b. Opacity of the lens behind the cornea
c. Bleeding from the areas across the cornea
d. Shattered look to the light rays reflecting off the cornea

ANS: D
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. The other
responses are not correct.
37. An ophthalmic examination reveals papilledema. The nurse is aware that this
finding indicates:
a. Retinal detachment.
b. Diabetic retinopathy.
c. Acute-angle glaucoma.
d. Increased intracranial pressure.

ANS: D
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.
Papilledema is not associated with the conditions in the other responses.
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:
a. Hypopyon.
b. Hyphema.
c. Corneal abrasion.
d. Pterygium.
ANS: B
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. (See Table 14-7 for descriptions of the other
terms.)
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?
a. Assessing the eye for a possible foreign body
b. Documenting the finding as ptosis
c. Assessing for other signs of ectropion
d. Contacting the prescriber; these are signs of basal cell carcinoma

ANS: C
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.
MULTIPLE RESPONSE
1. 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.
a. Patient may experience sensitivity to light, nausea, and halos around lights.
b. Patient experiences tunnel vision in the late stages.
c. Immediate treatment is needed.
d. Vision loss begins with peripheral vision.
e. Open-angle glaucoma causes sudden attacks of increased pressure that cause
blurred vision.
f.
Virtually no symptoms are exhibited.
ANS: B, D, F
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.
Chapter 15: Ears

Chapter 15: Ears
MULTIPLE CHOICE
1. 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:
a. Auricle.
b. Concha.
c. Outer meatus.
d. Mastoid process.
ANS: A
The external ear is called the auricle or pinna and consists of movable cartilage and
skin.
2. The nurse is examining a patients ears and notices cerumen in the external canal.
Which of these statements about cerumen is correct?

a. Sticky honey-colored cerumen is a sign of infection.
b. The presence of cerumen is indicative of poor hygiene.
c. The purpose of cerumen is to protect and lubricate the ear.
d. Cerumen is necessary for transmitting sound through the auditory canal.

ANS: C
The ear is lined with glands that secrete cerumen, which is a yellow waxy material
that lubricates and protects the ear.
3. When examining the ear with an otoscope, the nurse notes that the tympanic
membrane should appear:
a. Light pink with a slight bulge.
b. Pearly gray and slightly concave.
c. Pulled in at the base of the cone of light.
d. Whitish with a small fleck of light in the superior portion.

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

a. The eustachian tube is responsible for the production of cerumen.
b. It remains open except when swallowing or yawning.
c. The eustachian tube allows passage of air between the middle and outer ear.
d. It helps equalize air pressure on both sides of the tympanic membrane.

ANS: D
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.
5. 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:
a. Maintain balance.
b. Interpret sounds as they enter the ear.
c. Conduct vibrations of sounds to the inner ear.
d. Increase amplitude of sound for the inner ear to function.

ANS: C
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.
6. 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?
a. I
b. III
c. VIII
d. XI
ANS: C
The nerve impulses are conducted by the auditory portion of CN VIII to the brain.
7. The nurse is assessing a patient who may have hearing loss. Which of these
statements is true concerning air conduction?

a. Air conduction is the normal pathway for hearing.
b. Vibrations of the bones in the skull cause air conduction.
c. Amplitude of sound determines the pitch that is heard.
d. Loss of air conduction is called a conductive hearing loss.

ANS: A
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.
8. A patient has been shown to have a sensorineural hearing loss. During the
assessment, it would be important for the nurse to:
a. Speak loudly so the patient can hear the questions.
b. Assess for middle ear infection as a possible cause.
c. Ask the patient what medications he is currently taking.
d. Look for the source of the obstruction in the external ear.

ANS: C
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.
9. 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:
a. Cochlea.
b. CN VIII.
c. Organ of Corti.
d. Labyrinth.
ANS: D
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.
10. 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?
a. Rubella may affect the mothers hearing but not the infants.
b. Rubella can damage the infants organ of Corti, which will impair hearing.
c. Rubella is only dangerous to the infant in the second trimester of pregnancy.
d. Rubella can impair the development of CN VIII and thus affect hearing.
ANS: B
If maternal rubella infection occurs during the first trimester, then it can damage the
organ of Corti and impair hearing.
11. 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?
a.
It
is unusual for a small child to have frequent ear infections unless something
else is wrong.
b.
We
c.
Ear
d.
Your
need to check the immune system of your son to determine why he is having
so many ear infections.
infections are not uncommon in infants and toddlers because they tend to have
more cerumen in the external ear.
sons eustachian tube is shorter and wider than yours because of his age,
which allows for infections to develop more easily.
ANS: D
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.
12. 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:
a. Otosclerosis.
b. Presbycusis.
c. Trauma to the bones.
d. Frequent ear infections.

ANS: A
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.
13. 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?
a. Atrophy of the apocrine glands
b. Cilia becoming coarse and stiff
c. Nerve degeneration in the inner ear
d. Scarring of the tympanic membrane

ANS: C
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.
14. 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:
a. Is probably the result of lesions from eczema in his ear.
b. Represents poor hygiene.
c. Is a normal finding, and no further follow-up is necessary.
d. Could be indicative of change in cilia; the nurse should assess for hearing loss.
ANS: C
Asians and Native Americans are more likely to have dry cerumen, whereas Blacks
and Whites usually have wet cerumen.
15. The nurse is taking the history of a patient who may have a perforated eardrum.
What would be an important question in this situation?

a.
Do
you ever notice ringing or crackling in your ears?
b.
When
c.
Have
d.
Is
was the last time you had your hearing checked?
you ever been told that you have any type of hearing loss?
there any relationship between the ear pain and the discharge you mentioned?
ANS: D
Typically with perforation, ear pain occurs first, stopping with a popping sensation,
and then drainage occurs.
16. 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:
a. Is normal for people of his age.
b. Is a characteristic of recruitment.
c. May indicate a middle ear infection.
d. Indicates that the patient has a cerumen impaction.

ANS: B
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.
17. 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?
a.
Does
b.
Has
c.
Have
your baby seem to startle with loud noises?
your baby had any surgeries on her ears?

you noticed any drainage from her ears?
d.
How
many ear infections has your baby had since birth?
ANS: A
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.
18. The nurse is performing an otoscopic examination on an adult. Which of these
actions is correct?
a. Tilting the persons head forward during the examination
b. Once the speculum is in the ear, releasing the traction
c. Pulling the pinna up and back before inserting the speculum
d. Using the smallest speculum to decrease the amount of discomfort

ANS: C
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.
19. 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?
a. If the drum has ruptured, then purulent drainage will result.
b. Bloody or clear watery drainage can indicate a basal skull fracture.
c. The auditory canal many be occluded from increased cerumen.
d. Foreign bodies from the accident may cause occlusion of the canal.
ANS: B
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.
20. In performing a voice test to assess hearing, which of these actions would the
nurse perform?
a. Shield the lips so that the sound is muffled.
b. Whisper a set of random numbers and letters, and then ask the patient to repeat
them.
c. Ask the patient to place his finger in his ear to occlude outside noise.
d. Stand approximately 4 feet away to ensure that the patient can really hear at this
distance.
ANS: B
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.
21. In performing an examination of a 3-year-old child with a suspected ear infection,
the nurse would:

a. Omit the otoscopic examination if the child has a fever.
b. Pull the ear up and back before inserting the speculum.
c. Ask the mother to leave the room while examining the child.
d. Perform the otoscopic examination at the end of the assessment.

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

a. Immobility of the drum is a normal finding.
b. An injected membrane would indicate an infection.
c. The normal membrane may appear thick and opaque.
d. The appearance of the membrane is identical to that of an adult.

ANS: C
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. The other statements are not correct.
23. The nurse assesses the hearing of a 7-month-old by clapping hands. What is the
expected response? The infant:

a. Turns his or her head to localize the sound.
b. Shows no obvious response to the noise.
c. Shows a startle and acoustic blink reflex.
d. Stops any movement, and appears to listen for the sound.

ANS: A
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.

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

a. High-tone frequency loss
b. Increased elasticity of the pinna
c. Thin, translucent membrane
d. Shiny, pink tympanic membrane

ANS: A
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.
25. 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?
a. Any change in the ability to hear
b. Any recent drainage from the ear
c. Recent history of trauma to the ear
d. Any prolonged exposure to extreme cold

ANS: D
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.
26. 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):
a. Fungal infection.
b. Acute otitis media.
c. Perforation of the eardrum.
d. Cholesteatoma.
ANS: B
Absent or distorted light reflex and a bright red color of the eardrum are indicative of
acute otitis media. (See Table 15-5 for descriptions of the other conditions.)
27. 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?
a. The tubes are placed in the inner ear.
b. The tubes are used in children with sensorineural loss.
c. The tubes are permanently inserted during a surgical procedure.
d. The purpose of the tubes is to decrease the pressure and allow for drainage.
ANS: D
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.
28. In an individual with otitis externa, which of these signs would the nurse expect to
find on assessment?
a. Rhinorrhea
b. Periorbital edema
c. Pain over the maxillary sinuses
d. Enlarged superficial cervical nodes

ANS: D
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.
29. 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 amberyellow 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:
a. Most likely has serous otitis media.
b. Has an acute purulent otitis media.
c. Has evidence of a resolving cholesteatoma.
d. Is experiencing the early stages of perforation.

ANS: A
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. The other responses are not correct.
30. 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:
a. Is most likely a benign sebaceous cyst.
b. Is most likely a keloid.
c. Could be a potential carcinoma, and the patient should be referred for a biopsy.
d. Is a tophus, which is common in the older adult and is a sign of gout.

ANS: C
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 (see Table 15-2). The other responses
are not correct.
31. The nurse suspects that a patient has otitis media. Early signs of otitis media
include which of these findings of the tympanic membrane?

a. Red and bulging
b. Hypomobility
c. Retraction with landmarks clearly visible
d. Flat, slightly pulled in at the center, and moves with insufflation

ANS: B
An early sign of otitis media is hypomobility of the tympanic membrane. As pressure

increases, the tympanic membrane begins to bulge.
32. 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:
a. Refer the patient for the possibility of a fungal infection.
b. Know that these are scars caused from frequent ear infections.
c. Consider that these findings may represent the presence of blood in the middle ear.
d. Be concerned about the ability to hear because of this abnormality on the tympanic
membrane.
ANS: B
Dense white patches on the tympanic membrane are sequelae of repeated ear
infections. They do not necessarily affect hearing.
33. The nurse is preparing to do an otoscopic examination on a 2-year-old child.
Which one of these reflects the correct procedure?

a. Pulling the pinna down
b. Pulling the pinna up and back

c. Slightly tilting the childs head toward the examiner
d. Instructing the child to touch his chin to his chest

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

a. Family history
b. Air conditioning
c. Excessive cerumen
d. Passive cigarette smoke

ANS: D
Exposure to passive and gestational smoke is a risk factor for ear infections in infants
and children.
MSC: Client Needs: Physiologic Integrity: Reduction of Risk Potential
35. 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?
a. Malignancy
b. Viral infection
c. Blood in the middle ear
d. Yeast or fungal infection

ANS: D
A colony of black or white dots on the drum or canal wall suggests a yeast or fungal
infection (otomycosis).
MSC: Client Needs: Physiologic Integrity: Basic Care and Comfort
36. 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:
a. Use a cotton-tipped swab to dry the ear canals thoroughly after each swim.
b. Use rubbing alcohol or 2% acetic acid eardrops after every swim.
c. Irrigate the ears with warm water and a bulb syringe after each swim.
d. Rinse the ears with a warmed solution of mineral oil and hydrogen peroxide.
ANS: B
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.
37. 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:
a. Vertigo.
b. Pruritus.
c. Tinnitus.
d. Cholesteatoma.
ANS: C
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.
38. 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:
a. Objective vertigo.
b. Subjective vertigo.
c. Tinnitus.
d. Dizziness.
ANS: A
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.
39. 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?
a. Make note of this finding for the report to the next shift.
b. Prepare to remove cerumen from the patients ear.
c. Notify the patients health care provider.
d. Irrigate the ear with rubbing alcohol.

ANS: C
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.
MULTIPLE RESPONSE
1. 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.
a. Hearing loss related to aging begins in the mid 40s.
b. Progression of hearing loss is slow.
c. The aging person has low-frequency tone loss.
d. The aging person may find it harder to hear consonants than vowels.
e. Sounds may be garbled and difficult to localize.
f.
Hearing loss reflects nerve degeneration of the middle ear.
ANS: B, D, E
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.
Chapter 16: Nose, Mouth, and Throat

Chapter 16: Nose, Mouth, and Throat
MULTIPLE CHOICE
1. The primary purpose of the ciliated mucous membrane in the nose is to:
a. Warm the inhaled air.
b. Filter out dust and bacteria.
c. Filter coarse particles from inhaled air.
d. Facilitate the movement of air through the nares.

ANS: B
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.
MSC: Client Needs: General
2. The projections in the nasal cavity that increase the surface area are called the:
a. Meatus.
b. Septum.
c. Turbinates.
d. Kiesselbach plexus.
ANS: C
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.
3. The nurse is reviewing the development of the newborn infant. Regarding the
sinuses, which statement is true in relation to a newborn infant?

a. Sphenoid sinuses are full size at birth.
b. Maxillary sinuses reach full size after puberty.
c. Frontal sinuses are fairly well developed at birth.
d. Maxillary and ethmoid sinuses are the only sinuses present at birth.
ANS: D
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.

4. The tissue that connects the tongue to the floor of the mouth is the:
a. Uvula.
b. Palate.
c. Papillae.
d. Frenulum.
ANS: D
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.
5. The salivary gland that is the largest and located in the cheek in front of the ear is
the _________ gland.

a. Parotid
b. Stensens
c. Sublingual
d. Submandibular
ANS: A
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.
6. 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?
a. Refer the patient to a throat specialist.
b. No response is needed; this appearance is normal for the tonsils.
c. Continue with the assessment, looking for any other abnormal findings.
d. Obtain a throat culture on the patient for possible streptococcal (strep) infection.
ANS: B
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.
7. 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:
a.
Youre
b.
It
c.
This
d.
She
right, drooling is usually a sign of the first tooth.
would be unusual for a 3 month old to be getting her first tooth.

could be the sign of a problem with the salivary glands.
is just starting to salivate and hasnt learned to swallow the saliva.
ANS: D
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.
8. The nurse is assessing an 80-year-old patient. Which of these findings would be
expected for this patient?

a. Hypertrophy of the gums
b. Increased production of saliva
c. Decreased ability to identify odors
d. Finer and less prominent nasal hair

ANS: C
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.
9. 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:
a. Leukoedema and is common in dark-pigmented persons.
b. The result of hyperpigmentation and is normal.
c. Torus palatinus and would normally be found only in smokers.
d. Indicative of cancer and should be immediately tested.

ANS: A
Leukoedema, a grayish-white benign lesion occurring on the buccal mucosa, is most

often observed in Blacks.
10. 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?
a.
While
sitting up, place a cold compress over your nose.
b.
Sit
up with your head tilted forward and pinch your nose.
c.
Just
d.
Lie
allow the bleeding to stop on its own, but dont blow your nose.
on your back with your head tilted back and pinch your nose.
ANS: B
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.
11. 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?

a. Epistaxis
b. Rhinorrhea
c. Dysphagia
d. Xerostomia
ANS: C
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.
12. 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:
a.
Youre
right. Bottles make very good pacifiers.
b.
Using
c.
Its
d.
Prolonged
a bottle as a pacifier is better for the teeth than thumb-sucking.
okay to use a bottle as long as it contains milk and not juice.

use of a bottle can increase the risk for tooth decay and ear infections.
ANS: D
Prolonged bottle use during the day or when going to sleep places the infant at risk for
tooth decay and middle ear infections.
13. 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:
a.
Do
b.
Have
c.
At
d.
Have
ANS: D
you use a fluoride supplement?

you had tonsillitis in the last year?
what age did you get your first tooth?

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.
14. The nurse is using an otoscope to assess the nasal cavity. Which of these
techniques is correct?
a. Inserting the speculum at least 3 cm into the vestibule
b. Avoiding touching the nasal septum with the speculum
c. Gently displacing the nose to the side that is being examined
d. Keeping the speculum tip medial to avoid touching the floor of the nares
ANS: B
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.
15. 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?
a.
Are
you aware of having any allergies?
b.
Do
you have an elevated temperature?
c.
Have
you had any symptoms of a cold?
d.
Have
you been having frequent nosebleeds?
ANS: A
With chronic allergies, the mucosa looks swollen, boggy, pale, and gray. Elevated
body temperature, colds, and nosebleeds do not cause these mucosal changes.
16. The nurse is palpating the sinus areas. If the findings are normal, then the patient
should report which sensation?

a. No sensation
b. Firm pressure
c. Pain during palpation
d. Pain sensation behind eyes

ANS: B
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).
17. 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?
a. Check the patients hemoglobin for anemia.
b. Assess for other signs of insufficient oxygen supply.
c. Proceed with the assessment, knowing that this appearance is a normal finding.
d. Ask if he has been exposed to an excessive amount of carbon monoxide.

ANS: C
Some Blacks may have bluish lips and a dark line on the gingival margin; this
appearance is a normal finding.
18. 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:
a. Dehydration.
b. Irritation by gastric juices.
c. A normal oral assessment.
d. Side effects from nausea medication.

ANS: A
Dry mouth occurs with dehydration or fever. The tongue has deep vertical fissures.
19. 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?
a.
These
b.
These
c.
This
d.
These
spots indicate an infection such as strep throat.
bumps could be indicative of a serious lesion, so I will refer you to a

specialist.
condition is called leukoplakia and can be caused by chronic irritation such
as with smoking.
bumps are Fordyce granules, which are sebaceous cysts and are not a
serious condition.
ANS: D
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.
20. 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?
a. Tonsils 1+/1-4+ and pink; the same color as the oral mucosa
b. Tonsils 2+/1-4+ with small plugs of white debris
c. Tonsils 3+/1-4+ with large white spots
d. Tonsils 3+/1-4+ with pale coloring

ANS: C
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.
21. 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?
a. Attempt to suction again with a bulb syringe.
b. Wait a few minutes, and try again once the infant stops crying.
c. Recognize that this situation requires immediate intervention.
d. Contact the physician to schedule an appointment for the infant at his or her next
hospital visit.
ANS: C
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 intervention.
22. 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:
a. Swollen, red tonsils.
b. Ulcerations on the hard palate.
c. Bruising on the buccal mucosa or gums.
d. Small yellow papules along the hard palate.

ANS: C
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.
23. 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?
a. Refer to the physician for an antibiotic order.
b. Have the mother bring the child back in 1 week.
c. Perform an otoscopic examination of the left nares.
d. Tell the mother that this drainage is normal for a child of this age.
ANS: C
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.
24. 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?
a. Tell the patient she needs to see a skin specialist.
b. Discuss the benefits of having a biopsy performed on any unusual lesion.
c. 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.

d. Tell the patient that these vesicles are most likely the result of a riboflavin
deficiency and discuss nutrition.

ANS: C
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 lipskin junction. Infection often recurs in the same site. Recurrent herpes infections may
be precipitated by sunlight, fever, colds, or allergy.
25. 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?
a. Nutritional status
b. When the patient first noticed the lesion
c. Whether the patient has had a recent cold
d. Whether the patient has had any recent exposure to sick animals
ANS: B
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.
26. 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?
a.
Your
condition is probably due to a vitamin C deficiency.
b.
Im
c.
You
d.
Swollen
not sure what causes swollen and bleeding gums, but let me know if its not
better in a few weeks.
need to make an appointment with your dentist as soon as possible to have
this checked.
and bleeding gums can be caused by the change in hormonal balance in
your system during pregnancy.
ANS: D
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.
27. 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:
a. Aphthous ulcers.
b. Candidiasis.
c. Leukoplakia.
d. Koplik spots.
ANS: B
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. (See Table
16-4 for descriptions of the other lesions.)
28. 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?
will need to get a biopsy to determine the cause.
a.
We
b.
This
c.
Black,
d.
This
is an overgrowth of hair and will go away in a few days.
hairy tongue is a fungal infection caused by all the antibiotics you have
received.
is probably caused by the same bacteria you had in your lungs.
ANS: C
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.
29. 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:
a. Acquired immunodeficiency syndrome (AIDS).
b. Measles.
c. Leukemia.
d. Carcinoma.
ANS: A
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.
30. 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?
a.
This
b.
This
c.
This
d.
This
area of irritation is caused from teething and is nothing to worry about.
finding is abnormal and should be evaluated by another health care

provider.
area of irritation is the result of chronic drooling and should resolve within
the next month or two.
elevated area is a sucking tubercle caused from the friction of breastfeeding
or bottle-feeding and is normal.

ANS: D
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.
31. 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:
a.
How
b.
All
c.
This
d.
many teeth did you have at this age?
20 deciduous teeth are expected to erupt by age 4 years.

is a normal number of teeth for an 18 month old.
Normally,
by age 2
years, 16 deciduous teeth are expected.
ANS: C
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.
32. When examining the mouth of an older patient, the nurse recognizes which finding
is due to the aging process?

a. Teeth appearing shorter
b. Tongue that looks smoother in appearance
c. Buccal mucosa that is beefy red in appearance
d. Small, painless lump on the dorsum of the tongue

ANS: B
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.
33. 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?
a. Nasal polyps
b. Acute sinusitis
c. Allergic rhinitis
d. Acute rhinitis
ANS: C
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. (See Table 16-1 for descriptions of the
other conditions.)
34. When assessing the tongue of an adult, the nurse knows that an abnormal finding
would be:
a. Smooth glossy dorsal surface.
b. Thin white coating over the tongue.
c. Raised papillae on the dorsal surface.
d. Visible venous patterns on the ventral surface.

ANS: A
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 (see Table 16-5).
35. The nurse is performing an assessment. Which of these findings would cause the
greatest concern?
a. Painful vesicle inside the cheek for 2 days
b. Presence of moist, nontender Stensens ducts
c. Stippled gingival margins that snugly adhere to the teeth
d. Ulceration on the side of the tongue with rolled edges

ANS: D
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. The other responses are normal findings.
36. A patient has been diagnosed with strep throat. The nurse is aware that without
treatment, which complication may occur?

a. Rubella
b. Leukoplakia
c. Rheumatic fever
d. Scarlet fever
ANS: C
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.

37. 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:
a.
You
b.
You
c.
Continuing
d.
Using
should never use over-the-counter nasal sprays because of the risk of

addiction.
should try switching to another brand of medication to prevent this problem.
to use this spray is important to keep your allergies under control.
these nasal medications irritates the lining of the nose and may cause
rebound swelling.
ANS: D
The misuse of over-the-counter nasal medications irritates the mucosa, causing

rebound swelling, which is a common problem.
38. 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?
a. This condition is a cleft palate and is common in Native Americans.
b. A bifid uvula may occur in some Native-American groups.
c. This condition is due to an injury and should be reported to the authorities.
d. A bifid uvula is palatinus, which frequently occurs in Native Americans.

ANS: B
Bifid uvula, a condition in which the uvula is split either completely or partially,
occurs in some Native-American groups.
39. 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:
a. Posterior epistaxis.
b. Frontal sinusitis.
c. Maxillary sinusitis.
d. Nasal polyps.
ANS: C
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.
40. 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:
a. A problem with the patients coagulation system.
b. Increased vascularity in the upper respiratory tract as a result of the pregnancy.
c. Increased susceptibility to colds and nasal irritation.
d. Inappropriate use of nasal sprays.

ANS: B
Nasal stuffiness and epistaxis may occur during pregnancy as a result of increased
vascularity in the upper respiratory tract.
MULTIPLE RESPONSE
1. 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.
a. One pinch of SLT in the mouth for 30 minutes delivers the equivalent of one
cigarette.
b. Using SLT has been associated with a greater risk of oral cancer than smoking.
c. Pain is an early sign of oral cancer.
d. Pain is rarely an early sign of oral cancer.
e. Tooth decay is another risk of SLT because of the use of sugar as a sweetener.
f.
SLT is considered a healthy alternative to smoking.
ANS: B, D, E
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.
2. 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.
a. Chronic alcohol use
b. Cigarette smoking
c. Frequent episodes of strep throat
d. Chronic allergies
e. Aging
f.
Herpes simplex virus I
ANS: B, D, E
Sen
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.
Chapter 14
DAmico/Barbarito Health & Physical Assessment in Nursing, 2/e
Chapter 14
Question 1
Type: HOTSPOT
A client is having difficulty maintaining equilibrium. The client is unable to ambulate without pushing
a wheelchair or using a walker. Draw an arrow indicating which part of the ear is not functioning
adequately.
Correct Answer:
Rationale : The ear is divided into three areas: the external ear, the middle ear, and the inner ear.
All three are involved in hearing, but only the inner ear is involved in equilibrium. The vestibular
apparatus contained in the inner ear must be working adequately for the client to be able to maintain
a sense of balance.
Global Rationale:
Cognitive Level: Analyzing
Client Need: Physiological Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 14.1: Identify the anatomy and physiology of the ear, nose, mouth, and throat.
Question 2
Type: MCSA
The client is experiencing the effects of a recent cerebrovascular accident. The client is unable to
hear out of the left ear. Which of the following cranial nerves was most likely affected?
1. Cranial nerve I
2. Cranial nerve XII
3. Cranial nerve VIII
4. Cranial nerve VII
Correct Answer: 3
Rationale 1: The sense of smell is controlled by cranial nerve I.
Rationale 2: Tongue movement is controlled by cranial nerve XII.
Rationale 3: Hearing and balance is controlled by cranial nerve VII.
Rationale 4: The sense of taste is controlled by cranial nerves VII and IX.
Global Rationale: Hearing and balance is controlled by cranial nerve VII. The sense of smell is
controlled by cranial nerve I. Tongue movement is controlled by cranial nerve XII. The sense of taste
is controlled by cranial nerves VII and IX.
Cognitive Level: Understanding
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Diagnosis
Question 3
Type: MCHS
The nurse is assessing the clients vestibule of the oral cavity. The student nurse requests
information regarding the vestibule and the mouth. Draw an arrow to the structure that separates the
vestibule from the mouth.
Correct Answer:
Rationale : The vestibule is made up of the lips, buccal mucosa, outer surface of the gums and the
teeth and cheeks. The mouth is separated from the vestibule by the teeth. The mouth is made up of
the tongue, hard and soft palate, uvula, mandibular arch, and axillary arch.
Global Rationale:
Client Need Sub:
Question 4
Type: MCSA
The nurse educates the client about the major functions of the nose and sinuses. Which of the
following structures is specifically responsible for filtering, moistening, and warming air that enters
the lower portion of the respiratory tract?
1. Olfactory cells
2. Columella
3. Turbinates
4. Nares
Correct Answer: 3
Rationale 1: The olfactory cells assist the client to smell.
Rationale 2: The columella is located at the base of the nose and helps form the nares.
Rationale 3: The superior, middle, and inferior turbinates are specifically responsible for warming,
moistening, and filtering the air before it enters the trachea and lungs.
Rationale 4: The nares are structures that lead into the internal vestibule and nasal cavity.
Global Rationale: The superior, middle, and inferior turbinates are specifically responsible for
warming, moistening, and filtering the air before it enters the trachea and lungs. The olfactory cells
assist the client to smell. The columella is located at the base of the nose and helps form the nares.
The nares are structures that lead into the internal vestibule and nasal cavity.
Client Need Sub:
Question 5
Type: MCSA
Which of the following structures attaches the tongue to the floor of the mouth?
1. Hard palate
2. Papillae
3. Frenulum
4. Alveoli sockets
Correct Answer: 3
Rationale 1: The hard palate is the anterior portion of the roof of the mouth.
Rationale 2: The papillae contain the taste buds and assist with moving food within the mouth. The
papillae are located on the dorsal surface of the tongue.
Rationale 3: The frenulum connects the anterior portion of the tongue to the floor of the mouth.
Rationale 4: The alveoli sockets contain the teeth within the mandible and maxilla.
Global Rationale: The frenulum connects the anterior portion of the tongue to the floor of the
mouth. The hard palate is the anterior portion of the roof of the mouth. The papillae contain the taste
buds and assist with moving food within the mouth. The papillae are located on the dorsal surface of
the tongue. The alveoli sockets contain the teeth within the mandible and maxilla.
Cognitive Level: Remembering

Client Need Sub:
Question 6
Type: MCMA
The nurse is performing a focused interview with a client who has been cleaning the ears with a
cotton-tipped applicator. The nurse should educate the client about which of the following
complications that can occur as a result of this practice?
Standard Text: Select all that apply.
1. The client has a higher risk of developing otitis externa.
2. The client has a higher risk of developing tophi along the outer rim of the ears.
3. The client could perforate the tympanic membrane.
4. The client could require tympanostomy tubes.
5. The clients cerumen might become impacted.
Correct Answer: 3,5
Rationale 1: The client has a higher risk of developing otitis externa. Otitis externa is an
infection of the clients outer ear. This client does not have an increased risk of developing otitis
externa.
Rationale 2: The client has a higher risk of developing tophi along the outer rim of the ears.
Tophi are small white nodules that are found on the helix or antihelix. These nodules are a sign of
gout and contain uric acid crystals.
Rationale 3: The client could perforate the tympanic membrane. This client is at risk for
perforating the tympanic membrane with the cotton-tipped applicator. The inside of the ear should
not be cleaned. Cerumen moves to the outside of the ear canal naturally.
Rationale 4: The client could require tympanostomy tubes. Tympanostomy tubes are placed
when clients develop repeated otitis media infections. These tubes help relieve middle ear pressure
and allow drainage that occurs as a result of the infection. This client does not require
tympanostomy tubes.
Rationale 5: The clients cerumen might become impacted. This client is at risk for impacting the
cerumen within the ears with the cotton-tipped applicator. The inside of the ear should not be
cleaned. Cerumen moves to the outside of the ear canal naturally.
Global Rationale: Otitis externa is an infection of the clients outer ear. This client does not have an
increased risk of developing otitis externa. Tophi are small white nodules that are found on the helix
or antihelix. These nodules are a sign of gout and contain uric acid crystals. This client is at risk for
perforating the tympanic membrane with the cotton-tipped applicator. The inside of the ear should
not be cleaned. Cerumen moves to the outside of the ear canal naturally. Tympanostomy tubes are
placed when clients develop repeated otitis media infections. These tubes help relieve middle ear
pressure and allow drainage that occurs as a result of the infection. This client does not require
tympanostomy tubes. This client is at risk for impacting the cerumen within the ears with the cottontipped applicator. The inside of the ear should not be cleaned. Cerumen moves to the outside of the
ear canal naturally.
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 14.2: Develop questions to be used when completing the focused interview.
Question 7
Type: MCSA
The nurse is performing a focused interview with the client. The nurse asks the client if the client has
noticed any drainage from the ears, and the client states, Yes. Which of the following statements
indicate that the client may have developed acute otitis media?
1. The ear canal itself is really red, raw, and sore.
2. I noticed that the drainage looked clear, like water.
3. The drainage looks like what is draining from my nose, kind of clear and mucousy.
4. It is kind of yellowish-reddish color.
Correct Answer: 4
Rationale 1: When the client complains that the ear canal is inflamed, painful, and with erythema,
this indicates that the client may have developed otitis externa.
Rationale 2: Clear drainage from the ear may indicate that the client has developed a cerebrospinal
fluid leak following trauma.
Rationale 3: Serous drainage can indicate that the client has developed drainage from the ears as a
result of allergies.
Rationale 4: The client with acute otitis media will state that he is experiencing drainage from the
ears that is purulent. Reddish-yellow drainage would be classified as purulent.
Global Rationale: The client with acute otitis media will state that they are experiencing drainage
from the ears that is purulent. Reddish-yellow drainage would be classified as purulent. When the
client complains that the ear canal is inflamed, painful, and with erythema, this indicates that the
client may have developed otitis externa. Clear drainage from the ear may indicate that the client
has developed a cerebrospinal fluid leak following trauma. Serous drainage can indicate that the
client has developed drainage from the ears as a result of allergies.
Cognitive Level: Applying
Client Need Sub:
Question 8
Type: MCMA
The client was given several medications during a recent hospital admission. The client has come to
the medical office with complaints of tinnitus and bilateral hearing loss. The nurse understands that
which of the following medications are associated with hearing loss or tinnitus?
1. Streptomycin
2. Steroid inhalers
3. Aspirin
4. Neomycin
5. Acetaminophen
Correct Answer: 1,3,4
Rationale 1: Streptomycin. Streptomycin is an antibiotic that can cause hearing loss.
Rationale 2: Steroid inhalers. Steroid inhalers are associated with Candida (yeast infections) in the
nasal mucosa.
Rationale 3: Aspirin. Aspirin can cause ringing in the ears.
Rationale 4: Neomycin. Neomycin is an antibiotic that can cause hearing loss.
Rationale 5: Acetaminophen. Acetaminophen is not associated with hearing loss.
Global Rationale: Streptomycin is an antibiotic that can cause hearing loss. Steroid inhalers are
associated with Candida (yeast infections) in the nasal mucosa. Aspirin can cause ringing in the
ears. Neomycin is an antibiotic that can cause hearing loss. Acetaminophen is not associated with
hearing loss.
Client Need Sub:
Learning Outcome: 14.3: Describe the techniques required for assessment of the structures of the
ear, nose, mouth, and throat.
Question 9
Type: MCSA
The client has developed anosmia. The healthcare provider educates the client about the possible
causes. The nurse recognizes that which of the following would be an unexpected explanation for
this condition?
1. Commonly associated with gingivitis
2. Possibly linked to heredity

3. Related to a diet deficient in zinc
4. An indicator of a neurological problem
Correct Answer: 1
Rationale 1: Anosmia is the inability to smell. It is unrelated to gingivitis. Clients with gingivitis often
complain of a bad taste in their mouth.
Rationale 2: Anosmia is the inability to smell. Anosmia may be related to genetic makeup.
Rationale 3: Anosmia is the inability to smell. Anosmia may be related to a diet that is deficient in
food containing zinc.
Rationale 4: Anosmia is the inability to smell. Anosmia may be related to a neurological disorder.
Global Rationale: Anosmia is the inability to smell. Anosmia may be related to a neurological
disorder, genetic makeup, or a diet that is deficient in food containing zinc. It is unrelated to
gingivitis. Clients with gingivitis often complain of a bad taste in their mouth.
Client Need Sub:
Question 10
Type: MCSA
The client has been brought via ambulance to the emergency room following a motor vehicle
accident. The nurse notes that the clients ear is draining clear fluid. What is the nurses priority
nursing action?
1. Request information from the client regarding any chronic allergies.
2. Test the drainage for glucose.
3. Ask the patient if she has experienced a recent middle ear infection.
4. Irrigate the ear with warm mineral oil, peroxide, and flush with warm water.
Correct Answer: 2
Rationale 1: Chronic allergies would not result in clear fluid draining from the clients ear. However,
an acute allergic reaction may result in serous fluid that drains from the clients ear.
Rationale 2: When a clients ear is draining clear fluid, this might indicate the client has a
cerebrospinal fluid leak. The fluid should be tested for glucose. Glucose is present in cerebrospinal
fluid.
Rationale 3: A recent middle ear infection may result in purulent or bloody drainage from the clients
ear.
Rationale 4: The ear should not be irrigated at this time. Irrigation with warm mineral oil, peroxide,
and flushing with warm water is often used to remove cerumen. There is nothing to suggest that the
client has impacted cerumen.
Global Rationale: When a clients ear is draining clear fluid, this might indicate the client has a
cerebrospinal fluid leak. The fluid should be tested for glucose. Glucose is present in cerebrospinal
fluid. Chronic allergies would not result in clear fluid draining from the clients ear. However, an acute
allergic reaction may result in serous fluid that drains from the clients ear. A recent middle ear
infection may result in purulent or bloody drainage from the clients ear. The ear should not be
irrigated at this time. Irrigation with warm mineral oil, peroxide, and flushing with warm water is often
used to remove cerumen. There is nothing to suggest that the client has impacted cerumen.
Client Need Sub:
Question 11
Type: MCSA
The nurse is assessing the tympanic membrane of a client and notes the presence of a bluish color.
The nurse would suspect which of the following?
1. Acute otitis media

2. Recent head trauma
3. Blocked eustachian tubes
4. History of frequent middle ear infections
Correct Answer: 2
Rationale 1: Acute otitis media is associated with a reddish or yellowish tinge on the tympanic
membrane.
Rationale 2: The presence of a bluish tinge on the tympanic membrane is most likely due to blood in
the middle ear and may be indicative of recent head trauma.
Rationale 3: A blocked eustachian tube will cause the tympanic membrane to retract.
Rationale 4: Previous middle ear infections will result in white patches noted on the tympanic
membrane that indicate scarring.
Global Rationale: The presence of a bluish tinge on the tympanic membrane is most likely due to
blood in the middle ear and may be indicative of recent head trauma. Acute otitis media is
associated with a reddish or yellowish tinge on the tympanic membrane. A blocked eustachian tube
will cause the tympanic membrane to retract. Previous middle ear infections will result in white
patches noted on the tympanic membrane that indicate scarring.
Client Need Sub:
Learning Outcome: 14.4: Explain the use of otoscope.
Question 12
Type: MCSA
The nursing is performing an otoscopic examination on an adult client and is unable to visualize the
tympanic membrane. The nurse should perform which of the following steps to better visualize this
structure?
1. Pull the pinna up and back, then reinsert the otoscope

2. Tell the client to move away from the speculum if they experience any pain as the otoscope is
advanced.
3. Reinsert the otoscope quickly and press against both sides of the inner auditory canal.
4. Pull the pinna down and back, then reinsert the otoscope.
Correct Answer: 1
Rationale 1: To avoid trauma to the ear, the otoscope is to be removed and the pinna should be
pulled up and back for better visualization.
Rationale 2: The client should be instructed to state any feelings of discomfort or pain but not to pull
away because this may result in injury during this examination.
Rationale 3: The otoscope should not be inserted quickly and should not be pressed against either
side of the inner auditory canal because it would be painful for the client.
Rationale 4: Pulling down and back is recommended in children because of the shape of their
auditory canal.
Global Rationale: To avoid trauma to the ear, the otoscope is to be removed and the pinna should
be pulled up and back for better visualization. The client should be instructed to state any feelings of
discomfort or pain but not to pull away because this may result in injury during this examination. The
otoscope should not be inserted quickly and should not be pressed against either side of the inner
auditory canal because it would be painful for the client. Pulling down and back is recommended in
children because of the shape of their auditory canal.
Client Need Sub:
Question 13
Type: MCMA
The nurse is examining a clients ears and notes that right ear is occluded with wax. The nurse
would choose which of the following to remove the earwax?
1. Irrigation with warm mineral oil, peroxide, followed by warm water
2. A sharp instrument to break up the ear wax
3. Irrigation with a cold solution
4. A cerumen spoon to remove the wax
5. Irrigation with warm sudsy water
Correct Answer: 1,4
Rationale 1: Irrigate the ear canal with warm mineral oil, peroxide, followed by warm water.
Care must be taken when removing cerumen. Warmed mineral oil and peroxide soften the earwax
and the ear can be irrigated with warm water afterwards.
Rationale 2: A sharp instrument to break up the ear wax within the ear canal. Sharp
instruments should not be placed within the ear canal because it may injure the tympanic
membrane.
Rationale 3: Irrigate the ear canal with a cold solution. Cold solutions may harden the ear wax,
making it more difficult to remove.
Rationale 4: A cerumen spoon can be placed in the ear canal to remove the wax. The cerumen
can also be safely removed with a cerumen spoon. The cerumen spoon is designed to remove the
wax safely without risking injury or perforation of the eardrum.
Rationale 5: Irrigate the ear canal with warm sudsy water. Warm, sudsy solutions may irritate the
ear canal.
Global Rationale: Care must be taken when removing cerumen. Warmed mineral oil and peroxide
soften the earwax and the ear can be irrigated with warm water afterwards. Sharp instruments
should not be placed within the ear canal because it may injure the tympanic membrane. Cold
solutions may harden the ear wax, making it more difficult to remove. The cerumen can also be
safely removed with a cerumen spoon. The cerumen spoon is designed to remove the wax safely
without risking injury or perforation of the eardrum. Warm, sudsy solutions may irritate the ear canal.
Client Need: Safe Effective Care Environment
Client Need Sub:

Question 14
Type: MCMA
During the focused interview, the client admits to regularly abusing cocaine. Which of the following
findings does the nurse expect to discover during the physical assessment of the clients nose?
1. The nurse notes that the nasal septum has perforated.
2. Temporomandibular joint pain when the client opens and closes the mouth
3. The septum is noted to be very pale in color.
4. Yeast infection of nasal mucosa and in mouth
5. Difficulty swallowing water
Correct Answer: 1,3
Rationale 1: The nurse notes that the nasal septum has perforated. When a client is abusing
cocaine, the nurse may note that the nasal septum has broken down and has even perforated.
Rationale 2: Temporomandibular joint pain when the client opens and closes the mouth.
Temporomandibular joint pain could be the result of otitis externa or might indicate
temporomandibular joint dysfunction. It is unrelated to cocaine use.
Rationale 3: The septum is noted to be very pale in color. When a client is abusing cocaine, the
nasal mucosa might appear vasoconstricted and very pale in color.
Rationale 4: Yeast infection of nasal mucosa and in mouth. Steroid inhalers can cause growth of
Candida in the nose, mouth, or throat. It is unrelated to cocaine use.
Rationale 5: Difficulty swallowing water. If the client experiences difficulty in swallowing, this may
be due to a neurological or gastrointestinal problem, or it may be related to ill-fitting dentures or
malocclusion.
Global Rationale: When a client is abusing cocaine, the nurse may note that the nasal septum has
broken down and has even perforated. Temporomandibular joint pain could be the result of otitis
externa or might indicate temporomandibular joint dysfunction. It is unrelated to cocaine use. When
a client is abusing cocaine, the nasal mucosa might appear vasoconstricted and very pale in color.
Steroid inhalers can cause growth of Candida in the nose, mouth, or throat. It is unrelated to cocaine
use. If the client experiences difficulty in swallowing, this may be due to a neurological or
gastrointestinal problem, or it may be related to ill-fitting dentures or malocclusion.
Client Need Sub:
Learning Outcome: 14.5: Differentiate normal from abnormal findings in physical assessment of the
Question 15
Type: MCSA
The nurse is caring for a client who was admitted to the medical unit. The healthcare provider states
that the clients Romberg test was positive. As the nurse plans to meet the clients elimination needs,
the nurse would implement which of the following interventions?
1. Allow the client to walk independently.
2. Obtain an order for a catheter.
3. Limit fluid intake.
4. Obtain a bedside commode.
Correct Answer: 4
Rationale 1: A positive Romberg sign indicates problems with the vestibular apparatus that controls
balance. This client might experience difficult ambulating and has a higher risk of falling. The nurse
must help the client eliminate safely.
Rationale 2: Catheter insertion is invasive and increases the clients risk of developing a urinary
tract infection.
Rationale 3: Restricting fluid intake is not indicated in this situation.
Rationale 4: A positive Romberg sign indicates problems with the vestibular apparatus that controls
balance. This client might experience difficult ambulating and has a higher risk of falling. The nurse
must help the client eliminate safely. Obtaining a bedside commode for the client will help prevent
the client from falling while attempting to ambulate independently to and from the bathroom.
Global Rationale: A positive Romberg sign indicates problems with the vestibular apparatus that
controls balance. This client might experience difficult ambulating and has a higher risk of falling.
The nurse must help the client eliminate safely. Obtaining a bedside commode for the client will help
prevent the client from falling while attempting to ambulate independently to and from the bathroom.
Catheter insertion is invasive and increases the clients risk of developing a urinary tract infection.
Restricting fluid intake is not indicated in this situation.
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Planning
Learning Outcome: 15. 5: Differentiate normal from abnormal findings in physical assessment of
the ear, nose, mouth, and throat.
Question 16
Type: MCSA
A client with a fever is also complaining of difficulty hearing. The nurse realizes this client might be
experiencing which of the following disorders?
1. Sinusitis
2. Otitis media
3. Tonsillitis
4. Otitis externa
Correct Answer: 2
Rationale 1: Sinusitis is associated with facial pain, inflammation, and nasal discharge.
Rationale 2: Fever and hearing loss are clinical manifestations associated with otitis media.
Rationale 3: Tonsillitis is associated with reddened, inflamed tonsils and a fever.
Rationale 4: Otitis externa is associated with a red, swollen auricle and ear canal. Clients with otitis
externa also might have a fever.
Global Rationale: Fever and hearing loss are clinical manifestations associated with otitis media.
Sinusitis is associated with facial pain, inflammation, and nasal discharge. Tonsillitis is associated
with reddened, inflamed tonsils and a fever. Otitis externa is associated with a red, swollen auricle
and ear canal. Clients with otitis externa also might have a fever.
Client Need Sub:
Question 17
Type: MCSA
The emergency room triage nurse is assessing a child who has a history of a cough and nasal
congestion for the last three days. When assessing patency of the nares, the nurse notes that the
child is unable to breathe through the right nostril. The nurse would interpret these assessment
findings as which of the following?
1. Produced by severe nasal inflammation or obstruction
2. Normal for a child
3. A result of chronic allergies
4. A result of sinusitis
Correct Answer: 1
Rationale 1: If the client cannot breathe through each naris, severe inflammation or an obstruction
may be present.
Rationale 2: This is not a normal finding in an adult or a child.
Rationale 3: If nasal mucosa is pale and boggy or swollen, the client may have chronic allergies.
Due to the clients history, this is an acute problem and not associated with chronic allergies.
Rationale 4: The client with sinusitis will have tenderness over sinus cavities.
Global Rationale: If the client cannot breathe through each naris, severe inflammation or an
obstruction may be present. This is not a normal finding in an adult or a child. If nasal mucosa is pale
and boggy or swollen, the client may have chronic allergies. Due to the clients history, this is an
acute problem and not associated with chronic allergies. The client with sinusitis will have
tenderness over sinus cavities.
Client Need Sub:
Question 18
Type: MCSA
A client presents in the healthcare providers office with complaints of headache and malaise. The
nurse assesses the client and finds that the client has severe pain when the sinuses are palpated.
The nurse would suspect which of the following disorders?
1. Sinusitis
2. Mastoiditis
3. Chronic allergies
4. Anemia
Correct Answer: 1
Rationale 1: Pain is a common finding during palpation of the sinuses when an infection or
inflammation is present in the sinuses.
Rationale 2: Mastoiditis is associated with pain and tenderness over the mastoid process, which is
located behind the clients ears.
Rationale 3: The client with chronic allergies may have pale, boggy, or swollen nasal mucosa.
Rationale 4: Anemia would be associated with pale mucous membranes.

Global Rationale: Pain is a common finding during palpation of the sinuses when an infection or
inflammation is present in the sinuses. Mastoiditis is associated with pain and tenderness over the
mastoid process, which is located behind the clients ears. The client with chronic allergies may have
pale, boggy, or swollen nasal mucosa. Anemia would be associated with pale mucous membranes.
Client Need Sub:
Question 19
Type: MCSA
The nurse is educating a group of teenagers in high school about the risks of chewing tobacco. The
nurse would include information about which of the following signs of oral cancer?
1. Bleeding and inflamed gums
2. Smooth and shiny tongue
3. Red, swollen tonsils
4. Ulcerations on the lip or under the tongue
Correct Answer: 4
Rationale 1: Bleeding and inflamed gums are associated with gingivitis.
Rationale 2: A smooth, shiny tongue is associated with deficiencies of vitamin B and iron.
Rationale 3: Red and swollen tonsils are associated with tonsillitis
Rationale 4: Oral cancers are most commonly found on the lower lip or the base of the tongue. They
do not heal normally.
Global Rationale: Oral cancers are most commonly found on the lower lip or the base of the
tongue. They do not heal normally. Bleeding and inflamed gums are associated with gingivitis. A
smooth, shiny tongue is associated with deficiencies of vitamin B and iron. Red and swollen tonsils
are associated with tonsillitis.
Client Need: Health Promotion and Maintenance
Client Need Sub:
Question 20
Type: MCMA
A client arrives in the emergency room with complaints of intermittent nosebleeds for the past two
days. Which of the following assessments would be a priority for the nurse is this situation?
1. Request information from the client regarding increased propensity for bruising or bleeding.
2. Assess the tonsils for redness or swelling.
3. Obtain a blood pressure.
4. Check for deviated septum.
5. Request information from the client to determine if there was any recent thin, watery drainage
from the nose.
Rationale 1: Request information from the client regarding increased propensity for bruising
or bleeding. The client may have a blood coagulation disorder that may result in increased bruising
or bleeding. This disorder may have produced the episodes of epistaxis.
Rationale 2: Assess the tonsils for redness or swelling. Red, swollen tonsils are associated with
tonsillitis. Tonsillitis is not associated with epistaxis.
Rationale 3: Obtain a blood pressure. Hypertension is a contributory factor to the occurrence of

nosebleeds. The nurse should assess the clients blood pressure to determine if it is elevated.
Rationale 4: Check for deviated septum. A deviated septum is not associated with epistaxis.
Rationale 5: Request information from the client to determine if there was any recent thin,
watery drainage from the nose. Thin, watery drainage from the nose is associated with rhinitis.
Rhinitis is associated with epistaxis.
Global Rationale: The client may have a blood coagulation disorder that may result in increased
bruising or bleeding. This disorder may have produced the episodes of epistaxis. Red, swollen
tonsils are associated with tonsillitis. Tonsillitis is not associated with epistaxis. Hypertension is a
contributory factor to the occurrence of nosebleeds. The nurse should assess the clients blood
pressure to determine if it is elevated. A deviated septum is not associated with epistaxis. Thin,
watery drainage from the nose is associated with rhinitis. Rhinitis is associated with epistaxis.
Client Need Sub:
Question 21
Type: MCSA
The nurse is examining a 14-month-old child when the mother tells the nurse that the child cries
frequently, has a fever, and is pulling at both ears. The nurse suspects the child has which of the
following disorders from this assessment data?
1. Otitis media
2. Otitis externa
3. Hemotympanum
4. Tophi
Correct Answer: 1
Rationale 1: The auditory canal of infants is shorter and has an upward curve that persists until
about the age of 3. In addition, their auditory tube is more horizontal than the adult, which leads to
easier migration of organisms from the throat to the middle ear. Infants and children with otitis media
often display the behavior of pulling at their ears.
Rationale 2: Otitis externa is an infection of the external auditory canal manifested by red, swollen
ear canal, fever, and purulent drainage.
Rationale 3: Hemotympanum is a bluish tinge of the tympanic membrane indicating the presence of
blood in the middle ear. It is usually associated with head trauma.
Rationale 4: Tophi are small white nodules on the helix or antihelix. These nodules contain uric acid
crystals and are a sign of gout.
Global Rationale: The auditory canal of infants is shorter and has an upward curve that persists
until about the age of 3. In addition, their auditory tube is more horizontal than the adult, which leads
to easier migration of organisms from the throat to the middle ear. Infants and children with otitis
media often display the behavior of pulling at their ears. Otitis externa is an infection of the external
auditory canal manifested by red, swollen ear canal, fever, and purulent drainage. Hemotympanum
is a bluish tinge of the tympanic membrane indicating the presence of blood in the middle ear. It is
usually associated with head trauma. Tophi are small white nodules on the helix or antihelix. These
nodules contain uric acid crystals and are a sign of gout.
Client Need Sub:
Question 22
Type: MCSA
The nurse is triaging a client and notes pallor and cyanosis of the oral cavity and lips. Based on this
finding, the nurse would implement which of the following actions first?
1. Administer IV fluids.
2. Provide oral hygiene.
3. Administer oxygen.
4. Provide a warm drink.

Correct Answer: 3
Rationale 1: There is no indication the client has an electrolyte or fluid imbalance at this time,
making the administration of IV fluids inappropriate at this time.
Rationale 2: Pallor and cyanosis of the oral cavity and lips are assessment findings that indicate
hypoxia. Providing oral hygiene is not an appropriate intervention because it will not increase the
clients oxygenation levels.
hypoxia. The nurse should apply oxygen for the client.
hypoxia. Providing a warm drink will not correct the clients oxygenation problem.
Global Rationale: Pallor and cyanosis of the oral cavity and lips are assessment findings that
indicate hypoxia. The nurse should apply oxygen for the client. There is no indication the client has
an electrolyte or fluid imbalance at this time, making the administration of IV fluids inappropriate at
this time. Providing oral hygiene is not an appropriate intervention because it will not increase the
clients oxygenation levels. Providing a warm drink will not correct the clients oxygenation problem.
Client Need Sub:
Question 23
Type: MCSA
The nurse is assessing the clients nasal mucosa and notes the presence of a thin, watery
discharge. The client complains of sneezing and nasal congestion. The nurse would suspect which
of the following in this situation?
1. Rhinitis
2. Perforated septum
3. Previous epistaxis
4. Nasal polyps
Correct Answer: 1
Rationale 1: These clinical manifestations are associated with rhinitis. Rhinitis is inflammation of the
nasal mucosa due to a viral infection or allergy.
Rationale 2: A perforated septum is a hole in the septum caused by chronic infection, trauma, or
sniffing cocaine. It can be detected by shining a penlight through the naris on the other side.
Rationale 3: With a history of epistaxis, the nurse would note that there is old dried blood on the
nasal mucosa.
Rationale 4: Nasal polyps are pale, round, firm, nonpainful overgrowth of nasal mucosa.
Global Rationale: These clinical manifestations are associated with rhinitis. Rhinitis is inflammation
of the nasal mucosa due to a viral infection or allergy. A perforated septum is a hole in the septum
caused by chronic infection, trauma, or sniffing cocaine. It can be detected by shining a penlight
through the naris on the other side. With a history of epistaxis, the nurse would note that there is old
dried blood on the nasal mucosa. Nasal polyps are pale, round, firm, nonpainful overgrowth of nasal
mucosa.
Client Need Sub:
Question 24
Type: MCSA
The nurse is assessing the oral cavity of a client and notes a blackish, furry-looking coating on the
tongue. Which of the following questions would be appropriate for the nurse to include when
obtaining further assessment data?
1. Have you eaten licorice lately?
2. How often do you brush your tongue?

3. Have you recently taken antibiotics?
4. Have you ever had this happen before?
Correct Answer: 3
Rationale 1: This finding is unrelated to food intake such as eating licorice.
Rationale 2: This finding is not related to poor oral hygiene practices.
Rationale 3: The presence of a black, furry-looking coating on the tongue is usually related to an
overgrowth of fungus due to inhibition of normal bacteria due to antibiotic use.
Rationale 4: It may helpful for the nurse to determine if the condition has occurred previously but it
is not the most important question. The nurse should question the client regarding recent antibiotic
use.
Global Rationale: The presence of a black, furry-looking coating on the tongue is usually related to
an overgrowth of fungus due to inhibition of normal bacteria due to antibiotic use. This finding is not
related to poor oral hygiene practices. It is unrelated to food intake such as eating licorice. It may
helpful for the nurse to determine if the condition has occurred previously but it is not the most
important question. The nurse should question the client regarding recent antibiotic use.
Client Need Sub:
Question 25
Type: MCSA
An elderly client says, I cant seem to hear as well as I could when I was younger. The nurse
suspects this client is experiencing which of the following disorders?
1. Presbycusis
2. Mastoiditis
3. Otitis media
4. Otitis externa
Correct Answer: 1
Rationale 1: Age-related changes include loss of low- and high-frequency hearing, also known as
presbycusis.
Rationale 2: Mastoiditis is a complication of either a middle ear infection or a throat infection. The
client would complain of pain or tenderness behind the ear.
Rationale 3: Otitis media is an infection of the middle ear producing a red, bulging eardrum, fever,
and hearing loss.
Rationale 4: Otitis externa is an infection of the outer ear, often called swimmers ear. Otitis
externa causes redness and swelling of the auricle and ear canal.
Global Rationale: Age-related changes include loss of low- and high-frequency hearing, also known
as presbycusis. Mastoiditis is a complication of either a middle ear infection or a throat infection. The
client would complain of pain or tenderness behind the ear. Otitis media is an infection of the middle
ear producing a red, bulging eardrum, fever, and hearing loss. Otitis externa is an infection of the
outer ear, often called swimmers ear. Otitis externa causes redness and swelling of the auricle and
ear canal.
Client Need Sub:
Question 26
Type: MCSA
The nurse is assessing the oral mucosa of a pregnant female and notes enlargement of the gums.
The client states that regular oral hygiene is performed and that she does not understand why this
has occurred. Which of the following is the nurses best response?
1. You may have oral cancer.

2. You are experiencing a normal change during pregnancy.
3. You may have leukoplakia.
4. You need to decrease the frequency of your oral hygiene.
Correct Answer: 2
Rationale 1: Early signs of oral cancer are manifested by ulcers in the lower lip and under the
tongue that do not heal normally.
Rationale 2: Gingival hyperplasia (enlargement of the gums) is a normal physiologic change
associated with pregnancy. It is also seen in clients with leukemia and prolonged use of Dilantin.
Rationale 3: Leukoplakia is a whitish thickening of the mucous membrane in the mouth or tongue. It
cannot be scraped off. It is most often associated with heavy smoking or drinking, and it can be a
precancerous condition.
Rationale 4: Advanced gingivitis and poor dental hygiene are manifested by swollen red gums that
will bleed when brushed, and will show separation of the gum from the tooth.
Global Rationale: Gingival hyperplasia (enlargement of the gums) is a normal physiologic change
associated with pregnancy. It is also seen in clients with leukemia and prolonged use of Dilantin.
Early signs of oral cancer are manifested by ulcers in the lower lip and under the tongue that do not
heal normally. Leukoplakia is a whitish thickening of the mucous membrane in the mouth or tongue.
It cannot be scraped off. It is most often associated with heavy smoking or drinking, and it can be a
precancerous condition. Advanced gingivitis and poor dental hygiene are manifested by swollen red
gums that will bleed when brushed, and will show separation of the gum from the tooth.
Client Need Sub:
Learning Outcome: 14.6: Describe developmental, psychosocial, cultural, and environmental
variations in assessment techniques and findings.
Question 27
Type: MCMA
The nurse is discharging an 11-month-old child who was brought to the emergency room for the
treatment of an ear infection and fever. The nurse would include which of the following statements in
the discharge teaching to the parents?
1. The babys last bottle before bedtime should only contain water.
2. It is important not to prop the babys bottle during feeding.
3. You must rinse the babys mouth right after the baby falls asleep.
4. You must perform oral hygiene more frequently throughout the day.
5. The last bottle of the evening should not be given just before the baby goes to sleep.
Correct Answer: 2,5
Rationale 1: The babys last bottle before bedtime should only contain water. Milk should not
be replaced with water because the baby may not receive enough nutrition. Bottles should not be
given just before bedtime.
Rationale 2: It is important not to prop the babys bottle during feeding. A primary source of
ear infection in infants and small children is the practice of propping the bottle with milk or juice. The
sugar in these liquids remains in the mouth and contributes to the potential for infection in the throat,
which travels through the shorter, narrower, and more horizontal auditory tube.
Rationale 3: You must rinse the babys mouth right after the baby falls asleep. This would
not be appropriate and might be dangerous for the baby. Providing oral hygiene for children
immediately before bedtime might be helpful to help reduce the risk of ear infections.
Rationale 4: You must perform oral hygiene more frequently throughout the day. Increasing
the oral hygiene frequency throughout the day will not improve this situation if bottle propping is
occurring or if the baby is given a bottle immediately prior to bedtime.
Rationale 5: The last bottle of the evening should not be given just before the baby goes to
sleep. A major source of ear infection in infants and small children is the practice of giving the baby
a bottle at bedtime. The sugar in these liquids remains in the mouth and contributes to the potential
for infection in the throat, which travels through the shorter, narrower, and more horizontal auditory
tube.
Global Rationale: Milk should not be replaced with water because the baby may not receive
enough nutrition. Bottles should not be given just before bedtime. A primary source of ear infection in
infants and small children is the practice of propping the bottle with milk or juice. The sugar in these
liquids remains in the mouth and contributes to the potential for infection in the throat, which travels
through the shorter, narrower, and more horizontal auditory tube. This would not be appropriate and
might be dangerous for the baby. Providing oral hygiene for children immediately before bedtime
might be helpful to help reduce the risk of ear infections. Increasing the oral hygiene frequency
throughout the day will not improve this situation if bottle propping is occurring or if the baby is given
a bottle immediately prior to bedtime. A major source of ear infection in infants and small children is
the practice of giving the baby a bottle at bedtime. The sugar in these liquids remains in the mouth
and contributes to the potential for infection in the throat, which travels through the shorter, narrower,
and more horizontal auditory tube.
Client Need Sub:
Question 28
Type: MCSA
The nurse is assessing the ears, nose and mouth of an Asian client with a student nurse. Which of
the following statements made by the nurse to the student nurse about cultural differences is
accurate?
1. Asians are more likely to experience greater difficulty with otitis media than people from other
cultures.
2. Sometimes in Asians and Native Americans, their ear wax looks dry and dark.
3. Asians have a higher risk of having issues associated with cleft lips and cleft palates.
4. Asians have a high incidence of tooth decay.
Correct Answer: 2
Rationale 1: Asians do not have a tendency to develop otitis media more than other cultures.
Rationale 2: Cerumen appears dry and gray to brown in Asians and Native Americans. Cerumen
found in Caucasians and African Americans looks moist and yellow-orange in color.
Rationale 3: Cleft lip and palate occur with greatest frequency in Asians and least often in African
Americans.
Rationale 4: Caucasians have the highest incidence of tooth decay.

Global Rationale: Cerumen appears dry and gray to brown in Asians and Native Americans.
Cerumen found in Caucasians and African Americans looks moist and yellow-orange in color.
Asians do not have a tendency to develop otitis media more than other cultures. Cleft lip and palate
occur with greatest frequency in Asians and least often in African Americans. Caucasians have the
highest incidence of tooth decay.
Client Need Sub:
Question 29
Type: MCSA
The nurse is assessing several children in a pediatric clinic. Which of the following children might be
experiencing delayed development?
1. The 6-year-old child has lost 2 deciduous teeth.
2. The 26-month-old child has one baby tooth.
3. The 4-month-old infant is drooling.
4. The 2-month-old infants salivary glands are not producing saliva.
Correct Answer: 2
Rationale 1: Eruption of permanent teeth begins at around age 6 and continues through
adolescence.
Rationale 2: Deciduous (baby) teeth begin to erupt between 6 months and 2 years of age. A 26month-old child might be expected to have more than one deciduous tooth.
Rationale 3: Drooling of saliva occurs for several months after saliva is produced (3 months old)
until swallowing saliva is learned.
Rationale 4: Salivation begins at 3 months of age.

Global Rationale: Eruption of permanent teeth begins at around age 6 and continues through
adolescence. Deciduous (baby) teeth begin to erupt between 6 months and 2 years of age. A 26month-old child might be expected to have more than one deciduous tooth. Drooling of saliva occurs
for several months after saliva is produced (3 months old) until swallowing saliva is learned.
Salivation begins at 3 months of age.
Client Need Sub:
Question 30
Type: MCMA
During the focused interview, the client provides information to the nurse regarding her daughters
recent diagnosis with cancer. The client is exhibiting clinical manifestations associated with anxiety.
During the physical assessment, which of the following findings might be expected?
1. The client complains of pain when the tragus is gently manipulated.
2. The client has several small ulcers on her lip.
3. Pale nasal mucosa
4. Small sores are noted within the mouth.
5. Perforated nasal septum
Rationale 1: The client complains of pain when the tragus is gently manipulated. Pain that
occurs with manipulation of the tragus may accompany temporomandibular joint dysfunction that
may be associated with jaw clenching. Jaw clenching can accompany psychological stress.
Rationale 2: The client has several small ulcers on her lip. Clients who are under a great deal of
stress might bite their lips.
Rationale 3: Pale nasal mucosa. Pale nasal mucosa is associated with cocaine use, infection,
hypoxia, and allergies.
Rationale 4: Small sores are noted within the mouth. Clients who are under a great deal of stress
might present with ulcers in their mouth.
Rationale 5: Perforated nasal septum. A perforated nasal septum is associated with cocaine use.
Global Rationale: Pain that occurs with manipulation of the tragus may accompany
temporomandibular joint dysfunction that may be associated with jaw clenching. Jaw clenching can
accompany psychological stress. Clients who are under a great deal of stress might bite their lips.
Pale nasal mucosa is associated with cocaine use, infection, hypoxia, and allergies. Clients who are
under a great deal of stress might present with ulcers in their mouth. A perforated nasal septum is
associated with cocaine use.
Client Need Sub:
Question 31
Type: MCMA
The nurse is conducting a hearing assessment on an older adult client with impacted cerumen noted
in the right ear canal. When performing the Weber test, the nurse would expect to learn which of the
following?
1. Air conduction is longer than bone conduction.
2. Bone conduction is longer than air conduction.
3. Sound lateralized to the right ear.
4. The client is unable to maintain balance while standing.

5. The 4 year old placed a pea into his nose during lunch.
Correct Answer: 3
Rationale 1: The Rinne test, not the Weber test, compares air and bone conduction.
Rationale 2: The Rinne test, not the Weber test, compares air and bone conduction.
Rationale 3: The Weber test uses bone conduction to evaluate hearing in a person who hears better
in one ear than in the other. With impacted cerumen, an ear infection, or a perforated tympanic
membrane, the sound will lateralize to the affected ear during the Weber test.
Rationale 4: The Romberg test is used to determine equilibrium and the clients ability to maintain
balance while standing.
Rationale 5: The 4 year old placed a pea into his nose during lunch. Children are more likely to
introduce foreign objects into their mouth and nose. This behavior is not associated with gum or oral
mucosa problems.
Global Rationale: The Rinne test compares air and bone conduction. Normally, the sound is heard
twice as long by air conduction than by bone conduction after bone conduction stops. The Weber
test uses bone conduction to evaluate hearing in a person who hears better in one ear than in the
other. With impacted cerumen, an ear infection, or a perforated tympanic membrane, the sound will
lateralize to the affected ear during the Weber test. The Romberg test is used to determine
equilibrium and the clients ability to maintain balance while standing.
Client Need Sub:
Learning Outcome: 14.8: Apply critical thinking in selected simulations related to physical
assessment of the structures of the ear, nose, mouth, and throat.
Question 32
Type: MCSA
The nurse is performing the Weber test. The nurse documents that the sound lateralized to the
clients right ear. The student nurse observing the assessment asks the nurse about the meaning of
this documentation. Which of the following is the nurses best response?
1. This just means that I am unable to visualize the clients tympanic membrane.
2. It refers to the clients inability to hear whispered statements.
3. The client is able to hear bone-conducted sound longer than air conducted sound.
4. The client is able to hear bone-conducted sound better through the impaired ear.
Correct Answer: 4
Rationale 1: While it is possible that the nurse is unable to visualize the tympanic membrane due to
cerumen and this is the reason for sound lateralizing to one ear during the Weber test, this is not the
nurses best response.
Rationale 2: The clients ability to hear whispered statements at 12 feet away is assessed during
the whisper test.
Rationale 3: The Weber test is performed to determine if during bone conduction, with the use of a
tuning fork, the client hears the sound in one ear better than the other. If there is impaired
conduction in one ear, the sound will lateralize to that ear during the Weber test.
Rationale 4: The Rinne test compares air and bone conduction of sound with the use of a tuning
fork.
Global Rationale: While it is possible that the nurse is unable to visualize the tympanic membrane
due to cerumen and this is the reason for sound lateralizing to one ear during the Weber test, this is
not the nurses best response. The Weber test is performed to determine if during bone conduction,
with the use of a tuning fork, the client hears the sound in one ear better than the other. If there is
impaired conduction in one ear, the sound will lateralize to that ear during the Weber test. The
clients ability to hear whispered statements at 12 feet away is assessed during the whisper test.
The Rinne test compares air and bone conduction of sound with the use of a tuning fork.
Client Need Sub:
Question 33
Type: MCSA
The client admits to cleaning his ears with a cotton-tipped applicator. As a consequence, the client
has developed impacted cerumen and unilateral hearing loss. As the nurse prepares the clients plan
of care, which of the following nursing diagnoses is most applicable?
1. Acute pain
2. Knowledge deficit
3. Acute confusion
4. Unilateral neglect
Correct Answer: 2
Rationale 1: Acute pain would be appropriate if the client had perforated the tympanic membrane
with the cotton-tipped applicator. However, there are no data to suggest this.
Rationale 2: Of the choices, the best nursing diagnosis for this client is knowledge deficit regarding
how to adequately care for his ears. Another possible nursing diagnosis that would be applicable for
this client is disturbed sensory perception because he will be unable to hear well out of the ear that
is impacted with cerumen.
Rationale 3: Acute confusion is not an appropriate nursing diagnosis. This client will not develop
confusion as a result of unilateral hearing loss.
Rationale 4: The client will not neglect one side as a result of unilateral hearing loss.
Global Rationale: Of the choices, the best nursing diagnosis for this client is knowledge deficit
regarding how to adequately care for his ears. Another possible nursing diagnosis that would be
applicable for this client is disturbed sensory perception because he will be unable to hear well out of
the ear that is impacted with cerumen. Acute pain would be appropriate if the client had perforated
the tympanic membrane with the cotton-tipped applicator. However, there are no data to suggest
this. Acute confusion is not an appropriate nursing diagnosis. This client will not develop confusion
as a result of unilateral hearing loss. The client will not neglect one side as a result of unilateral
hearing loss.
Client Need: Safe Effective Care Environment
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Planning

Chapter 13
DAmico/Barbarito Health & Physical Assessment in Nursing, 2/e
Chapter 13
Question 1
Type: MCMA
The nurse is assessing a client who is 34 weeks pregnant. Which of the following visual changes are
usually normal in this stage in pregnancy and should disappear at some point after delivery?
1. The client is complaining that her eyes feel very dry.
2. She states that she is experiencing blurry vision.
3. Periorbital edema is noted.
4. Cataracts are noted.
5. She has been unable to wear her contact lenses.
Rationale 1: The client is complaining that her eyes feel very dry. The pregnant client may
complain of dry eyes. This symptom is usually not significant and disappears after childbirth.
Rationale 2: She states that she is experiencing blurry vision. The pregnant client may describe
visual changes such as blurry vision due to shifting fluid within the eye. Blurriness or distorted vision
can occur because of temporary changes in the shape of the eye during the last trimester of
pregnancy.
Rationale 3: Periorbital edema is noted. Eyelid edema is not a common problem associated with
pregnancy. Periorbital edema may signal an underlying problem.
Rationale 4: Cataracts are noted. Cataracts are not commonly associated with pregnancy.
Rationale 5: She has been unable to wear her contact lenses. Pregnant women often
discontinue wearing their contact lenses during their pregnancy as a result of fit and comfort.
Global Rationale: The pregnant client may complain of dry eyes. This symptom is usually not
significant and disappears after childbirth. The pregnant client may describe visual changes such as
blurry vision due to shifting fluid within the eye. Blurriness or distorted vision can occur because of
temporary changes in the shape of the eye during the last trimester of pregnancy. Pregnant women
often discontinue wearing their contact lenses during their pregnancy as a result of fit and comfort.
Eyelid edema is not a common problem associated with pregnancy. Periorbital edema may signal an
underlying problem. Cataracts are not commonly associated with pregnancy.
Client Need Sub:
Learning Outcome: 13.1: Discuss the anatomy and physiology of the eye.
Question 2
Type: MCSA
The nurse noted that the client was unable to control the amount of light that came into her eye. The
dysfunction of which of the following structures is the most likely cause of this problem?
1. Cornea
2. Sclera
3. Conjunctiva
4. Iris
Correct Answer: 4
Rationale 1: The cornea is the window of the eye. It is the clear, transparent part of the sclera and
forms the anterior one sixth of the eye.
Rationale 2: The sclera supports and protects the structures of the eye.
Rationale 3: The conjunctiva protects the eye and produces a lubricating fluid that prevents the eye
from becoming too dry.
Rationale 4: The iris responds to the light coming through the cornea by making the pupil larger or
smaller, thereby controlling the amount of light that enters the eye.
Global Rationale: The cornea is the window of the eye. It is the clear, transparent part of the sclera
and forms the anterior one sixth of the eye. The sclera supports and protects the structures of the
eye. The conjunctiva protects the eye and produces a lubricating fluid that prevents the eye from
becoming too dry. The iris responds to the light coming through the cornea by making the pupil
larger or smaller, thereby controlling the amount of light that enters the eye.
Client Need Sub:
Question 3
Type: MCMA
The nurse is examining the eye. The client asks about the specific structures within the eye that are
responsible for refraction of light rays. The nurse accurately states that the following structures are
involved in this process:
1. Lens
2. Macula
3. Cornea
4. Iris
5. Optic disc
Correct Answer: 1,3
Rationale 1: Lens. The lens is located directly behind the pupil and is used to refract light through
the eye.
Rationale 2: Macula. The macula is located within the retina and does not assist with light
refraction.
Rationale 3: Cornea. The cornea is a transparent part of the eye and located anteriorly. It allows
light to enter the eye and assists with refraction.
Rationale 4: Iris. The iris controls the amount of light that enters the eye, but is not associated with
refraction.
Rationale 5: Optic disc. The optic disc is where the optic nerve and retina meet. It is where the
vascular network enters the eye. This structure is not associated with refraction.
Global Rationale: The lens is located directly behind the pupil and is used to refract light through
the eye. The macula is located within the retina and does not assist with light refraction. The cornea
is a transparent part of the eye and located anteriorly. It allows light to enter the eye and assists with
refraction. The iris controls the amount of light that enters the eye, but is not associated with
refraction. The optic disc is where the optic nerve and retina meet. It is where the vascular network
enters the eye. This structure is not associated with refraction.
Client Need Sub:
Question 4
Type: MCSA
The nurse taught the client how to self-administer eye drops and the client was performing a return
demonstration. During this time, the client inadvertently touched the applicator to their cornea, which
caused the client to blink and produce tears. The nurse may document this response as which of the
following?
1. Abnormal and should be reported to the healthcare provider
2. Hyperactive
3. A medication side effect
4. A normal response
Correct Answer: 4
Rationale 1: When the cornea is touched, the eyelids blink and tears are produced. The cornea
contains many nerve endings and this action would produce a painful sensation for the client. This is
not an abnormal response.
Rationale 2: This would not be noted as a hyperactive response.
Rationale 3: This is not due to a medication side effect.
Rationale 4: This is a normal response because the cornea is very sensitive.
Global Rationale: When the cornea is touched, the eyelids blink and tears are produced. The
cornea contains many nerve endings and this action would produce a painful sensation for the client.
This is not an abnormal response. This would not be noted as a hyperactive response. This is not
due to a medication side effect. This is a normal response because the cornea is very sensitive.
Client Need Sub:
Question 5
Type: MCHS
The client requests information about where visual information is processed within the brain. Draw
an arrow pointing to the location of the occipital lobe.
Correct Answer:
Rationale : Optic tracts encircle the brain and the impulses are transmitted to the occipital lobe of
the brain for interpretation.
Global Rationale:
Client Need Sub:
Question 6
Type: MCMA
The nurse is assessing the clients eyes during a comprehensive health assessment. Which of the
following pieces of information should the nurse also gather?
1. The client is 62 years old.
2. The clients parents were born in Spain.

3. The clients annual income is below the poverty level.
4. The client is a welder.
5. The client recently attempted to commit suicide after his wife died in an automobile accident.
Correct Answer: 1,2,3,4,5
Rationale 1: The client is 62 years old. During a comprehensive health assessment, it is important
to gather objective information such as the clients age.
Rationale 2: The clients parents were born in Spain. During a comprehensive health
assessment, it is important to gather information about the clients ethnicity and race. Ethnicity may
influence how a client performs self-care activities. Hispanics have higher rates of visual
impairments than other races.
Rationale 3: The clients annual income is below the poverty level. During a comprehensive
health assessment, it is important to gather information about the clients socioeconomic status. This
may affect how often the client will visit a health care provider for his health care needs and routine
screening activities.
Rationale 4: The client is a welder. During a comprehensive health assessment, it is important to
gather information about the clients occupation. People who work in some settings are more likely to
experience eye injuries.
Rationale 5: The client recently attempted to commit suicide after his wife died in an
automobile accident. During a comprehensive health assessment, it is important to gather
information about the clients emotional well-being.
Global Rationale: During a comprehensive health assessment, it is important to gather objective
information such as the clients age. It is also important to gather information about the clients
ethnicity and race. Ethnicity may influence how a client performs self-care activities. Hispanics have
higher rates of visual impairments than other races. It is important to gather information about the
clients socioeconomic status. This may affect how often the client will visit a health care provider for
his health care needs and routine screening activities. It is important to gather information about the
clients occupation. People who work in some settings are more likely to experience eye injuries. It is
important to gather information about the clients emotional well-being.
Client Need Sub:

Question 7
Type: MCSA
The nurse is interviewing the mother of a three-week-old Caucasian infant. Which statement by the
mother indicates she requires further education about her infants eyes?
1. Its normal for my baby not to produce tears when she cries.
2. At this stage, my baby should be able to fixate on a bright light or something that moves.
3. My babys eyes are blue and definitely will stay blue.
4. It was normal for my babys eyes to be swollen after birth.
Correct Answer: 3
Rationale 1: At this stage, the baby may not be able to produce tears. By the fourth week, the baby
will begin to produce tears.
Rationale 2: At six weeks, the baby will begin to develop binocular vision. At this stage, the baby will
fixate on a bright light or a moving object.
Rationale 3: Light-skinned infants are born with blue eyes. By about the third month of age, the
color of the eyes begins to change to a more permanent shade.
Rationale 4: At birth, many infants have edematous eyelids.
Global Rationale: At this stage, the baby may not be able to produce tears. By the fourth week, the
baby will begin to produce tears. At six weeks, the baby will begin to develop binocular vision. At this
stage, the baby will fixate on a bright light or a moving object. Light-skinned infants are born with
blue eyes. By about the third month of age, the color of the eyes begins to change to a more
permanent shade. Before six weeks of age, infants will fixate on a bright or moving object. At birth,
many infants have edematous eyelids.
Client Need Sub:

Question 8
Type: MCSA
The nurse is assessing the eyes of an 82-year-old client. Which of the following findings are
expected by the nurse based on the clients age?
1. The client is easily able to read from a paper held at close range without corrective glasses.
2. There is a noticeable increase in fat within the orbit of the eye.
3. The client states that she feels her tear production has increased over the years.
4. The pupillary light reflex is slower bilaterally.
Correct Answer: 4
Rationale 1: The lens of the older clients eye is less elastic and the clients ciliary muscles will
become weaker. This results in a decreased ability to focus on objects that are held at close range.
Rationale 2: There is a decrease in the amount of fat in the orbit of the eye, which produces a
drooping appearance of the eye.
Rationale 3: Older adults experience a decrease in lacrimal secretions.
Rationale 4: The pupillary light reflex slows with age.
Global Rationale: The lens of the older clients eye is less elastic and the clients ciliary muscles will
become weaker. This results in a decreased ability to focus on objects that are held at close range.
There is a decrease in the amount of fat in the orbit of the eye, which produces a drooping
appearance of the eye. Older adults experience a decrease in lacrimal secretions. The pupillary light
reflex slows with age.
Client Need Sub:
Question 9
Type: MCSA
The nurse is performing a visual examination on a client due to the clients complaints of black dots
appearing in the visual field. Which of the following statement is the nurses best response to the
client?
1. The black dots are known as floaters and are usually normal.
2. We need to refer you to an eye surgeon immediately.
3. You may have glaucoma.
4. You may have a cataract.
Correct Answer: 1
Rationale 1: Black dots or spots are known as floaters. Floaters are considered normal unless they
obstruct vision, so they should not be immediately referred to a healthcare provider.
Rationale 2: Floaters are considered normal unless they obstruct vision, so they should not be
immediately referred to a healthcare provider.
Rationale 3: Halos around lights are associated with glaucoma.
Rationale 4: Floaters are not seen with cataracts.
Global Rationale: Black dots or spots are known as floaters. Floaters are considered normal unless
they obstruct vision, so they should not be immediately referred to a healthcare provider. Halos
around lights are associated with glaucoma. Floaters are not seen with cataracts.
Client Need Sub:
Question 10
Type: MCSA
The nurse is completing a focused interview with assessment of the eye. Which of the following is
most helpful to the nurse during the focused interview?
1. The client graduated from college.
2. The client interacts easily with the nurse.
3. The client is an African American male.
4. The client is 23 years old.
Correct Answer: 2
Rationale 1: It is important to determine the clients educational level.
Rationale 2: The clients ability to communicate is most essential to the interview. The nurse must
determine how well the client will be able to participate in the focused interview and follow directions
during the physical assessment.
Rationale 3: It is important to assess the clients race because this may influence what types of eye
conditions the client is at risk for developing.
Rationale 4: The clients age is important to assess because anatomical and physiologic changes
can occur in the eye across the lifespan.
Global Rationale: The clients ability to communicate is most essential to the interview. The nurse
must determine how well the client will be able to participate in the focused interview and follow
directions during the physical assessment. It is important to determine the clients educational level.
It is important to assess the clients race because this may influence what types of eye conditions
the client is at risk for developing. The clients age is important to assess because anatomical and
physiologic changes can occur in the eye across the lifespan.
Client Need Sub:
Question 11
Type: MCSA
A client was referred to the clinic with complaints of blurred vision. The initial question for the nurse
to ask the client would be which of the following?
1. Would you please tell me about your vision today?
2. Do you experience double vision?
3. Have you had any eye pain?
4. What kinds of activities do you perform at work?
Correct Answer: 1
Rationale 1: The best way to start the focused interview is to begin with open-ended questions that
provide the client with an opportunity to describe his own perceptions about his vision.
Rationale 2: Information about double vision is important, but not the best way to start the interview.
Rationale 3: Information about eye pain is important, but not the best way to start the interview.
Rationale 4: Information about work activities is important, but not the best way to start the
interview.
Global Rationale: The best way to start the focused interview is to begin with open-ended questions
that provide the client with an opportunity to describe his own perceptions about his vision. All of the
other questions are appropriate to ask at some point during the focused interview but are not the
best way to start the interview. It is important to determine if the client has experienced double
vision. Double vision can be caused by muscle or nerve problems and some types of medications. It
is important to determine if the client is experiencing eye pain because it can be associated with
glaucoma or other eye problems. It is important to determine the clients occupation because some
types of occupations put the client at risk for eye injury or eyestrain.
Client Need Sub:
Question 12
Type: MCSA
During an eye assessment, a 24-year-old client reports difficulty seeing items well at close range.
The nurse realizes this finding is consistent with:
1. aging.
2. presbyopia.
3. hyperopia.
4. astigmatism.
Correct Answer: 3
Rationale 1: Aging can produce changes in the eye but this client is 24 years old.
Rationale 2: Presbyopia is an age-related condition. The lens loses its ability to accommodate
viewing items at close range.
Rationale 3: Younger clients who are unable to see items well at close range have a condition
called hyperopia. This condition is also referred to as farsightedness.
Rationale 4: Astigmatism occurs when light is refracted over a wide area rather than on a distinct
area of the retina.
Global Rationale: Younger clients who are unable to see items well at close range have a condition
called hyperopia. This condition is also referred to as farsightedness. Aging can produce changes in
the eye but this client is 24 years old. Presbyopia is an age-related condition. The lens loses its
ability to accommodate viewing items at close range. Astigmatism occurs when light is refracted over
a wide area rather than on a distinct area of the retina.
Client Need Sub:
Learning Outcome: 13.3: Describe the techniques required for assessment of the eye.
Question 13
Type: MCSA
The nurse notices that a clients pupils constrict when reading the consent form for medical
treatment. This observation would lead the nurse to consider which of the following?
1. The room is too dark.
2. The client is able to read.
3. This is a normal response.
4. The client requires glasses for reading.
Correct Answer: 3
Rationale 1: When a room is dark, the clients pupils should dilate in response.
Rationale 2: Pupil constriction occurs as the client focuses on the paper. It does not indicate the
client can read.
Rationale 3: This is a normal finding. The clients pupils should constrict in response to trying to
read what is on the paper.
Rationale 4: Pupil constriction would not lead the nurse to believe the client needs reading glasses.
Global Rationale: When a room is dark, the clients pupils should dilate in response. Pupil
constriction occurs as the client focuses on the paper. It does not indicate the client can read. This is
a normal finding. The clients pupils should constrict in response to trying to read what is on the
paper. Pupil constriction would not lead the nurse to believe the client needs reading glasses.
Client Need Sub:
Question 14
Type: MCMA
During an eye examination, the nurse requests that the client read letters located on the Snellen E
chart. The clients vision is determined to be 20/200. Which of the following is true regarding these
findings?
1. The client is legally blind.
2. The client is unable to read from a paper at close range.
3. The client is found to be farsighted.
4. The client is myopic.
5. This is common in clients who are over 45 years old.
Correct Answer: 1,4
Rationale 1: The client is legally blind. When a clients vision is found to be 20/200, the client is
legally blind.
Rationale 2: The client is unable to read from a paper at close range. The Snellen E chart
assists with determining if the client is able to see items in the distance.
Rationale 3: The client is found to be farsighted. Clients who are farsighted are able to see things
in the distance. This client is unable to see distant objects.
Rationale 4: The client is myopic. Clients who are myopic are unable to see objects in the
distance.
Rationale 5: This is common in clients who are over 45 years old. Presbyopia is the inability to
see items at close range. This condition is more common in people who are over 45 years old.
Global Rationale: When a clients vision is found to be 20/200, the client is legally blind. The
Snellen E chart assists with determining if the client is able to see items in the distance. Clients who
are farsighted are able to see things in the distance. This client is unable to see distant objects.
Clients who are myopic are unable to see objects in the distance. Presbyopia is the inability to see
items at close range. This condition is more common in people who are over 45 years old.
Client Need Sub:

Question 15
Type: MCSA
The nurse is assessing a clients visual fields by confrontation. Which of the following nursing actions
indicates that the nurse requires further education regarding this test?
1. The nurse asks the client to cover one of her eyes with a card.
2. The nurse uses a penlight to assist with performing the test.
3. The nurse asks the client to sit 20 feet away.
4. The client tells the nurse when she first sees the object.
Correct Answer: 3
Rationale 1: Confrontation to test visual fields is done by asking the client to cover one eye with a
cover while the nurse covers the eye opposite to the client.
Rationale 2: The nurse and client sit 23 feet away from each other, at eye level. An object such as
a pen or penlight is advanced from the periphery to the midline. Both the client and the nurse should
be able to see the object at the same time.
Rationale 3: The nurse and client should sit only 23 feet away from each other.
Rationale 4: The client should tell the nurse when she first sees the object in her peripheral vision.
Global Rationale: Confrontation to test visual fields is done by asking the client to cover one eye
with a cover while the nurse covers the eye opposite to the client. The nurse and client sit 23 feet
away from each other, at eye level. An object such as a pen or penlight is advanced from the
periphery to the midline. Both the client and the nurse should be able to see the object at the same
time. The nurse and client should sit only 23 feet away from each other. The client should tell the
nurse when she first sees the object in her peripheral vision.
Client Need Sub:

Question 16
Type: HOTSPOT
The nurse is assessing the clients corneal reflex. Draw an arrow pointing to the area of the eye that
the nurse should test for the presence of this reflex.
Standard Text: Select the correct area on the image.

Correct Answer:
Rationale : The nurse should use a lateral approach and gently touch the clients cornea on the
outer aspect.
Global Rationale:
Client Need Sub:

Question 17
Type: MCSA
The nurse is assessing the clients eye with an ophthalmoscope. The nurse is preparing to focus on
the fundus and rotates the lens diopter wheel into the negative numbers. Based on this information,
which of the following conditions does the client most likely have?
1. Hyperopia
2. Presbyopia
3. Myopia
4. Astigmatism
Correct Answer: 3
Rationale 1: The diopter is rotated toward the positive numbers when the client is hyperopic.
Rationale 2: For presbyopia the diopter wheel is rotated until the fundus can be visualized
adequately.
Rationale 3: The diopter wheel is rotated into the negative numbers when the client is myopic.
Rationale 4: For astigmatism the diopter wheel is rotated until the fundus can be visualized
adequately.
Global Rationale: The diopter is rotated to help the nurse focus on the clients fundus. The diopter
is rotated toward the positive numbers when the client is hyperopic. The diopter wheel is rotated into
the negative numbers when the client is myopic. For any other condition such as presbyopia or
astigmatism, the diopter wheel is rotated until the fundus can be visualized adequately.
Client Need Sub:
Learning Outcome: 13.4: Explain the use of the ophthalmoscope.

Question 18
Type: HOTSPOT
The nurse is assessing the clients retina. Draw an arrow pointing toward the location of the optic
disc.
Standard Text: Select the correct area on the image.
Correct Answer:
Rationale : The optic disc can be identified by following the path of the blood vessels. As they grow
larger, they lead to the optic disc which is located on the nasal side of the retina. The optic disc
normally looks like a round or oval yellow-orange depression with a distinct margin. This is the site
where the optic nerve and blood vessels exit from the eye.
Global Rationale:

Client Need Sub:
Question 19
Type: MCSA
The nurse is assessing the fundus of the elderly clients eye with an ophthalmoscope. The nurse
determines that there is a cyst within the macula. Which of the following client symptoms may be
associated with this finding?
1. Impaired central vision
2. Impaired peripheral vision
3. Consistently elevated serum glucose levels
4. Uncontrolled hypertension
Correct Answer: 1
Rationale 1: Degeneration of the macula can be related to cysts located in this area. It is more
common in older adults and results in impaired central vision.
Rationale 2: Impaired peripheral vision can be related to problems with the rods that are located in
the retina.
Rationale 3: Elevated serum glucose levels may be associated with diabetic retinopathy.
Rationale 4: Uncontrolled hypertension can be associated with hypertensive retinopathy.
Global Rationale: Degeneration of the macula can be related to cysts located in this area. It is more
common in older adults and results in impaired central vision. Impaired peripheral vision can be
related to problems with the rods that are located in the retina. Elevated serum glucose levels may
be associated with diabetic retinopathy. Uncontrolled hypertension can be associated with
hypertensive retinopathy.

Client Need Sub:
Learning Outcome: 13.4: Explain the use of the ophthalmoscope
Question 20
Type: MCSA
The nurse is preparing to assess the clients eye with an ophthalmoscope while a student nurse is
observing. Which of the following statements by the nurse to the student nurse is accurate regarding
this portion of the assessment?
1. Im going to examine the clients right eye with my left eye.
2. Im going to advance the ophthalmoscope until the instrument touches the clients cornea.
3. Im going to begin with the lens set to the 0 diopter.
4. I can see the red reflex as the light reflects off of the clients lens.
Correct Answer: 3
Rationale 1: The nurse should prepare to assess the clients eye with an ophthalmoscope by
examining the clients right eye with the nurses right eye.
Rationale 2: The nurse should advance the ophthalmoscope only until it almost touches the clients
eyelashes. The cornea contains many nerve endings and this would be painful for the client.
Rationale 3: The nurse should always begin with the lens set to the 0 diopter.
Rationale 4: The red reflex is seen as light reflects off of the clients retina, not his lens.
Global Rationale: The nurse should always begin with the lens set to the 0 diopter. The nurse
should prepare to assess the clients eye with an ophthalmoscope by examining the clients right eye
with the nurses right eye. The nurse should advance the ophthalmoscope only until it almost
touches the clients eyelashes. The cornea contains many nerve endings and this would be painful
for the client. The red reflex is seen as light reflects off of the clients retina, not his lens.

Client Need Sub:
Question 21
Type: MCSA
The nurse is assessing a clients eyes during a comprehensive health assessment. The nurse knows
that the client who demonstrates clinical manifestations of which of the following conditions will
require immediate intervention?
1. Acute glaucoma
2. Blepharitis
3. Periorbital edema
4. Anisocoria
Correct Answer: 1
Rationale 1: Acute glaucoma results from a sudden increase in intraocular pressure caused by a
blockage in fluid flow around the anterior chamber. Acute glaucoma requires immediate
interventions to prevent further eye damage.
Rationale 2: Blepharitis is when the eyelid becomes inflamed. The eye burns, itches, and tears but
does not require an immediate intervention.
Rationale 3: Periorbital edema is when the eyelid becomes puffy and swollen. It can be related to
crying, infection, or systemic problems. It does not require an immediate intervention.
Rationale 4: Anisocoria refers to unequal pupil size, which may be a normal finding or it may
indicate that the client has a central nervous system disease.
Global Rationale: Acute glaucoma results from a sudden increase in intraocular pressure caused
by a blockage in fluid flow around the anterior chamber. Acute glaucoma requires immediate
interventions to prevent further eye damage. Blepharitis is when the eyelid becomes inflamed. The
eye burns, itches, and tears but does not require an immediate intervention. Periorbital edema is
when the eyelid becomes puffy and swollen. It can be related to crying, infection, or systemic
problems. It does not require an immediate intervention. Anisocoria refers to unequal pupil size,
which may be a normal finding or it may indicate that the client has a central nervous system
disease.
Client Need Sub:
Learning Outcome: 13.5: Differentiate normal from abnormal findings in physical assessment.
Question 22
Type: MCSA
The nurse is performing the cover test and notes inward turning of the eye. Which of the following
ways will the nurse accurately document this finding?
1. Exophoria
2. Strabismus
3. Esophoria
4. Mydriasis
Correct Answer: 3
Rationale 1: Exophoria is when the eye turns outward during the cover test.
Rationale 2: Strabismus is when the axes of the eye cannot be directed at the same object.
Rationale 3: Esophoria is when the eye turns inward during the cover test.
Rationale 4: Mydriasis refers to fixed and dilated pupils.
Global Rationale: Exophoria is when the eye turns outward during the cover test. Strabismus is
when the axes of the eye cannot be directed at the same object. Esophoria is when the eye turns
inward during the cover test. Mydriasis refers to fixed and dilated pupils.

Client Need Sub:
Question 23
Type: MCSA
A client is found to need corrective lenses for myopia. Which of the following explanations would the
nurse provide to this client?
1. Your glasses will help you to see objects in the distance.
2. Your glasses will help you to see objects that are very close to you.
3. Your glasses will help you to improve your eyes ability to focus and reduce your blurred vision.
4. Your age has made it more difficult to read items that are at close range. Your new glasses will
help.
Correct Answer: 1
Rationale 1: Myopia is the inability to see objects in the distance.
Rationale 2: Hyperopia is the inability to see objects at close range.
Rationale 3: Astigmatism causes blurred or double vision when the eyes attempt to focus.
Rationale 4: Presbyopia causes the client to experience difficulty focusing on items that are at close
range. Presbyopia affects people who are over 45 years old.
Global Rationale: Myopia is the inability to see objects in the distance. Hyperopia is the inability to
see objects at close range. Astigmatism causes blurred or double vision when the eyes attempt to
focus. Presbyopia causes the client to experience difficulty focusing on items that are at close range.
Presbyopia affects people who are over 45 years old.

Client Need Sub:
Question 24
Type: MCSA
The nurse is assessing the clients pupillary responses. The client is found to have no consensual
response. The finding indicates which of the following to the nurse?
1. Cranial nerve III may not be functioning appropriately.
2. This is a normal finding.
3. This is evidence of increased intracranial pressure.
4. This is evidence of optic nerve damage.
Correct Answer: 1
Rationale 1: When evaluating pupillary response, the unilluminated, or consensual, pupil should
also constrict. When this does not occur, it may be indicative of problems associated with cranial
nerve III.
Rationale 2: This is not a normal finding.
Rationale 3: Increased intracranial pressure is associated with pupils that are unequal and
irregularly shaped.
Rationale 4: This is not evidence that optic nerve damage has occurred. Optic nerve damage can
produce changes in the clients visual fields.
Global Rationale: When evaluating pupillary response, the unilluminated, or consensual, pupil
should also constrict. When this does not occur, it may be indicative of problems associated with
cranial nerve III. This is not a normal finding. Increased intracranial pressure is associated with
pupils that are unequal and irregularly shaped. This is not evidence that optic nerve damage has
occurred. Optic nerve damage can produce changes in the clients visual fields.

Client Need Sub:
Question 25
Type: MCSA
During the assessment of a clients eyes, the nurse suspects the client has entropian. Which of the
following did the nurse most likely find while assessing this client?
1. Eversion of the lower eyelid
2. Inversion of the lid and eyelashes
3. Swollen, red hair follicles
4. Firm, nontender nodule on the eyelid
Correct Answer: 2
Rationale 1: Ectropian is eversion of the lower eyelid caused by muscle weakness.
Rationale 2: Entropian is inversion of the lid and lashes caused by a muscle spasm of the eyelid.
Rationale 3: A stye causes swelling and redness in the affected eye. A stye is a result of a
staphylococcal infection of hair follicles on the margin of the lids.
Rationale 4: A chalazion is a firm, nontender nodule on the eyelid.
Global Rationale: Entropian is inversion of the lid and lashes caused by a muscle spasm of the
eyelid. Ectropian is eversion of the lower eyelid caused by muscle weakness. A stye causes swelling
and redness in the affected eye. A stye is a result of a staphylococcal infection of hair follicles on the
margin of the lids. A chalazion is a firm, nontender nodule on the eyelid.
Client Need Sub:

Question 26
Type: MCSA
During the assessment of a clients eyes, the nurse suspects that the client has ptosis. Which of the
following did the nurse most likely find?
1. The palpebral conjunctiva is exposed.
2. The iris and cornea are reddened.
3. The eyelid is drooping.
4. The eyelids are swollen and puffy.
Correct Answer: 3
Rationale 1: Ectropian is eversion of the lower eyelid caused by muscle weakness that produces
exposure of the palpebral conjunctiva.
Rationale 2: Iritis is characterized by redness of the iris and cornea.
Rationale 3: Ptosis is drooping of the eyelid.
Rationale 4: Periorbital edema refers to swollen, puffy eyelids.
Global Rationale: Ptosis is drooping of the eyelid. Ectropian is eversion of the lower eyelid caused
by muscle weakness that produces exposure of the palpebral conjunctiva. Iritis is characterized by
redness of the iris and cornea. Periorbital edema refers to swollen, puffy eyelids.
Client Need Sub:
Question 27
Type: MCSA
The nurse is assessing an adult African American client who is experiencing visual changes. Which
of the following questions would be the most important to ask this client?
1. Have you or anyone in your family ever been diagnosed with diabetes?
2. Do you wear sunglasses when you are outside?
3. Did your mother have a vaginal infection at the time of your delivery?
4. Do you see any halos around lights?
Correct Answer: 1
Rationale 1: Diabetic retinopathy is the leading cause of blindness in the United States. It is
important for the nurse to determine if the client has a personal or family history of diabetes. Type 2
diabetes occurs more frequently in African Americans, Asian Americans, Hispanic Americans, and
Native Americans than in Caucasian clients. This will assist the nurse to determine if the client may
be suffering visual changes as a result of diabetic retinopathy.
Rationale 2: The nurse can ask about the clients behaviors to determine his risk of developing
problems associated with ultraviolet radiation.
Rationale 3: When the nurse is assessing an infant, the nurse should inquire about whether the
mother of the infant had a vaginal infection at the time of delivery because this can result in eye
infections in the newborn.
Rationale 4: Clients who see halos around lights may be suffering from glaucoma and increased
intraocular pressure.
Global Rationale: Diabetic retinopathy is the leading cause of blindness in the United States. It is
important for the nurse to determine if the client has a personal or family history of diabetes. Type 2
diabetes occurs more frequently in African Americans, Asian Americans, Hispanic Americans, and
Native Americans than in Caucasian clients. This will assist the nurse to determine if the client may
be suffering visual changes as a result of diabetic retinopathy. The nurse can ask about the clients
behaviors to determine his risk of developing problems associated with ultraviolet radiation. When
the nurse is assessing an infant, the nurse should inquire about whether the mother of the infant had
a vaginal infection at the time of delivery because this can result in eye infections in the newborn.
Clients who see halos around lights may be suffering from glaucoma and increased intraocular
pressure.

Client Need Sub:
variations in assessment techniques and findings of the eye.
Question 28
Type: MCMA
The nurse is assessing a child previously diagnosed with fetal alcohol syndrome. Which of the
following statements by the clients adoptive mother are consistent with the childs diagnosis?
1. It seems as if one of his eyelids is droopy.
2. Theres a firm little bump on his eyelid but he says it doesnt hurt.
3. His eyes almost look cloudy.
4. He has required glasses to see well since he was 2 years old.
5. His eyelids look they have turned under and he complains that his eyes hurt.
Rationale 1: It seems as if one of his eyelids is droopy. A child with fetal alcohol syndrome
may experience ptosis.
Rationale 2: Theres a firm little bump on his eyelid but he says it doesnt hurt. Chalazions
are firm, nontender nodules located on the eyelids that are associated with infection. They are not
associated with fetal alcohol syndrome.
Rationale 3: His eyes almost look cloudy. Cataracts are associated with children who have
been diagnosed with fetal alcohol syndrome.
Rationale 4: He has required glasses to see well since he was 2 years old. Structural
abnormalities of the eye are associated with fetal alcohol syndrome. These abnormalities may result
in reduced visual acuity.
Rationale 5: His eyelids look like they have turned under and he complains that his eyes
hurt. Entropion is when the eyelids invert and the lashes can scratch the cornea. Entropion is not
associated with fetal alcohol syndrome.
Global Rationale: A child with fetal alcohol syndrome may experience ptosis. Chalazions are firm,
nontender nodules located on the eyelids that are associated with infection. They are not associated
with fetal alcohol syndrome. Cataracts are associated with children who have been diagnosed with
fetal alcohol syndrome. Structural abnormalities of the eye are associated with fetal alcohol
syndrome. These abnormalities may result in reduced visual acuity. Entropion is when the eyelids
invert and the lashes can scratch the cornea. Entropion is not associated with fetal alcohol
syndrome.
Client Need Sub:
Question 29
Type: MCSA
The nurse is preparing to discuss the cultural implications associated with eye diseases with a small
group of nursing students. Which of the following statement indicates that the nurse requires further
education about this subject?
1. It is important to assess the African American client for clinical manifestations associated with
increased intraocular pressure.
2. We should assess serum glucose levels in our adult Hispanic clients.
3. Our diabetic clients should return every 2 years for an assessment of their vision and their retina.
4. Poorly controlled serum glucose levels can result in retinal changes that affect the clients vision
and can even result in blindness.
Correct Answer: 3
Rationale 1: African Americans have a higher risk for developing glaucoma. Glaucoma occurs when
the flow of fluid around the anterior chamber of the eye is blocked and the clients intraocular
pressure increases.
Rationale 2: Hispanics are more likely to develop type 2 diabetes which can increase their risk of
developing visual changes associated with diabetic retinopathy.
Rationale 3: A client who has a personal or family history of diabetes should return each year for a
thorough examination of his vision and retina. Diabetic retinopathy is the leading cause of blindness
in the United States.
Rationale 4: Poorly controlled serum glucose levels are associated with diabetes. The client with
diabetes can develop diabetic retinopathy. The client with this condition can develop changes in his
retina and circulatory system.
Global Rationale: African Americans have a higher risk for developing glaucoma. Glaucoma occurs
when the flow of fluid around the anterior chamber of the eye is blocked and the clients intraocular
pressure increases. Hispanics are more likely to develop type 2 diabetes, which can increase their
risk of developing visual changes associated with diabetic retinopathy. A client who has a personal
or family history of diabetes should return each year for a thorough examination of his vision and
retina. Diabetic retinopathy is the leading cause of blindness in the United States. Poorly controlled
serum glucose levels are associated with diabetes. The client with diabetes can develop diabetic
retinopathy. The client with this condition can develop changes in his retina and circulatory system.
Client Need Sub:
Question 30
Type: MCSA
The nurse presented a program regarding objectives related to the overall health of eyes that are
addressed in Healthy People 2020. Which of the following statements made by an adult participant
in the program indicates an adequate understanding of these objectives?
1. My 4-year-old doesnt need his vision screened.
2. Im going to call my eye doctor and ask that she performs a dilated eye exam.
3. My mom has been complaining of dry eyes, but I knew it was all in her head.
4. I didnt know that Asians have the highest risk for developing glaucoma.
Correct Answer: 2
Rationale 1: Preschooler-aged children should have their vision screened to detect problems early.
Early detection can lead to early treatment.
Rationale 2: One of the objectives of Healthy People 2020 is to increase the number of people who
have dilated eye examinations performed. This is a screening method that can lead to early
detection of eye problems.
Rationale 3: Older adults have a decrease in tear secretions that result in complaints of dry eyes.
Rationale 4: African Americans have the greatest risk for developing glaucoma when compared to
other racial groups.
Global Rationale: Preschooler-aged children should have their vision screened to detect problems
early. Early detection can lead to early treatment. One of the objectives of Healthy People 2020 is to
increase the number of people who have dilated eye examinations performed. This is a screening
method that can lead to early detection of eye problems. Older adults have a decrease in tear
secretions that result in complaints of dry eyes. African Americans have the greatest risk for
developing glaucoma when compared to other racial groups.
Client Need Sub:
Learning Outcome: 13.7: Discuss the objectives related to overall health of the eyes and vision as
presented in Healthy People 2020.
Question 31
Type: MCMA
The nurse is performing a focused interview and eye assessment on a client. The nurse suspects
that the client is experiencing problems associated with her vision based on which of the following
pieces of data?
1. The client is frowning and squinting while she is reading the Snellen chart.
2. The client exhibits a symmetrical pupillary light reflex response.
3. As the nurse checks for accommodation, the pupils remain dilated.

4. The clients near vision acuity is 14/14 bilaterally.
5. When the cornea is lightly touched in the right eye, both eyelids close.
Correct Answer: 1,3
Rationale 1: The client is frowning and squinting while she is reading the Snellen chart. If the
client is frowning or squinting during the test of their ability to see distant objects, this is indicator that
the client may be experiencing visual problems.
Rationale 2: The client exhibits a symmetrical pupillary light reflex response. Symmetrical
pupillary responses are normal.
Rationale 3: As the nurse checks for accommodation, the pupils remain dilated. When
checking accommodation, the eyes should converge and the pupils should constrict as the eyes
focus on the penlight.
Rationale 4: The clients near vision acuity is 14/14 bilaterally. The normal result for near vision
is 14/14 in each eye.
Rationale 5: When the cornea is lightly touched in the right eye, both eyelids close. When
testing the corneal reflex, touch the eye gently and quickly with a wisp of cotton. The client will react
by blinking both eyes. If one or both eyes fail to respond, there could be a problem.
Global Rationale: If the client is frowning or squinting during the test of her ability to see distant
objects, this is indicator that the client may be experiencing visual problems. Symmetrical pupillary
responses are normal. When checking accommodation, the eyes should converge and the pupils
should constrict as the eyes focus on the penlight. The normal result for near vision is 14/14 in each
eye. When testing the corneal reflex, touch the eye gently and quickly with a wisp of cotton. The
client will react by blinking both eyes. If one or both eyes fail to respond, there could be a problem.
Client Need Sub:
assessment of the eye.
Question 32
Type: MCSA
The African American middle-aged client has been diagnosed with glaucoma. Which of the following
statements by the client indicate that further education is required?
1. I just thought my pupils were big, I didnt know it could be associated with glaucoma.
2. So, my headaches may be occurring because of the increased pressure within my eyes.
3. My race doesnt have anything to do with this diagnosis.
4. Those halos that I see around lights are associated with glaucoma.
Correct Answer: 3
Rationale 1: Glaucoma is a result of restricted fluid flow around the anterior chamber of the eye. The
blocked fluid flow results in an increase in the clients intraocular pressure. Dilated pupils can be
found in clients with glaucoma.
Rationale 2: Headaches are associated with glaucoma.
Rationale 3: African-Americans are more likely to develop glaucoma.
Rationale 4: Clients with glaucoma may state that they see halos around lights.
Global Rationale: Glaucoma is a result of restricted fluid flow around the anterior chamber of the
eye. The blocked fluid flow results in an increase in the clients intraocular pressure. Dilated pupils
can be found in clients with glaucoma. Headaches are associated with glaucoma. African-Americans
are more likely to develop glaucoma. Clients with glaucoma may state that they see halos around
lights.
Client Need Sub:
Question 33
Type: MCSA
The nurse is assessing the clients eyes. Which of the following findings is most consistent with
glaucoma?
1. Eyeballs are firm to palpation.
2. Pupils are constricted bilaterally.
3. Central vision is impaired.
4. The client has a history of syphilis.
Correct Answer: 1
Rationale 1: A clients eyeballs that are firm when palpated may have glaucoma.
Rationale 2: Dilated, not constricted, pupils are most often associated with glaucoma.
Rationale 3: Impaired central vision is associated with macular degeneration.
Rationale 4: Clients who have been infected previously with syphilis may develop a condition called
Argyll Robertson pupils. This is when the clients pupils are bilaterally constricted, small, irregular,
and nonreactive to light.
Global Rationale: A clients eyeballs that are firm when palpated may have glaucoma. Dilated, not
constricted, pupils are most often associated with glaucoma. Impaired central vision is associated
with macular degeneration. Clients who have been infected previously with syphilis may develop a
condition called Argyll Robertson pupils. This is when the clients pupils are bilaterally constricted,
small, irregular, and nonreactive to light.
Client Need Sub:
1.
The nurse is preparing to assess a middle-aged client. What should the nurse do first?
Hint: Basic Techniques of Physical Assessment; Inspection
a. Inspection
b. Percussion
c. Palpation
d. Auscultation
Inspection
Inspection always precedes the other assessment skills and is never rushed. The order of
assessment techniques is: inspection, palpation, percussion, and auscultation, except when
assessing the abdomen, where the techniques are inspection, auscultation, percussion, and
palpation.
2.
A client comes into the clinic with the complaint of swollen ankles. The nurse will utilize which
assessment technique to find out more information about this client?
Hint: Basic Techniques of Physical Assessment; Palpation
a. Inspection
b. Percussion
c. Palpation
d. Auscultation
Palpation
Palpation is the use of touch to assess specific body characteristics, which include size, shape,
location, mobility, position, vibration, temperature, texture, moisture, tenderness, and edema.
Palpating the ankle will give the nurse information about tenderness, temperature, mobility, and
edema characteristics. Visual inspection is also included in the assessment of the ankles, but
palpation will yield the most information. Percussion and auscultation are not techniques used to
assess the ankles.
3.
A client comes into the clinic with acute right lower quadrant abdominal pain. During the
abdominal assessment of this client, the nurse should:
Hint: Basic Techniques of Physical Assessment; Palpation
a. palpate the area first
b. palpate the area last
c. assess the area using deep palpation techniques
d. not palpate the area
palpate the area last
Known painful areas of the body are usually the last areas to be palpated. Palpating the painful
area first would not only increase the client's discomfort, but could also alter the assessment of
the rest of the abdomen. Deep palpation should be used with caution, especially if one suspects
that there is inflammation, peritonitis, or ectopic pregnancy. The area should be assessed using
light to moderate palpation.
4.
The nurse is preparing to assess a client with flank pain, discomfort with voiding, and pink-
tinged urine. Which assessment technique should the nurse use?

Hint: Basic Techniques of Physical Assessment; Percussion
a. Direct percussion
b. Reflexive percussion
c. Indirect percussion
d. Blunt percussion
Blunt percussion
Blunt percussion is used for assessing pain and tenderness in the gallbladder, liver, and kidneys.
With blunt percussion, the palm of the nondominant hand is flat against the body, and a closed
fist is used to strike the hand on the body. Direct percussion is tapping the body directly to
examine the sinuses or the thorax of an infant. Reflexive percussion is not an assessment
technique. Indirect percussion is the most common method used to produce sounds within the
body. To perform indirect percussion, the middle finger of the nondominant hand is placed
firmly over the area being examined. The middle finger of the dominant hand quickly strikes the
middle finger of the nondominant hand, producing vibrations and a sound.
5.
During the percussion of a client's abdomen, the nurse hears a loud, high-pitched, drumlike tone.
The nurse should document this finding as:
Hint: Basic Techniques of Physical Assessment; Percussion
a. resonance
b. hyperresonance
c. tympany
d. flatness
tympany
Tympany is a loud, high-pitched, drumlike tone of medium duration commonly heard over the
stomach or intestines. Resonance is a loud, low-pitched sound heard over the lungs.
Hyperresonance is a loud, long sound heard when air is trapped in the lungs. Flatness is a soft,
short sound heard over solid tissue such as bone.
6.
While auscultating the abdomen of a client, the nurse recognizes the bowel sounds are long. The
nurse understands this refers to:
Hint: Basic Techniques of Physical Assessment; Auscultation
a. intensity
b. pitch
c. duration
d. quality
duration
Duration refers to the length of time of the produced sound. This time frame ranges from very
short to very long with variation in between. Intensity refers to the softness or loudness of the
sound. Pitch refers to the number of vibrations of sound per second. Quality refers to the
overtones produced by the vibration such as clear, hollow, muffled, or dull.
7.
The nurse places the bell of the stethoscope on a client in order to assess:
Hint: Equipment; Stethoscope

a. heart murmur
b. lung sounds
c. normal heart sounds
d. abdominal sounds
heart murmur
The bell detects low-pitched sounds such as heart murmurs or bruits in arteries. Lung sounds,
normal heart sounds, and abdominal sounds are all considered high-pitched sounds and are
assessed using the diaphragm of the stethoscope.
To assess a client's blood pressure, the nurse will need:
Select all that apply.
Hint: Table 9.1 Equipment Used During the Physical Assessment
a. flashlight
b. sphygmomanometer
c. gloves
d. stethoscope
e. watch with a second hand
stethoscope
sphygmomanometer
To measure blood pressure, the stethoscope and sphygmomanometer are used. A flashlight,
gloves, and a watch with a second hand are not used in the measurement of blood pressure.
9.
A client complaining of ear pain is assessed by the nurse. What equipment will the nurse use in
the assessment of this client?
Hint: Special Equipment
a. Skin-fold calipers
b. Goniometer
c. Penlight
d. Otoscope
Otoscope
An otoscope is used in the assessment of the ear canal and tympanic membrane. Skin-fold
calipers are used to determine body fat. A goniometer measures the degree of joint flexion and
extension. A penlight is used to examine the pupils, mouth, and pharynx.
10.
A client with lower-extremity edema comes into the clinic. During the assessment, the nurse is
unable to palpate the client's pedal pulses. The nurse should:
Hint: Doppler Ultrasonic Stethoscope
a. do nothing
b. elevate the client's legs and reassess later
c. obtain the client's blood pressure
d. use a Doppler to assess the pulses
use a Doppler to assess the pulses

A Doppler uses ultrasonic waves that can detect the presence of pulses that are not palpable.
Doing nothing is not appropriate in this situation since the nurse needs to assess circulation to the
affected areas. Elevating the client's legs may help with edema over time, but the client's
circulation to the lower extremities should be assessed now. Blood pressure assessment should
be done with every client encounter; however, this will not assess the client's circulation in the
lower extremities.
While assessing the lower extremities of a client, the nurse notices several small scabs along the
inner aspects of both lower extremities. What is the most appropriate response by the nurse?
Hint: Professional Responsibilities; Cues
a. "You really did a job on yourself while shaving!"
b. "Are you in an abusive situation at home?"
c. "Can you tell me what caused these scabs on your legs?"
d. "Those scabs look painful. What happened to you?"
"Can you tell me what caused these scabs on your legs?"
The nurse is identifying a physical cue that is present during the physical examination. The nurse
is attempting to validate the finding, without assuming the cause of the cue. In this case, the
nurse is gathering more information about the cause of the scabs. The other options represent
assumptions on the nurse's part as far as the cause of the lesions.
12.
The nurse is preparing to conduct a physical assessment on a young adult with a gaping wound
on the right forearm. Before beginning this assessment, the nurse should first:
Hint: Providing a Safe and Comfortable Environment
a. wash hands
b. put on goggles
c. put on a sterile gown
d. put on a gloves
wash hands
The first thing that the nurse should do before beginning the physical examination of any client is
to wash the hands. After washing hands, the nurse should put on gloves since the client has a
gaping wound. A sterile gown and goggles are not necessary for the examination of this client.
13.
During the assessment of an obese client, it is necessary for the nurse to place the client in the
supine position. The nurse understands while the client is supine, it is most important to monitor
this client for:
Hint: Assessment of the Obese Patient
a. abdominal pain
b. respiratory distress
c. difficulty swallowing
d. fatigue
Auricle
The external portion of the ear. Cartilage covered with skin that funnels sound into the meatus
(opening) of the external auditory canal. Aka pinna
Tympanic Membrane
Aka Eardrum. Thin, translucent membrane is pearly gray in color and lies obliquely in the canal.
Eustachian Tube
Connects with the middle ear with the nasopharynx. These tubes help to equalize air pressure on
both side of the tympanic membrane.
Presbycusis
Gradual hearing loss with age
Air Conduction
Transmission of sound through the tympanic membrane to the cochlea and auditory nerve
Bone Conduction
Transmission of sound through the bones of the skull to the cochlea and the auditory nerve
Hemotympanum
A bluish tinge to the tympanic membrane indicating the presence of blood in the middle ear. It is
usually caused by head trauma.
Otis Externa
Infection of the outer ear, often called "swimmer's ear". Causes redness and swelling of the
auricle and ear canal
Otis Media
Infection the middle ear, producing a red bulging ear drum, fever and hearing loss. More
common in children, whose auditory tubes are wider, shorter and more horizontal than adults
Tophi
Small, white nodules on the helix or antihelix. Contain uric acid, crystals are are a sign of gout
Epistaxis
Nose bleed
Rhinitis
Nasal inflammation usually due to a viral infection or allergy.
-Acute rhinitis is caused by a virus.
-Allergic rhinitis caused from contact with allergen like pollen and dust
Deviated Septum
Slight ingrowth of the lower nasal septum
Perforated Septum
Hole in the septum caused by chronic infection, trauma or sniffing cocaine
Nasal Polyps
Pale, round, non-painful overgrowth of nasal mucosa. Usually caused by chronic allergic rhinitis
Smooth Tongue
Vitamin b and iron deficiency. Surface of the tongue is smooth and red with a shiny appearance
Anklyoglossia
Fixation of the tip on the tongue to the floor of the mouth due to a shortened frenulum
Aphthous Ulcers
Canker sores
Gingival Hyperplasia
Enlargement of the gums frequently seen in pregnancy, leukemia or after prolonged use of
phenytoin (Dilantin)
During an otoscopic assessment, the nurse notes the presence of large amounts of cerumen in the
client's external canal. The nurse knows:
1. Cerumen helps to lubricate and protect the ear.
2. Cerumen is needed to assist in the conduction of sound vibrations to the middle ear.
3. This indicates poor hygiene.
4. The client should clean his ears with cotton swabs.
1. Cerumen helps to lubricate and protect the ear.
-Cerumen helps to lubricate and protect the ear. It is not needed to assist in air conduction of
sound vibrations to the middle ear. The presence and amount of cerumen is not related to
hygiene practices. Cerumen removal with cotton swabs is not recommended.
A client tells the nurse, "I have a headache and pressure right above my nose and eyes. My nose
is stuffy too." The nurse knows that these symptoms might indicate:
1. Infection or inflammation of the frontal sinuses
2. Infection or inflammation of the maxillary sinuses
3. Infection or inflammation of the columella
4. Infection or irritation of the interior turbinate
1. Infection or inflammation of the frontal sinuses
-The paranasal sinuses are mucous-lined, air-filled cavities that surround the nasal cavity and
perform the functions of filtration, moistening, and warming. They are named for the bones of
the skill in which they are contained. The columella is the cartilaginous structure located
between the nares. The inferior turbinate is the lowest bony projection within the nose and is
covered with mucosa.
A two-year-old child is scheduled for the removal of her tonsils and adenoids. In which area of
this client's throat will the surgery be done?
1. Oropharynx and palate
2. Nasopharynx and oropharynx
3. Nasopharynx and laryngopharynx
4. Oropharynx and laryngopharynx
2. Nasopharynx and oropharynx
-The adenoids and openings of the eustachian tubes are located in the nasopharynx. The tonsils
are located behind the pillars within the oropharynx on either side.
When inspecting the mouth and throat of a client, the nurse considers which of the following to
be normal findings? Select all that apply.
1. Symmetrical rise of the soft palate and uvula when the client says, "aah."
2. The tonsils are red with white exudates present.
3. Salivary ducts are moist without redness or swelling.
4.The dorsal surface of the tongue is moist with papillae.
5. Smooth, pink nodules on the lateral sides of the tongue.
1, 3 and 4.
------------------------------------------------------------------------------------Symmetrical rise of the soft palate and uvula when the client says, "aah." Normal findings of the
tongue include symmetrical rise of the soft palate and uvula when the client says, "aah."
The tonsils are red with white exudates present. The tonsils should be pink without exudates.
Salivary ducts are moist without redness or swelling. Salivary ducts that are moist without
redness or swelling are a normal finding.
The dorsal surface of the tongue is moist with papillae. The dorsal surface of the tongue should
be well papillated and moist.
Smooth, pink nodules on the lateral sides of the tongue. The tongue should be free of lesions.
The mother of a young child tells the nurse that her her child has speech problems and was
diagnosed with ankyloglossia. She states that she doesn't understand what this condition is. What
can the nurse explain to the mother about this condition?
1. "Your child's tongue is slightly larger than normal and may be causing his speech problems."
2. "The aphthous ulcers your child has are related to this condition."
3. "Your child's nose bleed is caused by a perforated septum."
4. "The piece of tissue from the tip of the tongue to the floor of the mouth is shortened and is
likely causing your child's speech difficulties."
4. "The piece of tissue from the tip of the tongue to the floor of the mouth is shortened and is
likely causing your child's speech difficulties."
-Ankyloglossia is a fixation of the tip of the tongue to the floor of the mouth due to a shortened
lingual frenulum. The condition is usually congenital and may be corrected with surgery.
Enlargement of the tongue is not related to ankyloglossia. Aphthous ulcers (canker sores) are
lesions on the oral mucosa and not associated with this condition. Nose bleeds (epistaxis) are
also not related to ankyloglossia.
During the Weber test, the sound lateralizes to the client's right ear. This finding suggests:
1. A normal finding for the Weber test.
2. The test should be repeated.
3. The client has nerve damage.
4. The client has a potential hearing loss.
4. The client has a potential hearing loss.
-Lateralization of the Weber test indicates that the client could have a hearing loss. The client
could have either a conductive hearing loss or nerve damage with lateralization of the Weber
test. The normal response is no lateralization-the client should hear the sound equally in both
ears. If the client has poor conduction in one ear, the sound is heard better in the impaired ear
because the sound is being conducted directly through the bone to the ear and the extraneous
sounds in the environment are not picked up. There is no indication that the test should be
repeated. The Rinne test should be performed if the results of the Weber test are abnormal.
The nurse notes that a client has a smooth, red, shiny tongue with no lesions. Which of the
following is the most appropriate in this situation?
1. Ask whether the client has a history of halitosis.
2. Ask the client to describe his diet.
3. Look in the client record for a history of leukoplakia.
4. Continue with assessment as this is a normal finding for the tongue.
2. Ask the client to describe his diet.
-A smooth tongue is a condition resulting from vitamin B and iron deficiency. The surface of the
tongue is smooth and red with a shiny appearance. Halitosis is the presence of bad breath and not
applicable in this situation. Leukoplakia is a whitish thickening of the mucous membrane in the
mouth or tongue and is often a precancerous lesion. A smooth, shiny, red tongue is not a normal
finding.
When performing a focused interview with a pregnant client, the nurse asks the client whether
she has a "feeling of fullness" in her ears. What is the rationale for asking this question?
1. Fullness in the ears is often associated with hypertension and preeclampsia.
2. It indicates the presence of otitis media.
3. It is a normal symptom during pregnancy due to increased vascularity.
4. It is often associated with hearing loss.

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Chapter 14: Eyes

Chapter 14: Eyes

approximate completely. The nurse recognizes that this assessment finding:

b. May indicate a problem with extraocular muscles.

c. May result in problems with tearing.

d. Indicates increased intraocular pressure.

extraocular muscles is:

b. Impaired in a patient with cataracts.

c. Stimulated by cranial nerves (CNs) I and II.

d. Stimulated by CNs III, IV, and VI.

the outer layer of the eye is true?

the outer surface of the eye is stimulated.

impulses is located in the outer layer of the eye.

MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation

sympathetic branch of the autonomic nervous system:

b. Adjusts the eye for near vision.

c. Elevates the eyelid and dilates the pupil.

d. Causes contraction of the ciliary body.

factors determines intraocular pressure?

b. Posterior chamber as it accommodates increased fluid

Intraocular pressure is determined by a balance between the amount of aqueous

visual pathways and visual fields is true?

appearance in the outside world.

MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation

b. Pupillary dilation when looking at a far object

c. Changes in peripheral vision in response to light

d. Involuntary blinking in the presence of bright light

b. Light is reflected at the same spot in both eyes.

c. The eye focuses the image in the center of the pupil.

d. Constriction of both pupils occurs in response to bright light.

is not totally developed until 2 years of age.

develop the ability to focus on an object at approximately 8 months of

approximately 3 months of age, infants develop more coordinated eye

physiologic changes is responsible for presbyopia?

a. Degeneration of the cornea

b. Loss of lens elasticity

c. Decreased adaptation to darkness

d. Decreased distance vision abilities

the eyes of a black patient?

b. Dark retinal background

d. Narrowed palpebral fissures

moving in front of his eyes. The nurse should:

c. Consider these to be abnormal findings, and refer him to an ophthalmologist.

should the nurse proceed?

b. Ask the patient to read the print on a handheld Jaeger card.

d. Determine the patients ability to read newsprint at a distance of 12 to 14 inches.

nurse interprets these results to indicate that:

should take which action next?

front of his or her eyes.

record that distance.

finding to mean that the patient:

b. Has acute vision.

c. Has normal vision.

is reflected at 2 oclock in each eye. The nurse should:

b. Refer the individual for further evaluation.

c. Document this finding as an asymmetric light reflex.

d. Perform the confrontation test to validate the findings.

which of these results?

a. Convergence of the eyes

b. Parallel movement of both eyes

c. Nystagmus in extreme superior gaze

which of these an expected finding?

b. Pallor near the outer canthus of the lower lid