PE G178 (Cardiovascular Lab); EXAM 3- PHYSICAL | PE G178 _ 100% Correct Answers, Download to Score A.

EXAM 3 CHAPTER 13 1. A physician tells the nurse that a patient’s vertebra prominens is tender and asks the nurse to reevaluate the area in 1 hour. The area of the body the nurse will assess is: a. Just above the diaphragm. b. Just lateral to the knee cap. c. At the level of the C7 vertebra. d. At the level of the T11 vertebra. ANS: C The C7 vertebra has a long spinous process, called the vertebra prominens, which is palpable when the head is flexed. 2. A mother brings her 2-month-old daughter in for an examination and says, “My daughter rolled over against the wall, and now I have noticed that she has this spot that is soft on the top of her head. Is something terribly wrong?” The nurse’s best response would be: a. “Perhaps that could be a result of your dietary intake during pregnancy.” b. “Your baby may have craniosynostosis, a disease of the sutures of the brain.” c. “That ‘soft spot’ may be an indication of cretinism or congenital hypothyroidism.” d. “That ‘soft spot’ is normal, and actually allows for growth of the brain during the first year of your baby’s life.” ANS: D Membrane-covered “soft spots” allow for growth of the brain during the first year of life. They gradually ossify; the triangular-shaped posterior fontanel is closed by 1 to 2 months, and the diamond-shaped anterior fontanel closes between 9 months and 2 years. 3. The nurse notices that a patient’s palpebral fissures are not symmetric. On examination, the nurse may find that damage has occurred to which cranial nerve (CN)? a. III b. V c. VII d. VIII ANS: C Facial muscles are mediated by CN VII; asymmetry of palpebral fissures may be attributable to damage to CN VII (Bell palsy). 4. A patient is unable to differentiate between sharp and dull stimulation to both sides of her face. The nurse suspects: a. Bell palsy. b. Damage to the trigeminal nerve. c. Frostbite with resultant paresthesia to the cheeks. d. Scleroderma. ANS: B Facial sensations of pain or touch are mediated by CN V, which is the trigeminal nerve. Bell palsy is associated with CN VII damage. Frostbite and scleroderma are not associated with this problem. 5. When examining the face of a patient, the nurse is aware that the two pairs of salivary glands that are accessible to examination are the and glands. a. Occipital; submental b. Parotid; jugulodigastric c. Parotid; submandibular d. Submandibular; occipital ANS: C Two pairs of salivary glands accessible to examination on the face are the parotid glands, which are in the cheeks over the mandible, anterior to and below the ear; and the submandibular glands, which are beneath the mandible at the angle of the jaw. The parotid glands are normally nonpalpable. 6. A patient comes to the clinic complaining of neck and shoulder pain and is unable to turn her head. The nurse suspects damage to CN and proceeds with the examination by . a. XI; palpating the anterior and posterior triangles b. XI; asking the patient to shrug her shoulders against resistance d. XII; assessing for a positive Romberg sign ANS: B The major neck muscles are the sternomastoid and the trapezius. They are innervated by CN XI, the spinal accessory. The innervated muscles assist with head rotation and head flexion, movement of the shoulders, and extension and turning of the head. 7. When examining a patient’s CN function, the nurse remembers that the muscles in the neck that are innervated by CN XI are the: a. Sternomastoid and trapezius. b. Spinal accessory and omohyoid. c. Trapezius and sternomandibular. d. Sternomandibular and spinal accessory. ANS: A The major neck muscles are the sternomastoid and the trapezius. They are innervated by CN XI, the spinal accessory. 8. A patient’s laboratory data reveal an elevated thyroxine (T4) level. The nurse would proceed with an examination of the gland. a. Thyroid b. Parotid d. Parathyroid ANS: A The thyroid gland is a highly vascular endocrine gland that secretes T4 and triiodothyronine (T3). The other glands do not secrete T4. 9. A patient says that she has recently noticed a lump in the front of her neck below her “Adam’s apple” that seems to be getting bigger. During the assessment, the finding that leads the nurse to suspect that this may not be a cancerous thyroid nodule is that the lump (nodule): a. Is tender. b. Is mobile and not hard. c. Disappears when the patient smiles. d. Is hard and fixed to the surrounding structures. ANS: B Painless, rapidly growing nodules may be cancerous, especially the appearance of a single nodule in a young person. However, cancerous nodules tend to be hard and fixed to surrounding structures, not mobile. 10. The nurse notices that a patient’s submental lymph nodes are enlarged. In an effort to identify the cause of the node enlargement, the nurse would assess the patient’s: a. Infraclavicular area. b. Supraclavicular area. c. Area distal to the enlarged node. d. Area proximal to the enlarged node. ANS: D When nodes are abnormal, the nurse should check the area into which they drain for the source of the problem. The area proximal (upstream) to the location of the abnormal node should be explored. DIF: Cognitive Level: Analyzing (Analysis) REF: p. 255 MSC: Client Needs: Safe and Effective Care Environment: Management of Care 11. The nurse is aware that the four areas in the body where lymph nodes are accessible are the: a. Head, breasts, groin, and abdomen. b. Arms, breasts, inguinal area, and legs. c. Head and neck, arms, breasts, and axillae. d. Head and neck, arms, inguinal area, and axillae. ANS: D Nodes are located throughout the body, but they are accessible to examination only in four areas: head and neck, arms, inguinal region, and axillae. 12. A mother brings her newborn in for an assessment and asks, “Is there something wrong with my baby? His head seems so big.” Which statement is true regarding the relative proportions of the head and trunk of the newborn? a. At birth, the head is one fifth the total length. b. Head circumference should be greater than chest circumference at birth. c. The head size reaches 90% of its final size when the child is 3 years old. d. When the anterior fontanel closes at 2 months, the head will be more proportioned to the body. ANS: B The nurse recognizes that during the fetal period, head growth predominates. Head size is greater than chest circumference at birth, and the head size grows during childhood, reaching 90% of its final size when the child is age 6 years. 13. A patient, an 85-year-old woman, is complaining about the fact that the bones in her face have become more noticeable. What explanation should the nurse give her? a. Diets low in protein and high in carbohydrates may cause enhanced facial bones. b. Bones can become more noticeable if the person does not use a dermatologically approved moisturizer. c. More noticeable facial bones are probably due to a combination of factors related to aging, such as decreased elasticity, subcutaneous fat, and moisture in her skin. d. Facial skin becomes more elastic with age. This increased elasticity causes the skin to be more taught, drawing attention to the facial bones. ANS: C The facial bones and orbits appear more prominent in the aging adult, and the facial skin sags, which is attributable to decreased elasticity, decreased subcutaneous fat, and decreased moisture in the skin. 14. A patient reports excruciating headache pain on one side of his head, especially around his eye, forehead, and cheek that has lasted approximately to 2 hours, occurring once or twice each day. The nurse should suspect: a. Hypertension. b. Cluster headaches. c. Tension headaches. d. Migraine headaches. ANS: B Cluster headaches produce pain around the eye, temple, forehead, and cheek and are unilateral and always on the same side of the head. They are excruciating and occur once or twice per day and last to 2 hours each. 15. A patient complains that while studying for an examination he began to notice a severe headache in the frontotemporal area of his head that is throbbing and is somewhat relieved when he lies down. He tells the nurse that his mother also had these headaches. The nurse suspects that he may be suffering from: a. Hypertension. b. Cluster headaches. c. Tension headaches. d. Migraine headaches. ANS: D Migraine headaches tend to be supraorbital, retroorbital, or frontotemporal with a throbbing quality. They are severe in quality and are relieved by lying down. Migraines are associated with a family history of migraine headaches. 16. A 19-year-old college student is brought to the emergency department with a severe headache he describes as, “Like nothing I’ve ever had before.” His temperature is 40° C, and he has a stiff neck. The nurse looks for other signs and symptoms of which problem? a. Head injury b. Cluster headache c. Migraine headache d. Meningeal inflammation ANS: D The acute onset of neck stiffness and pain along with headache and fever occurs with meningeal inflammation. A severe headache in an adult or child who has never had it before is a red flag. Head injury and cluster or migraine headaches are not associated with a fever or stiff neck. 17. During a well-baby checkup, the nurse notices that a 1-week-old infant’s face looks small compared with his cranium, which seems enlarged. On further examination, the nurse also notices dilated scalp veins and downcast or “setting sun” eyes. The nurse suspects which condition? a. Craniotabes b. Microcephaly c. Hydrocephalus ANS: C Hydrocephalus occurs with the obstruction of drainage of cerebrospinal fluid that results in excessive accumulation, increasing intracranial pressure, and an enlargement of the head. The face looks small, compared with the enlarged cranium, and dilated scalp veins and downcast or “setting sun” eyes are noted. Craniotabes is a softening of the skull’s outer layer. Microcephaly is an abnormally small head. A caput succedaneum is edematous swelling and ecchymosis of the presenting part of the head caused by birth trauma. 18. The nurse needs to palpate the temporomandibular joint for crepitation. This joint is located just below the temporal artery and anterior to the: a. Hyoid bone. b. Vagus nerve. c. Tragus. d. Mandible. ANS: C The temporomandibular joint is just below the temporal artery and anterior to the tragus. 19. A patient has come in for an examination and states, “I have this spot in front of my ear lobe on my cheek that seems to be getting bigger and is tender. What do you think it is?” The nurse notes swelling below the angle of the jaw and suspects that it could be an inflammation of his: a. Thyroid gland. c. Occipital lymph node. d. Submental lymph node. ANS: B Swelling of the parotid gland is evident below the angle of the jaw and is most visible when the head is extended. Painful inflammation occurs with mumps, and swelling also occurs with abscesses or tumors. Swelling occurs anterior to the lower ear lobe. 20. A male patient with a history of acquired immunodeficiency syndrome (AIDS) has come in for an examination and he states, “I think that I have the mumps.” The nurse would begin by examining the: a. Thyroid gland. b. Parotid gland. c. Cervical lymph nodes. d. Mouth and skin for lesions. ANS: B 21. The nurse suspects that a patient has hyperthyroidism, and the laboratory data indicate that the patient’s T4 and T3 hormone levels are elevated. Which of these findings would the nurse most likely find on examination? a. Tachycardia b. Constipation c. Rapid dyspnea d. Atrophied nodular thyroid gland ANS: A T4 and T3 are thyroid hormones that stimulate the rate of cellular metabolism, resulting in tachycardia. With an enlarged thyroid gland as in hyperthyroidism, the nurse might expect to find diffuse enlargement (goiter) or a nodular lump but not an atrophied gland. Dyspnea and constipation are not findings associated with hyperthyroidism. 22. A visitor from Poland who does not speak English seems to be somewhat apprehensive about the nurse examining his neck. He would probably be more comfortable with the nurse examining his thyroid gland from: a. Behind with the nurse’s hands placed firmly around his neck. b. The side with the nurse’s eyes averted toward the ceiling and thumbs on his neck. c. The front with the nurse’s thumbs placed on either side of his trachea and his head tilted forward. d. The front with the nurse’s thumbs placed on either side of his trachea and his head tilted backward. ANS: C Examining this patient’s thyroid gland from the back may be unsettling for him. It would be best to examine his thyroid gland using the anterior approach, asking him to tip his head forward and to the right and then to the left. 23. A patient’s thyroid gland is enlarged, and the nurse is preparing to auscultate the thyroid gland for the presence of a bruit. A bruit is a sound that is heard best with the of the stethoscope. a. Low gurgling; diaphragm b. Loud, whooshing, blowing; bell c. Soft, whooshing, pulsatile; bell d. High-pitched tinkling; diaphragm ANS: C If the thyroid gland is enlarged, then the nurse should auscultate it for the presence of a bruit, which is a soft, pulsatile, whooshing, blowing sound heard best with the bell of the stethoscope. 24. The nurse notices that an infant has a large, soft lump on the side of his head and that his mother is very concerned. She tells the nurse that she noticed the lump approximately 8 hours after her baby’s birth and that it seems to be getting bigger. One possible explanation for this is: a. Hydrocephalus. b. Craniosynostosis. c. Cephalhematoma. d. Caput succedaneum. ANS: C A cephalhematoma is a subperiosteal hemorrhage that is the result of birth trauma. It is soft, fluctuant, and well defined over one cranial bone. It appears several hours after birth and gradually increases in size. 25. A mother brings in her newborn infant for an assessment and tells the nurse that she has noticed that whenever her newborn’s head is turned to the right side, she straightens out the arm and leg on the same side and flexes the opposite arm and leg. After observing this on examination, the nurse tells her that this reflex is: a. Abnormal and is called the atonic neck reflex. b. Normal and should disappear by the first year of life. c. Normal and is called the tonic neck reflex, which should disappear between 3 and 4 months of age. d. Abnormal. The baby should be flexing the arm and leg on the right side of his body when the head is turned to the right. ANS: C By 2 weeks, the infant shows the tonic neck reflex when supine and the head is turned to one side (extension of same arm and leg, flexion of opposite arm and leg). The tonic neck reflex disappears between 3 and 4 months of age. 26. During an admission assessment, the nurse notices that a male patient has an enlarged and rather thick skull. The nurse suspects acromegaly and would further assess for: a. Exophthalmos. b. Bowed long bones. c. Coarse facial features. d. Acorn-shaped cranium. ANS: C Acromegaly is excessive secretion of growth hormone that creates an enlarged skull and thickened cranial bones. Patients will have elongated heads, massive faces, prominent noses and lower jaws, heavy eyebrow ridges, and coarse facial features. Exophthalmos is associated with hyperthyroidism. Bowed long bones and an acorn- shaped cranium result from Paget disease. 27. When examining children affected with Down syndrome (trisomy 21), the nurse looks for the possible presence of: a. Ear dysplasia. b. Long, thin neck. c. Protruding thin tongue. d. Narrow and raised nasal bridge. ANS: A With the chromosomal aberration trisomy 21, also known as Down syndrome, head and face characteristics may include upslanting eyes with inner epicanthal folds, a flat nasal bridge, a small broad flat nose, a protruding thick tongue, ear dysplasia, a short broad neck with webbing, and small hands with a single palmar crease. 28. A patient visits the clinic because he has recently noticed that the left side of his mouth is paralyzed. He states that he cannot raise his eyebrow or whistle. The nurse suspects that he has: a. Cushing syndrome. b. Parkinson disease. c. Bell palsy. d. Experienced a cerebrovascular accident (CVA) or stroke. ANS: D With an upper motor neuron lesion, as with a CVA, the patient will have paralysis of lower facial muscles, but the upper half of the face will not be affected owing to the intact nerve from the unaffected hemisphere. The person is still able to wrinkle the forehead and close the eyes. (See Table 13-4, Abnormal Facial Appearances with Chronic Illnesses, for descriptions of the other responses.) 29. A woman comes to the clinic and states, “I’ve been sick for so long! My eyes have gotten so puffy, and my eyebrows and hair have become coarse and dry.” The nurse will assess for other signs and symptoms of: a. Cachexia. b. Parkinson syndrome. c. Myxedema. d. Scleroderma. ANS: C Myxedema (hypothyroidism) is a deficiency of thyroid hormone that, when severe, causes a nonpitting edema or myxedema. The patient will have a puffy edematous face, especially around the eyes (periorbital edema); coarse facial features; dry skin; and dry, coarse hair and eyebrows. (See Table 13-4, Abnormal Facial Appearances with Chronic Illnesses, for descriptions of the other responses.) 30. During an examination of a female patient, the nurse notes lymphadenopathy and suspects an acute infection. Acutely infected lymph nodes would be: a. Clumped. b. Unilateral. c. Firm but freely movable. d. Firm and nontender. ANS: C Acutely infected lymph nodes are bilateral, enlarged, warm, tender, and firm but freely movable. Unilaterally enlarged nodes that are firm and nontender may indicate cancer. 31. The physician reports that a patient with a neck tumor has a tracheal shift. The nurse is aware that this means that the patient’s trachea is: a. Pulled to the affected side. b. Pushed to the unaffected side. c. Pulled downward. d. Pulled downward in a rhythmic pattern. ANS: B The trachea is pushed to the unaffected side with an aortic aneurysm, a tumor, unilateral thyroid lobe enlargement, or a pneumothorax. The trachea is pulled to the affected side with large atelectasis, pleural adhesions, or fibrosis. Tracheal tug is a rhythmic downward pull that is synchronous with systole and occurs with aortic arch aneurysm. 32. During an assessment of an infant, the nurse notes that the fontanels are depressed and sunken. The nurse suspects which condition? a. Rickets b. Dehydration c. Mental retardation d. Increased intracranial pressure ANS: B Depressed and sunken fontanels occur with dehydration or malnutrition. Mental retardation and rickets have no effect on the fontanels. Increased intracranial pressure would cause tense or bulging and possibly pulsating fontanels. 33. The nurse is performing an assessment on a 7-year-old child who has symptoms of chronic watery eyes, sneezing, and clear nasal drainage. The nurse notices the presence of a transverse line across the bridge of the nose, dark blue shadows below the eyes, and a double crease on the lower eyelids. These findings are characteristic of: a. Allergies. b. Sinus infection. c. Nasal congestion. d. Upper respiratory infection. ANS: A Chronic allergies often develop chronic facial characteristics and include blue shadows below the eyes, a double or single crease on the lower eyelids, open-mouth breathing, and a transverse line on the nose. 34. While performing a well-child assessment on a 5 year old, the nurse notes the presence of palpable, bilateral, cervical, and inguinal lymph nodes. They are approximately 0.5 cm in size, round, mobile, and nontender. The nurse suspects that this child: a. Has chronic allergies. b. May have an infection. c. Is exhibiting a normal finding for a well child of this age. d. Should be referred for additional evaluation. ANS: C Palpable lymph nodes are normal in children until puberty when the lymphoid tissue begins to atrophy. Lymph nodes may be up to 1 cm in size in the cervical and inguinal areas but are discrete, movable, and nontender. 35. The nurse has just completed a lymph node assessment on a 60-year-old healthy female patient. The nurse knows that most lymph nodes in healthy adults are normally: a. Shotty. b. Nonpalpable. c. Large, firm, and fixed to the tissue. ANS: B Most lymph nodes are nonpalpable in adults. The palpability of lymph nodes decreases with age. Normal nodes feel movable, discrete, soft, and nontender. 36. During an examination of a patient in her third trimester of pregnancy, the nurse notices that the patient’s thyroid gland is slightly enlarged. No enlargement had been previously noticed. The nurse suspects that the patient: a. Has an iodine deficiency. b. Is exhibiting early signs of goiter. c. Is exhibiting a normal enlargement of the thyroid gland during pregnancy. d. Needs further testing for possible thyroid cancer. ANS: C The thyroid gland enlarges slightly during pregnancy because of hyperplasia of the tissue and increased vascularity. 37. During an examination, the nurse knows that the best way to palpate the lymph nodes in the neck is described by which statement? a. Using gentle pressure, palpate with both hands to compare the two sides. b. Using strong pressure, palpate with both hands to compare the two sides. c. Gently pinch each node between one’s thumb and forefinger, and then move down the neck muscle. rotating pattern. ANS: A Using gentle pressure is recommended because strong pressure can push the nodes into the neck muscles. Palpating with both hands to compare the two sides symmetrically is usually most efficient. 38. During a well-baby checkup, a mother is concerned because her 2-month-old infant cannot hold her head up when she is pulled to a sitting position. Which response by the nurse is appropriate? a. “Head control is usually achieved by 4 months of age.” b. “You shouldn’t be trying to pull your baby up like that until she is older.” c. “Head control should be achieved by this time.” d. “This inability indicates possible nerve damage to the neck muscles.” ANS: A Head control is achieved by 4 months when the baby can hold the head erect and steady when pulled to a vertical position. The other responses are not appropriate. 39. During an examination of a 3-year-old child, the nurse notices a bruit over the left temporal area. The nurse should: a. Continue the examination because a bruit is a normal finding for this age. b. Check for the bruit again in 1 hour. c. Notify the parents that a bruit has been detected in their child. d. Stop the examination, and notify the physician. ANS: A Bruits are common in the skull in children under 4 or 5 years of age and in children with anemia. They are systolic or continuous and are heard over the temporal area. 40. During an examination, the nurse finds that a patient’s left temporal artery is tortuous and feels hardened and tender, compared with the right temporal artery. The nurse suspects which condition? a. Crepitation b. Mastoiditis c. Temporal arteritis d. Bell palsy ANS: C With temporal arteritis, the artery appears more tortuous and feels hardened and tender. These assessment findings are not consistent with the other responses. MULTIPLE RESPONSE 1. The nurse is assessing a 1-month-old infant at his well-baby checkup. Which assessment findings are appropriate for this age? Select all that apply. a. Head circumference equal to chest circumference b. Head circumference greater than chest circumference c. Head circumference less than chest circumference d. Fontanels firm and slightly concave e. Absent tonic neck reflex f. Nonpalpable cervical lymph nodes ANS: B, D, F CHAPTER 14 1. When examining the eye, the nurse notices that the patient’s 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. 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 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 patient’s 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 patient’s 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 infant’s 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 approximately 3 months of age, infants develop more coordinated eye movements and can fixate on an object.” d. “Most 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. 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. 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. 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 patient’s 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 patient’s 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 nurse’s 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 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 patient’s 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 o’clock 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 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 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 individual’s 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 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 patient’s 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 patient’s eyes, the nurse notices a red glow in the patient’s 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 person’s 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 patient’s 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 yellow- orange to a pink, and the edges are distinct and sharply demarcated, not blurred. A pigmented crescent is black and is due to the accumulation of pigment in the choroid. 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 child’s 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 child’s 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 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 patient’s 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. 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 “can’t 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. 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. 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. 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 Chapter 15 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 patient’s 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 infant’s hearing? a. Rubella may affect the mother’s hearing but not the infant’s. b. Rubella can damage the infant’s 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 need to check the immune system of your son to determine why he is having so many ear infections.” c. “Ear infections are not uncommon in infants and toddlers because they tend to have more cerumen in the external ear.” d. “Your son’s eustachian tube is shorter and wider than yours because of his age, which allows for infections to develop more easily.” ANS: D The infant’s eustachian tube is relatively shorter and wider than the adult’s 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 “can’t 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 was the last time you had your hearing checked?” c. “Have you ever been told that you have any type of hearing loss?” d. “Is 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 your baby seem to startle with loud noises?” b. “Has your baby had any surgeries on her ears?” c. “Have 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 person’s 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 patient’s 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 son’s 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 amber- yellow in color and that air bubbles are visible behind the tympanic membrane. The child reports occasional hearing loss and a popping sound with swallowing. The preliminary analysis based on this information is that the child: 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