HLED 450 Week Four Post Class Questions & Answers and Rationale Latest,100% CORRECT

HLED 450 Week Four Post Class Questions & Answers and Rationale Latest Chapter 15 1. 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. Rationale: “Movement of the EOMs is stimulated by three cranial nerves (CNs). The abducens nerve (CN VI) innervates the lateral rectus muscle, which abducts the eye. The trochlear nerve (CN IV) innervates the superior oblique muscle; and the oculomotor nerve (CN III) innervates the rest; the superior, inferior, and medial rectus and the inferior oblique muscles” p.277 2. The nurse is testing a patient’s visual accommodation, what is a simple explanation of this? 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 Rationale: “Accommodation is adaption of the eye for near vision. The components of accommodation that can be observed are convergence (motion toward) of the axes of the eyeballs and pupillary constriction” (Jarvis, C. 2019. p. 279) 3. Which of these assessment findings would the nurse expect to see when examining the eyes of an African American patient? a. Increased night vision b. Dark retinal background c. Increased photosensitivity d. Narrowed palpebral fissures Rationale: “Culturally based variability exists in the color of the iris and retinal pigmentation with darker irides having darker retinas behind them” (Jarvis, C. 2019. P. 280) 4. 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. Rationale: “Floaters are common with myopia or after middle age as a result of condensed vitreous fibers. {They are} usually not significant” (Jarvis, C. 2019. p. 281) 5. 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 12 to 14 inches. Rationale: “Place the Snellen alphabet chart in a well-lit spot at eye level. Position the person on a mark exactly 20 feet from the chart” p. 283 6. 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. Rationale: “Normal visual acuity is 20/20. Contrary to some people’s impression, the numeric fraction is not a percentage of normal vision. Instead, the top number (numerator) indicates the distance the person is standing from the chart, and the denominator gives the distance at which a normal eye could have read that particular line. Thus “20/30” means, “You can read at 20 feet what the normal eye can see from 30 feet away” p. 284 7. 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. Rationale: “Eye movements may be poorly coordinated at birth. By 3 to 4 months of age the infant establishes binocularity and can fixate on a single image with both eyes simultaneously” p. 280 8. 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. Rationale: “Lid tissues are loosely connected, so excess fluid is easily apparent.” p. 305 9. 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. Rationale: “With primary open-angle glaucoma, the increased intraocular pressure decreases blood supply to retinal structures. The physiologic cup enlarges to more than half of the disc diameter, vessels appear to plunge over edge of cup, and vessels are displaced nasally. This is asymptomatic, although the person may have decreased vision or visual field defects in the late stages of glaucoma. Glaucoma can reduce peripheral vision without yet harming central vision.” p. 302 & 310 Chapter 16 1. 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. Rationale: “Sensorineural hearing loss may be cause by presbycusis, a gradual nerve degeneration that occurs with aging, and by ototoxic drugs, which affect the hair cells in the cochlea” p. 319 2. 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.” Rationale: “The infant’s Eustachian tube is relatively shorter and wider, and its position is more horizontal than the adults; thus, it is easier for pathogens from the nasopharynx to migrate through to the middle ear” p. 320 3. 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?” Rationale: “Otorrhea or drainage suggests infected canal or perforated eardrum” p. 321 4. 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 Rationale: “Pull the pinna up and black on an adult or older child; this helps straighten the S- shape of the canal. Pull the pinna down on an infant and child younger than 3 years. Hold the pinna gently but firmly. Do not release traction on the ear until you have finished the examination and the otoscope is removed” p. 325 5. 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. Rationale: “Frank blood or clear, watery drainage (cerebrospinal fluid {CSF} after head injury suggests basal skull fracture and warrants immediate referral” p326 6. 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 Rationale: “Reddish-blue discoloration and swelling of auricle after exposure to extreme cold. Vesicles or bullae may develop, the person feels pain and tenderness, and ear necrosis may ensue” p. 335 7. 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 o’clock 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. Rationale: “Dense white patches on the eardrum are sequelae of repeated ear infections. They do not necessarily affect hearing” 338 Chapter 17 1. 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. Rationale: “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” p. 348 2. 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 nurse’s best response would be: a. “You’re right, drooling is usually a sign of the first tooth.” b. “It would be unusual for a 3-month-old to be getting her first tooth.” c. “This could be the sign of a problem with the salivary glands.” d. “She is just starting to salivate and hasn’t learned to swallow the saliva.” Rationale: “In the infant salivation starts at 3 months. The baby drools for a months before learning to swallow saliva.” P. 348 3. 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 nurse’s 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 allow the bleeding to stop on its own, but don’t blow your nose.” d. “Lie on your back with your head tilted back and pinch your nose.” Rationale: “Person should sit with head tilted forward, pinch soft part of nose above nostrils for 10 to 15 minutes.” P. 351 4. 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?” Rationale: “With chronic allergy mucosa looks swollen, boggy, pale, and gray” p. 354 5. 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. Rationale: “Vertical, or longitudinal, fissures also occur with dehydration because of reduced tongue volume” p. 370 6. 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 spots indicate an infection such as strep throat.” b. “These bumps could be indicative of a serious lesion, so I will refer you to a specialist.” c. “This condition is called leukoplakia and can be caused by chronic irritation such as with smoking.” d. “These bumps are Fordyce granules, which are sebaceous cysts and are not a serious condition.” Rationale: “Fordyce granules are small as well as isolated white or yellow papules on the mucosa of the cheek, tongue, and lips. These little sebaceous cysts are painless and not significant” p. 358 7. 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. Rationale: “Children particularly are expected to put objects up their nostrils (here, yellow, plastic foam), producing unilateral mucopurulent drainage and foul odor. Because some risk for aspiration exist, removal should be prompt.” p. 367 8. 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. Rationale: “It is essential to determine the patency of the nares in the immediate newborn period because most newborns are obligate nose breathers. Nares blocked with amniotic fluid are suctioned gently with a bulb syringe. If obstruction is suspected, a small-lumen catheter is passed down each naris to confirm patency” p. 362 9. 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. Rationale: “Note any bruising or laceration on the buccal mucosa or gums of the infant or young child. Trauma may indicate child abuse from forced feeding of bottle or spoon.” p. 362 10. 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. Rationale: “Chronic tobacco use leads to tooth loss, coronal and root caries and periodontal disease in older adults. Chronic use of tobacco, alcohol, and both together highly 9increases risk for oral and pharyngeal cancers” p. 352 Reference: Jarvis, C. (2019). Physical examination and health assessment E-Book. Elsevier Health Sciences.