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

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Question 1

Multiple Choice

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

A) "I felt faint, like I was going to pass out."
B) "I just could not keep my balance when I sat up."
C) "It seemed that the room was spinning around."
D) "I was afraid that I was going to lose consciousness."

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Question 2

Multiple Choice

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Wearing gloves, the nurse grasps the patient's tongue with a gauze pad and palpates a small, firm nodule on the left side of the tongue. Based upon this finding, what is the nurse's appropriate response?

A) Document that the patient's tongue is normal on palpation.
B) Inspect the left submandibular salivary glands for redness.
C) Ask the patient to move the tongue in all directions.
D) Palpate cervical and submental lymph nodes for enlargement.

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D

Question 3

Multiple Choice

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

During an eye assessment, a nurse asks the patient to cover one eye with a card as the nurse covers his or her eye directly opposite the patient's covered eye. The nurse moves an object into the field of vision and asks the patient to tell when the object can be seen. This assessment technique collects what data about the patient's eyes?

During the history, a 65-year-old male patient reports smoking two packs of cigarettes a day for more than 40 years. With this knowledge, what does the nurse expect during the examination of this patient's mouth?

A nurse shines a light toward the bridge of the patient's nose and notices that the light reflection in the right cornea is at the 9 o'clock position and in the left cornea at the 9 o'clock position. What is the interpretation of this finding?

In assessing a patient with head injury, the nurse should be most concerned with which finding?

A nurse assessing the hearing of a patient with presbycusis expects which finding on a test for hearing?

During the history, a patient reports watery nasal drainage from allergies. Based on this information, what does the nurse expect to find on inspection of the nares?

A nurse suspects the patient has an infection of the maxillary sinuses. How can this suspicion be confirmed?

During the history, a patient reports blurred vision, seeing double at times, and a glare from headlights from oncoming cars at night. Based on this information, what finding does the nurse expect to find on assessment of this patient's eyes?

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

After assessment of the nose and paranasal sinuses, which finding requires further investigation by the nurse?

How does a nurse recognize a patient's mydriasis?

How does a nurse assess movements of the eyes?

A nurse shines a light in the right pupil to test constriction and notices that the left pupil constricts as well. Based on these data, the nurse should take what action?

What changes in using the ophthalmoscope should the nurse need to make when inspecting the eye of a patient who is nearsighted?

A nurse shines a light toward the bridge of the patient's nose and notices that the light reflection in the right cornea is at the 2 o'clock position and in the left cornea at the 10 o'clock position. Based on these data, the nurse should take what action?

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

How does the nurse perform a Weber test to assess hearing function?