During an otoscopic assessment, the nurse notes the presence of large amounts of cerumen in the client’s external canal. The nurse knows:
Cerumen helps to lubricate and protect the ear
A 60 year-old client tells the nurse that he has noticed a decrease in his hearing. The nurse knows that the age-related changes of the ear that likely are contributing to the decrease in his hearing are the result of:
A client reports a family history of ear problems and hearing loss and is concerned about aging deafness. The most appropriate response by the nurse is:
“Hearing loss can be hereditary . Have you noticed any changes in your hearing?”
The nurse is preparing to use the otoscope to visualize the auditory canal and tympanic membrane of an adult client. Which of the following is most appropriate?
Pull the pinna up and back
Cranial nerve IV is known as
Cranial nerve II’s function is eyesight
This cranial nerve arises from the cranial and spinal roots which controls swallowing movements and governs movement of the head and shoulders
Cranial nerve __ moves the eyeballs/eyelids and adjusts the pupil and lens of the eye
Cranial nerves __ move the eyeballs
III, IV, VI
Vestibulocochlear nerve (cranial nerve VIII) is responsible for auditory
During an otoscopic examination, which action should be avoided to prevent the client from discomfort and injury
Inserting the otoscopic inferiorly into the distal portion of the external canal
If the client reports loss of short-term memory, the nurse would assess this using which one of the following
Ask the client to describe how he or she arrived at this location
While assessing a patient’s lower extremities, the nurse notes edema around the feet and ankles. When the area is depressed, it lasts for more than 1 minute before the shape returns. How would the nurse document this?
3+ pitting edema
When performing an assessment, the nurse wants to determine circulation. The nurse would anticipate finding which of the following?
Capillary refill of less than 2 seconds of the extremeties
The most commonly used test for accurate measure of visual acuity is which of the following?
Snellen Eye Chart
A 42 year-old woman who has problems during the near vision testing, due to the decrease in power of accommodation, suffers from which of the following conditions?
The assessment of the parallel alignment of the eye axes is done by shining a light towards the person’s eyes, and noting the symmetry or asymmetry of the reflection on the corneas. This test is known as which of the following?
The Hirschberg Test
When one eye is exposed to bright light, a ___ occurs (constriction of the pupil) as well as ___ (simultaneous constriction of the other pupil)
Direct light reflex, consensual light reflex
A normal response to the accommodation test includes
Convergence of the axes of the eyes and Pupillary constriction
While examining a person with an ophthalmoscope, the red glow filling the person;s pupil is known as the Red Reflex, this colour change is caused by which of the following? Reflection of the ophthalmoscope light comes off the ___
The posterior fontanelle in neonates is closed by age 1 to 2 months
The posterior fontanelle is triangle shaped
The anterior fontanelle is diamond shaped
When assessing a patient’s head and neck, which of the following finding is abnormal?
When palpating a patient’s lymph nodes, the nurses notices a large tender submental lymph node
What is an enlargment of the head and bony facial structures caused by excessive secretion of growth hormone?
What is a clinical manifestation of Bell’s palsy?
Asymmetry of the entire side of the face
What are the symptoms or manifestation of meningitis?
Fever, headache, sensitivity to bright lights