22.7.0: Review Questions
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Review Questions
1 .
On assessment, the nurse notes the patient has an enlarged nose, protruding jaw, and prominent forehead. The patient reports joint pain, headaches, and recent vision changes. The nurse concludes the patient is most likely experiencing what condition?
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acromegaly
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myxedema
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Cushing syndrome
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Raynaud phenomenon
2 .
The nurse is caring for a patient newly diagnosed with a simple goiter. What intervention should the nurse expect the provider to order?
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thyroid-stimulating hormone
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dietary changes to increase iodized salt intake
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surgical removal of the goiter
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chemotherapy
3 .
The nurse is performing an assessment of the patient’s head and neck. What question should the nurse ask to collect objective data?
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“Have you had a headache, dizziness, or neck pain?”
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“On a scale of zero to ten, how would you rate your pain?”
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“Have you ever had a stroke, concussion, or head injury?”
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“May I feel around your neck and behind your ears?”
4 .
The nurse recalls that Cushing syndrome is a condition created by what body organ?
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adrenal gland
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hypothalamus gland
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pituitary gland
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thyroid gland
5 .
The nurse is performing an assessment on a 17-year-old patient who was thrown from a four-wheeler. What symptom is the most concerning and would require the nurse to take immediate action?
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dizziness
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palpable mass and swelling
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sensitivity to light
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severe headache
6 .
The nurse is performing a visual acuity test. What interpretation demonstrates an accurate understanding of the results?
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Visual acuity of 20/50 means the patient can see at 20 feet what a person with normal vision can see at 50 feet.
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Visual acuity of 20/40 means the patient can see at 40 feet what a person with normal vision can see at 20 feet.
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Visual acuity of 20/40 means the patient can see 20 percent of the items that are 40 feet away.
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Visual acuity of 20/50 means the patient can see 50 percent of the items that are 20 feet away.
7 .
The nurse is performing an assessment of the eyes. What action accurately describes how to perform an eye assessment?
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To test convergence, ask the patient to keep their head still and follow a target (your fingertip or a pen) with their eyes only in all six cardinal directions.
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To test extraocular movements, ask the patient to focus on an object (e.g., your fingertip) held about 2 inches in front of their nose, while slowly moving the object toward the patient’s nose.
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To assess the pupils, hold the penlight or flashlight about 5 to 10 inches away from the patient’s face and shine the light directly into one eye; observing both pupils for their initial size and equality.
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To test pupil accommodation, ask the patient to focus on a near object (e.g., your finger) and then switch their focus to a distant object.
8 .
The nurse is reviewing the structures of the eye with a newly graduated nurse. What statement made by the newly graduated nurse would warrant further education?
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“Rods are photoreceptors that are responsible for vision in low-light conditions and for detecting movement.”
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“The optic nerve is the bundle of nerve fibers that carries visual information from the retina to the brain for processing.”
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“The cornea is a small, central area of the retina responsible for central vision and color perception.”
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“The retina is the innermost layer of the eye that contains photoreceptors, which detect light and transmit visual signals to the brain.”
9 .
The nurse is performing an eye assessment on an 86-year-old patient who reports gradual changes in vision. The patient reports, “It looks like I’m looking through the end of a paper towel roll, but everything is blurry.” The nurse recognizes the patient is most likely experiencing what eye abnormality?
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cataracts
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glaucoma
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macular degeneration
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presbyopia
10 .
The nurse is performing an eye assessment on a 40-year-old patient and notices the pupils are unequal in size. How would the nurse denote this eye abnormality in the patient’s chart?
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amblyopia
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anisocoria
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miosis
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ptosis
11 .
Upon assessment, the nurse notes the patient’s ear is elflike in shape. How would the nurse document this ear abnormality?
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cauliflower ear
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ear tag
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microtia
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Stahl ear
12 .
The nurse suspects the patient may be experiencing a perforated eardrum. What assessment would be used to determine if this prediction is accurate?
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Weber test
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inspection with otoscope
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Rinne test
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Romberg test
13 .
The nurse is precepting a newly graduated nurse. What statement made by the newly graduated nurse demonstrates an accurate understanding of symptoms related to ear abnormalities?
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“Vertigo is characterized by ringing or buzzing in the ears.”
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“Individuals working around loud environmental hazards are at risk for tinnitus.”
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“Vertigo can be caused by several factors, such as ototoxic medications.”
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“Tinnitus can be treated with medications to manage the symptoms.”
14 .
The nurse is educating a patient on hearing loss. What statement made by the patient demonstrates an accurate understanding of the teaching?
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“Conductive hearing loss is caused by pathology of the inner ear, cranial nerve VIII, or auditory areas of the cerebral cortex.”
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“Ototoxic medications can also cause conductive hearing loss by affecting the hair cells in the cochlea.”
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“Presbycusis is a sensorineural hearing loss that occurs with aging due to gradual nerve degeneration.”
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“Sensorineural hearing loss occurs when something in the external or middle ear is obstructing the transmission of sound.”
15 .
The nurse is performing a Weber and Rinne test to assess hearing loss. What statement demonstrates a correct interpretation of the test results?
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If the patient hears the sound longer through air conduction than through BC, it is considered a negative Rinne and suggests conductive hearing loss in that ear.
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If the patient hears the sound equally or longer through bone conduction than through AC, it is considered a positive Rinne and suggests normal or sensorineural hearing in that ear.
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If the patient hears the sound equally in both ears during the Weber test, the patient has normal hearing in both ears.
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If the patient hears the sound louder in one ear during the Weber test, it may suggest hearing loss in both ears.
16 .
The nurse is caring for a 9-year-old patient who presents with epistaxis. The nurse should instruct the patient to take what action?
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apply a cold compress to the nose
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blow the nose to remove excess bloody residue
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breathe through their nose
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tilt their head back
17 .
The nurse is performing a throat assessment and would like to inspect the tonsils. Where are the tonsils located?
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nasopharynx and laryngopharynx
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nasopharynx and oropharynx
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oropharynx and laryngopharynx
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laryngopharynx
18 .
During an examination of the oral cavity, what technique by the nurse is most appropriate to examine the gums and teeth?
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Ask the patient to open their mouth and say “ah.”
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Use a penlight and tongue depressor to retract the lips.
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Use a gloved hand to retract the lips and cheeks.
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Use gauze to move the tongue to each side.
19 .
A nurse performs an assessment on a patient complaining of a sore throat. Upon assessment, the throat is red, and the tonsils are touching the uvula midline. Using the grading scale of 0 to 4+, how should the nurse document the tonsils?
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grade 1+
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grade 2+
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grade 3+
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grade 4+
20 .
What assessment finding is indicative of candidiasis?
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bleeding gums
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persistent bad breath
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red patches on the oral mucosa
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white patches on the tongue