Question 1

A patient complains of a lesion in his nose. Which technique does a nurse use to inspect the nasal mucosa?

Accepted Answer

Option B is the appropriate technique for inspecting the nares. Horizontal insertion puts pressure on the nasal septum, which is painful. The alternate light source is from an otoscope, rather than an ophthalmoscope. The otoscope has an ear speculum that can be used when a nasal speculum is unavailable. Vertical insertion obstructs the nurse's view of the internal nares.

Question 2

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?

Accepted Answer

The nodules may indicate a malignancy of the tongue, which may also cause enlarged cervical or submental lymph nodes. The nodule is not an expected finding. The salivary glands are not affected by a nodule of the tongue. Option C assesses the hypoglossal cranial nerve or movement of the tongue, which is not related to the nodule found.

Question 3

How does the nurse perform a Rinne test of hearing function?

Accepted Answer

Technique D describes the Rinne test. Technique A describes the whisper test. Technique B describes the Weber test. Technique C describes the use of an audiometer.

Question 4

Which finding indicates that this patient has a sensorineural hearing loss?

Accepted Answer

In the Rinne test, hearing sound from a vibrating tuning fork longer by air conduction than by bone conduction is consistent with a sensorineural hearing loss. Option B from the Weber test is consistent with a conduction hearing loss. Option C is an expected finding using audiometry. Option D is an expected finding using the finger rubbing screening hearing test.

Question 5

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

Accepted Answer

Unilateral clear, watery nasal discharge may be cerebrospinal fluid, indicating a skull fracture. Pain on palpation of the scalp is expected after a head injury and is not a cause for concern. A scalp laceration at the sight of injury is expected after a head injury and is not a cause for concern. Complaints of dizziness is expected after a head injury and is not a cause for concern.

Question 6

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

Accepted Answer

A deviated septum is an abnormal finding that needs further investigation. Option B is an expected finding. Options C and D are normal findings.

Question 7

When inspecting a patient's posterior wall of the pharynx and tonsils, a nurse documents which finding as abnormal?

Accepted Answer

Option B indicates an enlargement documented as 4+. A smooth surface is expected for the tonsils. Options C and D are expected findings for the tonsils.

Question 8

What instruction does a nurse give a patient to facilitate palpation of the right lobe of the thyroid gland?

Accepted Answer

The patient is asked to swallow to make the thyroid lobe easier to palpate. Option B is incorrect to palpate the right lobe. The patient flexes the neck toward the side being palpated. Option C is incorrect to palpate the right lobe. The patient flexes the neck toward the side being palpated, but does not rotate the head. Option D is not part of the thyroid palpation.

Question 9

During the Rinne test, a nurse determines that the patient hears the tuning fork held on the mastoid process for 15 seconds and hears the tuning fork held in front of the ear for 30 seconds. The same results are found in both ears. Based on this finding, what is the most appropriate response of the nurse?

Accepted Answer

Option B is a normal finding. Air conduction (30 seconds) is twice as long as bone conduction (15 seconds). Options A, C, and D are unnecessary because the finding of the Rinne test was normal.

Question 10

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

Accepted Answer

Technique B describes the Weber test. Technique A describes the whisper test. Technique C describes the use of an audiometer. Technique D describes part of the Rinne test.

Question 11

A nurse assesses neck range of movement of several adults. Which patient has an expected range of motion of the neck?

Accepted Answer

Option C is an expected finding. Option A is abnormal. Option B is abnormal. The patient should be able to laterally bend the head 40 degrees from midline in each direction. The patient should be able to hyperextend the head 55 degrees from midline.

Question 12

During a Weber test, a patient with right ear hearing loss reports hearing sound louder in the right ear than the left ear. What results should the nurse expect to find from this patient during a Rinne test?

Accepted Answer

Option C from the Rinne test indicates a conduction hearing loss, which is consistent with the finding from the Weber test described in the question. Option A is an expected finding. Option B is consistent with a sensorineural hearing loss, but this patient has a conduction hearing loss based on the results of the Weber test. Option D is not consistent with the conductive hearing loss described.

Question 13

A patient is being seen in the clinic for suspected nasal obstruction from a foreign body. The nurse recognizes which finding as most consistent with this diagnosis?

Accepted Answer

Option A is consistent with presence of a foreign object in one side of the nose. Option B is consistent with a nasal or sinus infection. Option C is consistent with localized trauma, such as a nasal fracture. Option D is consistent with a history of head injury and may indicate skull fracture.

Question 14

What technique does a nurse use when palpating the right lobe of a patient's thyroid gland using the posterior approach?

Accepted Answer

Option C is the correct technique. Option A is not a correct technique. In the posterior approach, the right lobe is felt with the right hand. Option B is not a correct technique. The trachea, not the muscle, is moved to the side. Option D is not a correct technique. The fingers are placed below the cricoid cartilage.

Question 15

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

Accepted Answer

Option B indicates a sensorineural health loss, the most common cause of presbycusis. Option A indicates a conduction hearing loss, rather than a sensorineural hearing loss. Option C indicates a conduction hearing loss, rather than a sensorineural hearing loss. Option D is a normal finding on this test.

Question 16

What technique does a nurse use when palpating the right lobe of a patient's thyroid gland using the anterior approach?

Accepted Answer

Option B is the correct technique for palpating the thyroid gland using the anterior approach. Options A, C, and D are not correct techniques.

Question 17

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

Accepted Answer

Option C palpates the maxillary sinuses to detect tenderness, which may indicate sinus congestion or infection. To transilluminate the maxillary sinuses, the nurse places the source of light lateral to the nose, just beneath the medial aspect of the eye, and looks through the patient's open mouth for illumination of the hard palate. Option B palpates the frontal sinuses rather than the maxillary sinuses. Option D is not a correct technique to confirm infection of the maxillary sinuses.

Question 18

A patient comes to the clinic for evaluation after a sinus infection. To evaluate the therapy, the nurse uses transillumination to assess the sinuses and notes which finding indicating recovery from a frontal sinus infection?

Accepted Answer

Finding a reddish light above the eyebrows when the light is placed against each supraorbital rim is consistent with frontal sinuses free of infection. Option A describes incorrect technique for transillumination. An absence of a glow during transillumination of the sinuses may indicate that the sinuses are congested. Option C describes incorrect technique for transillumination.

Question 19

When inspecting a patient's nasal mucous membrane, which finding does the nurse expect to see?

Accepted Answer

Deep pink turbinates are expected for a nasal inspection. Red, edematous mucous membranes indicate a local infection within the nose. Septum that angles to the left is abnormal. Clear exudate occurs with nasal allergies.

Question 20

While taking a history, the nurse notices that the patient's family member repeats most of the questions to the patient in a loud voice. Based on this information, what finding does the nurse anticipate when assessing this patient's hearing using an audioscope?

Accepted Answer

A 40 dB loss in all frequencies causes moderate difficulty in hearing normal speech. A 5 dB hearing loss at all frequencies is not tested by an audioscope. A 10 dB loss in high frequencies results in difficulty hearing quiet sounds, such as a heartbeat. A 20 dB loss in high frequencies results in difficulty hearing high-pitched consonants, such as a whisper.

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