Chapter 10: Head, Eyes, Ears, Nose, and Throat
Wilson: Health Assessment for Nursing Practice, 6th Edition
MULTIPLE CHOICE
1. A patient is admitted with edema of the occipital lobe following a head
injury. The nurse correlates which finding with damage to this area?
a. Ipsilateral ptosis
b. Impaired vision
c. Pupillary constriction
d. Increased intraocular pressure
ANS: B
The occipital lobe contains the visual context. Ipsilateral ptosis (drooping of the eye lid)
is controlled by the oculomotor cranial nerve (CN III) that is located in the midbrain. The
nurse must correlate anatomy with function and assessment. Pupillary constriction is
controlled by the oculomotor cranial nerve (CN III) that is located in the midbrain. This
abnormality is associated with glaucoma rather than injury to the occipital lobe.
DIF: Cognitive Level: Analyze REF: p. 134
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body
Systems
2. The nurse is taking a health history on a patient who reports frequent
stabbing headaches occurring once a day lasting about an hour. Which statement by the
patient is most indicative of cluster headaches?
a. “I usually have nausea and vomiting with
my headaches.”
b. “My whole head is constantly throbbing.”
c. “It feels like my head is in a vice.”
d. “The pain is on the left side over my eye,
forehead, and cheek.”
ANS: D
The description mentioned in option D is consistent with cluster headaches. Option A is
descriptive of migraines rather than cluster headaches. Option B is descriptive of
migraines rather than cluster headaches. Option C is descriptive of tension rather than
cluster headaches.
DIF: Cognitive Level: Apply REF: p. 104 | p. 141
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body
Systems
3. A patient reports having migraine headaches on one side of the head that
often start with an aura and last 1 to 3 days. As a part of the symptom analysis, the patient
,reports which associated symptoms of migraine headaches?
a. Nausea, vomiting, or visual disturbances
b. Nasal stuffiness or discharge
c. Ringing in the ears or dizziness
d. Red, watery eyes or drooping eyelids
ANS: A
Nausea, vomiting, or visual disturbances are symptoms associated with migraine
headaches. Nasal stuffiness or discharge is a symptom associated with cluster headaches
rather than migraine headaches. Ringing in the ears or dizziness is a symptom not
associated with migraine headaches. Red, watery eyes or drooping eyelids are symptoms
associated with cluster headaches rather than migraine headaches.
DIF: Cognitive Level: Analyze REF: p. 141
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body
Systems
4. The nurse is taking a health history on a patient who reports frequent
headaches with pain in the front of the head, but sometimes felt in the back of the head.
Which statement by the patient is most indicative of tension headaches?
a. “I usually have nausea and vomiting with
my headaches.”
b. “My whole head is constantly throbbing.”
c. “It feels like my head is in a vice.”
d. “The pain is on the left side over my eye,
forehead, and cheek.”
ANS: C
Option C is descriptive of tension headaches, which is consistent with the rest of the data
reported by the patient. Option A is descriptive of migraines rather than tension
headaches. Option B is descriptive of migraines rather than tension headaches. Option D
is consistent with cluster headaches rather than tension headaches.
DIF: Cognitive Level: Apply REF: p. 141
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body
Systems
5. 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.”
ANS: C
Option C is consistent with vertigo because it includes a sensation of motion. Option A is
a description of lightheadedness, a form of dizziness. Option B is a description of
disequilibrium, a form of dizziness. Option D is a description of syncope, a form of
dizziness.
DIF: Cognitive Level: Analyze REF: p. 141
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body
Systems
6. During symptom analysis, the nurse helps the patient distinguish between
dizziness and vertigo. Which description by the patient indicates dizziness?
a. “I felt faint, like I was going to pass out.”
b. “It felt like I was on a merry-go-round.”
c. “The room seemed to be spinning
around.”
d. “My body felt like it was revolving and
could not stop.”
ANS: A
Option A is a description of lightheadedness, a form of dizziness. Option B is consistent
with objective vertigo because it includes a sensation of motion. Option C is consistent
with objective vertigo because it includes a sensation of motion. Option D is consistent
with subjective vertigo because it includes a sensation of one’s body rotating in space.
DIF: Cognitive Level: Analyze REF: p. 141
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body
Systems
7. Which patient in the eye clinic should the nurse assess first?
a. The patient who reports a gradual
clouding of vision
b. The patient who complains of sudden loss
of vision
c. The patient who complains of double
vision
d. The patient who complains of poor night
vision
ANS: B
Sudden vision loss may indicate a detached retina and requires immediate referral. A
gradual clouding of vision is a symptom of cataracts that develop slowly and do not
require immediate assessment. Double vision is a symptom of cataracts that develop
, slowly and do not require immediate assessment. Poor night vision is a symptom of
cataracts that develop slowly and do not require immediate assessment.
DIF: Cognitive Level: Apply REF: p. 142
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body
Systems
8. A patient complains of right ear pain. What findings does the nurse
anticipate on inspecting the patient’s ears?
a. Redness and edema of the pinna of the
right ear
b. Report of pain when the nurse
manipulates the right ear
c. Bulging and red tympanic membrane in
the right ear
d. Increased cerumen in the right ear canal
ANS: C
Bulging and red tympanic membrane in the right ear is consistent with internal ear pain
that may be associated with otitis media. Redness and edema of the pinna of the right ear
is consistent with external ear pain that may be associated with otitis externa or
swimmer’s ear. Report of pain when the nurse manipulates the right ear is consistent with
external ear pain that may be associated with otitis externa or swimmer’s ear. Increased
cerumen in the right ear canal is not consistent with internal ear pain.
DIF: Cognitive Level: Apply REF: p. 159 | p. 175
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body
Systems
9. 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. Enlarged and pale turbinates
b. Polyps within the nares
c. High vascularity of the turbinates
d. Dry and dull turbinates
ANS: A
Enlarged and pale turbinates are expected findings for allergic rhinitis. Polyps within the
nares is not an expected finding. High vascularity of the turbinates is not an expected
finding. Dry and dull turbinates is not an expected finding.
DIF: Cognitive Level: Apply REF: p. 176
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body
Systems
10. A patient complains of nasal drainage and sinus headache. The nurse
Wilson: Health Assessment for Nursing Practice, 6th Edition
MULTIPLE CHOICE
1. A patient is admitted with edema of the occipital lobe following a head
injury. The nurse correlates which finding with damage to this area?
a. Ipsilateral ptosis
b. Impaired vision
c. Pupillary constriction
d. Increased intraocular pressure
ANS: B
The occipital lobe contains the visual context. Ipsilateral ptosis (drooping of the eye lid)
is controlled by the oculomotor cranial nerve (CN III) that is located in the midbrain. The
nurse must correlate anatomy with function and assessment. Pupillary constriction is
controlled by the oculomotor cranial nerve (CN III) that is located in the midbrain. This
abnormality is associated with glaucoma rather than injury to the occipital lobe.
DIF: Cognitive Level: Analyze REF: p. 134
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body
Systems
2. The nurse is taking a health history on a patient who reports frequent
stabbing headaches occurring once a day lasting about an hour. Which statement by the
patient is most indicative of cluster headaches?
a. “I usually have nausea and vomiting with
my headaches.”
b. “My whole head is constantly throbbing.”
c. “It feels like my head is in a vice.”
d. “The pain is on the left side over my eye,
forehead, and cheek.”
ANS: D
The description mentioned in option D is consistent with cluster headaches. Option A is
descriptive of migraines rather than cluster headaches. Option B is descriptive of
migraines rather than cluster headaches. Option C is descriptive of tension rather than
cluster headaches.
DIF: Cognitive Level: Apply REF: p. 104 | p. 141
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body
Systems
3. A patient reports having migraine headaches on one side of the head that
often start with an aura and last 1 to 3 days. As a part of the symptom analysis, the patient
,reports which associated symptoms of migraine headaches?
a. Nausea, vomiting, or visual disturbances
b. Nasal stuffiness or discharge
c. Ringing in the ears or dizziness
d. Red, watery eyes or drooping eyelids
ANS: A
Nausea, vomiting, or visual disturbances are symptoms associated with migraine
headaches. Nasal stuffiness or discharge is a symptom associated with cluster headaches
rather than migraine headaches. Ringing in the ears or dizziness is a symptom not
associated with migraine headaches. Red, watery eyes or drooping eyelids are symptoms
associated with cluster headaches rather than migraine headaches.
DIF: Cognitive Level: Analyze REF: p. 141
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body
Systems
4. The nurse is taking a health history on a patient who reports frequent
headaches with pain in the front of the head, but sometimes felt in the back of the head.
Which statement by the patient is most indicative of tension headaches?
a. “I usually have nausea and vomiting with
my headaches.”
b. “My whole head is constantly throbbing.”
c. “It feels like my head is in a vice.”
d. “The pain is on the left side over my eye,
forehead, and cheek.”
ANS: C
Option C is descriptive of tension headaches, which is consistent with the rest of the data
reported by the patient. Option A is descriptive of migraines rather than tension
headaches. Option B is descriptive of migraines rather than tension headaches. Option D
is consistent with cluster headaches rather than tension headaches.
DIF: Cognitive Level: Apply REF: p. 141
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body
Systems
5. 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.”
ANS: C
Option C is consistent with vertigo because it includes a sensation of motion. Option A is
a description of lightheadedness, a form of dizziness. Option B is a description of
disequilibrium, a form of dizziness. Option D is a description of syncope, a form of
dizziness.
DIF: Cognitive Level: Analyze REF: p. 141
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body
Systems
6. During symptom analysis, the nurse helps the patient distinguish between
dizziness and vertigo. Which description by the patient indicates dizziness?
a. “I felt faint, like I was going to pass out.”
b. “It felt like I was on a merry-go-round.”
c. “The room seemed to be spinning
around.”
d. “My body felt like it was revolving and
could not stop.”
ANS: A
Option A is a description of lightheadedness, a form of dizziness. Option B is consistent
with objective vertigo because it includes a sensation of motion. Option C is consistent
with objective vertigo because it includes a sensation of motion. Option D is consistent
with subjective vertigo because it includes a sensation of one’s body rotating in space.
DIF: Cognitive Level: Analyze REF: p. 141
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body
Systems
7. Which patient in the eye clinic should the nurse assess first?
a. The patient who reports a gradual
clouding of vision
b. The patient who complains of sudden loss
of vision
c. The patient who complains of double
vision
d. The patient who complains of poor night
vision
ANS: B
Sudden vision loss may indicate a detached retina and requires immediate referral. A
gradual clouding of vision is a symptom of cataracts that develop slowly and do not
require immediate assessment. Double vision is a symptom of cataracts that develop
, slowly and do not require immediate assessment. Poor night vision is a symptom of
cataracts that develop slowly and do not require immediate assessment.
DIF: Cognitive Level: Apply REF: p. 142
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body
Systems
8. A patient complains of right ear pain. What findings does the nurse
anticipate on inspecting the patient’s ears?
a. Redness and edema of the pinna of the
right ear
b. Report of pain when the nurse
manipulates the right ear
c. Bulging and red tympanic membrane in
the right ear
d. Increased cerumen in the right ear canal
ANS: C
Bulging and red tympanic membrane in the right ear is consistent with internal ear pain
that may be associated with otitis media. Redness and edema of the pinna of the right ear
is consistent with external ear pain that may be associated with otitis externa or
swimmer’s ear. Report of pain when the nurse manipulates the right ear is consistent with
external ear pain that may be associated with otitis externa or swimmer’s ear. Increased
cerumen in the right ear canal is not consistent with internal ear pain.
DIF: Cognitive Level: Apply REF: p. 159 | p. 175
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body
Systems
9. 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. Enlarged and pale turbinates
b. Polyps within the nares
c. High vascularity of the turbinates
d. Dry and dull turbinates
ANS: A
Enlarged and pale turbinates are expected findings for allergic rhinitis. Polyps within the
nares is not an expected finding. High vascularity of the turbinates is not an expected
finding. Dry and dull turbinates is not an expected finding.
DIF: Cognitive Level: Apply REF: p. 176
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body
Systems
10. A patient complains of nasal drainage and sinus headache. The nurse
