Questions & Detailed Rationales Questions & Detailed Rationales
A 19-year-old college student is brought to the D
A 2-week-old infant can fixate on an object but A emergency department with a severe headache
cannot follow a light or bright toy. The nurse he describes as, Like nothing Ive ever had
would: before. His temperature is 40 C, and he has a
stiff neck. The nurse looks for other signs and
a. Consider this a normal finding. symptoms of which problem?
b. Assess the pupillary light reflex a. Head injury
forpossible blindness.
b. Cluster headache
c. Continue with the examination,
andassess visual fields. c. Migraine headache
d. Expect that a 2-week-old infant d. Meningeal inflammation
shouldbe able to fixate and follow an object.
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Questions & Detailed Rationales Questions & Detailed Rationales
A 31-year-old patient tells the nurse that he has A A 31-year-old patient tells the nurse that he B
noticed a progressive loss in his hearing. He has noticed pain in his left ear when people
says that it does seem to help when people speak loudly to him. The nurse knows that
speak louder or if he turns up the volume of a this finding:
television or radio. The most likely cause of his
hearing loss is: a. Is normal for people of his age.
a. Otosclerosis. b. Is a characteristic of recruitment.
b. Presbycusis. c. May indicate a middle ear infection.
c. Trauma to the bones. d. Indicates that the patient has
acerumen impaction.
d. Frequent ear infections.
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Questions & Detailed Rationales Questions & Detailed Rationales
A 52-year-old patient describes the presence D A 60-year-old man is at the clinic for an eye C
of occasional floaters or spots moving in front examination. The nurse suspects that he has
of his eyes. The nurse should: ptosis of one eye. How should the nurse check
for this?
a. Examine the retina to determine
thenumber of floaters. a. Perform the confrontation test.
b. Presume the patient has glaucoma b. Assess the individuals near vision.
andrefer him for further testing.
c. Observe the distance between
c. Consider these to be abnormalfindings, thepalpebral fissures.
and refer him to an ophthalmologist.
d. Perform the corneal light test, and
d. Know that floaters are lookfor symmetry of the light reflex.
usuallyinsignificant and are caused by
condensed vitreous fibers.
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Questions & Detailed Rationales Questions & Detailed Rationales
A 68-year-old woman is in the eye clinic for a A
checkup. She tells the nurse that she has been A 70-year-old patient tells the nurse that he C
having trouble reading the paper, sewing, and has noticed that he is having trouble hearing,
even seeing the faces of her grandchildren. On especially in large groups. He says that he cant
examination, the nurse notes that she has some always tell where the sound is coming from
loss of central vision but her peripheral vision is and the words often sound mixed up. What
normal. These findings suggest that she may might the nurse suspect as the cause for this
have: change?
a. Macular degeneration. a. Atrophy of the apocrine glands
b. Vision that is normal for someone herage. b. Cilia becoming coarse and stiff
c. The beginning stages of c. Nerve degeneration in the inner ear
cataractformation.
d. Scarring of the tympanic membrane
d. Increased intraocular pressure
orglaucoma.