Head and eye

When using the PERRLA acronym, the nurse is assessing which body part(s)?

Eyes

Why is it important to ask the client regarding discharge or drainage from the eyes?

• Discharge is associated with inflammation or infection

A client visits the health care clinic with reports of itchy and watery eyes for three days. The nurse observes a generalized redness to the conjunctiva. The nurse recognizes this as what condition?

Conjunctivitis

The nurse tests the distant visual acuity of several clients and records the findings. Which finding indicates that the client with the poorest vision?

• 20/60

A 2-month-old infant is being examined at the pediatrician's office. The mother said she noticed the baby was not making tears in the left eye. What does this finding suggest?

• A blocked lacrimal apparatus

During the physical examination of a client's eyes, the nurse asks the client to follow the tracing of a giant H with the eyes. What function is the nurse assessing in this client?

• Extraocular movements

What eye function is the nurse preparing to assess when the client is asked to stand 20 feet from a specific chart that is mounted on the examination room wall?

• Distant vision

A client presents to the health care clinic with red, watery eyes and constant tearing. The nurse understands that which of the following is the organ that produces tears?

• Lacrimal gland

The nurse is assessing cranial nerves III, IV, and VI. Which instructions should the nurse provide to the client in order to perform this assessment?

• "Follow my finger with only your eyes."

A client is concerned because the sclera of the right eye has been pink in color for several days and tearing. What should the nurse suspect is occurring with this client?

• conjunctivitis

During an eye assessment, the nurse is testing a client's visual acuity using a Snellen chart. In order to prepare the client for this component of assessment, what instruction should the nurse provide?

• “Cover one of your eyes and then read out the letters on the chart, starting from the top.”

The nurse asks the client to perform the action pictured. What is the nurse assessing?

• Near vision

A client performs the test for distant visual acuity and scores 20/50. How should the nurse most accurately interpret this finding?

• At 20 feet from the chart, the client sees what a person with good vision can see at 50 feet

A client has conjunctivitis. The nurses understand that conjunctivitis differs from conjunctival hemorrhage in that conjunctivitis

• has a watery, mucoid discharge.

A client performs the test for distant visual acuity and scores 20/50. How should the nurse most accurately interpret this finding?

• At 20 feet from the chart, the client sees what a person with good vision can see at 50 feet.

A client presents to the health care clinic and reports pain in the eyes when working on the computer for long periods of time. The client states that he almost ran into a parked car yesterday because he misjudged the distance from the bumper of his own car. He works for a computer software company and has noticed he is experiencing difficulty reading the manuals that accompany the software he installs for companies. What nursing diagnosis can the nurse confirm based on this data?

• Risk for Injury

A client is being assessed following a motor vehicle accident. The client's right eye is swollen shut and very painful. Why does this require further assessment?

• Blunt-force trauma often results in fracture of the orbit

A client shares that a first-degree relative has an eye problem, but they not sure what the diagnosis is. What major eye problem will the nurse suggest screening the client for?

• Glaucoma

Which vision acuity reading indicates blindness?

• 20/200

While the nurse examines a client's pupillary response to light in the right eye, the pupil in the left eye is constricted. What does this finding suggest to the nurse?

• Consensual reaction

Which of the following is a symptom of the eye?

Scotomas

The thin mucous membrane that lines the inner eyelid and covers the sclera is known as what?

• Conjunctiva

When preparing to examine a client's sclera and conjunctiva during an eye examination, the nurse should instruct the client to move both eyes to look in which direction?

• Up

A 12-year-old presents to the clinic with his father for evaluation of a painful lump in the left eye. It started this morning. The client denies any trauma or injury. There is no visual disturbance. Upon physical examination, there is a red raised area at the margin of the eyelid that is tender to palpation; no tearing occurs with palpation of the lesion. Based on this description, what is the most likely diagnosis?

Stye

A nurse notices a middle-aged client in the waiting room pick up a magazine to read while she waits to be seen. She opens the magazine and then extends her arms to move it further from her eyes. Which condition does the nurse most suspect in this client?

• Presbyopia

An adult client tells the nurse that her peripheral vision is not what it used to be and she has a blind spot in her left eye. The nurse should refer the client for evaluation of possible

glaucoma

When performing a client's ophthalmoscopic exam, the nurse observes a round shape with distinct margins. How would the nurse document this finding?

• Optic disc

The nurse is planning to assess a client’s near vision. Which technique should be used?

• have the client read newspaper print held 14 inches from the eyes

How can a nurse accurately assess the distant visual acuity of a client who is non-English speaking?

• Use a Snellen E chart to perform the examination

The meibomian glands secrete

• an oily substance to lubricate the eyes.

A client complains of excessive tearing of the eyes. Which assessment would the nurse do next?

• Assess the nasolacrimal sac

On a health history, a client reports no visual disturbances, last eye exam two years ago, and does not wear glasses. The nurse notices that the client squints when signing the consent for treatment form and holds the paper close to the face. What should the nurse do next?

• Perform both the distant and near visual acuity tests

A 29-year-old physical therapist presents for evaluation of an eyelid problem. On observation, the right eyeball appears to be protruding forward. Based on this description, what is the most likely diagnosis?

• Exophthalmos

When performing the cover test, a nurse notices that the client's left eye turns outward. How should the nurse document this finding in the client's record?

Exotropia

On a health history, a client reports no visual disturbances, last eye exam being 2 years ago, and not wearing glasses. The nurse notices that the client squints when signing the consent for treatment form and holds the paper close to the face. What should the nurse do next?

• Perform both the distant and near visual acuity tests

A client has been diagnosed with astigmatism. The nurse should be prepared to teach the client about which treatment for this condition?

• Corrective lenses

Photoreceptors of the eye are located in the eye’s

retina

The nurse is preparing to examine an adult client’s eyes, using a Snellen chart. The nurse should

• position the client 609.6 cm (20 ft) away from the chart.

The nurse selects the chart shown here to assess a client’s vision. Which client characteristic caused the nurse to select this chart?

• Does not speak English

Which of the following would a nurse expect to assess in a client with esotropia?

• Eye turning inward

A middle-aged client reports difficulty in reading. Which action by the nurse is appropriate to test near visual acuity using a Jaeger reading card?

• Instruct the client hold the chart 14 inches from the eyes

A nurse assesses the vision of an older adult client with a long history of uncontrolled type 2 diabetes. The nurse determines the client’s vision with corrective lenses is 20/200. How should the nurse interpret these findings?

• These findings indicate the client is legally blind.

A nurse shines a light into one eye during ocular exam and the pupil of the other constricts. The nurse interprets this as which of the following?

• Consensual response

A client complains of feeling like he is slowly losing his central vision. The nurse knows this symptom could represent

• macular degeneration

The nurse observes an inward turning of the lower lid in a 77-year-old client. The nurse documents

• entropion

A light is pointed at a client's pupil, which then contracts. It is also noted that the other pupil contracts as well, though it is not exposed to bright light. Which of the following terms describes this latter phenomenon?

• Consensual reaction

Which of the following assessment findings suggests a problem with the client's cranial nerves?

• A client's extraocular movements are asymmetrical and she complains of diplopia.

A factory worker has presented to the occupational health nurse with a small wood splinter in his left eye. The nurse has assessed the affected eye and irrigated with warm tap water, but the splinter remains in place. What should the nurse do next?

• Arrange for worker to be promptly assessed by an eye specialist.

What is a characteristic symptom of Graves hyperthyroidism?

• Exophthalmos

A client has been found to have abnormal vision. What would be the nurse's next step?

• Facilitate a referral to an ophthalmologist.

Which risk factor for traumatic brain injury (TBI) should a nurse include in a discussion about prevention for a group of adolescents?

• Concussions in sports and motor vehicle accidents cause the largest number of TBIs in teens.

The nurse does a health history. The client states he has lost 30 pounds in the last couple months without really trying. The client also states he feels warm all the time and sometimes feels like he has heart palpitations. The nurse would anticipate orders to evaluate the client for

hyperthyroidism

A client suffering from a headache complains of throbbing, severe, unilateral pain that feels worse when exposed to bright lights. The client also complains of nausea and vomiting. What is the nurse's best action?

• Administer migraine medication

When the nurse is preparing to assess the thyroid gland of a client with suspected hypothyroidism, why is it important to bring a cup of water to the physical examination?

• to observe the movement of the thyroid gland

Which type of vessels filter pathogens from the body and drain the fluid that has moved outside of the circulation back into the vessels?

Lymphatic

A client reports having a headache. The nurse performs a specialized focused assessment and notes the following: client rates pain 10 on a scale of 1 to 10 (10 being the worst), nauseated and vomited, reporting sensitivity to noise and light. The nurse determines that the client is most likely experiencing which of the following types of headache?

migraine

A client is being assessed for a headache. Symptoms include throbbing and severe pain lasting for the last 8 hours. The client also has a history of vomiting with the headache. What type of headache could these findings indicate?

• Migraine

The nurse feels a small mass in the neck of a client. It is mobile in both the up-and-down and side-to-side directions. Which of the following is the nurse most likely feeling?

• Lymph node

A nurse is providing care for a client who experienced a head injury and who just moved to the United States from Southeast Asia. What cultural nursing consideration should the nurse take into account when performing an assessment on clients from different cultures?

• Consider cultural norms.

Which of the following would the nurse suspect if assessment reveals a skull and facial bones that are larger and thicker than normal?

Acromegaly

While assessing the head and neck of an adult client, the client tells the nurse that she has been experiencing sharp shooting facial pains that last from 10 to 20 seconds but are occurring more frequently. The nurse should refer the client for possible

• trigeminal neuralgia.

Which vessel is the nurse assessing if the major artery of the neck is being examined?

Carotid

When assessing an adult client experiencing diarrhea, the nurse notes a round “moon” face, a buffalo hump at the nape of the neck, and a velvety discoloration around the neck. What is the possible cause of these signs?

• Cushing's syndrome

The nurse is planning to instruct a group of adolescents on ways to prevent traumatic brain injuries. What should be included in these instructions?

• Always use seat belts.

A 73-year-old woman comes to the office for evaluation of new onset of tremors. She is not taking any medications, herbs, or supplements. She has no chronic medical conditions. She does not smoke or drink alcohol. She walks into the examination room with slow, shuffling steps. She has decreased facial mobility with a blunt expression without any changes in hair distribution on her face. Based on this description, what is the most likely reason for the client's symptoms?

• Parkinson's disease

The nurse is palpating a client's neck as part of a physical assessment. Which of the following blood vessels should the nurse be especially careful to avoid bilaterally compressing during the assessment?

• Carotid artery

A nurse is palpating the head and neck of a newly referred client. Which of the following would the nurse suspect if assessment reveals that the client's skull and facial bones are larger and thicker than normal?

Acromegaly

The nurse is preparing to assess the lymph nodes of an adult client. The nurse should instruct the client to

• sit in an upright position.

A 66-year-old woman has come to the clinic with complaints of increasing fatigue over the last several months. She claims to frequently feel lethargic and listless and states that, “I can never seem to get warm, no matter what the thermostat is set at.” How should the nurse proceed with assessment?

• Assess the woman for hypothyroidism.

The nurse is preparing to assess the neck of an adult client. To inspect movement of the client’s thyroid gland, the nurse should ask the client to

• swallow a small sip of water.

Which of the following would the nurse consider to be an urgent situation?

• New onset chest pain

A client describes headaches as severe and lasting for days. Which question would be most appropriate to use to determine if these headaches are migraines?

• “Do you have any visual changes before the headache?”

Which of the following would the nurse document as an abnormal finding with lymph node assessment?

• Tender

A female client visits the clinic and tells the nurse that she frequently experiences severe recurring headaches that sometimes last for several days and are accompanied by nausea and vomiting. The nurse determines that the type of headache the client is describing is a

• migraine headache.

When examining a client's thyroid gland, the nurse ensures that which equipment is readily available?

• Cup of water

A client is having trouble turning her head to the side. Which of the following muscles should the nurse most suspect as being involved?

Sternocleidomastoid

A nurse is preparing to examine a client from Southeast Asia who has been experiencing chronic headaches. Which of the following should the nurse do in light of this client's cultural background?

• Ask permission before palpating the head and neck

A nurse has completed an assessment of a client's lymph nodes. Which of the following data would the nurse document as an abnormal finding?

Tender

Assessment of an adult female client's face reveals a moon shape, increased hair distribution, and a reddened tone to the client's cheeks. What collaborative problem is most clearly suggested to the nurse by these assessment data?

• RC: Cushing's syndrome

A nurse asks the client to describe the pain associated with a headache by rating the pain on a scale from 1 to 10. This subjective data should be documented in which section of the assessment?

• characteristic symptoms

A nurse is examining a client's neck and is preparing to palpate the thyroid gland. The nurse would most likely expect to palpate how many lobes?

2

A 38-year-old accountant comes to the clinic for evaluation of a headache. The throbbing sensation is located in the right temporal region, and is an 8 on a pain scale of 1 to 10. It started a few hours ago, and she has noted nausea with sensitivity to light; she has had headaches like this in the past, usually less than one per week, but not as severe. She does not know of any inciting factors. There has been no change in the frequency of her headaches. She usually takes an over-the-counter analgesic, which results in resolution of the headache. Based on this description, what is the most likely diagnosis of the type of headache?

Migraine

A nurse is caring for a client admitted with neck pain. The client is febrile. What is the most likely medical diagnosis for this client?

Meningitis

The nurse practitioner auscultates both lobes of a client’s enlarged thyroid gland. Identification of what sound would tend to confirm a diagnosis of a toxic goiter?

Bruit

Which risk factor for traumatic brain injury should a nurse include in a discussion about prevention for a group of adolescents?

• Modes of transportation are the leading cause

During your physical examination of the client you note an enlarged tender tonsillar lymph node. What would you do?

• Look for a source such as infection in the area that it drains

A client visits the clinic and tells the nurse that he is depressed because of a recent job loss. He complains of dull, aching, tight, and diffuse headaches that have lasted for several days. The nurse should recognize that these are symptoms of

• tension headaches.

While assessing an adult client’s skull, the nurse observes that the client’s skull and facial bones are larger and thicker than usual. The nurse should assess the client for

acromegaly

A client reports using pain medication and sitting in a dark room on the onset of a migraine headache. In which part of the subjective section of the physical examination should the nurse document this information?

• relieving factors

A client reports right-sided temporal headache accompanied by nausea and vomiting. A nurse recognizes that which condition is likely to produce these symptoms?

• Migraine headache

A client presents at the clinic for a routine check-up. The nurse notes that she is dressed in warm clothing even though the temperature outside is 73°F (22.8°C). The nurse also notes that the client has gained 10 pounds (4.5 kg) since her last visit 9 months ago. What might the nurse suspect?

Hypothyroidism

The nurses assesses the thyroid gland of a client with recent weight loss. On auscultation, a low, soft, rushing sound is heard over the lateral lobes. Which condition is most likely?

hyperthyroidism

A nurse is teaching nursing students about the risks associated with developing head and neck cancers. The nurse determines student understanding when the students make which of the following statements?

• “Most head and neck cancers are linked to smoking.”

A nurse performs a comprehensive assessment on a client. The nurse observes the following findings: enlarged hands, feet, and facial features (nose, ears). Which of the following disorders do these findings indicate?

acromegaly

Where is the temporal artery palpated?

• Above the cheek bone near the scalp line

What is the most common type of hyperthyroidism?

• Graves' disease

Palpation of a 15-year-old boy's submandibular lymph nodes reveals them to be enlarged and tender. What is the nurse's most reasonable interpretation of this assessment finding?

• There is an infection in the area that these nodes drain.

During the health history, a client reports complaints of intermittent facial pain lasting several minutes. The nurse would suspect which of the following?

• Trigeminal neuralgia

The nurse is discharging an adult client who received 18 staples for a head laceration received while mountain biking. What can the nurse focus on while doing discharge teaching?

• Encourage the use of safety equipment

A client's recent weight loss and diarrhea has been attributed to hyperthyroidism. When auscultating the client's thyroid gland, what assessment finding is most consistent with this diagnosis?

• A sound of turbulent blood flow in the thyroid