The nurse notes the presence of periorbital edema when performing eye assessment on a 70-year-old patient. The nurse will:

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NCLEX Practice Questions Health Assessment Questions

Question 1 of 5

The nurse notes the presence of periorbital edema when performing eye assessment on a 70-year-old patient. The nurse will:

Correct Answer: B

Rationale: The correct answer is B: suspect that the patient has hyperthyroidism. Periorbital edema is a common sign of hyperthyroidism due to the accumulation of fluid in the tissues around the eyes. By suspecting hyperthyroidism, the nurse can further assess for other associated symptoms and recommend appropriate diagnostic tests. Choice A (check for the presence of exophthalmos) is incorrect because exophthalmos refers to bulging eyes, which may be present in hyperthyroidism but is not directly related to periorbital edema. Choice C (ask the patient if he or she has a history of heart failure) is incorrect as periorbital edema is not typically associated with heart failure, which usually presents with generalized edema. Choice D (assess for blepharitis) is incorrect because while blepharitis can cause eyelid inflammation, it is not typically associated with periorbital edema seen in hyper

Question 2 of 5

During an ophthalmoscopic examination of a patient, the examiner notes areas of exudate that look like"cotton wool" or fluffy grey-white cumulus clouds. Which of the possible problems below does this finding indicate?

Correct Answer: A

Rationale: The correct answer is A: Diabetes. The presence of "cotton wool" or fluffy grey-white cumulus clouds on ophthalmoscopic examination indicates retinal nerve fiber layer infarcts due to microvascular damage, which is a common finding in diabetic retinopathy. This occurs due to ischemia and subsequent axonal swelling. In diabetes, hyperglycemia can lead to damage in the blood vessels supplying the retina, resulting in microaneurysms, hemorrhages, exudates, and ultimately vision loss if left untreated. Summary of other choices: B: Hyperthyroidism - This condition primarily affects the thyroid gland and does not directly cause the characteristic retinal findings described. C: Glaucoma - Glaucoma is a condition characterized by increased intraocular pressure and optic nerve damage, which does not typically present with the specific retinal findings mentioned. D: Hypotension - Low blood pressure may lead to retinal artery occlusion or ischemic optic neuropathy,

Question 3 of 5

The nurse is examining a patient's ears and notices cerumen in the external canal. Which of the following statements about cerumen is correct?

Correct Answer: C

Rationale: The correct answer is C: The purpose of cerumen is to protect and lubricate the ear. Cerumen, commonly known as earwax, acts as a natural barrier to prevent dust, debris, and microorganisms from entering the ear canal. It also helps to lubricate the skin in the ear canal and prevent dryness and itching. Choice A is incorrect because sticky, honey-colored cerumen is not necessarily a sign of infection; it can occur due to various factors. Choice B is incorrect as the presence of cerumen does not solely indicate poor hygiene; everyone produces earwax regardless of hygiene practices. Choice D is incorrect as cerumen can sometimes block the ear canal and impair sound transmission rather than aid it.

Question 4 of 5

Which of the following cranial nerves (CNs) is responsible for conducting nerve impulses to the brain from the organ of Corti?

Correct Answer: C

Rationale: The correct answer is C: CN VIII. The vestibulocochlear nerve (CN VIII) is responsible for conducting nerve impulses from the organ of Corti in the inner ear to the brain. This nerve specifically carries auditory information to the brainstem and auditory cortex for processing. Choice A (CN I) is incorrect as it is the olfactory nerve responsible for smell. Choice B (CN III) is incorrect as it is the oculomotor nerve responsible for eye movement. Choice D (CN XI) is incorrect as it is the accessory nerve responsible for neck and shoulder movements.

Question 5 of 5

A patient in her first trimester of pregnancy is diagnosed with rubella. Which of the following indicates the significance of this in relation to the infant's hearing?

Correct Answer: B

Rationale: The correct answer is B because rubella can indeed damage the organ of Corti in the fetus, which is responsible for hearing. During the first trimester, when the hearing structures are forming, any damage to the organ of Corti can result in impaired hearing for the infant. Choice A is incorrect because rubella can impact the fetus, including the organs responsible for hearing. Choice C is incorrect because rubella can be harmful to the fetus at any stage of pregnancy, not just the second trimester. Choice D is incorrect because CN VIII (the vestibulocochlear nerve) is not directly affected by rubella, rather it is the organ of Corti that is damaged.

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