HEENT

The nurse is caring for a 50-year-old male patient with hyperthyroidism. Which assessment does the nurse anticipate?

The nurse assesses which body part to detect jaundice in the patient with dark skin?

Which information does the nurse provide to the patient scheduled to receive intravenous cyclophosphamide for stage III breast cancer regarding hair loss? 

A client with an intracranial hemorrhage has a sudden increase of 25 mmHg intracranial pressure. The nurse also notes an elevated temperature, increased blood pressure, fixed and dilated right pupil, loss of consciousness, and irregular pulse and respirations. Which condition does the nurse suspect is causing these signs and symptoms?

The nurse educates the patient with newly-diagnosed type 2 diabetes mellitus about which long-term complications of poorly-controlled diabetes? Select all that apply.

An individual experiencing anaphylaxis due to ingestion of peanuts has received epinephrine via autoinjector. Following the injection, the individual’s respirations have become less labored. In which position should the individual be placed while waiting for emergency medical personnel to arrive?

A 14-year-old patient presents to the clinic complaining of right outer ear pain. Which characteristic most likely explains the cause of the pain?

Which exercise is appropriate for the patient who has a Glasgow Coma Scale of 4?

Following brain surgery, the patient is producing massive volumes of dilute urine. The nurse suspects which structure was inadvertently harmed during the surgery?

The patient receiving thyroid supplementation for hypothyroidism reports insomnia, fatigue, tachycardia, and headache. Which statement by the nurse is appropriate?

The patient receiving levothyroxine for hypothyroidism reports treatment failure after the third dose increase. The nurse anticipates the provider to order which test for this patient?

The patient with increased intracranial pressure has been administered mannitol. Which patient symptom indicates the drug is having its intended effect?

The patient is brought to the emergency department following a serious motor vehicular accident (MVA). List the assessments the nurse performs in order from highest to lowest priority.

The emergency department nurse is assessing the unconscious patient following a fall from the ladder while he was doing home improvement work. Which assessment is performed first?

The nurse is the first responder to a motor vehicular accident involving the injury of a 40-year-old male. Which action is the highest priority?

The nurse suspects that a patient has Ludwig’s angina. Which action does the nurse take first?

Which of the following conditions can cause exophthalmos? Select all that apply.

The nurse is caring for a 62-year-old female who was recently diagnosed with glaucoma. The patient is given docusate. Which of the following is the primary reason for giving the patient a stool softener?

The nurse is caring for a 71-year-old who was recently diagnosed with age-related macular degeneration (AMD) in the left eye. The nurse encourages the patient to increase dietary intake of which substances? 

Following a motor vehicle accident, the patient is brought to the emergency department with a head injury. Upon assessment, the nurse notes otorrhea and mastoid bruising. The nurse reports the findings to the provider and suspects further testing will reveal which injury? 

The nurse observes the affected eye of the patient with newly diagnosed Bell's palsy is not closing fully and performs which interventions? Select all that apply.

The 5-year-old boy with measles cries when the nurse enters the room and turns on the lights. The nurse is most concerned about which reason behind the patient's behavior?

The patient who has taken phenytoin for the past 12 years for seizure disorder reports feeling something strange in the mouth. The nurse anticipates observing which condition? 

The nurse is assigned to a 55-year-old patient with Streptococcus viridans endocarditis who is receiving penicillin and amikacin. The nurse is vigilant for which adverse effect?

The patient is prescribed phenytoin for treatment of a seizure disorder. The nurse instructs the patient about which adverse effect of treatment? 

The nurse learns the patient uses nasal irrigation to help prevent sickness during flu season. Which statement by the nurse is the most important?

In the weeks after a stroke, which patient problem is of the highest priority?

The nurse provides care for the client diagnosed with Barrett's esophagus. Which goals does the nurse establish in the plan of care? Select all that apply.

The patient has undergone cataract surgery and is preparing for discharge. Which statement by the patient indicates an understanding of discharge teaching?

The nurse is instructing the unlicensed assistive personnel (UAP) on the proper care of dentures. Which actions by the UAP indicate an understanding of the teaching? Select all that apply.

The child is brought to the clinic by the parent who reports the child has a lazy eye. The nurse assesses the patient for which condition?

The patient presents to the emergency department (ED) with nausea, vomiting, fever, severe knee and wrist pain, nosebleed, and lymphadenopathy. A new murmur is noted, as well. The nurse asks the patient about a recent history of which infection?

While individual labs vary, which is the normal range of thyroid-stimulating hormone (TSH) levels in healthy individuals?

A nurse is caring for a patient with hemiplegia who has excess oral secretions. Which action best demonstrates safe and effective suctioning technique?

The nurse orders which items for the patient who has been ordered to receive a clear liquid diet? Select all that apply.

The nurse learns in shift report the 1-year-old with respiratory distress due to parainfluenza virus has had increased nasal and oral secretions and has had increased coughing fits. Which personal protective equipment does the nurse don prior to caring for the patient? Select all that apply.

The nurse receives report from the operating room regarding a postoperative craniotomy patient and recognizes the patient is at risk for which complications? Select all that apply.

Which symptom can occur following vertical transmission of Neisseria gonorrhoeae?

Viewing the patient’s chart, the nurse notes the patient has 20/100 vision. How does the nurse interpret these results?

The patient is admitted due to concern for a cerebrovascular accident in the brainstem. Which reflexes does the nurse use to assess the integrity of the brainstem? Select all that apply.

Following a motor vehicle accident, the patient is brought to the emergency department with concern for a brainstem injury. Which tests are performed to assess the integrity of this patient’s brainstem? Select all that apply.

The nurse uses the caloric and doll’s eyes reflex tests to assess the functions of which cranial nerves in the comatose patient? Select all that apply.

The nurse on the neurological intensive care unit would intervene if the provider attempted to assess the oculovestibular reflex in the patient with which recent injury?

The patient has signs of dangerously increased intracranial pressure following a traumatic brain injury. The nurse prepares the patient for the insertion of which intracranial pressure monitoring device considered to be the gold standard?

The 16-year-old patient presents to the emergency department (ED) complaining of a headache, fever, malaise, and nuchal rigidity. The patient is found to have a fever of 106°F, heart rate 132 bpm, and blood pressure 135/62 mmHg. A complete blood count is normal with the exception of leukocytosis. Additional assessment reveal sunsetter eyes and papilledema. Which test, if instructed to perform first, prompts the nurse to question the order?

The patient is receiving therapeutic hypothermia treatment following a massive myocardial infarction with return of spontaneous circulation (ROSC) after 30 minutes of cardiopulmonary resuscitation (CPR). It is most important to plan care to address which complication of therapeutic hypothermia?

The nurse observes the following pupils in the patient: (R,L) The nurse alerts the provider to which possible scenario?

The nurse observes the following pupils in the patient just brought into the emergency department by ambulance: (R,L) The nurse immediately prepares the patient for which test?

The unresponsive patient is brought to the emergency department via ambulance. During an abbreviated neurologic exam, the nurse notes the following pupils, estimated to be 1 mm and fixed: The nurse prepares to administer which medication?

The patient in the intensive care unit is intubated, sedated, and chemically paralyzed following decompensation due to necrotizing pneumonia. During the routine neurological check, the nurse notes these pupils: How does the nurse interpret this assessment?