HEENT

The unconscious patient presents with the following respiratory pattern: The nurse anticipates further testing will reveal which condition?

Which instruction does the nurse give the patient during preoperative teaching prior to a middle ear surgery?

Fentanyl must be used with caution in which patient?

The patient presents to the clinic for a check-up and is noted to have a temperature of 35.2°C. The patient denies being feeling cold or hot, recent illnesses, or prolonged exposure to the cold. The nurse suspects further testing will reveal a lesion in which area of the brain?

The patient is brought to the emergency department (ED) with sudden onset blindness and deafness. The patient is being guided in by his wife but is walking well. The nurse suspects the patient is experiencing which condition?

The nurse tests which cranial nerves to assess for increased intracranial pressure? Select all that apply.

During a comprehensive physical assessment, the nurse instructs the patient to stand still with the eyes closed. After a few seconds, the patient begins to sway and the nurse guides the patient into the chair. How does the nurse document this finding?

The nurse is preparing the patient for a computed tomography (CT) scan of the brain following a blow to the head. Which instruction does the nurse give the patient?

The patient with severe anxiety and claustrophobia is administered intravenous midazolam prior to an outpatient magnetic resonance imaging (MRI) scan of the brain. The nurse informs the patient’s companion that the patient can leave at which time following the procedure?

The patient with epilepsy is observed to be staring off into the distance and cannot be aroused from this state for roughly a minute. The nurse documents which type of seizure in the patient?

The nurse anticipates which symptom in the patient newly diagnosed with Graves' disease?

The patient receiving hospice care reports constant, severe dry mouth. Which interventions does the nurse include in the patient's care plan? Select all that apply.

While reviewing the patient’s chart in preparation for admission to the intensive care unit, the nurse learns the patient is exhibiting ataxic breathing. Which pattern does the nurse expect to observe in the patient?

Which patient with dyspnea is seen first in the emergency department?

Which term is used to describe this visual field test result?

The patient has the following visual field test for the left eye in which the black spots represent where the patient cannot see. Which interpretation of the test result is correct?

The patient has been diagnosed with an arteriovenous malformation (AVM) and is scheduled to undergo surgery in the morning. Which nursing intervention is the most important to promote safety in the patient?

The patient with arteriovenous malformation who takes a monoamine oxidase inhibitor for depression develops an upper respiratory infection. The nurse requests a prescription for which medication?

The patient presents to the emergency department (ED) with unilateral facial paralysis. Comprehensive testing rules out cerebrovascular accident. The nurse prepares the patient for which test?

The nurse is providing education to the patient with Bell’s palsy. Which instruction does the nurse give the patient to promote safety?

Which statement by the patient indicates a need for further teaching about the new diagnosis of Bell’s palsy?

The patient with migraines undergoes an MRI and is found to have a cerebral aneurysm in the Circle of Willis. The nurse is vigilant for which symptoms that would indicate the patient is experiencing a life-threatening complication of the cerebral aneurysm? Select all that apply.

The triage nurse is assessing patients in the emergency department (ED). Which patient is seen first?

The nurse is caring for a patient with Guillain-Barré syndrome. The patient has an order for a pureed diet. Which assessment prompts the nurse to clarify the order with the provider?

The patient presents to primary care with two round patches of hair loss on his scalp. He reports no trauma or symptoms aside from the hair loss. The nurse gathers information about his environment, including his workplace. The patient states he recently moved to the area for a new job and that his wife, who is pregnant with their first child, works at the same company. Which diagnosis does the nurse anticipate this patient will receive?

The patient is hospitalized following a cerebrovascular accident (CVA). The patient calls out to report a sudden, pounding headache. Which assessments are the priority? Select all that apply.

The nurse has received orders for the patient admitted following a hemorrhagic stroke and clarifies orders for which medications? Select all that apply.

The nurse is supervising the care of the patient who suffered an embolic stroke of the right middle cerebral artery after a clot formed on the patient’s prosthetic mitral valve. Which instruction does the nurse provide to the unlicensed assistive personnel that will be most important to prevent bacterial endocarditis?

During a comprehensive neurologic exam, the provider brushes a wisp of cotton over the patient’s cornea, which causes the patient to blink. The nurse notes that which cranial nerve is intact based on this test?

The patient has been prescribed an irrigation for the right eye. The nurse assists the patient into which position?

The nurse is supervising the student nurse in the irrigation of the patient’s right eye. Which action by the student nurse prompts the nurse to intervene with additional education?

The patient presents to the urgent care clinic complaining of eye pain and feeling like there’s a foreign object in the eye. The provider examines the patient and orders a 500 mL irrigation of sterile saline. After warming the solution to 37°C and positioning the patient, the nurse begins to administer the irrigation. The patient cries out in pain and jerks away from the nurse. Which response by the nurse is most appropriate?

The nurse is testing the patient’s eyes for accommodation by holding a finger in front of the eyes and asking the patient to look at a point over the nurse’s shoulder then look at the finger. The nurse documents which bilateral response as normal?

The nurse utilizes the ophthalmoscope to assess the patient’s retina and notes narrowing in the vessels where the arteries and veins cross. Which vital sign is consistent with this finding?

The nurse is preparing the patient for an ophthalmoscopic exam in which cyclopentolate drops must be instilled to allow for better visualization of the retina. Which characteristics, if present in the patient’s medical history, prompt the nurse to hold the drops and contact the provider for further instruction? Select all that apply.

Which instruction does the nurse give the patient prior to administering cyclopentolate eye drops?

The nurse is preparing the patient for a pneumotonometry test. Which instruction does the nurse give the patient?

Which test is used to assess the retina and fundus of the patient with severe cataracts?

The nurse is educating the patient on self-administering antibiotic eye drops. Which instruction does the nurse include?

The patient has undergone an extracapsular cataract extraction. Which discharge instructions does the nurse give the patient? Select all that apply.

Which statement does the nurse include in discharge teaching to the parents of the 9-year-old who underwent tonsillectomy and adenoidectomy?

The nurse is providing preoperative teaching to the patient scheduled to undergo an iridectomy. Which statement indicates a need for further teaching?

During a routine checkup, the patient reports undergoing a scleral buckling procedure since the last visit. Which follow-up question does the nurse ask regarding this event?

Following a scleral buckling procedure, the patient complains of nausea. Which action does the nurse take?

The patient is scheduled to undergo a trabeculectomy for the treatment of refractory glaucoma. The nurse is providing preoperative teaching to the patient. Which statement indicates a need for further teaching?

The nurse is visiting the home of a patient who recently underwent a trabeculectomy. Which statement improves patient safety?

During the initial examination of the full-term baby, the nurse notes an irregular red reflex. The nurse reports the finding to the provider and reviews the mother’s chart for which information?

The nurse is performing an admission assessment on the 73-year-old patient. Which question does the nurse ask to determine if the patient is experiencing cataract development?

The patient walks into to the emergency department (ED) complaining of significant pain in the right eye. It appears red and swollen. The pupils are not equal in size or reactivity – the right pupil remains dilated despite the bright exam room and the flash light. The patient cringes from the bright light, though, and complains the bright lights are hurting his head. He reports that over the last week, both eyes have been aching and he has been seeing halos around lights. The nurse prepares for which test to be performed first?

The patient with a sore throat has tested positive for group A beta-hemolytic Streptococcus pyogenes. The nurse educates the patient to complete the entire course of antibiotics in order to prevent which complications? Select all that apply.