HEENT
A nurse is assessing an older adult who reports hearing “ringing” and difficulty understanding speech in crowded areas. Which condition is most consistent with these findings?
A. Presbycusis
B. Vertigo
C. Conductive hearing loss
D. Meniere’s disease
Presbycusis
A nurse is caring for four clients. Which client should the nurse assess first?
A. A client with Alzheimer’s disease who is pacing the hallway
B. A client with new-onset confusion and slurred speech
C. A client with bilateral hearing aids reporting feedback noise
D. A client with macular degeneration who needs help reading meal labels
A client with new-onset confusion and slurred speech
A client in the ICU with soft wrist restraints and no family present appears withdrawn and uninterested in conversation. Which nursing intervention is most appropriate?
A. Increase television volume for background stimulation
B. Provide meaningful interaction and explain care before touching
C. Decrease environmental stimuli and cluster care
D. Encourage the client to rest quietly throughout the shift
Provide meaningful interaction and explain care before touching
After implementing a care plan for a client with depression, which observation indicates the plan is effective?
A. The client verbalizes a plan for suicide but promises not to act on it
B. The client reports feeling tired and avoids eye contact
C. The client initiates conversation and participates in group therapy
D. The client isolates to “rest and recharge”
The client initiates conversation and participates in group therapy
The nurse shines a penlight into each eye to test pupillary constriction. Which cranial nerve pair is involved?
A. II and III
B. IV and VI
C. III and V
D. II and VII
A. II and III
optic and oculomotor
A nurse is caring for a client admitted with a head injury who complains of a severe headache and is restless. The room is bright and full of visitors. Which action should the nurse take first?
A. Administer the prescribed pain medication
B. Dim the lights and reduce environmental noise
C. Educate visitors to avoid loud talking
D. Reassess the client’s pain level in 30 minutes
Dim the lights and reduce environmental noise
The nurse is assessing a client’s eyes. Which finding requires immediate follow-up?
A. Sclera that appears slightly yellow in a dark-skinned patient
B. A small, firm bump on the eyelid that is not tender
C. Pupils unequal in size that do not react to light
D. Occasional watery drainage in both eyes
Pupils unequal in size that do not react to light
A client with a history of sinusitis reports a headache and nasal congestion. Which nursing intervention should the nurse implement first?
A. Educate about increasing fluid intake.
B. Assess for fever and tenderness over the sinuses.
C. Instruct on proper hand hygiene to prevent infection.
D. Recommend the use of a humidifier.
B. Assess for fever and tenderness over the sinuses.
A nurse is developing a care plan for a client with dementia. Which intervention should be prioritized to promote safety and orientation?
A. Encourage the client to take long naps during the day
B. Provide a consistent daily routine with familiar objects
C. Offer multiple choices for meals and activities
D. Frequently reorient the client to new staff and surroundings
Provide a consistent daily routine with familiar objects
A client’s right eye does not move laterally. The nurse recognizes dysfunction of which cranial nerve?
A. Oculomotor (III)
B. Trochlear (IV)
C. Abducens (VI)
D. Optic (II)
C. Abducens (VI)
During an HEENT assessment, the nurse notes a firm, non-healing lesion on the client’s lower lip. Which nursing diagnosis is most appropriate?
A. Risk for infection related to poor oral hygiene
B. Impaired skin integrity related to pressure
C. Risk for impaired tissue integrity related to potential oral malignancy
D. Deficient knowledge related to lack of dental care
Risk for impaired tissue integrity related to potential oral malignancy
After providing education on preventing ear injury, the nurse documents: “Client verbalized understanding of avoiding Q-tip use for cleaning ears.” Which aspect of the nursing process does this best reflect?
A. Planning
B. Implementation
C. Evaluation
D. Diagnosis
Evaluation
A client with recurrent sinus infections asks how to prevent future episodes. Which teaching should the nurse include in the care plan?
A. “Use a nasal spray daily to prevent inflammation.”
B. “Avoid exposure to cigarette smoke and drink plenty of fluids.”
C. “Increase caffeine intake to keep airways open.”
D. “Take antibiotics at the first sign of congestion.
“Avoid exposure to cigarette smoke and drink plenty of fluids.”
A nurse is caring for an older adult who suddenly becomes confused, agitated, and disoriented after surgery. Which assessment finding best supports a diagnosis of delirium rather than dementia?
A. The confusion developed gradually over several months
B. The client’s orientation fluctuates throughout the day
C. The client’s long-term memory is impaired but short-term is intact
D. The client is calm and cooperative
The client’s orientation fluctuates throughout the day
When testing cranial nerve V, the nurse assesses which combination of functions?
A. Facial movement and taste
B. Facial sensation and chewing
C. Vision and accommodation
D. Swallowing and gag reflex
B. Facial sensation and chewing
trigeminal
While performing an oral exam, the nurse observes a suspicious lesion on a client’s tongue. The client refuses further evaluation, stating, “I don’t want to know.” What is the nurse’s best response?
A. “You have the right to refuse, but this could be serious.”
B. “We can wait a few weeks to see if it resolves on its own.”
C. “You should allow me to schedule you for an oral biopsy.”
D. “I understand. Can you tell me what worries you about getting it checked?”
“I understand. Can you tell me what worries you about getting it checked?”
During a thyroid assessment, the nurse notes a visibly enlarged gland that is firm and nodular. What is the nurse’s priority action?
A. Palpate deeply to confirm size and consistency.
B. Auscultate for a bruit over the thyroid.
C. Document and recheck during the next visit.
D. Massage the area to assess for tenderness.
B. Auscultate for a bruit over the thyroid.
A client with early cataracts asks how to slow progression. Which statement by the nurse shows appropriate health promotion teaching?
A. “You can’t really prevent cataracts, but you can get surgery later.”
B. “Avoid sunlight exposure and wear UV-protective sunglasses.”
C. “Stop eating foods with vitamin A.”
D. “Rinse your eyes daily to remove toxins.”
“Avoid sunlight exposure and wear UV-protective sunglasses.”
A nurse caring for a confused, hearing-impaired client needs to provide discharge teaching. Which approach is most effective?
A. Provide written instructions in complex medical terms
B. Use short, simple sentences and maintain eye contact while speaking slowly
C. Stand behind the client to minimize distraction
D. Rely on family to provide all teaching at home
Use short, simple sentences and maintain eye contact while speaking slowly
A nurse performing a Romberg test and a whisper test is assessing which cranial nerve?
A. Vestibulocochlear (VIII)
B. Glossopharyngeal (IX)
C. Trigeminal (V)
D. Trochlear (IV)
Vestibulocochlear (VIII)
controls hearing and balance
After performing a HEENT assessment, which documentation entry is most accurate and legally appropriate?
A. “Patient denies pain and appears fine.”
B. “TMJ clicks noted bilaterally with opening and closing; no tenderness or swelling.”
C. “Neck normal and no problems observed.”
D. “Eyes look healthy, and patient says vision is okay.”
“TMJ clicks noted bilaterally with opening and closing; no tenderness or swelling.”
A client reports dizziness and hearing loss. The nurse observes unsteady gait and positive Romberg test. Which action is most appropriate?
A. Document findings and recheck in 24 hours
B. Notify the provider and implement fall precautions
C. Encourage the client to ambulate frequently for balance
D. Administer prescribed ear drops for pain relief
Notify the provider and implement fall precautions
The nurse provides teaching to a client with glaucoma. Which statement indicates the need for further teaching?
A. “I’ll use my prescribed eye drops every day even if my vision feels fine.”
B. “It’s important that I don’t stop my medication abruptly.”
C. “I should avoid wearing sunglasses because they increase eye pressure.”
D. “I’ll report any eye pain or halos around lights right away.”
“I should avoid wearing sunglasses because they increase eye pressure.”
The nurse is caring for an 84-year-old client who is disoriented to time and place. The family reports the confusion began two days ago after a urinary tract infection. Which action is most appropriate?
A. Reorient the client frequently and monitor vital signs
B. Minimize conversation to reduce confusion
C. Encourage long discussions about the client’s childhood
D. Begin memory-retraining exercises for dementia
Reorient the client frequently and monitor vital signs
A client reports a loss of taste on the posterior tongue and a hoarse voice. Which cranial nerves are likely affected?
A. VII and IX
B. IX and X
C. X and XI
D. V and VII
B. IX and X
vagus - speech and swallowing
glossopharyngeal - taste in posterior 1/3 of tongue