Patient states that they are having trouble breathing on one side of their nose. As the nurse completing a head and neck assessment, what is one possible diagnosis that you will assess for?

Epistaxis

Perforated septum

Deviated septum

Ankyloglossia

Answer and Explanation

The Correct Answer is C

A) Epistaxis: Epistaxis, or a nosebleed, typically presents with the sudden onset of blood coming from one or both nostrils. Although a nosebleed can cause discomfort and a sense of obstruction, it does not typically present as difficulty breathing through one side of the nose. Epistaxis is more related to trauma, dry air, or nasal irritation rather than a structural issue causing airflow restriction.

B) Perforated septum: A perforated septum refers to a hole or tear in the nasal septum, the cartilage and bone that separates the two nasal passages. It may cause symptoms such as a whistling sound when breathing or increased susceptibility to infections, but difficulty breathing on one side of the nose alone isn't the most common symptom. A perforated septum is often associated with chronic drug use or injury, but it doesn't usually present with unilateral breathing difficulty unless it's very severe.

C) Deviated septum: A deviated septum occurs when the thin wall of bone and cartilage that divides the nasal cavity is displaced to one side. This condition is one of the most common causes of breathing difficulty on one side of the nose. The deviation can obstruct airflow, leading to symptoms like difficulty breathing through one nostril, congestion, or sinus infections. This diagnosis is most likely based on the patient's complaint.

D) Ankyloglossia: Ankyloglossia, also known as tongue-tie, refers to a condition where the frenulum (the membrane under the tongue) is abnormally short, restricting the tongue's movement. While it can cause feeding difficulties in infants or speech issues, it has no connection to nasal airflow or breathing problems. This diagnosis is unrelated to the symptoms described.

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Correct Answer is ["B","C"]

Explanation

A) Acromegaly: Acromegaly is a condition caused by excess growth hormone, leading to enlargement of bones and tissues, particularly in the hands, feet, and face. While facial features can appear more pronounced due to bone growth, acromegaly itself does not cause facial drooping as a prominent symptom. The condition does not typically present with the sudden onset of facial weakness or asymmetry associated with drooping.

B) Bell’s Palsy: Bell’s Palsy is a disorder that affects the facial nerve, leading to sudden, unilateral facial drooping or paralysis. It is often caused by inflammation of the facial nerve, and facial drooping is one of its hallmark symptoms. It usually occurs on one side of the face, causing weakness or loss of muscle tone, leading to the drooping appearance.

C) CVA (Cerebrovascular Accident): A CVA, or stroke, can result in facial drooping, typically on one side of the face, if the stroke affects areas of the brain controlling facial muscles. A common sign of a stroke is the sudden development of facial asymmetry, including drooping of the mouth or eyelid. It is an important symptom to monitor in assessing neurological function following a stroke.

D) Parkinson’s Disease: Parkinson’s disease can cause facial changes, such as reduced blinking and a "masked" appearance, but it does not typically cause facial drooping in the same way that Bell's Palsy or a CVA would. Parkinson’s-related facial changes stem from reduced movement rather than sudden weakness or paralysis of the facial muscles. While facial expression can be diminished, true drooping is less common.

A. Consensual constriction present B. Snellen chart finding 20/40 C. sting to the upper eyelid D. Pupil size 4 mm E. Jerky eye movements with the 6 Cardinal Fields of Gaze F. Pupil size 6 mm G. Erythema to lower eyelid

Correct Answer is ["C","E","G"]

Explanation

A) Consensual constriction present: Consensual constriction of the pupil is a normal finding when light is shined into one eye, causing both pupils to constrict simultaneously. This is a normal response and not an unexpected finding.

B) Snellen chart finding 20/40: A Snellen chart result of 20/40 indicates that the patient's vision is slightly less than normal but still within acceptable limits for daily functioning. This is not considered an unexpected or abnormal finding for an adult.

C) Sting to the upper eyelid: A sting or discomfort in the upper eyelid is an unexpected finding and may suggest irritation, infection (such as blepharitis), or trauma. This symptom should be further evaluated, as it is not typical during a normal eye assessment.

D) Pupil size 4 mm: A pupil size of 4 mm is considered normal and expected in a well-lit environment for most adults. It falls within the typical range for pupil size, so it is not an unexpected finding.

E) Jerky eye movements with the 6 Cardinal Fields of Gaze: Jerky or abnormal eye movements, such as nystagmus or inability to follow the cardinal fields of gaze smoothly, are unexpected findings. This could suggest neurological conditions, muscle weakness, or issues with the vestibular system, all of which warrant further investigation.

F) Pupil size 6 mm: A pupil size of 6 mm can be normal in low-light conditions (dilated pupils), but in a well-lit environment, it is on the larger end of the normal range. If this is observed in normal light, it may indicate a pathological condition, medication side effect, or neurological issue, but it could also be normal for some individuals. It’s less of an "unexpected" finding than jerky eye movements or a stinging sensation, but it may warrant monitoring if unusual for the patient.

G) Erythema to lower eyelid: Erythema (redness) to the lower eyelid is an unexpected finding, which could suggest an infection (such as conjunctivitis), irritation, or inflammation. This finding should be further assessed, as redness in the eyelid area is not typical during a normal eye assessment.

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Patient states that they are having trouble breathing on one side of their nose. As the nurse completing a head and neck assessment, what is one possible diagnosis that you will assess for?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Facial drooping can be associated with which two disorders? (Select All that Apply.)

Correct Answer is ["B","C"]

Explanation

A nurse is performing a focused eye assessment. Select up to 5 unexpected findings.

Correct Answer is ["C","E","G"]

Explanation

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