Chapter 11

Question 1

A physician tells the nurse that a patients vertebra prominens is tender and asks the nurse to reevaluate the area in 1 hour. The area of the body the nurse will assess is:

a) Just above the diaphragm
b) Just lateral to the knee cap
c) At the level of the C7 vertebra
d) At the level of the T11 vertebra

Answer 1

ANS: C
The C7 vertebra has a long spinous process, called the vertebra prominens, which is palpable when the head is flexed.

Question 2

A mother brings her 2-month-old daughter in for an examination and says, My daughter rolled over against the wall, and now I have noticed that she has this spot
that is soft on the top of her head. Is something terribly wrong? The nurses best response would be:

a) Perhaps that could be a result of your dietary intake during pregnancy
b) Your baby may have craniosynostosis, a disease of the sutures of the brain
c) That soft spot may be an indication of cretinism or congenital hypothyroidism
d) That soft spot is normal and actually allows for growth of the brain during the first year of your baby’s life

Answer 2

ANS: D
Membrane-covered soft spots allow for growth of the brain during the first year of life. They gradually ossify; the triangular-shaped posterior fontanel is closed by 1 to 2 months, and the diamond-shaped anterior fontanel closes between 9 months and 2 years.

Question 3

The nurse notices that a patients palpebral fissures are not symmetric. On examination, the nurse may find that damage has occurred to which cranial nerve (CN)?

a) III
b) V
c) VII
d) VIII

Answer 3

ANS: C
Facial muscles are mediated by CN VII; asymmetry of palpebral fissures may be attributable to damage to CN VII (Bell palsy).

Question 4

A patient is unable to differentiate between sharp and dull stimulation to both sides of her face. The nurse suspects:

a) Bell palsy
b) Damage to the trigeminal nerve
c) Frostbite with resultant paresthesia to the cheeks
d) Scleroderma

Answer 4

ANS: B
Facial sensations of pain or touch are mediated by CN V, which is the trigeminal nerve. Bell palsy is associated with CN VII damage. Frostbite and scleroderma are not associated with this problem.

Question 5

When examining the face of a patient, the nurse is aware that the two pairs of salivary glands that are accessible to examination are the ______ and _____ glands.

a) Occipital; submental
b) Parotid; jugulodigastric
c) Parotid; submandibular
d) Submandibular; occipital

Answer 5

ANS: C
Two pairs of salivary glands accessible to examination on the face are the parotid glands, which are in the cheeks over the mandible, anterior to and below the ear; and
the submandibular glands, which are beneath the mandible at the angle of the jaw. The parotid glands are normally nonpalpable.

Question 6

A patient comes to the clinic complaining of neck and shoulder pain and is unable to turn her head. The nurse suspects damage to CN and proceeds with the examination by:

a) XI; palpating the anterior and posterior triangles
b) XI; asking the patient to shrug her shoulders against resistance
c) XII; percussing the sternomastoid and submandibular neck muscles
d) XII; assessing for a positive Romberg sign

Answer 6

ANS: B
The major neck muscles are the sternomastoid and the trapezius. They are innervated by CN XI, the spinal accessory. The innervated muscles assist with head rotation and
head flexion, movement of the shoulders, and extension and turning of the head.

Question 7

When examining a patients CN function, the nurse remembers that the muscles in the neck that are innervated by CN XI are the:

a) Sternomastoid and trapezius
b) Spinal accessory and omohyoid
c) Trapezius and sternomandibular
d) Sternomandibular and spinal accessory

Answer 7

ANS: A
The major neck muscles are the sternomastoid and the trapezius. They are innervated by CN XI, the spinal accessory.

Question 8

A patients laboratory data reveal an elevated thyroxine (T4) level. The nurse would proceed with an examination of the ______ gland.

a) Thyroid
b) Parotid
c) Adrenal
d) Parathyroid

Answer 8

ANS: A
The thyroid gland is a highly vascular endocrine gland that secretes T4 and
triiodothyronine (T3). The other glands do not secrete T4.

Question 9

A patient says that she has recently noticed a lump in the front of her neck below her Adams apple that seems to be getting bigger. During the assessment, the finding that leads the nurse to suspect that this may not be a cancerous thyroid
nodule is that the lump (nodule):

a) Is tender
b) Is mobile and not hard
c) Disappears when the patient smiles
d) Is hard and fixed to the surrounding structures

Answer 9

ANS: B
Painless, rapidly growing nodules may be cancerous, especially the appearance of a single nodule in a young person. However, cancerous nodules tend to be hard and fixed to surrounding structures, not mobile.

Question 10

The nurse notices that a patients submental lymph nodes are enlarged. In an effort to identify the cause of the node enlargement, the nurse would assess the patients:

a) Infraclavicular area
b) Supraclavicular area
c) Area distal to the enlarged node
d) Area proximal to the enlarged node

Answer 10

ANS: D
When nodes are abnormal, the nurse should check the area into which they drain for the source of the problem. The area proximal (upstream) to the location of the abnormal node should be explored.

Question 11

The nurse is aware that the four areas in the body where lymph nodes are accessible are the:

a) Head, breasts, groin, and abdomen
b) Arms, breasts, inguinal area, and legs
c) Head and neck, arms, breasts, and axillae
d) Head and neck, arms, inguinal area, and axillae

Answer 11

ANS: D
Nodes are located throughout the body, but they are accessible to examination only in four areas:
head and neck, arms, inguinal region, and axillae.

Question 12

A mother brings her newborn in for an assessment and asks, Is there something wrong with my baby? His head seems so big. Which statement is true regarding the relative proportions of the head and trunk of the newborn?

a) At birth, the head is one fifth the total length
b) Head circumference should be greater than chest circumference at birth
c) The head size reaches 90% of its final size when the child is 3 years old
d) When the anterior fontanel closes at 2 months, the head will be more proportioned to the body

Answer 12

ANS: B
The nurse recognizes that during the fetal period, head growth predominates. Head size is greater than chest circumference at birth, and the head size grows during childhood, reaching 90% of its final size when the child is age 6 years.

Question 13

A patient, an 85-year-old woman, is complaining about the fact that the bones in her face have become more noticeable. What explanation should the nurse give her?

a) Diets low in protein and high in
carbohydrates may cause enhanced facial bones
b) Bones can become more noticeable if the person does not use a dermatologically approved moisturizer
c) More noticeable facial bones are probably due to a combination of factors related to aging, such as decreased elasticity, subcutaneous fat, and moisture in her skin
d) Facial skin becomes more elastic with age. This increased elasticity causes the skin to be more taught, drawing attention to the facial
bones

Answer 13

ANS: C
The facial bones and orbits appear more prominent in the aging adult, and the facial skin sags, which is attributable to decreased elasticity, decreased subcutaneous fat, and
decreased moisture in the skin.

Question 14

A patient reports excruciating headache pain on one side of his head, especially around his eye, forehead, and cheek that has lasted approximately to 2 hours, occurring once or twice each day. The nurse should suspect:

a) Hypertension
b) Cluster headaches
c) Tension headaches
d) Migraine headaches

Answer 14

ANS: B
Cluster headaches produce pain around the eye, temple, forehead, and cheek and are unilateral and always on the same side of the head. They are excruciating and occur
once or twice per day and last to 2 hours each.

Question 15

A patient complains that while studying for an examination he began to notice a severe headache in the frontotemporal area of his head that is throbbing and is
somewhat relieved when he lies down. He tells the nurse that his mother also had these headaches. The nurse suspects that he may be suffering from:

a) Hypertension
b) Cluster headaches
c) Tension headaches
d) Migraine headaches

Answer 15

ANS: D
Migraine headaches tend to be supraorbital, retroorbital, or frontotemporal with a throbbing quality. They are severe in quality and are relieved by lying down. Migraines
are associated with a family history of migraine headaches.

Question 16

A 19-year-old college student is brought to the emergency department with a severe headache he describes as, Like nothing Ive ever had before. His temperature is 40 C, and he has a stiff neck. The nurse looks for other signs and
symptoms of which problem?

a) Head injury
b) Cluster headache
c) Migraine headache
d) Meningeal inflammation

Answer 16

ANS: D
The acute onset of neck stiffness and pain along with headache and fever occurs with meningeal inflammation. A severe headache in an adult or child who has never had it before is a red flag. Head injury and cluster or migraine headaches are not associated with a fever or stiff neck.

Question 17

During a well-baby checkup, the nurse notices that a 1-week-old infants face looks small compared with his cranium, which seems enlarged. On further examination, the nurse also notices dilated scalp veins and downcast or setting
sun eyes. The nurse suspects which condition?

a) Craniotabes
b) Microcephaly
c) Hydrocephalus
d) Caput succedaneum

Answer 17

ANS: C
Hydrocephalus occurs with the obstruction of drainage of cerebrospinal fluid that results in excessive accumulation, increasing intracranial pressure, and an
enlargement of the head. The face looks small, compared with the enlarged cranium, and dilated scalp veins and downcast or setting sun eyes are noted. Craniotabes is a softening of the skulls outer layer. Microcephaly is an abnormally small head. A caput succedaneum is edematous swelling and ecchymosis of the presenting part of the head caused by birth trauma.

Question 18

The nurse needs to palpate the temporomandibular joint for crepitation. This joint is located just below the temporal artery and anterior to the:

a) Hyoid bone
b) Vagus nerve
c) Tragus
d) Mandible

Answer 18

ANS: C
The temporomandibular joint is just below the temporal artery and anterior to the tragus.

Question 19

A patient has come in for an examination and states, I have this spot in front of my ear lobe on my cheek that seems to be getting bigger and is tender. What do
you think it is? The nurse notes swelling below the angle of the jaw and suspects that it could be an inflammation of his:

a) Thyroid gland
b) Parotid gland
c) Occipital lymph node
d) Submental lymph node

Answer 19

ANS: B
Swelling of the parotid gland is evident below the angle of the jaw and is most visible when the head is extended. Painful inflammation occurs with mumps, and swelling
also occurs with abscesses or tumors. Swelling occurs anterior to the lower ear lobe.

Question 20

A male patient with a history of acquired immunodeficiency syndrome (AIDS) has come in for an examination and he states, I think that I have the mumps. The nurse would begin by examining the:

a) Thyroid gland
b) Parotid gland
c) Cervical lymph nodes
d) Mouth and skin for lesions

Answer 20

ANS: B
The parotid gland may become swollen with the onset of mumps, and parotid enlargement has been found with human immunodeficiency virus (HIV).

Question 21

The nurse suspects that a patient has hyperthyroidism, and the laboratory data indicate that the patients T4 and T3 hormone levels are elevated. Which of these findings would the nurse most likely find on examination?

a) Tachycardia
b) Constipation
c) Rapid dyspnea
d) Atrophied nodular thyroid gland

Answer 21

ANS: A
T4 and T3 are thyroid hormones that stimulate the rate of cellular metabolism, resulting in tachycardia. With an enlarged thyroid gland as in hyperthyroidism, the nurse might expect to find diffuse enlargement (goiter) or a nodular lump but not an
atrophied gland. Dyspnea and constipation are not findings associated with hyperthyroidism.

Question 22

A visitor from Poland who does not speak English seems to be somewhat apprehensive about the nurse examining his neck. He would probably be more comfortable with the nurse examining his thyroid gland from:

a) Behind with the nurses hands placed firmly around his neck
b) The side with the nurses eyes averted toward the ceiling and thumbs on his neck
c) The front with the nurses thumbs placed on either side of his trachea and his head tilted forward
d) The front with the nurses thumbs placed on either side of his trachea and his head tilted backward

Answer 22

ANS: C
Examining this patients thyroid gland from the back may be unsettling for him. It would be best to examine his thyroid gland using the anterior approach, asking him to tip his head forward and to the right and then to the left.

Question 23

A patient’s thyroid gland is enlarged, and the nurse is preparing to auscultate the thyroid gland for the presence of a bruit. A bruit is a ______ sound that is heard best with
the _______ of the stethoscope.

a) Low gurgling; diaphragm
b) Loud, whooshing, blowing; bell
c) Soft, whooshing, pulsatile; bell
d) High-pitched tinkling; diaphragm

Answer 23

ANS: C
If the thyroid gland is enlarged, then the nurse should auscultate it for the presence of a bruit, which is a soft, pulsatile, whooshing, blowing sound heard best with the bell of the stethoscope.

Question 24

The nurse notices that an infant has a large, soft lump on the side of his head and that his mother is very concerned. She tells the nurse that she noticed the lump approximately 8 hours after her baby’s birth and that it seems to be getting bigger. One possible explanation for this is:

a) Hydrocephalus
b) Craniosynostosis
c) Cephalhematoma
d) Caput succedaneum

Answer 24

ANS: C
A cephalhematoma is a subperiosteal hemorrhage that is the result of birth trauma. It is soft, fluctuant, and well defined over one cranial bone. It appears several hours after birth and gradually increases in size.

Question 25

A mother brings in her newborn infant for an assessment and tells the nurse that she has noticed that whenever her newborns head is turned to the right side, she straightens out the arm and leg on the same side and flexes the opposite arm and leg. After observing this on examination, the nurse tells her that this reflex is:

a) Abnormal and is called the atonic neck reflex.
b) Normal and should disappear by the first year of life.
c) Normal and is called the tonic neck reflex, which should disappear between 3 and 4 months of age.
d) Abnormal. The baby should be flexing the arm and leg on the right side of his body when the head is turned to the right.

Answer 25

ANS: C
By 2 weeks, the infant shows the tonic neck reflex when supine and the head is turned to one side (extension of same arm and leg, flexion of opposite arm and leg).
The tonic neck reflex disappears between 3 and 4 months of age.