Jarvis 3rd Ed Chapter 14 Flashcards
A physician tells the nurse that a patient’s vertebra prominens is tender and asks the nurse to re-evaluate 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.
c. at the level of the C7 vertebra.
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 nurse’s best response would be:
a. “Perhaps that is 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 my 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.”
d. “That soft spot is normal and actually allows for growth of the brain during the first year of your baby’s life.”
The nurse notices that a patient’s palpebral fissures are unequal. On examination, the nurse may find that damage has occured to which cranial nerve?
a. III
b. V
c. VII
d. VIII
c. VII
facial muscles are mediated by cranial nerves VII.
A patient is unable to differentiate between sharp and dull stimulations to both sides of her face. The nurse suspects:
a. Bell’s palsy
b. Damage to the trigeminal nerve.
c. Frostbite with resultant paraesthesia to the cheeks.
d. Scleroderma
b. Damage to the trigeminal nerve.
Facial sensations of pain or touch are mediated by cranial nerve V, which is the trigeminal nerve. Bell palsy is associated with cranial nerve VII damage.
When examining the face of patient, the nurse is aware that the two pairs of salivary glands that are accessible for examination are the _______ and________glands.
a. occipital; submental
b. parotid; jugulodigastric
c. parotid; submandibular
d. submandibular; occipital
c. parotid; submandibular
A patient comes to the clinic complaining of neck and shoulder pain and is unable to turn her head. The nurse suspects damage to cranial nerve_______ 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
b. XI; asking the patient to shrug her shoulders against resistance.
When examining a patient after a biopsy of the cervical lymph nodes, to ensure there is no damage to the major neck muscles, the nurse should check the function of cranial nerve:
a. V; trigeminal nerve
b. XI; spinal accessory nerve.
c. VII; facial nerve
d. VI; abducens nerve
b. XI; spinal accessory nerve.
A patient’s 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
a. thyroid
Only the thyroid secretes t4 and t3. The other glands do not.
A patient says that she has recently noticed a lump in the front of her neck below her “adam’s apple” that seems to be getting bigger. During assessment, the nurse suspects a noncancerous finding as the lump:
a. is singular and firm.
b. consists of multiple nodules/ mobile and not hard
c. dissapears when the patient smiles
d. is hard and fixed to the surrounding structures.
b. consists of multiple nodules
Multiple nodules usually indicate inflammation or a multinodular goitre, rather than a neoplasm. Any rapidly enlarging for firm nodule should be further investigated. Painless, rapidly growing nodules may be cancerous, especially the appearance of a single nodule in a young person. Cancerous nodules tend to be hard and fixed to surrounding structures.
A patient who is 7 months pregnant is at the clinic for her routine checkup. During assessment the nurse notes that the patient’s thyroid is palpable. The nurse will:
a. refer the patient to a thyroid specialist
b. send the patient for laboratory tests for thyroid hormones
c. document the findings as normal
d. as a colleague to check the findings
c. document the findings as normal.
normally the adult thyroid is not palpable. However, the thyroid gland may be palpable normally during pregnancy.
The nurse notices that a patient’s submental lymph nodes are enlarged. To identify the cause of the enlargement of the patient’s nodes, the nurse assesses the:
a. infraclavicular area.
b. supraclavicular area
c. area distal to the enlarged node.
d. area proximal to the enlarged node.
d. area proximal to the enlarged node.
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.
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.
d. Head and neck, arms, inguinal area, and axillae.
Although available throughout the body, they are only accessible to examination in four areas: Head and neck, arms, inguinal region, and axillae.
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 fontanelle closes at 2 months, the head will be more proportionate to the body.
b. Head circumference should be greater than chest circumference at birth.
A patient, an 85 year old woman, is concerned that the bones in her face have become more noticeable. The nurse tells her that:
a. diets low in protein and high in carbohydrates may cause enhanced facial bones.
b. Bones can become more noticable if the person does not use dermatologically approved moisturizer.
c. more noticeable facial bones are probably caused by 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.
c. more noticeable facial bones are probably caused by a combination of factors related to aging, such as decreased elasticity,
A patient reports to the nurse that he has been experiencing excruciating headache pain on one side of his head, especially around his eye, forehead, and cheek that lasts approximately one-half to 2 hours, occuring once or twice each day. The nurse suspects that he is having:
a. hypertension
b. cluster headaches
c. tension headaches
d. migraine headaches
d. cluster headaches.
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 one-half to 2 hours each.
A patient is concerned that while studying for an examination he began to notice a severe headache in the left front and side of his head that was throbbing and was relieved when he lay down. He tells the nurse that his mother also had these headaches. The nurses suspects that he may be suffering from:
a. Hypertension
b. cluster headaches
c. tension headaches
d. migraine headaches
d. migraine headaches
Migraine headaches tend to be supraorbital, retro-orbital 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.
A 19-year old college student is brought to the emergency department with a severe headache he describes as, “like nothing i’ve ever had before.” His temp is 40 degrees C, and he has a stiff neck. The nurse recognizes that he needs testing for:
a. a head injury
b cluster headaches
c. migraine headaches
d. meningeal inflammation
d. meningeal inflammation.
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.
During a well-baby checkup, the nurse notices that a 1-week-old infant’s 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
c. hydrocephalus
- occurs with 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 teh enlarged cranium, dilated scalp veins and downcast or “setting sun” eyes are noted. Craniotabes is a softening of the skill’s outer layer. Microcephaly is an abnormally small head. A caput succedaneum is edematous swelling and ecchymosis of the presenting par tof the head cause by birth trauma.
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
c. tragus
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 angel 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
b. parotid gland.
Swelling of the parotid gland is evident below the angel of the jaw and is most visible when the head is extended. Painful inflammation occurs with mumps, and swelling also occurs with abscesses of tumours. Swelling occurs anterior to the lower ear lobe.
A male patient with a history of 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
d. cervical lymph nodes
d. mouth and skin for lesions
b. parotid gland.
The parotid gland may become swollen with the onset of mumps, and parotid enlargement has been found with HIV.
The nurse suspects that a patient has hyperthyroidism, and the laboratory data indicate that the patient’s T4 and T3 are elevated. During assessment, the nurse will likely find the patient has:
a. tachycardia
b. constipation
c. rapid dyspnea
d. atrophied nodular thyroid gland
a. Tachycardia
T4 and T3 are thyroid hormones that stimulate the rate of cellular metabolism, resulting in tachycardia.
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 the nurse’s hands placed firmly around his neck.
b. the side of the nurse’s eyes averted towards the ceiling and thumbs on his neck.
c. the front with the nurse’s 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 tilter backward.
c. the front with the nurse’s thumbs placed on either side of his trachea and his head tilted forward.
Examining a patient’s 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 the tight when then to the left.
A patients 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, whosing, blowing; bell
c. soft, whooshing pulsatile; bell
d. high-pitcjed tinkling; diaphragm
c. soft, whooshing pulsatile; bell
If the thyroid gland is enlarged, then the nurse should auscultate it for the presence of a burit, which is a soft, pulsatile, whooshing, blowing sound heard best with the bell of the stethoscope.
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 the baby’s birth and that it seems to be getting bigger. The nurse explains that this likely is:
a. hydrocephalus
b. craniosynostosis
c. cephalhematoma
d. caput succedaneum
c. cephalhematoma
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.
A mother brings her newborn infant for an assessment and tells the nurse that she has noticed that whenever her newborn’s 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 and the baby should be flexing the arm and le on the right side of his body when the head is turned to the right.
c. normal and is called the tonic neck reflex, which should disappear between 3 and 4 months of age.
By 2 weeks, the infant shows the tonic neck reflex when supine and the head is turned to one side. The tonic neck reflex disappears between 3 and 5 months of age.
During an admission assessment, the nurse notices that a male patient has an enlarged and rather thick skull. The nurse suspects acromegaly and assesses the patient for:
a. exophthalmos
b. sunken eyes
c. coarse facial features
d. rounded moonlike face
c. coarse facial features
Acromegaly is excessive secretion of growth hormone that creates an enlarged skill and thickened cranial bones. Patients have elongated heads, massive faces, prominent noses and lower jaws, heavy eyebrow ridges, and coarse facial features, exophthalmos is associated with hyperthyroidism. A round mmonlife face is seen with Cushing’s syndrome. Sunken eyes are reflective of a cachectic appearance.
When examining children affected with Down’s syndrome, the nurse looks for the possible presence of:
a. Misshapen ears
b. Long, thin neck
c. Thin tongue sticking out
d. Narrow and raised nasal bridge
a. Misshapen ears
A patient is admitted to the hosptial with paralysis to the left side of his mouth. On assessment, the nurse notes that the patient can close his eyes but is not able to whistle or smile when asked to. The nurses recognizes that the patient needs additional assessment for:
a. cushing’s syndrome
b. parkinson’s disease
c. lower motor lesion
d. upper motor lesion
d. upper motor lesion
With an upper motor neuron lesion that can occur with a cerebrovascular accident (CVA), the patient will have paralysis of lower facial muscles, but he upper half of the face will not be affected owing to the intact nerve from the unaffected hemisphere. The person is still able to wrinkle teh forehead and close the eyes.
A woman comes to the clinic and states, “I’ve been sick for so long! My eyes have gotten so puffy, and my eyebrows and hair have become coarse and dry.” The nurse will assess for other signs and symptoms of:
a. Cachexia
b. Parkinson’s disease
c. Myxedema
d. Scleroderma
c. Myxedema
Myxedema (hypothyroidism) is a deficiency of the thyroid hormone that, when severe, causes a non pitting edema or myxedema. The patient has a puffy edematous face, especially around the eyes (periorbital edema); coarse facial features; dry skin; and dry, coarse hair and eyebrows.
During an examination of a female patient, the nurse notes lymphadenopathy (swollen lymph nodes) and suspects an acute infection. Acutely infected lymph nodes would be:
a. clumped
b. unilateral
c. firm but freely movable
d. firm and nontender
c. firm but freely movable.
Acutely infected lymph nodes are bilateral, enlarged, warm, tender, and firm but freely movable. Unilaterally enlarged nodes that are firm and nontender may indicate cancer.
The physician reports that a patient with a neck tumour has a tracheal shift. The nurse is aware that this means that the patient’s trachea is:
a. pulled to the affected side.
b. pushed to the unaffected side.
c. pulled downward.
d. pulled downward in a rhythmic pattern.
b. pushed to the unaffected side.
During assessment of an infant, the nurse notes that the fontanelles are depressed and sunken. The nurse suspects which condition?
a. rickets
b. dehydration
c. mental retardation
d. increased intracranial pressure
b. dehydration
Depressed and sunken fontanels occur with dehydration or malnutrition.
The nurse is performing an assessment on a 7-year old child who has symptoms of chronic watery eyes, sneezing, and clear nasal drainage. The nurse notices the presence of a transverse line across the bridge of the nose, dark blue shadows below the eyes, and a double crease on the lower eyelids. This findings are characteristic of:
a. allergies
b. sinus infection
c. nasal congestion
d. upper respiratory infection
a. allergies
While performing a well-child assessment on a 5-eyar-old, the nurse notes the presence of palpable, bilateral, cervical, and inguinal lymph nodes. They are approximately 0.5cm in size, round, mobile and nontender. The nurse documents that the child:
a. has chronic allergies
b. has an infection
c. has normal findings for a 5 year old child
d. should be referred for additional evaluation.
c. has normal findings for a 5 year old child
Palpable lymph nodes are normal in children until puberty when the lymphoid tissues begin to atrophy. Lymph nodes may be up to 1 cm in size and inguinal areas but are discrete, movable, and non tender.
The nurse has just completed a lymph node assessment on a 60-year old healthy female patient. The nurse knows that most lymph nodes in healthy adults are normally:
a. shotty
b. nonpalpable
c. large, firm and fixed to the tissue
d. rubbery, discrete, and mobile
b. nonpalpable
During an examination of a patient in her third trimester of pregnancy, the nurse notices that the patient’s thyroid gland is slightly enlarged. No enlargement had been previously noticed. the nurse recognizes that the patient:
a. has an iodine deficiency.
b. is exhibiting early sings of a goitre.
c. is exhibiting a normally enlargement of the thyroid gland during pregnancy.
d. Needs further testing for possible thyroid cancer.
c. is exhibiting a normally enlargement of the thyroid gland during pregnancy.
During an examination, the nurse knows that the best way to palpate the lymph nodes in the neck is by:
a. using gentle pressure and palpating with both hands to compare the two sides.
b. using strong pressure and palpating with both hands to compare the two sides.
c. gently pinching each node between one’s thumb and forefinger and then moving down the neck muscle.
d. Using the index and middle fingers and gently palpating by applying pressure in a rotating pattern.
a. using gentle pressure and palpating with both hands to compare the two sides.
During a well-baby checkup, a mother is concerned because her 2 month-old infant cannot hold her head up when she is pulled to a sitting position. Which response by the nurse is appropriate?
a. head control is usually achieved by 4 months of age.
b. you should not be trying to pull your baby up like that until she is older.
d. head control should be achieved by this time.
d. this inability indicates possible nerve damage to the neck and muscles.
a. head control is usually achieved by 4 months of age.
During examination of a 3-year-old child, the nurse notices a burit over the left temporal area. The nurse should:
a. continue the examination because a bruit is a normal finding for this age.
b. check for the burit again in 1 hour.
c. notify the parents that a bruit has been detected in their child.
d. stop the examination, and notify the physician.
a. continue the examination because a bruit is a normal finding for this age.
During examination, the nurse finds that a patient’s left temporal artery is tortuous and feels hardened and tender, compared with the right temporal artery. The nurse suspects which condition?
a. Crepiration
b. mastoiditis
c. temporal arteritis
d. bell’s palsy
c. temporal arteritis
With temporal arteritis, the artery appears more tortuous and feels hardened and tender.
