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EXAM #3 - NUR 1060C - HEALTH ASSESSMENT | 136 QUESTIONS | WITH PASSED SOLUTIONS!!
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EXAM #3 - NUR 1060C - HEALTH ASSESSMENT | 136 QUESTIONS | WITH PASSED SOLUTIONS!!
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EXAM #3 - NUR 1060C- HEALTH
ASSESSMENT | 136
QUESTIONS | WITH
PASSED SOLUTIONS!!
NUR 1060C
Evatee 8/22/24 NUR 1060C
,EXAM #3 - NUR 1060C - HEALTH
ASSESSMENT | 136 QUESTIONS | WITH
PASSED SOLUTIONS!!
What are the three parts of the ear? Answer - *inner ear* (cochlea/labryinth),
*middle ear* (eustachian tube - necessitate tubes to help drain fluid bc kids'
eustachian tubes are more horizontal), *outer ear* = "what we can see"
(external auditory canal) + the end of the outer ear is marked by the tympanic
membrane
Are lymph nodes normally palpable? Answer - No and they aren't normally
visible either
What are the names of these lymph nodes and location? (11 nodes) Answer -
1. Preauricular
2. Posterior auricular
3. Occiptal
4. Submental
5. Submandibular
6. Tonsillar/jugulodigastric/retropharyngeal
7. Superficial Cervical
8. Deep Cervical Chain
9. Posterior Cervical
10. Supraclavicular
11. Parotid (below #1)
,What is a nurse looking for during an inspection of the neck? Answer - - ROM
- Symmetry
- Trachea is midline - e.g. trachea may be *deviated* w/ tension from a
pneumothorax
- There shouldn't be any swelling, you shouldn't be able to see the butterfly
shape of the thyroid
What is some subjective data to ask a pt during a neck assessment? Answer - -
Do you have neck pain? - usually an orthopedic issue, r/t to movement, any
stiffness or HA
- Is there any lumps or swelling? -Tonsillitis, any tenderness? if so, may indicate
infection (lymphadenopathy), if not, may be cancer and it will feel "like a rock"
and immovable/fixed
- Hx of neck/head surgery - might have muscles removed
- Decreased or increased fatigue? i.e. hyperthyroidism - antsy and agitated
hypothyroidism - extreme fatigue
- Any smoking?
- Dysphagia - difficulty swallowing
- Do they use chewing tobacco?
What are some unexpected findings during the inspection of the neck? Answer
- - Enlarged thyroid gland
> note the location, size (cm) (normally 4 cm wide and the right side is slightly
large than the left), consistency, tenderness, shape, movability or fixation
- Enlarged cervical lymph glands
What can a nurse palpate during an assessment of the neck? Answer - - Is the
trachea midline? - use fingers and go along the trachea and make sure that it's
straight and in the middle of your neck
- To palpate the neck use circular motions and feel the edges
, - Thyroid gland is NOT palpable (meaning you shouldn't feel any masses), but
you feel it move when the pt swallows
What is the expected finding of trachea during inspection and palpation?
Answer - the rings of the trachea are distinct and non-tender
What is the enlargement of lymph nodes a sign of? Answer - infection
How does a nurse palpate the thyroid using a posterior approach? Answer -
The nurse stands behind the pt and uses their right hand to displace the
trachea slightly and palpates with the left hand then does the same with the
opposite hands
You should feel movement, but no masses
How are a child's lymph nodes different from an adults? Answer - A child's
lymph nodes unlike an adult's nodes are small, round, firm, discrete, movable
and nontender
these are typical finding for newborns, young children, and preadolescents
especially their occiptal, postauricular, and deep cervical chain nodes
~ @ 6 yrs old they're thyroid will be @ adult size
What are 3 other places you can palpate lymph nodes? Answer - groin, axilla,
and behind the knees
What three systems make up the Nervous System? Answer - Central - CNS -
Brain & spinal cord
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