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Health Assessment - Test Bank (Exam 4) 2024 9th Edition by Jarvis
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Health Assessment - Test Bank (Exam 4) 2024 9th Edition by Jarvis
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Health Assessment - Test Bank (Exam 4)FOR CHAPTERS 13, 14, 15, 16, 17, 18, 19, 20, & 21 - FOCUS ON THE AGING ADULT;
SKIP OR DELETE ANY OTHER QUESTIONS NOT RELATED TO THE OLDER ADULT! - ANS
SKIP OR DELETE ANY OTHER QUESTIONS NOT RELATED TO THE OLDER ADULT!
BEGINNING OF CHAPTER 14 - HEAD, FACE, AND NECK, AND REGIONAL LYMPHATICS
***FOCUS ONLY ON THE AGING ADULT QUESTIONS!! - ANS BEGINNING OF CHAPTER 14
- HEAD, FACE, AND NECK, AND REGIONAL LYMPHATICS
A physician tells the nurse that a patient's vertebra prominens is tender and asks the nurse to
reevaluate the area in 1 hour. What
area of the body will the nurse assess?
a. At the level of the C7 vertebra
b. At the level of the T11 vertebra
c. At the level of the L5 vertebra
d. At the level of the S3 vertebra - ANS ANS: A
The C7 vertebra has a long spinous process, called the vertebra prominens, which is palpable
when the head is flexed.
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?" How should the nurse respond?
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 skull."
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." - ANS 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.
The nurse notices that a patient's palpebral fissures are not symmetric. On examination, the
nurse may find that damage has
occurred to which cranial nerve (CN)?
a. V
,b. VII
c. XI
d. XIII - ANS ANS: B
Facial muscles are mediated by CN VII; asymmetry of palpebral fissures may be attributable to
damage to CN VII (Bell palsy).
Cranial nerve V, the trigeminal nerve, mediates facial sensations of pain and touch. Cranial
nerve XI is the spinal accessory nerve
that innervates the sternomastoid and trapezius muscles of the neck. There is no cranial nerve
XIII (only 12 cranial nerves).
A patient is unable to differentiate between sharp and dull stimulation to both sides of her face.
What does the nurse suspect?
a. Bell palsy
b. Scleroderma
c. Damage to the trigeminal nerve
d. Frostbite with resultant paresthesia to the cheeks - ANS A patient is unable to differentiate
between sharp and dull stimulation to both sides of her face. What does the nurse suspect?
a. Bell palsy
b. Scleroderma
c. Damage to the trigeminal nerve
d. Frostbite with resultant paresthesia to the cheeks
When examining the face of a patient, what are the two pairs of salivary glands that are
accessible for examination?
a. Occipital; submental
b. Parotid; submandibular
c. Submandibular; occipital
d. Sublingual; parotid - ANS ANS: B
The 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. The occipital and submental are lymph nodes, not
glands and the sublingual glands lie on
the floor of the mouth, so are not readily accessible for examination. The two pairs of salivary
glands that are accessible for
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.
A patient comes to the clinic complaining of neck and shoulder pain and is unable to turn her
head. Which nerve does the nurse
suspect is damaged and how should the nurse proceed with the examination?
a. XII; assess for a positive Romberg sign.
,b. XI; palpate the anterior and posterior triangles.
c. XI; have patient shrug their shoulders against resistance.
d. XII; percuss the sternomastoid and submandibular neck muscles. - ANS ANS: C
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.
To assess the function of cranial nerve XI the nurse should have the patient shrug their
shoulders against resistance. Cranial nerve
XII is the hypoglossal nerve which innervates the muscles of the tongue involved with speech
and swallowing and is not involved
in head movement. Identifying the anterior and posterior triangles are helpful guidelines when
describing findings in the neck but
palpating them does not assess any cranial nerves.
When examining a patient's CN function, what muscles should the nurse assess to assess the
function of CN XI?
a. Sternomastoid and trapezius
b. Spinal accessory and omohyoid
c. Trapezius and sternomandibular
d. Sternomandibular and spinal accessory - ANS ANS: A
The muscles innervated by CN XI are the sternomastoid and the trapezius muscles in the neck.
Options B, C, and D are incorrect
because the spinal accessory is not a muscle but the name of CN XI and there is no
sternomandibular muscle.
A patient's laboratory data reveal an elevated thyroxine (T4) level. What gland should the nurse
assess?
a. Thyroid
b. Parotid
c. Adrenal
d. Parathyroid - ANS ANS: A
The thyroid gland is a highly vascular endocrine gland that secretes T4 and triiodothyronine
(T3). The other glands do not secrete
T4. The parotid glands are salivary glands and secrete saliva. The adrenal glands secrete
corticosteroids, not T4, and the
parathyroid glands control the body's calcium. The gland that secretes thyroxine, or T4, is the
thyroid gland. The thyroid gland is a
highly vascular endocrine gland that secretes thyroxine (T4) and triiodothyronine (T3).
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 the assessment, what finding would lead the nurse to suspect that this may not
be a cancerous thyroid nodule?
, a. It is tender.
b. It is mobile and soft.
c. It disappears when the patient smiles.
d. It is hard and fixed to the surrounding structures. - ANS 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.
The nurse notices that a patient's submental lymph nodes are enlarged. In an effort to identify
the cause of the node enlargement,
what should the nurse assess?
a. Infraclavicular area
b. Supraclavicular area
c. Area distal to the enlarged node
d. Area proximal to the enlarged node - ANS 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.
The nurse is explaining to a student nurse the four areas in the body where lymph nodes are
accessible. Which areas should the
nurse include in her explanation to the student?
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 - ANS 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.
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. - ANS 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.
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