Exam (elaborations)
NUR 382: EXAM 1&2 , Modules 9-11
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- Institution
Ch 23: Musculoskeletal System Ch 13: Skin, Hair, and Nails Ch 14: Head, Face, Neck, and Regional Lymphatics Ch 15: Eyes Ch 16: Ears
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NUR 382: EXAM 1&2 , Modules 9-111. 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. - ANS c. At the level of the C7 vertebra.
The C7 vertebra has a long spinous process, called the vertebra prominens, which is palpable when
the head is
flexed.
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 - ANS c. VII
Facial muscles are mediated by CN VII; asymmetry of palpebral fissures may be attributable to
damage to CN VII (Bell palsy).
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. - ANS b. Damage to the trigeminal nerve.
,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.
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 - ANS c. Parotid; submandibular
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.
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 - ANS b. XI; asking the patient to shrug her shoulders
against resistance
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.
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. - ANS a. Sternomastoid and trapezius.
The major neck muscles are the sternomastoid and the trapezius. They are innervated by CN XI, the
spinal accessory.
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 - ANS a. Thyroid
The thyroid gland is a highly vascular endocrine gland that secretes T4 and triiodothyronine (T3). The
other
glands do not secrete T4
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. - ANS b. Is mobile and not hard.
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.
, 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. - ANS 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.
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. - ANS d. Head and neck, arms, inguinal area, and
axillae.
Nodes are located throughout the body, but they are accessible to examination only in four areas:
head and neck, arms, inguinal region, and axillae.
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. - ANS c. More noticeable facial bones are probably due
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