1
Q
1. A physician tells the nurse that a patient’s 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.
A
ANS: C
2
Q
- 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 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.”
A
ANS: D
3
Q
- 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. III
b. V
c. VII
d. VIII
A
ANS: C
4
Q
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.
A
ANS: B
5
Q
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
A
ANS: C
6
Q
- 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
A
ANS: B
7
Q
7. When examining a patient’s 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.
A
ANS: A
8
Q
8. 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
ANS: A
9
Q
9. 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, 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.
A
ANS: B
10
Q
10. The nurse notices that a patient’s submental lymph nodes are enlarged. In an effort to identify the cause of the node enlargement, the nurse would assess the patient’s: a. Infraclavicular area. b. Supraclavicular area. c. Area distal to the enlarged node. d. Area proximal to the enlarged node.
A
ANS: D
11
Q
- 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.
A
ANS: D
12
Q
- 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.
A
ANS: B
13
Q
- 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.
A
ANS: C
14
Q
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.
A
ANS: B
15
Q
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.
A
ANS: D
16
Q
16. 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 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
A
ANS: D
17
Q
17. 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
A
ANS: C
18
Q
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.
A
ANS: C
19
Q
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.
A
ANS: B
20
Q
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.
A
ANS: B
21
Q
21. The nurse suspects that a patient has hyperthyroidism, and the laboratory data indicate that the patient’s 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
A
ANS: A
22
Q
- 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 nurse’s hands placed firmly around his neck.
b.
The side with the nurse’s eyes averted toward 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 nurse’s thumbs placed on either side of his trachea and his head tilted backward.
A
ANS: C
23
Q
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
A
ANS: C
24
Q
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.
A
ANS: C
25
25. A mother brings in 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. The baby should be flexing the arm and leg on the right side of his body when the head is turned to the right.
ANS: C
26
```
26. During an admission assessment, the nurse notices that a male patient has an enlarged and rather thick skull. The nurse suspects acromegaly and would further assess for:
a.
Exophthalmos.
b.
Bowed long bones.
c.
Coarse facial features.
d.
Acorn-shaped cranium.
```
ANS: C
27
```
27. When examining children affected with Down syndrome (trisomy 21), the nurse looks for the possible presence of:
a.
Ear dysplasia.
b.
Long, thin neck.
c.
Protruding thin tongue.
d.
Narrow and raised nasal bridge.
```
ANS: A
28
```
28. A patient visits the clinic because he has recently noticed that the left side of his mouth is paralyzed. He states that he cannot raise his eyebrow or whistle. The nurse suspects that he has:
a.
Cushing syndrome.
b.
Parkinson disease.
c.
Bell palsy.
d.
Experienced a cerebrovascular accident (CVA) or stroke.
```
ANS: D
29
```
29. 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 syndrome.
c.
Myxedema.
d.
Scleroderma.
```
ANS: C
30
```
30. During an examination of a female patient, the nurse notes lymphadenopathy and suspects an acute infection. Acutely infected lymph nodes would be:
a.
Clumped.
b.
Unilateral.
c.
Firm but freely movable.
d.
Firm and nontender.
```
ANS: C
31
```
31. The physician reports that a patient with a neck tumor 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.
```
ANS: B
32
```
32. During an assessment of an infant, the nurse notes that the fontanels are depressed and sunken. The nurse suspects which condition?
a.
Rickets
b.
Dehydration
c.
Mental retardation
d.
Increased intracranial pressure
```
ANS: B
33
```
33. 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. These findings are characteristic of:
a.
Allergies.
b.
Sinus infection.
c.
Nasal congestion.
d.
Upper respiratory infection.
```
ANS: A
34
34. While performing a well-child assessment on a 5 year old, the nurse notes the presence of palpable, bilateral, cervical, and inguinal lymph nodes. They are approximately 0.5 cm in size, round, mobile, and nontender. The nurse suspects that this child:
a.
Has chronic allergies.
b.
May have an infection.
c.
Is exhibiting a normal finding for a well child of this age.
d.
Should be referred for additional evaluation.
ANS: C
35
```
35. 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.
```
ANS: B
36
36. 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 suspects that the patient:
a.
Has an iodine deficiency.
b.
Is exhibiting early signs of goiter.
c.
Is exhibiting a normal enlargement of the thyroid gland during pregnancy.
d.
Needs further testing for possible thyroid cancer.
ANS: C
37
37. During an examination, the nurse knows that the best way to palpate the lymph nodes in the neck is described by which statement?
a.
Using gentle pressure, palpate with both hands to compare the two sides.
b.
Using strong pressure, palpate with both hands to compare the two sides.
c.
Gently pinch each node between one’s thumb and forefinger, and then move down the neck muscle.
d.
Using the index and middle fingers, gently palpate by applying pressure in a rotating pattern.
ANS: A
38
38. 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 shouldn’t be trying to pull your baby up like that until she is older.”
c.
“Head control should be achieved by this time.”
d.
“This inability indicates possible nerve damage to the neck muscles.”
ANS: A
39
39. During an examination of a 3-year-old child, the nurse notices a bruit 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 bruit 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.
ANS: A
40
```
40. During an 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.
Crepitation
b.
Mastoiditis
c.
Temporal arteritis
d.
Bell palsy
```
ANS: C
41
41. The nurse is assessing a 1-month-old infant at his well-baby checkup. Which assessment findings are appropriate for this age? Select all that apply.
a.
Head circumference equal to chest circumference
b.
Head circumference greater than chest circumference
c.
Head circumference less than chest circumference
d.
Fontanels firm and slightly concave
e.
Absent tonic neck reflex
f.
Nonpalpable cervical lymph nodes
ANS: B, D, F
Health Assessment
flashcards
Decks in class (21)
# Cards
-
Final Exam14
-
Neuro-final26
-
Pediatrics- Final2
-
Module 1 Chapter 1: EBP22
-
Module 1 Chapter 3: The interview3
-
Module 1 Chapter 4: Health History19
-
Module 2 Chapter 2: Cultural Competence22
-
Module 2 Chapter 6: Substance abuse assessment17
-
Module 2 Chapter 10: Pain Assessment30
-
Anus, Rectum, Prostate19
-
Cardiac36
-
Practice Ch129
-
Practice 1341
-
Practice 1438
-
Practice 1540
-
Practice 1641
-
Cardiac review questions12
-
1941
-
2037
-
Chapter 22: Musculoskeletal36
-
chapter 2140
