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
... [Show More] 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
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." - D
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 - CA 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. - B
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 - C
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 - B
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
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
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. - B
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. - D [Show Less]