NSG 351 TEST BANK TEST 2
QUESTIONS AND ANSWERS
A patient repeats, I feel hot. Hot, cot, rot, tot, got. Im a spot. The nurse documents
this as an illustration of:
a. Blocking
b. Clanging
c. Echolalia
d. Neologism - Answer-b. Clanging
During an interview, the nurse notes that the patient gets up several times to wash
her hands even though they are not dirty. This behavior is an example of:
a. Social phobia
b. Compulsive disorder
c. Generalized anxiety disorder
d. Posttraumatic stress disorder - Answer-b. Compulsive disorder
The nurse is administering a Mini-Cog test to an older adult woman. When asked to
draw a clock showing the time of 10:45, the patient drew a clock with the numbers
out of order and with an incorrect time. This result indicates which finding?
a. Cognitive impairment
b. Amnesia
c. Delirium
d. Attention-deficit disorder - Answer-a. Cognitive impairment
During morning rounds, the nurse asks a patient, How are you today? The patient
responds, You today, you today, you today! and mumbles the words. This speech
pattern is an example of:
a. Echolalia
b. Clanging
c. Word salad
d. Perseveration - Answer-a. Echolalia
The nurse is assessing a patient who is admitted with possible delirium. Which of
these are manifestations of delirium? Select all that apply.
a. Develops over a short period.
b. Person is experiencing apraxia.
c. Person is exhibiting memory impairment or deficits.
d. Occurs as a result of a medical condition, such as systemic infection.
e. Person is experiencing agnosia. - Answer-a. Develops over a short period.
c. Person is exhibiting memory impairment or deficits.
d. Occurs as a result of a medical condition, such as systemic infection.
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. - Answer-c. At the level of the C7 vertebra.
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 nurses 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 babys life. - Answer-d. That soft spot is normal, and actually allows for
growth of the brain during the first year of your babys life.
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 - Answer-c. VII
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. - Answer-b. Damage to the trigeminal nerve.
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 - Answer-c. Parotid; submandibular
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 - Answer-b. XI; asking the patient to
shrug her shoulders against resistance
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. - Answer-a. Sternomastoid and trapezius.
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 - Answer-a. Thyroid
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. - Answer-b. Is mobile and not
hard.
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. - Answer-d. Area proximal to the enlarged
node.
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. - Answer-d. Head and neck,
arms, inguinal area, 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. - Answer-b. Head circumference should be greater than chest
circumference at birth.
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. - Answer-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.
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. - Answer-b. Cluster headaches.
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. - Answer-d. Migraine headaches.
A 19-year-old college student is brought to the emergency department with a severe
headache he describes as, Like nothing Ive 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 - Answer-d. Meningeal inflammation
During a well-baby checkup, the nurse notices that a 1-week-old infants 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 - Answer-c. Hydrocephalus
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. - Answer-c. Tragus.
QUESTIONS AND ANSWERS
A patient repeats, I feel hot. Hot, cot, rot, tot, got. Im a spot. The nurse documents
this as an illustration of:
a. Blocking
b. Clanging
c. Echolalia
d. Neologism - Answer-b. Clanging
During an interview, the nurse notes that the patient gets up several times to wash
her hands even though they are not dirty. This behavior is an example of:
a. Social phobia
b. Compulsive disorder
c. Generalized anxiety disorder
d. Posttraumatic stress disorder - Answer-b. Compulsive disorder
The nurse is administering a Mini-Cog test to an older adult woman. When asked to
draw a clock showing the time of 10:45, the patient drew a clock with the numbers
out of order and with an incorrect time. This result indicates which finding?
a. Cognitive impairment
b. Amnesia
c. Delirium
d. Attention-deficit disorder - Answer-a. Cognitive impairment
During morning rounds, the nurse asks a patient, How are you today? The patient
responds, You today, you today, you today! and mumbles the words. This speech
pattern is an example of:
a. Echolalia
b. Clanging
c. Word salad
d. Perseveration - Answer-a. Echolalia
The nurse is assessing a patient who is admitted with possible delirium. Which of
these are manifestations of delirium? Select all that apply.
a. Develops over a short period.
b. Person is experiencing apraxia.
c. Person is exhibiting memory impairment or deficits.
d. Occurs as a result of a medical condition, such as systemic infection.
e. Person is experiencing agnosia. - Answer-a. Develops over a short period.
c. Person is exhibiting memory impairment or deficits.
d. Occurs as a result of a medical condition, such as systemic infection.
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. - Answer-c. At the level of the C7 vertebra.
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 nurses 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 babys life. - Answer-d. That soft spot is normal, and actually allows for
growth of the brain during the first year of your babys life.
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 - Answer-c. VII
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. - Answer-b. Damage to the trigeminal nerve.
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 - Answer-c. Parotid; submandibular
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 - Answer-b. XI; asking the patient to
shrug her shoulders against resistance
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. - Answer-a. Sternomastoid and trapezius.
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 - Answer-a. Thyroid
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. - Answer-b. Is mobile and not
hard.
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. - Answer-d. Area proximal to the enlarged
node.
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. - Answer-d. Head and neck,
arms, inguinal area, 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. - Answer-b. Head circumference should be greater than chest
circumference at birth.
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. - Answer-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.
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. - Answer-b. Cluster headaches.
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. - Answer-d. Migraine headaches.
A 19-year-old college student is brought to the emergency department with a severe
headache he describes as, Like nothing Ive 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 - Answer-d. Meningeal inflammation
During a well-baby checkup, the nurse notices that a 1-week-old infants 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 - Answer-c. Hydrocephalus
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. - Answer-c. Tragus.
