HEALTH ASSESSMENT - TEST BANK (EXAM 4) QUESTIONS AND CORRECT ANSWERS

HEALTH ASSESSMENT - TEST BANK
(EXAM 4) QUESTIONS AND CORRECT
ANSWERS
FORA2CHAPTERSA213,A214,A215,A216,A217,A218,A219,A220,A2&A221A2-
A2FOCUSA2ONA2THEA2AGINGA2ADULT;A2


SKIPA2ORA2DELETEA2ANYA2OTHERA2QUESTIONSA2NOTA2RELATEDA2TOA2THEA2OLD
ERA2ADULT!A2-A2Ans--
SKIPA2ORA2DELETEA2ANYA2OTHERA2QUESTIONSA2NOTA2RELATEDA2TOA2THEA2OLD
ERA2ADULT!

BEGINNINGA2OFA2CHAPTERA214A2-
A2HEAD,A2FACE,A2ANDA2NECK,A2ANDA2REGIONALA2LYMPHATICS


***FOCUSA2ONLYA2ONA2THEA2AGINGA2ADULTA2QUESTIONS!!A2-A2Ans--
BEGINNINGA2OFA2CHAPTERA214A2-
A2HEAD,A2FACE,A2ANDA2NECK,A2ANDA2REGIONALA2LYMPHATICS


AA2physicianA2tellsA2theA2nurseA2thatA2aA2patient'sA2vertebraA2prominensA2isA2tenderA2andA
2asksA2theA2nurseA2toA2reevaluateA2theA2areaA2inA21A2hour.A2What
areaA2ofA2theA2bodyA2willA2theA2nurseA2assess?
a.A2AtA2theA2levelA2ofA2theA2C7A2vertebra
b.A2AtA2theA2levelA2ofA2theA2T11A2vertebra
c.A2AtA2theA2levelA2ofA2theA2L5A2vertebra
d.A2AtA2theA2levelA2ofA2theA2S3A2vertebraA2-A2Ans--ANS:A2A
TheA2C7A2vertebraA2hasA2aA2longA2spinousA2process,A2calledA2theA2vertebraA2prominens,A
2whichA2isA2palpableA2whenA2theA2headA2isA2flexed.


AA2motherA2bringsA2herA22-month-
oldA2daughterA2inA2forA2anA2examinationA2andA2says,A2"MyA2daughterA2rolledA2overA2again
stA2theA2wall,A2andA2nowA2I
haveA2noticedA2thatA2sheA2hasA2thisA2spotA2thatA2isA2softA2onA2theA2topA2ofA2herA2head.A2IsA
2somethingA2terriblyA2wrong?"A2HowA2shouldA2theA2nurseA2respond?
a.A2"PerhapsA2thatA2couldA2beA2aA2resultA2ofA2yourA2dietaryA2intakeA2duringA2pregnancy."
b.A2"YourA2babyA2mayA2haveA2craniosynostosis,A2aA2diseaseA2ofA2theA2suturesA2ofA2theA2s
kull."
c.A2"ThatA2'softA2spot'A2mayA2beA2anA2indicationA2ofA2cretinismA2orA2congenital
hypothyroidism."
d.A2"ThatA2'softA2spot'A2isA2normal,A2andA2actuallyA2allowsA2forA2growthA2ofA2theA2brainA2du
ringA2the
firstA2yearA2ofA2yourA2baby'sA2life."A2-A2Ans--ANS:A2D

,Membrane-
coveredA2"softA2spots"A2allowA2forA2growthA2ofA2theA2brainA2duringA2theA2firstA2yearA2ofA2life
.A2TheyA2graduallyA2ossify;A2the
triangular-
shapedA2posteriorA2fontanelA2isA2closedA2byA21A2toA22A2months,A2andA2theA2diamond-
shapedA2anteriorA2fontanelA2closesA2betweenA29A2months
andA22A2years.

TheA2nurseA2noticesA2thatA2aA2patient'sA2palpebralA2fissuresA2areA2notA2symmetric.A2OnA2e
xamination,A2theA2nurseA2mayA2findA2thatA2damageA2has
occurredA2toA2whichA2cranialA2nerveA2(CN)?
a.A2V
b.A2VII
c.A2XI
d.A2XIIIA2-A2Ans--ANS:A2B
FacialA2musclesA2areA2mediatedA2byA2CNA2VII;A2asymmetryA2ofA2palpebralA2fissuresA2may
A2beA2attributableA2toA2damageA2toA2CNA2VIIA2(BellA2palsy).
CranialA2nerveA2V,A2theA2trigeminalA2nerve,A2mediatesA2facialA2sensationsA2ofA2painA2andA
2touch.A2CranialA2nerveA2XIA2isA2theA2spinalA2accessoryA2nerve
thatA2innervatesA2theA2sternomastoidA2andA2trapeziusA2musclesA2ofA2theA2neck.A2ThereA2i
sA2noA2cranialA2nerveA2XIIIA2(onlyA212A2cranialA2nerves).

AA2patientA2isA2unableA2toA2differentiateA2betweenA2sharpA2andA2dullA2stimulationA2toA2bot
hA2sidesA2ofA2herA2face.A2WhatA2doesA2theA2nurseA2suspect?
a.A2BellA2palsy
b.A2Scleroderma
c.A2DamageA2toA2theA2trigeminalA2nerve
d.A2FrostbiteA2withA2resultantA2paresthesiaA2toA2theA2cheeksA2-A2Ans--
AA2patientA2isA2unableA2toA2differentiateA2betweenA2sharpA2andA2dullA2stimulationA2toA2bot
hA2sidesA2ofA2herA2face.A2WhatA2doesA2theA2nurseA2suspect?
a.A2BellA2palsy
b.A2Scleroderma
c.A2DamageA2toA2theA2trigeminalA2nerve
d.A2FrostbiteA2withA2resultantA2paresthesiaA2toA2theA2cheeks

WhenA2examiningA2theA2faceA2ofA2aA2patient,A2whatA2areA2theA2twoA2pairsA2ofA2salivaryA2gl
andsA2thatA2areA2accessibleA2forA2examination?
a.A2Occipital;A2submental
b.A2Parotid;A2submandibular
c.A2Submandibular;A2occipital
d.A2Sublingual;A2parotidA2-A2Ans--ANS:A2B
TheA2twoA2pairsA2ofA2salivaryA2glandsA2accessibleA2toA2examinationA2onA2theA2faceA2areA2t
heA2parotidA2glands,A2whichA2areA2inA2theA2cheeksA2overA2the
mandible,A2anteriorA2toA2andA2belowA2theA2ear;A2andA2theA2submandibularA2glands,A2whic
hA2areA2beneathA2theA2mandibleA2atA2theA2angleA2ofA2theA2jaw.A2The

,parotidA2glandsA2areA2normallyA2nonpalpable.A2TheA2occipitalA2andA2submentalA2areA2lym
phA2nodes,A2notA2glandsA2andA2theA2sublingualA2glandsA2lieA2on
theA2floorA2ofA2theA2mouth,A2soA2areA2notA2readilyA2accessibleA2forA2examination.A2TheA2tw
oA2pairsA2ofA2salivaryA2glandsA2thatA2areA2accessibleA2for
examinationA2onA2theA2faceA2areA2theA2parotidA2glands,A2whichA2areA2inA2theA2cheeksA2ov
erA2theA2mandible,A2anteriorA2toA2andA2belowA2theA2ear;A2andA2the
submandibularA2glands,A2whichA2areA2beneathA2theA2mandibleA2atA2theA2angleA2ofA2theA2j
aw.

AA2patientA2comesA2toA2theA2clinicA2complainingA2ofA2neckA2andA2shoulderA2painA2andA2isA
2unableA2toA2turnA2herA2head.A2WhichA2nerveA2doesA2theA2nurse
suspectA2isA2damagedA2andA2howA2shouldA2theA2nurseA2proceedA2withA2theA2examination
?
a.A2XII;A2assessA2forA2aA2positiveA2RombergA2sign.
b.A2XI;A2palpateA2theA2anteriorA2andA2posteriorA2triangles.
c.A2XI;A2haveA2patientA2shrugA2theirA2shouldersA2againstA2resistance.
d.A2XII;A2percussA2theA2sternomastoidA2andA2submandibularA2neckA2muscles.A2-A2Ans--
ANS:A2C
TheA2majorA2neckA2musclesA2areA2theA2sternomastoidA2andA2theA2trapezius.A2TheyA2areA2i
nnervatedA2byA2CNA2XI,A2theA2spinalA2accessory.A2The
innervatedA2musclesA2assistA2withA2headA2rotationA2andA2headA2flexion,A2movementA2ofA2t
heA2shoulders,A2andA2extensionA2andA2turningA2ofA2theA2head.
ToA2assessA2theA2functionA2ofA2cranialA2nerveA2XIA2theA2nurseA2shouldA2haveA2theA2patien
tA2shrugA2theirA2shouldersA2againstA2resistance.A2CranialA2nerve
XIIA2isA2theA2hypoglossalA2nerveA2whichA2innervatesA2theA2musclesA2ofA2theA2tongueA2inv
olvedA2withA2speechA2andA2swallowingA2andA2isA2notA2involved
inA2headA2movement.A2IdentifyingA2theA2anteriorA2andA2posteriorA2trianglesA2areA2helpfulA2
guidelinesA2whenA2describingA2findingsA2inA2theA2neckA2but
palpatingA2themA2doesA2notA2assessA2anyA2cranialA2nerves.

WhenA2examiningA2aA2patient'sA2CNA2function,A2whatA2musclesA2shouldA2theA2nurseA2ass
essA2toA2assessA2theA2functionA2ofA2CNA2XI?
a.A2SternomastoidA2andA2trapezius
b.A2SpinalA2accessoryA2andA2omohyoid
c.A2TrapeziusA2andA2sternomandibular
d.A2SternomandibularA2andA2spinalA2accessoryA2-A2Ans--ANS:A2A
TheA2musclesA2innervatedA2byA2CNA2XIA2areA2theA2sternomastoidA2andA2theA2trapeziusA2
musclesA2inA2theA2neck.A2OptionsA2B,A2C,A2andA2DA2areA2incorrect
becauseA2theA2spinalA2accessoryA2isA2notA2aA2muscleA2butA2theA2nameA2ofA2CNA2XIA2andA2
thereA2isA2noA2sternomandibularA2muscle.

AA2patient'sA2laboratoryA2dataA2revealA2anA2elevatedA2thyroxineA2(T4)A2level.A2WhatA2glan
dA2shouldA2theA2nurseA2assess?
a.A2Thyroid
b.A2Parotid
c.A2Adrenal

, d.A2ParathyroidA2-A2Ans--ANS:A2A
TheA2thyroidA2glandA2isA2aA2highlyA2vascularA2endocrineA2glandA2thatA2secretesA2T4A2andA
2triiodothyronineA2(T3).A2TheA2otherA2glandsA2doA2notA2secrete
T4.A2TheA2parotidA2glandsA2areA2salivaryA2glandsA2andA2secreteA2saliva.A2TheA2adrenalA2g
landsA2secreteA2corticosteroids,A2notA2T4,A2andA2the
parathyroidA2glandsA2controlA2theA2body'sA2calcium.A2TheA2glandA2thatA2secretesA2thyroxi
ne,A2orA2T4,A2isA2theA2thyroidA2gland.A2TheA2thyroidA2glandA2isA2a
highlyA2vascularA2endocrineA2glandA2thatA2secretesA2thyroxineA2(T4)A2andA2triiodothyronin
eA2(T3).

AA2patientA2saysA2thatA2sheA2hasA2recentlyA2noticedA2aA2lumpA2inA2theA2frontA2ofA2herA2nec
kA2belowA2herA2"Adam'sA2apple"A2thatA2seemsA2toA2beA2getting
bigger.A2DuringA2theA2assessment,A2whatA2findingA2wouldA2leadA2theA2nurseA2toA2suspectA
2thatA2thisA2mayA2notA2beA2aA2cancerousA2thyroidA2nodule?
a.A2ItA2isA2tender.
b.A2ItA2isA2mobileA2andA2soft.
c.A2ItA2disappearsA2whenA2theA2patientA2smiles.
d.A2ItA2isA2hardA2andA2fixedA2toA2theA2surroundingA2structures.A2-A2Ans--ANS:A2B
Painless,A2rapidlyA2growingA2nodulesA2mayA2beA2cancerous,A2especiallyA2theA2appearanc
eA2ofA2aA2singleA2noduleA2inA2aA2youngA2person.A2However,
cancerousA2nodulesA2tendA2toA2beA2hardA2andA2fixedA2toA2surroundingA2structures,A2notA2
mobile.

TheA2nurseA2noticesA2thatA2aA2patient'sA2submentalA2lymphA2nodesA2areA2enlarged.A2InA2a
nA2effortA2toA2identifyA2theA2causeA2ofA2theA2nodeA2enlargement,
whatA2shouldA2theA2nurseA2assess?
a.A2InfraclavicularA2area
b.A2SupraclavicularA2area
c.A2AreaA2distalA2toA2theA2enlargedA2node
d.A2AreaA2proximalA2toA2theA2enlargedA2nodeA2-A2Ans--ANS:A2D
WhenA2nodesA2areA2abnormal,A2theA2nurseA2shouldA2checkA2theA2areaA2intoA2whichA2they
A2drainA2forA2theA2sourceA2ofA2theA2problem.A2TheA2areaA2proximal
(upstream)A2toA2theA2locationA2ofA2theA2abnormalA2nodeA2shouldA2beA2explored.

TheA2nurseA2isA2explainingA2toA2aA2studentA2nurseA2theA2fourA2areasA2inA2theA2bodyA2wher
eA2lymphA2nodesA2areA2accessible.A2WhichA2areasA2shouldA2the
nurseA2includeA2inA2herA2explanationA2toA2theA2student?
a.A2Head,A2breasts,A2groin,A2andA2abdomen
b.A2Arms,A2breasts,A2inguinalA2area,A2andA2legs
c.A2HeadA2andA2neck,A2arms,A2breasts,A2andA2axillae
d.A2HeadA2andA2neck,A2arms,A2inguinalA2area,A2andA2axillaeA2-A2Ans--ANS:A2D
NodesA2areA2locatedA2throughoutA2theA2body,A2butA2theyA2areA2accessibleA2toA2examinati
onA2onlyA2inA2fourA2areas:A2headA2andA2neck,A2arms,A2inguinal
region,A2andA2axillae.