NU 518 Exam 2 Questions and Answers
Question 1.
Chapter 11 (Head and Neck)
Correct Answer: FACE -Irregular brownish patches around the forehead, cheeks,
nose, and jaw, known as chloasma or melasma ("the mask of pregnancy"), and is
a normal skin finding during pregnancy. -Facial edema after 20 gestational
weeks is suspicious for preeclampsia and should be investigated HAIR May
become dry, oily, or sparse during pregnancy. • Mild hirsutism on the face,
abdomen, and extremities common Localized patches of hair loss should not be
attributed to pregnancy, though postpartum hair loss is common EYES Assess
the conjunctivae and sclera for signs of pallor and jaundice. • Anemia may cause
conjunctival pallor. NOSE Inspect the mucous membranes and septum. •
Erosions and perforations of the nasal septum may represent intranasal cocaine
use. • Nasal congestion and nose bleeds are more common during pregnancy.
MOUTH Examine the teeth and gums (Gingival enlargement with bleeding is
common during pregnancy) • Dental problems are associated with poor
pregnancy outcomes (dental referrals should be made for tooth/gum pain or
infections) THYROID GLAND Modest symmetric enlargement is normal on
inspection and palpation. • Thyroid enlargement, goiters, and nodules are
abnormal and require investigation.
Question 2.
Cervical lymph nodes
Correct Answer: Note: tonsillar, submandibular, and submental nodes drain
portions of the mouth and throat as well as the face Suspicion of malignant or
inflammatory lesion: assess for enlargement of the regional lymph nodes that
drain it (when a node is enlarged or tender > look for a source in its nearby
drainage area) Patient Assessment: patient should be relaxed, neck flexed
slightly forward (if needed) turned slightly toward side being examined. •
INSPECT the NECK: note symmetry or any masses or scars; assess for
enlargement of parotid or submandibular glands; note any visible lymph nodes •
PALPATE LYMPH NODES: using pads of index and middle fingers, press gently,
moving the skin over the underlying tissues (NOTE: size, shape, delimitation
(discrete or matted together), mobility, consistency, and any tenderness)
Findings: • Small, mobile, discrete, nontender nodes ("shotty"): frequently
found in normal people [should be able to roll a node in two directions > up and
down, and side to side; muscles/arteries will not do this] • Enlarged or tender
nodes: without explanation require reexamination of the regions they drain, and
careful assessment of lymph nodes in other regions to identify regional from
generalized lymphadenopathy; tender nodes suggest inflammation; hard or
fixed nodes suggest malignancy Abnormal Findings Charting: describe enlarged
nodes in two dimensions à maximal length and width (e.g., 1 cm x 2 cm)
Question 3.
,SEQUENCE FOR PALPATING NODES
Correct Answer: 1. Preauricular 2. Posterior auricular 3. Occipital 4. Tonsillar 5.
Submandibular 6. Submental 7. Superficial cervical 8. Posterior cervical 9. Deep
cervical chain 10. Supraclavicular
Question 4.
Thyroid gland
Correct Answer: INSPECT By tipping the patient's head back a bit (using
tangential lighting directed downward from the tip of the patient's chin) >
inspect the region below the cricoid cartilage to identify the contours of the
gland OBSERVE SWALLOWING Have them sip some water, extend the neck
again, and swallow > watch for upward movement of the thyroid gland (noting
its contour and symmetry) **Patient has a goiter with swallowing: lower border
of the enlarged gland rises and looks less symmetric Steps for palpating the
thyroid gland: 1. Find landmarks - the notched thyroid cartilage and the cricoid
cartilage below, and the thyroid isthmus, usually overlying the second, third,
and fourth tracheal rings. 2. Ask patient to flex neck forward and relax
sternocleidomastoid muscles. 3. Place fingers on both sides of the neck so that
index fingers are just below the cricoid cartilage 4. Ask patient to sip and
swallow water. Feel for the thyroid isthmus rising up under your finger pads. 5.
Displace trachea to the right with fingers of left hand; with right hand fingers,
palpate laterally for the right lobe in space between displaced trachea and
relaxed sternocleidomastoid muscle, find lateral margin, then repeat on left side
for left lobe 6. Note: size, shape, consistency (soft, firm, or hard) of gland and
identify nodules or tenderness. 7. If thyroid gland is enlarged, listen over lateral
lobes with stethoscope for a bruit 8. For palpable solitary nodules, ultrasound
and possible fine-needle aspiration are advised Assessment Findings: • Graves'
Disease > soft and may be nodular • Hashimoto's thyroiditis > firm • Malignancy
> firm • Hyperthyroidism from Graves' disease or toxic multinodular goiter >
localized systolic or continuous bruit may be heard • Tracheal compression from
Retrosternal goiters > hoarseness, SOB, stridor, or dysphagia
Question 5.
Chapter 12 (Eyes)
Correct Answer:
Question 6.
Vision changes
,Correct Answer: Begin with open-ended questions such as "Have you had any
trouble with your eyes?" If the patient reports a change in vision, pursue the
related details. -Is vision worse during close work or at distances? Difficulty with
close work suggests hyperopia (farsightedness) or presbyopia (aging vision),
and, difficulty with distance vision, suggest myopia (nearsightedness). -Is there
blurred vision? If yes, is the onset sudden or gradual? If sudden and unilateral,
is the visual loss painless or painful? Is it associated with headache? If sudden
visual loss is unilateral and painless, consider vitreous hemorrhage from
diabetes or trauma, macular degeneration, retinal detachment, retinal vein
occlusion, or central retinal artery occlusion. If painful, causes are usually in the
cornea and anterior chamber such as corneal ulcer, uveitis, traumatic hyphema,
and acute angle closure glaucoma. Optic neuritis from multiple sclerosis may
also be painful. Immediate referral is warranted. If associated with headache, a
thorough neurologic examination is warranted. -Is the visual loss unilateral? If
so, is it painful or painless? If it is associated with headache, jaw pain or
claudication, it may be associated with giant-cell arteritis. If painless, it may be
associated with a vascular occlusion, retinal detachment, or hemorrhage. -Is the
visual loss bilateral? (Sudden bilateral visual loss is rare.) If so, is it painful? If
bilateral and painless, consider vascular etiologies, stroke, or non-physiologic
causes. If bilateral and painful, consider intoxication, trauma, chemical or
radiation exposures. -Is the onset of bilateral visual loss gradual? Gradual vision
loss usually arises from cataracts, glaucoma, or macular degeneration.
Question 7.
Correct Answer: -Location of visual loss may also be helpful. Is there blurring of
the entire field of vision or only parts of it? Slow central loss may occur with
nuclear cataract (p. 387) and macular degeneration (p. 377). Peripheral loss can
be seen in advanced open-angle glaucoma (p. 381) with unilateral loss with
hemianopsia and quadrantic defects (p. 384). Though they may be asymmetric,
these conditions are often bilateral disease processes. -If the visual field defect
is partial, is it central, peripheral, or on only one side? -Is the visual field defect
bilateral? Are there any patterns that we can help localize the lesion? -Are there
specks in the vision or areas where the patient cannot see (scotomas)? If so, do
they move around in the visual field with shifts in gaze or are they fixed? Moving
specks or strands suggest vitreous floaters; fixed defects, or scotomas, suggest
lesions in the retina, visual pathway, or brain. -Are there lights flashing across
the field of vision? Vitreous floaters may accompany this symptom. Flashing
lights with new vitreous floaters suggest traction on the retina with detachment
of the vitreous body from the retina. Prompt consultation is indicated to rule out
retinal tears or detachments. -Does the patient wear glasses? Contact lenses?
Has the patient undergone refractive surgery? -Ask about pain in or around the
eyes, redness, and excessive tearing or watering. A red painless eye is seen in
subconjunctival hemorrhage and episcleritis. A red eye with a gritty sensation is
seen in viral conjunctivitis and dry eye. A red painful eye is seen in corneal
abrasions, foreign bodies, corneal ulcers, acute angle closure glaucoma, herpes
keratitis, fungal keratitis, hyphema, and uveitis
, Question 8.
Double vision
Correct Answer: Check for double vision, or diplopia. If present, find out if the
images are side by side (horizontal diplopia) or on top of each other (vertical
diplopia). Does diplopia persist with one eye closed? Which eye is affected?
Diplopia is seen in lesions in the brainstem or cerebellum and with weakness or
paralysis of one or more extraocular muscles, as in horizontal diplopia from
palsy of CN III or VI or vertical diplopia from palsy of CN III or IV. Diplopia in one
eye, with the other closed, suggests a problem in the ocular surface, cornea,
lens, or macula. One kind of horizontal diplopia is physiologic. Hold one finger
upright approximately 6 inches in front of your face, a second at arm's length.
When you focus on either finger, the image of the other is double. A patient who
notices this phenomenon can be reassured.
Question 9.
Visual acuity
Correct Answer: • To test the acuity of central vision, use a well-lit Snellen eye
chart, if possible. • Position the patient 20 feet from the chart. Patient who use
glasses other than for reading should wear them. • Ask the patient to cover one
eye and to read the smallest line of print possible. o A patient who cannot read
the largest letter should be positioned closer to the chart; note distance. •
Determine the smallest line of print from which the patient can identify more
than half the letters. • Record the visual acuity designated at the side of this
line, along with use of glasses, if any. • Visual acuity is expressed as two
numbers (e.g., 20/30): the first indicates the distance of the patient from the
chart, and the second, the distance at which a normal eye can read the line of
letters. • Testing near vision with a special hand-held card helps identify the
need for reading glasses or bifocals in patients older than 45 years. You can also
use this card to test visual acuity at the bedside. Held 14 inches from the
patient's eyes, the card simulates a Snellen chart. • If you have no charts,
screen visual acuity with any available print. • If patients cannot read even the
largest letters, test their ability to count your upraised fingers and distinguish
light from dark. Myopia (nearsightedness) causes focusing problems for
distance vision, whereas hyperopia (farsightedness) describes eyesight that is
blurry on objects nearby. Astigmatism is an imperfection of the cornea or lens
causing distortion while looking at near and far objects Presbyopia causes
focusing problems for near vision, found in middle-aged and older adults. A
person with presbyopia often sees better when the card is farther away.
Question 10.
Cornea and lens
Correct Answer: • Corneal arcus: grayish white circle at edge of cornea, usually
benign. • Kayser-Fleischer ring: golden/red-brown ring in peripheral cornea,
found in Wilson disease. • Corneal scar: superficial gray/white opacity in cornea,
from injury or inflammation. Do not confused with cataract. • Pterygium:
triangular thickening of bulbar conjunctiva across surface of cornea. May
Question 1.
Chapter 11 (Head and Neck)
Correct Answer: FACE -Irregular brownish patches around the forehead, cheeks,
nose, and jaw, known as chloasma or melasma ("the mask of pregnancy"), and is
a normal skin finding during pregnancy. -Facial edema after 20 gestational
weeks is suspicious for preeclampsia and should be investigated HAIR May
become dry, oily, or sparse during pregnancy. • Mild hirsutism on the face,
abdomen, and extremities common Localized patches of hair loss should not be
attributed to pregnancy, though postpartum hair loss is common EYES Assess
the conjunctivae and sclera for signs of pallor and jaundice. • Anemia may cause
conjunctival pallor. NOSE Inspect the mucous membranes and septum. •
Erosions and perforations of the nasal septum may represent intranasal cocaine
use. • Nasal congestion and nose bleeds are more common during pregnancy.
MOUTH Examine the teeth and gums (Gingival enlargement with bleeding is
common during pregnancy) • Dental problems are associated with poor
pregnancy outcomes (dental referrals should be made for tooth/gum pain or
infections) THYROID GLAND Modest symmetric enlargement is normal on
inspection and palpation. • Thyroid enlargement, goiters, and nodules are
abnormal and require investigation.
Question 2.
Cervical lymph nodes
Correct Answer: Note: tonsillar, submandibular, and submental nodes drain
portions of the mouth and throat as well as the face Suspicion of malignant or
inflammatory lesion: assess for enlargement of the regional lymph nodes that
drain it (when a node is enlarged or tender > look for a source in its nearby
drainage area) Patient Assessment: patient should be relaxed, neck flexed
slightly forward (if needed) turned slightly toward side being examined. •
INSPECT the NECK: note symmetry or any masses or scars; assess for
enlargement of parotid or submandibular glands; note any visible lymph nodes •
PALPATE LYMPH NODES: using pads of index and middle fingers, press gently,
moving the skin over the underlying tissues (NOTE: size, shape, delimitation
(discrete or matted together), mobility, consistency, and any tenderness)
Findings: • Small, mobile, discrete, nontender nodes ("shotty"): frequently
found in normal people [should be able to roll a node in two directions > up and
down, and side to side; muscles/arteries will not do this] • Enlarged or tender
nodes: without explanation require reexamination of the regions they drain, and
careful assessment of lymph nodes in other regions to identify regional from
generalized lymphadenopathy; tender nodes suggest inflammation; hard or
fixed nodes suggest malignancy Abnormal Findings Charting: describe enlarged
nodes in two dimensions à maximal length and width (e.g., 1 cm x 2 cm)
Question 3.
,SEQUENCE FOR PALPATING NODES
Correct Answer: 1. Preauricular 2. Posterior auricular 3. Occipital 4. Tonsillar 5.
Submandibular 6. Submental 7. Superficial cervical 8. Posterior cervical 9. Deep
cervical chain 10. Supraclavicular
Question 4.
Thyroid gland
Correct Answer: INSPECT By tipping the patient's head back a bit (using
tangential lighting directed downward from the tip of the patient's chin) >
inspect the region below the cricoid cartilage to identify the contours of the
gland OBSERVE SWALLOWING Have them sip some water, extend the neck
again, and swallow > watch for upward movement of the thyroid gland (noting
its contour and symmetry) **Patient has a goiter with swallowing: lower border
of the enlarged gland rises and looks less symmetric Steps for palpating the
thyroid gland: 1. Find landmarks - the notched thyroid cartilage and the cricoid
cartilage below, and the thyroid isthmus, usually overlying the second, third,
and fourth tracheal rings. 2. Ask patient to flex neck forward and relax
sternocleidomastoid muscles. 3. Place fingers on both sides of the neck so that
index fingers are just below the cricoid cartilage 4. Ask patient to sip and
swallow water. Feel for the thyroid isthmus rising up under your finger pads. 5.
Displace trachea to the right with fingers of left hand; with right hand fingers,
palpate laterally for the right lobe in space between displaced trachea and
relaxed sternocleidomastoid muscle, find lateral margin, then repeat on left side
for left lobe 6. Note: size, shape, consistency (soft, firm, or hard) of gland and
identify nodules or tenderness. 7. If thyroid gland is enlarged, listen over lateral
lobes with stethoscope for a bruit 8. For palpable solitary nodules, ultrasound
and possible fine-needle aspiration are advised Assessment Findings: • Graves'
Disease > soft and may be nodular • Hashimoto's thyroiditis > firm • Malignancy
> firm • Hyperthyroidism from Graves' disease or toxic multinodular goiter >
localized systolic or continuous bruit may be heard • Tracheal compression from
Retrosternal goiters > hoarseness, SOB, stridor, or dysphagia
Question 5.
Chapter 12 (Eyes)
Correct Answer:
Question 6.
Vision changes
,Correct Answer: Begin with open-ended questions such as "Have you had any
trouble with your eyes?" If the patient reports a change in vision, pursue the
related details. -Is vision worse during close work or at distances? Difficulty with
close work suggests hyperopia (farsightedness) or presbyopia (aging vision),
and, difficulty with distance vision, suggest myopia (nearsightedness). -Is there
blurred vision? If yes, is the onset sudden or gradual? If sudden and unilateral,
is the visual loss painless or painful? Is it associated with headache? If sudden
visual loss is unilateral and painless, consider vitreous hemorrhage from
diabetes or trauma, macular degeneration, retinal detachment, retinal vein
occlusion, or central retinal artery occlusion. If painful, causes are usually in the
cornea and anterior chamber such as corneal ulcer, uveitis, traumatic hyphema,
and acute angle closure glaucoma. Optic neuritis from multiple sclerosis may
also be painful. Immediate referral is warranted. If associated with headache, a
thorough neurologic examination is warranted. -Is the visual loss unilateral? If
so, is it painful or painless? If it is associated with headache, jaw pain or
claudication, it may be associated with giant-cell arteritis. If painless, it may be
associated with a vascular occlusion, retinal detachment, or hemorrhage. -Is the
visual loss bilateral? (Sudden bilateral visual loss is rare.) If so, is it painful? If
bilateral and painless, consider vascular etiologies, stroke, or non-physiologic
causes. If bilateral and painful, consider intoxication, trauma, chemical or
radiation exposures. -Is the onset of bilateral visual loss gradual? Gradual vision
loss usually arises from cataracts, glaucoma, or macular degeneration.
Question 7.
Correct Answer: -Location of visual loss may also be helpful. Is there blurring of
the entire field of vision or only parts of it? Slow central loss may occur with
nuclear cataract (p. 387) and macular degeneration (p. 377). Peripheral loss can
be seen in advanced open-angle glaucoma (p. 381) with unilateral loss with
hemianopsia and quadrantic defects (p. 384). Though they may be asymmetric,
these conditions are often bilateral disease processes. -If the visual field defect
is partial, is it central, peripheral, or on only one side? -Is the visual field defect
bilateral? Are there any patterns that we can help localize the lesion? -Are there
specks in the vision or areas where the patient cannot see (scotomas)? If so, do
they move around in the visual field with shifts in gaze or are they fixed? Moving
specks or strands suggest vitreous floaters; fixed defects, or scotomas, suggest
lesions in the retina, visual pathway, or brain. -Are there lights flashing across
the field of vision? Vitreous floaters may accompany this symptom. Flashing
lights with new vitreous floaters suggest traction on the retina with detachment
of the vitreous body from the retina. Prompt consultation is indicated to rule out
retinal tears or detachments. -Does the patient wear glasses? Contact lenses?
Has the patient undergone refractive surgery? -Ask about pain in or around the
eyes, redness, and excessive tearing or watering. A red painless eye is seen in
subconjunctival hemorrhage and episcleritis. A red eye with a gritty sensation is
seen in viral conjunctivitis and dry eye. A red painful eye is seen in corneal
abrasions, foreign bodies, corneal ulcers, acute angle closure glaucoma, herpes
keratitis, fungal keratitis, hyphema, and uveitis
, Question 8.
Double vision
Correct Answer: Check for double vision, or diplopia. If present, find out if the
images are side by side (horizontal diplopia) or on top of each other (vertical
diplopia). Does diplopia persist with one eye closed? Which eye is affected?
Diplopia is seen in lesions in the brainstem or cerebellum and with weakness or
paralysis of one or more extraocular muscles, as in horizontal diplopia from
palsy of CN III or VI or vertical diplopia from palsy of CN III or IV. Diplopia in one
eye, with the other closed, suggests a problem in the ocular surface, cornea,
lens, or macula. One kind of horizontal diplopia is physiologic. Hold one finger
upright approximately 6 inches in front of your face, a second at arm's length.
When you focus on either finger, the image of the other is double. A patient who
notices this phenomenon can be reassured.
Question 9.
Visual acuity
Correct Answer: • To test the acuity of central vision, use a well-lit Snellen eye
chart, if possible. • Position the patient 20 feet from the chart. Patient who use
glasses other than for reading should wear them. • Ask the patient to cover one
eye and to read the smallest line of print possible. o A patient who cannot read
the largest letter should be positioned closer to the chart; note distance. •
Determine the smallest line of print from which the patient can identify more
than half the letters. • Record the visual acuity designated at the side of this
line, along with use of glasses, if any. • Visual acuity is expressed as two
numbers (e.g., 20/30): the first indicates the distance of the patient from the
chart, and the second, the distance at which a normal eye can read the line of
letters. • Testing near vision with a special hand-held card helps identify the
need for reading glasses or bifocals in patients older than 45 years. You can also
use this card to test visual acuity at the bedside. Held 14 inches from the
patient's eyes, the card simulates a Snellen chart. • If you have no charts,
screen visual acuity with any available print. • If patients cannot read even the
largest letters, test their ability to count your upraised fingers and distinguish
light from dark. Myopia (nearsightedness) causes focusing problems for
distance vision, whereas hyperopia (farsightedness) describes eyesight that is
blurry on objects nearby. Astigmatism is an imperfection of the cornea or lens
causing distortion while looking at near and far objects Presbyopia causes
focusing problems for near vision, found in middle-aged and older adults. A
person with presbyopia often sees better when the card is farther away.
Question 10.
Cornea and lens
Correct Answer: • Corneal arcus: grayish white circle at edge of cornea, usually
benign. • Kayser-Fleischer ring: golden/red-brown ring in peripheral cornea,
found in Wilson disease. • Corneal scar: superficial gray/white opacity in cornea,
from injury or inflammation. Do not confused with cataract. • Pterygium:
triangular thickening of bulbar conjunctiva across surface of cornea. May
