Physical assessment test bank for exam 3

Physical assessment test bank for exam 3 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: - At the level of the C7 vertebra.The C7 vertebra has a long spinous process, called the vertebra prominens, which is palpable when the head is flexed. 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: - 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)? - VII A patient is unable to differentiate between sharp and dull stimulation to both sides of her face. The nurse suspects: - 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. - 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 _____________. - 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: - Sternomastoid and trapezius. A patients laboratory data reveal an elevated thyroxine (T4) level. The nurse would proceed with an examination of the _____ gland. - 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): - 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: - Area proximal to the enlarged node. The nurse is aware that the four areas in the body where lymph nodes are accessible are the: - 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? - 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? - 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: - 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: - 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? - 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? - Hydrocephalus The nurse needs to palpate the temporomandibular joint for crepitation. This joint is located just below the temporal artery and anterior to the: - Tragus. 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: - Parotid gland. 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: - Parotid gland. The nurse suspects that a patient has hyperthyroidism, and the laboratory data indicate that the patients T4 and T3 hormone levels are elevated. Which of these findings would the nurse most likely find on examination? - Tachycardia 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: - The front with the nurses thumbs placed on either side of his trachea and his head tilted forward. A patients 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. - Soft, whooshing, pulsatile; bell 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 babys birth and that it seems to be getting bigger. One possible explanation for this is: - Cephalhematoma. A mother brings in her newborn infant for an assessment and tells the nurse that she has noticed that whenever her newborns 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