health assessment final - jarvis test bank
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. - correct answers>>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 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 - correct answers>>D
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 - correct answers>>C
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. - correct answers>>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 - correct answers>>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 - correct answers>>B
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. - correct answers>>A
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 - correct answers>>A
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. - correct answers>>B
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. - correct answers>>D
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.
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. - correct answers>>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 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 - correct answers>>D
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 - correct answers>>C
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. - correct answers>>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 - correct answers>>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 - correct answers>>B
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. - correct answers>>A
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 - correct answers>>A
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. - correct answers>>B
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. - correct answers>>D
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.
