Test Bank - Jarvis Chapter 14
A physician tells the nurse that a patient's vertebra prominens is tender and asks the nurse to
reevaluate the area in 1 hour. What area of the body will the nurse assess?
a. At the level of the C7 vertebra
b. At the level of the T11 vertebra
c. At the level of the L5 vertebra
d. At the level of the S3 vertebra - ANSA. 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?" How should the nurse respond?
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 skull."
c. "That 'soft spot' may be an indication of cretinism or congenital hypothyroidis - ANSD. "That
'soft spot' is normal, and actually allows for growth of the brain during the first year of your
baby's life."
The nurse notices that a patient's palpebral fissures are not symmetric. On examination, the
nurse may find that damage has occurred to which cranial nerve (CN)?
a. V
b. VII
c. XI
d. XIII - ANSB. VII
A patient is unable to differentiate between sharp and dull stimulation to both sides of her face.
What does the nurse suspect?
a. Bell palsy
b. Scleroderma
c. Damage to the trigeminal nerve
d. Frostbite with resultant paresthesia to the cheeks - ANSC. damage to the trigeminal nerve
When examining the face of a patient, what are the two pairs of salivary glands that are
accessible for examination?
a. Occipital; submental
b. Parotid; submandibular
c. Submandibular; occipital
, d. Sublingual; parotid - ANSB. parotid & submandibular
A patient comes to the clinic complaining of neck and shoulder pain and is unable to turn her
head. Which nerve does the nurse suspect is damaged and how should the nurse proceed with
the examination?
a. XII; assess for a positive Romberg sign.
b. XI; palpate the anterior and posterior triangles.
c. XI; have patient shrug their shoulders against resistance.
d. XII; percuss the sternomastoid and submandibular neck muscles. - ANSC. XI; have patient
shrug their shoulders against resistance.
When examining a patient's CN function, what muscles should the nurse assess to assess the
function of CN XI?
a. Sternomastoid and trapezius
b. Spinal accessory and omohyoid
c. Trapezius and sternomandibular
d. Sternomandibular and spinal accessory - ANSA. sternomastoid and trapezius
A patient's laboratory data reveal an elevated thyroxine (T4) level. What gland should the nurse
assess?
a. Thyroid
b. Parotid
c. Adrenal
d. Parathyroid - ANSA. thyroid
A patient says that she has recently noticed a lump in the front of her neck below her "Adam's
apple" that seems to be getting bigger. During the assessment, what finding would lead the
nurse to suspect that this may not be a cancerous thyroid nodule?
a. It is tender.
b. It is mobile and soft.
c. It disappears when the patient smiles.
d. It is hard and fixed to the surrounding structures. - ANSB. It is mobile and soft.
The nurse notices that a patient's submental lymph nodes are enlarged. In an effort to identify
the cause of the node enlargement, what should the nurse assess?
a. Infraclavicular area
b. Supraclavicular area
c. Area distal to the enlarged node
d. Area proximal to the enlarged node - ANSD. Area proximal (upstream) to the enlarged node
A physician tells the nurse that a patient's vertebra prominens is tender and asks the nurse to
reevaluate the area in 1 hour. What area of the body will the nurse assess?
a. At the level of the C7 vertebra
b. At the level of the T11 vertebra
c. At the level of the L5 vertebra
d. At the level of the S3 vertebra - ANSA. 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?" How should the nurse respond?
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 skull."
c. "That 'soft spot' may be an indication of cretinism or congenital hypothyroidis - ANSD. "That
'soft spot' is normal, and actually allows for growth of the brain during the first year of your
baby's life."
The nurse notices that a patient's palpebral fissures are not symmetric. On examination, the
nurse may find that damage has occurred to which cranial nerve (CN)?
a. V
b. VII
c. XI
d. XIII - ANSB. VII
A patient is unable to differentiate between sharp and dull stimulation to both sides of her face.
What does the nurse suspect?
a. Bell palsy
b. Scleroderma
c. Damage to the trigeminal nerve
d. Frostbite with resultant paresthesia to the cheeks - ANSC. damage to the trigeminal nerve
When examining the face of a patient, what are the two pairs of salivary glands that are
accessible for examination?
a. Occipital; submental
b. Parotid; submandibular
c. Submandibular; occipital
, d. Sublingual; parotid - ANSB. parotid & submandibular
A patient comes to the clinic complaining of neck and shoulder pain and is unable to turn her
head. Which nerve does the nurse suspect is damaged and how should the nurse proceed with
the examination?
a. XII; assess for a positive Romberg sign.
b. XI; palpate the anterior and posterior triangles.
c. XI; have patient shrug their shoulders against resistance.
d. XII; percuss the sternomastoid and submandibular neck muscles. - ANSC. XI; have patient
shrug their shoulders against resistance.
When examining a patient's CN function, what muscles should the nurse assess to assess the
function of CN XI?
a. Sternomastoid and trapezius
b. Spinal accessory and omohyoid
c. Trapezius and sternomandibular
d. Sternomandibular and spinal accessory - ANSA. sternomastoid and trapezius
A patient's laboratory data reveal an elevated thyroxine (T4) level. What gland should the nurse
assess?
a. Thyroid
b. Parotid
c. Adrenal
d. Parathyroid - ANSA. thyroid
A patient says that she has recently noticed a lump in the front of her neck below her "Adam's
apple" that seems to be getting bigger. During the assessment, what finding would lead the
nurse to suspect that this may not be a cancerous thyroid nodule?
a. It is tender.
b. It is mobile and soft.
c. It disappears when the patient smiles.
d. It is hard and fixed to the surrounding structures. - ANSB. It is mobile and soft.
The nurse notices that a patient's submental lymph nodes are enlarged. In an effort to identify
the cause of the node enlargement, what should the nurse assess?
a. Infraclavicular area
b. Supraclavicular area
c. Area distal to the enlarged node
d. Area proximal to the enlarged node - ANSD. Area proximal (upstream) to the enlarged node
