Question 1

A patient's 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.

Accepted Answer

A)  Low gurgling; diaphragm
B)  Loud, whooshing, blowing; bell
C)  Soft, whooshing, pulsatile; bell
D)  High-pitched tinkling; diaphragm C

Question 2

A patient visits the clinic because he has recently noticed that the left side of his mouth is paralyzed.He states that he cannot raise his eyebrow or whistle.The nurse suspects that he has:

Accepted Answer

A)  Cushing syndrome.
B)  Parkinson disease.
C)  Bell palsy.
D)  Experienced a cerebrovascular accident (CV
A)   or stroke. D

Question 3

The physician reports that a patient with a neck tumor has a tracheal shift.The nurse is aware that this means that the patient's trachea is:

Accepted Answer

A)  Pulled to the affected side.
B)  Pushed to the unaffected side.
C)  Pulled downward.
D)  Pulled downward in a rhythmic pattern. B

Question 4

During a well-baby checkup,a mother is concerned because her 2-month-old infant cannot hold her head up when she is pulled to a sitting position.Which response by the nurse is appropriate?

Accepted Answer

A)  "Head control is usually achieved by 4 months of age."
B)  "You shouldn't be trying to pull your baby up like that until she is older."
C)  "Head control should be achieved by this time."
D)  "This inability indicates possible nerve damage to the neck muscles."

Question 5

During an examination,the nurse finds that a patient's left temporal artery is tortuous and feels hardened and tender,compared with the right temporal artery.The nurse suspects which condition?

Accepted Answer

A)  Crepitation
B)  Mastoiditis
C)  Temporal arteritis
D)  Bell palsy

Question 6

A physician tells the nurse that a patient's 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:

Accepted Answer

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.

Question 7

A patient is unable to differentiate between sharp and dull stimulation to both sides of her face.The nurse suspects:

Accepted Answer

A)  Bell palsy.
B)  Damage to the trigeminal nerve.
C)  Frostbite with resultant paresthesia to the cheeks.
D)  Scleroderma.

Question 8

During an examination,the nurse knows that the best way to palpate the lymph nodes in the neck is described by which statement?

Accepted Answer

A)  Using gentle pressure, palpate with both hands to compare the two sides.
B)  Using strong pressure, palpate with both hands to compare the two sides.
C)  Gently pinch each node between one's thumb and forefinger, and then move down the neck muscle.
D)  Using the index and middle fingers, gently palpate by applying pressure in a rotating pattern.

Question 9

While performing a well-child assessment on a 5 year old,the nurse notes the presence of palpable,bilateral,cervical,and inguinal lymph nodes.They are approximately 0.5 cm in size,round,mobile,and nontender.The nurse suspects that this child:

Accepted Answer

A)  Has chronic allergies.
B)  May have an infection.
C)  Is exhibiting a normal finding for a well child of this age.
D)  Should be referred for additional evaluation.

Question 10

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?

Accepted Answer

A)  At birth, the head is one fifth the total length.
B)  Head circumference should be greater than chest circumference at birth.
C)  The head size reaches 90% of its final size when the child is 3 years old.
D)  When the anterior fontanel closes at 2 months, the head will be more proportioned to the body.

Question 11

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?

Accepted Answer

A)  Diets low in protein and high in carbohydrates may cause enhanced facial bones.
B)  Bones can become more noticeable if the person does not use a dermatologically approved moisturizer.
C)  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.
D)  Facial skin becomes more elastic with age. This increased elasticity causes the skin to be more taught, drawing attention to the facial bones.

Question 12

The nurse is assessing a 1-month-old infant at his well-baby checkup.Which assessment findings are appropriate for this age? Select all that apply.

Accepted Answer

A)  Head circumference equal to chest circumference
B)  Head circumference greater than chest circumference
C)  Head circumference less than chest circumference
D)  Fontanels firm and slightly concave
E)  Absent tonic neck reflexF) Nonpalpable cervical lymph nodes

Question 13

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:

Accepted Answer

A)  Behind with the nurse's hands placed firmly around his neck.
B)  The side with the nurse's eyes averted toward the ceiling and thumbs on his neck.
C)  The front with the nurse's thumbs placed on either side of his trachea and his head tilted forward.
D)  The front with the nurse's thumbs placed on either side of his trachea and his head tilted backward.

Question 14

A woman comes to the clinic and states,"I've been sick for so long! My eyes have gotten so puffy,and my eyebrows and hair have become coarse and dry." The nurse will assess for other signs and symptoms of:

Accepted Answer

A)  Cachexia.
B)  Parkinson syndrome.
C)  Myxedema.
D)  Scleroderma.

Question 15

When examining children affected with Down syndrome (trisomy 21),the nurse looks for the possible presence of:

Accepted Answer

A)  Ear dysplasia.
B)  Long, thin neck.
C)  Protruding thin tongue.
D)  Narrow and raised nasal bridge.

Question 16

During an admission assessment,the nurse notices that a male patient has an enlarged and rather thick skull.The nurse suspects acromegaly and would further assess for:

Accepted Answer

A)  Exophthalmos.
B)  Bowed long bones.
C)  Coarse facial features.
D)  Acorn-shaped cranium.

Question 17

The nurse notices that a patient's submental lymph nodes are enlarged.In an effort to identify the cause of the node enlargement,the nurse would assess the patient's:

Accepted Answer

A)  Infraclavicular area.
B)  Supraclavicular area.
C)  Area distal to the enlarged node.
D)  Area proximal to the enlarged node.

Question 18

A 19-year-old college student is brought to the emergency department with a severe headache he describes as,"Like nothing I've 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?

Accepted Answer

A)  Head injury
B)  Cluster headache
C)  Migraine headache
D)  Meningeal inflammation

Question 19

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 _____________.

Accepted Answer

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

Question 20

The nurse is aware that the four areas in the body where lymph nodes are accessible are the:

Accepted Answer

A)  Head, breasts, groin, and abdomen.
B)  Arms, breasts, inguinal area, and legs.
C)  Head and neck, arms, breasts, and axillae.
D)  Head and neck, arms, inguinal area, and axillae.

Exam 13: Head, Face, and Neck, Including Regional Lymphatics

A patient's 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.