Health Assessment Final Exam Spring 2022
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.
...
Health Assessment Final Exam Spring 2022
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 Answer- 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 Answer- 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 Answer- 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 Answer- 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 Answer- 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 Answer- 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 Answer- 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 Answer- 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 Answer- 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 Answer- 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.
c. Head and neck, arms, breasts, and axillae.
d. Head and neck, arms, inguinal area, and axillae. - Correct Answer- D
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?
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. - Correct Answer- B
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?
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. - Correct Answer- C
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:
a. Hypertension.
b. Cluster headaches.
c. Tension headaches.
d. Migraine headaches. - Correct Answer- B
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:
a. Hypertension.
b. Cluster headaches.
c. Tension headaches.
d. Migraine headaches. - Correct Answer- D
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?
a. Head injury
b. Cluster headache
c. Migraine headache
d. Meningeal inflammation - Correct Answer- D
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?
a. Craniotabes
b. Microcephaly
c. Hydrocephalus
d. Caput succedaneum - Correct Answer- C
The nurse needs to palpate the temporomandibular joint for crepitation. This joint is
located just below the temporal artery and anterior to the:
a. Hyoid bone.
b. Vagus nerve.
c. Tragus.
d. Mandible. - Correct Answer- C
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:
a. Thyroid gland.
b. Parotid gland.
c. Occipital lymph node.
d. Submental lymph node. - Correct Answer- B
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:
a. Thyroid gland.
b. Parotid gland.
c. Cervical lymph nodes.
d. Mouth and skin for lesions. - Correct Answer- B
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?
a. Tachycardia
b. Constipation
c. Rapid dyspnea
d. Atrophied nodular thyroid gland - Correct Answer- A
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:
a. Behind with the nurses hands placed firmly around his neck.
b. The side with the nurses eyes averted toward the ceiling and thumbs on his neck.
c. The front with the nurses thumbs placed on either side of his trachea and his head
tilted forward.
d. The front with the nurses thumbs placed on either side of his trachea and his head
tilted backward. - Correct Answer- C
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.
a. Low gurgling; diaphragm
b. Loud, whooshing, blowing; bell
c. Soft, whooshing, pulsatile; bell
d. High-pitched tinkling; diaphragm - Correct Answer- C
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:
a. Hydrocephalus.
b. Craniosynostosis.
c. Cephalhematoma.
d. Caput succedaneum - Correct Answer- C
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 that this reflex is:
a. Abnormal and is called the atonic neck reflex.
b. Normal and should disappear by the first year of life.
c. Normal and is called the tonic neck reflex, which should disappear between 3 and
4 months of age.
d. Abnormal. The baby should be flexing the arm and leg on the right side of his
body when the head is turned to the right. - Correct Answer- C
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:
a. Exophthalmos.
b. Bowed long bones.
c. Coarse facial features.
d. Acorn-shaped cranium. - Correct Answer- C
When examining children affected with Down syndrome (trisomy 21), the nurse looks
for the possible presence of:
a. Ear dysplasia.
b. Long, thin neck.
c. Protruding thin tongue.
d. Narrow and raised nasal bridge. - Correct Answer- A
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:
a. Cushing syndrome.
b. Parkinson disease.
c. Bell palsy.
d. Experienced a cerebrovascular accident (CVA) or stroke. - Correct Answer- D
A woman comes to the clinic and states, Ive 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:
a. Cachexia.
b. Parkinson syndrome.
c. Myxedema.
d. Scleroderma. - Correct Answer- C
During an examination of a female patient, the nurse notes lymphadenopathy and
suspects an acute infection. Acutely infected lymph nodes would be:
a. Clumped.
b. Unilateral.
c. Firm but freely movable.
d. Firm and nontender. - Correct Answer- C
The physician reports that a patient with a neck tumor has a tracheal shift. The nurse
is aware that this means that the patients trachea is:
a. Pulled to the affected side.
b. Pushed to the unaffected side.
c. Pulled downward.
d. Pulled downward in a rhythmic pattern. - Correct Answer- B
During an assessment of an infant, the nurse notes that the fontanels are depressed
and sunken. The nurse suspects which condition?
a. Rickets
b. Dehydration
c. Mental retardation
d. Increased intracranial pressure - Correct Answer- B
The nurse is performing an assessment on a 7-year-old child who has symptoms of
chronic watery eyes, sneezing, and clear nasal drainage. The nurse notices the
presence of a transverse line across the bridge of the nose, dark blue shadows
below the eyes, and a double crease on the lower eyelids. These findings are
characteristic of:
a. Allergies.
b. Sinus infection.
c. Nasal congestion.
d. Upper respiratory infection. - Correct Answer- A......
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