Chapter 14 Head, Face, Neck, and Regional Lymphatics

         176 Chapter14:Head,Face,Neck,andRegionalLymphatics MULTIPLECHOICE 1.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. ANS:C TheC7vertebrahasalongspinousprocess,calledthevertebraprominens,whichispalpablewhentheheadis flexed. DIF:CognitiveLevel:Applying(Application) MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptation 2.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hasoft  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. ANS:D Membrane-coveredsoftspotsallowforgrowthofthebrainduringthefirstyearoflife.Theygraduallyossify; thetriangular-shapedposteriorfontanelisclosedby1to2months,andthediamond-shapedanteriorfontanel closesbetween9monthsand2years. DIF:CognitiveLevel:Applying(Application) MSC:ClientNeeds:HealthPromotionandMaintenance 3.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        177 ANS:C FacialmusclesaremediatedbyCNVII;asymmetryofpalpebralfissuresmaybeattributabletodamagetoCN VII(Bellpalsy). DIF:CognitiveLevel:Applying(Application) MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptation 4.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. ANS:B FacialsensationsofpainortoucharemediatedbyCNV,whichisthetrigeminalnerve.Bellpalsyisassociated withCNVIIdamage.Frostbiteandsclerodermaarenotassociatedwiththisproblem. DIF:CognitiveLevel:Applying(Application) MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptation 5.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 ANS:C Twopairsofsalivaryglandsaccessibletoexaminationonthefacearetheparotidglands,whichareinthe          178 cheeksoverthemandible,anteriortoandbelowtheear;andthesubmandibularglands,whicharebeneaththe mandibleattheangleofthejaw.Theparotidglandsarenormallynonpalpable. DIF:CognitiveLevel:Understanding(Comprehension) MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare 6.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 ANS:B Themajorneckmusclesarethesternomastoidandthetrapezius.TheyareinnervatedbyCNXI,thespinal accessory.Theinnervatedmusclesassistwithheadrotationandheadflexion,movementoftheshoulders,and extensionandturningofthehead. DIF:CognitiveLevel:Analyzing(Analysis) MSC:ClientNeeds:SafeandEffectiveCareanagement of Care     7.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. ANS:A Themajorneckmusclesarethesternomastoidandthetrapezius.TheyareinnervatedbyCNXI,thespinal accessory. DIF:CognitiveLevel:Remembering(Knowledge) MSC:ClientNeeds:General 8.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       179 ANS:A ThethyroidglandisahighlyvascularendocrineglandthatsecretesT4andtriiodothyronine(T3).Theother glandsdonotsecreteT4. DIF:CognitiveLevel:Understanding(Comprehension) MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare 9.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smil d. Ishardandfixedtothesurroundingstructures. ANS:B Painless,rapidlygrowingnodulesmaybecancerous,especiallytheappearanceofasinglenoduleinayoung person.However,cancerousnodulestendtobehardandfixedtosurroundingstructures,notmobile. DIF:CognitiveLevel:Applying(Application) MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptation 10.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. ANS:D          180 Whennodesareabnormal,thenurseshouldchecktheareaintowhichtheydrainforthesourceoftheproblem. Theareaproximal(upstream)tothelocationoftheabnormalnodeshouldbeexplored. DIF:CognitiveLevel:Analyzing(Analysis) MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare 11.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. ANS:D Nodesarelocatedthroughoutthebody,buttheyareaccessibletoexaminationonlyinfourareas:headand neck,arms,inguinalregion,andaxillae. DIF:CognitiveLevel:Remembering(Knowledge) MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare 12.Amotherbringshernewborninforanass, Is there something His   wrong  with my baby?     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. ANS:B Thenurserecognizesthatduringthefetalperiod,headgrowthpredominates.Headsizeisgreaterthanchest circumferenceatbirth,andtheheadsizegrowsduringchildhood,reaching90%ofitsfinalsizewhenthechild isage6years. DIF:CognitiveLevel:Understanding(Comprehension) MSC:ClientNeeds:HealthPromotionandMaintenance 13.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.          181 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. ANS:C Thefacialbonesandorbitsappearmoreprominentintheagingadult,andthefacialskinsags,whichis attributabletodecreasedelasticity,decreasedsubcutaneousfat,anddecreasedmoistureintheskin. DIF:CognitiveLevel:Understanding(Comprehension) MSC:ClientNeeds:HealthPromotionandMaintenance 14.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. ANS:B Clusterheadachesproducepainaroundtheeye,temple,forehead,andcheekandareunilateralandalwayson thesamesideofthehead.Theyareexcruciatingandoccuronceortwiceperdayandlastto2hourseach. DIF:CognitiveLevel:Applying(Application) MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptation 15.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.         182 Migraineheadaches. ANS:D Migraineheadachestendtobesupraorbital,retroorbital,orfrontotemporalwithathrobbingquality.Theyare severeinqualityandarerelievedbylyingdown.Migrainesareassociatedwithafamilyhistoryofmigraine headaches. DIF:CognitiveLevel:Applying(Application) MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptation 16.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 ANS:D Theacuteonsetofneckstiffnessandpainalongwithheadacheandfeveroccurswithmeningealinflammation. Asevereheadacheinanadultorchildwhohasneverhaditbeforeisaredflag.Headinjuryandclusteror migraineheadachesarenotassociatedwithafeverorstiffneck. DIF:CognitiveLevel:Analyzing(Analysis) MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptation 17.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 ANS:C Hydrocephalusoccurswiththeobstructionofdrainageofcerebrospinalfluidthatresultsinexcessive accumulation,increasingintracranialpressure,andanenlargementofthehead.Thefacelookssmall, comparedwiththeenlargedcranium,anddilatedscalpveinsanddowncastorsettingsuneyesarenoted.          183 Craniotabesisasofteningoftheskullsouterlayer.Microcephalyisanabnormallysmallhead.Acaput succedaneumisedematousswellingandecchymosisofthepresentingpartoftheheadcausedbybirthtrauma. DIF:CognitiveLevel:Applying(Application) MSC:ClientNeeds:HealthPromotionandMaintenance 18.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. ANS:C Thetemporomandibularjointisjustbelowthetemporalarteryandanteriortothetragus. DIF:CognitiveLevel:Understanding(Comprehension) MSC:ClientNeeds:General 19.Apatienthascomeinforanexamination e 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. ANS:B Swellingoftheparotidglandisevidentbelowtheangleofthejawandismostvisiblewhentheheadis extended.Painfulinflammationoccurswithmumps,andswellingalsooccurswithabscessesortumors. Swellingoccursanteriortothelowerearlobe. DIF:CognitiveLevel:Applying(Application) MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptation 20.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.     184 ANS:B Theparotidglandmaybecomeswollenwiththeonsetofmumps,andparotidenlargementhasbeenfoundwith humanimmunodeficiencyvirus(HIV). DIF:CognitiveLevel:Applying(Application) MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptation 21.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 ANS:A T4andT3arethyroidhormonesthatstimulatetherateofcellularmetabolism,resultingintachycardia.Withan enlargedthyroidglandasinhyperthyroidism,thenursemightexpecttofinddiffuseenlargement(goiter)ora nodularlumpbutnotanatrophiedgland.Dyspneaandconstipationarenotfindingsassociatedwith hyperthyroidism. DIF:CognitiveLevel:Analyzing(Analysis) MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptation 22.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.          185 ANS:C Examiningthispatientsthyroidglandfromthebackmaybeunsettlingforhim.Itwouldbebesttoexaminehis thyroidglandusingtheanteriorapproach,askinghimtotiphisheadforwardandtotherightandthentothe left. DIF:CognitiveLevel:Applying(Application) MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare 23.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 ANS:C Ifthethyroidglandisenlarged,thenthenurseshouldauscultateitforthepresenceofabruit,whichisasoft, pulsatile,whooshing,blowingsoundheardbestwiththebellofthestethoscope. DIF:CognitiveLevel:Understanding(Comp MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare 24.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. ANS:C Acephalhematomaisasubperiostealhemorrhagethatistheresultofbirthtrauma.Itissoft,fluctuant,andwell definedoveronecranialbone.Itappearsseveralhoursafterbirthandgraduallyincreasesinsize. DIF:CognitiveLevel:Analyzing(Analysis) MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptation 25.Amotherbringsinhernewborninfantforanassessmentandtellsthenursethatshehasnoticedthat          186 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. ANS:C By2weeks,theinfantshowsthetonicneckreflexwhensupineandtheheadisturnedtooneside(extensionof samearmandleg,flexionofoppositearmandleg).Thetonicneckreflexdisappearsbetween3and4months ofage. DIF:CognitiveLevel:Analyzing(Analysis) MSC:ClientNeeds:HealthPromotionandMaintenance 26.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. ANS:C Acromegalyisexcessivesecretionofgrowthhormonethatcreatesanenlargedskullandthickenedcranial bones.Patientswillhaveelongatedheads,massivefaces,prominentnosesandlowerjaws,heavyeyebrow ridges,andcoarsefacialfeatures.Exophthalmosisassociatedwithhyperthyroidism.Bowedlongbonesandan acorn-shapedcraniumresultfromPagetdisease. DIF:CognitiveLevel:Analyzing(Analysis) MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptation 27.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.     187 ANS:A Withthechromosomalaberrationtrisomy21,alsoknownasDownsyndrome,headandfacecharacteristics mayincludeupslantingeyeswithinnerepicanthalfolds,aflatnasalbridge,asmallbroadflatnose,a protrudingthicktongue,eardysplasia,ashortbroadneckwithwebbing,andsmallhandswithasinglepalmar crease. DIF:CognitiveLevel:Understanding(Comprehension) MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptation 28.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ac stroke.    ANS:D Withanuppermotorneuronlesion,aswithaCVA,thepatientwillhaveparalysisoflowerfacialmuscles,but theupperhalfofthefacewillnotbeaffectedowingtotheintactnervefromtheunaffectedhemisphere.The personisstillabletowrinkletheforeheadandclosetheeyes. DIF:CognitiveLevel:Applying(Application) MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptation 29.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. ANS:C Myxedema(hypothyroidism)isadeficiencyofthyroidhormonethat,whensevere,causesanonpittingedema          188 ormyxedema.Thepatientwillhaveapuffyedematousface,especiallyaroundtheeyes(periorbitaledema); coarsefacialfeatures;dryskin;anddry,coarsehairandeyebrows. DIF:CognitiveLevel:Applying(Application) MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptation 30.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. ANS:C Acutelyinfectedlymphnodesarebilateral,enlarged,warm,tender,andfirmbutfreelymovable.Unilaterally enlargednodesthatarefirmandnontendermayindicatecancer. DIF:CognitiveLevel:Understanding(Comprehension) MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptation 31.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. ANS:B Thetracheaispushedtotheunaffectedsidewithanaorticaneurysm,atumor,unilateralthyroidlobe enlargement,orapneumothorax.Thetracheaispulledtotheaffectedsidewithlargeatelectasis,pleural adhesions,orfibrosis.Trachealtugisarhythmicdownwardpullthatissynchronouswithsystoleandoccurs withaorticarchaneurysm. DIF:CognitiveLevel:Understanding(Comprehension) MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptation 32.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     189 ANS:B Depressedandsunkenfontanelsoccurwithdehydrationormalnutrition.Mentalretardationandricketshaveno effectonthefontanels.Increasedintracranialpressurewouldcausetenseorbulgingandpossiblypulsating fontanels. DIF:CognitiveLevel:Applying(Application) MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptation 33.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. ANS:A Chronicallergiesoftendevelopchronicfacialcharacteristicsandincludeblueshadowsbelowtheeyes,a doubleorsinglecreaseonthelowereyelids,open-mouthbreathing,andatransverselineonthenose. DIF:CognitiveLevel:Analyzing(Analysis) MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptation 34.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: a. Haschronicallergies. b. Mayhaveaninfection. c. Isexhibitinganormalfindingforawellchildofthisage.  d.         190 Shouldbereferredforadditionalevaluation. ANS:C Palpablelymphnodesarenormalinchildrenuntilpubertywhenthelymphoidtissuebeginstoatrophy.Lymph nodesmaybeupto1cminsizeinthecervicalandinguinalareasbutarediscrete,movable,andnontender. DIF:CognitiveLevel:Analyzing(Analysis) MSC:ClientNeeds:HealthPromotionandMaintenance 35.Thenursehasjustcompletedalymphnodeassessmentona60-year-oldhealthyfemalepatient.Thenurse knowsthatmostlymphnodesinhealthyadultsarenormally: a. Shotty. b. Nonpalpable. c. Large,firm,andfixedtothetissue. d. Rubbery,discrete,andmobile. ANS:B Mostlymphnodesarenonpalpableinadults.Thepalpabilityoflymphnodesdecreaseswithage.Normal nodesfeelmovable,discrete,soft,andnonte DIF:CognitiveLevel:Applying(Application) MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptation 36.Duringanexaminationofapatientinherthirdtrimesterofpregnancy,thenursenoticesthatthepatients thyroidglandisslightlyenlarged.Noenlargementhadbeenpreviouslynoticed.Thenursesuspectsthatthe patient: a. Hasaniodinedeficiency. b. Isexhibitingearlysignsofgoiter. c. Isexhibitinganormalenlargementofthethyroidglandduringpregnancy. d. Needsfurthertestingforpossiblethyroidcancer. ANS:C Thethyroidglandenlargesslightlyduringpregnancybecauseofhyperplasiaofthetissueandincreased vascularity. DIF:CognitiveLevel:Applying(Application) MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare          191 37.Duringanexamination,thenurseknowsthatthebestwaytopalpatethelymphnodesintheneckis describedbywhichstatement? 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ones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. ANS:A Usinggentlepressureisrecommendedbecausestrongpressurecanpushthenodesintotheneckmuscles. Palpatingwithbothhandstocomparethetwosidessymmetricallyisusuallymostefficient. DIF:CognitiveLevel:Understanding(Comprehension) MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare 38.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? a. Headcontrolisusuallyachievedby4monthsofage. b. Youshouldnt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. ANS:A Headcontrolisachievedby4monthswhenthebabycanholdtheheaderectandsteadywhenpulledtoa verticalposition.Theotherresponsesarenotappropriate. DIF:CognitiveLevel:Analyzing(Analysis) MSC:ClientNeeds:HealthPromotionandMaintenance 39.Duringanexaminationofa3-year-oldchild,thenursenoticesabruitoverthelefttemporalarea.Thenurse should: a. Continuetheexaminationbecauseabruitisanormalfindingforthisage. b. Checkforthebruitagainin1hour. c. Notifytheparentsthatabruithasbeendetectedintheirchild.  d.         192 Stoptheexamination,andnotifythephysician. ANS:A Bruitsarecommonintheskullinchildrenunder4or5yearsofageandinchildrenwithanemia.Theyare systolicorcontinuousandareheardoverthetemporalarea. DIF:CognitiveLevel:Analyzing(Analysis) MSC:ClientNeeds:HealthPromotionandMaintenance 40.Duringanexamination,thenursefindsthatapatientslefttemporalarteryistortuousandfeelshardened andtender,comparedwiththerighttemporalartery.Thenursesuspectswhichcondition? a. Crepitation b. Mastoiditis c. Temporalarteritis d. Bellpalsy ANS:C Withtemporalarteritis,thearteryappearsmoretortuousandfeelshardenedandtender.Theseassessment findingsarenotconsistentwiththeotherresp DIF:CognitiveLevel:Applying(Application) MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptation MULTIPLERESPONSE 1.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. 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reflex f. Nonpalpablecervicallymphnodes ANS:B,D,F          193 Aninfantsheadcircumferenceislargerthanthechestcircumference.Atage2years,bothmeasurementsare thesame.Duringchildhood,thechestcircumferencegrowstoexceedtheheadcircumferenceby5to7cm. Thefontanelsshouldfeelfirmandslightlyconcaveintheinfant,andtheyshouldclosebyage9months.The tonicneckreflexispresentuntilbetween3and4monthsofage,andcervicallymphnodesarenormally nonpalpableinaninfant. DIF:CognitiveLevel:Applying(Application) MSC:ClientNeeds:HealthPromotionandMaintenance