A physician tells the nurse that a patient's vertebra prominens is tender and asks the nurse to re- evaluate the area in 1 hour. The area of the body the nurse will assess is the area: at the level of the C7 vertebra.-The C7 vertebra has a long spinous process, called the vertebra prominens, that is palpable when the head is flexed.The nurse notices that a patient's palpebral fissures are not symmetrical. On examination, the
nurse may find that there has been damage to:
CN VII.
-Facial muscles are mediated by CN VII; asymmetry of palpebral fissures may be due to CN VII damage.A patient is unable to differentiate between sharp and dull stimulation to both sides of her face.
The nurse suspects:
damage to the trigeminal nerve.-Facial sensations of pain or touch are mediated by CN V, the trigeminal nerve.When examining the face, the nurse is aware that the two pairs of salivary glands that are accessible to examination are the _____ glands.parotid and submandibular -Two pairs of salivary glands accessible to examination on the face are the parotid glands in the cheeks over the mandible, anterior to and below the ear, and the submandibular glands, beneath the mandible at the angle of the jaw. The parotid glands are not normally palpable.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: XI; asking the patient to shrug her shoulders against resistance.-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.
The muscles in the neck that are innervated by CN XI are the:
sternomastoid and trapezius.-The major neck muscles are the sternomastoid and the trapezius. They are innervated by CN XI, the spinal accessory.A patient's laboratory data reveal an elevated thyroxine level. The nurse would proceed with an
examination of the:
thyroid gland.-The thyroid gland is a highly vascular endocrine gland that secretes thyroxine (T4) and tri- iodothyronine (T3).Health Assessment Final Exam Review Questions and Answers 2022 1 / 4
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, the finding that reassures the nurse
that this may not be a cancerous thyroid nodule is that the lump (nodule):
is mobile and not hard.-Suspect any painless, rapidly growing nodule, especially the appearance of a single nodule in a young person. Cancerous nodules tend to be hard and are fixed to surrounding structures.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:
area proximal to the enlarged node.-When nodes are abnormal, check the area they drain for the source of the problem. Explore the area proximal (upstream) to the location of the abnormal node.The nurse is aware that the four areas in the body where lymph nodes are accessible are the: head and neck, arms, inguinal area, and axillae.-Nodes are located throughout the body, but are accessible to examination only in four areas: head and neck, arms, axillae, and inguinal region.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 to her?It is probably due to a combination of factors such as decreased elasticity, subcutaneous fat, and moisture in her skin.-The facial bones and orbits appear more prominent in the aging adult, and the facial skin sags owing to decreased elasticity, decreased subcutaneous fat, and decreased moisture in the skin.A patient presents with excruciating headache pain on one side of his head, especially around his eye, forehead, and cheek that lasts about 1/2 to 2 hours, occurring once or twice each day. The
nurse suspects:
cluster headaches.-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 1/2 to 2 hours each.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:
migraine headaches.-Migraine headaches tend to be supraorbital, retro-orbital, or frontotemporal with a throbbing quality. They are of a severe quality and are relieved by lying down. Migraines are associated with family history of migraine. 2 / 4
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 104° F, and he has a stiff neck. What do these signs and symptoms suggest?Meningeal inflammation -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.The temporomandibular joint is just below the temporal artery and anterior to the: tragus.-The temporomandibular joint is just below the temporal artery and anterior to the tragus.A patient has come in for an examination and states, "I have this spot in front of my ear lobe here on my cheek that seems to be getting bigger and is real 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:
parotid gland.-Swelling with the parotid gland occurs 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.A male patient with a history of AIDS has come in for an examination and he states, "I think that
I have the mumps." The nurse would begin by examining the:
parotid gland.-The parotid gland may become swollen with the onset of mumps, and parotid enlargement has been found with HIV.The nurse suspects that a patient has hyperthyroidism and laboratory data indicate that the patient's thyroxine and tri-iodothyronine hormone levels are elevated. Which of the following findings would the nurse most likely find on examination?Tachycardia -Thyroxine and triiodothyronine are thyroid hormones that stimulate the rate of cellular metabolism, thus resulting in tachycardia. With an enlarged thyroid as in hyperthyroidism, you might expect to find diffuse enlargement (goiter) or a nodular lump.A visitor from Poland who does not speak English seems to be somewhat apprehensive about the nurse examining his neck. He would probably be most comfortable with the nurse examining his
thyroid:
from the front with the nurse's thumbs placed on either side of his trachea and his head tilted forward.-Examining this patient's thyroid from the back may be unsettling for him. It would be best to examine his thyroid using the anterior approach, asking him to tip his head forward and to the right and then the left. 3 / 4
A patient's thyroid is enlarged, and the nurse is preparing to auscultate the thyroid for the
presence of a bruit. A bruit is a:
soft, whooshing, pulsatile sound best heard with the bell of the stethoscope.-If the thyroid gland is enlarged, auscultate it for the presence of a bruit, which is a soft, pulsatile, whooshing, blowing sound heard best with the bell of the stethoscope.During an examination, the nurse knows that Paget's disease would be indicated by which of the following findings?Headache, vertigo, tinnitus, and deafness -Paget's disease occurs more often in males and is characterized by bowed, long bones, sudden fractures, and enlarging skull bones that press on cranial nerves causing symptoms of headache, vertigo, tinnitus, and progressive deafness.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:
coarse facial features.-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.When examining children affected with Down syndrome (trisomy 21), the nurse looks for the
possible presence of:
ear dysplasia.-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.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: had a cerebrovascular accident (stroke).-With an upper motor neuron lesion (as with CVA) the patient will have paralysis of lower facial muscles, but the upper half of the face is not affected owing to the intact nerve from the unaffected hemisphere. The person is still able to wrinkle the forehead and close the eyes.A woman comes to the clinic and states, "My eyes have gotten so puffy, and my eyebrows and
hair have become coarse and dry." The nurse suspects:
myxedema.-Myxedema (hypothyroidism) is a deficiency of thyroid hormone that, when severe, causes a nonpitting edema or myxedema. The patient will have a puffy edematous face especially around eyes (periorbital edema), coarse facial features, dry skin, and dry, coarse hair and eyebrows
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