Two pairs of salivary glands accessible to examination on the face are the parotid glands, which are in the cheeks over the mandible,

Practice NR 302 Question Bank - Chamberlain College of Nursing

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• 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 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) REF: p. 253 MSC: Client Needs: Safe and Effective Care Environment: Management of Care

• 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; palpating the anterior and posterior triangles

b . XI; asking the patient to shrug her shoulders against resistance 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) REF: p. 260 MSC: Client Needs: Safe and Effective Care Environment: Management of Care

• When examining a patient‘s CN function, the nurse remembers that the muscles in the neck that are innervated by CN XI are the:
• Sternomastoid and trapezius.

b . Spinal accessory and omohyoid.

• 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) REF: p. 253 MSC: Client Needs: General

• A patient‘s laboratory data reveal an elevated thyroxine (T4) level. The nurse would proceed with an examination of the

gland.

• Thyroid

b . Parotid

• Adrenal

d . Parathyroid

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) REF: p. 253 MSC: Client Needs: Safe and Effective Care Environment: Management of Care

• 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 leads the nurse to suspect that this may not be a cancerous thyroid nodule is that the

lump (nodule): 2 / 4

• Is tender.

b . Is mobile and not hard.

• Disappears when the patient smiles.

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) REF: p. 262 MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation

• 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:

• Infraclavicular area.

b . Supraclavicular area.

• Area distal to the enlarged node.

d . Area proximal to the enlarged node.

ANS: D

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) REF: p. 255 MSC: Client Needs: Safe and Effective Care Environment: Management of Care

• The nurse is aware that the four areas in the body where lymph nodes are accessible are the:
• Head, breasts, groin, and abdomen.

b . Arms, breasts, inguinal area, and legs.

• 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) REF: p. 255 MSC: Client Needs: Safe and Effective Care Environment: Management of Care

• 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?

• At birth, the head is one fifth the total length.

b Head circumference should be greater than chest . circumference at birth.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) REF: p. 264 3 / 4

MSC: Client Needs: Health Promotion and Maintenance

• 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?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.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.

Facial skin becomes more elastic with age. This increased d 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) REF: p. 255 MSC: Client Needs: Health Promotion and Maintenance

• 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:

• Hypertension.

b . Cluster headaches.

• 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) REF: p. 256 MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation

• 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:

• Hypertension.

b . Cluster headaches.

• Tension headaches.

d . 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) REF: p. 256 MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation

• 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?

• Head injury
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