Chapter 13: Head, Face, and Neck, Including Regional Lymphatics My Nursing Test Banks

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

Jarvis: Physical Examination & Health Assessment, 7th Edition

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) REF: p. 251

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 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.

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) REF: p. 255

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

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) REF: p. 259

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) REF: pp. 252-253

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 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

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) REF: p. 260

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

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

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

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 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

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

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

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) REF: p. 255

MSC: Client Needs: Safe and Effective Care Environment: Management of Care

12. 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.

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

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.

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) REF: p. 255

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) REF: p. 256

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.

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

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) REF: p. 258

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. 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) REF: p. 272

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) REF: p. 259

MSC: Client Needs: General

19. 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.

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) REF: p. 253

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.

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) REF: p. 276

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) REF: p. 277

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.

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) REF: p. 263

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 (Comprehension) REF: p. 264

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) REF: p. 265

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 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) REF: p. 266

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) REF: p. 278

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.

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) REF: p. 272

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 accident (CVA) or 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. (See Table 13-4, Abnormal Facial Appearances with Chronic Illnesses, for descriptions of the other responses.)

DIF: Cognitive Level: Applying (Application) REF: p. 278

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 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. (See Table 13-4, Abnormal Facial Appearances with Chronic Illnesses, for descriptions of the other responses.)

DIF: Cognitive Level: Applying (Application) REF: p. 277

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) REF: p. 262

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) REF: p. 263

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

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) REF: p. 266

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) REF: p. 273

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.

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) REF: p. 267

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 nontender.

DIF: Cognitive Level: Applying (Application) REF: p. 262

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) REF: p. 255

MSC: Client Needs: Safe and Effective Care Environment: Management of Care

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) REF: p. 260

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) REF: p. 266

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.

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) REF: p. 267

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 responses.

DIF: Cognitive Level: Applying (Application) REF: p. 259

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

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) REF: p. 264 |p. 266 |p. 267

MSC: Client Needs: Health Promotion and Maintenance

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