Health Assessment Exam 2

A configuraation of individual lesions arranged in circles or arcs, as occurs with ringworm, is described as a: A) Linear lesion B) Clustered lesion C) Annular lesion D) Gyrate lesion

C. Annular, or circular, lesion - begins in center and spreads to periphery. Linear lesion - a scratch, streak, line or stripe. Clustered lesion - grouped. Gyrate lesion - twisted, coiled spiral, snakelike

A common cause of a conductive hearing loss is: a) impacted cerumen b) acute rheumatic fever c) a CVA d) otitis externa

a

A positive Babinski sign is: a) dorsiflexion of the big toe and fanning of all toes b) plantar flexion of the big toe with a fanning of all toes c) the expected response in healthy adults d) withdrawal of the stimulated extremity from the stimulus

a

Bell's palsy is characterized by: a) unilateral paralysis of half of the face b) bulging eyeballs c) a face that appears masklike d) a puffy, edematous face

a

Cephalhematoma is associated with: a) subperiosteal hemorrhage b) increased intracranial pressure c) Down syndrome d) mental retardation

a

Upon examination of the tympanic membrane, visualization of which of the following findings indicates the infection of acute purulent otitis media? a) absent light reflex, bluish drum, oval dark areas b) absent light reflex, reddened drum, bulging drum c) oval dark areas on drum d) absent light reflex, air-fluid level, or bubbles behind drum e) retracted drum, very prominent landmarks

b

When the ear is being examined with an otoscope, the patient's head should be: a) tilted toward the examiner b) tilted away from the examiner c) as vertical as possible d) tilted down

b

1. During the assessment of deep tendon reflexes, the nurse finds that a patient's responses are bilaterally normal. What number is used to indicate normal deep tendon reflexes when the documenting this finding? ____+

ANS: 2 Responses to assessment of deep tendon reflexes are graded on a 4-point scale. A rating of 2+ indicates normal or average response. A rating of 0 indicates no response, and a rating of 4+ indicates very brisk, hyperactive response with clonus, which is indicative of disease.

The nurse is palpating the sinus areas. If the findings are normal, the patient would report which sensation? 1. No sensation 2. Firm pressure 3. Pain during palpation 4. Pain sensation behind eyes

ANS: 2 The person should feel firm pressure but no pain.

A patient comes in for a physical, and she complains of "freezing to death" while waiting for her examination. The nurse notes that her skin is pale and cool and attributes this finding to: 1.venous pooling. 2.peripheral vasodilation. 3.peripheral vasoconstriction. 4.decreased arterial perfusion.

ANS: 3 A chilly or air-conditioned environment causes vasoconstriction, which results in false pallor and coolness. See Table 12-1.

A 32-year-old female patient complains that she has noticed several small, slightly raised, bright red dots on her chest. On examination, the nurse expects that the spots are probably: 1.anascara. 2.scleroderma. 3.senile angiomas. 4.latent myeloma.

ANS: 3 Cherry (senile) angiomas are small, punctate, slightly raised bright red dots that commonly appear on the trunk in all adults over 30 years old.

The nurse is discussing epidermal appendages with a patient. Which of the following would be included in the discussion? 1.Skin 2.Arms 3.Sweat glands 4.Parotid glands

ANS: 3 Epidermal appendages include hair, sebaceous glands, sweat glands, and nails.

A patient comes to the clinic and tells the nurse that he has been confined to his recliner chair for about 3 days with his feet down and he wants the nurse to evaluate his feet. During the assessment, the nurse might expect to find: 1.pallor. 2.coolness. 3.distended veins. 4.decreased capillary filling time.

ANS: 3 Keeping the feet in a dependent position causes venous pooling, resulting in redness, warmth and distended veins. See Table 12-1.

The projections in the nasal cavity that increase the surface area are called the: 1. meatus. 2. septum. 3. turbinates. 4. Kiesselbach's plexus.

ANS: 3 The lateral walls of each nasal cavity contain three parallel bony projections: the superior, middle, and inferior turbinates. They increase the surface area so that more blood vessels and mucous membrane are available to warm, humidify, and filter the inhaled air.

18. In obtaining a health history on a 74-year-old patient, the nurse notes that he drinks alcohol daily and that he has noticed a tremor in his hands that affects his ability to hold things. With this information, what response should the nurse make? a. "Does your family know you are drinking every day?" b. "Does the tremor change when you drink alcohol?" c. "We'll do some tests to see what is causing the tremor." d. "You really shouldn't drink so much alcohol; it may be causing your tremor."

ANS: B Senile tremor is relieved by alcohol, although not a recommended treatment. The nurse should assess whether the person is abusing alcohol in an effort to relieve the tremor.

Pallor

Absence of red-pink tones from the oxygenated hemoglobin in blood

Jaundice

Increase in bilirubin in the blood causing a yellow color in the skin

Cafe au lait

Large round of oval patch of light brown usually present at birth

A benign, milky, bluish white, opaque area, more common in blacks and east indians

Leukoplakia

Matching: Skin Layers A. Epidermis B. Dermis C. Subcutaneous Descriptor: 1. ___ Basal cell layer 2. ___ Aids protection by cushioning 3. ___ Collagen 4. ___ Adipose tissue 5. ___ Uniformly thin 6. ___ Stratum corneum 7. ___ Elastic tissue

Matching: Skin Layers 1. A 2. C 3. B 4. C 5. A 6. A 7. B

Smooth, pale gray, avascular, mobile, nontender

Polyps

Nasal flaring in the infant indicates___________.

Respiratory distress

Swelling or nasal mucousa

Rhinitis

Adipose Tissue

Subcutaneous layer

Acrocyanosis

Bluish color around the lips, hands, fingernails, feet, and toenails

A bony or membranous septum between the nasal cavity and the pharynx of the newborn.

Choanal Atresia

Olfactory

Cranial Nerve I: smell

Basal Cell Layer

Epidermis

Nontender, fibrous nodule of the gum, seen emerging between the teeth.

Epulis

Nevus is the medical term for: a) a freckle b) a birthmark c) an infected hair follicle d) a mole

d

How are tonsils graded?

1+ visible 2+ halfway between tonsillar pillars and uvula 3+ touching the uvula 4+ touching each other

Deep cervical

deep under the sternomastoid muscle

When assessing the tongue, the examiner should: A) palpate the U-shaped area under the tongue B) check tongue color for cyanosis C) use a tongue blade to elevate the tongue while placing your finger under the jaw D) ask the person to say "ahhh" and note a rise in the midline

A) palpate the U-shaped area under the tongue

During a routine visit, M.B., age 78, asks about small, round, flat, brown macules on the hands. What is your best response after assessing the data? A) "These are the result of sun exposure and do not require treatment." B) "There are related to exposure to the sun. They may become cancerous." C) "These are the skin tags that occur with aging. No treatment is required." D) "I'm glad you brought this to my attention. I will arrange for a biopsy."

A. Senile lentigines ("liver spots") are common variations of hyperpigmentation. These are small, flat, brown macules. These circumscribed areas are clusters of melanocytes that appear after extensive sun exposure. They appear on the forearms and dorsal of the hands. They are NOT malignant and require NO treatment.

The nurse is assessing a patient with a history of intravenous drug abuse. In assessing his mouth, the nurse notices a dark red confluent macule on the hard palate. This could be an early sign of: 1. AIDS. 2. measles. 3. leukemia. 4. carcinoma.

ANS: 1 Oral Kaposi's sarcoma is a bruise-like, dark red or violet, confluent macule that usually occurs on the hard palate. It may appear on the soft palate or gingival margin. Oral lesions may be among the earliest lesions to develop with acquired immunodeficiency syndrome.

A 31-year-old patient tells the nurse that he has noticed a progressive loss in his hearing. He says that it does seem to help when people speak louder or if he turns up the volume. The most likely cause of his hearing loss is: 1. otosclerosis. 2. presbycusis. 3. trauma to the bones. 4. frequent ear infections.

ANS: 1 Otosclerosis is a common cause of conductive hearing loss in young adults between the ages of 20 and 40 years.

During an examination, the nurse finds that a patient has excess dryness of the skin. The best term to describe this condition is: 1.xerosis. 2.pruritus. 3.scoliosis. 4.seborritus.

ANS: 1 Xerosis is the term used to describe skin that is excessively dry.

A mother brings in her newborn infant for an assessment and tells the nurse that she has noticed that whenever her newborn's 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 finding this on examination, the nurse would tell her that this is: 1. abnormal and is called the atonic neck reflex. 2. normal and should disappear by the first year of life. 3. normal and should disappear between 3 and 4 months of age. 4. 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: 3 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.

A patient has been admitted for severe iron deficiency anemia. The nurse can expect to see what finding in the patient's fingernails? 1.Splinter hemorrhages 2.Paronchyia 3.Koilonychia (spoon nails) 4.Beau's lines

ANS: 3 Koilonychia, or spoon nails, are thin, depressed nails with lateral edges tilted up, forming a concave profile. If all nails involved, they may be due to iron deficiency anemia.

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: 1. cachexia. 2. cretinism. 3. myxedema. 4. scleroderma.

ANS: 3 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

A 70-year-old patient tells the nurse that he has noticed that he is having trouble hearing, especially in large groups. He says he "can't always tell where the sound is coming from" and the words often sound "mixed up." What might the nurse suspect as the cause for this change? 1. Atrophy of the apocrine glands 2. Cilia becoming coarse and stiff 3. Nerve degeneration in the inner ear 4. Scarring of the tympanic membrane

ANS: 3 Presbycusis is a type of hearing loss that occurs with aging, even in people living in a quiet environment. It is a gradual sensorineural loss caused by nerve degeneration in the inner ear or auditory nerve. This makes words sound garbled. The ability to localize sound is impaired also. This communication dysfunction is accentuated when background noise is present.

When examining the nares of a 45-year-old patient who has complaints of rhinorrhea, itching of the nose and eyes, and sneezing, the nurse notes the following: pale turbinates, swelling of the turbinates, and clear rhinorrhea. Which of the following is most likely the cause? 1. Nasal polyps 2. Acute sinusitis 3. Allergic rhinitis 4. Nasal carcinoma

ANS: 3 With allergic rhinitis, rhinorrhea, itching of the nose and eyes, and sneezing are present. On physical examination, there is serous edema, and the turbinates usually appear pale with a smooth, glistening surface.

A 10-year-old is at the clinic for "a sore throat lasting 6 days." The nurse is aware that which of the following would be consistent with an acute infection? 1. Tonsils 1+/1-4+ and pink 2. Tonsils 2+/1-4+ with small plugs of white debris 3. Tonsils 3+/1-4+ with large white spots 4. Tonsils 3+/1-4+ with yellowish exudate

ANS: 3 With an acute infection, tonsils are bright red and swollen and may have exudate or large white spots. Tonsils are enlarged to 2+, 3+, or 4+ with an acute infection.

The nurse is obtaining a history on a 3-month-old infant. During the interview, the mom states, "I think she is getting her first tooth because she has started drooling a lot." The nurse's best response would be 1. "You're right, drooling is usually a sign of the first tooth." 2. "It would be unusual for a 3-month-old to be getting her first tooth." 3. "This could be the sign of a problem with the salivary glands." 4. "She is just starting to salivate and hasn't learned to swallow the saliva."

ANS: 4 In the infant, salivation starts at 3 months. The baby will drool periodically for a few months before learning to swallow the saliva. This drooling does not herald the eruption of the first tooth, although many parents think it does.

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 there something terribly wrong?" The nurse's response would be: 1."Perhaps that could be a result of your dietary intake during pregnancy." 2."Your baby may have craniosynostosis, a disease of the sutures of the brain." 3."That 'soft spot' you are referring to may be an indication of cretinism or congeni- tal hypothyroidism." 4."That 'soft spot' is normal, and actually allows for growth of the brain during the first year of your baby's life."

ANS: 4 Membrane-covered "soft spots" allow for growth of the brain during the first year. 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.

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: 1. hypertension. 2. cluster headaches. 3. tension headaches. 4. migraine headaches.

ANS: 4 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.

During a check-up, a 22-year-old woman tells the nurse that she uses an over-the-counter nasal spray because of her allergies. She also notes that it does not work as well as it used to when she started using it. The best response by the nurse would be: 1. "You should never use over-the-counter nasal sprays because of the risk of addiction." 2. "You should try switching to another brand of medication to prevent this problem." 3. "It is important to keep using this spray to keep your allergies under control." 4. "Using these nasal medications irritates the lining of the nose and may cause rebound swelling."

ANS: 4 Misuse of over-the-counter nasal medications irritates the mucosa, causing rebound swelling, a common problem.

The mother of a 2-year-old is concerned about the upcoming placement of tympanostomy tubes in her son's ears. The nurse would include which of the following in the teaching plan? 1. The tubes are placed in the inner ear. 2. The tubes are used in children with sensorineural loss. 3. The tubes are permanently inserted during a surgical procedure. 4. The purpose of the tubes is to decrease the pressure and allow for drainage.

ANS: 4 Polyethylene tubes are inserted surgically into the eardrum to relieve middle ear pressure and promote drainage of chronic or recurrent middle ear infections. Tubes extrude spontaneously in 6 months to 1 year.

A father brings in his 2-month-old infant to the clinic because the infant has had diarrhea for the last 24 hours. He says that his baby has not been able to keep any formula down and that the diarrhea has been at least every 2 hours. The nurse suspects dehydration. Where should the nurse test skin mobility and turgor in this infant? 1.Over the sternum 2.Over the forehead 3.Over the forearms 4.Over the abdomen

ANS: 4 Test mobility and turgor over the abdomen in an infant. Poor turgor, or "tenting," indicates dehydration or malnutrition.

The nurse is assessing a patient's eyes for the accommodation response and would expect to see: 1. dilation of the pupils. 2. a consensual light reflex. 3. conjugate movement of the eyes. 4. convergence of the axes of the eyes.

ANS: 4 The accommodation reaction includes pupillary constriction and convergence of the axes of the eyes.

The nurse educator is preparing an education module for the nursing staff on the dermis layer of skin. Which of the following would be included in the module? 1.The dermis contains mostly fat cells. 2.The dermis consists mostly of keratin. 3.The dermis is replaced every 4 weeks. 4.The dermis contains sensory receptors

ANS: 4 The dermis consists mostly of collagen, has resilient elastic tissue that allows the skin to stretch, contains nerves, sensory receptors, blood vessels, and lymphatics.

The nurse educator is preparing an education module for the nursing staff on the epidermal layer of skin. Which of the following would be included in the module? 1.The epidermis is very vascular. 2.The epidermis is thick and tough. 3.The epidermis is thin and non-stratified. 4.The epidermis is replaced every 4 weeks.

ANS: 4 The epidermis is thin, replaced every 4 weeks, avascular, and stratified into several zones.

Which of the following statements concerning the eustachian tube is true? 1. It is responsible for the production of cerumen. 2. It remains open except when swallowing or yawning. 3. It allows passage of air between the middle and outer ear. 4. It helps equalize air pressure on both sides of the tympanic membrane.

ANS: 4 The eustachian tube allows equalization of air pressure on each side of the tympanic membrane so that the membrane does not rupture (e.g., during altitude changes in an airplane). The tube is normally closed, but it opens with swallowing or yawning.

The tissue that connects the tongue to the floor of the mouth is the: 1. uvula. 2. palate. 3. papillae. 4. frenulum.

ANS: 4 The frenulum is a midline fold of tissue that connects the tongue to the floor of the mouth.

A 72-year-old patient has a history of hypertension and chronic lung disease. An important question for the nurse to include in the history would be: 1. "Do you use a fluoride supplement?" 2. "Have you had tonsillitis in the last year?" 3. "At what age did you get your first tooth?" 4. "Have you noticed any dryness in your mouth?"

ANS: 4 Xerostomia (dry mouth) is a side effect of many drugs used by older people: antidepressants, anticholinergics, antispasmodics, antihypertensives, antipsychotics, bronchodilators.

52. The nurse is reviewing a patient's medical record and notes that he is in a coma. Using the Glasgow Coma Scale, which number indicates that the patient is in a coma? a. 6 b. 12 c. 15 d. 24

ANS: A A fully alert, normal person has a score of 15, whereas a score of 7 or less reflects coma on the Glasgow Coma Scale (see Figure 23-59).

37. To test for gross motor skill and coordination of a 6-year-old child, which of these techniques would be appropriate? Ask the child to: a. Hop on one foot. b. Stand on his head. c. Touch his finger to his nose. d. Make "funny" faces at the nurse.

ANS: A Normally, a child can hop on one foot and can balance on one foot for approximately 5 seconds by 4 years of age and can balance on one foot for 8 to 10 seconds at 5 years of age. Children enjoy performing these tests. Failure to hop after 5 years of age indicates incoordination of gross motor skills. Asking the child to touch his or her finger to the nose checks fine motor coordination; and asking the child to make "funny" faces tests CN VII. Asking a child to stand on his or her head is not appropriate.

17. While obtaining a health history of a 3-month-old infant from the mother, the nurse asks about the infant's ability to suck and grasp the mother's finger. What is the nurse assessing? a. Reflexes b. Intelligence c. CNs d. Cerebral cortex function

ANS: A Questions regarding reflexes include such questions as, "What have you noticed about the infant's behavior," "Are the infant's sucking and swallowing seem coordinated," and "Does the infant grasp your finger?" The other responses are incorrect.

7. The ability that humans have to perform very skilled movements such as writing is controlled by the: a. Basal ganglia. b. Corticospinal tract. c. Spinothalamic tract. d. Extrapyramidal tract.

ANS: B Corticospinal fibers mediate voluntary movement, particularly very skilled, discrete, and purposeful movements, such as writing. The corticospinal tract, also known as the pyramidal tract, is a newer, "higher" motor system that humans have that permits very skilled and purposeful movements. The other responses are not related to skilled movements.

51. The nurse knows that testing kinesthesia is a test of a person's: a. Fine touch. b. Position sense. c. Motor coordination. d. Perception of vibration.

ANS: B Kinesthesia, or position sense, is the person's ability to perceive passive movements of the extremities. The other options are incorrect.

6. A patient with a lack of oxygen to his heart will have pain in his chest and possibly in the shoulder, arms, or jaw. The nurse knows that the best explanation why this occurs is which one of these statements? a. A problem exists with the sensory cortex and its ability to discriminate the location. b. The lack of oxygen in his heart has resulted in decreased amount of oxygen to the areas experiencing the pain. c. The sensory cortex does not have the ability to localize pain in the heart; consequently, the pain is felt elsewhere. d. A lesion has developed in the dorsal root, which is preventing the sensation from being transmitted normally.

ANS: C The sensory cortex is arranged in a specific pattern, forming a corresponding map of the body. Pain in the right hand is perceived at a specific spot on the map. Some organs, such as the heart, liver, and spleen, are absent from the brain map. Pain originating in these organs is referred because no felt image exists in which to have pain. Pain is felt by proxy, that is, by another body part that does h

4. The area of the nervous system that is responsible for mediating reflexes is the: a. Medulla. b. Cerebellum. c. Spinal cord. d. Cerebral cortex.

ANS: C The spinal cord is the main highway for ascending and descending fiber tracts that connect the brain to the spinal nerves; it is responsible for mediating reflexes.

5. While gathering equipment after an injection, a nurse accidentally received a prick from an improperly capped needle. To interpret this sensation, which of these areas must be intact? a. Corticospinal tract, medulla, and basal ganglia b. Pyramidal tract, hypothalamus, and sensory cortex c. Lateral spinothalamic tract, thalamus, and sensory cortex d. Anterior spinothalamic tract, basal ganglia, and sensory cortex

ANS: C The spinothalamic tract contains sensory fibers that transmit the sensations of pain, temperature, and crude or light touch. Fibers carrying pain and temperature sensations ascend the lateral spinothalamic tract, whereas the sensations of crude touch form the anterior spinothalamic tract. At the thalamus, the fibers synapse with another sensory neuron, which carries the message to the sensory cortex for full interpretation. The other options are not correct.

39. While the nurse is taking the history of a 68-year-old patient who sustained a head injury 3 days earlier, he tells the nurse that he is on a cruise ship and is 30 years old. The nurse knows that this finding is indicative of a(n): a. Great sense of humor. b. Uncooperative behavior. c. Inability to understand questions. d. Decreased level of consciousness.

ANS: D A change in consciousness may be subtle. The nurse should notice any decreasing level of consciousness, disorientation, memory loss, uncooperative behavior, or even complacency in a previously combative person. The other responses are incorrect.

9. Which of these statements about the peripheral nervous system is correct? a. The CNs enter the brain through the spinal cord. b. Efferent fibers carry sensory input to the central nervous system through the spinal cord. c. The peripheral nerves are inside the central nervous system and carry impulses through their motor fibers. d. The peripheral nerves carry input to the central nervous system by afferent fibers and away from the central nervous system by efferent fibers.

ANS: D A nerve is a bundle of fibers outside of the central nervous system. The peripheral nerves carry input to the central nervous system by their sensory afferent fibers and deliver output from the central nervous system by their efferent fibers. The other responses are not related to the peripheral nervous system.

19. A 50-year-old woman is in the clinic for weakness in her left arm and leg that she has noticed for the past week. The nurse should perform which type of neurologic examination? a. Glasgow Coma Scale b. Neurologic recheck examination c. Screening neurologic examination d. Complete neurologic examination

ANS: D The nurse should perform a complete neurologic examination on an individual who has neurologic concerns (e.g., headache, weakness, loss of coordination) or who is showing signs of neurologic dysfunction. The Glasgow Coma Scale is used to define a person's level of consciousness. The neurologic recheck examination is appropriate for those who are demonstrating neurologic deficits. The screening neurologic examination is performed on seemingly well individuals who have no significant subjective findings from the health history.

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? 1. Head injury 2. Cluster headache 3. Migraine headache 4. Meningeal inflammation

ANS:4 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.

A short lingual frenulum

Ankyloglossia

A "canker sore" is a vesicle at first and then a small, round, "punched out" ulcer with a white base surrounded by a red halo.

Aphthous Ulcers

During an inspection of the nares, a deviated septum is noted. The best action is to: A) request a consult with an ENT specialist B) document the deviation in the medical record in case the person needs to be suctioned C) teach the person what to do if a nosebleed should occur D) explore further because polyps frequently accompany a deviated septum

B) document the deviation in the medical record in case the person needs to be suctioned

The most common site of nosebleeds is: A) the turbinates B) the columnellae C) Kiesselbach plexus D) the meatus

C) Kiesselbach plexus

Painful fissures in the corner of the mouth

Cheilitis

Optic

Cranial Nerve II: vision

Acoustic

Cranial Nerve VIII: hearing and equilibrium

Vagus

Cranial Nerve X: talking, swallowing, and sensory information from pharynx and carotid sinus

Spinal

Cranial Nerve XI:movement of trapezius and sternomastoid muscles

Hypoglossal

Cranial Nerve XII: movement of the tongue

The sinuses that are accessible to examination are the: A) ethmoid and sphenoid B) frontal and ethmoid C) maxillary and sphenoid D) frontal and maxillary

D) frontal and maxillary

Oral malignancies are most likely to develop: A) on the soft palate B) on the tongue C) in the buccal cheek mucosa D) in the mucosal "gutter" under the tongue

D) in the mucosal "gutter" under the tongue

Collagen

Dermis

Elastic Tissue

Dermis

Occurs with pharyngitis, gastroesophageal reflux diseas, stroke and other neurologic diseases, esophageal cancer (difficult swallowing)

Dysphagia

Stratum corneum

Epidermis

Uniformly Thin

Epidermis

Occurs with trauma, vigorous nose blowing, foreign body (nose bleeds)

Epistaxis

Small, isolated white or yellow papules on the mucosa of cheek, tongue, and lips.

Fordyce granules

Briefly describe the method of assessing the six cardinal fields of vision.

Instruct the patient to hold the head steady and follow the examiner's finger. The examiner holds the finger 12 inches from the individual and moves it clockwise to the 2, 3, 4, 8, 9, and 10 o'clock positions and back to the center each time. A normal response is parallel tracking of the object with both eyes.

Erythema

Intense redness of the skin due to excess blood in the dilated superficial capillaries

Occurs with colds, allergies, sinus infection, trauma (drainage from nose)

Rhinorrhea

You note a lesion during an examination. Select the description that is most complete. a) raised, irregular lesion the size of a quarter, located on dorsum of left hand. b) open lesion with no drainage or odor, approximately 1/4 inch in diameter. c) pedunculated lesion below left scapula with consistent red color, no drainage or odor d) dark brown, raised lesion, with irregular border, on dorsum of right foot, 3 cm in size with no drainage

d

A benign bony ridge running in the middle of the hard palate

Torus Palatinus

Supraclavicular

above and behind the clavicle

Occipital

at the base of the skull

A person is known to be blind in the left eye. What happens to the pupils when the right eye is illuminated by a penlight beam? a) No response in both b) Both pupils constrict c) Right pupil constricts, left has no response d) Left pupil constricts, right has no response

b

During a neurologic examination, the tendon reflex fails to appear. Before striking the tendon again, the examiner might use the technique of: a) two-point discrimination b) reinforcement c) vibration d) graphesthesia

b

Submental

behind the tip of the mandible

The "A" in the ABCDE rule stands for: a) accuracy b) appearance c) asymmetry d) attenuated

c

The capillary beds should refill after being depressed in: a) <1 second b) >2 seconds c) 1-2 seconds d) time is not significant as long as color returns

c

A side effect of many drugs; antidepresants, anticholinergics, antispasmodics, antihypertensives, antipsychotics, brochodilators (dry mouth)

Xerostomia

Normal cervical lymph nodes are: a) smaller than 1 cm b) warm to palpation c) fixed d) firm

a

Conjunctivitis is always associated with: a) absent red reflex b) reddened conjunctiva c) impairment of vision d) fever

b

Preauricular

in front of the ear

Harlequin

lower half of body turns red, upper half blanches

Superficial cervical

overlying the sternomastoid muscle

Posterior auricular

superficial to the mastoid process

Erythema toxicum

tiny, punctate red macules and papules on the cheeks, trunk, chest, back, and buttocks

Cutis marmorata

transient mottling on trunk and extremities

Jugulodigastric

under the angle of the mandible

Carotenemia

yellow-orange color in light-skinned persons from large amounts of foods containing carotene

Chalky white, thick, raised patch with well defined borders. Lesion does not scrape off. Lesions are precancerous.

Leukoplakia

Posterior cervical

in the posterior triangle along the edge of the trapezius muscle

The nurse needs to be familiar with the various lesions that may be identified on assessment of the skin. Match each description given below with the appropriate term. 1.Tiny punctate hemorrhages, 1-3 mm, round and discrete, dark red, purple, or brown in color 2.A large patch of capillary bleeding into tissues 3.A hypertrophic scar 4.Elevated cavity containing free fluid, up to 1 cm. Clear serum flows if wall is ruptured. 5.Also known as a friction blister 6.Solid, elevated, hard or soft, larger than 1 cm

1. Bulla 2. Petechiae 3. Nodule 4. Keloid 5. Vesicle 6. Ecchymosis (bruise) ASN: 2,6,4,5,1,3

During assessment of infants and children, the nurse measures the head circumference and compares the measure to the chest circumference. For each finding listed below, match to the appropriate age. 1. Newborn infant 2. Toddler, age 2 years 3. Child, age 4 years

1. Head circumference equal to chest circumference. 2. Head circumference greater than chest circumference. 3. Head circumference less than chest circumference. ANS:2,1,3

The frenulum is: A) the midline fold of tissue that connects the tongue to the floor of the mouth B) the anterior border of the oral cavity C) the arching roof of the mouth D) the free projection hanging down from the middle of the soft palate

A) the midline fold of tissue that connects the tongue to the floor of the mouth

A nasal polyp may be distinguished from the nasal turbinates for 3 of the following reasons. Which is false? A) the polyp is highly vascular B) the polyp is movable C) the polyp is pale gray in color D) the polyp is nontender

A) the polyp is highly vascular

The function of the nasal turbinates is to: A) warm the inhaled air B) detect odors C) stimulate tear formations D) lighten the weight of the skull bones

A) warm the inhaled air

The larges salivary gland is located: A) within the cheeks in the front of the ear B) beneath the mandible at the angle of the jaw C) within the floor of the mouth under the tongue D) at the base of the tongue

A) within the cheeks in the front of the ear

To assess for early jaundice, you will assess: A) Sclera and hard palate B) Nail beds C) Lips D) All visible surfaces

A. Except for physiological jaundice in newborns, jaundice does NOT occur normally. It is FIRST noted in the junction of the hard and soft palate in the mouth and in the sclera. DO NOT confuse scleral jaundice with the normal yellow subconjunctival fatty deposits that are common in the outer sclera of dark-skinned persons. The scleral yellow of jaundice extends up to the edge of the iris.

You are assessing capillary refill. The room is warm. Which finding would be considered normal? A) <1 second B) >2 seconds C) 2 to 3 seconds D) Time is not significant as long as color returns

A. Normally color return is instant or at least within a few seconds in a cold environment. This indicates the status of the peripheral circulation. A sluggish color return takes longer than 1 or 2 seconds.

A flat macular hemorrhage is called a(n): A) purpura. B) ecchymosis. C) petechiae. D) hemangioma.

A. Purpura is a flat, macular, red-to-purple hemorrhage that is a confluent and extensive patch of petechiae and ecchymoses greater than 3 mm. An ecchymosis is a hemorrhage that is greater than 3 mm. Petechiae are tiny punctate hemorrhages that are 1 to 3 mm; round and discrete; and dark red, purple, or brown caused by bleeding from superficial capillaries. Hemangiomas are vascular lesions caused by a benign proliferation of blood vessels in the dermis.

The components of a nail examination include: A) contour, consistency, and color. B) shape, surface, and circulation. C) clubbing, pitting, and grooving. D) texture, toughness, and translucency.

A. The nails should be assessed for shape and contour, consistency, and color.

To determine if a dark-skinned patient is pale, the nurse should assess the color of the: A) conjunctivae. B) earlobes. C) palms of the hands. D) skin in the antecubital space.

A. To detect pallor in a dark-skinned patient, the nurse should assess an area with the least pigmentation, such as the conjunctivae or mucous membranes.

What term refers to a linear skin lesion that runs along a nerve route? A) Zosteriform B) Annular C) Dermatome D) Shingles

A. Zosteriform describes a lesion that has a linear arrangement along a nerve root. Annular describes a lesion that is circular and begins in the center and spreads to the periphery. A dermatome is an area of skin that is mainly supplied by a single spinal nerve. Shingles (herpes zoster) are small grouped vesicles that emerge along the route of a cutaneous sensory nerve, followed by pustules, and then crusts; shingles is caused by the herpes zoster virus.

1. The two parts of the nervous system are the: a. Motor and sensory. b. Central and peripheral. c. Peripheral and autonomic. d. Hypothalamus and cerebral.

ANS: B The nervous system can be divided into two parts—central and peripheral. The central nervous system includes the brain and spinal cord. The peripheral nervous system includes the 12 pairs of cranial nerves (CNs), the 31 pairs of spinal nerves, and all of their branches.

The nurse is doing an assessment on a 21-year-old patient and notes that his nasal mucosa appears pale, gray, and swollen. What would be the most appropriate question to ask the patient? 1. "Are you aware of having any allergies?" 2. "Do you have an elevated temperature?" 3. "Have you had any symptoms of a cold?" 4. "Have you been having frequent nosebleeds?"

ANS: 1 With chronic allergy, mucosa looks swollen, boggy, pale, and gray.

During the ear examination of an 80-year-old patient, which of the following would be a normal finding? 1. A high-tone frequency loss 2. Increased elasticity of the pinna 3. A thin, translucent membrane 4. A shiny, pink tympanic membrane

ANS: 1 A high-tone frequency hearing loss is apparent for those affected with presbycusis, the hearing loss that occurs with aging.

A 75-year-old woman who has a history of diabetes and peripheral vascular disease has been trying to remove a corn on the bottom of her foot with a pair of scissors. The nurse will encourage her to stop trying to remove the corn with her scissors because: 1.the woman could be at increased risk for infection and lesions because of her chronic disease. 2.with her diabetes, she has increased circulation to her foot and it could cause severe bleeding. 3.she is 75 years old and is unable to see, so she puts herself at greater risk for self- injury with the scissors. 4.with her peripheral vascular disease, her range of motion is limited and she may not be able to reach the corn safely.

ANS: 1 A personal history of diabetes and peripheral vascular disease increases a person's risk for skin lesions in the feet or ankles.

A patient tells the nurse that he has noticed that one of his nevi has started to burn and bleed. When assessing his skin, the nurse would pay special attention to the danger signs for pigmented lesions and would be concerned with which additional finding? 1.Color variation 2.Border regularity 3.Symmetry of lesions 4.Diameter less than 6 mm

ANS: 1 Abnormal characteristics of pigmented lesions are summarized in the mnemonic ABCD: asymmetry of pigmented lesion, border irregularity, color variation, and diameter greater than 6 mm.

When performing an otoscopic examination of a 5-year-old child with a history of chronic ear infections, the nurse sees that his right tympanic membrane is amber- yellow in color and there are air bubbles behind the tympanic membrane. The child reports occasional hearing loss and a popping sound with swallowing. The preliminary analysis based on this information is that: 1. this is most likely a serous otitis media. 2. the child has an acute purulent otitis media. 3. there is evidence of a resolving cholesteatoma. 4. the child is experiencing the early stages of perforation.

ANS: 1 An amber-yellow color to the tympanic membrane suggests serum in the middle ear. Often an air/fluid level or bubbles behind the tympanic membrane are visible. The patient may have feelings of fullness, transient hearing loss, and a popping sound with swallowing.

When performing an assessment of a 65-year-old man with a history of hypertension and coronary artery disease, the nurse notes the presence of pitting edema in the lower legs bilaterally. The skin is puffy and tight but of normal color. There is no increased redness or tenderness over his lower legs, and the peripheral pulses are equal and strong. In this situation, which of the following is the most likely cause of the edema? 1.Heart failure 2.Venous thrombosis 3.A local inflammation 4.Blockage of lymphatic drainage

ANS: 1 Bilateral edema or edema that is generalized over the entire body is caused by a central problem such as heart failure or kidney failure. Unilateral edema usually has a local or peripheral cause.

During an examination of a 3-year-old child, the nurse notes a bruit over the left temporal area. What should the nurse do? 1. Continue the examination because this is a normal finding for this age. 2. Check for the bruit again in 1 hour. 3. Notify the parents that a bruit has been detected in their child. 4. Stop the examination and notify the physician.

ANS: 1 Bruits are common in the skull in children under 4 or 5 years of age or in children with anemia. They are systolic or continuous and are heard over the temporal area.

A 2-week-old infant can fixate on an object but not follow a light or bright toy. The nurse would: 1. consider this a normal finding. 2. assess the pupillary light reflex for possible blindness. 3. continue with the examination and assess visual fields. 4. expect that a 2-week-old infant should be able to fixate and follow an object.

ANS: 1 By 2 to 4 weeks an infant can fixate on an object. By 1 month, the infant should fixate and follow a bright light or toy.

While discussing the history of a 6-month-old infant, the mother tells the nurse that she took a great deal of aspirin while she was pregnant. What question would the nurse want to include in the history? 1. "Does your baby seem to startle with loud noise?" 2. "Has the baby had any surgeries on the ears?" 3. "Have you noticed any drainage from her ears?" 4. "How many ear infections has your baby had since birth?"

ANS: 1 Children at risk for hearing deficit include those exposed in utero to a variety of conditions, such as maternal rubella, or to maternal ototoxic drugs.

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 notes 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: 1. allergies. 2. a sinus infection. 3. nasal congestion. 4. an upper respiratory infection.

ANS: 1 Chronic allergies often develop chronic facial characteristics. These 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.

During an assessment of a 20-year-old patient with a 3-day history of nausea and vomiting, the nurse notes the following: dry mucosa and deep fissures in the tongue. This finding is reflective of: 1. dehydration. 2. irritation by gastric juices. 3. a normal oral assessment. 4. side effects from nausea medication.

ANS: 1 Dry mouth occurs with dehydration or fever. The tongue has deep vertical fissures.

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? 1. "Head control is usually achieved by 4 months of age." 2. "You shouldn't be trying to pull your baby up like that until she is older." 3. "This is a concern because head control should be achieved by this time." 4. "This is a concern because it indicates possible nerve damage to the neck muscles."

ANS: 1 Head control is achieved by 4 months, when the baby can hold the head erect and steady when pulled to a vertical position.

A patient is unable to read the 20/100 line on the Snellen chart. The nurse would: 1. refer the patient to an ophthalmologist or optometrist for further evaluation. 2. assess whether the patient can count the nurse's fingers when they are placed in front of his or her eyes. 3. ask the patient to put on his or her reading glasses and attempt to read the Snellen chart again. 4. shorten the distance between the patient and the chart and ask him or her to read the smallest line of print possible.

ANS: 1 If vision is poorer than 20/30, refer the person to an ophthalmologist or optometrist.

The nurse is doing an oral assessment on a 40-year-old black patient and notes the presence of a 1-cm, nontender, grayish-white lesion on the left buccal mucosa. Which of the following is true concerning this lesion? 1. This lesion is leukoedema and is common in blacks. 2. This is the result of hyperpigmentation and is normal. 3. This is torus palatinus and would normally only be found in smokers. 4. This type of lesion is indicative of cancer and should be tested immediately.

ANS: 1 Leukoedema, a grayish-white benign lesion occurring on the buccal mucosa, is present more often in blacks than in whites.

A 68-year-old woman is in the eye clinic for a checkup. She tells the nurse that she has been having trouble with reading the paper, sewing, and even seeing the faces of her grandchildren. On examination, the nurse notes that she has some loss of central vision but her peripheral vision is normal. These findings suggest that: 1. she may have macular degeneration. 2. her vision is normal for someone her age. 3. she has the beginning stages of cataract formation. 4. she has increased intraocular pressure or glaucoma.

ANS: 1 Macular degeneration is the most common cause of blindness. It is characterized by loss of central vision.

A patient's vision is recorded as 20/80 in each eye. The nurse recognizes that this finding indicates that: 1. the patient has poor vision. 2. the patient has acute vision. 3. the patient has normal vision. 4. the patient is presbyopic.

ANS: 1 Normal visual acuity is 20/20 in each eye. The larger the denominator, the poorer the vision.

The nurse is preparing to do an otoscopic examination on a 2-year-old child. Which of the following reflects correct procedure? 1. Pull the pinna down. 2. Pull the pinna up and back. 3. Tilt the child's head slightly toward the examiner. 4. Have the child touch his chin to his chest.

ANS: 1 Pull the pinna down on an infant and a child under 3 years of age.

When performing the corneal light reflex assessment, the nurse notes that the light is reflected at 2 o'clock in each eye. The nurse would: 1. consider this a normal finding. 2. refer the individual for further evaluation. 3. document this as an asymmetric light reflex. 4. perform the confrontation test to validate the findings.

ANS: 1 Reflection of the light on the corneas should be in exactly the same spot on each eye, or symmetric.

During an ophthalmscopic examination of the eye, the examiner notes areas of exudate that look like "cotton wool" or fluffy gray-white cumulus clouds. This finding indicates which possible problem? 1. Diabetes 2. Hyperthyroidism 3. Glaucoma 4. Hypotension

ANS: 1 Soft exudates or "cotton wool" areas look like fluffy gray-white cumulus clouds, They occur with diabetes, hypertension, subacute bacterial endocarditis, lupus, and papilledema of any cause.

When examining the eye, the nurse is aware that the bulbar conjunctiva: 1. overlies the sclera. 2. covers the iris and pupil. 3. is visible at the inner canthus of the eye. 4. is a thin mucous membrane that lines the lids.

ANS: 1 The bulbar conjunctiva overlies the eyeball with the white sclera showing through.

When assessing the tongue of an adult, the nurse knows that an abnormal finding would be: 1. a smooth glossy dorsal surface. 2. a thin white coating over the tongue. 3. raised papillae on the dorsal surface. 4. visible venous patterns on the ventral surface.

ANS: 1 The dorsal surface of the tongue is normally roughened from papillae. A thin white coating may be present.

A patient has tingling sensations in her feet and has noticed that her tongue has become very red and painful. The nurse suspects that she has: 1.polycythemia. 2.pernicious anemia. 3.micronucleus anemia. 4.iron deficiency anemia.

ANS: 2 Pernicious anemia is indicated by neurologic deficits and a red, painful tongue along with a lemon yellow tint of the face and slightly yellow sclera.

A colleague is assessing an 80-year-old patient who has ear pain and asks him to hold his nose and swallow. The nurse knows that which of the following is true concerning this technique? 1. This should not be used in an 80-year-old patient. 2. This technique is helpful in assessing for otitis media. 3. This is especially useful in assessing a patient with an upper respiratory infection. 4. This will cause the eardrum to bulge slightly and make landmarks more visible.

ANS: 1 The eardrum is flat, slightly pulled in at the center, and flutters when the person performs the Valsalva maneuver or holds the nose and swallows (insufflation). One may elicit these maneuvers to assess drum mobility. Avoid these with an aging person because they may disrupt equilibrium.

The nurse is examining a patient who tells the nurse, "I sure sweat a lot, especially on my face and feet but it doesn't have an odor." The nurse knows that this could be related to: 1.the eccrine glands. 2.the apocrine glands. 3.a disorder of the stratum corneum. 4.a disorder of the stratum germinativum.

ANS: 1 The eccrine glands are coiled tubules that open directly onto the skin surface and produce a dilute saline solution called sweat. Apocrine glands are located mainly in the axillae, anogenital area, nipples, and naval and mix with bacterial flora to produce characteristic musky body odor.

The portion of the ear that consists of movable cartilage and skin is called the: 1. auricle. 2. concha. 3. outer meatus. 4. mastoid process.

ANS: 1 The external ear is called the auricle or pinna and consists of movable cartilage and skin.

The nurse is caring for a black child who has been diagnosed with marasmus. The nurse would expect to find: 1.the hair to be less kinky and to be a copper-red color. 2.the head to be larger than normal, with wide-set eyes. 3.the skin on the hands and feet to be scaly and tender. 4.the lymph nodes in the groin to be enlarged and tender.

ANS: 1 The hair of black children with severe malnutrition (e.g., marasmus) frequently changes not only in texture but in color—the child's hair becomes less kinky and assumes a copper-red color.

The muscles in the neck that are innervated by CN XI are the: 1. sternomastoid and trapezius. 2. spinal accessory and omohyoid. 3. trapezius and sternomandibular. 4. sternomandibular and spinal accessory.

ANS: 1 The major neck muscles are the sternomastoid and the trapezius. They are innervated by CN XI, the spinal accessory.

The salivary gland that is located in the cheek in front of the ear is the: 1. parotid gland. 2. Stenson's gland. 3. sublingual gland. 4. submandibular gland.

ANS: 1 The mouth contains three pairs of salivary glands. The largest, the parotid gland, lies within the cheeks in front of the ear extending from the zygomatic arch down to the angle of the jaw.

The nurse is testing a patient's visual accommodation, which refers to: 1. pupillary constriction when looking at a near object. 2. pupillary dilation when looking at a far object. 3. changes in peripheral vision in response to light. 4. involuntary blinking in the presence of bright light.

ANS: 1 The muscle fibers of the iris contract the pupil in bright light and accommodate for near vision.

Which of the following statements is true concerning air conduction? 1. It is the most efficient pathway for hearing. 2. It is caused by the vibrations of bones in the skull. 3. The amplitude of sound determines the pitch that is heard. 4. A loss of air conduction is called a conductive hearing loss.

ANS: 1 The normal pathway of hearing is air conduction, and it is the most efficient.

When the retina is examined, which of the following is considered a normal finding? 1. An optic disc that is a yellow-orange color 2. Optic disc margins that are blurred around the edges 3. The presence of pigmented crescents in the macular area 4. The presence of the macula located on the nasal side of the retina

ANS: 1 The optic disc is located on the nasal side of the retina. It is a creamy yellow-orange to pink color.

A patient's laboratory data reveal an elevated thyroxine level. The nurse would proceed with an examination of the: 1. thyroid gland. 2. parotid gland. 3. adrenal gland. 4. thyroxine gland.

ANS: 1 The thyroid gland is a highly vascular endocrine gland that secretes thyroxine (T4) and tri-iodothyronine (T3).

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? 1. Tachycardia 2. Constipation 3. Rapid dyspnea 4. Atrophied nodular thyroid

ANS: 1 Thyroxine and tri-iodothyronine 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 45-year-old farmer comes in for a skin evaluation and complains of hair loss on his head. He has noticed that his hair seems to be breaking off in patches and that he has some scaling on his head. The nurse would begin the examination suspecting: 1.tinea capitis. 2.tinea corporis. 3.toxic alopecia. 4.seborrheic dermatitis.

ANS: 1 Tinea capitis is rounded patchy hair loss on scale, leaving broken-off hairs, pustules, and scales on the skin. It is due to fungal infection. Lesions are fluorescent under a Wood's light. It is usually seen in children and farmers and is highly contagious.

During an examination, the nurse knows that the best way to palpate the lymph nodes in the neck is described by which statement? 1. Using gentle pressure, palpate with both hands to compare the two sides. 2. Using strong pressure, palpate with both hands to compare the two sides. 3. Gently pinch each node between one's thumb and forefinger and move down the neck muscle. 4. Using the index and middle fingers, gently palpate by applying pressure in a rotating pattern.

ANS: 1 Use gentle pressure because strong pressure could push the nodes into the neck muscles. It is usually most efficient to palpate with both hands, comparing the two sides symmetrically.

The nurse assesses the hearing of a 7-month-old by clapping hands. What is the expected response? 1. The infant turns the head to localize sound. 2. No obvious response to noise 3. A startle and acoustic blink reflex 4. The infant stops movement and appears to listen.

ANS: 1 With a loud sudden noise, you should note these responses: 6 to 8 months—infant turns head to localize sound, responds to own name.

A patient states that she is unable to hear well with her left ear. The Weber test shows lateralization to the right ear. Rinne has AC>BC with ratio of 2:1 in both ears, left-AC 10 sec and BC 5 sec, right-AC 30 sec and BC 15 sec. What would be the interpretation of these results? 1. The patient may have sensorineural loss. 2. The test results are reflective of normal hearing. 3. Conduction of sound through bones is impaired. 4. These results make no sense, so further tests should be done.

ANS: 1 With sensorineural loss, sound lateralizes to "better" ear or unaffected ear. Normal ratio of AC>BC is intact but is reduced overall. That is, the person hears poorly both ways.

When examining children affected with Down syndrome (trisomy 21), the nurse looks for the possible presence of: 1. ear dysplasia. 2. a long, thin neck. 3. a protruding thin tongue. 4. a narrow and raised nasal bridge.

ANS: 1 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 semiconscious woman is brought to the emergency department after she was found on the floor in her kitchen. Her face, nail beds, lips, and oral mucosa are a bright cherry-red color. The nurse suspects that this coloring is due to: 1.polycythemia. 2.carbon monoxide poisoning. 3.carotenemia. 4.uremia.

ANS: 2 A bright cherry-red coloring in the face, upper torso, nail beds, lips, and oral mucosa appears in cases of carbon monoxide poisoning.

Which of the following is an expected normal finding when performing the diagnostic positions test? 1. Convergence of the eyes 2. Parallel movement of both eyes 3. Nystagmus in extreme superior gaze 4. A slight amount of lid lag when moving the eyes from a superior to inferior position

ANS: 2 A normal response for the diagnostic positions test is parallel tracking of the object with both eyes.

While performing the otoscopic exam of a 3-year-old boy who has been pulling on his left ear, the nurse finds that his left tympanic membrane is bright red and the light reflex is not visible. The most likely cause is: 1. fungal infection. 2. acute otitis media. 3. rupture of the drum. 4. blood behind the drum.

ANS: 2 Absent or distorted light reflex and a bright red color of the eardrum are indicative of acute otitis media.

The nurse suspects that a patient has otitis media. Early signs of otitis media include which of the following findings of the tympanic membrane? 1. Red and bulging 2. Hypomobility 3. Retraction with landmarks clearly visible 4. Flat, slightly pulled in at the center, and moves with insufflation

ANS: 2 An early sign of otitis media is hypomobility of the tympanic membrane.

A 52-year-old woman has a papule on her nose that has rounded, pearly borders and a central red ulcer. She said she has noticed it for several months and it has slowly grown larger. The nurse suspects which condition? 1.Acne 2.Basal cell carcinoma 3.Malignant melanoma 4.Squamous cell carcinoma

ANS: 2 Basal cell carcinoma usually starts as a skin-colored papule that develops rounded, pearly borders with a central red ulcer. It is the most common form of skin cancer, and it grows slowly.

During an oral examination of a 4-year-old American Indian child, the nurse notices that her uvula is partially split. Which of the following statements is accurate? 1. This is a cleft palate and is common in American Indians. 2. This is a bifid uvula, which occurs in some American Indian groups. 3. This is due to an injury and should be reported to the authorities. 4. This is torus palatinus, which occurs frequently in American Indians.

ANS: 2 Bifid uvula, a condition in which the uvula is split either completely or partially, occurs in some American Indian groups.

A 40-year-old patient who has just finished chemotherapy for breast cancer tells the nurse that she is concerned about her mouth. During the assessment the nurse finds the following: areas of buccal mucosa that are raw and red with some bleeding as well as other areas that have a white, cheesy coating. The nurse recognizes that this abnormality is: 1. carcinoma. 2. candidiasis. 3. leukoplakia. 4. Koplik's spots.

ANS: 2 Candidiasis is a white, cheesy, curd-like patch on the buccal mucosa and tongue. It scrapes off, leaving raw, red surface that bleeds easily. It also occurs after the use of antibiotics or corticosteroids and in immunosuppressed persons.

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: 1. hypertension. 2. cluster headaches. 3. tension headaches. 4. migraine headaches.

ANS: 2 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.

The nurse is performing a middle ear assessment on a 15-year-old patient who has a history of chronic ear infections. When examining the right tympanic membrane, the nurse sees the presence of dense white patches. The tympanic membrane is otherwise unremarkable. It is pearly, with the light reflex at 5 o'clock and landmarks visible. The nurse should: 1. refer the patient for the possibility of a fungal infection. 2. know that these are scars caused from frequent ear infections. 3. consider that these findings may represent the presence of blood in the middle ear. 4. be concerned about the ability to hear because of this abnormality on the tympanic membrane.

ANS: 2 Dense white patches on the tympanic membrane are sequelae of repeated ear infections. They do not necessarily affect hearing.

During an assessment of an infant, the nurse notes that the fontanels are depressed and sunken. The nurse suspects which condition? 1. Rickets 2. Dehydration 3. Mental retardation 4. Increased intracranial pressure

ANS: 2 Depressed and sunken fontanels occur with dehydration or malnutrition.

A 22-year-old-woman comes to the clinic because of a severe sunburn and states, "I was just out in the sun for a couple of minutes." The nurse begins a medication review with her, paying special attention to the medication she is taking for: 1.pain. 2.acne. 3.heartburn. 4.hyperthyroidism.

ANS: 2 Drugs that may increase sunlight sensitivity and give burn response include sulfonamides, thiazide diuretics, oral hypoglycemic agents, and tetracycline.

A mother brings her newborn in for an assessment and asks, "Is there something wrong with my baby? His head seems so big." The nurse knows the following about relative proportions of the head and trunk of the newborn: 1. At birth, the head is one fifth the total length. 2. Head circumference should be greater than chest circumference at birth. 3. The head size reaches 90% of its final size when the child is 3 years old. 4. When the anterior fontanel closes at 2 months, the head will be more proportioned to the body.

ANS: 2 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.

A patient is unable to differentiate between sharp and dull stimulation to both sides of her face. The nurse suspects: 1. Bell's palsy. 2. damage to the trigeminal nerve. 3. frostbite with resultant paresthesia to the cheeks. 4. scleroderma with a pronounced proliferation of connective tissue in the face and cheeks.

ANS: 2 Facial sensations of pain or touch are mediated by CN V, the trigeminal nerve.

The nurse is assessing a 16-year-old patient with head injuries from a recent motor vehicle accident. Which of the following statements indicates the most important reason for assessing for any drainage from the canal? 1. If the drum has ruptured, there will be purulent drainage. 2. Bloody or clear watery drainage can indicate a basal skull fracture. 3. The auditory canal many be occluded from increased cerumen. 4. There may be occlusion of the canal caused by foreign bodies from the accident.

ANS: 2 Frank blood or clear watery drainage (cerebrospinal leak) after trauma suggests a basal skull fracture and warrants immediate referral.

During a physical education class, a student is hit in the eye with the end of a baseball bat. When examined in the emergency department, the nurse notes the presence of blood in the anterior chamber of the eye. This finding indicates the presence of: 1. hypopyon. 2. hyphema. 3. corneal abrasion. 4. iritis.

ANS: 2 Hyphema is the term for blood in anterior chamber is a serious result of blunt trauma (a fist or a baseball) or spontaneous hemorrhage and may indicate scleral rupture or major intraocular trauma.

A patient in her first trimester of pregnancy is diagnosed with rubella. The nurse recognizes that the significance of this in relation to the infant's hearing is which of the following? 1. Rubella may affect the mother's hearing but not the infant's. 2. Rubella can damage the infant's organ of Corti, which will impair hearing. 3. Rubella is only dangerous to the infant in the second trimester of pregnancy. 4. Rubella can impair the development of CN VIII and thus affect hearing.

ANS: 2 If maternal rubella infection occurs during the first trimester, it can damage the organ of Corti and impair hearing.

The nurse is assessing the skin of a patient who has AIDS and notices a widely disseminated, violet-colored tumor covering the skin and mucous membranes. The nurse would conclude that: 1.he is in the first stage of AIDS. 2.he is in the advanced stage of AIDS. 3.this person has been exposed to a viral infection. 4.these lesions indicate an advanced case of herpes zoster.

ANS: 2 In the advanced stage of AIDS, you may notice widely disseminated lesions involving the skin, mucous membranes, and visceral organs.

When examining an elderly patient, the nurse recognizes that which finding is due to the aging process? 1. Teeth that appear shorter 2. A tongue that looks smoother in appearance 3. Buccal mucosa that is beefy red in appearance 4. A small, painless lump on the dorsum of the tongue

ANS: 2 In the aging adult, the tongue looks smoother because of papillary atrophy. The teeth are slightly yellowed and appear longer because of recession of gingival margins.

When using an otoscope to assess the nasal cavity, which of the following would the nurse need to do? 1. Insert the speculum at least 3 cm into the vestibule. 2. Avoid touching the nasal septum with the speculum. 3. Gently displace the nose to the side that is being examined. 4. Keep the speculum tip medial to avoid touching the floor of the nares.

ANS: 2 Insert the apparatus into the nasal vestibule, again avoiding pressure on the sensitive nasal septum.

When examining the ear with an otoscope, the nurse remembers that the tympanic membrane should appear: 1. light pink with a slight bulge. 2. pearly gray and slightly concave. 3. pulled in at the base of the cone of light. 4. whitish with a small fleck of light in the superior portion.

ANS: 2 It is a translucent membrane with a pearly gray color and a prominent cone of light in the anteroinferior quadrant, which is the reflection of the otoscope light. The drum is oval and slightly concave, pulled in at its center by one of the middle ear ossicles, the malleus.

During a skin assessment, the nurse notices that a Mexican-American patient has skin that is yellowish-brown in color. However, the skin on the hard/soft palate is a pink in color. From this finding, the nurse could probably rule out: 1.pallor. 2.jaundice. 3.cyanosis. 4.iron deficiency.

ANS: 2 Jaundice is exhibited by a yellow color, indicating rising amounts of bilirubin in the blood and is first noticed in the junction of the hard and soft palate in the mouth and in the sclera.

A few days after a summer hiking trip, a 25-year-old man comes to the clinic with a rash. On examination, the nurse notes that the rash is red, macular, with a bull's eye pattern across his midriff and behind his knees. The nurse suspects: 1.rubeola. 2.Lyme disease. 3.allergy to mosquito bites. 4.Rocky Mountain spotted fever.

ANS: 2 Lyme disease occurs in people who spend time outdoors in May through September. The first state has the distinctive bull's eye, a red macular or popular rash that radiates from the site of the tick bite with some central clearing, 5 cm or larger, usually in the axilla, midriff, inguina, or behind the knee, with regional lymphadenopathy.

The nurse has just completed a lymph assessment on a 60-year-old healthy female patient. The nurse knows that most lymph nodes in healthy adults are normally: 1. shotty. 2. not palpable. 3. large, firm, and fixed to the tissue. 4. rubbery, discrete, and mobile.

ANS: 2 Most lymph nodes are not palpable in adults. The palpability of lymph nodes decreases with age.

A woman who is in the second trimester of pregnancy mentions that she has had "more nosebleeds than ever" since she became pregnant. The nurse recognizes that this is due to: 1. a problem with the patient's coagulation system. 2. increased vascularity in the upper respiratory tract as a result of the pregnancy. 3. increased susceptibility to colds and nasal irritation. 4. inappropriate use of nasal sprays.

ANS: 2 Nasal stuffiness and epistaxis may occur during pregnancy as a result of increased vascularity in the upper respiratory tract.

The nurse is performing an eye assessment on an 80-year-old patient. Which of the following findings is considered abnormal? 1. A decrease in tear production 2. Unequal pupillary constriction in response to light 3. The presence of arcus senilis seen around the cornea 4. Loss of the outer hair on the eyebrows due to a decrease in hair follicles

ANS: 2 Pupils are small in old age, and the pupillary light reflex may be slowed, but pupillary constriction should be symmetric.

A 31-year-old patient tells the nurse that he has noticed pain in his left ear when people speak loudly to him. The nurse knows that this finding: 1. is normal for people of that age. 2. is a characteristic of recruitment. 3. may indicate a middle ear infection. 4. indicates that the patient has a cerumen impaction.

ANS: 2 Recruitment is a marked loss occurring when sound is at low intensity; sound actually may become painful when repeated at a louder volume.

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): 1. is tender. 2. is mobile and not hard. 3. disappears when the patient smiles. 4. is hard and fixed to the surrounding structures.

ANS: 2 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.

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: 1. thyroid gland. 2. parotid gland. 3. occipital lymph node. 4. submental lymph node.

ANS: 2 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 40-year-old woman reports a change in mole size, accompanied by color changes, itching, burning, and bleeding over the past month. She has a dark complexion and has no family history of skin cancer, but she has had many blistering sunburns in the past. The nurse would would: 1.tell the patient to watch the lesion and report back in 2 months. 2.refer the patient because of the suspicion of melanoma on the basis of her symptoms. 3.ask additional questions regarding environmental irritants that may have caused this condition. 4.suspect that this is a compound nevus, which is very common in young to middle- aged adults.

ANS: 2 The ABCD danger signs of melanoma are asymmetry, border irregularity, color variation, and diameter. In addition, individuals may report a change in size, development of itching, burning, bleeding, or a new-pigmented lesion. Any of these signs raise suspicion of malignant melanoma and warrant referral.

The nurse is conducting a visual examination. Which of the following statements regarding visual pathways and visual fields is true? 1. The right side of the brain interprets vision for the right eye. 2. The image formed on the retina is upside down and reversed from its actual appearance in the outside world. 3. Light rays are refracted through the transparent media of the eye before striking the pupil. 4. The light impulses are conducted through the optic nerve to the temporal lobes of the brain.

ANS: 2 The image formed on the retina is upside down and reversed from its actual appearance in the outside world.

Which of the following physiological changes is responsible for presbyopia? 1. Degeneration of the cornea 2. Loss of lens elasticity 3. Decreased adaptation to darkness 4. Decreased distance vision abilities

ANS: 2 The lens loses elasticity and decreases its ability to change shape to accommodate for near vision. This condition is called presbyopia.

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: 1. XI; palpating the anterior and posterior triangles. 2. XI; asking the patient to shrug her shoulders against resistance. 3. XII; percussing the sternomastoid and submandibular neck muscles. 4. XII; assessing for a positive Romberg's sign.

ANS: 2 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 primary purpose of the ciliated mucous membrane in the nose is to: 1. warm the inhaled air. 2. filter out dust and bacteria. 3. filter coarse particles from inhaled air. 4. facilitate movement of air through the nares.

ANS: 2 The nasal hairs filter the coarsest matter from inhaled air, whereas the mucous blanket filters out dust and bacteria.

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: 1. thyroid gland. 2. parotid gland. 3. cervical lymph nodes. 4. mouth and skin for lesions.

ANS: 2 The parotid gland may become swollen with the onset of mumps, and parotid enlargement has been found with HIV.

A thorough skin assessment is very important because the skin holds information about: 1.support systems. 2.circulatory status. 3.socioeconomic status. 4.psychological wellness.

ANS: 2 The skin holds information about the body's circulation, nutritional status, and signs of systemic diseases as well as topical data on the integument itself.

In assessing the tonsils of a 30-year-old, the nurse notes that they are involuted, granular in appearance, and appear to have deep crypts. What is correct response to these findings? 1. Refer the patient to a throat specialist. 2. Nothing, this is the appearance of normal tonsils. 3. Continue with assessment looking for any other abnormal findings. 4. Obtain a throat culture on the patient for possible strep infection.

ANS: 2 The tonsils are the same color as the surrounding mucous membrane, although they look more granular and their surface shows deep crypts. Tonsillar tissue enlarges during childhood until puberty and then involutes.

A mother asks when her newborn infant's eyesight will be developed. The nurse should reply: 1. "Vision is not totally developed until 2 years of age." 2. "Infants develop the ability to focus on an object at around 8 months." 3. "By about 3 months, infants develop more coordinated eye movements and can fixate on an object." 4. "Most infants have uncoordinated eye movements for the first year of life."

ANS: 3 By 3 to 4 months of age, the infant establishes binocularity and can fixate on a single image with both eyes simultaneously.

A patient's vision is recorded as 20/30 when the Snellen eye chart is used. The nurse recognizes that these results indicate that: 1. at 30 feet the patient can read the entire chart. 2. the patient can read at 20 feet what a person with normal vision can read at 30 feet. 3. the patient can read the chart from 20 feet in the left eye and 30 feet in the right eye. 4. the patient can read from 30 feet what a person with normal vision can read from 20 feet.

ANS: 2 The top number indicates the distance the person is standing from the chart; the denominator gives the distance at which a normal eye can see.

The physician reports that a patient has a tracheal shift. The nurse is aware that this means that the patient's trachea is: 1. pulled to the affected side with systole. 2. pushed to the unaffected side with a tumor. 3. pulled to the unaffected side with plural adhesions. 4. pushed to the affected side with thyroid enlargement.

ANS: 2 The trachea is pushed to the unaffected side with an aortic aneurysm, a tumor, unilateral thyroid lobe enlargement, and pneumothorax.

Jaundice is exhibited by a yellow skin color, indicating rising levels of bilirubin in the blood. Which of the following findings is indicative of true jaundice? 1.Yellow patches throughout the sclera 2.Yellow color of the sclera that extends up to the iris 3.Skin that appears yellow when examined under low light 4.Yellow deposits on the palms and soles of the feet where jaundice first appears

ANS: 2 The yellow sclera of jaundice extends up to the edge of the iris. Calluses on the palms and soles of the feet often look yellow but are not classified as jaundice.

Which of the following would the nurse expect to find when examining the eyes of a black patient? 1. Increased night vision 2. A dark retinal background 3. Increased photosensitivity 4. Narrowed palpebral fissures

ANS: 2 There is an ethnically based variability in the color of the iris and in retinal pigmen- tation, with darker irides having darker retinas behind them.

During the history, a patient tells the nurse that he has frequent nosebleeds and asks the best way to get them to stop. What would be the nurse's best response? 1. "While sitting up, place a cold compress over your nose." 2. "Sit up with your head tilted forward and pinch your nose." 3. "Just let the bleeding stop on its own, but don't blow your nose." 4. "Lie on your back with your head tilted back and pinch your nose."

ANS: 2 With a nosebleed, the person should sit up with the head tilted forward and pinch the nose between the thumb and forefinger for 5 to 15 minutes.

While performing an assessment of the mouth, the nurse notices that the patient has a 1-cm ulceration that is crusted with an elevated border. It is located on the outer third of the lower lip. What other information would be most important for the nurse to assess? 1. Nutritional status 2. When the patient first noticed the lesion 3. Whether the patient has had a recent cold 4. Whether the patient has had any recent exposure to sick animals

ANS: 2 With carcinoma, the initial lesion is round and indurated, and then it becomes crusted and ulcerated with an elevated border. Most cancers occur between the outer and middle thirds of the lip. Any lesion that is still unhealed after 2 weeks should be referred.

A 17-year-old student is a swimmer on her high school's swim team. She has had three bouts of otitis externa so far this season and wants to know what to do to prevent it. The nurse instructs her to: 1. use a cotton-tipped swab to dry the ear canals thoroughly after each swim. 2. use rubbing alcohol or 2% acetic acid eardrops after every swim. 3. irrigate the ears with warm water and a bulb syringe after each swim. 4. rinse the ears with a warmed solution of mineral oil and hydrogen peroxide.

ANS: 2 With otitis externa (swimmer's ear), swimming causes the external canal to become waterlogged and swell; skinfolds are set up for infection. Prevent by using rubbing alcohol or 2% acetic acid ear drops after every swim.

A patient comes to the emergency department after a boxing match, and his left eye is swollen almost shut. He has bruises on his face and neck. He says he is worried because he "can't see well" from his left eye. The physician suspects retinal damage. The nurse recognizes that signs of retinal detachment include 1. loss of central vision. 2. shadow or diminished vision in one quadrant or one half visual field. 3. loss of peripheral vision. 4. sudden loss of pupillary constriction and accommodation.

ANS: 2 With retinal detachment, the person has shadow or diminished vision in one quadrant or one half visual field.

In performing a voice test to assess hearing, which of the following would the nurse do? 1. Shield the lips so that the sound is muffled. 2. Whisper two-syllable words and ask the patient to repeat them. 3. Ask the patient to place his finger in his ear to occlude outside noise. 4. Stand about 4 feet away to ensure that the patient can really hear at this distance.

ANS: 2 With your head 30 to 60 cm (1 to 2 ft) from the person's ear, exhale and whisper slowly some two-syllable words such as Tuesday, armchair, baseball, or fourteen. Normally, the person repeats each word correctly after you say it.

1. The nurse is teaching a health class to high-school-age boys. When discussing the topic of the use of smokeless tobacco (SLT), which of the following statements are accurate? (Select all that apply. 1. One pinch of SLT in the mouth for 30 minutes delivers the equivalent of one cigarette. 2. The use of SLT has been associated with a greater risk of oral cancer than smoking has. 3. Pain is an early sign of oral cancer. 4. Pain is rarely an early sign of oral cancer. 5. Tooth decay is another risk of SLT because of the use of sugar as a sweetener. 6. SLT is considered a healthy alternative to smoking.

ANS: 2, 4, 5 One pinch of SLT in the mouth for 30 minutes delivers the equivalent of three cigarettes; pain is rarely an early sign of oral cancer. Many brands of SLT are sweetened with sugars, promoting tooth decay. SLT is not considered a healthy alternative to smoking, and the use of SLT has been associated with a greater risk of oral cancer than smoking has.

The nurse is testing the hearing of a 78-year-old man and keeps in mind the changes in hearing that occur with aging, such as: (Select all that apply.) 1. Hearing loss related to aging begins in the mid 40s. 2. The progression is slow. 3. The aging person has low-frequency tone loss. 4. The aging person may find it harder to hear consonants than vowels. 5. Sounds may be garbled and difficult to localize. 6. Hearing loss reflects nerve degeneration of the middle ear.

ANS: 2, 4, 5 Presbycusis is a type of hearing loss that occurs with aging; it is a gradual sorineural loss caused by nerve degeneration in the inner ear or auditory nerve. Its onset usually occurs in the fifth decade, and then it slowly progresses. The person first notices a high-frequency tone loss; it is harder to hear consonants (high-pitched components of speech) than vowels. This makes words sound garbled. The ability to localize sound is impaired also.

During an examination, a patient states that she was diagnosed with open-angle glaucoma 2 years ago. The nurse recalls that there are various types of glaucoma, such as open-angle glaucoma and closed-angle glaucoma. Which of the following are characteristics of open-angle glaucoma? Select all that apply. 1. The patient may experience sensitivity to light, nausea, and halos around lights. 2. It is the most common type of glaucoma. 3. Immediate treatment is needed. 4. Vision loss begins with peripheral vision. 5. It causes sudden attacks of increased pressure that causes blurred vision. 6. There are virtually no symptoms

ANS: 2, 4, 6 Open-angle glaucoma is the most common type of glaucoma; there are virtually no symptoms. Vision loss begins with the peripheral vision, which often goes unnoticed because individuals learn to compensate intuitively by turning their heads. The other characteristics are those of closed-angle glaucoma.

The nurse is assessing a patient in the hospital who has received numerous antibiotics and notes that his tongue appears to be black and hairy. In response to his concern, what would the nurse say? 1. "We need to get a biopsy and see what the cause is." 2. "This is an overgrowth of hair and will go away in a few days." 3. "This is a fungal infection caused by all the antibiotics you've received." 4. "This is probably caused by the same bacteria you had in your lungs."

ANS: 3 A black, hairy tongue is not really hair but the elongation of filiform papillae and painless overgrowth of mycelial threads of fungus infection on the tongue. It occurs after the use of antibiotics, which inhibit normal bacteria and allow proliferation of fungus.

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 about 8 hours after her baby's birth, and that it seems to be getting bigger. One possible explanation for this is: 1. hydrocephalus. 2. craniosynostosis. 3. cephalhematoma. 4. caput succedaneum.

ANS: 3 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.

A patient comes into the clinic complaining of pain in her right eye. On examination, the nurse sees a pustule at the lid margin that is painful to touch, red, and swollen. The nurse recognizes that this is 1. a chalazion. 2. a hordeolum (stye). 3. dacryocystitis. 4. blepharitis.

ANS: 3 A hordeolum, or stye, is a painful, red, and swollen pustule at the lid margin.

A patient has been shown to have a sensorineural hearing loss. During the assessment, it would be important for the nurse to: 1. speak loudly so he can hear the questions. 2. assess for middle ear infection as a possible cause. 3. ask the patient what medications he is currently taking. 4. look for the source of the obstruction in the external ear.

ANS: 3 A simple increase in amplitude may not enable the person to understand words. Sensorineural hearing loss may be caused by presbycusis, a gradual nerve degenera- tion that occurs with aging and by ototoxic drugs, which affect the hair cells in the cochlea.

A 13-year old girl is interested in obtaining information about the cause of her acne. The nurse would share with her that acne is: 1.contagious. 2.caused by a poor diet. 3.found in about 70% of all teens. 4.has been found to be related to poor hygiene.

ANS: 3 About 70% of teens will have acne, and, although the cause is unknown, it is not caused by poor diet, oily complexion, or contagion.

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: 1. exophthalmos. 2. bowed long bones. 3. coarse facial features. 4. an acorn-shaped cranium.

ANS: 3 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.

During an examination of a female patient, the nurse notes lymphadenopathy and suspects an acute infection. Acutely infected lymph nodes would be: 1. clumped. 2. unilateral. 3. firm but freely movable. 4. hard and nontender.

ANS: 3 Acutely infected lymph nodes are bilateral, enlarged, warm, tender, and firm but freely movable.

A patient with a middle ear infection asks the nurse, "What does the middle ear do?" The nurse responds by telling the patient that the middle ear functions to: 1. maintain balance. 2. interpret sounds as they enter the ear. 3. conduct vibrations of sounds to the inner ear. 4. increase amplitude of sound for the inner ear to function.

ANS: 3 Among its other functions, the middle ear conducts sound vibrations from the outer ear to the central hearing apparatus in the inner ear.

The nurse is performing an assessment on a 65-year-old male. He reports a crusty nodule behind the pinna. It bleeds intermittently and has not healed over the past 6 months. On physical assessment, the nurse finds an ulcerated crusted nodule with an indurated base. The preliminary analysis in this situation is that this: 1. is most likely a benign sebaceous cyst. 2. is most likely a Darwin's tubercle and is not significant. 3. could be a potential carcinoma and should be referred. 4. is a tophus, which is common in the elderly and is a sign of gout.

ANS: 3 An ulcerated crusted nodule with an indurated base that fails to heal is characteristic of a carcinoma. These lesions fail to heal and bleed intermittently. Individuals with such symptoms should be referred for a biopsy.

During an assessment of a 20-year-old Asian patient, the nurse notices that he has dry, flaky cerumen in his canal. What is the significance of this finding? 1. This is probably the result of lesions from eczema in his ear. 2. This represents poor hygiene. 3. This is a normal finding and no further follow-up is necessary. 4. This could be indicative of change in cilia; the nurse should assess for conductive hearing loss.

ANS: 3 Asians and American Indians are more likely to have dry cerumen, whereas blacks and whites usually have wet cerumen.

During an oral assessment of a 30-year-old black patient, the nurse notes bluish lips and a dark line along the gingival margin. What would the nurse do in response to this finding? 1. Check the patient's hemoglobin for anemia. 2. Assess for other signs of insufficient oxygen supply. 3. Proceed with assessment, knowing that this is a normal finding. 4. Ask if he has been exposed to an excessive amount of carbon monoxide.

ANS: 3 Black persons normally may have bluish lips.

The nurse is assessing a 3-year-old who is here for "drainage from the nose." On assessment, it is found that there is a purulent drainage from the left nares that has a very foul odor and no drainage from the right nares. The child is afebrile with no other symptoms. What should the nurse do next? 1. Refer to the physician for an antibiotic order. 2. Have the mother bring the child back in 1 week. 3. Perform an otoscopic examination of the left nares. 4. Tell the mother that this is normal for children of this age.

ANS: 3 Children are apt to put an object up the nose, producing unilateral purulent drainage and foul odor. Because some risk for aspiration exists, removal should be prompt.

40. The nurse has discovered decreased skin turgor in a patient and knows that this is an expected finding in which of the following conditions? 1.Cases of severe obesity 2.During childhood growth spurts 3.In an individual who is severely dehydrated 4.With conditions of connective tissue disorders such as scleroderma

ANS: 3 Decreased skin turgor is associated with severe dehydration, aging, or extreme weight loss.

Which of the following would be true regarding otoscopic examination of a newborn? 1. Immobility of the drum is a normal finding. 2. An injected membrane would indicate infection. 3. The normal membrane may appear thick and opaque. 4. The appearance of the membrane is identical to that of an adult.

ANS: 3 During the first few days, the tympanic membrane often looks thickened and opaque. It may look "injected" and have a mild redness from increased vascularity.

A 92-year-old patient has had a stroke. The right side of his face is drooping. The nurse might also suspect which of the following? 1. Epistaxis 2. Agenesis 3. Dysphagia 4. Xerostomia

ANS: 3 Dysphagia is difficulty with swallowing and may occur with a variety of disorders, including stroke and other neurologic diseases.

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: 1. from behind with the nurse's hands placed firmly around his neck. 2. from the side with the nurse's eyes averted toward the ceiling and thumbs on his neck. 3. from the front with the nurse's thumbs placed on either side of his trachea and his head tilted forward. 4. from the front with the nurse's thumbs placed on either side of his trachea and his head tilted backward.

ANS: 3 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.

The nurse notices that a patient's palpebral fissures are not symmetrical. On examination, the nurse may find that there has been damage to:1. 1.CN III. 2.CN V. 3.CN VII. 4.CN VIII.

ANS: 3 Facial muscles are mediated by CN VII; asymmetry of palpebral fissures may be due to CN VII damage.

Because hair for humans is no longer needed for protection from cold or trauma, it is called: 1.vellus. 2.vagus. 3.vestigial. 4.vestibule.

ANS: 3 Hair is vestigial for humans. It no longer is needed for protection from cold or trauma.

During a well-baby check, the nurse notices that a 1-week-old infant's face looks small compared with his cranium, which seems enlarged. On further examination, the nurse also notes dilated scalp veins and downcast, or "setting sun," eyes. The nurse suspects which condition? 1. Craniotabes 2. Microcephaly 3. Hydrocephalus 4. Caput succedaneum

ANS: 3 Hydrocephalus occurs with obstruction of drainage of cerebrospinal fluid that results in excessive accumulation, increasing intracranial pressure, and 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.

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: 1. low gurgling sound best heard with the diaphragm of the stethoscope. 2. loud, whooshing, blowing sound best heard with the bell of the stethoscope. 3. soft, whooshing, pulsatile sound best heard with the bell of the stethoscope. 4. high-pitched tinkling sound best heard with the diaphragm of the stethoscope.

ANS: 3 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.

A 35-year-old pregnant woman comes to the clinic for a monthly appointment. During the assessment, the nurse notices that she has a brown patch of hyperpigmentation on her face. The nurse continues the skin assessment aware that another finding may be: 1.keratosis. 2.mitoasma. 3.linea nigra. 4.linea gravida.

ANS: 3 In pregnancy, skin changes can include striae, linea nigra, chloasma (brown patches of hyperpigmentation), and vascular spiders.

When assessing inflammation in a dark-skinned person, the nurse may need to: 1.assess the skin for cyanosis and swelling. 2.assess the oral mucosa for generalized erythema. 3.palpate the skin for edema and increased warmth. 4.palpate for tenderness and local areas of ecchymosis.

ANS: 3 Inflammation is not easily recognized, and it is often necessary to palpate the skin for increased warmth, taut surfaces that may be indicative of edema, and hardening of deep tissues or blood vessels.

An Inuit visiting Nevada from Anchorage has come to the clinic in July during the hottest part of the day. It so happens that the clinic's air conditioning is broken and the temperature is very hot. The nurse knows that which of the following is true about the Inuit sweating tendencies? 1.They will sweat profusely all over their bodies because they are not used to the hot temperatures. 2.They don't sweat because their diet is so high in roughage that their apocrine glands are less efficient in hot climates. 3.They will sweat more on their faces because this is an adaptation that has been made over time for survival in their environment. 4.They have an overabundance of eccrine sweat glands and so the nurse might expect them to have body odor because of the bacterial flora reacting with the apocrine sweat.

ANS: 3 Inuits have made an interesting environmental adaptation whereby they sweat less than whites on their trunks and extremities but more on their faces.

In assessing the sclera of a black patient, which of the following would be an expected finding? 1. Yellow fatty deposits over the cornea 2. Pallor near the outer canthus of the lower lid 3. Yellow color of the sclera that extends up to the iris 4. The presence of small brown macules on the sclera

ANS: 4 In dark-skinned people, one normally may see small brown macules in the scle

Immediately after birth, the nurse is unable to suction the nares of a newborn. An attempt is made to pass a catheter through both nasal cavities with no success. What would be the nurse's best response? 1. Attempt to suction again with a bulb syringe. 2. Wait a few minutes and try again once the infant stops crying. 3. Recognize this is a situation that requires immediate intervention. 4. Contact the physician and request assistance when he gets a chance.

ANS: 3 It is essential to determine patency of the nares in the immediate newborn period because most newborns are obligate nose breathers. Nares blocked with amniotic fluid are suctioned gently with a bulb syringe. If obstruction is suspected, a small lumen (5F to 10F) catheter is passed down each naris to confirm patency. The inability to pass a catheter through the nasal cavity indicates choanal atresia, which needs immediate intervention.

29. During a hearing assessment the nurse finds that sound lateralizes to the patient's left ear with the Weber test. What can the nurse conclude from this? 1. The patient has a conductive hearing loss in the right ear. 2. Lateralization is a normal finding with the Weber test. 3. The patient could have either a sensorineural or a conductive loss. 4. A mistake has occurred; the test must be repeated.

ANS: 3 It is necessary to perform the Weber and Rinne tests to determine the type of loss. With conductive loss, sound lateralizes to the "poorer" ear owing to background room noise. With sensorineural loss, sound lateralizes to the "better" ear or unaffected ear.

A 70-year-old woman who loves to garden has small, flat, brown macules over her arms and hands. She asks, "What causes these liver spots?" The nurse tells her: 1."They are signs of decreased hematocrit related to anemia." 2."They are due to destruction of melanin in your skin from exposure to the sun." 3."They are clusters of melanocytes that appear after extensive sun exposure." 4."They are areas of hyperpigmentation related to decreased perfusion and vasoconstriction."

ANS: 3 Liver spots, or senile lentigines, are clusters of melanocytes that appear on the forearms and dorsa of the hands after extensive sun exposure.

The nurse notices that the mother of a 2-year-old boy brings him into the clinic quite frequently for various injuries and suspects there may be some child abuse involved. In doing the inspection of his mouth, the nurse should inspect for: 1. swollen, red tonsils. 2. ulcerations on the hard palate. 3. bruising on the buccal mucosa or gums. 4. small yellow papules along the hard palate.

ANS: 3 Note any bruising or laceration on the buccal mucosa or gums of an infant or young child. Trauma may indicate child abuse from a forced feeding of a bottle or spoon.

During an examination, the nurse knows that Paget's disease would be indicated by which of the following findings? 1. Positive Macewen's sign 2. Premature closure of the sagittal suture 3. Headache, vertigo, tinnitus, and deafness 4. Elongated head with heavy eyebrow ridge

ANS: 3 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.

A black patient is in the intensive care unit because of impending shock after an accident. The nurse would expect to find what characteristics in this patient's skin? 1.Ruddy blue 2.Generalized pallor 3.Ashen, gray, or dull 4.Patchy areas of pallor

ANS: 3 Pallor in black-skinned people will appear ashen, gray, or dull. See Table 12-2.

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 approxi- mately 0.5 cm in size, round, mobile, and nontender. The nurse suspects that this: 1. child has chronic allergies. 2. child may have an infection. 3. is a normal finding for a well child of this age. 4. child should be referred for additional evaluation.

ANS: 3 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.

The nurse notes the presence of periorbital edema when performing an eye assessment on a 70-year-old patient. The nurse will: 1. check for the presence of exophthalmos. 2. suspect that the patient has hyperthyroidism. 3. ask the patient if he or she has a history of heart failure. 4. assess for blepharitis because this is often associated with periorbital edema.

ANS: 3 Periorbital edema occurs with local infections, crying, and systemic conditions such as heart failure, renal failure, allergy, and hypothyroidism.

A 60-year-old man is at the clinic for an eye examination. The nurse suspects that he has a ptosis of one eye. How would the nurse check for this? 1. Perform the confrontation test. 2. Assess the individual's near vision. 3. Observe the distance between the palpebral fissures. 4. Perform the corneal light test and look for symmetry of the light reflex.

ANS: 3 Ptosis is drooping of the upper eyelid that would be apparent by observing the distance between the upper and lower eyelids.

The nurse is performing an otoscopic examination on an adult. Which of the following is true? 1. Tilt the person's head forward during the exam. 2. Once the speculum is in the ear, release the traction. 3. Pull the pinna up and back before inserting the speculum. 4. Use the smallest speculum to decrease the amount of discomfort.

ANS: 3 Pull the pinna up and back on an adult or older child. This helps straighten the S- shape of the canal.

A physician has diagnosed a patient with purpura. After leaving the room, a nursing student asks the nurse what the physician saw that led to that diagnosis. The nurse should say: 1."He is referring to that blue dilation of blood vessels in a star-shaped linear pattern on the legs." 2."He is referring to that fiery red, star-shaped marking on the cheek that has a solid circular center." 3."He is referring to that confluent and extensive patch of petechiae and ecchymoses on the feet." 4."He is referring to those tiny little areas of hemorrhage that are less than 2 mm, round, discrete, and dark red in color."

ANS: 3 Purpura is a confluent and extensive patch of petechiae and ecchymoses and a flat macular hemorrhage seen in generalized disorders such as thrombocytopenia and scurvy.

During the aging process, the hair can look gray or white and begin to feel thin and fine. The nurse knows that this is because of a decrease in the number of functioning: 1.metrocytes. 2.fungacytes. 3.phagocytes. 4.melanocytes.

ANS: 4 In the aging hair matrix, the number of functioning melanocytes decreases so the hair looks gray or white and feels thin and fine.

A patient comes into the clinic complaining of facial pain, fever, and malaise. On examination, the nurse notes swollen turbinates and purulent discharge from the nose. The patient also complains of a dull, throbbing pain in his cheeks and teeth on the right side and pain when the nurse palpates the areas. The nurse recognizes that this patient has: 1. posterior epistaxis. 2. frontal sinusitis. 3. maxillary sinusitis. 4. nasal polyps.

ANS: 3 Signs include facial pain, after upper respiratory infection, red swollen nasal mucosa, swollen turbinates, and purulent discharge. Person also has fever, chills, and malaise. With maxillary sinusitis, dull throbbing pain occurs in cheeks and teeth on the same side, and pain with palpation is present. With frontal sinusitis, pain is above the supraorbital ridge

When examining a patient's eyes, the nurse recalls that stimulation of the sympathetic branch of the autonomic nervous system: 1. causes pupillary constriction. 2. adjusts the eye for near vision. 3. elevates the eyelid and dilates the pupil. 4. causes contraction of the ciliary body.

ANS: 3 Stimulation of the sympathetic branch dilates the pupil and elevates the eyelid.

To assess color vision on a male child, the nurse would: 1. check color vision annually until the age of 18 years. 2. ask the child to identify the color of his or her clothing. 3. test for color vision once between the ages of 4 and 8. 4. begin color vision screening at the child's 2-year check-up.

ANS: 3 Test only boys for color vision once between the ages of 4 and 8 years.

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: 1.just above the diaphragm. 2.just lateral to the knee cap. 3.at the level of the C7 vertebra. 4.at the level of the T11 vertebra.

ANS: 3 The C7 vertebra has a long spinous process, called the vertebra prominens, that is palpable when the head is flexed.

The nurse is preparing to assess the visual acuity of a 16-year-old patient. How would the nurse proceed? 1. Perform the confrontation test. 2. Ask the patient to read the print on a hand-held Jaeger card. 3. Use the Snellen chart positioned 20 feet away from the patient. 4. Determine the patient's ability to read newsprint at a distance of 12 to 14 inches.

ANS: 3 The Snellen alphabet chart is the most commonly used and accurate measure of visual acuity.

During an examination, the nurse finds that a patient's left temporal artery is more tortuous and feels hardened and tender compared with the right temporal artery. The nurse suspects which condition? 1. Crepitation 2. Mastoiditis 3. Temporal arteritis 4. Bell's palsy

ANS: 3 The artery looks more tortuous and feels hardened and tender with temporal arteritis.

During an assessment of a 26-year-old at the clinic for "a spot on my lip I think is cancer" the nurse notes the following findings: a group of clear vesicles with an erythematous base around them located at the lip-skin border. The patient mentions that she just returned from Hawaii. What would be the most appropriate response by the nurse? 1. Tell the patient she will need to see a skin specialist. 2. Discuss the benefits of having a biopsy done of any unusual lesion. 3. Tell the patient this is herpes simplex I and will heal in 4 to 10 days. 4. Tell the patient that this is most likely the result of a riboflavin deficiency and discuss nutrition.

ANS: 3 The cold sores are groups of clear vesicles with a surrounding erythematous base. These evolve into pustules or crusts and heal in 4 to 10 days. The most likely site is the lip-skin junction. Infection often recurs in the same site. It may be precipitated by sunlight, fever, colds, or allergy.

The nurse is examining a patient's ears and notices cerumen in the external canal. Which of the following statements about cerumen is correct? 1. Sticky honey-colored cerumen is a sign of infection. 2. The presence of cerumen is indicative of poor hygiene. 3. The purpose of cerumen is to protect and lubricate the ear. 4. Cerumen is necessary for transmitting sound through the auditory canal.

ANS: 3 The ear is lined with glands that secrete cerumen, a yellow waxy material that lubricates and protects the ear.

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? 1. Diets low in protein and high in carbohydrates may cause enhanced facial bones. 2. It is probably because she doesn't use a dermatologically approved moisturizer. 3. It is probably due to a combination of factors such as decreased elasticity, subcutaneous fat, and moisture in her skin. 4. Facial skin becomes more elastic with age. This increased elasticity causes the skin to be more taught, drawing attention to the facial bones.

ANS: 3 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 mother is concerned that her 18-month-old has 12 teeth. She is wondering if this is normal for a child of this age. The nurse's best response would be: 1. "How many teeth did you have at this age?" 2. "All 20 deciduous teeth are expected to erupt by age 4 years." 3. "This is a normal number of teeth for an 18-month-old." 4. "Normally, by age 2 1/2, 16 deciduous teeth are expected."

ANS: 3 The guidelines for the number of teeth for children under 2 years old are as follows: the child's age in months minus the number 6 should be equal to the expected number of deciduous teeth. Normally, all 20 teeth are in by 21/2 years old. In this instance, the child is 18 months old, minus 6, equals 12 deciduous teeth expected.

Which of the following cranial nerves is responsible for conducting nerve impulses to the brain from the organ of Corti? 1. CN I 2. CN III 3. CN VIII 4. CN XI

ANS: 3 The nerve impulses are conducted by the auditory portion of CN VIII to the brain.

A newborn infant is in the clinic for a well-baby check. The nurse observes the infant for the possibility of fluid loss because of which of the following? 1.Subcutaneous fat deposits are high in the newborn 2.Sebaceous glands are over productive in the newborn 3.The newborn's skin is more permeable than that of the adult 4.The amount of vernix caseosa rises dramatically in the newborn

ANS: 3 The newborn's skin is thin, smooth, and elastic and is relatively more permeable than that of the adult, so the infant is at greater risk for fluid loss.

When a light is directed across the iris of the eye from the temporal side, the examiner is assessing for: 1. drainage from dacryocystitis. 2. the presence of conjunctivitis over the iris. 3. the presence of shadows, which may indicate glaucoma. 4. a scattered light reflex, which may be indicative of cataracts.

ANS: 3 The presence of shadows in the anterior chamber may be a sign of acute angle- closure glaucoma.

In using the ophthalmoscope to assess a patient's eyes, the nurse notes a red glow in the patient's pupils. On the basis of this finding, the nurse would: 1. suspect that there is an opacity in the lens or cornea. 2. check the light source of the ophthalmoscope to verify that it is functioning. 3. consider this a normal reflection of the ophthalmoscope light off the inner retina. 4. continue with the ophthalmoscopic examination and refer the patient for further evaluation.

ANS: 3 The red glow filling the person's pupil is the red reflex. This is caused by the reflection of the ophthalmoscope light off the inner retina.

During an assessment of an 80-year-old patient, the nurse would expect to find: 1. hypertrophy of the gums. 2. an increased production of saliva. 3. a decreased ability to identify odors. 4. finer and less prominent nasal hair.

ANS: 3 The sense of smell may be reduced because of a decrease in the number of olfactory nerve fibers.

The temporomandibular joint is just below the temporal artery and anterior to the:1. hyoid. 2. vagus. 3. tragus. 4. mandible.

ANS: 3 The temporomandibular joint is just below the temporal artery and anterior to the tragus.

During an examination of a patient in her third trimester of pregnancy, the nurse notices that the patient's thyroid gland is slightly enlarged. No enlargement had been noted previously. The nurse suspects that: 1. she has an iodine deficiency. 2. she is exhibiting early signs of goiter. 3. this is a normal finding during pregnancy. 4. further tests are needed for possible thyroid cancer.

ANS: 3 The thyroid gland enlarges slightly during pregnancy owing to hyperplasia of the tissue and increased vascularity.

During an examination, the patient states he is hearing a buzzing sound and says that it is "driving me crazy!" The nurse recognizes that this symptom is: 1. vertigo. 2. pruritus. 3. tinnitus. 4. cholesteatoma.

ANS: 3 Tinnitus is a sound that comes from within a person; it can be a ringing, crackling, or buzzing sound. It accompanies some hearing or ear disorders.

When assessing the pupillary light reflex, the nurse should use which technique? 1. Shine a penlight from directly in front of the patient and inspect for pupillary constriction. 2. Ask the patient to follow the penlight in eight directions and observe for bilateral pupil constriction. 3. Shine a light across the pupil from the side and observe for direct and consensual pupillary constriction. 4. Ask the patient to focus on a distant object. Then ask the patient to follow the penlight to about 7 cm from the nose.

ANS: 3 To test the pupillary light reflex, advance a light in from the side and note the direct and consensual pupillary constriction.

When examining the face, the nurse is aware that the two pairs of salivary glands that are accessible to examination are the _____ glands. 1. occipital and submental 2. parotid and jugulodigastric 3. parotid and submandibular 4. submandibular and occipital

ANS: 3 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.

In a patient who has anisocoria, the nurse would expect to observe: 1. dilated pupils. 2. excessive tearing. 3. pupils of unequal size. 4. an uneven curvature of the lens.

ANS: 3 Unequal pupil size is termed anisocoria. It exists normally in 5% of the population but may also be indicative of central nervous system disease.

A patient has been diagnosed with strep throat. The nurse is aware that without treatment which complication may occur? 1. Rubella 2. Leukoplakia 3. Rheumatic fever 4. Scarlet fever

ANS: 3 Untreated strep throat may lead to rheumatic fever. When performing a health history, ask whether the patient's sore throats were documented as streptococcal.

A patient is especially worried about an area of skin on her feet that has turned white. The health care provider has told her that her condition is vitiligo. The nurse explains to her that vitiligo is: 1.caused by an excess of melanin pigment. 2.caused by an excess of apocrine glands in her feet. 3.caused by the complete absence of melanin pigment. 4.related to impetigo and that it can be treated with an ointment.

ANS: 3 Vitiligo is the complete absence of melanin pigment in patchy areas of white or light skin on the face, neck, hands, feet, body folds, and around orifices—otherwise the depigmented skin is normal.

During an otoscopic examination, the nurse notes an area of black and white dots on the tympanic membrane and ear canal wall. What does this finding suggest? 1. Malignancy 2. Viral infection 3. Blood in the middle ear 4. Yeast or fungal infection

ANS: 4 A colony of black or white dots on the drum or canal wall suggests a yeast or fungal infection (otomycosis).

A patient comes into the emergency department after an accident at work. A machine blew dust into his eyes and he was not wearing safety glasses. The nurse examines his corneas by shining a light from the side across the cornea. What findings would suggest that he has suffered a corneal abrasion? 1. Smooth and clear corneas 2. Opacity of the lens behind the cornea 3. Bleeding from the areas across the cornea 4. A shattered look to the light rays reflecting off the cornea

ANS: 4 A corneal abrasion causes irregular ridges in reflected light, producing a shattered look to light rays.

A mother brings her 4-month-old to the clinic with concerns regarding a small pad in the middle of the upper lip that has been there since 1 month of age. The infant has no health problems. On physical examination, the nurse notes a 0.5-cm, fleshy, elevated area in the middle of the upper lip. There is no evidence of inflammation or drainage. What would the nurse tell this mother? 1. "This is an area of irritation caused from teething and is nothing to worry about." 2. "This is an abnormal finding and should be evaluated by another health care provider." 3. "This is the result of chronic drooling and should resolve within the next month or two." 4. "This is a sucking tubercle caused from the friction of breast- or bottle-feeding and is normal."

ANS: 4 A normal finding in infants is the sucking tubercle, a small pad in the middle of the upper lip from the friction of breast- or bottle-feeding.

The nurse notices that a patient has a solid, elevated, circumscribed lesion that is less than 1 cm in diameter. When documenting this finding, the nurse would report this as a: 1.bulla. 2.wheal. 3.nodule. 4.papule.

ANS: 4 A papule is something one can feel, is solid, elevated, circumscribed, less than 1 cm diameter, and is due to superficial thickening in the epidermis.

The nurse is bathing an 80-year-old man and notices that his skin is wrinkled, thin, lax, and dry. This finding would be related to: 1.increased vascularity of the skin in the elderly. 2.increased numbers of sweat and sebaceous glands in the elderly. 3.an increase in elastin and a decrease in subcutaneous fat in the elderly. 4.an increased loss of elastin and a decrease in subcutaneous fat in the elderly.

ANS: 4 An accumulation of factors place the aging person at risk for skin disease and breakdown: the thinning of the skin, the decrease in vascularity and nutrients, the loss of protective cushioning of the subcutaneous layer, a lifetime of environmental trauma to skin, the social changes of aging, the increasingly sedentary lifestyle, and the chance of immobility.

When assessing the tongue of an adult, the nurse knows that an abnormal finding would be: 1. A painful vesicle inside the cheek for 2 days 2. The presence of moist, nontender Stenson's ducts 3. Stippled gingival margins that adhere snugly to the teeth 4. An ulceration on the side of the tongue with rolled edges.

ANS: 4 An ulceration on the side, base, or under the tongue raises the suspicion of cancer and must be investigated. Risk of early metastasis is present because of rich lymphatic drainage.

Which of the following best describes the test the nurse should use to assess the function of cranial nerve X? 1. Observe the patient's ability to articulate specific words. 2. Assess movement of the hard palate and uvula with the gag reflex. 3. Have the patient stick out the tongue and observe for tremors or pulling to one side. 4. Ask the patient to say "ahhh" and watch for movement of the soft palate and uvula.

ANS: 4 Ask the person to say "ahhh" and note that the soft palate and uvula rise in the midline. This tests one function of CN X, the vagus nerve.

A 65-year-old man with emphysema and bronchitis has come to the clinic for a follow-up appointment. On assessment of his skin, the nurse might expect to find the following: 1.anasarca. 2.scleroderma. 3.pedal erythema. 4.clubbing of the nails.

ANS: 4 Clubbing of the nails occurs with congenital, chronic, cyanotic heart disease and with emphysema and chronic bronchitis.

A woman is leaving on a trip to Hawaii and has come in for a checkup. During the examination the nurse notices that she is diabetic and takes oral hypoglycemic agents. She needs to be concerned about which of the following? 1.An increased possibility of bruising 2.Skin sensitivity as a result of exposure to salt water 3.Lack of availability of glucose monitoring supplies 4.The importance of sunscreen and avoiding direct sunlight

ANS: 4 Drugs that may increase sunlight sensitivity and give burn response include sulfonamides, thiazide diuretics, oral hypoglycemic agents, and tetracycline.

A patient comes to the clinic and states that he has noticed that his skin is redder than normal. The nurse understands this condition to be due to hyperemia and knows that it can be caused by: 1.decreased amounts of bilirubin in the blood. 2.excess blood in the underlying blood vessels. 3.decreased perfusion to the surrounding tissues. 4.excess blood in the dilated superficial capillaries.

ANS: 4 Erythema is an intense redness of the skin caused by excess blood (hyperemia) in the dilated superficial capillaries.

A 52-year-old patient describes the presence of occasional "floaters or spots" moving in front of his eyes. The nurse should: 1. examine the retina to determine the number of floaters. 2. presume the patient has glaucoma and refer him for further testing. 3. consider this an abnormal finding and refer him to an ophthalmologist. 4. know that "floaters" are usually not significant and are caused by condensed vitreous fibers.

ANS: 4 Floaters are a common sensation with myopia or after middle age owing to condensed vitreous fibers. Usually, they are not significant.

A 32-year-old woman is at the clinic for "little white bumps in my mouth." During the assessment, the nurse notes that she has a 0.5 cm white, nontender papule under her tongue and one on the mucosa of her right cheek. What would the nurse tell the patient? 1. "These spots are seen with infections such as strep throat." 2. "These could be indicative of a serious lesion, so I will refer you to a specialist." 3. "This is called leukoplakia and can be caused by chronic irritation such as smoking." 4. "These bumps are Fordyce's granules, which are sebaceous cysts and not a serious condition."

ANS: 4 Fordyce's granules are small, isolated white or yellow papules on the mucosa of the cheek, tongue, and lips. These little sebaceous cysts are painless and not significant.

An assessment of a 23-year-old patient reveals the following: an auricle that is tender and reddish-blue in color with small vesicles. Additional information the nurse would need to know includes which of the following? 1. Any change in the ability to hear 2. Any recent drainage from the ear 3. Recent history of trauma to the ear 4. Any prolonged exposure to extreme cold

ANS: 4 Frostbite causes reddish-blue discoloration and swelling of the auricle after exposure to extreme cold. Vesicles or bullae may develop, and the person feels pain and tenderness.

A pregnant woman states that she is concerned about her gums because she has noticed they are swollen and have started bleeding. What would be an appropriate response by the nurse? 1. "This is probably due to a vitamin C deficiency." 2. "I'm not sure what causes it but let me know if it's not better in a few weeks." 3. "You need to make an appointment with your dentist as soon as possible to have this checked." 4. "This can be caused by the change in hormone balance in your system when you're pregnant."

ANS: 4 Gingivitis is when gum margins are red and swollen and bleed easily. The condition may occur in pregnancy and puberty because of a changing hormonal balance.

During an interview, the patient states he has the sensation that "everything around him is spinning." The nurse recognizes that the portion of the ear responsible for this sensation is: 1. the cochlea. 2. cranial nerve VIII. 3. the organ of Corti. 4. the bony labyrinth.

ANS: 4 If the labyrinth ever becomes inflamed, it feeds the wrong information to the brain, creating a staggering gait and a strong, spinning, whirling sensation called vertigo.

In performing an examination of a 3-year-old with a suspected ear infection, the nurse would: 1. omit the otoscopic exam if the child has a fever. 2. pull the ear up and back before inserting the speculum. 3. ask the mother to leave the room while examining the child. 4. perform the otoscopic examination at the end of the assessment.

ANS: 4 In addition to its place in the complete examination, eardrum assessment is manda- tory for any infant or child requiring care for illness or fever. For the infant or young child, the timing of the otoscopic examination is best toward the end of the complete examination.

Intraocular pressure is determined by the: 1. thickness or bulging of the lens. 2. posterior chamber as it accommodates for an increase in fluid. 3. contraction of the ciliary body in response to the aqueous within the eye. 4. amount of aqueous produced and resistance to its outflow at the angle of the anterior chamber.

ANS: 4 Intraocular pressure is determined by a balance between the amount of aqueous produced and resistance to its outflow at the angle of the anterior chamber.

A patient has had a "terrible itch" for several months that he has been scratching continuously. On examination, the nurse might expect to find: 1.a keloid. 2.a fissure. 3.keratosis. 4.lichenification.

ANS: 4 Lichenification results from prolonged, intense scratching that eventually thickens the skin and produces tightly packed sets of papules.

During ocular examinations, the nurse keeps in mind that movement of the extraocular muscles is: 1. decreased in the elderly. 2. impaired in a patient with cataracts. 3. stimulated by cranial nerves I and II. 4. stimulated by cranial nerves III, IV, and VI.

ANS: 4 Movement of the extraocular muscles is stimulated by three cranial nerves: III, IV, and VI.

The nurse is aware that the four areas in the body where lymph nodes are accessible are the: 1. head, breasts, groin, and abdomen. 2. arms, breasts, inguinal area, and legs. 3. head and neck, arms, breasts, and axillae. 4. head and neck, arms, inguinal area, and axillae.

ANS: 4 Nodes are located throughout the body, but are accessible to examination only in four areas: head and neck, arms, axillae, and inguinal region.

Which of the following is true in relation to a newborn infant? 1. The sphenoid sinuses are full size at birth. 2. The maxillary sinuses reach full size after puberty. 3. The frontal sinuses are fairly well developed at birth. 4. The maxillary and ethmoid sinuses are the only ones present at birth.

ANS: 4 Only the maxillary and ethmoid sinuses are present at birth.

An ophthalmic examination reveals papilledema. The nurse is aware that this finding indicates: 1. retinal detachment. 2. diabetic retinopathy. 3. acute-angle glaucoma. 4. increased intracranial pressure.

ANS: 4 Papilledema, or choked disk, is caused by increased intracranial pressure, which is caused by a space-occupying mass such as a brain tumor or hematoma. This pressure causes venous stasis in the globe, redness, congestion, and elevation of the optic disc, blurred margins, hemorrhages, and absent venous pulsations.

Which of the following is a risk factor for ear infections in young children? 1. Family history 2. Air conditioning 3. Excessive cerumen 4. Secondhand cigarette smoke

ANS: 4 Passive or second hand smoke is a risk factor for ear infections.

A newborn infant has Down syndrome. During the skin assessment, the nurse notices a transient mottling in the trunk and extremities in response to the cooler examination room temperature. The infant's mother also notices the mottling and asks what it is. The nurse knows that this mottling is called: 1.café au lait. 2.carotenemia. 3.acrocyanosis. 4.cutis marmorata.

ANS: 4 Persistent or pronounced cutis marmorata occurs with Down syndrome or prematurity and is a transient mottling in the trunk and extremities in response to cooler room temperatures.

While obtaining a history from the mother of a 1-year-old, the nurse notices that the baby has had a bottle in his mouth the entire time. The mother states, "it makes a great pacifier." The best response by the nurse would be: 1. "You're right, bottles make very good pacifiers." 2. "Use of a bottle is better for the teeth than thumb sucking." 3. "It's okay to do this as long as the bottle contains milk and not juice." 4. "Prolonged use of a bottle can increase the risk for tooth decay and ear infections."

ANS: 4 Prolonged use of a bottle during the day or when going to sleep places the infant at risk for tooth decay and middle ear infections.

A man has come in to the clinic for a skin assessment because he is afraid he might have skin cancer. During the skin assessment the nurse notices several areas of pigmentation that look greasy, dark, and "stuck on" his skin. Which is the best prediction? 1.He probably has senile lentigines, which do not become cancerous. 2.He probably has actinic keratoses, a precursor to basal cell carcinoma. 3.He probably has acrochordons, precursors to squamous cell carcinoma. 4.He probably has seborrheic keratoses, which do not become cancerous.

ANS: 4 Seborrheic keratoses look like dark, greasy, "stuck-on" lesions that develop mostly on the trunk. These lesions do not become cancerous.

The nurse is performing an eye-screening clinic at the day care center. When examining a 2-year-old child, the nurse suspects that the child has "lazy eye" and would: 1. examine the external structures of the eye. 2. assess visual acuity with the Snellen eye chart. 3. assess the child's visual fields with the confrontation test. 4. test for strabismus by performing the corneal light reflex test.

ANS: 4 Testing for strabismus is done by performing the corneal light reflex test. The light should be reflected at exactly the same spot in both eyes.

The mother of a 2-year-old is concerned because her son has had three ear infections in the past year. What would be an appropriate response by the nurse? 1. "It is unusual for a small child to have frequent ear infections unless there is something else wrong." 2. "We need to check the immune system of your son to see why he is having so many ear infections." 3. "Ear infections are not uncommon in infants and toddlers because they tend to have more cerumen in the external ear." 4. "Your son's eustachian tube is shorter and wider than yours because of his age, which allows for infections to develop more easily."

ANS: 4 The infant's eustachian tube is relatively shorter and wider, and its position is more horizontal than the adult's, so it is easier for pathogens from the nasopharynx to migrate through to the middle ear.

In an individual with otitis externa, which of the following signs would the nurse expect to find on assessment? 1. Rhinorrhea 2. Periorbital edema 3. Pain over the maxillary sinuses 4. Enlarged superficial cervical nodes

ANS: 4 The lymphatic drainage of the external ear flows to the parotid, mastoid, and superficial cervical nodes. The signs are severe swelling of the canal, inflammation, and tenderness.

Which of the following assessment findings is most consistent with clubbing of the fingernails? 1.A nail base that is firm to palpation and slightly tender 2.Curved nails with a convex profile and ridges across the nail 3.A nail base that feels spongy with an angle of the nail base of 150 degrees 4.An angle of the nail base of 180 degrees or greater with a nail base that feels spongy

ANS: 4 The normal nail is firm at its base and has an angle of 160 degrees. In clubbing, the angle straightens to 180 degrees or greater and the nail base feels spongy.

A patient has a normal pupillary light reflex. The nurse recognizes that this indicates that: 1. the eyes converge to focus on the light. 2. light is reflected at the same spot in both eyes. 3. the eye focuses the image in the center of the pupil. 4. constriction of both pupils occurs in response to bright light.

ANS: 4 The pupillary light reflex is the normal constriction of the pupils when bright light shines on the retina.

During an examination of the eye, the nurse would expect what normal finding when assessing the lacrimal apparatus? 1. The presence of tears along the inner canthus 2. A blocked nasolacrimal duct in a newborn infant 3. A slight swelling over the upper lid and along the bony orbit if the individual has a cold 4. The absence of drainage from the puncta when pressing against the inner orbital rim

ANS: 4 There should be no swelling, redness, or drainage from the puncta.

A mother brings her child in to the clinic for an examination of the scalp and hair. She states that the child has developed some places where there are irregularly shaped patches with broken-off, stub-like hair and she is worried that this could be some form of premature baldness. She tells the nurse that the child's hair is always kept very short. The nurse reassures her by telling her that it is: 1.folliculitis and that it can be treated with an antibiotic. 2.traumatic alopecia that can be treated with antifungal medications. 3.tinea capitis and that it is highly contagious and needs immediate attention. 4.trichotillomania and that her child probably has a habit of twirling her hair absent- mindedly.

ANS: 4 Trichotillomania, self-induced hair loss, is usually due to habit. It forms irregularly- shaped patches with broken-off, stub-like hairs of varying lengths. A person is never completely bald. It occurs as a child rubs or twirls the area absently while falling asleep, reading, or watching television.

The nurse is taking the history of a patient who may have a perforated eardrum. What would be an important question in this situation? 1. "Do you ever notice ringing or crackling in your ears?" 2. "When was the last time you had your hearing checked?" 3. "Have you ever been told you have any type of hearing loss?" 4. "Was there any relationship between the ear pain and the discharge you mentioned?"

ANS: 4 Typically with perforation, ear pain occurs first, stopping with a popping sensation, and then drainage occurs.

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: 1. infraclavicular area. 2. supraclavicular area. 3. area distal to the enlarged node. 4. area proximal to the enlarged node.

ANS: 4 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.

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: 1. Cushing's syndrome. 2. Parkinson's syndrome. 3. Bell's palsy. 4. had a cerebrovascular accident (stroke).

ANS: 4 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.

The nurse notices that a patient has bluish-white, red-based spots in her mouth that are elevated about 1 mm to 3 mm. What other signs would the nurse expect to find in this patient? 1.A pink, papular rash on the face and neck 2.Pruritic vesicles over her trunk and neck 3.Hyperpigmentation on the chest, abdomen, and the back of the arms 4.A red-purple, maculopapular, blotchy rash behind the ears and on the face

ANS: 4 With measles (rubeola), the examiner would assess a red-purple, blotchy rash on the third or fourth day of illness that appears first behind the ears and spreads over the face and then over the neck, trunk, arms and legs. It looks coppery and does not blanch. Koplik's spots in the mouth would also be found.

11. A 21-year-old patient has a head injury resulting from trauma and is unconscious. There are no other injuries. During the assessment what would the nurse expect to find when testing the patient's deep tendon reflexes? a. Reflexes will be normal. b. Reflexes cannot be elicited. c. All reflexes will be diminished but present. d. Some reflexes will be present, depending on the area of injury.

ANS: A A reflex is a defense mechanism of the nervous system. It operates below the level of conscious control and permits a quick reaction to potentially painful or damaging situations.

33. In the assessment of a 1-month-old infant, the nurse notices a lack of response to noise or stimulation. The mother reports that in the last week he has been sleeping all of the time, and when he is awake all he does is cry. The nurse hears that the infant's cries are very high pitched and shrill. What should be the nurse's appropriate response to these findings? a. Refer the infant for further testing. b. Talk with the mother about eating habits. c. Do nothing; these are expected findings for an infant this age. d. Tell the mother to bring the baby back in 1 week for a recheck.

ANS: A A high-pitched, shrill cry or cat-sounding screech occurs with central nervous system damage. Lethargy, hyporeactivity, and hyperirritability, as well as the parent's report of significant changes in behavior all warrant referral. The other options are not correct responses.

35. To assess the head control of a 4-month-old infant, the nurse lifts up the infant in a prone position while supporting his chest. The nurse looks for what normal response? The infant: a. Raises the head, and arches the back. b. Extends the arms, and drops down the head. c. Flexes the knees and elbows with the back straight. d. Holds the head at 45 degrees, and keeps the back straight.

ANS: A At 3 months of age, the infant raises the head and arches the back as if in a swan dive. This response is the Landau reflex, which persists until 1 years of age (see Figure 23-43). The other responses are incorrect.

46. In a person with an upper motor neuron lesion such as a cerebrovascular accident, which of these physical assessment findings should the nurse expect? a. Hyperreflexia b. Fasciculations c. Loss of muscle tone and flaccidity d. Atrophy and wasting of the muscles

ANS: A Hyperreflexia, diminished or absent superficial reflexes, and increased muscle tone or spasticity can be expected with upper motor neuron lesions. The other options reflect a lesion of lower motor neurons (see Table 23-7).

38. During the assessment of an 80-year-old patient, the nurse notices that his hands show tremors when he reaches for something and his head is always nodding. No associated rigidity is observed with movement. Which of these statements is most accurate? a. These findings are normal, resulting from aging. b. These findings could be related to hyperthyroidism. c. These findings are the result of Parkinson disease. d. This patient should be evaluated for a cerebellar lesion.

ANS: A Senile tremors occasionally occur. These benign tremors include an intention tremor of the hands, head nodding (as if saying yes or no), and tongue protrusion. Tremors associated with Parkinson disease include rigidity, slowness, and a weakness of voluntary movement. The other responses are incorrect.

29. The nurse is testing the deep tendon reflexes of a 30-year-old woman who is in the clinic for an annual physical examination. When striking the Achilles heel and quadriceps muscle, the nurse is unable to elicit a reflex. The nurse's next response should be to: a. Ask the patient to lock her fingers and pull. b. Complete the examination, and then test these reflexes again. c. Refer the patient to a specialist for further testing. d. Document these reflexes as 0 on a scale of 0 to 4+.

ANS: A Sometimes the reflex response fails to appear. Documenting the reflexes as absent is inappropriate this soon in the examination. The nurse should try to further encourage relaxation, varying the person's position or increasing the strength of the blow. Reinforcement is another technique to relax the muscles and enhance the response. The person should be asked to perform an isometric exercise in a muscle group somewhat away from the one being tested. For example, to enhance a patellar reflex, the person should be asked to lock the fingers together and pull.

49. The nurse knows that determining whether a person is oriented to his or her surroundings will test the functioning of which structure(s)? a. Cerebrum b. Cerebellum c. CNs d. Medulla oblongata

ANS: A The cerebral cortex is responsible for thought, memory, reasoning, sensation, and voluntary movement. The other structures are not responsible for a person's level of consciousness.

2. The wife of a 65-year-old man tells the nurse that she is concerned because she has noticed a change in her husband's personality and ability to understand. He also cries very easily and becomes angry. The nurse recalls that the cerebral lobe responsible for these behaviors is the __________ lobe. a. Frontal b. Parietal c. Occipital d. Temporal

ANS: A The frontal lobe has areas responsible for personality, behavior, emotions, and intellectual function. The parietal lobe has areas responsible for sensation; the occipital lobe is responsible for visual reception; and the temporal lobe is responsible for hearing, taste, and smell.

43. During an assessment of a 62-year-old man, the nurse notices the patient has a stooped posture, shuffling walk with short steps, flat facial expression, and pill-rolling finger movements. These findings would be consistent with: a. Parkinsonism. b. Cerebral palsy. c. Cerebellar ataxia. d. Muscular dystrophy.

ANS: A The stooped posture, shuffling walk, short steps, flat facial expression, and pill-rolling finger movements are all found in parkinsonism. (See Table 23-8 for more information and for the descriptions of the other options.)

34. Which of these tests would the nurse use to check the motor coordination of an 11-month-old infant? a. Denver II b. Stereognosis c. Deep tendon reflexes d. Rapid alternating movements

ANS: A To screen gross and fine motor coordination, the nurse should use the Denver II with its age-specific developmental milestones. Stereognosis tests a person's ability to recognize objects by feeling them and is not appropriate for an 11-month-old infant. Testing the deep tendon reflexes is not appropriate for checking motor coordination. Testing rapid alternating movements is appropriate for testing coordination in adults.

15. During the taking of the health history, a patient tells the nurse that "it feels like the room is spinning around me." The nurse would document this finding as: a. Vertigo. b. Syncope. c. Dizziness. d. Seizure activity.

ANS: A True vertigo is rotational spinning caused by a neurologic dysfunction or a problem in the vestibular apparatus or the vestibular nuclei in the brainstem. Syncope is a sudden loss of strength or a temporary loss of consciousness. Dizziness is a lightheaded, swimming sensation. Seizure activity is characterized by altered or loss of consciousness, involuntary muscle movements, and sensory disturbances.

47. A 59-year-old patient has a herniated intervertebral disk. Which of the following findings should the nurse expect to see on physical assessment of this individual? a. Hyporeflexia b. Increased muscle tone c. Positive Babinski sign d. Presence of pathologic reflexes

ANS: A With a herniated intervertebral disk or lower motor neuron lesion, loss of tone, flaccidity, atrophy, fasciculations, and hyporeflexia or areflexia are demonstrated. No Babinski sign or pathologic reflexes would be observed (see Table 23-7). The other options reflect a lesion of upper motor neurons.

26. The assessment of a 60-year-old patient has taken longer than anticipated. In testing his pain perception, the nurse decides to complete the test as quickly as possible. When the nurse applies the sharp point of the pin on his arm several times, he is only able to identify these as one "very sharp prick." What would be the most accurate explanation for this? a. The patient has hyperesthesia as a result of the aging process. b. This response is most likely the result of the summation effect. c. The nurse was probably not poking hard enough with the pin in the other areas. d. The patient most likely has analgesia in some areas of arm and hyperalgesia in others.

ANS: B At least 2 seconds should be allowed to elapse between each stimulus to avoid summation. With summation, frequent consecutive stimuli are perceived as one strong stimulus. The other responses are incorrect.

54. The nurse is assessing the neurologic status of a patient who has a late-stage brain tumor. With the reflex hammer, the nurse draws a light stroke up the lateral side of the sole of the foot and inward, across the ball of the foot. In response, the patient's toes fan out, and the big toe shows dorsiflexion. The nurse interprets this result as: a. Negative Babinski sign, which is normal for adults. b. Positive Babinski sign, which is abnormal for adults. c. Clonus, which is a hyperactive response. d. Achilles reflex, which is an expected response.

ANS: B Dorsiflexion of the big toe and fanning of all toes is a positive Babinski sign, also called up-going toes. This response occurs with upper motor neuron disease of the corticospinal (or pyramidal) tract and is an abnormal finding for adults.

50. During an examination, the nurse notices severe nystagmus in both eyes of a patient. Which conclusion by the nurse is correct? Severe nystagmus in both eyes: a. Is a normal occurrence. b. May indicate disease of the cerebellum or brainstem. c. Is a sign that the patient is nervous about the examination. d. Indicates a visual problem, and a referral to an ophthalmologist is indicated.

ANS: B End-point nystagmus at an extreme lateral gaze normally occurs; however, the nurse should carefully assess any other nystagmuses. Severe nystagmus occurs with disease of the vestibular system, cerebellum, or brainstem.

41. During an assessment of a 22-year-old woman who sustained a head injury from an automobile accident 4 hours earlier, the nurse notices the following changes: pupils were equal, but now the right pupil is fully dilated and nonreactive, and the left pupil is 4 mm and reacts to light. What do these findings suggest? a. Injury to the right eye b. Increased intracranial pressure c. Test inaccurately performed d. Normal response after a head injury

ANS: B In a person with a brain injury, a sudden, unilateral, dilated, and nonreactive pupil is ominous. CN III runs parallel to the brainstem. When increasing intracranial pressure pushes down the brainstem (uncal herniation), it puts pressure on CN III, causing pupil dilation. The other responses are incorrect.

28. The nurse places a key in the hand of a patient and he identifies it as a penny. What term would the nurse use to describe this finding? a. Extinction b. Astereognosis c. Graphesthesia d. Tactile discrimination

ANS: B Stereognosis is the person's ability to recognize objects by feeling their forms, sizes, and weights. Astereognosis is an inability to identify objects correctly, and it occurs in sensory cortex lesions. Tactile discrimination tests fine touch. Extinction tests the person's ability to feel sensations on both sides of the body at the same point.

20. During an assessment of the CNs, the nurse finds the following: asymmetry when the patient smiles or frowns, uneven lifting of the eyebrows, sagging of the lower eyelids, and escape of air when the nurse presses against the right puffed cheek. This would indicate dysfunction of which of these CNs? a. Motor component of CN IV b. Motor component of CN VII c. Motor and sensory components of CN XI d. Motor component of CN X and sensory component of CN VII

ANS: B The findings listed reflect a dysfunction of the motor component of the facial nerve (CN VII).

3. Which statement concerning the areas of the brain is true? a. The cerebellum is the center for speech and emotions. b. The hypothalamus controls body temperature and regulates sleep. c. The basal ganglia are responsible for controlling voluntary movements. d. Motor pathways of the spinal cord and brainstem synapse in the thalamus.

ANS: B The hypothalamus is a vital area with many important functions: body temperature controller, sleep center, anterior and posterior pituitary gland regulator, and coordinator of autonomic nervous system activity and emotional status. The cerebellum controls motor coordination, equilibrium, and balance. The basal ganglia control autonomic movements of the body. The motor pathways of the spinal cord synapse in various areas of the spinal cord, not in the thalamus.

12. A mother of a 1-month-old infant asks the nurse why it takes so long for infants to learn to roll over. The nurse knows that the reason for this is: a. A demyelinating process must be occurring with her infant. b. Myelin is needed to conduct the impulses, and the neurons of a newborn are not yet myelinated. c. The cerebral cortex is not fully developed; therefore, control over motor function gradually occurs. d. The spinal cord is controlling the movement because the cerebellum is not yet fully developed.

ANS: B The infant's sensory and motor development proceeds along with the gradual acquisition of myelin, which is needed to conduct most impulses. Very little cortical control exists, and the neurons are not yet myelinated. The other responses are not correct.

22. During the neurologic assessment of a "healthy" 35-year-old patient, the nurse asks him to relax his muscles completely. The nurse then moves each extremity through full range of motion. Which of these results would the nurse expect to find? a. Firm, rigid resistance to movement b. Mild, even resistance to movement c. Hypotonic muscles as a result of total relaxation d. Slight pain with some directions of movement

ANS: B Tone is the normal degree of tension (contraction) in voluntarily relaxed muscles. It shows a mild resistance to passive stretching. Normally, the nurse will notice a mild, even resistance to movement. The other responses are not correct.

1. A 69-year-old patient has been admitted to an adult psychiatric unit because his wife thinks he is getting more and more confused. He laughs when he is found to be forgetful, saying "I'm just getting old!" After the nurse completes a thorough neurologic assessment, which findings would be indicative of Alzheimer disease? Select all that apply. a. Occasionally forgetting names or appointments b. Difficulty performing familiar tasks, such as placing a telephone call c. Misplacing items, such as putting dish soap in the refrigerator d. Sometimes having trouble finding the right word e. Rapid mood swings, from calm to tears, for no apparent reason f. Getting lost in one's own neighborhood

ANS: B, C, E, F Difficulty performing familiar tasks, misplacing items, rapid mood swings, and getting lost in one's own neighborhood can be warning signs of Alzheimer disease. Occasionally forgetting names or appointments, and sometimes having trouble finding the right word are part of normal aging. (For other examples of Alzheimer disease, see Table 23-2.)

10. A patient has a severed spinal nerve as a result of trauma. Which statement is true in this situation? a. Because there are 31 pairs of spinal nerves, no effect results if only one nerve is severed. b. The dermatome served by this nerve will no longer experience any sensation. c. The adjacent spinal nerves will continue to carry sensations for the dermatome served by the severed nerve. d. A severed spinal nerve will only affect motor function of the patient because spinal nerves have no sensory component.

ANS: C A dermatome is a circumscribed skin area that is primarily supplied from one spinal cord segment through a particular spinal nerve. The dermatomes overlap, which is a form of biologic insurance; that is, if one nerve is severed, then most of the sensations can be transmitted by the spinal nerve above and the spinal nerve below the severed nerve.

16. When taking the health history on a patient with a seizure disorder, the nurse assesses whether the patient has an aura. Which of these would be the best question for obtaining this information? a. "Does your muscle tone seem tense or limp?" b. "After the seizure, do you spend a lot of time sleeping?" c. "Do you have any warning sign before your seizure starts?" d. "Do you experience any color change or incontinence during the seizure?"

ANS: C Aura is a subjective sensation that precedes a seizure; it could be auditory, visual, or motor. The other questions do not solicit information about an aura.

53. A man who was found wandering in a park at 2 AM has been brought to the emergency department for an examination; he said he fell and hit his head. During the examination, the nurse asks him to use his index finger to touch the nurse's finger, then his own nose, then the nurse's finger again (which has been moved to a different location). The patient is clumsy, unable to follow the instructions, and overshoots the mark, missing the finger. The nurse should suspect which of the following? a. Cerebral injury b. Cerebrovascular accident c. Acute alcohol intoxication d. Peripheral neuropathy

ANS: C During the finger-to-finger test, if the person has clumsy movement with overshooting the mark, either a cerebellar disorder or acute alcohol intoxication should be suspected. The person's movements should be smooth and accurate. The other options are not correct.

27. The nurse is performing a neurologic assessment on a 41-year-old woman with a history of diabetes. When testing her ability to feel the vibrations of a tuning fork, the nurse notices that the patient is unable to feel vibrations on the great toe or ankle bilaterally, but she is able to feel vibrations on both patellae. Given this information, what would the nurse suspect? a. Hyperalgesia b. Hyperesthesia c. Peripheral neuropathy d. Lesion of sensory cortex

ANS: C Loss of vibration sense occurs with peripheral neuropathy (e.g., diabetes and alcoholism). Peripheral neuropathy is worse at the feet and gradually improves as the examiner moves up the leg, as opposed to a specific nerve lesion, which has a clear zone of deficit for its dermatome. The other responses are incorrect.

48. A patient is unable to perform rapid alternating movements such as rapidly patting her knees. The nurse should document this inability as: a. Ataxia. b. Astereognosis. c. Presence of dysdiadochokinesia. d. Loss of kinesthesia.

ANS: C Slow clumsy movements and the inability to perform rapid alternating movements occur with cerebellar disease. The condition is termed dysdiadochokinesia. Ataxia is an uncoordinated or unsteady gait. Astereognosis is the inability to identify an object by feeling it. Kinesthesia is the person's ability to perceive passive movement of the extremities or the loss of position sense.

13. During an assessment of an 80-year-old patient, the nurse notices the following: an inability to identify vibrations at her ankle and to identify the position of her big toe, a slower and more deliberate gait, and a slightly impaired tactile sensation. All other neurologic findings are normal. The nurse should interpret that these findings indicate: a. CN dysfunction. b. Lesion in the cerebral cortex. c. Normal changes attributable to aging. d. Demyelination of nerves attributable to a lesion.

ANS: C Some aging adults show a slower response to requests, especially for those calling for coordination of movements. The findings listed are normal in the absence of other significant abnormal findings. The other responses are incorrect.

40. The nurse is caring for a patient who has just had neurosurgery. To assess for increased intracranial pressure, what would the nurse include in the assessment? a. CNs, motor function, and sensory function b. Deep tendon reflexes, vital signs, and coordinated movements c. Level of consciousness, motor function, pupillary response, and vital signs d. Mental status, deep tendon reflexes, sensory function, and pupillary response

ANS: C Some hospitalized persons have head trauma or a neurologic deficit from a systemic disease process. These people must be closely monitored for any improvement or deterioration in neurologic status and for any indication of increasing intracranial pressure. The nurse should use an abbreviation of the neurologic examination in the following sequence: level of consciousness, motor function, pupillary response, and vital signs.

36. While assessing a 7-month-old infant, the nurse makes a loud noise and notices the following response: abduction and flexion of the arms and legs; fanning of the fingers, and curling of the index finger and thumb in a C position, followed by the infant bringing in the arms and legs to the body. What does the nurse know about this response? a. This response could indicate brachial nerve palsy. b. This reaction is an expected startle response at this age. c. This reflex should have disappeared between 1 and 4 months of age. d. This response is normal as long as the movements are bilaterally symmetric.

ANS: C The Moro reflex is present at birth and usually disappears at 1 to 4 months. Absence of the Moro reflex in the newborn or its persistence after 5 months of age indicates severe central nervous system injury. The other responses are incorrect.

8. A 30-year-old woman tells the nurse that she has been very unsteady and has had difficulty in maintaining her balance. Which area of the brain that is related to these findings would concern the nurse? a. Thalamus b. Brainstem c. Cerebellum d. Extrapyramidal tract

ANS: C The cerebellar system coordinates movement, maintains equilibrium, and helps maintain posture. The thalamus is the primary relay station where sensory pathways of the spinal cord, cerebellum, and brainstem form synapses on their way to the cerebral cortex. The brainstem consists of the midbrain, pons, and medulla and has various functions, especially concerning autonomic centers. The extrapyramidal tract maintains muscle tone for gross automatic movements, such as walking.

31. When the nurse is testing the triceps reflex, what is the expected response? a. Flexion of the hand b. Pronation of the hand c. Extension of the forearm d. Flexion of the forearm

ANS: C The normal response of the triceps reflex is extension of the forearm. The normal response of the biceps reflex causes flexion of the forearm. The other responses are incorrect.

24. The nurse is performing an assessment on a 29-year-old woman who visits the clinic complaining of "always dropping things and falling down." While testing rapid alternating movements, the nurse notices that the woman is unable to pat both of her knees. Her response is extremely slow and she frequently misses. What should the nurse suspect? a. Vestibular disease b. Lesion of CN IX c. Dysfunction of the cerebellum d. Inability to understand directions

ANS: C When a person tries to perform rapid, alternating movements, responses that are slow, clumsy, and sloppy are indicative of cerebellar disease. The other responses are incorrect.

32. The nurse is testing superficial reflexes on an adult patient. When stroking up the lateral side of the sole and across the ball of the foot, the nurse notices the plantar flexion of the toes. How should the nurse document this finding? a. Positive Babinski sign b. Plantar reflex abnormal c. Plantar reflex present d. Plantar reflex 2+ on a scale from "0 to 4+"

ANS: C With the same instrument, the nurse should draw a light stroke up the lateral side of the sole of the foot and across the ball of the foot, similar to an upside-down J. The normal response is plantar flexion of the toes and sometimes of the entire foot. A positive Babinski sign is abnormal and occurs with the response of dorsiflexion of the big toe and fanning of all toes. The plantar reflex is not graded on a 0 to 4+ scale.

23. When the nurse asks a 68-year-old patient to stand with his feet together and arms at his side with his eyes closed, he starts to sway and moves his feet farther apart. The nurse would document this finding as: a. Ataxia. b. Lack of coordination. c. Negative Homans sign. d. Positive Romberg sign.

ANS: D Abnormal findings for the Romberg test include swaying, falling, and a widening base of the feet to avoid falling. A positive Romberg sign is a loss of balance that is increased by the closing of the eyes. Ataxia is an uncoordinated or unsteady gait. Homans sign is used to test the legs for deep-vein thrombosis.

14. A 70-year-old woman tells the nurse that every time she gets up in the morning or after she's been sitting, she gets "really dizzy" and feels like she is going to fall over. The nurse's best response would be: a. "Have you been extremely tired lately?" b. "You probably just need to drink more liquids." c. "I'll refer you for a complete neurologic examination." d. "You need to get up slowly when you've been lying down or sitting."

ANS: D Aging is accompanied by a progressive decrease in cerebral blood flow. In some people, this decrease causes dizziness and a loss of balance with a position change. These individuals need to be taught to get up slowly. The other responses are incorrect.

42. A 32-year-old woman tells the nurse that she has noticed "very sudden, jerky movements" mainly in her hands and arms. She says, "They seem to come and go, primarily when I am trying to do something. I haven't noticed them when I'm sleeping." This description suggests: a. Tics. b. Athetosis. c. Myoclonus. d. Chorea.

ANS: D Chorea is characterized by sudden, rapid, jerky, purposeless movements that involve the limbs, trunk, or face. Chorea occurs at irregular intervals, and the movements are all accentuated by voluntary actions. (See Table 23-5 for the descriptions of athetosis, myoclonus, and tics.)

30. In assessing a 70-year-old patient who has had a recent cerebrovascular accident, the nurse notices right-sided weakness. What might the nurse expect to find when testing his reflexes on the right side? a. Lack of reflexes b. Normal reflexes c. Diminished reflexes d. Hyperactive reflexes

ANS: D Hyperreflexia is the exaggerated reflex observed when the monosynaptic reflex arc is released from the influence of higher cortical levels. This response occurs with upper motor neuron lesions (e.g., a cerebrovascular accident). The other responses are incorrect.

21. The nurse is testing the function of CN XI. Which statement best describes the response the nurse should expect if this nerve is intact? The patient: a. Demonstrates the ability to hear normal conversation. b. Sticks out the tongue midline without tremors or deviation. c. Follows an object with his or her eyes without nystagmus or strabismus. d. Moves the head and shoulders against resistance with equal strength.

ANS: D The following normal findings are expected when testing the spinal accessory nerve (CN XI): The patient's sternomastoid and trapezius muscles are equal in size; the person can forcibly rotate the head both ways against resistance applied to the side of the chin with equal strength; and the patient can shrug the shoulders against resistance with equal strength on both sides. Checking the patient's ability to hear normal conversation checks the function of CN VIII. Having the patient stick out the tongue checks the function of CN XII. Testing the eyes for nystagmus or strabismus is performed to check CNs III, IV, and VI.

25. During the taking of the health history of a 78-year-old man, his wife states that he occasionally has problems with short-term memory loss and confusion: "He can't even remember how to button his shirt." When assessing his sensory system, which action by the nurse is most appropriate? a. The nurse would not test the sensory system as part of the examination because the results would not be valid. b. The nurse would perform the tests, knowing that mental status does not affect sensory ability. c. The nurse would proceed with an explanation of each test, making certain that the wife understands. d. Before testing, the nurse would assess the patient's mental status and ability to follow directions.

ANS: D The nurse should ensure the validity of the sensory system testing by making certain that the patient is alert, cooperative, comfortable, and has an adequate attention span. Otherwise, the nurse may obtain misleading and invalid results.

44. During an assessment of a 32-year-old patient with a recent head injury, the nurse notices that the patient responds to pain by extending, adducting, and internally rotating his arms. His palms pronate, and his lower extremities extend with plantar flexion. Which statement concerning these findings is most accurate? This patient's response: a. Indicates a lesion of the cerebral cortex. b. Indicates a completely nonfunctional brainstem. c. Is normal and will go away in 24 to 48 hours. d. Is a very ominous sign and may indicate brainstem injury.

ANS: D These findings are all indicative of decerebrate rigidity, which is a very ominous condition and may indicate a brainstem injury.

45. A 78-year-old man has a history of a cerebrovascular accident. The nurse notes that when he walks, his left arm is immobile against the body with flexion of the shoulder, elbow, wrist, and fingers and adduction of the shoulder. His left leg is stiff and extended and circumducts with each step. What type of gait disturbance is this individual experiencing? a. Scissors gait b. Cerebellar ataxia c. Parkinsonian gait d. Spastic hemiparesis

ANS: D With spastic hemiparesis, the arm is immobile against the body. Flexion of the shoulder, elbow, wrist, and fingers occurs, and adduction of the shoulder, which does not swing freely, is observed. The leg is stiff and extended and circumducts with each step. Causes of this type of gait include cerebrovascular accident. (See Table 23-6 for more information and for the descriptions of the other abnormal gaits.)

The nurse just noted from a patient's medical record that the patient has a lesion that is confluent in nature. On examination, the nurse would expect to find: 1.lesions that run together. 2.annular lesions that have grown together. 3.lesions arranged in a line along a nerve route. 4.lesions that are grouped or clustered together.

ANS:1 Grouped lesions are clustered together. Polycyclic lesions are annular in nature. Zosteriform lesions are arranged along a nerve route. Confluent lesions run together.

Which of the following statements regarding the outer layer of the eye is true? 1. The outer layer of the eye is very sensitive to touch. 2. The outer layer of the eye is darkly pigmented to prevent light from reflecting internally. 3. The trigeminal (CN V) and the trochlear (CN IV) nerves are stimulated when the outer surface of the eye is stimulated. 4. The visual receptive layer of the eye in which light waves are changed into nerve impulses is located in the outer layer of the eye.

ANS:1 The cornea and the sclera make up the outer layer of the eye. The cornea is very sensitive to touch.

A patient's mother has noticed that her son, who has been to a new babysitter, has some blisters and scabs on his face and buttocks. On examination, the nurse notices moist, thin-roofed vesicles with a thin erythematous base and suspects: 1.eczema. 2.impetigo. 3.herpes zoster. 4.diaper dermatitis.

ANS:2 Impetigo is moist, thin-roofed vesicles with a thin erythematous base. This is a contagious bacterial infection of the skin and most common in infants and children.

Select the best description of the secretion of the eccrine glands. A) Thick, milky B) Dilute saline solution C) Protective lipid substance D) Keratin

B. Eccrine glands are coiled tubules that open directly onto the skin surface and produce a dilute saline solution (sweat). The evaporation of sweat reduces body temperature. Eccrine glands are widely distributed through the body and are mature in the 2-month-old infant. Apocrine glands produce a thick, milky secretion and open into the hair follicles.

A 70 year old woman complains of dry mouth. The most frequent cause of this problem is: A) the aging process B) related to medications she may be taking C) the use of dentures D) related to a diminished sense of smell

B) related to medications she may be taking

Functions of the skin include: A) production of vitamin C. B) temperature regulation. C) production of new cells by melanocytes. D) secretion of a drying substance called sebum.

B. Functions of the skin include protection, prevention of penetration, perception (of touch, pain, temperature, and pressure), temperature regulation, identification, communication, wound repair, absorption and excretion, and production of vitamin D. The skin produces vitamin D, not vitamin C. The basal cell layer of the epidermis forms new skin cells. Melanocytes produce melanin, which gives brown tones to the skin and hair. Sebum is produced by the sebaceous glands to lubricate the skin and hair.

Herpes zoster infection (shingles) is characterized by: A) A bacterial cause B) Lesion on only one side of body; does not cross midline C) Absence of pain or edema D) Pustular, umbilicated lesions

B. Herpes zoster (shingles): Small grouped vesicles emerge along route of cutaneous sensory nerve, then pustules, then crusts. Caused by the varicella zoster virus (VZV), a reactivation of the dormant virus of chickenpox. Acute appearance, unilateral, DOES NOT cross midline. Commonly on trunk; can be anywhere. If on ophthalmic branch of cranial nerve V, it poses risk to eye. Most common in adults older than 50 years. Pain is often severe and long lasting in aging adults (postherpetic neuralgia)

Assessing a patient's skin turgor is done to assess which clinical finding? A) Edema B) Dehydration C) Vitiligo D) Scleroderma

B. Poor skin turgor is evident in severe dehydration or extreme weight loss; the pinched skin recedes slowly or "tents" and stands by itself. Edema is fluid accumulating in the interstitial spaces; it is not present normally. Vitiligo, an acquired condition, is the complete absence of melanin pigment in path areas of white or light on the face, neck, hands, feet, and body folds and around orifices. Scleraderma ("hard skin") is a chronic connective tissue disorder associated with decreased mobility.

Cyanosis

Bluish mottled color that signifies decreased perfusion

The examiner notes small, round, white, shiny papules on the hard palate and gums of a 2 month old. What is the significance of this finding? A) these are aphthous areas or ulcers that are resulting of sucking B) teeth buds are beginning to appear C) this is a normal finding called Epstein pearls D) it indicates the presence of a monilial infection

C) this is a normal finding called Epstein pearls

In a medical record, the tonsils are grades as 3+. The tonsils would be: A) visible B) halfway between the tonsillar pillars and uvula C) touching the uvula D) touching each other

C) touching the uvula

Risk factors that may lead to skin disease and breakdown include: A) loss of protective cushioning of the dermal skin layer. B) decreased vascular fragility. C) a lifetime of environmental trauma. D) increased thickness of the skin.

C. Accumulating factors that place an aging person at risk for skin disease and breakdown include thinning of the skin, decrease in vascularity and nutrients, loss of protective cushioning of the subcutaneous layer, a lifetime of environmental trauma to skin, social changes of aging, an increasingly sedentary lifestyle, and the chance of immobility. Aging results in the loss of protective cushioning of the subcutaneous layer of the skin. Aging results in decreased vascularity of the skin. Aging results in thinning of the skin.

An area of thin shiny skin with decreased visibility of normal skin markings is most likely: A) Lichenification B) Plaque C) Atrophy D) Keloid

C. Atrophy - the resulting skin level is depressed with loss of tissue; a thinning of the epidermis. Lichenification - prolonged, intese scratching eventually thickens skin and produces tightly packed sets of papules; looks like surface of moss (or lichen). Plaque - papules coalesce to form surface elevation wider than 1cm; a plateaulike, disk-shaped lesion. Keloid - a benign excess of scar tissue beyond sites of original injury; looks smooth, rubbery, shiny and "claylike"; feels smooth and firm; higher incidence in Blacks, Hispanics and Asians.

You examine the nail beds of a patient. Which finding indicates a normal angle? A) 60 degrees B) 100 degrees C) 160 degrees D) 180 degrees

C. Normal angle of nail bed: ~160 degrees. Curved nail bed: <160 degrees. Early clubbing: 180 degrees.

An example of a primary lesion is a(n): A) erosion. B) ulcer. C) urticaria. D) port-wine stain.

C. Urticaria is a primary lesion; a primary lesion is one that develops on previously unaltered skin. Erosions are secondary lesions; a secondary lesion is one that changes over time or changes because of a factor such as scratching or infection. Ulcers are secondary lesions; a secondary lesion is one that changes over time or changes because of a factor such as scratching or infection. A port-wine stain is a vascular lesion.

The "A" in the ABCDE rule for skin cancer stands for: A) Accuracy B) Appearance C) Asymmetry D) Attenuated

C. Danger signs: abnormal characteristics of pigmented lesions are summarized by ABCDE: - Asymmetry (NOT regularly round or oval, two halves of the lesion do not look the same) - Border irregularity (notching, scalloping, ragged edges, poorly defined margins) - Color variation (areas of brown, tan, black, blue, red, white, or combination) - Diameter >6mm (i.e. size of pencil eraser), although early melanomas may be diagnosed at a smaller size - Elevation or Evolution

A risk factor for melanoma is: A) Brown eyes B) Darkly pigmented skin C) Skin that freckles or burns before tanning D) Use of sunscreen products

C. Risk factors for melanoma are UV radiation from sun exposure and indoor tanning and family history.

Oculomotor

Cranial Nerve III: extraocular movement, pupil constriction, down and inward movement of the eye

Trochlear

Cranial Nerve IV: down and inward movement of the eye

Glossopharyngeal

Cranial Nerve IX: phonation, swallowing, taste posterior third of tongue

Trigeminal

Cranial Nerve V: mastication and sensation of face, scalp, cornea

Abducens

Cranial Nerve VI: lateral movement of the eyes

Facial

Cranial Nerve VII: taste anterior two thirds of tongue, close eyes

The opening of an adult's parotid gland (Stensen's duct) is opposite the: A) lower 2nd molar B) lower incisors C) upper incisors D) upper second molar

D) upper second molar

A scooped-out, shallow depression in the skin is called a(n): A) ulcer. B) excoriation. C) fissure. D) erosion.

D. An ulcer is a deeper depression extending into the dermis. An excoriation is a self-inflicted abrasion that is superficial. A fissure is a narrow opening of tissue or skin. An erosion is a scooped-out, shallow depression in the skin.

You note a lesion during a skin assessment. Which is the best way to document this finding? A) Raised, irregular lesion the size of a quarter, located on dorsal of left hand B) Open lesion with no drainage or odor, approximately 1/4 inch in diameter C) Pedunculated lesion below left scapula with consistent red color and no drainage or odor D) Dark brown raised lesion, with irregular border, on dorsal of right foot, 3 cm in size, with no drainage

D. Danger signs: abnormal characteristics of pigmented lesions are summarized by ABCDE: - Asymmetry (NOT regularly round or oval, two halves of the lesion do not look the same) - Border irregularity (notching, scalloping, ragged edges, poorly defined margins) - Color variation (areas of brown, tan, black, blue, red, white, or combination) - Diameter >6mm (i.e. size of pencil eraser), although early melanomas may be diagnosed at a smaller size - Elevation or Evolution

When taking the health history, the patient complains of pruritus. What is a common cause of this symptom? A) Excessive bruising B) Hyperpigmentation C) Melasma D) Drug reactions

D. Drug reactions can lead to pruritus or itching. Excessive bruising can occur in response to a traumatic event or a coagulation abnormality. It is associated with erythema, not pruritus. Hyperpigmentation is related to color changes. Melasma (also known as chloasma or the mask of pregnancy) is a facial skin discoloration related to hormones of pregnancy.

A student nurse has been assigned to teach fourth graders about hygiene. While preparing, the student nurse adds information about the sweat glands. Which of the following should be included while discussing this topic? A) There are two types of sweat glands: eccrine glands and sebaceous glands. B) The evaporation of sweat, a dilute saline solution, increases body temperature. C) Eccrine glands produce sweat and are mainly located in the axillae, anogenital area, and navel. D) Newborn infants do not sweat and use compensatory mechanisms to control body temperature.

D. Newborn infants' eccrine glands do not secrete sweat in response to heat until the first few months of life; newborn temperature regulation is ineffective. There are two types of sweat glands: eccrine glands and apocrine glands. The evaporation of sweat reduces body temperature. The apocrine glands produce a thick, milky secretion and open into the hair follicles; they are located mainly in the axillae, anogenital area, nipples, and navel.

Flattening of the angle between the nail and its base is: A) Found in subacute bacterial endocarditis. B) A description of spoon-shaped nails. C) Related to calcium-deficiency D) Described as clubbing.

D. Clubbing of nails occurs with congenital cyanotic heart disease, lung cancer, and pulmonary diseases. In early clubbing that angle straightens out to 180 degrees, and the nail base feels spongy to palpation. Then the nail becomes convex as the digit grows.

Checking for skin temperature is best accomplished by using: A) The palmar surface of the hands. B) The ventral surface of the hands. C) The fingertips. D) The dorsal surface of the hands.

D. Note the temperature of your own hands. Then us the backs (dorsa) of your hands to palpate the person and check bilaterally. The skin should be warm, and the temperature should be equal bilaterally; warmth suggests normal circulatory status. Hands and feet may be slightly cooler in a cooler environment.

Matching: Color Change A. Intense redness of the skin due to excess blood in the dilated superficial capillaries B. Bluish mottled color that signifies decreased perfusion C. Absence of red-punk tones from the oxygenated hemoglobin in blood D. Increase in bilirubin in the blood causing a yellow color in the skin Descriptor: 1. ___ Pallor 2. ___ Erythema 3. ___ Cyanosis 4. ___ Jaundice

Matching: Color Change 1. C 2. A 3. B 4. D

Matching: Skin Color Change A. Harlequin B. Erythema toxicum C. Acrocyanosis D. Physiologic jaundice E. Carotenemia F. Café au lait spot G. Cutis marmorata Descriptor: 1. ___ Tiny, punctate red merciless and papules on the cheeks, trunk, chest, back, and buttocks. 2. ___ Lower half of body turns red, upper half blanches. 3. ___ Transient mottling on trunk and extremities. 4. ___ Bluish color around the lips, hands, fingernails, feet, and toenails. 5. ___ Large round or oval patch of light brown usually present at birth. 6. ___ Yellowing of skin, sclera, and mucous membranes due to increased numbers of red blood cells hemollyzed after birth. 7. ___ Yellow-orange color in light-skinned persons from large amounts of food containing carotene.

Matching: Skin Color Change 1. B 2. A 3. G 4. C 5. F 6. D 7. E

Documentation of an eye examination can include the term PERRLA. What does this mean?

Pupils Equal Round React (to) Light (and) Accommodation

Aids Protection by Cushioning

Subcutaneous layer

Physiologic jaundice

Yellowing of skin, sclera, and mucous membranes due to increased numbers of red blood cells hemolyzed following birth

During a routine visit, M.B., age 78, asks about small, round, flat, brown macules on the hands. Your best response after examining the areas is: a) "These are the result of sun exposure and do not require treatment." b) "These are related to exposure to the sun. They may become cancerous." c) "These are the skin tags that occur with aging. No treatment is required." d) "I'm glad you brought this to my attention. I will arrange for a biopsy."

a

In examining a young adult woman, you observe her tympanic membrane to be yellow in color. You suspect she has: a) serum in the middle ear b) blood in the middle ear c) infection of the drumhead d) jaundice

a

It is normal to palpate a few lymph nodes in the neck of a healthy person. What are the characteristics of these nodes? a) mobile, soft, contender b) large, clumped, tender c) matted, fixed, tender d) matted, fixed, nontender

a

Lyme disease is more prevalent: a) from May through September b) along the West Coast. c) in children younger than 3 years d) in those participating in water sports

a

Milia occur because: a) sebum occludes skin follicles b) of a vascular occlusion in the skin c) excess carotene is ingested d) of a genetic variation in skin tone

a

Select the statement that is true regarding cluster headaches. a) may be precipitated by alcohol and daytime napping b) usual occurrence is two per month, each lasting 1 to 3 days c) characterized as throbbing d) tend to be supraorbital, retro-orbital, or frontotemporal

a

Sensorineural hearing loss may be related to: a) a gradual nerve degeneration b) foreign bodies c) impacted cerumen d) perforated tympanic membrane

a

The medical record indicates that a person has an injury to Broca's area. When meeting this person you expect: a) difficulty speaking b) receptive aphasia c) visual disturbances d) emotional lability

a

The retinal structures viewed through the opthalmoscope are: a) the optic disc, the retinal vessels, the general background, and the macula b) the cornea, the lens, the choroid, and the ciliary body c) the optic papilla, the sclera, the retina, and the iris d) the pupil, the sclera, the ciliary body, and the macula

a

To assess for early jaundice, you will assess: a) sclera and hard palate b) nail beds c) lips d) all visible skin surfaces

a

Use of the opthalmoscope: an interruption of the red reflex occurs when: a) there is an opacity in the cornea or lens b) the patient has pathology of the optic tract c) the blood vessels are tortuous d) the pupils are constricted

a

Visual acuity is assessed with: a) the Snellen eye chart b) an opthalmoscope c) the Hirschberg test d) the confrontation test

a

When using the opthalmoscope, you would: a) remove your own glasses and approach the patient's left eye with your left eye. b) leave light on in the examining room and remove glasses from the patient. c) remove glasses and set the diopter setting at 0. d) use the smaller white light and instruct the patient to focus on the opthalmoscope.

a

While viewing with the otoscope, the examiner instructs the person to hold the nose and swallow. During this maneuver, the eardrum should: a) flutter b) retract c) bulge d) remain immobile

a

A patient with a head injury has clear, watery drainage from the ear; the examiner should: a) place a cotton ball loosely at the entrance to the ear canal b) assess for the presence of glucose in the drainage c) perform pneumatic otoscopy to assess for drum hypomotility. d) assess for the presence of a tympanostomy tube in the ear.

b

During the otoscopic examination of a child younger than 3 years, the examiner: a) pulls the pinna up and back b) pulls the pinna down c) holds the pinna gently but firmly in its normal position d) tilts the head slightly towards the examiner.

b

Herpes zoster (shingles): a) caused by bacteria b) lesion on only one side of body; does not cross midline c) has absence of pain or edema d) forms pustular, umbilicated lesions

b

One cause of visual impairment in aging adults is: a) strabismus b) glaucoma c) amblyopia d) retinoblastoma

b

Select the best description of the secretion of the eccrine glands. a) thick, milky b) dilute saline solution c) protective lipid substance d) keratin

b

Senile tremors may resemble parkinsonism, except that senile tremors do not include: a) nodding the head as if responding yes or no b) rigidity and weakness of voluntary movement c) tremor of the hands d) tongue protrusion

b

Skin turgor is assessed by picking up a large fold of skin on the anterior chest under the clavicle. This is one to determine the presence of: a) edema b) dehydration c) vitiligo d) scleroderma

b

The Glasgow Coma Scale (GCS) is divided into three areas. They include: a) pupillary response, a reflex test, and assessing pain b) eye opening, motor response to stimuli, and verbal response c) response to fine touch, stereognosis, and sense of position d) orientation, rapid alternating movements, and the Romberg test.

b

The cremasteric response: a) is positive when disease of the pyramidal tract is present b) is positive when the ipsilateral testicle elevates upon stroking of the inner aspect of the thigh c) is a reflex of the receptors in the muscles of the abdomen d) is not a valid neurologic examination

b

The examiner records "positive consensual light reflex." This is: a) the convergence of the axes of the eyeballs b) the simultaneous constriction of the other pupil when one eye is exposed to bright light c) a reflex direction of the eye toward an object attracting a person's attention d) the adaptation of the eye for near vision

b

The examiner suspects an infant's head is of abnormal size and can use which procedure to verify these findings? a) palpation b) measuring tape c) observing for symmetry of facial features d) noting absence of the tonic neck reflex

b

The isthmus of the thyroid gland lies just below the: a) mandible b) cricoid cartilage c) hyoid cartilage d) thyroid cartilage

b

The palpebral fissure is: a) the border between the cornea and sclera b) the open space between the eyelids c) the angle where the eyelids meet d) visible on the upper and lower lids at the inner canthus

b

The sensation of vertigo is the result of: a) otitis media b) pathology in the semicircular canals c) pathology in the cochlea d) 4th cranial nerve damage

b

To elicit a Babinski reflex: a) gently tap the achilles tendon b) stroke the lateral aspect of the sole of the foot from heel to the ball c) present a noxious odor to the person d) observe the person walking heel to toe.

b

Checking for skin temperature is best accomplished by using: a) palmar surface of the hands b) ventral surface of the hands c) fingertips d) dorsal surface of the hands

d

Darwin's tubercle is: a) an overgrowth of scar tissue b) a blocked sebaceous gland c) a sign of gout called tophi d) a congenital, painless nodule at the helix

d

Flattening of the angle between the nail and its base is: a) found in subacute bacterial endocarditis b) a description of spoon-shaped nails c) related to calcium deficiency d) describes as clubbing

d

Identify the blood vessel that runs diagonally across the sternomastoid muscle. a) temporal artery b) carotid artery c) external jugular vein d) internal jugular vein

c

In examining the ear of an adult, the canal is straightened by pulling the auricle: a) down and forward b) down and back c) up and back d) up and forward

c

People who have Parkinson disease usually have which of the following characteristic styles of speech? a) a garbled manner b) loud, urgent c) slow, monotonous d) word confusion

c

A patient has blurred peripheral vision. You suspect glaucoma, and test the visual fields. A person with normal vision would see your moving finger temporally at: a) 50 degrees b) 60 degrees c) 90 degrees d) 180 degrees

c

A risk factor for melanoma is: a) brown eyes b) darkly pigmented skin c) skin that freckles or burns before tanning d) use of sunscreen products

c

A throbbing, unilateral pain associated with nausea, vomiting, and photophobia is characteristic of: a) cluster headache b) subarachnoid hemorrhage c) migraine headache d) tension headache

c

An area of thin, shiny skin with decreased visibility of normal skin markings is called: a) lichenification b) plaque c) atrophy d) keloid

c

Be alert to symptoms that may constitute an eye emergency. Identify the symptom(s) that should be referred immediately. a) floaters b) epiphoria c) sudden onset of vision change d) photophobia

c

Cerebellar function is assessed by which of the following tests? a) muscle size and strength b) cranial nerve examination c) coordination- hop on one foot d) spinothalamic test

c

Clubbing can be assessed by: a) observing for transverse ridges in the nails b) the presence of pits in the nails c) noting a change in the angle of the nail base d) palpating a rigid nail base

c

During the examination of an infant, use a cotton-tipped applicator to stimulate the anal sphincter. The absence of a response suggests a lesion of: a) L2 b) T12 c) S2 d) C5

c

The configuration for individual lesions arranged in circles or arcs, as occurs with ringworm, is called: a) linear b) clustered c) annular d) gyrate

c

The corneal reflex is mediated by cranial nerves: a) II and III b) II and VI c) V and VII d) VI and IV

c

The cover test is used to assess for: a) nystagmus b) peripheral vision c) muscle weakness d) visual acuity

c

The six muscles that control eye movement are innervated by cranial nerves: a) II, III, V b) IV, VI, VII c) III, IV, VI d) II, III, VI

c

To test for stereognosis: a) have the person close his or her eyes, and then raise the person's arm and ask the person to describe its location b) touch the person with a tuning fork c) place a coin in the person's hand and ask him or her to identify it d) touch the person with a cold object.

c

Upon examination, the fontanels should feel: a) tense or bulging b) depressed or sunken c) firm, slightly concave, and well defined d) pulsating

c

Using the otoscope, the tympanic membrane is visualized. The color of a normal membrane is: a) deep pink b) creamy white c) pearly gray d) dependent upon the ethnicity of the individual.

c

What is the cause of the red reflex? a) petechial hemorrhages in the sclera b) diabetic retinopathy c) light reflecting from the retina d) blood in the vitreous

c

When assessing hearing acuity in a 6 month-old child, the examiner should: a) use an audiometer b) observe for shyness and withdrawal c) watch for head turning when saying the child's name d) test the startle (Moro) reflex

c

You examine nail beds for clubbing. The normal angle between the nail base and the nails is: a) 60 degrees b) 100 degrees c) 160 degrees d) 180 degrees

c

Before examining the ear with the otoscope, the ________ should be palpated for tenderness. a) helix, eternal auditory meatus, and lobule b) mastoid process, tympanic membrane, and malleus c) pinna, pars flaccida, and antitragus d) pinna, tragus, and mastoid process

d

Identify the facial bone that articulates at a joint instead of a suture. a) zygomatic b) maxilla c) nasal d) mandible

d

If the thyroid gland is enlarged bilaterally, which of the following maneuvers is appropriate? a) Check for deviation of the trachea. b) Listen for a bruit over the carotid arteries c) Listen for a murmur over the aortic area d) listen for a bruit over the thyroid lobes

d

Providing resistance while the patient shrugs the shoulders is a test of the status of cranial nerve: a) II b) V c) IX d) XI

d

Risk reduction for acute otitis media includes: a) use of pacifiers b) increasing group daycare c) avoiding breastfeeding d) eliminating smoking in the house and car

d

Select the symptom that is least likely to indicate a possible malignancy. a) history of radiation therapy to head, neck, or upper chest b) history of using chewing tobacco c) history of large alcohol consumption d) tenderness

d

Several changes occur in the eye with the aging process. The thickening and yellowing of the lens is referred to as: a) presbyopia b) floaters c) macular degeneration d) senile cataract

d

The Landau reflex in the infant is seen when: a) the head is held and then flops forward as the baby is pulled into a sitting position by holding the wrists b) the toes curl down tightly in response to touch on the ball of the baby's foot c) the infant attempts to place his foot on the table while being help with the top of the foot touching the underside of the table. d) the baby raises the head and arches the back, as in swan dive.

d

The control of body temperature is located in: a) Wernicke's area b) the thalamus c) the cerebellum d) the hypothalamus

d

The hearing receptors are located in the: a) vestibule b) semicircular canals c) middle ear d) cochlea

d

To examine for the function of the trigeminal nerve in an infant, you would: a) startle the baby b) hold an object within the child's line of vision c) pinch the nose of the child d) offer the baby a bottle

d

Submandibular

halfway between the angle and the tip of the mandible