Jarvis 3rd Ed Chapter 14 Flashcards
(41 cards)
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:
a. just above the diaphragm.
b. just lateral to the knee cap.
c. at the level of the C7 vertebra.
d. at the level of the T11 vertebra.
c. at the level of the C7 vertebra.
A mother brings her 2 month old daughter in for an examination and says, “my daughter rolled over against the wall, and now I have noticed that she has this spot that is soft on the top of her head. Is something terribly wrong?” The nurse’s best response would be:
a. “Perhaps that is a result of your dietary intake during pregnancy.”
b. “your baby may have craniosynostosis, a disease of the sutures of the brain.”
c. “that soft spot my be an indication of cretinism or congenital hypothyroidism.”
d. “That soft spot is normal and actually allows for growth of the brain during the first year of your baby’s life.”
d. “That soft spot is normal and actually allows for growth of the brain during the first year of your baby’s life.”
The nurse notices that a patient’s palpebral fissures are unequal. On examination, the nurse may find that damage has occured to which cranial nerve?
a. III
b. V
c. VII
d. VIII
c. VII
facial muscles are mediated by cranial nerves VII.
A patient is unable to differentiate between sharp and dull stimulations to both sides of her face. The nurse suspects:
a. Bell’s palsy
b. Damage to the trigeminal nerve.
c. Frostbite with resultant paraesthesia to the cheeks.
d. Scleroderma
b. Damage to the trigeminal nerve.
Facial sensations of pain or touch are mediated by cranial nerve V, which is the trigeminal nerve. Bell palsy is associated with cranial nerve VII damage.
When examining the face of patient, the nurse is aware that the two pairs of salivary glands that are accessible for examination are the _______ and________glands.
a. occipital; submental
b. parotid; jugulodigastric
c. parotid; submandibular
d. submandibular; occipital
c. parotid; submandibular
These two are the only salivary glands that a nurse or clinician can actually feel during a face and neck exam—unless you have X-ray vision, which, tragically, nursing school does not provide.
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Here’s the rundown:
• Parotid glands
• Location: In front of the ear, over the mandible (a.k.a. your jaw hinge)
• Notable feature: They’re the biggest salivary glands and where the Stensen’s duct lives
• Can swell up like a chipmunk on allergy meds if you have mumps
• Submandibular glands
• Location: Under the jaw, along the inside edge of the mandible
• Notable feature: Wharton’s ducts drain these babies under the tongue
A patient comes to the clinic complaining of neck and shoulder pain and is unable to turn her head. The nurse suspects damage to cranial nerve_______ and proceeds with the examination by ____________.
a. XI; palpating the anterior and posterior triangles
b. XI; asking the patient to shrug her shoulders against resistance.
c. XII; percussing the sternomastoid and submandibular neck muscles
d. XII; assessing for a positive Romberg sign
b. XI; asking the patient to shrug her shoulders against resistance.
Cranial Nerve XI: the accessory nerve, aka the one that lets you say “I don’t know” with your shoulders and aggressively turn away from people you don’t like. Super important stuff.
This nerve controls the sternocleidomastoid and trapezius muscles, which means it’s in charge of:
• Shoulder shrugging (traps)
• Turning your head side to side (SCM)
So when someone can’t turn their head or lift their shoulders, it’s time to test CN XI by—wait for it—asking them to shrug their shoulders against resistance. Revolutionary, I know.
As for the other options:
• a. Palpating triangles? Great for anatomy class. Useless for this nerve.
• c. Percussing neck muscles? What are we doing, tuning them like bongos?
• d. Romberg test? That’s for balance, not “my neck doesn’t neck anymore.”
So yeah, b. is your golden ticket. Honestly, if your cranial nerves were a reality show, XI would be the brooding side character that only shows up to flex and leave
When examining a patient after a biopsy of the cervical lymph nodes, to ensure there is no damage to the major neck muscles, the nurse should check the function of cranial nerve:
a. V; trigeminal nerve
b. XI; spinal accessory nerve.
c. VII; facial nerve
d. VI; abducens nerve
b. XI; spinal accessory nerve.
Why?
The spinal accessory nerve (cranial nerve XI) innervates two major muscles in the neck:
• Sternocleidomastoid
• Trapezius
These muscles are essential for:
• Turning the head (sternocleidomastoid)
• Elevating the shoulders (trapezius)
During a cervical lymph node biopsy, there’s a risk of damaging this nerve because of its location in the neck. If it’s injured, the patient may have:
• Difficulty shrugging the shoulders
• Weakness when turning the head to the opposite side
Quick Refresher on the Other Options:
• V (Trigeminal): Sensation to face + chewing muscles
• VII (Facial): Facial expressions, taste on anterior 2/3 of tongue
• VI (Abducens): Lateral eye movement (lateral rectus muscle)
A patient’s laboratory data reveal an elevated thyroxine (T4) level. The nurse would proceed with an examination of the _______ gland.
a. thyroid
b. parotid
c. adrenal
d. parathyroid
a. thyroid
Only the thyroid secretes t4 and t3. The other glands do not.
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 assessment, the nurse suspects a noncancerous finding as the lump:
a. is singular and firm.
b. consists of multiple nodules/ mobile and not hard
c. dissapears when the patient smiles
d. is hard and fixed to the surrounding structures.
b. consists of multiple nodules
Why?
• Multiple nodules are more likely to indicate benign conditions like:
• Multinodular goiter
• Thyroiditis
• Benign hyperplasia
• Nodules that are mobile and soft or rubbery are usually noncancerous.
• Cancerous lumps are typically:
• Single
• Hard
• Fixed to surrounding structures
• Sometimes painless but growing rapidly
A patient who is 7 months pregnant is at the clinic for her routine checkup. During assessment the nurse notes that the patient’s thyroid is palpable. The nurse will:
a. refer the patient to a thyroid specialist
b. send the patient for laboratory tests for thyroid hormones
c. document the findings as normal
d. as a colleague to check the findings
c. document the findings as normal.
normally the adult thyroid is not palpable. However, the thyroid gland may be palpable normally during pregnancy.
The nurse notices that a patient’s submental lymph nodes are enlarged. To identify the cause of the enlargement of the patient’s nodes, the nurse assesses the:
a. infraclavicular area.
b. supraclavicular area
c. area distal to the enlarged node.
d. area proximal to the enlarged node.
d. area proximal to the enlarged node.
when nodes are abnormal, the nurse should check the area into which they drain for the source of the problem. The area proximal (upstream) to the location of the abnormal node should be explored.
The nurse is aware that the four areas in the body where lymph nodes are accessible are the:
a. Head, breasts, groin, and abdomen.
b. Arms, breasts, inguinal area, and legs.
c. Head and neck, arms, breasts, and axillae.
d. Head and neck, arms, inguinal area, and axillae.
d. Head and neck, arms, inguinal area, and axillae.
Although available throughout the body, they are only accessible to examination in four areas: Head and neck, arms, inguinal region, and axillae.
A mother brings her newborn in for an assessment and asks, “is there something wrong with my baby? his head seems so big.” Which statement is true regarding the relative proportions of the head and trunk of the newborn?
a. At birth, the head is one-fifth the total length.
b. Head circumference should be greater than chest circumference at birth.
c. The head size reaches 90% of its final size when the child is 3 years old.
d. When the anterior fontanelle closes at 2 months, the head will be more proportionate to the body.
b. Head circumference should be greater than chest circumference at birth.
A patient, an 85 year old woman, is concerned that the bones in her face have become more noticeable. The nurse tells her that:
a. diets low in protein and high in carbohydrates may cause enhanced facial bones.
b. Bones can become more noticable if the person does not use dermatologically approved moisturizer.
c. more noticeable facial bones are probably caused by a combination of factors related to aging, such as decreased elasticity, subcutaneous fat, and moisture in her skin.
d. Facial skin becomes more elastic with age. This increased elasticity causes the skin to be more taught, drawing attention to the facial bones.
c. more noticeable facial bones are probably caused by a combination of factors related to aging, such as decreased elasticity,
A patient reports to the nurse that he has been experiencing excruciating headache pain on one side of his head, especially around his eye, forehead, and cheek that lasts approximately one-half to 2 hours, occuring once or twice each day. The nurse suspects that he is having:
a. hypertension
b. cluster headaches
c. tension headaches
d. migraine headaches
d. cluster headaches.
Cluster headaches produce pain around the eye, temple, forehead and cheek and are unilateral and always on the same side of the head. They are excruciating and occur once or twice per day and last one-half to 2 hours each.
A patient is concerned that while studying for an examination he began to notice a severe headache in the left front and side of his head that was throbbing and was relieved when he lay down. He tells the nurse that his mother also had these headaches. The nurses suspects that he may be suffering from:
a. Hypertension
b. cluster headaches
c. tension headaches
d. migraine headaches
d. migraine headaches
Migraine headaches tend to be supraorbital, retro-orbital or frontotemporal with a throbbing quality. They are severe in quality and are relieved by lying down. Migraines are associated with a family history of migraine headaches.
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 temp is 40 degrees C, and he has a stiff neck. The nurse recognizes that he needs testing for:
a. a head injury
b cluster headaches
c. migraine headaches
d. meningeal inflammation
d. meningeal inflammation.
The acute onset of neck stiffness and pain along with headache and fever occurs with meningeal inflammation. A severe headache in an adult or child who has never had it before is a red flag. Head injury and cluster or migraine headaches are not associated with a fever or stiff neck.
During a well-baby checkup, 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 notices dilated scalp veins and downcast or “setting sun” eyes. The nurse suspects which condition?
a. craniotabes
b. microcephaly
c. hydrocephalus
d. caput succedaneum
c. hydrocephalus
- occurs with obstruction of drainage of cerebrospinal fluid that results in excessive accumulation, increasing intracranial pressure, and an enlargement of the head. The face looks small, compared with teh enlarged cranium, dilated scalp veins and downcast or “setting sun” eyes are noted. Craniotabes is a softening of the skill’s outer layer. Microcephaly is an abnormally small head. A caput succedaneum is edematous swelling and ecchymosis of the presenting par tof the head cause by birth trauma.
The nurse needs to palpate the temporomandibular joint for crepitation. This joint is located just below the temporal artery and anterior to the:
a. Hyoid bone
b. vagus nerve
c. tragus
d. mandible
c. tragus
patient has come in for an examination and states, “I have this spot in front of my ear lobe on my cheek that seems to be getting bigger and is tender.What do you think it is? “The nurse notes swelling below the angel of the jaw and suspects that it could be an inflammation of his:
a. Thyroid gland
b. Parotid gland
c. Occipital lymph node
d. Submental lymph node
b. parotid gland.
Swelling of the parotid gland is evident below the angel of the jaw and is most visible when the head is extended. Painful inflammation occurs with mumps, and swelling also occurs with abscesses of tumours. Swelling occurs anterior to the lower ear lobe.
A male patient with a history of AIDS has come in for an examination and he states, “I think that i have the mumps.” The nurse would begin by examining the:
a. thyroid gland
b. parotid gland
d. cervical lymph nodes
d. mouth and skin for lesions
b. parotid gland.
The parotid gland may become swollen with the onset of mumps, and parotid enlargement has been found with HIV.
The nurse suspects that a patient has hyperthyroidism, and the laboratory data indicate that the patient’s T4 and T3 are elevated. During assessment, the nurse will likely find the patient has:
a. tachycardia
b. constipation
c. rapid dyspnea
d. atrophied nodular thyroid gland
a. Tachycardia
T4 and T3 are thyroid hormones that stimulate the rate of cellular metabolism, resulting in tachycardia.
A visitor from Poland, who does not speak english, seems to be somewhat apprehensive about the nurse examining his neck. He would probably be more comfortable with the nurse examining his thyroid gland from:
a. behind the nurse’s hands placed firmly around his neck.
b. the side of the nurse’s eyes averted towards the ceiling and thumbs on his neck.
c. the front with the nurse’s thumbs placed on either side of his trachea and his head tilted forward.
d. the front with the nurses thumbs placed on either side of his trachea and his head tilter backward.
c. the front with the nurse’s thumbs placed on either side of his trachea and his head tilted forward.
Examining a patient’s thyroid gland from the back may be unsettling for him. It would be best to examine his thyroid gland using the anterior approach, asking him to tip his head forward and the tight when then to the left.
A patients thyroid gland is enlarged, and the nurse is preparing to auscultate the thyroid gland for the presence of a bruit. A bruit is a _____ sound that is heard best with the _______ of the stethoscope.
a. low gurgling; diaphragm
b. loud, whosing, blowing; bell
c. soft, whooshing pulsatile; bell
d. high-pitcjed tinkling; diaphragm
c. soft, whooshing pulsatile; bell
If the thyroid gland is enlarged, then the nurse should auscultate it for the presence of a burit, which is a soft, pulsatile, whooshing, blowing sound heard best with the bell of the stethoscope.
