Chapter 10: Lymphatic System

Multiple Choice

1. Which organ does not have lymphatic vessels?

a. Brain b. Kidneys c. Liver d. Lungs

ANS: A

Lymphatic tissues are found abundantly throughout the body except in two places, the placenta and the brain (central nervous system). Lymphatic tissues are found abundantly in the kidneys, liver, and lungs.

DIF: Cognitive Level: Remembering (Knowledge)

OBJ: Nursing process assessment MSC: Physiologic Integrity: Physiologic Adaptation

2. Cells that line the lymph node sinuses perform the specific function of: a. fat absorption. b. fetal immunization. c. hematopoiesis. d. phagocytosis.

ANS: D

Lymph nodes defend against the invasion of microorganisms by phagocytosis.

DIF: Cognitive Level: Remembering (Knowledge)

OBJ: Nursing process assessment MSC: Physiologic Integrity: Physiologic Adaptation

3. Lymph flows faster in response to: a. increased metabolic activity. b. decreased blood volume. c. decreased metabolic rate. d. decreased permeability of the capillary walls.

ANS: A

Lymph flow increases with mounting capillary pressure, greater permeability of the capillary walls, or increased metabolic rate.

DIF: Cognitive Level: Remembering (Knowledge)

OBJ: Nursing process assessment MSC: Physiologic Integrity: Physiologic Adaptation

4. An organ that is essential to the development of protective immune function in the infant but has little or no demonstrated function in the adult is the: a. spleen. b. liver. c. thymus. d. pancreas.

ANS: C

In the adult, the thymus atrophies and, in the older adult, is replaced by fat and connective tissue.

DIF: Cognitive Level: Remembering (Knowledge)

OBJ: Nursing process assessment MSC: Physiologic Integrity: Physiologic Adaptation a. Spleen b. Liver c. Stomach d. Pancreas

5. Mr. Shea is a 45-year-old patient who presents to the office for multiple complaints. The examination of the upper left quadrant of the abdominal cavity is essential to the evaluation of the immune system because of the location of which organ?

ANS: A

The spleen is the largest of the lymphatic organs. It is located in the upper left portion of the abdomen.

DIF: Cognitive Level: Understanding (Comprehension)

OBJ: Nursing process assessment MSC: Physiologic Integrity: Physiologic Adaptation

6. Mrs. Farrel brings in her 6-year-old son with complaints of a sore throat and fever. As the healthcare provider, you are concerned about his tonsils and adenoids. Enlarged tonsils and adenoids may obstruct the: a. thoracic duct. b. esophagus. c. nasopharyngeal passageway. d. external auditory meatus.

ANS: C

The palatine tonsils are located on either side of the pharynx; the adenoids (pharyngeal tonsils) are found on the posterior wall of the pharynx and superior to the soft palate. If these structures become enlarged, they block the passage between the pharynx and nasal cavity.

DIF: Cognitive Level: Analyzing (Analysis)

OBJ: Nursing process assessment MSC: Physiologic Integrity: Physiologic Adaptation a. Occipital b. Anterior cervical c. Supraclavicular d. Femoral

7. Mrs. Sing is a 44-year-old patient who presents to the office with a complaint of enlarged lymph nodes. When enlarged, which lymph nodes are most likely to be a sign of pathology (e.g., malignancy)?

ANS: C

Supraclavicular nodal enlargement is of special concern because it suggests a malignancy, even in children; an enlarged supraclavicular lymph node may be the sentinel node of Hodgkin disease.

DIF: Cognitive Level: Analyzing (Analysis)

OBJ: Nursing process assessment MSC: Physiologic Integrity: Physiologic Adaptation

8. As adults age, their ability to resist infection is reduced because of the lymphatic nodes becoming more: a. fibrotic. b. mucoid. c. porous. d. profuse.

ANS: A

Older ad l s l mph nodes diminish in bo h n mber and si e and are replaced i h more fibrotic and fatty tissues.

DIF: Cognitive Level: Understanding (Comprehension)

OBJ: Nursing process assessment MSC: Physiologic Integrity: Physiologic Adaptation

9. Equipment for examining the lymphatic system includes a: a. caliper. b. centimeter ruler. c. goniometer. d. syringe and needle.

ANS: B

The centimeter ruler and marking pencil are the only equipment needed for examination of the lymphatic system. They are used to measure and outline the borders of the nodes.

DIF: Cognitive Level: Remembering (Knowledge)

OBJ: Nursing process assessment MSC: Physiologic Integrity: Physiologic Adaptation a. Shotty b. Movable c. Fixed d. Tender

10. Which nodes are most often associated with inflammation?

ANS: D

Tenderness is almost always indicative of inflammation. Shotty nodes (feel like the tip of an eraser) that are fixed are of greater concern. Shotty, movable, or fixed nodes are not usually associated with inflammation.

DIF: Cognitive Level: Understanding (Comprehension)

OBJ: Nursing process assessment MSC: Physiologic Integrity: Physiologic Adaptation a. Internal mammary b. Anterior axillary c. Deep cervical d. Supraclavicular

11. Which nodes are also called Virchow nodes?

ANS: D

The supraclavicular nodes are also referred to as Virchow nodes.

DIF: Cognitive Level: Remembering (Knowledge)

OBJ: Nursing process assessment MSC: Physiologic Integrity: Physiologic Adaptation

12. The harder and more discrete a node, the more likely that there is a(n): a. innocent cause. b. infection. c. malignancy. d. metabolic disease.

ANS: C

Tender nodes almost always indicate the presence of an infection, whereas a hard, discrete, and nontender node is more likely to represent a malignancy.

DIF: Cognitive Level: Understanding (Comprehension)

OBJ: Nursing process assessment MSC: Physiologic Integrity: Physiologic Adaptation a. A bruit b. Inflammation c. Tenderness d. Redness

13. Which finding indicates that the examiner is assessing a blood vessel rather than a lymph node?

ANS: A

Pulsations and auscultation of bruits indicate a blood vessel and not a lymph node.

DIF: Cognitive Level: Analyzing (Analysis)

OBJ: Nursing process assessment MSC: Physiologic Integrity: Physiologic Adaptation a. Extension of the extremity b. Circumduction of the extremity c. Flexion of the extremity d. Rotation of the extremity

14. When examining lymph nodes near a joint in the arm or leg, which of the following maneuvers is likely to facilitate the examination?

ANS: C

Bending joint areas will ease taut tissues and allow for better accessibility to palpation.

DIF: Cognitive Level: Applying (Application)

OBJ: Nursing process assessment MSC: Physiologic Integrity: Physiologic Adaptation

15. To palpate the inguinal nodes, you should have the patient: a. bend over a table and cough. b. lie supine with knees slightly flexed. c. lie supine with legs extended. d. stand and cough vigorously.

ANS: B

To palpate the inguinal nodes, you should have the patient lie supine and slightly flex her or his knees.

DIF: Cognitive Level: Understanding (Comprehension)

OBJ: Nursing process assessment MSC: Physiologic Integrity: Physiologic Adaptation

16. The most important clue to the diagnosis of immunodeficiency disease in a child is: a. family history. b. illness in siblings. c. previous hospitalizations. d. serious recurring infections.

ANS: D

Although family history, illness in siblings, and previous hospitalizations are helpful clues to discover an immunodeficiency in a child, it is most important to review the occurrence of serious, uncommon infections, such as Pneumocystis jirovecii, or other fungal infections that do not respond as expected to therapy.

DIF: Cognitive Level: Analyzing (Analysis)

OBJ: Nursing process assessment MSC: Physiologic Integrity: Physiologic Adaptation

17. A red streak that follows the course of the lymphatic collecting duct is a finding associated with: a. Hodgkin disease. b. lymphangitis. c. lymphedema. d. lymphoma.

ANS: B

Lymphangitis inflammation of the lymphatic vessels is evident by a red streak that follows the course of the inflamed lymphatic duct. Hodgkin disease and lymphoma refer to malignancies manifested primarily by nodal enlargements; lymphedema is lymph swelling that distinguishes itself from interstitial edema because it does not pit.

DIF: Cognitive Level: Understanding (Comprehension)

OBJ: Nursing process assessment MSC: Physiologic Integrity: Physiologic Adaptation a. Retropharyngeal abscess b. Streptococcal pharyngitis c. Mononucleosis d. Toxoplasmosis

18. Which disorder is characterized by a single node that is chronically enlarged and nontender in a patient with no other symptoms?

ANS: D

Toxoplasmosis is characterized by a chronically enlarged, nontender, single node usually in the posterior cervical chain.

DIF: Cognitive Level: Analyzing (Analysis)

OBJ: Nursing process assessment MSC: Physiologic Integrity: Physiologic Adaptation

19. Initial signs and symptoms of Epstein-Barr virus mononucleosis usually include: a. pharyngitis, fever, and malaise. b. bleeding gums and spontaneous nosebleeds. c. headache, visual disturbance, and rash. d. inguinal adenopathy and painful urination.

ANS: A

Presenting signs and symptoms of Epstein-Barr virus mononucleosis are pharyngitis, fever, fatigue, malaise, often splenomegaly, and occasionally hepatomegaly and/or rash.

DIF: Cognitive Level: Remembering (Knowledge)

OBJ: Nursing process assessment MSC: Physiologic Integrity: Physiologic Adaptation a. Epitrochlear area b. Popliteal area c. Axilla d. Inguinal area

20. Tender nodes associated with cat scratch disease are usually found in which area?

ANS: C

Cat scratch disease usually results in enlargement of nodes in the head, neck, and axillae. Although epitrochlear enlargement occurs most exclusively in cat scratch fever, its occurrence is less common.

DIF: Cognitive Level: Understanding (Comprehension)

OBJ: Nursing process assessment MSC: Physiologic Integrity: Physiologic Adaptation

21. Serum sickness is usually characterized first by the appearance of: a. lymph node enlargement. b. joint pain. c. urticaria. d. fever.

ANS: C

Urticaria is the first sign of serum sickness, followed by lymphadenopathy, joint pain, fever, and facial edema.

DIF: Cognitive Level: Remembering (Knowledge)

OBJ: Nursing process assessment MSC: Physiologic Integrity: Physiologic Adaptation

Multiple Response

1. Which condition stimulates lymph node enlargement? (Select all that apply.)

a. Graves disease b. Lymphangioma c. Esophageal reflux d. Parotid swelling

ANS: A, B, D

Lymph node enlargement is stimulated by Graves disease, lymphangioma, and parotid swelling.

DIF: Cognitive Level: Applying (Application)

OBJ: Nursing process assessment MSC: Physiologic Integrity: Physiologic Adaptation

Chapter 11: Head and Neck

Multiple Choice

1. Which cranial nerves innervate the face?

a. II and V b. III and VI c. V and VII d. VIII and IX

ANS: C

Facial nerves are controlled by cranial nerves V and VII; cranial nerves II, III, and VI control the eyes, cranial nerve VIII deals with hearing, and cranial nerve IX deals with swallowing.

DIF: Cognitive Level: Remembering (Knowledge)

OBJ: Nursing process assessment MSC: Physiologic Integrity: Physiologic Adaptation a. Coronal sutures b. Hyoid and cricoid cartilages c. Mandible and maxilla bones d. Nose and thyroid cartilages

2. Mrs. Britton brings her 16-year-old son in with a complaint that he is not developing correctly into adolescence. Which structures disproportionately enlarge in the male during adolescence?

ANS: D

In adolescent males, the nose enlarges and the thyroid cartilage becomes the largest component of the anterior lar n , kno n as the Adam s apple.

DIF: Cognitive Level: Remembering (Knowledge)

OBJ: Nursing process assessment MSC: Physiologic Integrity: Physiologic Adaptation a. Palpation of the gland becomes difficult. b. A bruit is auscultated. c. Inspection reveals a goiter. d. The gland is tender on palpation.

3. Which of the following is an expected change in the assessment of the thyroid during pregnancy?

ANS: B

During pregnancy, the thyroid gland hypertrophies (not to the point of a goiter), palpation is easier and, because the gland also has increased vascularity, bruits are common. It is an abnormal finding for the thyroid to feel fibrotic, tender, or smaller.

DIF: Cognitive Level: Applying (Application)

OBJ: Nursing process assessment MSC: Physiologic Integrity: Physiologic Adaptation

4. Mr. Mathews is a 47-year-old patient who presents for a routine physical examination. On examination, you noted a bruit heard over the thyroid. This is suggestive of: a. hypothyroidism. b. hyperthyroidism. c. thyroid cancer. d. thyroid cyst.

ANS: B

Because of hypermetabolic states such as hyperthyroidism, a bruit may be heard as a result of the increased blood flow to the area. Auscultating a bruit is not symptomatic of hypothyroidism, cancer, or a cyst. A nodule is more indicative of cancer.

DIF: Cognitive Level: Applying (Application)

OBJ: Nursing process assessment MSC: Physiologic Integrity: Physiologic Adaptation a. Current medications b. Elimination patterns c. Immunization status d. Previous pregnancies

5. Ms. Galvan is a 22-year-old secretar ho comes to the clinic ith headaches of 6 eeks duration. She tells the office assistant about her heavy schedule, including part-time work and evening classes. Her vital signs are normal. Which information is most appropriate to Ms. Gal an s histor ?

ANS: A

Some current medications, such as birth control pills, nitroglycerin, antihypertensives, antiseizure drugs, and some diabetic drugs, can be headache triggers. Withdrawal of headache medication can also trigger headaches.

DIF: Cognitive Level: Analyzing (Analysis)

OBJ: Nursing process assessment MSC: Physiologic Integrity: Physiologic Adaptation

6. Observation during history taking is the best way to examine for: a. head position. b. scalp lice. c. thyroid size. d. tracheal alignment.

ANS: A

Head position as well as facial features is best observed when talking to the patient during the history. Scalp lice, thyroid size, and tracheal alignment are best assessed by palpation and closer physical observation.

DIF: Cognitive Level: Applying (Application)

OBJ: Nursing process assessment MSC: Physiologic Integrity: Physiologic Adaptation

7. During a head and neck assessment of a neonate, it is important to screen for: a. the presence of torticollis. b. signs and symptoms of cerebral palsy. c. uneven movement of the eyes. d. unilateral movement of the tongue.

ANS: A

Torticollis is usually caused by constraint of the newborn in utero or injury during vaginal deli er . The other s mptoms ma be diffic lt to discern beca se of the infant s lack of fine motor skills and control of voluntary muscle groups. During a head and neck assessment of a neonate, it is not important to screen for signs and symptoms of cerebral palsy, uneven movement of the eyes, or unilateral movement of the tongue.

DIF: Cognitive Level: Applying (Application)

OBJ: Nursing process assessment MSC: Physiologic Integrity: Physiologic Adaptation

8. During a physical examination of a 30-year-old Chinese man, you notice a slight asymmetry of his face. The cranial nerve examination is normal. Your best action is to: a. ask the patient if this characteristic runs in his family. b. perform monofilament testing on the face. c. consult with the clinician regarding the laboratory tests needed. d. record the finding in the patient s chart.

ANS: D

It is not abnormal to have some slight asymmetry of the face that does not require further questioning, tests, or unnecessary laboratory work, but it does require a notation in the chart that could be referenced for future concerns.

DIF: Cognitive Level: Applying (Application)

OBJ: Nursing process assessment MSC: Physiologic Integrity: Physiologic Adaptation a. Flexed away from the side being examined b. Flexed directly forward c. Flexed toward the side being examined d. Hyperextended directly backward

9. Which is the best a to position a patient s neck for palpation of the th roid?

ANS: C

The patient should be positioned so that the sternocleidomastoid muscle is relaxed and the thyroid is easier to palpate. This is done by having the patient flex the neck slightly forward and laterally toward the side being examined.

DIF: Cognitive Level: Applying (Application)

OBJ: Nursing process assessment MSC: Physiologic Integrity: Physiologic Adaptation

10. The thyroid gland should: a. be slightly left of midline. b. have a clear vascular sound. c. move when the patient swallows. d. tug with each heartbeat.

ANS: C

It is a normal finding for the thyroid gland to move with swallowing; however, being off center may indicate a nodular growth or enlargement. The thyroid gland should not be slightly left of midline. Vascular sounds indicate hypermetabolic states such as hyperthyroidism, and a tug with each heartbeat is a sign of an aortic aneurysm.

DIF: Cognitive Level: Understanding (Comprehension)

OBJ: Nursing process assessment MSC: Physiologic Integrity: Physiologic Adaptation

11. Yo are palpating a patient s th roid and find that its broadest dimension meas res 4 cm. The right lobe is 25% larger than the left. These data would indicate: a. a congenital anomaly. b. a multinodular goiter. c. a normal thyroid gland. d. thyroiditis.

ANS: C

The situation described is most likely a normal finding; the right lobe of the thyroid gland is typically 25% larger than the left and measures 4 cm. The other choices produce enlargements beyond these normal findings.

DIF: Cognitive Level: Analyzing (Analysis)

OBJ: Nursing process assessment MSC: Physiologic Integrity: Physiologic Adaptation

12. The correct a to transill minate an infant s sk ll is to: a. hold the light 18 inches from the skull. b. move the light toward and then away from the head. c. place the light firmly against the skull. d. shine the light inside the infant s mo th.

ANS: C

The correct techniq e for transill mination of the infant s sk ll is to place th e light source tightly against the skull so that no light escapes.

DIF: Cognitive Level: Applying (Application)

OBJ: Nursing process assessment MSC: Physiologic Integrity: Physiologic Adaptation a. It is bound by suture lines. b. The affected part feels soft. c. It is obvious at birth. d. The margins are poorly defined.

13. Which of the following is true regarding a cephalohematoma?

ANS: A

The condition is subperiosteal, under the bone, and contained by the margins of the suture lines; it does not cross the suture line. It is often unnoticed at birth and typically feels firm, with its edges well defined.

DIF: Cognitive Level: Understanding (Comprehension)

OBJ: Nursing process assessment MSC: Physiologic Integrity: Physiologic Adaptation

14. Nuchal rigidity is most commonly associated with: a. thyroiditis. b. meningeal irritation. c. Down syndrome. d. cranial nerve V damage.

ANS: B

Stiffness and inability to flex the neck, or nuchal rigidity, constitute a classic symptom of meningeal irritation.

DIF: Cognitive Level: Applying (Application)

OBJ: Nursing process assessment MSC: Physiologic Integrity: Physiologic Adaptation

15. When noting a bulging fontanel with marked pulsations in a 6-month-old, you suspect: a. normal development. b. congenital anomaly. c. increased intracranial pressure. d. fever response to a viral infection.

ANS: C

A bulging fontanel with pulsations suggests increased intracranial pressure. A normal fontanel feels slightly depressed, with mild pulsations.

DIF: Cognitive Level: Applying (Application)

OBJ: Nursing process assessment MSC: Physiologic Integrity: Physiologic Adaptation a. Classic migraine b. Temporal arteritis c. Cluster d. Hypertensive

16. Which type of headache usually occurs at night, is precipitated by alcohol consumption, and occurs more often in men than in women?

ANS: C

Cluster headaches usually occur at night; they are associated with alcohol consumption and occur more often in men.

DIF: Cognitive Level: Understanding (Comprehension)

OBJ: Nursing process assessment MSC: Physiologic Integrity: Physiologic Adaptation

17. Mr. Johnson presents with a freely movable cystic mass in the midline of the high neck region, at the base of the tongue. This is most likely a: a. parotid gland tumor. b. branchial cleft cyst. c. Stensen duct stone. d. thyroglossal duct cyst.

ANS: D

A thyroglossal duct cyst presents as a freely movable mass at the base of the tongue. A parotid gland tumor occurs in the ear and cheek bone area. A branchial cleft cyst occurs in the lateral neck area. A Stensen duct stone occurs in the parotid duct.

DIF: Cognitive Level: Understanding (Comprehension)

OBJ: Nursing process assessment MSC: Physiologic Integrity: Physiologic Adaptation

18. The premature union of cranial sutures that involves the shape of the head without mental retardation is: a. craniosynostosis. b. encephalocele. c. microcephaly. d. myxedema.

ANS: A

In patients with craniosynostosis, the cranial sutures fuse prematurely, causing a misshapen head, but mental retardation is not involved. Encephalocele and microcephaly involve mental retardation. Myxedema is a condition of hyperthyroidism.

DIF: Cognitive Level: Understanding (Comprehension)

OBJ: Nursing process assessment MSC: Physiologic Integrity: Physiologic Adaptation a. Palpate the patient s hair, noting te t re, color, and distrib tion. b. Palpate the temporomandibular joint. c. Palpate the skull from front to back. d. Palpate the temporal artery.

19. Mr. Donaldson is a 64-year-old patient with complaints of headaches. As the examiner, you are palpating his head during your physical examination. Which of the following would be your first step?

ANS: C

Palpate the skull in a gentle rotary movement first, progressing systematically from front to back.

DIF: Cognitive Level: Understanding (Comprehension)

OBJ: Nursing process assessment MSC: Physiologic Integrity: Physiologic Adaptation

Multiple Choice

1. Mrs. Alden is a 29-year-old pregnant patient in her third trimester. She tells you that her vision has been a little blurred, and she thinks she needs to get new contact lenses. You should advise her to: a. get new lenses as soon as possible to avoid complications. b. wait until several weeks after delivery to get new lenses. c. go to the nearest emergency department for evaluation. d. change her diet to include more yellow vegetables.

ANS: B

Because of the increased level of lysozyme in the tears during pregnancy, a blurred sensation may occur but will subside several weeks after pregnancy. The blurred vision is a normal occurrence during pregnancy. It is not an emergency, nor is it diet -dependent.

DIF: Cognitive Level: Applying (Application)

OBJ: Nursing process assessment MSC: Physiologic Integrity: Physiologic Adaptation

2. A condition that typically develops by the age of 45 years is: a. presbyopia. b. hyperopia. c. myopia. d. astigmatism.

ANS: A

By 45 years of age, a condition known as presbyopia develops; presbyopia involves a weakening of accommodation. Hyperopia occurs in early infancy. Myopia and astigmatism can occur at any time.

DIF: Cognitive Level: Understanding (Comprehension)

OBJ: Nursing process assessment MSC: Physiologic Integrity: Physiologic Adaptation a. Difficulty tracking objects with the eyes b. Appearing to have better peripheral than central vision c. Blinking when bright light is directed at the face d. White pupils on photographs

3. Which finding, when seen in the infant, is ominous?

ANS: D

The absence of a red reflex, determined by physical examination or the appearance of white pupils on a photograph, is indicative of retinoblastoma, a serious retinal tumor.

DIF: Cognitive Level: Analyzing (Analysis)

OBJ: Nursing process assessment MSC: Physiologic Integrity: Physiologic Adaptation

4. Mr. C s is al ac i is 20/50. This means ha he: a. can see 50% of what the average person sees at 20 feet. b. has perfect vision when tested at 50 feet. c. can see 20% of he le ers on he char s 20/50 line. d. can read letters while standing 20 feet from the chart that the average person could read at 50 feet.

ANS: D

Visual acuity is measured as a fraction, in which the top number is the distance that the patient is standing from the chart; the bottom number is the distance that an average person can stand and still read the line.

DIF: Cognitive Level: Analyzing (Analysis)

OBJ: Nursing process assessment MSC: Physiologic Integrity: Physiologic Adaptation

5. The cri erion for de ermining he adeq ac of a pa ien s is al field is: a. the ability to discriminate primary colors. b. the ability to discriminate details. c. correspondence with the visual field of the examiner. d. distance vision equal to that of an average person.

ANS: C

The examiner compares his or her own peripheral vision to that of the patient while performing the confrontation test, so unless the examiner is aware of a problem with his or her own vision, the examiner could assume that the fields are full if they match.

DIF: Cognitive Level: Understanding (Comprehension)

OBJ: Nursing process assessment MSC: Physiologic Integrity: Physiologic Adaptation

6. Mrs. S. is a 69-year-old woman who presents for a physical examination. On inspection of her eyes, you note that the left upper eyelid droops, covering more of the iris than does the right. This is recorded as: a. exophthalmos on the right. b. ptosis on the left. c. nystagmus on the left. d. astigmatism on the right.

ANS: B

Ptosis is when one of the upper eyelids covers more of the iris than the other lid, possibly extending over the pupil.

DIF: Cognitive Level: Applying (Application)

OBJ: Nursing process assessment MSC: Physiologic Integrity: Physiologic Adaptation

7. A condition in which the eyelids do not completely meet to cover the globe is called: a. glaucoma. b. lagophthalmos. c. exophthalmos. d. hordeolum.

ANS: B

Lagophthalmos is a term used to describe the condition in which eyelids do not completely meet when closing. Glaucoma involves elevated pressure in the eye. Exophthalmus involves bulging eyes. A hordeolum is better known as a stye.

DIF: Cognitive Level: Remembering (Knowledge)

OBJ: Nursing process assessment MSC: Physiologic Integrity: Physiologic Adaptation

8. Mr. Morris is a 38-year-old patient who presents to the clinic with complaints of allergies. An allergy can cause the conjunctiva to have a: a. cobblestone pattern. b. dry surface. c. subconjunctival hemorrhage. d. rust-colored pigment.

ANS: A

A red or cobblestone pattern, especially to the upper conjunctiva, indicates allergic conjunctivitis. Allergies also cause itchy, watery eyes rather than dry surfaces, hemorrhage, or rust-colored pigment.

DIF: Cognitive Level: Analyzing (Analysis)

OBJ: Nursing process assessment MSC: Physiologic Integrity: Physiologic Adaptation

9. A pterygium is more common in people heavily exposed to: a. high altitudes. b. tuberculosis. c. ultraviolet light. d. cigarette smoke.

ANS: C

Persons heavily exposed to ultraviolet light are more susceptible to the development of a pterygium.

DIF: Cognitive Level: Analyzing (Analysis)

OBJ: Nursing process assessment MSC: Physiologic Integrity: Physiologic Adaptation

10. Mr. Brown was admitted from the emergency department, and you are completing his physical examination. His pupils are 2 mm bilaterally, and you notice that they fail to dilate when the penlight is moved away. This is characteristic in patients who are or have been: a. in a coma. b. taking sympathomimetic drugs (cocaine). c. taking opioid drugs (morphine). d. treated for head trauma.

ANS: C

Pupil constriction to less than 2 mm is called miosis. With miosis, the pupils f ail to dilate in the dark, a common result of opioid ingestion or the use of drops for glaucoma. Pupils are usually dilated greater than 6 mm in a patient described in the other choices.

DIF: Cognitive Level: Applying (Application)

OBJ: Nursing process assessment MSC: Physiologic Integrity: Physiologic Adaptation

11. When testing corneal sensitivity controlled by cranial nerve V, you should expect the patient to respond with: a. brisk blinking. b. copious tearing. c. pupil dilation. d. reflex smiling.

ANS: A

Brisk blinking is an expected response to corneal sensitivity testing, which involves gently touching the cornea with a piece of cotton.

DIF: Cognitive Level: Applying (Application)

OBJ: Nursing process assessment MSC: Physiologic Integrity: Physiologic Adaptation

12. You observe pupillary response as the patient looks at a distant object and then at an object held 10 cm from the bridge of the nose. You are assessing for: a. confrontation reaction. b. accommodation. c. pupillary light reflex. d. nystagmus.

ANS: B

Testing for accommodation involves asking the patient to look at an object at a distance (pupils dilate) and then to look at another, much closer object (pupils constrict).

DIF: Cognitive Level: Applying (Application)

OBJ: Nursing process assessment MSC: Physiologic Integrity: Physiologic Adaptation

13. When inspecting the region of the lacrimal gland, palpate: a. the lower orbital rim, near the inner canthus. b. in the area between the arch of the eyebrow and upper lid. c. beneath the lower lid, adjacent to the inner canthus. d. adjacent to the lateral aspect of the eye, just beneath the upper lid.

ANS: A

The lacrimal gland is located at the lower orbital rim near the inner canthus of the eye.

DIF: Cognitive Level: Remembering (Knowledge)

OBJ: Nursing process assessment MSC: Physiologic Integrity: Physiologic Adaptation

14. Examination to assess for extraocular muscle imbalance is conducted by: a. comparing pupillary responses to different shapes. b. having the patient follow your finger through planes. c. inspecting slightly closed lids for fasciculations. d. transilluminating the cornea with tangential light.

ANS: B

The test for extraocular muscle function is to have the patient follow an object as you move it through planes of vision while observing for nystagmus.

DIF: Cognitive Level: Applying (Application)

OBJ: Nursing process assessment MSC: Physiologic Integrity: Physiologic Adaptation

15. Mr. Older is a 40-year-old patient who presents to the office for a follow-up eye examination after the diagnosis of myopia. To see retinal details in a myopic patient, you will need to: a. adjust your ophthalmoscope into the plus lens. b. move your ophthalmoscope backward. c. move your hand farther forward. d. turn your ophthalmoscope to a minus lens.

ANS: D

The myopic patient (nearsighted) has longer eyeballs, so that light rays focus in front of the retina. To see the retina, use the minus (red) numbers by moving the diopter wheel counterclockwise; to assess a hyperopic patient, use a plus lens.

DIF: Cognitive Level: Applying (Application)

OBJ: Nursing process assessment MSC: Physiologic Integrity: Physiologic Adaptation

16. Ask the patient to look directly at the light of the ophthalmoscope when you are ready to examine the: a. retina. b. optic disc. c. retinal vessels. d. macula.

ANS: D

The macula is the site of central vision and is observed when the patient looks directly at the ophthalmoscope light.

DIF: Cognitive Level: Applying (Application)

OBJ: Nursing process assessment MSC: Physiologic Integrity: Physiologic Adaptation

17. Opacities of the red reflex may indicate the presence of: a. hypertension. b. hydrocephalus. c. cataracts. d. myopia.

ANS: C

Opacities or dark spots of the red reflex may indicate the presence of congenital cataracts in the newborn.

DIF: Cognitive Level: Understanding (Comprehension)

OBJ: Nursing process assessment MSC: Physiologic Integrity: Physiologic Adaptation

18. If a patient has early papilledema, using an ophthalmoscope, the examiner will be able to detect: a. dilated retinal veins. b. retinal vein pulsations. c. sharply defined optic discs. d. visual defects.

ANS: A

Papilledema is caused by increased intracranial pressure along the optic nerve, pushing the vessels forward (cup protrudes forward) and dilating the retinal veins. Retinal vein pulsations and visual defects are not visible with an ophthalmoscope. On examination, papilledema is characterized by loss of definition of the optic disc.

DIF: Cognitive Level: Applying (Application)

OBJ: Nursing process assessment MSC: Physiologic Integrity: Physiologic Adaptation

19. Cupping of the optic disc may be a result of: a. migraine headaches. b. diabetes. c. glaucoma. d. dehydration

ANS: C

Cupping is seen with causes of increased intraocular pressure, such as glaucoma. Migraine headaches, diabetes, and dehydration do not cause cupping of the optic disc. Diabetes results in cotton wool patches and hemorrhages.

DIF: Cognitive Level: Analyzing (Analysis)

OBJ: Nursing process assessment MSC: Physiologic Integrity: Physiologic Adaptation

20. When drusen bodies are noted to be increasing in number or in intensity of color, the patient should be further evaluated with a(n): a. Amsler grid. b. Snellen E chart. c. litmus test. d. confrontation test.

ANS: A

Drusen bodies, when they increase in number or intensity of color, may indicate a precursor s a e of mac lar degenera ion. When his happens, he pa ien s cen ral ision sho ld be assessed using the Amsler grid. The Snellen E chart measures visual acuity, the litmus test is used for testing pH, and a confrontation test examines peripheral vision.

DIF: Cognitive Level: Applying (Application)

OBJ: Nursing process assessment MSC: Physiologic Integrity: Physiologic Adaptation

21. Cotton wool spots are most closely associated with: a. glaucoma. b. normal aging processes. c. hypertension. d. eye trauma.

ANS: C

Cotton wool spots actually represent infarcts of the retina and are associated with hypertension or diabetes.

DIF: Cognitive Level: Applying (Application)

OBJ: Nursing process assessment MSC: Physiologic Integrity: Physiologic Adaptation a. Drusen bodies b. Papilledema c. Narrow palpebral fissures d. Prominent epicanthal folds

22. Which may be suggestive of Down syndrome?

ANS: D

Prominent epicanthal folds, or slanting of the eyes, may be normal in Asian infants, but in other ethnic groups it may indicate Down syndrome.

DIF: Cognitive Level: Applying (Application)

OBJ: Nursing process assessment MSC: Physiologic Integrity: Physiologic Adaptation

23. To differentiate between infants who have strabismus and those who have pseudostrabismus, use the: a. confrontation test. b. corneal light reflex. c. E chart. d. Amsler grid.

ANS: B

The corneal light reflex is used with infants to differentiate between strabismus and pseudostrabismus by noting an asymmetric versus symmetric light reflex.

DIF: Cognitive Level: Applying (Application)

OBJ: Nursing process assessment MSC: Physiologic Integrity: Physiologic Adaptation

24. You are attempting to examine the eyes of a newborn. To facilitate eye opening, you would first: a. dim the room lights. b. elicit pain. c. place him in the supine position. d. shine the penlight in his or her eyes.

ANS: A

The best way to assess the eyes of a newborn is to start by dimming the lights because it encourages infants to open their eyes.

DIF: Cognitive Level: Applying (Application)

OBJ: Nursing process assessment MSC: Physiologic Integrity: Physiologic Adaptation

25. Dot hemorrhages, or microaneurysms, in the retina and the presence of hard and soft exudates are most commonly seen in those with: a. Down syndrome. b. diabetic retinopathy. c. systemic lupus. d. glaucoma.

ANS: B

Dot hemorrhages or tiny aneurysms are characteristics of background retinopathy. A trapping of lipids within incompetent capillaries causes the hemorrhages.

DIF: Cognitive Level: Analyzing (Analysis)

OBJ: Nursing process assessment MSC: Physiologic Integrity: Physiologic Adaptation a. Have the woman keep her eyes closed for several minutes. b. Instill half the usual dosage. c. Keep the patient supine, with her head turned and flexed. d. Use nasolacrimal occlusion after instillation.

26. Which maneuver can be done to reduce the systemic absorption of cycloplegic and mydriatic agents when examining a pregnant woman if the examination is mandatory?

ANS: D

To reduce absorption systemically, the examiner may use nasolacrimal occlusion after applying, which involves pinching the upper bridge of the nose.

DIF: Cognitive Level: Applying (Application)

OBJ: Nursing process assessment MSC: Physiologic Integrity: Physiologic Adaptation

27. Changes seen in proliferative diabetic retinopathy are the result of: a. anoxic stimulation. b. macular damage. c. papilledema. d. minute hemorrhages.

ANS: A

New vessels are a characteristic seen in proliferative retinopathy resulting from anoxic stimulation. An insufficient blood supply from failing capillaries causes new vessel growth.

DIF: Cognitive Level: Analyzing (Analysis)

OBJ: Nursing process assessment MSC: Physiologic Integrity: Physiologic Adaptation

Multiple Response

1. Which are the signs and symptoms of infant retinoblastoma? (Select all that apply.)

a. White reflex b. Red reflex c. Corneal light reflex d. Absence of a blink reflex e. Autosomal dominant trait f. Drainage from the affected eye g. Visual acuity of 20/500

ANS: A, E

Re inoblas oma in an infan is marked b a charac eris ic hi e refle , also called ca s e e reflex or leukocoria. Red reflex and corneal light reflex are expected findings. Absence of the blink reflex is not associated with retinoblastoma.

DIF: Cognitive Level: Understanding (Comprehension)

OBJ: Nursing process assessment MSC: Physiologic Integrity: Physiologic Adaptation

Chapter 13: Ears, Nose, and Throat Ball:

Multiple Choice

1. Mr. Sprat is a 21-year-old patient who complains of nasal congestion. He admits to using recreational drugs. On examination, you have noted a septal perforation. Which of the following recreational drugs is commonly associated with nasal septum perforation?

a. Heroin b. Cocaine c. PCP d. Ecstasy

ANS: B

Long-term cocaine snorting causes ischemic necrosis of the septal cartilage and leads to perforation of the nasal septum.

DIF: Cognitive Level: Understanding (Comprehension)

OBJ: Nursing process assessment MSC: Physiologic Integrity: Physiologic Adaptation

2. A 5-year-old child presents with nasal congestion and a headache. To assess for sinus tenderness, you should palpate over the: a. sphenoid and frontal sinuses. b. maxillary and frontal sinuses. c. maxillary sinuses only. d. sphenoid sinuses only.

ANS: C

Only the maxillary and the frontal sinuses are accessible for physical examination; however, the young child does not develop frontal sinuses until 7 to 8 years of age.

DIF: Cognitive Level: Applying (Application)

OBJ: Nursing process assessment MSC: Physiologic Integrity: Physiologic Adaptation

3. Mr. and Mrs. Johnson have presented to the office with their infant son with complaints of ear drainage. When examining an infa idd e ea , he e h d e e ha d abi i e the otoscope against the head while using the other hand to: a. pull the auricle down and back. b. hold the speculum in the canal. c. distract the infant. d. stabilize the chest.

ANS: A

The nurse should use the other hand to pull the auricle down and back in an effort to straighten the upward curvature of the canal.

DIF: Cognitive Level: Analyzing (Analysis)

OBJ: Nursing process assessment MSC: Physiologic Integrity: Physiologic Adaptation

4. Mrs. Donaldson is a 31-year-old patient who is pregnant. In providing Mrs. Donaldson with healthcare information, you will explain that she can expect to experience: a. more nasal stuffiness. b. a sensitive sense of smell. c. drooling. d. enhanced hearing.

ANS: A

Physiologic changes of pregnancy include nasal stuffiness, a decreased sense of smell, impaired hearing, epistaxis, and a sense of fullness in the ears.

DIF: Cognitive Level: Applying (Application)

OBJ: Nursing process assessment MSC: Physiologic Integrity: Physiologic Adaptation a. A 7-year-old b. An 18-year-old c. A 30-year-old d. A 50-year-old

5. You are performing hearing screening tests. Who would be expected to find difficulty in hearing the highest frequencies?

ANS: D

Sensorineural hearing loss begins after 50 years of age, initially with losses of high -frequency sounds and then progressing to tones of lower frequency.

DIF: Cognitive Level: Applying (Application)

OBJ: Nursing process assessment MSC: Physiologic Integrity: Physiologic Adaptation a. Chlorothiazide b Acetaminophen c. Salicylates d. Cephalosporins

6. Mr. Spencer presents with the complaint of hearing loss. You specifically inquire about current medications. Which medications, if listed, are likely to contribute to his hearing loss?

ANS: C

Ototoxic medications include aminoglycoside, salicylates, furosemide, streptomycin, quinine, ethacrynic acid, and cisplatin.

DIF: Cognitive Level: Analyzing (Analysis)

OBJ: Nursing process assessment MSC: Physiologic Integrity: Physiologic Adaptation a. 100 to 300 Hz b. 200 to 400 Hz c. 500 to 1000 Hz d. 1500 to 2000 Hz

7. To approximate vocal frequencies, which tuning fork should be used to assess hearing?

ANS: C

Use of a 500- to 1000-Hz tuning fork approximates vocal frequencies.

DIF: Cognitive Level: Remembering (Knowledge)

OBJ: Nursing process assessment MSC: Physiologic Integrity: Physiologic Adaptation

8. You are using a pneumatic attachment on the otoscope while assessing tympanic membrane movement. You gently squeeze the bulb but see no movement of the membrane. Your next action should be to: a. remove all cerumen from the canal. b. change to a larger speculum. c. squeeze the bulb with more force. d. insert the speculum to a depth of 2 cm.

ANS: B

To see tympanic movement when using the pneumatic attachment, there should be a seal around the speculum to block outside air. In this manner, the normal tympanic membrane moves as a result of pressure changes from the insufflator bulb. A soft rubber speculum is recommended to establish the seal.

DIF: Cognitive Level: Analyzing (Analysis)

OBJ: Nursing process assessment MSC: Physiologic Integrity: Physiologic Adaptation

9. When conducting an adult otoscopic examination, you should: a. i i he a ie head ea i g a d . b. grasp the handle of the otoscope as you would a baseball bat. c. select the largest speculum that will fit in the canal. d. ask the patient to keep his or her eyes closed.

ANS: C

When conducting an adult otoscopic examination, select the largest speculum that will c f ab fi i he a ie ea . Whe a e conducting an adult otoscopic examination, he a ie head h d be i i ed a d he i e h de . H d he ha d e f he otoscope between the thumb and index finger, supporting it on the middle finger. There is no reason for the patient to keep her or his eyes shut.

DIF: Cognitive Level: Applying (Application)

OBJ: Nursing process assessment MSC: Physiologic Integrity: Physiologic Adaptation

10. Bulging of an amber tympanic membrane without mobility is usually associated with: a. middle ear effusion. b. healed tympanic membrane perforation. c. impacted cerumen in the canal. d. repeated and prolonged crying cycles.

ANS: A

An amber color, with bulging of the tympanic membrane and without mobility or redness, usually indicates the presence of fluid in the middle ear.

DIF: Cognitive Level: Applying (Application)

OBJ: Nursing process assessment MSC: Physiologic Integrity: Physiologic Adaptation a. III b. IV c. VIII d. XII

11. When hearing is evaluated, which cranial nerve is being tested?

ANS: C

Cranial nerve VIII, the vestibulocochlear nerve, is associated with hearing.

DIF: Cognitive Level: Remembering (Knowledge)

OBJ: Nursing process assessment MSC: Physiologic Integrity: Physiologic Adaptation

12. Speech with a monotonous tone and erratic volume may indicate: a. otitis externa. b. hearing loss. c. serous otitis media. d. sinusitis.

ANS: B

Speech with a monotonous tone and erratic volume may indicate hearing loss.

DIF: Cognitive Level: Understanding (Comprehension)

OBJ: Nursing process assessment MSC: Physiologic Integrity: Physiologic Adaptation

13. You are performing Weber and Rinne hearing tests. For the Weber test, the sound lateralized to the unaffected ear; for the Rinne test, air conduction-to-bone conduction ratio is less than 2:1. You interpret these findings as suggestive of: a. a defect in the inner ear. b. a defect in the middle ear. c. otitis externa. d. impacted cerumen.

ANS: A

These results are consistent with a sensorineural hearing loss, a defect in the inner ear. Otitis externa and impacted cerumen are conditions of the external ear that can cause conductive hearing problems.

DIF: Cognitive Level: Analyzing (Analysis)

OBJ: Nursing process assessment MSC: Physiologic Integrity: Physiologic Adaptation

14. Nasal symptoms that imply an allergic response include: a. purulent nasal drainage. b. bluish gray turbinates. c. small, atrophied nasal membranes. d. firm consistency of turbinates.

ANS: B

Nasal symptoms that imply an allergic response include bluish gray or pale pink nasal turbinates that are swollen and boggy and a transverse crease at the junction between the cartilage and bone of the nose.

DIF: Cognitive Level: Analyzing (Analysis)

OBJ: Nursing process assessment MSC: Physiologic Integrity: Physiologic Adaptation

15. You are interviewing a parent whose child has a fever, is pulling at her right ear, and is i i ab e. Y a k he a e ab he chi d a e i e a d fi d ha he chi d ha a dec ea ed appetite. This additional finding is more suggestive of: a. acute otitis media. b. otitis externa c. serous otitis media. d. middle ear effusion.

ANS: A

Anorexia is an initial symptom of acute otitis media.

DIF: Cognitive Level: Analyzing (Analysis)

OBJ: Nursing process assessment MSC: Physiologic Integrity: Physiologic Adaptation

16. A hairy tongue with yellowish brown to black elongated papillae on the dorsum: a. is indicative of oral cancer. b. is sometimes seen following antibiotic therapy. c. usually indicates vitamin deficiency. d. usually indicates anemia.

ANS: B

Recent antibiotic use can turn the tongue yellow-brown to black and make it appear hairy. Oral cancer involves lesions. A smooth red tongue with a slick appearance may indicate a niacin or vitamin B12 deficiency. Pallor usually indicates anemia.

DIF: Cognitive Level: Understanding (Comprehension)

OBJ: Nursing process assessment MSC: Physiologic Integrity: Physiologic Adaptation

17. To inspect the lateral borders of the tongue, you should: a. ask the patient to extend the tongue outward. b. insert the tongue blade obliquely against the tongue. c. lift the tongue upward with gloved fingers. d. pull the gauze-wrapped tongue to each side.

ANS: D

To inspect the lateral borders of the tongue, you should wrap the tongue with a piece of gauze and then pull the tongue to each side for inspection.

DIF: Cognitive Level: Applying (Application)

OBJ: Nursing process assessment MSC: Physiologic Integrity: Physiologic Adaptation

18. For best results, an otoscopic and oral examination in a child should be: a. conducted at the beginning of the assessment. b. done after inspection. c. performed at the end of the examination. d. performed before palpation.

ANS: C

Because young children often resist an otoscopic and oral examination, it may be wise to postpone these procedures until the end, after you have gained some trust.

DIF: Cognitive Level: Understanding (Comprehension)

OBJ: Nursing process assessment MSC: Physiologic Integrity: Physiologic Adaptation

Multiple Response

1. Mr. Akins is a 78-year-old patient who presents to the clinic with complaints of hearing loss. Which are changes in hearing that occur in older adults? (Select all that apply.)

a. Results from cranial nerve VII b. Slow progression c. Loss of high frequency d. Bone conduction heard longer than air conduction e. Sounds may be garbled, difficult to localize f. Unable to hear in a crowded room

ANS: C, E, F

Age-related hearing loss is associated with degeneration of hair cells in the organ of Corti, loss of cortical and organ of Corti auditory neurons, degeneration of the cochlear conductive membrane, and decreased vascularity in the cochlea. Sensorineural hearing loss first occurs with high-frequency sounds and then progresses to tones of lower frequency. Loss of high-frequency sounds usually interferes with the understanding of speech and localization of sound. Conductive hearing loss may result from an excess deposition of bone cells along the ossicle chain, causing fixation of the stapes in the oval window, cerumen impaction, or a sclerotic tympanic membrane.

DIF: Cognitive Level: Applying (Application)

OBJ: Nursing process assessment MSC: Physiologic Integrity: Physiologic Adaptation a. Air conduction shorter than bone conduction b. Lateralization to the affected ear c. Loss of high-frequency sounds d. Speaks more loudly e. Disorder of the inner ear f. Air conduction longer than bone conduction

2. Which signs and symptoms occur with a sensorineural hearing loss? (Select all that apply.)

ANS: C, D, E, F

The signs and symptoms of sensorineural hearing loss include loss of high-frequency sounds, speaks more loudly, disorder of the inner ear, air conduction longer than bone conduction, and lateralization to the unaffected ear.

DIF: Cognitive Level: Applying (Application)

OBJ: Nursing process assessment MSC: Physiologic Integrity: Physiologic Adaptation

Completion

1. When you ask the patient to identify smells, you are assessing cranial nerve __.

ANS: I

The first cranial nerve, the olfactory nerve, is tested when you ask a patient to identify different smells.

DIF: Cognitive Level: Remembering (Knowledge)

OBJ: Nursing process assessment MSC: Physiologic Integrity: Physiologic Adaptation

Multiple Choice

1. A 44-year-old male patient who complains of a cough has presented to the emergen cy department. He admits to smoking one pack per day. During your inspection of his chest, the most appropriate lighting source to highlight chest movement is: a. bright tangential lighting. b. daylight from a window. c. flashlight in a dark room. d. fluorescent ceiling lights.

ANS: A

Bright tangential light is best for visualizing chest movements.

DIF: Cognitive Level: Applying (Application)

OBJ: Nursing process assessment MSC: Physiologic Integrity: Physiologic Adaptation

2. When auscultating the apex of the lung, you should listen at a point: a. even with the second rib. b. 4 cm above the first rib. c. higher on the right side. d. on the convex diaphragm surface.

ANS: B

The apex of the lung is 4 cm above the first rib.

DIF: Cognitive Level: Analyzing (Analysis)

OBJ: Nursing process assessment MSC: Physiologic Integrity: Physiologic Adaptation

3. To count the ribs and the intercostal spaces, you begin by palpating the reference point of the: a. distal point of the xiphoid. b. manubriosternal junction. c. suprasternal notch. d. acromion process.

ANS: B

The angle of Louis, the junction of the manubrium and the sternum, corresponds to the second rib, the reference point for counting ribs and intercostal spaces.

DIF: Cognitive Level: Applying (Application)

OBJ: Nursing process assessment MSC: Physiologic Integrity: Physiologic Adaptation

4. Mr. Curtis is a 44-year-old patient who has presented to the emergency department with shortness of breath. During the history, the patient describes shortness of breath that gets worse when he sits up. To document this, you will use the term: a. platypnea. b. orthopnea. c. tachypnea. d. bradypnea.

ANS: A

Dyspnea that increases in the upright posture is called platypnea. Orthopnea is dyspnea that worsens when the person lies down. Tachypnea is an increased respiratory rate. Bradypnea is a decreased respiratory rate.

DIF: Cognitive Level: Understanding (Comprehension)

OBJ: Nursing process assessment MSC: Physiologic Integrity: Physiologic Adaptation a. Barrel chest b. Clubbed fingers c. Pectus carinatum d. Chest wall retractions

5. Which finding suggests a minor structural variation?

ANS: C

Pectus carinatum (pigeon chest) is a minor structural variation. Barrel chest, clubbing of the fingers, and chest wall retractions result from compromised respirations.

DIF: Cognitive Level: Applying (Application)

OBJ: Nursing process assessment MSC: Physiologic Integrity: Physiologic Adaptation a. Barrel chest b. Cor pulmonale c. Funnel chest d. Malodorous breath

6. Ms. Rudman, age 74 years, has no known health problems or diseases. You are doing a preventive healthcare history and examination. Which symptom is associated with intrathoracic infection?

ANS: D

Intrathoracic infections may make the breath malodorous.

DIF: Cognitive Level: Understanding (Comprehension)

OBJ: Nursing process assessment MSC: Physiologic Integrity: Physiologic Adaptation

7. The best time to observe and count respirations is while: a. the patient is answering questions. b. weighing the patient. c. palpating the pulse. d. the patient is sleeping.

ANS: C

Counting respirations while you palpate the pulse does not make the patient self-conscious because the patient expects you to be counting the pulse. Respiratory patterns change as the patient speaks. Attempting to count during weighing would make the patie nt self-conscious and affect the respiratory rate. Respiratory patterns change as the patient sleeps.

DIF: Cognitive Level: Applying (Application)

OBJ: Nursing process assessment MSC: Physiologic Integrity: Physiologic Adaptation

8. As you take vital signs on Mr. Barrow, age 78 years, you note that his respirations are 40 b ea h / i . He ha bee e i g, a d hi c a i i . I ega d M . Ba respirations, you would: a. document his rate as normal. b. do nothing because his color is pink. c. note that his rate is below normal. d. report that he has an above-average rate.

ANS: D

The normal adult respiratory rate is 12 to 20 breaths/min, and the ratio of breaths to heartbeats is 1:4. A respiratory rate of 40 breaths/min is not within the normal range and should be documented as above average.

DIF: Cognitive Level: Applying (Application)

OBJ: Nursing process assessment MSC: Physiologic Integrity: Physiologic Adaptation a. Patient who is depressed b. Patient who abuses narcotics c. Patient with metabolic acidosis d. Patient with myasthenia gravis

9. In which patient situation would you expect to assess tachypnea?

ANS: C

In metabolic acidosis, the body compensates by increasing the respiratory rate to blow off the excess carbon dioxide. A patient who is depressed, abuses narcotics, or has myasthenia gravis would have respiratory depression.

DIF: Cognitive Level: Applying (Application)

OBJ: Nursing process assessment MSC: Physiologic Integrity: Physiologic Adaptation a. Lower chest b. Along the anterior axillary line c. Above the clavicles d. At the nipple line

10. Which site of chest wall retractions indicates a more severe obstruction in the asthmatic patient?

ANS: C

Asthma usually causes retractions of the lower chest. The more severe the obstruction, the greater the negative pressure produced in the chest during inspiration, and retractions are manifested in the upper thorax.

DIF: Cognitive Level: Analyzing (Analysis)

OBJ: Nursing process assessment MSC: Physiologic Integrity: Physiologic Adaptation

11. You would expect to document the presence of a pleural friction rub for a patient being treated for: a. pneumonia. b. atelectasis. c. pleurisy. d. emphysema.

ANS: C

A pleural friction rub is caused by inflammation of the pleural surfaces and would be expected to be auscultated with pleurisy.

DIF: Cognitive Level: Understanding (Comprehension)

OBJ: Nursing process assessment MSC: Physiologic Integrity: Physiologic Adaptation a. Primary apnea b. Secondary apnea c. Sleep apnea d. Periodic apnea of the newborn

12. Which type of apnea requires immediate action?

ANS: B

Secondary apnea is a grave condition, and unless resuscitative measures are instituted immediately, breathing will not resume spontaneously. Primary apnea is self-limiting. Sleep apnea should be evaluated but does not require immediate action. Periodic apnea of the newborn is a normal condition.

DIF: Cognitive Level: Applying (Application)

OBJ: Nursing process assessment MSC: Physiologic Integrity: Physiologic Adaptation

13. With consolidation in the lung tissue, the breath sounds are louder and easier to hear, whereas healthy lung tissue produces softer sounds. This is because: a. consolidation echoes in the chest. b. consolidation is a poor conductor of sound. c. air-filled lung sounds are from smaller spaces. d. air-filled lung tissue is an insulator of sound.

ANS: D

Air is a poor conductor of sound. Denser consolidation promotes louder sounds and is a better conductor of sound. Consolidation is a better conductor of sound than air. Breath sounds are easier to hear when the lungs are consolidated; the mass surrounding the tube of the respiratory tree promotes sound transmission better than air-filled alveoli.

DIF: Cognitive Level: Analyzing (Analysis)

OBJ: Nursing process assessment MSC: Physiologic Integrity: Physiologic Adaptation

Multiple Response

1. Which lung sounds are associated with atelectasis? (Select all that apply.)

a. Wheezes b. Ronchi c. Crackles d. Crepitus e. Rales

ANS: A, B, C

Wheezes, ronchi, and crackles in varying amounts are associated with atelectasis.

DIF: Cognitive Level: Understanding (Comprehension)

OBJ: Nursing process assessment MSC: Physiologic Integrity: Physiologic Adaptation

COMPLETION

1. An Apgar score of __________ is given to the infant who demonstrates irregular respiratory effort.

ANS: 1

The Apgar score of 1 in an infant reflects slow or irregular breathing.

DIF: Cognitive Level: Understanding (Comprehension)

OBJ: Nursing process assessment MSC: Physiologic Integrity: Physiologic Adaptation

Multiple Choice

1. Mr. O, age 50 years, comes for his annual health assessment, which is provided by his employer. During your initial history-taking interview, Mr. O mentions that he routinely engages in light exercise. At this time, you should: a. ask if he makes his own bed daily. b. have the patient describe his exercise. c. make a note that he walks each day. d. record “light exercise” in the history.

ANS: B

When Mr. O says that he engages in light exercise, have him describe his exercise. To qualify his use of the term light, ask him the type, length of time, frequency, and intensity of his activities.

DIF: Cognitive Level: Applying (Application)

OBJ: Nursing process assessment MSC: Physiologic Integrity: Physiologic Adaptation a. Adolescent inguinal hernia b. Childhood mumps c. History of bee stings d. Previous unexplained fever

2. Which of the following information belongs in the past medical history section related to heart and blood vessel assessment?

ANS: D

Previous unexplained fever should be included in the past medical history of a heart and blood vessel assessment. This incidence may be related to acute rheumatic fever, with potential heart valve damage.

DIF: Cognitive Level: Understanding (Comprehension)

OBJ: Nursing process assessment MSC: Physiologic Integrity: Physiologic Adaptation a. “Did your father have coronary bypass surgery?” b. “Did your father s father have heart trouble also?” c. “What were your father s usual dietary habits?” d. “What age was your father at the time of his death?”

3. A patient you are seeing in the emergency department for chest pain is believed to be having a myocardial infarction. During the health history interview of his family history, he relates that his father had died of “heart trouble.” The most important follow-up question you should pose is which of the following?

ANS: D

A family history of sudden death, particularly in young and middle-aged relatives, significantly increases one s chance of a similar occurrence.

DIF: Cognitive Level: Applying (Application)

OBJ: Nursing process assessment MSC: Physiologic Integrity: Physiologic Adaptation a. Fatigue b. Joint pain c. Poor night vision d. Weight gain

4. Which one of the following is a common symptom of cardiovascular disorders in the older adult?

ANS: A

Common symptoms of cardiovascular disorders in older adults include confusion, dizziness, blackouts, syncope, palpitations, coughs and wheezes, hemoptysis, shortness of breath, chest pains or tightness, impotence, fatigue, and leg edema.

DIF: Cognitive Level: Understanding (Comprehension)

OBJ: Nursing process assessment MSC: Physiologic Integrity: Physiologic Adaptation a. Supine b. Upright c. Lithotomy d. Right lateral recumbent

5. In the adult, the apical impulse should be most visible when the patient is in what position?

ANS: B

In most adults, the apical impulse should be visible at about the midclavicular line in the fifth left intercostal space, but it is easily obscured by obesity, large breasts, or muscularity. The apical impulse may become visible only when the patient sits upright and the heart is brought closer to the anterior wall. A visible and palpable impulse when the patient is supine suggests an intensity that may be the result of a problem. In most adults, the apical im pulse will not be visible in the upright, lithotomy, or right lateral recumbent positions.

DIF: Cognitive Level: Understanding (Comprehension)

OBJ: Nursing process assessment MSC: Physiologic Integrity: Physiologic Adaptation

6. If the apical impulse is more vigorous than expected, it is called a: a. lift. b. thrill. c. bruit. d. murmur.

ANS: A

If the apical impulse is more vigorous than expected, it is referred to as a lift or heave. A thrill is a palpable murmur. A bruit is an auscultated arterial murmur. A murmur is an auscultated sound caused by turbulent blood flow into, through, or out of the heart.

DIF: Cognitive Level: Understanding (Comprehension)

OBJ: Nursing process assessment MSC: Physiologic Integrity: Physiologic Adaptation

7. A palpable rushing vibration over the base of the heart at the second intercostal space is called a: a. heave. b. lift. c. thrill. d. thrust.

ANS: C

A thrill is a fine, palpable, rushing vibration a palpable murmur. Cardiac thrills generally indicate a disruption of the expected blood flow related to some defect in the closure of one of the semilunar valves (generally aortic or pulmonic stenosis), pulmonary hypertension, or atrial septal defect. A heave or lift is a more vigorous apical impulse. A lift is another term for a heave, which is a more vigorous apical impulse. A thrust is sudden, forcible forward movement.

DIF: Cognitive Level: Understanding (Comprehension)

OBJ: Nursing process assessment MSC: Physiologic Integrity: Physiologic Adaptation

8. An apical PMI palpated beyond the fifth intercostal space may indicate: a. decreased cardiac output. b. obesity. c. left ventricular hypertrophy. d. hyperventilation.

ANS: C

An apical impulse that is more forceful and widely distributed, fills systole, or is displaced laterally and downward may be indicative of left ventricular hypertrophy. Obesity, large breasts, and muscularity can obscure the visibility of the apical impulse.

DIF: Cognitive Level: Understanding (Comprehension)

OBJ: Nursing process assessment MSC: Physiologic Integrity: Physiologic Adaptation

9. A lift along the left sternal border is most likely the result of: a. aortic stenosis. b. atrial septal defect. c. pulmonary hypertension. d. right ventricular hypertrophy.

ANS: D

A lift along the left sternal border may be caused by right ventricular hypertrophy. A thrill indicates a disruption of the expected blood flow related to a defect in the closure of one of the semilunar valves, which is seen in aortic or pulmonic stenosis, pulmonary hypertension, or atrial septal defect.

DIF: Cognitive Level: Applying (Application)

OBJ: Nursing process assessment MSC: Physiologic Integrity: Physiologic Adaptation

10. To estimate heart size by percussion, you should begin tapping at the: a. anterior axillary line. b. left sternal border. c. midclavicular line. d. midsternal line.

ANS: A

Estimating the size of the heart can be done by percussion. Begin tapping at the anterior axillary line, moving medially along the intercostal spaces toward the sternal border. The change from a resonant to a dull note marks the cardiac border.

DIF: Cognitive Level: Applying (Application)

OBJ: Nursing process assessment MSC: Physiologic Integrity: Physiologic Adaptation

11. To hear diastolic heart sounds, you should ask patients to: a. lie on their back. b. lie on their left side. c. lie on their right side. d. sit up and lean forward.

ANS: B

Left lateral recumbent is the best position to hear the low-pitched filling sounds in diastole with the bell of the stethoscope. Sitting up and leaning forward is the best position in which to hear relatively high-pitched murmurs with the diaphragm of the stethoscope. The right lateral recumbent position is the best position for evaluating the right rotated heart of dextrocardia.

DIF: Cognitive Level: Applying (Application)

OBJ: Nursing process assessment MSC: Physiologic Integrity: Physiologic Adaptation

12. You are listening to a patient s heart sounds in the aortic and pulmonic areas. The sound becomes asynchronous during inspiration. The prevalent heart sound in this area is most likely: a. S1 b. S2. c. S3. d. S4

ANS: B

S2 marks the closure of the semilunar valves, which indicates the end of systole; it is best heard in the aortic and pulmonic areas. It is higher pitched and shorter than S 1. S2 typically splits during inspiration.

DIF: Cognitive Level: Applying (Application)

OBJ: Nursing process assessment MSC: Physiologic Integrity: Physiologic Adaptation

13. Chest pain with an organic cause in a child is most likely the result of: a. cardiac disease. b. asthma. c. esophageal reflux. d. arthritis.

ANS: B

Unlike chest pain in adults, chest pain in children and adolescents is seldom caused by a cardiac problem. More likely, the case is related to trauma, exercise -induced asthma, or cocaine use.

DIF: Cognitive Level: Understanding (Comprehension)

OBJ: Nursing process assessment MSC: Physiologic Integrity: Physiologic Adaptation

14. A condition that is likely to present with dizziness and syncope is: a. bacterial endocarditis. b. hypertension. c. sick sinus syndrome. d. pericarditis.

ANS: C

Sick sinus syndrome (SSS) is a sinoatrial dysfunction that occurs secondary to hypertension, arteriosclerotic heart disease, or rheumatic heart disease. SSS causes dysrhythmia with subsequent syncope, transient dizzy spells, light-headedness, seizures, palpitations, angina, or congestive heart failure (CHF). Bacterial endocarditis presents with prolonged fever, signs of neurologic dysfunction, and sudden onset of CHF. Chest pain is an initial symptom in acute pericarditis, along with a triphasic friction rub.

DIF: Cognitive Level: Understanding (Comprehension)

OBJ: Nursing process assessment MSC: Physiologic Integrity: Physiologic Adaptation

15. Your patient, who abuses intravenous (IV) drugs, has a sudden onset of fever and symptoms of congestive heart failure. Inspection of the skin reveals nontender erythematic lesions to the palms. These findings are consistent with the development of: a. rheumatic fever. b. cor pulmonale. c. pericarditis. d. endocarditis.

ANS: D

Endocarditis is a bacterial infection of the endothelial layer of the heart. It should be suspected with at-risk patients (e.g., IV drug abusers) who present with fever and sudden onset of congestive heart symptoms. The lesions described are Janeway lesions.

DIF: Cognitive Level: Applying (Application)

OBJ: Nursing process assessment MSC: Physiologic Integrity: Physiologic Adaptation

16. The most helpful finding in determining left-sided heart failure is: a. dyspnea. b. orthopnea. c. jugular vein distention. d. an S3 heart sound.

ANS: C

Evidence-based research has shown that the most helpful clinical examination finding supportive of left-sided heart failure is jugular vein distention.

DIF: Cognitive Level: Analyzing (Analysis)

OBJ: Nursing process assessment MSC: Physiologic Integrity: Physiologic Adaptation

Multiple Response

1. Your patient has been diagnosed with pericarditis. Which are signs and symptoms, or a precipitating factor? (Select all that apply.)

a. Sharp pain b. Pain relieved by sitting up c. Pain relieved by resting d. Friction rub heard to right of sternum e. History of kidney failure f. Result of viral infection g. Result of medications such as procainamide

ANS: A, B, E, F, G

Pericarditis may be seen with a viral infection, kidney failure, or medications such as procainamide. Symptoms include pain relieved by sitting up or leaning forward. A friction rub is heard at the left of the sternum, at the third or fourth intercostal space.

DIF: Cognitive Level: Remembering (Knowledge)

OBJ: Nursing process assessment MSC: Physiologic Integrity: Physiologic Adaptation