Physical Examination and Health Assessment 8th Edition 0323510809
Chapter 14: Head, Face, and Neck, and Regional Lymphatics Jarvis: Physical Examination and Health Assessment, 8th Edition MULTIPLE CHOICE 1. A physician tells the nurse that a patient’s vertebra prominens is tender and asks the nurse to
reevaluate the area in 1 hour. What area of the body will the nurse assess? a. At the level of the C7 vertebra b. At the level of the T11 vertebra c. At the level of the L5 vertebra d. At the level of the S3 vertebra ANS: A
The C7 vertebra has a long spinous process, called the vertebra prominens, which is palpable when the head is flexed. DIF: Cognitive Level: Applying (Application) MSC: Client Needs: Physiological Integrity: Physiological Adaptation 2. A mother brings her 2-month-old daughter in for an examination and says, “My daughter
rolled over against the wall, and now I have noticed that she has this spot that is soft on the top of her head. Is something terribly wrong?” How should the nurse respond? a. “Perhaps that could be a result of your dietary intake during pregnancy.” b. “Your baby may have craniosynostosis, a disease of the sutures of the skull.” c. “That ‘soft spot’ may be an indication of cretinism or congenital hypothyroidism.” d. “That ‘soft spot’ is normal, and actually allows for growth of the brain during the first year of your baby’s life.” ANS: D
Membrane-covered “soft spots” allow for growth of the brain during the first year of life. They gradually ossify; the triangular-shaped posterior fontanel is closed by 1 to 2 months, and the diamond-shaped anterior fontanel closes between 9 months and 2 years. DIF: Cognitive Level: Applying (Application) MSC: Client Needs: Health Promotion and Maintenance 3. The nurse notices that a patient’s palpebral fissures are not symmetric. On examination, the
nurse may find that damage has occurred to which cranial nerve (CN)? a. V b. VII c. XI d. XIII ANS: B
Facial muscles are mediated by CN VII; asymmetry of palpebral fissures may be attributable to damage to CN VII (Bell palsy). Cranial nerve V, the trigeminal nerve, mediates facial sensations of pain and touch. Cranial nerve XI is the spinal accessory nerve that innervates the sternomastoid and trapezius muscles of the neck. There is no cranial nerve XIII (only 12 cranial nerves).
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