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Nursing
Q:
The nurse is performing an otoscopic examination on an adult. Which of these actions is correct?
a. Tilting the person's head forward during the examination
b. Once the speculum is in the ear, releasing the traction
c. Pulling the pinna up and back before inserting the speculum
d. Using the smallest speculum to decrease the amount of discomfort
Q:
While discussing the history of a 6-month-old infant, the mother tells the nurse that she took a significant amount of aspirin while she was pregnant. What question would the nurse want to include in the history?
a. "Does your baby seem to startle with loud noises?"
b. "Has your baby had any surgeries on her ears?"
c. "Have you noticed any drainage from her ears?"
d. "How many ear infections has your baby had since birth?"
Q:
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:
a. Is normal for people of his age.
b. Is a characteristic of recruitment.
c. May indicate a middle ear infection.
d. Indicates that the patient has a cerumen impaction.
Q:
The nurse is taking the history of a patient who may have a perforated eardrum. What would be an important question in this situation?
a. "Do you ever notice ringing or crackling in your ears?"
b. "When was the last time you had your hearing checked?"
c. "Have you ever been told that you have any type of hearing loss?"
d. "Is there any relationship between the ear pain and the discharge you mentioned?"
Q:
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? This finding:
a. Is probably the result of lesions from eczema in his ear.
b. Represents poor hygiene.
c. Is a normal finding, and no further follow-up is necessary.
d. Could be indicative of change in cilia; the nurse should assess for hearing loss.
Q:
A 70-year-old patient tells the nurse that he has noticed that he is having trouble hearing, especially in large groups. He says that 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?
a. Atrophy of the apocrine glands
b. Cilia becoming coarse and stiff
c. Nerve degeneration in the inner ear
d. Scarring of the tympanic membrane
Q:
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 of a television or radio. The most likely cause of his hearing loss is:
a. Otosclerosis.
b. Presbycusis.
c. Trauma to the bones.
d. Frequent ear infections.
Q:
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?
a. "It is unusual for a small child to have frequent ear infections unless something else is wrong."
b. "We need to check the immune system of your son to determine why he is having so many ear infections."
c. "Ear infections are not uncommon in infants and toddlers because they tend to have more cerumen in the external ear."
d. "Your son's eustachian tube is shorter and wider than yours because of his age, which allows for infections to develop more easily."
Q:
A patient in her first trimester of pregnancy is diagnosed with rubella. Which of these statements is correct regarding the significance of this in relation to the infant's hearing?
a. Rubella may affect the mother's hearing but not the infant's.
b. Rubella can damage the infant's organ of Corti, which will impair hearing.
c. Rubella is only dangerous to the infant in the second trimester of pregnancy.
d. Rubella can impair the development of CN VIII and thus affect hearing.
Q:
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 the:
a. Cochlea.
b. CN VIII.
c. Organ of Corti.
d. Labyrinth.
Q:
A patient has been shown to have a sensorineural hearing loss. During the assessment, it would be important for the nurse to:
a. Speak loudly so the patient can hear the questions.
b. Assess for middle ear infection as a possible cause.
c. Ask the patient what medications he is currently taking.
d. Look for the source of the obstruction in the external ear.
Q:
The nurse is assessing a patient who may have hearing loss. Which of these statements is true concerning air conduction?
a. Air conduction is the normal pathway for hearing.
b. Vibrations of the bones in the skull cause air conduction.
c. Amplitude of sound determines the pitch that is heard.
d. Loss of air conduction is called a conductive hearing loss.
Q:
The nurse is reviewing the function of the cranial nerves (CNs). Which CN is responsible for conducting nerve impulses to the brain from the organ of Corti?
a. I
b. III
c. VIII
d. XI
Q:
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:
a. Maintain balance.
b. Interpret sounds as they enter the ear.
c. Conduct vibrations of sounds to the inner ear.
d. Increase amplitude of sound for the inner ear to function.
Q:
The nurse is reviewing the structures of the ear. Which of these statements concerning the eustachian tube is true?
a. The eustachian tube is responsible for the production of cerumen.
b. It remains open except when swallowing or yawning.
c. The eustachian tube allows passage of air between the middle and outer ear.
d. It helps equalize air pressure on both sides of the tympanic membrane.
Q:
When examining the ear with an otoscope, the nurse notes that the tympanic membrane should appear:
a. Light pink with a slight bulge.
b. Pearly gray and slightly concave.
c. Pulled in at the base of the cone of light.
d. Whitish with a small fleck of light in the superior portion.
Q:
The nurse is examining a patient's ears and notices cerumen in the external canal. Which of these statements about cerumen is correct?
a. Sticky honey-colored cerumen is a sign of infection.
b. The presence of cerumen is indicative of poor hygiene.
c. The purpose of cerumen is to protect and lubricate the ear.
d. Cerumen is necessary for transmitting sound through the auditory canal.
Q:
The nurse needs to pull the portion of the ear that consists of movable cartilage and skin down and back when administering eardrops. This portion of the ear is called the:
a. Auricle.
b. Concha.
c. Outer meatus.
d. Mastoid process.
Q:
During an examination, a patient states that she was diagnosed with open-angle glaucoma 2 years ago. The nurse assesses for characteristics of open-angle glaucoma. Which of these are characteristics of open-angle glaucoma? Select all that apply.
a. Patient may experience sensitivity to light, nausea, and halos around lights.
b. Patient experiences tunnel vision in the late stages.
c. Immediate treatment is needed.
d. Vision loss begins with peripheral vision.
e. Open-angle glaucoma causes sudden attacks of increased pressure that cause blurred vision.
f. Virtually no symptoms are exhibited.
Q:
During an assessment, the nurse notices that an older adult patient has tears rolling down his face from his left eye. Closer examination shows that the lower lid is loose and rolling outward. The patient complains of his eye feeling "dry and itchy." Which action by the nurse is correct?
a. Assessing the eye for a possible foreign body
b. Documenting the finding as ptosis
c. Assessing for other signs of ectropion
d. Contacting the prescriber; these are signs of basal cell carcinoma
Q:
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 notices the presence of blood in the anterior chamber of the eye. This finding indicates the presence of:
a. Hypopyon.
b. Hyphema.
c. Corneal abrasion.
d. Pterygium.
Q:
An ophthalmic examination reveals papilledema. The nurse is aware that this finding indicates:
a. Retinal detachment.
b. Diabetic retinopathy.
c. Acute-angle glaucoma.
d. Increased intracranial pressure.
Q:
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?
a. Smooth and clear corneas
b. Opacity of the lens behind the cornea
c. Bleeding from the areas across the cornea
d. Shattered look to the light rays reflecting off the cornea
Q:
A 68-year-old woman is in the eye clinic for a checkup. She tells the nurse that she has been having trouble 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 she may have:
a. Macular degeneration.
b. Vision that is normal for someone her age.
c. The beginning stages of cataract formation.
d. Increased intraocular pressure or glaucoma.
Q:
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 a:
a. Chalazion.
b. Hordeolum (stye).
c. Dacryocystitis.
d. Blepharitis.
Q:
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:
a. Loss of central vision.
b. Shadow or diminished vision in one quadrant or one half of the visual field.
c. Loss of peripheral vision.
d. Sudden loss of pupillary constriction and accommodation.
Q:
In a patient who has anisocoria, the nurse would expect to observe:
a. Dilated pupils.
b. Excessive tearing.
c. Pupils of unequal size.
d. Uneven curvature of the lens.
Q:
When a light is directed across the iris of a patient's eye from the temporal side, the nurse is assessing for:
a. Drainage from dacryocystitis.
b. Presence of conjunctivitis over the iris.
c. Presence of shadows, which may indicate glaucoma.
d. Scattered light reflex, which may be indicative of cataracts.
Q:
The nurse notices the presence of periorbital edema when performing an eye assessment on a 70-year-old patient. The nurse should:
a. Check for the presence of exophthalmos.
b. Suspect that the patient has hyperthyroidism.
c. Ask the patient if he or she has a history of heart failure.
d. Assess for blepharitis, which is often associated with periorbital edema.
Q:
The nurse is performing an eye assessment on an 80-year-old patient. Which of these findings is considered abnormal?
a. Decrease in tear production
b. Unequal pupillary constriction in response to light
c. Presence of arcus senilis observed around the cornea
d. Loss of the outer hair on the eyebrows attributable to a decrease in hair follicles
Q:
The nurse is performing an eye-screening clinic at a daycare center. When examining a 2-year-old child, the nurse suspects that the child has a "lazy eye" and should:
a. Examine the external structures of the eye.
b. Assess visual acuity with the Snellen eye chart.
c. Assess the child's visual fields with the confrontation test.
d. Test for strabismus by performing the corneal light reflex test.
Q:
The nurse is assessing color vision of a male child. Which statement is correct? The nurse should:
a. Check color vision annually until the age of 18 years.
b. Ask the child to identify the color of his or her clothing.
c. Test for color vision once between the ages of 4 and 8 years.
d. Begin color vision screening at the child's 2-year checkup.
Q:
A 2-week-old infant can fixate on an object but cannot follow a light or bright toy. The nurse would:
a. Consider this a normal finding.
b. Assess the pupillary light reflex for possible blindness.
c. Continue with the examination, and assess visual fields.
d. Expect that a 2-week-old infant should be able to fixate and follow an object.
Q:
The nurse is examining a patient's retina with an ophthalmoscope. Which finding is considered normal?
a. Optic disc that is a yellow-orange color
b. Optic disc margins that are blurred around the edges
c. Presence of pigmented crescents in the macular area
d. Presence of the macula located on the nasal side of the retina
Q:
In using the ophthalmoscope to assess a patient's eyes, the nurse notices a red glow in the patient's pupils. On the basis of this finding, the nurse would:
a. Suspect that an opacity is present in the lens or cornea.
b. Check the light source of the ophthalmoscope to verify that it is functioning.
c. Consider the red glow a normal reflection of the ophthalmoscope light off the inner retina.
d. Continue with the ophthalmoscopic examination, and refer the patient for further evaluation.
Q:
The nurse is assessing a patient's eyes for the accommodation response and would expect to see which normal finding?
a. Dilation of the pupils
b. Consensual light reflex
c. Conjugate movement of the eyes
d. Convergence of the axes of the eyes
Q:
When assessing the pupillary light reflex, the nurse should use which technique?
a. Shine a penlight from directly in front of the patient, and inspect for pupillary constriction.
b. Ask the patient to follow the penlight in eight directions, and observe for bilateral pupil constriction.
c. Shine a light across the pupil from the side, and observe for direct and consensual pupillary constriction.
d. Ask the patient to focus on a distant object. Then ask the patient to follow the penlight to approximately 7 cm from the nose.
Q:
During an examination of the eye, the nurse would expect what normal finding when assessing the lacrimal apparatus?
a. Presence of tears along the inner canthus
b. Blocked nasolacrimal duct in a newborn infant
c. Slight swelling over the upper lid and along the bony orbit if the individual has a cold
d. Absence of drainage from the puncta when pressing against the inner orbital rim
Q:
A 60-year-old man is at the clinic for an eye examination. The nurse suspects that he has ptosis of one eye. How should the nurse check for this?
a. Perform the confrontation test.
b. Assess the individual's near vision.
c. Observe the distance between the palpebral fissures.
d. Perform the corneal light test, and look for symmetry of the light reflex.
Q:
During an assessment of the sclera of a black patient, the nurse would consider which of these an expected finding?
a. Yellow fatty deposits over the cornea
b. Pallor near the outer canthus of the lower lid
c. Yellow color of the sclera that extends up to the iris
d. Presence of small brown macules on the sclera
Q:
The nurse is performing the diagnostic positions test. Normal findings would be which of these results?
a. Convergence of the eyes
b. Parallel movement of both eyes
c. Nystagmus in extreme superior gaze
d. Slight amount of lid lag when moving the eyes from a superior to an inferior position
Q:
When performing the corneal light reflex assessment, the nurse notes that the light is reflected at 2 o"clock in each eye. The nurse should:
a. Consider this a normal finding.
b. Refer the individual for further evaluation.
c. Document this finding as an asymmetric light reflex.
d. Perform the confrontation test to validate the findings.
Q:
A patient's vision is recorded as 20/80 in each eye. The nurse interprets this finding to mean that the patient:
a. Has poor vision.
b. Has acute vision.
c. Has normal vision.
d. Is presbyopic.
Q:
A patient is unable to read even the largest letters on the Snellen chart. The nurse should take which action next?
a. Refer the patient to an ophthalmologist or optometrist for further evaluation.
b. Assess whether the patient can count the nurse's fingers when they are placed in front of his or her eyes.
c. Ask the patient to put on his or her reading glasses and attempt to read the Snellen chart again.
d. Shorten the distance between the patient and the chart until the letters are seen, and record that distance.
Q:
A patient's vision is recorded as 20/30 when the Snellen eye chart is used. The nurse interprets these results to indicate that:
a. At 30 feet the patient can read the entire chart.
b. The patient can read at 20 feet what a person with normal vision can read at 30 feet.
c. The patient can read the chart from 20 feet in the left eye and 30 feet in the right eye.
d. The patient can read from 30 feet what a person with normal vision can read from 20 feet.
Q:
The nurse is preparing to assess the visual acuity of a 16-year-old patient. How should the nurse proceed?
a. Perform the confrontation test.
b. Ask the patient to read the print on a handheld Jaeger card.
c. Use the Snellen chart positioned 20 feet away from the patient.
d. Determine the patient's ability to read newsprint at a distance of 12 to 14 inches.
Q:
A 52-year-old patient describes the presence of occasional floaters or spots moving in front of his eyes. The nurse should:
a. Examine the retina to determine the number of floaters.
b. Presume the patient has glaucoma and refer him for further testing.
c. Consider these to be abnormal findings, and refer him to an ophthalmologist.
d. Know that floaters are usually insignificant and are caused by condensed vitreous fibers.
Q:
Which of these assessment findings would the nurse expect to see when examining the eyes of a black patient?
a. Increased night vision
b. Dark retinal background
c. Increased photosensitivity
d. Narrowed palpebral fissures
Q:
The nurse is reviewing in age-related changes in the eye for a class. Which of these physiologic changes is responsible for presbyopia?
a. Degeneration of the cornea
b. Loss of lens elasticity
c. Decreased adaptation to darkness
d. Decreased distance vision abilities
Q:
A mother asks when her newborn infant's eyesight will be developed. The nurse should reply:
a. "Vision is not totally developed until 2 years of age."
b. "Infants develop the ability to focus on an object at approximately 8 months of age."
c. "By approximately 3 months of age, infants develop more coordinated eye movements and can fixate on an object."
d. "Most infants have uncoordinated eye movements for the first year of life."
Q:
A patient has a normal pupillary light reflex. The nurse recognizes that this reflex indicates that:
a. The eyes converge to focus on the light.
b. Light is reflected at the same spot in both eyes.
c. The eye focuses the image in the center of the pupil.
d. Constriction of both pupils occurs in response to bright light.
Q:
The nurse is testing a patient's visual accommodation, which refers to which action?
a. Pupillary constriction when looking at a near object
b. Pupillary dilation when looking at a far object
c. Changes in peripheral vision in response to light
d. Involuntary blinking in the presence of bright light
Q:
The nurse is conducting a visual examination. Which of these statements regarding visual pathways and visual fields is true?
a. The right side of the brain interprets the vision for the right eye.
b. The image formed on the retina is upside down and reversed from its actual appearance in the outside world.
c. Light rays are refracted through the transparent media of the eye before striking the pupil.
d. Light impulses are conducted through the optic nerve to the temporal lobes of the brain.
Q:
The nurse is reviewing causes of increased intraocular pressure. Which of these factors determines intraocular pressure?
a. Thickness or bulging of the lens
b. Posterior chamber as it accommodates increased fluid
c. Contraction of the ciliary body in response to the aqueous within the eye
d. Amount of aqueous produced and resistance to its outflow at the angle of the anterior chamber
Q:
When examining a patient's eyes, the nurse recalls that stimulation of the sympathetic branch of the autonomic nervous system:
a. Causes pupillary constriction.
b. Adjusts the eye for near vision.
c. Elevates the eyelid and dilates the pupil.
d. Causes contraction of the ciliary body.
Q:
The nurse is performing an external eye examination. Which statement regarding the outer layer of the eye is true?
a. The outer layer of the eye is very sensitive to touch.
b. The outer layer of the eye is darkly pigmented to prevent light from reflecting internally.
c. The trigeminal nerve (CN V) and the trochlear nerve (CN IV) are stimulated when the outer surface of the eye is stimulated.
d. 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.
Q:
During ocular examinations, the nurse keeps in mind that movement of the extraocular muscles is:
a. Decreased in the older adult.
b. Impaired in a patient with cataracts.
c. Stimulated by cranial nerves (CNs) I and II.
d. Stimulated by CNs III, IV, and VI.
Q:
When examining the eye, the nurse notices that the patient's eyelid margins approximate completely. The nurse recognizes that this assessment finding:
a. Is expected.
b. May indicate a problem with extraocular muscles.
c. May result in problems with tearing.
d. Indicates increased intraocular pressure.
Q:
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.
Q:
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
Q:
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 40 C, and he has a stiff neck. The nurse looks for other signs and symptoms of which problem?
a. Head injury
b. Cluster headache
c. Migraine headache
d. Meningeal inflammation
Q:
A patient complains that while studying for an examination he began to notice a severe headache in the frontotemporal area of his head that is throbbing and is somewhat relieved when he lies down. He tells the nurse that his mother also had these headaches. The nurse suspects that he may be suffering from:
a. Hypertension.
b. Cluster headaches.
c. Tension headaches.
d. Migraine headaches.
Q:
A patient reports excruciating headache pain on one side of his head, especially around his eye, forehead, and cheek that has lasted approximately to 2 hours, occurring once or twice each day. The nurse should suspect:
a. Hypertension.
b. Cluster headaches.
c. Tension headaches.
d. Migraine headaches.
Q:
A patient, an 85-year-old woman, is complaining about the fact that the bones in her face have become more noticeable. What explanation should the nurse give her?
a. Diets low in protein and high in carbohydrates may cause enhanced facial bones.
b. Bones can become more noticeable if the person does not use a dermatologically approved moisturizer.
c. More noticeable facial bones are probably due to a combination of factors related to aging, such as decreased elasticity, subcutaneous fat, and moisture in her skin.
d. Facial skin becomes more elastic with age. This increased elasticity causes the skin to be more taught, drawing attention to the facial bones.
Q:
A mother brings her newborn in for an assessment and asks, "Is there something wrong with my baby? His head seems so big." Which statement is true regarding the relative proportions of the head and trunk of the newborn?
a. At birth, the head is one fifth the total length.
b. Head circumference should be greater than chest circumference at birth.
c. The head size reaches 90% of its final size when the child is 3 years old.
d. When the anterior fontanel closes at 2 months, the head will be more proportioned to the body.
Q:
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.
Q:
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 patient's:
a. Infraclavicular area.
b. Supraclavicular area.
c. Area distal to the enlarged node.
d. Area proximal to the enlarged node.
Q:
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 leads the nurse to suspect that this may not be a cancerous thyroid nodule is that the lump (nodule):
a. Is tender.
b. Is mobile and not hard.
c. Disappears when the patient smiles.
d. Is hard and fixed to the surrounding structures.
Q:
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
Q:
When examining a patient's CN function, the nurse remembers that the muscles in the neck that are innervated by CN XI are the:
a. Sternomastoid and trapezius.
b. Spinal accessory and omohyoid.
c. Trapezius and sternomandibular.
d. Sternomandibular and spinal accessory.
Q:
A patient comes to the clinic complaining of neck and shoulder pain and is unable to turn her head. The nurse suspects damage to CN ______ and proceeds with the examination by _____________.
a. XI; palpating the anterior and posterior triangles
b. XI; asking the patient to shrug her shoulders against resistance
c. XII; percussing the sternomastoid and submandibular neck muscles
d. XII; assessing for a positive Romberg sign
Q:
When examining the face of a patient, the nurse is aware that the two pairs of salivary glands that are accessible to examination are the ___________ and ___________ glands.
a. Occipital; submental
b. Parotid; jugulodigastric
c. Parotid; submandibular
d. Submandibular; occipital
Q:
A patient is unable to differentiate between sharp and dull stimulation to both sides of her face. The nurse suspects:
a. Bell palsy.
b. Damage to the trigeminal nerve.
c. Frostbite with resultant paresthesia to the cheeks.
d. Scleroderma.
Q:
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. III
b. V
c. VII
d. VIII
Q:
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 could be a result of your dietary intake during pregnancy."
b. "Your baby may have craniosynostosis, a disease of the sutures of the brain."
c. "That "soft spot" may be an indication of cretinism or congenital hypothyroidism."
d. "That "soft spot" is normal, and actually allows for growth of the brain during the first year of your baby's life."
Q:
A physician tells the nurse that a patient's vertebra prominens is tender and asks the nurse to reevaluate the area in 1 hour. The area of the body the nurse will assess is:
a. Just above the diaphragm.
b. Just lateral to the knee cap.
c. At the level of the C7 vertebra.
d. At the level of the T11 vertebra.
Q:
The nurse is assessing a 1-month-old infant at his well-baby checkup. Which assessment findings are appropriate for this age? Select all that apply.
a. Head circumference equal to chest circumference
b. Head circumference greater than chest circumference
c. Head circumference less than chest circumference
d. Fontanels firm and slightly concave
e. Absent tonic neck reflex
f. Nonpalpable cervical lymph nodes
Q:
During an examination, the nurse finds that a patient's left temporal artery is tortuous and feels hardened and tender, compared with the right temporal artery. The nurse suspects which condition?
a. Crepitation
b. Mastoiditis
c. Temporal arteritis
d. Bell palsy
Q:
During an examination of a 3-year-old child, the nurse notices a bruit over the left temporal area. The nurse should:
a. Continue the examination because a bruit is a normal finding for this age.
b. Check for the bruit again in 1 hour.
c. Notify the parents that a bruit has been detected in their child.
d. Stop the examination, and notify the physician.
Q:
During a well-baby checkup, a mother is concerned because her 2-month-old infant cannot hold her head up when she is pulled to a sitting position. Which response by the nurse is appropriate?
a. "Head control is usually achieved by 4 months of age."
b. "You shouldn"t be trying to pull your baby up like that until she is older."
c. "Head control should be achieved by this time."
d. "This inability indicates possible nerve damage to the neck muscles."