Jarvis: Physical Examination & Health Assessment, 3rd Canadian edition

Jarvis: Physical Examination & Health Assessment, 3rd Canadian edition MULTIPLE CHOICE 1. The primary purpose of the ciliated mucous membrane in the nose is to: a. Warm the inhaled air. b. Filter out dust and bacteria. c. Filter coarse particles from inhaled air. d. Facilitate the movement of air through the nares. ANS: B The nasal hairs filter the coarsest matter from inhaled air, whereas the mucous blanket filters out dust and bacteria. The rich blood supply of the nasal mucosa warms the inhaled air. DIF: Cognitive Level: Remembering (Knowledge) MSC: Client Needs: General 2. The projections in the nasal cavity that increase the surface area are called the: a. Meatus. b. Septum. c. Turbinates. d. Kiesselbach plexus. ANS: C The lateral walls of each nasal cavity contain three parallel bony projections: the superior, middle, and inferior turbinates. These increase the surface area, making more blood vessels and mucous membrane available to warm, humidify, and filter the inhaled air. DIF: Cognitive Level: Remembering (Knowledge) MSC: Client Needs: General 3. The nurse is reviewing the development of the newborn infant. Regarding the sinuses, which statement in relation to a newborn infant is true? a. Sphenoid sinuses are full size at birth. b. Maxillary sinuses reach full size after puberty. c. Frontal sinuses are fairly well developed at birth. d. Maxillary and ethmoid sinuses are the only sinuses present at birth. ANS: D Only the maxillary and ethmoid sinuses are present at birth. The sphenoid sinuses are minute at birth and develop after puberty. The frontal sinuses are absent at birth, are fairly well developed at age 7 to 8 years, and reach full size after puberty. DIF: Cognitive Level: Remembering (Knowledge) MSC: Client Needs: General 4. The tissue that connects the tongue to the floor of the mouth is the: a. Uvula. NURSINGTB.COM Physical Examination and Health Assessment CANADIAN 3rd Edition Jarvis Test Bank contact: NU RS IN GT B.CO M b. Palate. c. Papillae. d. Frenulum. ANS: D The frenulum is a midline fold of tissue that connects the tongue to the floor of the mouth. The uvula is the free projection hanging down from the middle of the soft palate. The palate is the arching roof of the mouth. Papillae are the rough, bumpy elevations on the tongue’s dorsal surface. DIF: Cognitive Level: Remembering (Knowledge) MSC: Client Needs: General 5. The salivary gland that is the largest and located in the cheek in front of the ear is the _________ gland. a. Parotid b. Stensen’s c. Sublingual d. Submandibular ANS: A The mouth contains three pairs of salivary glands. The largest, the parotid gland, lies within the cheeks in front of the ear extending from the zygomatic arch down to the angle of the jaw. Stensen’s duct (not gland) drains the parotid gland onto the buccal mucosa opposite the second molar. The sublingual gland is located within the floor of the mouth under the tongue. The submandibular gland lies beneath the mandible at the angle of the jaw. DIF: Cognitive Level: Remembering (Knowledge) MSC: Client Needs: General 6. In assessing the tonsils of a 30-year-old, the nurse notices that they are involuted, granular in appearance, and appear to have deep crypts. The nurse will: a. Refer the patient to a throat specialist. b. Document as a normal finding. c. Continue with the assessment, looking for any other abnormal findings. d. Obtain a throat culture on the patient for possible streptococcal (strep) infection. ANS: B The tonsils are the same colour as the surrounding mucous membrane, although they look more granular and their surface shows deep crypts. Tonsillar tissue enlarges during childhood until puberty and then involutes. DIF: Cognitive Level: Applying (Application) MSC: Client Needs: Safe and Effective Care Environment: Management of Care 7. The nurse is obtaining a health history on a 3-month-old infant. During the interview, the mother states, “I think she is getting her first tooth because she has started drooling a lot.” The nurse’s best response would be: a. “You’re right, drooling is usually a sign of the first tooth.” b. “It would be unusual for a 3-month-old to be getting her first tooth.” NURSINGTB.COM Physical Examination and Health Assessment CANADIAN 3rd Edition Jarvis Test Bank NU RS IN GT B.CO M c. “This could be the sign of a problem with the salivary glands.” d. “She is just starting to salivate and hasn’t learned to swallow the saliva.” ANS: D In the infant, salivation starts at 3 months. The baby will drool for a few months before learning to swallow the saliva. This drooling does not herald the eruption of the first tooth, although many parents think it does. DIF: Cognitive Level: Understanding (Comprehension) MSC: Client Needs: Health Promotion and Maintenance 8. The nurse is assessing an 80-year-old patient. Which of these findings would be expected for this patient? a. Hypertrophy of the gums b. Increased production of saliva c. Decreased ability to identify odours d. Finer and less prominent nasal hair ANS: C The sense of smell may be reduced because of a decrease in the number of olfactory nerve fibres. Nasal hairs grow coarser and stiffer with aging. The gums may recede with aging, not hypertrophy, and saliva production decreases. DIF: Cognitive Level: Understanding (Comprehension) MSC: Client Needs: Health Promotion and Maintenance 9. The nurse is performing an oral assessment on a 40-year-old dark-skinned patient and notices the presence of a 1-cm, nontender, greyish-white lesion on the left buccal mucosa. The nurse will: a. Document as leukoedema and benign. b. Document as hyperpigmentation requiring further investigation. c. Document as torus palatinus and normal for smokers. d. Refer to specialist as finding is indicative of cancer and should be immediately tested. ANS: A Leukoedema, a greyish-white benign lesion occurring on the buccal mucosa, is most often observed in individuals of African descent. DIF: Cognitive Level: Understanding (Comprehension) MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation 10. During health history, the patient tells the nurse that he has frequent nosebleeds and asks the best way to get them to stop. What would be the nurse’s best response? a. “While sitting up, place a cold compress over your nose.” b. “Sit up with your head tilted forward and pinch your nose.” c. “Just allow the bleeding to stop on its own, but don’t blow your nose.” d. “Lie on your back with your head tilted back, and pinch your nose.” ANS: B NURSINGTB.COM Physical Examination and Health Assessment CANADIAN 3rd Edition Jarvis Test Bank NU RS IN GT B.CO M With a nosebleed, the person should sit up with the head tilted forward and pinch the nose between the thumb and forefinger for 5 to 15 minutes. DIF: Cognitive Level: Applying (Application) MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation 11. A 92-year-old patient has had a stroke. The right side of his face is drooping. The nurse might also suspect which of these assessment findings? a. Epistaxis b. Rhinorrhea c. Dysphagia d. Xerostomia ANS: C Dysphagia refers to difficulty swallowing and may occur with a variety of disorders, including stroke and other neurological diseases. Rhinorrhea refers to a runny nose, epistaxis to a bloody nose, and xerostomia to dry mouth. DIF: Cognitive Level: Analyzing (Analysis) MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation 12. While obtaining the health history from the mother of a 1-year-old child, the nurse notices that the baby has had a bottle in his mouth the entire time. The mother states, “It makes a great pacifier.” The best response by the nurse would be: a. “You’re right. Bottles make very good pacifiers.” b. “Using a bottle as a pacifier is better for the teeth than thumb-sucking.” c. “It’s okay to use a bottle as long as it contains milk and not juice.” d. “Prolonged use of a bottle can increase the risk for tooth decay and ear infections.” ANS: D Prolonged bottle use during the day or when going to sleep places the infant at risk for tooth decay and middle ear infections. DIF: Cognitive Level: Applying (Application) MSC: Client Needs: Health Promotion and Maintenance 13. A 72-year-old patient has a history of hypertension and chronic lung disease. An important question for the nurse to include in the health history would be: a. “Do you use a fluoride supplement?” b. “Have you had tonsillitis in the past year?” c. “At what age did you get your first tooth?” d. “Have you noticed any dryness in your mouth?” ANS: D Xerostomia (dry mouth) is a side effect of many drugs taken by older people, including antidepressants, anticholinergics, antispasmodics, antihypertensives, antipsychotics, and bronchodilators. DIF: Cognitive Level: Applying (Application) MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation NURSINGTB.COM Physical Examination and Health Assessment CANADIAN 3rd Edition Jarvis Test Bank NU RS IN GT B.CO M 14. The nurse is using an otoscope to assess the nasal cavity. Which of these techniques is correct? a. Inserting the speculum at least 3 cm into the vestibule b. Avoiding touching the nasal septum with the speculum c. Gently displacing the nose to the side that is being examined d. Keeping the speculum tip medial to avoid touching the floor of the nares ANS: B The correct technique for using an otoscope is to insert the apparatus into the nasal vestibule, avoiding pressure on the sensitive nasal septum. The tip of the nose should be lifted up before inserting the speculum. DIF: Cognitive Level: Understanding (Comprehension) MSC: Client Needs: Safe and Effective Care Environment: Management of Care 15. The nurse is performing an assessment on a 21-year-old patient and notices that his nasal mucosa appears pale, grey, and swollen. What would be the most appropriate question to ask the patient? a. “Are you aware of having any allergies?” b. “Do you have an elevated temperature?” c. “Have you had any symptoms of a cold?” d. “Have you been having frequent nosebleeds?” ANS: A With chronic allergies, the mucosa looks swollen, boggy, pale, and grey. Elevated body temperature, colds, and nosebleeds do not cause these mucosal changes. DIF: Cognitive Level: Applying (Application) MSC: Client Needs: Safe and Effective Care Environment: Management of Care 16. During assessment, the nurse palpates the patient’s sinus areas. The patient demonstrates that findings are normal when reporting: a. No sensation. b. Firm pressure. c. Pain during palpation. d. Pain sensation behind eyes. ANS: B The person should feel firm pressure but no pain. Sinus areas are tender to palpation in persons with chronic allergies or an acute infection (sinusitis). DIF: Cognitive Level: Understanding (Comprehension) MSC: Client Needs: Safe and Effective Care Environment: Management of Care 17. During an oral assessment of a 30-year-old patient of African descent, the nurse notices bluish lips and a dark line along the gingival margin. What action would the nurse perform in response to this finding? a. Check the patient’s hemoglobin for anemia b. Assess for other signs of insufficient oxygen supply NURSINGTB.COM Physical Examination and Health Assessment CANADIAN 3rd Edition Jarvis Test Bank NU RS IN GT B.CO M c. Proceed with the assessment, knowing that this appearance is a normal finding d. Ask if he has been exposed to an excessive amount of carbon monoxide ANS: C Some individuals of African descent may have bluish lips and a dark line on the gingival margin; this appearance is a normal finding. DIF: Cognitive Level: Applying (Application) MSC: Client Needs: Safe and Effective Care Environment: Management of Care 18. During an assessment of a 20-year-old patient with a 3-day history of nausea and vomiting, the nurse notices dry mucosa and deep vertical fissures in the tongue. These findings are reflective of: a. Dehydration. b. Irritation by gastric juices. c. A normal oral assessment. d. Side effects of nausea medication. ANS: A Dry mouth occurs with dehydration or fever. The tongue has deep vertical fissures. DIF: Cognitive Level: Applying (Application) MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation 19. A 32-year-old woman is at the clinic for “little white bumps in my mouth.” During the assessment, the nurse notes that she has a 0.5-cm, white, nontender papule under her tongue and one on the mucosa of her right cheek. What would the nurse tell the patient? a. “These spots indicate an infection, such as strep throat.” b. “These bumps could be indicative of a serious lesion, so I will refer you to a specialist.” c. “This condition is called leukoplakia and can be caused by chronic irritation, such as with smoking.” d. “These bumps are Fordyce’s granules, which are sebaceous cysts and are not a serious condition.” ANS: D Fordyce granules are small, isolated white or yellow papules on the mucosa of the cheek, tongue, and lips. These little sebaceous cysts are painless and are not significant. Chalky, white raised patches would indicate leukoplakia. In strep throat, the examiner would see tonsils that are bright red and swollen and may have exudates or white spots. DIF: Cognitive Level: Applying (Application) MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation 20. A 10-year-old is at the clinic for “a sore throat that has lasted 6 days.” Which of these findings would be consistent with an acute infection? a. Tonsils 1+and pink; the same colour as the oral mucosa b. Tonsils 2+with small plugs of white debris c. Tonsils 3+ with large white spots d. Tonsils 3+ with pale colouring NURSINGTB.COM Physical Examination and Health Assessment CANADIAN 3rd Edition Jarvis Test Bank NU RS IN GT B.CO M ANS: C With an acute infection, tonsils are bright red and swollen and may have exudate or large white spots. Tonsils are enlarged to 2+, 3+, or 4+ with an acute infection. DIF: Cognitive Level: Understanding (Comprehension) MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation 21. Immediately after delivery, the nurse is unable to suction the nares of a newborn. An attempt is made to pass a catheter through both nasal cavities with no success. What should the nurse do next? a. Attempt to suction again with a bulb syringe b. Wait a few minutes, and try again once the infant stops crying c. Recognize that this situation requires immediate intervention d. Contact the physician to schedule an appointment for the infant at his or her next hospital visit ANS: C Determining the patency of the nares in the immediate newborn period is essential because most newborns are obligate nose breathers. Nares blocked with amniotic fluid are gently suctioned with a bulb syringe. If obstruction is suspected, then a small lumen (5–10 French [Fr]) catheter is passed down each naris to confirm patency. The inability to pass a catheter through the nasal cavity indicates choanal atresia, which requires immediate intervention. DIF: Cognitive Level: Analyzing (Analysis) MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation 22. The nurse notices that the mother of a 2-year-old boy brings him into the clinic quite frequently for various injuries and suspects there may be some child abuse involved. During inspection of his mouth, the nurse should look for: a. Swollen, red tonsils. b. Ulcerations on the hard palate. c. Bruising on the buccal mucosa or gums. d. Small, yellow papules along the hard palate.