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Health Assessment

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Exam study book Laboratory Manual for Physical Examination & Health Assessment of Carolyn Jarvis - ISBN: 9780323395960 (Health Assessment)

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Carolyn Jarvis, Physical Examination and Health Assessment
4th Canadian Edition (Jarvis, 2024) TEST BANK, Verified
Chapters 1 - 31, Complete Newest Version

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.

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.

The nurse is reviewing the development of the newborn infant. Regarding the
sinuses, which statement is true in relation to a newborn infant?
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.

The tissue that connects the tongue to the floor of the mouth is the:
a. Uvula.
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.

,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. The 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.

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. What is correct response to
these findings?
a. Refer the patient to a throat specialist.
b. No response is needed; this appearance is normal for the tonsils.
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 color 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.

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."
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.

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 odors
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 fibers. Nasal hairs grow coarser and stiffer with aging. The gums may recede
with aging, not hypertrophy, and saliva production decreases.

, The nurse is performing an oral assessment on a 40-year-old Black patient and
notices the presence of a 1 cm, nontender, grayish-white lesion on the left buccal
mucosa. Which one of these statements is true? This lesion is:
a. Leukoedema and is common in dark-pigmented persons.
b. The result of hyperpigmentation and is normal.
c. Torus palatinus and would normally be found only in smokers.
d. Indicative of cancer and should be immediately tested. ANS: A
Leukoedema, a grayish-white benign lesion occurring on the buccal mucosa, is most
often observed in Blacks.

While obtaining a health history, a 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
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.

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 is difficulty with swallowing and may occur with a variety of disorders,
including stroke and other neurologic diseases. Rhinorrhea is a runny nose, epistaxis
is a bloody nose, and xerostomia is a dry mouth.

While obtaining a 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.

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 last year?"
c. "At what age did you get your first tooth?"
d. "Have you noticed any dryness in your mouth?" ANS: D

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