N125 EXAM 2 STUDY Q'S QUESTIONS WITH COMPLETE SOLUTIONS.
A physician tells the nurse that a patients 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. - (ANSWER)ANS: C
The C7 vertebra has a long spinous process, called the vertebra prominens, which is palpable when the
head is flexed.
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. - (ANSWER)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.
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 - (ANSWER)ANS: C
Facial muscles are mediated by CN VII; asymmetry of palpebral fissures may be attributable to damage
to CN VII (Bell palsy).
A patient is unable to differentiate between sharp and dull stimulation to both sides of her face. The
nurse suspects:
,N125 EXAM 2 STUDY Q'S QUESTIONS WITH COMPLETE SOLUTIONS.
a. Bell palsy.
b. Damage to the trigeminal nerve.
c. Frostbite with resultant paresthesia to the cheeks.
d. Scleroderma. - (ANSWER)ANS: B
Facial sensations of pain or touch are mediated by CN V, which is the trigeminal nerve. Bell palsy is
associated with CN VII damage. Frostbite and scleroderma are not associated with this problem.
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 - (ANSWER)ANS: C
Two pairs of salivary glands accessible to examination on the face are the parotid glands, which are in
the cheeks over the mandible, anterior to and below the ear; and the submandibular glands, which are
beneath the mandible at the angle of the jaw. The parotid glands are normally nonpalpable.
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 - (ANSWER)ANS: B
The major neck muscles are the sternomastoid and the trapezius. They are innervated by CN XI, the
spinal accessory. The innervated muscles assist with head rotation and head flexion, movement of the
shoulders, and extension and turning of the head.
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.
,N125 EXAM 2 STUDY Q'S QUESTIONS WITH COMPLETE SOLUTIONS.
d. Sternomandibular and spinal accessory. - (ANSWER)ANS: A
The major neck muscles are the sternomastoid and the trapezius. They are innervated by CN XI, the
spinal accessory.
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 - (ANSWER)ANS: A
The thyroid gland is a highly vascular endocrine gland that secretes T4 and triiodothyronine (T3). The
other glands do not secrete T4.
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. - (ANSWER)ANS: B
Painless, rapidly growing nodules may be cancerous, especially the appearance of a single nodule in a
young person. However, cancerous nodules tend to be hard and fixed to surrounding structures, not
mobile.
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 patients:
a. Infraclavicular area.
b. Supraclavicular area.
c. Area distal to the enlarged node.
d. Area proximal to the enlarged node. - (ANSWER)ANS: D
When nodes are abnormal, the nurse should check the area into which they drain for the source of the
problem. The area proximal (upstream) to the location of the abnormal node should be explored.
, N125 EXAM 2 STUDY Q'S QUESTIONS WITH COMPLETE SOLUTIONS.
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. - (ANSWER)ANS: D
Nodes are located throughout the body, but they are accessible to examination only in four areas: head
and neck, arms, inguinal region, and axillae.
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. - (ANSWER)ANS: C
The facial bones and orbits appear more prominent in the aging adult, and the facial skin sags, which is
attributable to decreased elasticity, decreased subcutaneous fat, and decreased moisture in the skin.
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. - (ANSWER)ANS: B
Cluster headaches produce pain around the eye, temple, forehead, and cheek and are unilateral and
always on the same side of the head. They are excruciating and occur once or twice per day and last to 2
hours each.
A physician tells the nurse that a patients 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. - (ANSWER)ANS: C
The C7 vertebra has a long spinous process, called the vertebra prominens, which is palpable when the
head is flexed.
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. - (ANSWER)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.
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 - (ANSWER)ANS: C
Facial muscles are mediated by CN VII; asymmetry of palpebral fissures may be attributable to damage
to CN VII (Bell palsy).
A patient is unable to differentiate between sharp and dull stimulation to both sides of her face. The
nurse suspects:
,N125 EXAM 2 STUDY Q'S QUESTIONS WITH COMPLETE SOLUTIONS.
a. Bell palsy.
b. Damage to the trigeminal nerve.
c. Frostbite with resultant paresthesia to the cheeks.
d. Scleroderma. - (ANSWER)ANS: B
Facial sensations of pain or touch are mediated by CN V, which is the trigeminal nerve. Bell palsy is
associated with CN VII damage. Frostbite and scleroderma are not associated with this problem.
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 - (ANSWER)ANS: C
Two pairs of salivary glands accessible to examination on the face are the parotid glands, which are in
the cheeks over the mandible, anterior to and below the ear; and the submandibular glands, which are
beneath the mandible at the angle of the jaw. The parotid glands are normally nonpalpable.
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 - (ANSWER)ANS: B
The major neck muscles are the sternomastoid and the trapezius. They are innervated by CN XI, the
spinal accessory. The innervated muscles assist with head rotation and head flexion, movement of the
shoulders, and extension and turning of the head.
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.
,N125 EXAM 2 STUDY Q'S QUESTIONS WITH COMPLETE SOLUTIONS.
d. Sternomandibular and spinal accessory. - (ANSWER)ANS: A
The major neck muscles are the sternomastoid and the trapezius. They are innervated by CN XI, the
spinal accessory.
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 - (ANSWER)ANS: A
The thyroid gland is a highly vascular endocrine gland that secretes T4 and triiodothyronine (T3). The
other glands do not secrete T4.
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. - (ANSWER)ANS: B
Painless, rapidly growing nodules may be cancerous, especially the appearance of a single nodule in a
young person. However, cancerous nodules tend to be hard and fixed to surrounding structures, not
mobile.
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 patients:
a. Infraclavicular area.
b. Supraclavicular area.
c. Area distal to the enlarged node.
d. Area proximal to the enlarged node. - (ANSWER)ANS: D
When nodes are abnormal, the nurse should check the area into which they drain for the source of the
problem. The area proximal (upstream) to the location of the abnormal node should be explored.
, N125 EXAM 2 STUDY Q'S QUESTIONS WITH COMPLETE SOLUTIONS.
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. - (ANSWER)ANS: D
Nodes are located throughout the body, but they are accessible to examination only in four areas: head
and neck, arms, inguinal region, and axillae.
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. - (ANSWER)ANS: C
The facial bones and orbits appear more prominent in the aging adult, and the facial skin sags, which is
attributable to decreased elasticity, decreased subcutaneous fat, and decreased moisture in the skin.
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. - (ANSWER)ANS: B
Cluster headaches produce pain around the eye, temple, forehead, and cheek and are unilateral and
always on the same side of the head. They are excruciating and occur once or twice per day and last to 2
hours each.
