Health Assessment Ch. 12

While examining the patient's neck, the nurse finds the trachea midline but has difficulty palpating the thyroid. What action would the nurse take next?

A. Document this finding as normal.

B. Tell the patient that this finding is unexpected.

C. Report to the physician a suspicion of a slow-growing goiter.

D. Look for signs of hypothyroidism.

A. Document this finding as normal.

Rationale: The thyroid gland is often not palpable. With

no signs or symptoms of hypothyroidism or hyperthyroidism, a nonpalpable thyroid would be a

normal finding

The lymph nodes that lie in front of the mastoid bone are the

A. preauricular nodes.

B. occipital nodes.

C. superficial cervical nodes.

D. supraclavicular nodes.

A. Preauricular nodes.

Rationale: The preauricular are, as the name implies, in front of (or pre-) the ear (auricle). Occipital nodes are at the base of the skull posteriorly. Cervical nodes are in the neck, and supraclavicular are above the clavicle

Which of the following descriptions is most consistent with a patient who has hypothyroidism?

A. Slightly obese, perspiring female, who complains of feeling cold all the time and having diarrhea.

B. Slightly obese female with periorbital edema, who complains of cold intolerance, brittle hair, dry skin.

C. Thin, anxious-appearing female with exophthalmos and a rapid pulse and who complains of diarrhea.

D. Thin, perspiring male with a deep hoarse voice, facial edema, a thick tongue, and reports of diarrhea.

B. Slightly obese female with periorbital edema who compaints of cold intolerance, brittle hair, and dry skin.

Rationale: The patient with hypothyroidism would likely demonstrate clinical signs and symptoms of a low metabolic rate resulting from relative depletion of

circulating thyroid hormone.

Physical examination of a patient reveals an enlarged tonsillar node. Acutely infected nodes would be

A. hard and nontender.

B. fixed and soft.

C. firm but movable and tender.

D. irregular and hard

C. Firm but movable and tender.

Rationale: Infected lymph nodes are usually tender. Fixed, hard, or irregular nodes should be further evaluated as a sign of possible cancer.

While assessing the skin of a 24-year-old patient, the nurse notes decreased skin turgor. The nurse should further assess for signs and symptoms of

A. hyperthyroidism.

B. hypothyroidism.

C. malnutrition.

D. dehydration

D. Dehydration.

Rationale: When water is lost from subcutaneous tissues, the skin becomes less elastic. The result is "tenting," which results when the skin is pulled away from the body and released. This is a sign of possible dehydration.

The nurse can best evaluate the strength of the sternocleidomastoid muscle by having the patient

A. clench his or her teeth during muscle palpation.

B. bring his or her head to the chest.

C. turn his or her head against resistance.

D. extend his or her arms against resistance

C. Turn his or her head against resistance.

Rationale: The sternocleidomastoid muscles play an

important role in turning the head from side to side. Asking the patient to turn the head against

resistance is one way to determine that the strength of these muscles is symmetrical and equal.

Which of the following best describes the instructions the nurse should give a patient when assessing the thyroid from the posterior approach?

A. Please tilt your head back as far as possible.

B. Please turn your head as far to the right as you can.

C. Please bring your chin down toward your neck.

D. Please tilt your head slightly down and to one side.

D. Please tilt your head slightly down and to one side.

Rationale: During assessment of the thyroid, it is helpful for the patient to relax the sternocleidomastoid muscle by turning the head slightly and lowering it slightly toward the chin. This position makes it easier for the nurse to palpate each lobe of the thyroid

While assessing a patient, the nurse finds a palpable lymph node in the left supraclavicular region. Which of the following should be the next action?

A. Recognize that it is not common to palpate lymph nodes in this region and they must be carefully evaluated.

B. Recognize that enlarged lymph nodes in this area indicate sinus inflammation.

C. Recognize that this is a common area for lymph nodes to be enlarged with minor infections.

D. Recognize that a palpable lymph node in this region is always indicative of malignancy.

A. Recognize that it is not common to palpate lymph nodes in this region and that they must be carefully evaluated.

Rationale: Cancers of the lung, breast, and abdomen may metastasize to the lymph nodes and be first accessible during clinical assessment in the supraclavicular region.

While reviewing laboratory values for thyroid function in an adult patient, the nurse sees that the TSH is elevated, and T3 and T4 are decreased. The nurse recognizes that these findings are indicative of

A. normal thyroid function.

B. hypothyroidism.

C. hyperthyroidism.

D. thyroid cancer.

B. Hypothyroidism.

Rationale: With hypothyroidism, TSH from the pituitary gland usually is increased. Because of decreased thyroid function, there is a decrease in circulating thyroid hormones as measured by T3 and T4 levels in the blood.

A patient presents with a complaint of drooping of the eyelid on one side. This finding is documented as which of the following?

A. Kernig sign

B. Pharyngitis

C. Thyroglossal cyst

D. Ptosis

D. Ptosis.

Rationale: Kernig sign is found with meningitis. Pharyngitis is inflamed and sore throat. A thyroglossal cyst is a birth defect mass found in the neck.

A client comes to the trauma unit in respiratory distress following a motor vehicle accident. On examination, the nurse notices that the trachea is deviated from the midline. What does this finding indicate?

a) Cardiac tamponade

b) Severe neck fracture

c) Flail chest

d) Tension pneumothorax

d) Tension pneumothorax

Rationale: Palpation of the thyroid gland reveals important landmarks of the trachea. Such landmarks are noted when assessing for tracheal deviation, which accompanies a potentially life-threatening condition called tension pneumothorax.

A woman brings her 1 mos old infant to the ED. The mother states the baby's head bulges when the baby cries. The nurse assesses the baby and notices both fontanels appear normal, and the baby seems perfectly healthy. What should the nurse do next?

a) Document a normal finding

b) Get the baby to cry

c) Call the physician

d) Assess for dehydration

a) Document a normal finding

A bulging fontanel may be normal when an infant cries but otherwise needs further evaluation as a sign of possible increase intracranial pressure.

A woman brings her 1 mos old infant to the ED. She says the baby is not eating or drinking well. The nurse finds the fontanels are depressed slightly. Why does this require further assessment?

a) This could be a sign of increased intracranial pressure

b) This could be a sign of dehydration

c) This could be a sign of physical abuse

d) This is a sign of a possible neurological disorder

b) This could be a sign of dehydration

Rationale: A depressed fontanel may indicate dehydration.

The nurse is discharging an adult client who received 18 staples for a head laceration received while mountain biking. What can the nurse focus on while doing discharge teaching?

a) Teach proper posture, bending, and lifting

b) Encourage the client to take a safety course

c) Encourage proper nutrition to promote healing

d) Encourage the use of safety equipment

d) Encourage the use of safety equipment

Rationale: Nurse encourage use of appropriate safety equipment to reduce risk of head or neck trauma. There is no identified need to encourage proper nutrition to promote healing in this client.

The nurse is assessing a client complaining of swelling in the neck. While palpating the neck, the nurse finds a 2 cm lump that is fixed and hard. Why does this finding require emergency investigation?

a) This could be a sign of pneumothorax

b) This could be a sign of a parotid stone

c) This could be a sign of cancer

d) This could be a sign of an embolus

c) This could be a sign of cancer

Rationale: Lymphatics larger than 1 cm, fixed, irregular, or hard or rubbery require emergency investigation. Such signs raise the possibility of cancer.