D443 Health Assessment - Set 4 - Part 1

Correct Answer: Group A streptococcal pharyngitis

The combination of tonsillar exudate, fever, tender anterior cervical lymphadenopathy, and absence of cough forms the classic clinical criteria used to predict group A streptococcal pharyngitis, often summarized in the Centor criteria. Strep throat characteristically lacks the cough and runny nose that dominate viral illness. A common cold produces cough, rhinorrhea, and mild throat irritation without significant exudate, allergic symptoms center on itching and clear drainage, and candidiasis produces removable white plaques rather than an acute febrile exudative pharyngitis. These findings warrant a rapid strep test and treatment to prevent complications.

Correct Answer: There is weakness of the left hypoglossal nerve, and the tongue deviates toward the weak side

Cranial nerve XII, the hypoglossal nerve, controls tongue movement, and when one side is weak the stronger side pushes the tongue toward the affected, weaker side on protrusion. Deviation to the left therefore indicates left hypoglossal weakness. A normal tongue protrudes in the midline without deviation. Cranial nerve VII controls facial expression and produces facial drooping rather than tongue deviation, and the glossopharyngeal nerve (IX) is involved in the gag reflex and taste, not tongue protrusion. Remembering that the tongue points toward the lesion helps localize the deficit.

Correct Answer: There is weakness on the left side, and the uvula deviates away from the affected side

When the patient says ah, an intact soft palate rises symmetrically and the uvula stays midline. With unilateral weakness of the vagus nerve (cranial nerve X), the paralyzed side of the palate fails to elevate and the uvula is pulled toward the stronger, intact side, deviating away from the lesion. Here the left palate does not rise and the uvula deviates to the right, indicating left-sided weakness. This differs from the hypoglossal nerve, which controls the tongue, and the finding does not represent a normal response or confirm an intact gag reflex. Uvular deviation points away from the affected side.

Correct Answer: Increased right-sided heart pressure and fluid volume overload

Jugular venous pressure reflects pressure in the right atrium, and the internal jugular vein is examined with the patient reclined at about 45 degrees. Distension of the jugular veins high up the neck indicates elevated right atrial pressure, seen in right-sided heart failure, fluid volume overload, and conditions that impede venous return to the heart. In contrast, hypovolemia and dehydration cause flat, collapsed neck veins with low venous pressure. Hyperthyroidism and cerebral artery occlusion do not directly raise jugular venous pressure. Elevated JVP is a key sign of the heart's inability to handle venous return.

Correct Answer: A carotid bruit indicating turbulent blood flow from arterial narrowing

A bruit is a blowing, whooshing sound produced by turbulent blood flow through a narrowed or partially obstructed artery. Heard over the carotid, it suggests atherosclerotic stenosis, which is clinically important in a patient with transient ischemic attacks because it signals risk of stroke. The bell is used because bruits are low-pitched, and the patient holds the breath to eliminate breath sounds. A thyroid bruit is heard over the thyroid gland in hyperthyroidism, not the carotid, and a venous hum is continuous and obliterated by light pressure. The nurse should never palpate both carotids at once, and a carotid bruit warrants further vascular evaluation.

Correct Answer: The thyroid is often not palpable, and when felt is smooth, soft, and non-tender and rises with swallowing

In most healthy adults the thyroid gland is small and often not palpable at all. When it can be felt, the normal gland is smooth, soft, symmetric, and non-tender, and it rises upward beneath the examiner's fingers when the patient swallows because it is attached to the trachea. Hardness, fixation, nodularity, or an irregular surface are abnormal and may suggest malignancy, while diffuse tenderness suggests inflammation such as thyroiditis. A visibly enlarged gland (goiter) is not a normal finding. Understanding the normal texture and mobility helps the nurse recognize abnormalities.

Correct Answer: Occipital lymph nodes

The occipital lymph nodes are located at the base of the skull posteriorly and drain the posterior scalp and back of the head, so an infection or lesion in that region typically produces occipital node enlargement. The submental nodes lie under the chin and drain the lower lip, floor of the mouth, and tip of the tongue, while the tonsillar nodes drain the tonsillar and posterior pharyngeal region. Supraclavicular nodes drain the thorax and abdomen and are concerning for malignancy when enlarged. Matching node location to drainage region helps the nurse localize the source of infection or disease.

Correct Answer: It deviates toward the unaffected side, away from the pressure

The trachea is normally midline, and its position is assessed by palpating within the suprasternal notch. In a tension pneumothorax, air trapped under increasing pressure in the pleural space pushes the mediastinal structures, including the trachea, away from the affected side toward the opposite, unaffected side. This contrasts with conditions that pull the trachea toward the affected side, such as atelectasis or lung collapse from fibrosis, where volume loss draws structures inward. Recognizing tracheal deviation away from the injured side is a critical sign of a life-threatening tension pneumothorax requiring emergency decompression.

Correct Answer: Asking the patient to shrug the shoulders and turn the head against the nurse's resistance

Cranial nerve XI, the spinal accessory nerve, innervates the sternocleidomastoid and trapezius muscles, so it is tested by having the patient shrug the shoulders and turn the head against the examiner's resistance while the nurse assesses strength and symmetry. Clenching the teeth tests the motor branch of cranial nerve V, tongue movement tests cranial nerve XII, and facial expressions such as smiling and puffing the cheeks test cranial nerve VII. Weakness or asymmetry in shoulder shrug or head rotation localizes to the spinal accessory nerve. Pairing the maneuver to the correct nerve ensures an accurate cranial nerve assessment.

Correct Answer: The asymmetric light reflex suggests misalignment of the eyes (strabismus)

The corneal light reflex test, also called the Hirschberg test, screens for extraocular muscle alignment by observing whether a penlight reflects symmetrically on both corneas. In normally aligned eyes the reflection falls at the same spot on each cornea, typically slightly nasal to center. An asymmetric reflection, as seen here with displacement in the left eye, indicates that the eyes are not aligned, suggesting strabismus. This finding warrants further evaluation because untreated strabismus in a child can lead to amblyopia. It does not indicate a cataract, which would obscure the red reflex, nor a normal pupil-size variation, since the test assesses alignment rather than pupil diameter.

Correct Answer: Vesicular breath sounds

Vesicular breath sounds are normal over most of the peripheral lung fields. They are soft, low-pitched, and breezy, with a longer inspiratory phase than expiratory phase. Bronchial sounds are loud and high-pitched with a longer expiratory phase and are normal only over the trachea; hearing them over the peripheral lung suggests consolidation. Bronchovesicular sounds are intermediate and normal over the mainstem bronchi.

Correct Answer: Fine crackles

Fine crackles (rales) are discontinuous, high-pitched, brief popping sounds heard typically at the end of inspiration. They are produced by the sudden opening of previously collapsed small airways and alveoli and are characteristic of pneumonia, pulmonary edema, and interstitial disease. Crackles from fluid or collapse do not clear with coughing, distinguishing them from rhonchi, which are lower-pitched and may clear.

Correct Answer: Sibilant wheezes caused by air moving through narrowed bronchioles

Sibilant wheezes are high-pitched, continuous, musical sounds produced when air flows rapidly through narrowed lower airways, as occurs with bronchospasm in asthma. They are usually louder on expiration because airways narrow further during exhalation. Rhonchi are lower-pitched and caused by secretions in larger airways. Stridor is a harsh sound over the upper airway heard on inspiration.

Correct Answer: Stridor, indicating upper airway obstruction

Stridor is a loud, harsh, high-pitched musical sound heard predominantly on inspiration and often audible without a stethoscope. It results from turbulent airflow through a narrowed or obstructed upper airway (larynx or trachea), as seen in croup, epiglottitis, or foreign body aspiration. Stridor is a medical emergency signaling potential airway compromise.

Correct Answer: Dullness

Percussion over an area of fluid or solid tissue produces a dull, thudlike note because fluid and consolidation transmit sound poorly. A pleural effusion, in which fluid collects in the pleural space, therefore yields dullness on percussion. Normal air-filled lung produces resonance, and hyperresonance occurs with excess air as in emphysema or pneumothorax.

Correct Answer: Hyperresonance, indicating trapped air

Hyperresonance is a very loud, low-pitched, booming percussion note that occurs when there is an abnormal increase in air in the lungs. In emphysema, alveolar destruction and air trapping increase the air-to-tissue ratio, producing hyperresonance. This note is also heard with pneumothorax. Dullness and flatness indicate increased density from fluid or solid tissue.

Correct Answer: Fremitus will be increased over the consolidated area

Tactile fremitus is the palpable vibration transmitted through the chest wall when a patient speaks. Solid or consolidated lung tissue, as occurs in pneumonia, transmits these vibrations more efficiently than air-filled lung, so fremitus is increased over the area of consolidation. Conditions that place air or fluid between the lung and chest wall, such as pneumothorax or pleural effusion, decrease fremitus.

Correct Answer: Tachypnea

Tachypnea is defined as a persistent respiratory rate above the normal adult range (greater than about 20 to 24 breaths per minute), often accompanied by shallow breathing. It commonly occurs with fever, pain, anxiety, respiratory distress, or metabolic acidosis. Bradypnea is an abnormally slow rate, apnea is the cessation of breathing, and hyperpnea refers to increased depth of breathing.

Correct Answer: The sternal angle (angle of Louis)

The sternal angle, also called the angle of Louis, is the palpable bony ridge where the manubrium joins the body of the sternum. It is continuous with the second rib, so it serves as the landmark for identifying the second intercostal space, from which the examiner counts down the ribs and interspaces. The angle of Louis is the standard reference point for anterior rib counting.

Correct Answer: Barrel chest with an anteroposterior-to-transverse ratio of 1:1

Chronic air trapping in emphysema causes the ribs to become more horizontal and the chest to expand, producing a barrel chest in which the anteroposterior diameter increases to roughly equal the transverse diameter (a 1:1 ratio). The normal adult AP-to-transverse ratio is about 1:2. The increased AP diameter of a barrel chest is the hallmark of emphysematous air trapping.