Exam 2: Head, Face, Mouth, & Neck Assessment

The major artery of the head that branches from within the external carotid artery and has a palpable pulse superior to the zygomatic arch is called the _________ artery.

temporal

You are assessing a patient and note that he has an enlarged head and face, hands, and feet. This syndrome is called: 1) acromegaly 2) macrocephaly 3) microcephaly 4) Parkinson's disease

1) acromegaly

The nurse assesses the patient's face. What documentation indicates normal findings of this assessment? Select all that apply. 1) face square 2) asymmetry of the face structures 3) nasolabial folds and palpebral fissures equal 4) flat affect 5) no involuntary muscle movement

1) face square 3) nasolabial folds and palpebral fissures equal 5) no involuntary muscle movement

The patient is experiencing xerostomia. Identify the factors that may cause xerostomia. Select all that apply. 1) medications 2) pain 3) systemic disease 4) radiation therapy 5) anxiety

1) medications 3) systemic disease 4) radiation therapy 5) anxiety

You are assessing a patient who has swelling of the face. Which of the following are normal findings when palpating the face? Select all that apply. 1) no tenderness 2) temporal artery nontender 3) temporomandibular joint (TMJ) has limited range of motion (ROM) 4) TMJ has no clicking sounds 5) mouth opens on the average of 1 to 2 cm

1) no tenderness 2) temporal artery nontender 4) TMJ has no clicking sounds

The nurse has inspected and palpated the nose during the patient's assessment. What documentation indicates normal findings? 1) nose symmetrical without tenderness 2) skin color red with nasal congestion 3) nose tender and bruised 4) nose symmetrical with deviated septum

1) nose symmetrical without tenderness

The nose is located centrally on the face and is composed of bone and cartilage. What structures are considered part of the anatomy of the nose? Select all that apply. 1) septum 2) turbinates 3) nares 4) adenoids 5) tonsils

1) septum 2) turbinates 3) nares

You are using the anterior approach to palpate the thyroid gland. The purpose of palpating this gland is to assess which of the following? Select all that apply. 1) smoothness 2) swelling 3) nodules 4) tenderness 5) size

1) smoothness 2) swelling 3) nodules 4) tenderness 5) size

When inspecting and palpating the nose, the nurse assesses for which of the following? 1) symmetry, septum alignment, color, swelling, and tenderness 2) symmetry, color, moisture, lesions, and pain 3) symmetry, movable, pain, lesions, and septum alignment 4) symmetry, pain, bleeding, moisture, lesions, and tenderness

1) symmetry, septum alignment, color, swelling, and tenderness

What is the purpose of assessing the patency of the nose? 1) to assess for nasal passageway occlusion 2) to assess for tenderness, inflammation, or deviation 3) to assess appearance and symmetry 4) to assess for normal size and shape

1) to assess for nasal passageway occlusion

You are inspecting the neck of an older adult. What is the purpose of this assessment technique? Select all that apply. 1) to assess symmetry 2) to assess for tenderness 3) to assess for lumps 4) to assess range of motion 5) to assess for swelling

1) to assess symmetry 4) to assess range of motion 5) to assess for swelling

You are inspecting the buccal mucosa of a 70-year-old male patient. Which of the following instructions should you give to this patient? 1) "Hold your mouth open until I tell you that I am finished." 2) "Please remove your dentures so that I can assess the gums of your mouth." 3) "Let me know if you have xerostomia and I will give you a cup of water to drink." 4) "I will be using a penlight to look in your mouth."

2) "Please remove your dentures so that I can assess the gums of your mouth."

You are providing patient education on dental health. The patient states that he has been using the same toothbrush for the past year and has not seen a dentist in 2 years. The nurse should educate the patient with which of the following statements? Select all that apply. 1) Toothbrushes should be replaced every 6 months. 2) Have a dental examination twice per year. 3) Brush all tooth surfaces for at least 60 seconds. 4) Place your toothbrush at a 90-degree angle to the gums. 5) Floss at least once a day, preferably more often.

2) Have a dental examination twice per year. 5) Floss at least once a day, preferably more often.

A 37-year-old female presents to the community health clinic complaining of a severe sore throat and swollen glands. You have already inspected the rising of the soft palate and uvula. Prior to using the tongue depressor to assess the oropharynx, which of the following should the nurse do first? 1) Ask the patient to open her mouth real wide. 2) Moisten the tongue blade with warm water. 3) Ask the patient to say "ahh". 4) Assess for swollen glands.

2) Moisten the tongue blade with warm water.

The student nurse is explaining the technique of palpating the face to the instructor. The instructor identifies that further teaching is necessary when the student nurse makes which of the following statements? 1) Using the finger pads of both hands, gently palpate the face for tenderness and swelling. 2) Place your fingers in back of the earlobes and below the eyes to palpate the temporal arteries simultaneously by each ear. 3) Place your fingertips in front of each ear at the zygomatic arch and ask the patient to open and close his or her mouth. 4) Assess for any clicking sounds or decreased range of motion (ROM) of the jaw, including temporomandibular joint (TMJ) disorder.

2) Place your fingers in back of the earlobes and below the eyes to palpate the temporal arteries simultaneously by each ear.

The patient states that she has frequent headaches. The patient explains that the headaches are a stabbing pain on one side of the face or sometimes occur behind one eye. The headaches occur most often in the early morning. What type of headache is the patient describing? 1) migraine 2) cluster 3) sinus 4) tension

2) cluster

You are inspecting and assessing a patient's teeth. What will you be assessing? Select all that apply. 1) buccal mucosa 2) color of teeth 3) tooth decay 4) malocclusion 5) tongue

2) color of teeth 3) tooth decay 4) malocclusion

You are assessing a 32-year-old man's mouth. Using a penlight, you inspect the mouth and note that he has red, bleeding gums. What is the name of this abnormal finding? 1) aphthous stomatitis 2) gingivitis 3) gingival hyperplasia 4) periodontal disease

2) gingivitis

You are performing a mouth assessment and are going to inspect and palpate the tongue. What equipment will you need? 1) gown and gloves 2) gloves and sterile gauze 3) goggles and penlight 4) penlight and gloves

2) gloves and sterile gauze

You are using the anterior approach to palpating the thyroid gland. What are normal findings? Select all that apply. 1) variations of firmness 2) palpable lobes 3) nonpalpable lobes 4) small nodules 5) nontender

2) palpable lobes 3) nonpalpable lobes 5) nontender

The patient is complaining of a sinus headache and nasal congestion. What technique is used to assess the sinuses? Select all that apply. 1) inspection 2) palpation 3) percussion 4) auscultation 5) inhalation

2) palpation 3) percussion

The purpose of inspecting the thyroid gland is to assess: 1) tenderness and size 2) size and mobility 3) position within the neck and nodules 4) mobility and tenderness

2) size and mobility

The nurse is inspecting and palpating the patient's head. What is the nurse specifically assessing? Select all that apply. 1) voluntary movement of the tongue 2) size and shape of the head 3) configuration 4) range of motion 5) movement

2) size and shape of the head 3) configuration 5) movement

The patient reports a chronic sore throat, chronic hoarseness, and dysphagia. What diagnostic tests would you expect the healthcare provider to order for further evaluation? Select all that apply. 1) computed tomography (CT) scan 2) swallowing evaluation 3) throat culture 4) fiberoptic endoscopic evaluation of swallowing (FEES) 5) magnetic resonance imaging (MRI)

2) swallowing evaluation 3) throat culture 4) fiberoptic endoscopic evaluation of swallowing (FEES)

The nasolabial folds and the palpebral fissures of the face are measured to assess for: 1) appearance of the face 2) symmetry of the face 3) edema of the face 4) involuntary movements of the face

2) symmetry of the face

A college student goes to the on-campus health clinic complaining of a severe sore throat and difficulty swallowing. You put on gloves and, with the aid of a penlight, assess her pharynx. You see that her throat is very red, her tonsils have white purulent spots, and the tonsils are almost touching her uvula. What objective data would you document? 1) throat is red, tonsils are enlarged 2) throat is red, tonsils are 3+ with multiple white spots 3) reports painful sore throat, swollen glands, and dysphagia 4) painful sore throat, white spots on tonsils, enlarged tonsils 3+

2) throat is red, tonsils are 3+ with multiple white spots

The patient is diagnosed with a neurological disorder. During the assessment of this patient's head, what abnormal assessment findings would the nurse expect to find? 1) tenderness and swelling of the head 2) tremors, tics, or jerking movements of the head 3) a mass or lesions on the skull 4) depression of the skull

2) tremors, tics, or jerking movements of the head

The adult skull is made up of _______ bones and ______ cranial bones.

22; 8

Nasopharyngeal cancers are most common in which racial or ethnic groups? 1) Latinos and Asians 2) Asians and Italians 3) Chinese Americans 4) African Americans and Latinos

3) Chinese Americans

Which statement best describes the function of the neck? 1) The neck is formed by seven cervical vertebrae, muscles, and ligaments to support the head. 2) The major muscles supporting the neck are the sternocleidomastoid and trapezius muscles. 3) The neck protects the nerves that carry sensory and motor impulses from the brain to the body. 4) The neck protects the thyroid gland in the anterior portion of the neck.

3) The neck protects the nerves that carry sensory and motor impulses from the brain to the body.

Which of the following statements is true concerning the anatomy and physiology of the mouth? 1) Stensen ducts are located in the lower oral cavity and drain saliva. 2) The hard palate is the largest and strongest bone of the face. 3) The soft palate is responsible for closing off the nasal passages during the act of swallowing. 4) Gingiva is the mucous membrane epithelium lining inside of the mouth.

3) The soft palate is responsible for closing off the nasal passages during the act of swallowing.

The aide reports to the nurse that the patient coughs when he drinks liquids and appears to be having difficulty swallowing solid foods. The medical term for difficulty swallowing is: 1) xerostomia 2) dysphasia 3) dysphagia 4) bruxism

3) dysphagia

You are assessing a patient's tongue and note that patches on the tongue are missing papillae. What is the name of this condition? 1) atrophic glossitis 2) hairy tongue 3) geographic tongue 4) leukoplakia

3) geographic tongue

You are preparing to assess the head, face, mouth, and neck of a patient. Choose your equipment. Select all the apply. 1) face shield 2) goggles 3) gloves 4) gauze 5) penlight

3) gloves 4) gauze 5) penlight

You are inspecting the trachea. Where will you place your right index finger to start the assessment for tracheal deviation? 1) below the cricoid cartilage 2) below the thyroid isthmus 3) in the sternal notch 4) to the right and left of the trachea

3) in the sternal notch

A patient comes to the urgent care center with a nosebleed. During the focused health history, the patient states that this is the first time she has ever had a nosebleed and is scared. You assess her nose and observe blood coming from the right nostril. What should the nurse do to try to stop the bleeding? 1) Have the patient apply pressure with an ice pack and tilt her head back. 2) Hold pressure on the nares by pinching the nostrils tightly for 10 minutes. 3) Have the patient lean forward and press on the bridge of the nose for 5 minutes. 4) Instruct the patient to sit up, tilt the head forward, and pinch the nostrils for 5 minutes.

4) Instruct the patient to sit up, tilt the head forward, and pinch the nostrils for 5 minutes.

What statement is true concerning the sinuses of the patient? 1) Frontal sinuses are between the eyes, deeper in the skull, and not visible for examination. 2) Ethmoid sinuses are behind the nasal cavity, deeper in the skull, and not visible for examination. 3) Sphenoid sinuses are above the eyes in the center of the forehead. 4) Maxillary sinuses are the largest and located in the cheekbones below the eyes.

4) Maxillary sinuses are the largest and located in the cheekbones below the eyes.

A patient comes to the outpatient clinic complaining of jaw pain and asks the nurse what might be some causes. The nurse explains to the patient that jaw pain is related to: 1) temporomandibular joint (TMJ) disorder, teeth grinding, or temporal arteritis 2) TMJ disorder, xerostomia, allergies, or goiter 3) TMJ disorder, rhinorrhea, sinusitis, or epistaxis 4) TMJ disorder, teeth grinding, or cardiac conditions

4) TMJ disorder, teeth grinding, or cardiac conditions

A patient comes to the emergency room stating that he woke up this morning with swollen lips. He reports that he has just started a new medication for his allergies. What is the name of this condition? 1) anaphylaxis 2) angioedema 3) herpes simplex 4) angular cheilitis

4) angular cheilitis

You are using the posterior approach to palpate the thyroid gland. Where will you place your finger pads? 1) at the level of the thyroid isthmus 2) below the thyroid isthmus 3) above the cricoid cartilage 4) below the cricoid cartilage

4) below the cricoid cartilage

The patient has a history of chronic sinus infections for the past 2 years. What diagnostic test would you expect the healthcare provider to order to provide detailed imaging of the sinuses? 1) x-ray of the face 2) x-ray of the sinuses 3) nasal culture of sinus drainage 4) computed tomography (CT) scan of the sinuses

4) computed tomography (CT) scan of the sinuses

What cranial nerve assess the position of the tongue? 1) cranial nerve I 2) cranial nerve III 3) cranial nerve X 4) cranial nerve XII

4) cranial nerve XII

The nurse is preparing to begin the physical assessment on a young adult starting with assessing the head, face, and neck. Order the following in the correct sequence. 1) auscultation 2) inspection 3) palpation 4) explain procedure 5) document findings

4) explain procedure 2) inspection 3) palpation 1) auscultation 5) document findings

Which bone of the face is considered the largest and strongest bone? 1) frontal bone 2) cranial bone 3) cranial vault 4) mandible

4) mandible

The patient reports that she is feeling tired all the time and has been gaining weight. She thinks that her face is "puffy". You assess the thyroid gland and find it to be enlarged. The healthcare provider suspects the patient has hypothyroidism. You expect that the healthcare provider will order which of the following blood work to assess the thyroid gland? 1) triiodothyronine (T3) 2) thyroid-stimulating hormone (TSH) only 3) thyroid-stimulating hormone (TSH) and free thyroxine (Free T4) 4) thyroid-stimulating hormone (TSH), free thyroxine (Free T4), and triiodothyronine (T3)

4) thyroid-stimulating hormone (TSH), free thyroxine (Free T4), and triiodothyronine (T3)

The purpose of inspecting and palpating the head is to assess the ________ and _______ of the head.

size and shape