Ch 15 Head and Neck

8. A nurse is palpating the head and neck of a newly referred client. Which of the following would the nurse suspect if assessment reveals that the client's skull and facial bones are larger and thicker than normal? A) Acromegaly B) Brain tumor C) Paget disease D) Parkinson disease

A) Acromegaly

9. When talking to a client before starting the physical exam, the nurse notes that the client consistently tilts her head to one side. Which of the following should the nurse examine first? A) Hearing acuity B) Thyroid gland C) Mental status D) Lymph nodes

A) Hearing acuity

14. Which of the following findings should the nurse document after assessing the thyroid gland of an older adult without abnormalities? A) Nodularity B) Tenderness C) Enlargement D) Bruits

A) Nodularity

20. During a health history, a client reports complaints of headaches. Which of the following would lead the nurse to suspect that the client is experiencing cluster headaches? A) Pain radiating from eye to temporal region B) Throbbing and severe pain C) Report of ringing in the ears prior to headache D) Complaint of sensitivity to light

A) Pain radiating from eye to temporal region

23. A nurse is providing care at an inner-city shelter, and a man who frequents the shelter presents with a significant frontal growth that is located midline at the base of his neck. The nurse should recognize the need for what referral? A) Referral for further assessment of thyroid function B) Referral for assessment of cranial nerve function C) Referral for assessment of lymphatic system function D) Referral for further assessment of swallowing ability

A) Referral for further assessment of thyroid function

4. During the health history, a client describes recent episodes of intermittent facial pain lasting several minutes. The nurse should recognize that this complaint is suggestive of what health problem? A) Trigeminal neuralgia B) Migraine headache C) Meningitis D) Temporomandibular joint dysfunction

A) Trigeminal neuralgia

3. The nurse's assessment reveals that a male client can neither turn his head against resistance nor shrug his shoulders. The nurse should document a potential deficit in the functioning of which cranial nerve? A) Abducens (VI) B) Accessory (XI) C) Hypoglossal (XII) D) Trochlear (IV)

B) Accessory (XI)

2. A nurse is preparing to assess an adult client's carotid pulses. Which of the following actions would be contraindicated? A) Asking the client to flex his or her neck B) Compressing the arteries bilaterally C) Performing the examination while the client is seated D) Asking the client to swallow water

B) Compressing the arteries bilaterally

26. A nurse is working with a client who has a history of headaches. When preparing to assess the client's temporomandibular joint (TMJ), the nurse should provide what instruction? A) I'm going to press on several different places below and in front of your ear. B) I'm going to put my fingers in front of your ears and ask you to open your mouth wide. C) Turn so I can see the side of your face and then open your mouth wide like you're yawning. D) When I place my hands on your cheeks, clench your teeth and then relax them.

B) I'm going to put my fingers in front of your ears and ask you to open your mouth wide.

22. A nurse is conducting a focused head and neck assessment of a client. When preparing to assess the client's thyroid gland, the nurse should be aware of which of the following principles? A) The thyroid gland is not normally palpable in female clients. B) Many clients have an additional (third) thyroid lobe. C) The thyroid gland is not normally palpable until clients are in their thirties or forties. D) Palpation creates a risk of rupturing the thyroid gland in some older adult clients.

B) Many clients have an additional (third) thyroid lobe.

1. The nurse is preparing to palpate a client's temporal artery. The nurse would place the hands at which location? A) On each side of the client's face, anterior and inferior to the ears B) On each side between the top of the ear and the eye C) Bilaterally, parallel to and anterior to the sternomastoid muscle D) Inferior to the lower jaw beneath the client's tongue

B) On each side between the top of the ear and the eye

12. A nurse is palpating the position of the client's trachea. At which anatomic site would the nurse first position a finger for palpation? A) Sternocleidomastoid muscle B) Sternal notch C) Submental space D) Supraclavicular space

B) Sternal notch

17. The nurse can best palpate the superficial cervical nodes, the deep cervical chain, and the supraclavicular nodes by first locating which muscle? A) Infraspinous B) Sternomastoid C) Trapezius D) Platysma

B) Sternomastoid

27. A nurse is performing a head and neck assessment of a client who is newly admitted to the hospital unit. When preparing to assess the client's thyroid gland, what landmarks should the nurse first identify? Select all that apply. A) Sternocleidomastoid muscle B) Hyoid bone C) Cricoid cartilage D) Carotid artery E) Esophagus

B, C B) Hyoid bone C) Cricoid cartilage

29. A client's recent weight loss and diarrhea has been attributed to hyperthyroidism. When auscultating the client's thyroid gland, what assessment finding is most consistent with this diagnosis? A) Audible referred breath sounds at the site of the thyroid B) An audible S3 sound at the site of the thyroid C) A sound of turbulent blood flow in the thyroid D) Irregular S1 and S2 rhythms in the thyroid

C) A sound of turbulent blood flow in the thyroid

28. The nurse is assessing the head and neck of a 51-year-old male client. Following inspection and palpation of the client's thyroid gland, the nurse determines that the gland is enlarged. What is the next action that the nurse should perform? A) Obtain a full set of vital signs. B) Percuss the client's thyroid. C) Auscultate the client's thyroid. D) Perform a swallowing assessment.

C) Auscultate the client's thyroid.

21. A nurse is assessing the head and neck of an adult client. Which vertebra should the nurse identify as a landmark in order to locate the client's other vertebrae? A) C3 B) C5 C) C7 D) T2

C) C7

30. A nurse has completed the assessment of an older adult client's head and neck and is now analyzing the assessment findings. Which of the following findings should the nurse attribute to age-related physiological changes? A) Increased size of a single thyroid nodule B) A nonpalpable carotid pulse C) Decreased strength of temporal artery pulsations D) Tenderness of lymph nodes on palpation

C) Decreased strength of temporal artery pulsations

7. A nurse is preparing a presentation for a local community group about preventing traumatic brain injury. The nurse would discuss which measure as prevention of the leading cause? A) Safe use of firearms B) Safe use of machinery C) Falls prevention D) Domestic violence prevention

C) Falls prevention

19. The nurse is assessing the face of a client with a diagnosis of Parkinson's disease. Which of the following would the nurse most likely assess? A) Sunken face B) Drooping of one side C) Masklike expression D) Asymmetry of earlobes

C) Masklike expression

25. Assessment of an adult female client's face reveals a moon shape, increased hair distribution, and a reddened tone to the client's cheeks. What collaborative problem is most clearly suggested to the nurse by these assessment data? A) RC: Thyroid crisis B) RC: Cerebrovascular accident C) RC: Cushing's syndrome D) RC: Acromegaly

C) RC: Cushing's syndrome

6. Which factor, if present in a client's lifestyle and health practices assessment, would alert the nurse to the need for performing a more thorough head and neck assessment? A) Alcohol abuse B) Recreational drug use C) Smokeless tobacco use D) Multiple sex partners

C) Smokeless tobacco use

18. A nurse has completed an assessment of a client's lymph nodes. Which of the following data would the nurse document as an abnormal finding? A) Diameter: 0.75 cm B) Mobile C) Tender D) Discrete

C) Tender

24. A community health nurse is planning a health promotion campaign that will focus on cancer prevention. Which educational intervention should the nurse select in order to most influence participants' risks of head and neck cancers? A) Teaching about genetic screening B) A nutritional health program C) Teaching about monthly self-examination D) A smoking cessation program

D) A smoking cessation program

16. A nurse is preparing to palpate a client's submental lymph nodes. At what anatomic location should the nurse position his or her hands? A) At the angle of the client's mandible B) At the base of the client's skull C) On the area behind the client's ears D) Behind the tip of the client's mandible

D) Behind the tip of the client's mandible

13. When preparing to assess a client's thyroid gland, the nurse should ensure that which piece of equipment is readily available? A) Penlight B) Tongue depressor C) Centimeter-scale ruler D) Cup of water

D) Cup of water

5. A client describes her frequent headaches as being severe and lasting for days. The client's positive response to what question would most clearly suggest to the nurse that these headaches are migraines? A) Do they occur after you have been tense or anxious? B) When you consume alcohol, do you get a headache? C) Do you have any eye symptoms, such as tearing? D) Do you have any visual changes before the headache?

D) Do you have any visual changes before the headache?

15. A nurse is assessing an adult client's neck. Which of the following would be most appropriate when auscultating the client's thyroid gland for bruits? A) Hyperextend the client's neck. B) Turn the client's head to the right. C) Have the client swallow water. D) Have the client hold his or her breath.

D) Have the client hold his or her breath.

11. A nursing educator is evaluating a colleague's examination of a client's thyroid gland. The educator would determine that the nurse needs additional instruction when the nurse demonstrates which technique? A) Inspection B) Auscultation C) Palpation D) Percussion

D) Percussion

10. The nurse assesses a client and palpates a temporal artery that is hard, thick, and tender with absent pulsations. The nurse would gather additional information related to which aspect of health? A) Mental status B) Hearing C) Neurologic status D) Vision

D) Vision