Chapter 12: Head and Neck, with Basic Vision and Hearing Basics

How many bones in the face? a) 20 b) 14

14

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) A sound of turbulent blood flow in the thyroid b) An audible S3 sound at the site of the thyroid

A sound of turbulent blood flow in the thyroid Rationale: bruits are common in hyperthyroidism as an increase in blood flow through arteries

A nurse palpates an enlarged, hard, and nontender left-sided supraclavicular lymph node in a client. Where should the nurse focus the physical assessment to obtain more data about this finding? a) Abdomen and thoracic area for changes associated with malignancy b) Upper extremities for changes in sensation, movement, and range of motion

Abdomen and thoracic area for changes associated with malignancy Rationale: Supraclavicular are located behind clavicles; not typically palpable; hard, nontender left-sided node may indicate malignancy of abdomen or thorax

Upon examination of the head and neck of a client, a nurse notes that the submandibular nodes are tender and enlarged. The nurse should assess the client for further findings related to what condition? a) Metastatic disease b) Chronic infection c) Acute infection d) Cushing's disease

Acute infection Rationale: enlarged + tender lymph nodes = acute infections; metastatic they are enlarged but are not tender

A nurse is preparing to examine a client from Southeast Asia who has been experiencing chronic headaches. Which of the following should the nurse do in light of this client's cultural background? a) Avoid asking the client to remove her clothes for the examination b) Have a nurse who is the same sex as the client perform the examination c) Ask permission before palpating the head and neck d) Palpate the client's feet before palpating the head

Ask permission before palpating the head and neck

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) Auscultate the client's thyroid. b) Perform a swallowing assessment.

Auscultate the client's thyroid.

A nurse palpates an elderly client's thyroid and detects an enlargement over the right lateral lobe. What action should the nurse take first? a) Document the findings in the nurse notes b) Auscultate with the bell over the lateral lobes

Auscultate with the bell over the lateral lobes

A nurse palpates an elderly client's thyroid and detects an enlargement over the right lateral lobe. What action should the nurse take first? a) Document the findings in the nurse notes b) Auscultate with the bell over the lateral lobe

Auscultate with the bell over the lateral lobes Rationale: If enlarged, auscultate for presence of bruit (soft, swishing sound bc of increased blood flow)

When palpating the lymph nodes of the neck, the nurse assesses for which of the following characteristics? a) Congruency, induration, size, turgor b) Delineation, integrity, shape, color c) Consistency, delineation, mobility, tenderness d) Configuration, discreteness, temperature, color

Consistency, delineation, mobility, tenderness

The nurse notes unilateral facial drooping and reports the finding immediately to the healthcare provider. The client is diagnosed with Bell palsy. The nurse should include assessment of which affected cranial nerve in the client's head and neck assessment?

Cranial nerve VII

When examining a client's thyroid gland, the nurse ensures that which equipment is readily available? a) Penlight b) Tongue depressor c) Centimeter-scale ruler d) Cup of water

Cup of water Rationale: swallow

A woman brings her 1-month-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) Call the physician b) Document a normal finding

Document a normal finding Rationale: bulging fontanel upon crying for infants is OKAY. if not crying, inspect further

A nurse performs palpation of a client's lymph nodes. Which finding should be reported to the health care provider? a) Soft consistency b) Fixed to underlying tissue

Fixed to underlying tissue Rationale: lymph nodes are round, soft, and less than 1cm in size, mobile, and nontender.

A nurse needs to examine a client's thyroid as part of the head and neck assessment. How should the nurse instruct the client to position his head to best facilitate this exam? a) Flex the head toward the side being examined b) Flex the head away from the side being examined

Flex the head toward the side being examined

What is the most common type of hyperthyroidism? a) Graves' disease b) Cushing's syndrome c) Moon face d) Thyroid cancer

Graves' disease

When identifying the midline structures of the neck from the mandible to the sternal notch, the nurse notes the structures in what order? a) Thyroid cartilage, thyroid isthmus, cricoid cartilage, hyoid bone b) Hyoid bone, thyroid cartilage, cricoid cartilage, isthmus of the thyroid

Hyoid bone, thyroid cartilage, cricoid cartilage, isthmus of the thyroid

The nurse is preparing to palpate the submandibular salivary glands. The nurse would place the hands at which location? a) Inferior to the mandible beneath the tongue b) On each side of the client's face, anterior and inferior to the ears

Inferior to the mandible beneath the tongue

A nurse is caring for a client admitted with neck pain. The client is febrile (fever). What is the most likely medical diagnosis for this client? a) Measles b) Meningitis

Meningitis Rationale: fever+headache may signify serious illness such as meningitis

Which risk factor for traumatic brain injury should a nurse include in a discussion about prevention for a group of adolescents? a) Females have twice the risk that males do b) Most firearm incidents are accidental c) Modes of transportation are the leading caused d) Falls occur more frequently in the younger population

Modes of transportation are the leading cause

A nurse is performing a head and neck assessment on a client. Which area should the nurse inspect for facial symmetry? a) Temporomandibular joint b) Nasolabial folds

Nasolabial folds

Should the thyroid gland be palpable?

No

A nurse documents which of the following as a normal finding when examining the thyroid gland of an older adult client? a) Tenderness b) Nodularity

Nodularity

A client complains of a unilateral headache near the scalp line and double vision. The nurse palpates the space above the cheekbone near the scalp line on the affected side, and the client complains of tenderness on palpation. What is the nurse's next action? a) Notify the healthcare provider immediately. b) Administer intravenous pain medication. c) Palpate the carotid pulses bilaterally at the same time. d) Prepare the client for a temporal artery biopsy.

Notify the healthcare provider immediately. Rationale: Temporal arteritis is a painful inflammation of the temporal artery. Clients report severe unilateral headache sometimes accompanied by visual disturbances. This condition needs immediate care.

Which instruction to the client will help facilitate examination of the temporomandibular joint by the nurse? a) Open the mouth b) Sit upright c) Sit without moving d) Perform a chewing action

Open the mouth

A college student presents with a sore throat, fever, and fatigue for several days. Exudates are on her enlarged tonsils. A careful lymphatic examination reveals some scattered small mobile lymph nodes just behind her sternocleidomastoid muscles bilaterally. What group of nodes is this? a) Submandibular b) Posterior cervical

Posterior cervical Rationale: The group of nodes posterior to the sternocleidomastoid muscle is the posterior cervical chain

The nurse questions a client about any radiation therapy to the neck area based on the understanding about which of the following? a) The client may experience dizziness and light-headedness more easily. b) Radiation therapy has been linked to the development of thyroid cancer.

Radiation therapy has been linked to the development of thyroid cancer.

The nurse is performing a physical examination and notes an enlarged left supraclavicular lymph node. The nurse understands that this could be indicative of a) a goiter b) a metastasis

a metastasis

The nurse is planning to assess an adult client's thyroid gland. The nurse should plan to a) approach the client posteriorly. b) place the fingers above the cricoid cartilage.

approach the client posteriorly

A client is brought to the emergency department via ambulance after experiencing difficulty speaking and weakness in the left arm and leg. The nurse understands that the client is most likely experiencing which of the following disorders? a) Bell palsy b) temporal arteritis c) trigeminal neuralgia d) cerebrovascular accident

cerebrovascular accident Rationale: visual disturbances, sudden trouble walking, dizziness, loss of balance, weakness or numbness in face = possible stroke

As the nurse palpates the lymph nodes of the neck, hard and fixed nodes are noted in the supra-clavicular region. This finding is consistent with which condition? a) hypothyroidism b) malignancy

malignancy Rationale: hard/fixed nodes in supraclavicular region suggest a malignancy

The nurse is planning to assess a client's lymph nodes. Which set of nodes should the nurse assess first? a) submental b) preauricular

preauricular Rationale: Lymph nodes in ear or preauricular are palpated first

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

tender Rationale: lymph nodes are not supposed to be tender