Chapter 9 Assessing the head, face, mouth , and neck

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

1,2,13,4,5 Feedback 1. This is correct. The purpose of palpating the thyroid gland is to assess smoothness. 2. This is correct. The purpose of palpating the thyroid gland is to assess for swelling. 3. This is correct. The purpose of palpating the thyroid gland is to assess for nodules or lumps. 4. This is correct. The purpose of palpating the thyroid gland is to assess for tenderness. 5. This is correct. The purpose of palpating the thyroid gland is to assess size, such as enlargement

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 6. Skin smooth and clear 7. No edema 8. Masklike facial appearance

1,3,5,6,7

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

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

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

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 and 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

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

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

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 syndrome.

1

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 This is incorrect. The patient should be told to let you know if he is uncomfortable holding open his mouth during this assessment. 2. This is correct. If the patient has full or partial dentures, have him remove the dentures for inspection and palpation of gum area. 3. This is incorrect. You should not use medical terminology when giving instructions to a patient because he may not understand the term xerostomia. 4. This is incorrect. You are explaining what you will be doing. This is not giving instructions to the patient

16. 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

2 Anaphylaxis is a general term for severe allergic reaction. The picture specifically shows swollen lips, which is angioedema. Angioedema is edema of the lips, usually related to an allergic reaction Herpes simplex virus manifests with cold sores or blisters on the lips Angular cheilitis is sore, cracked corners of the lips, commonly caused by yeast infections, dry mouth, or vitamin deficiency.

You are assessing a 32-year-old man's mouth. Using a penlight, you inspect the mouth and note that the 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 1.This is incorrect. Aphthous stomatitis is a canker sore. 2. This is correct. Gingivitis is the mildest type of periodontal disease. The patient's gums will be red, swollen, and bleeding. 3. This is incorrect. Gingival hyperplasia is an enlargement or overgrowth of the gum tissue. The gums do not bleed. 4. This is incorrect. Periodontal disease is a chronic infection of the gums and is caused by bacteria. The gums pull away from the teeth and form deep pockets around the teeth, causing damage to the teeth, gums, and underlying bone.

The patient reports a chronic sore throat, chronic hoarseness, and dysphagia. What diagnostic tests would you expect the health-care 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) 6. Modified barium swallow (MBS) study

2,3,4,6

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 6. Palpating for masses or depressions 7. Palpating the head for moisture

2,3,5,6

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

You are assessing the mouth of this patient. What technique are you performing? 1. Inspecting the upper dentition 2. Inspecting and palpating the dorsal surface of the tongue 3. Palpating the soft and hard palates 4. Inspecting and palpating the soft palate only

3

You are assessing this 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

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 Xerostomia is a dry mouth Dysphasia is difficulty speaking Dysphagia is difficulty swallowing Bruxism is grinding of teeth

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, lean forward, and pinch the nostrils for 10 to 15 minutes.

4

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 health-care provider suspects the patient has hypothyroidism. You expect that the health-care 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 Testa are used to differentiate thyroid malfunction

The patient has a history of chronic sinus infections for the past 2 years. What diagnostic test would you expect the health-care 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 CT scan of the sinuses is an imaging test that uses x-rays with or without contrast dye to create detailed pictures of the air-filled spaces inside the face (sinuses). This scan may help to diagnose infection, nasal polyps, birth defects, or abnormalities of the sinuses

What is the purpose of assessing the patency of the nose? A. To assess for nasal passageway occlusion B. To assess for tenderness, inflammation, or deviation C. To assess appearance and symmetry D. To assess for normal size and shape

A. Assess for nasal passageway occlusion page 162 This is correct. The purpose of assessing the patency of the nose is to assess for nasal passage occlusion This is incorrect. The purpose of inspecting and palpating the nose is to assess for tenderness, inflammation, or deviation. This is incorrect. The purpose of inspecting the face is to assess facial appearance and symmetry. This is incorrect. The purpose of inspecting and palpating the head is to assess for normal size and shape.

The patient states that she has frequent headaches. The patient explains that the headaches are 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 this patient describing? 1. Migraine 2. Cluster 3. Sinus 4. Tension

ANS: 2 This is incorrect. Migraine headaches are characterized by unilateral or bilateral, throbbing, intense pain lasting from hours to 3 days. They cause nausea or vomiting, are made worse with activity, typically occur one to three times per month, and cause sensitivity to light This is correct. Cluster headaches are characterized by stabbing pain on one side of the face or behind one eye or at the temple near the forehead. Pain is constant and occurs in "clusters" or periods of time. Cluster headaches occur at predictable times, most commonly in the very early morning between midnight and 0300. This is incorrect. Sinus headaches are characterized by throbbing pain in front of the face and are accompanied by upper respiratory symptoms. This is incorrect. Tension or stress headaches are characterized by feelings of pressure in the front of the head or both sides of the head or neck. They feel like a band is tightening around the head and may be related to stress or poor posture

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

Ans: 2 This is incorrect. Tenderness and swelling of the head is not a sign or symptom of a neurological disorder This is correct. Neurological disorders cause involuntary movements such as tremors, tics, or jerking movements of the head. This is incorrect. A mass or lesions of the skull is not a sign or symptom of a neurological disorder This is incorrect. Depression of the skull is not a sign of a neurological disorder

A 75 year-old female client states "when I eat meals, I feel like food gets stuck in my throat.' What is an appropriate nursing action? A. Tell the patient to cut up her food in smaller pieces. B. Notify the physician and anticipate a referral to speech therapy for a swallow evaluation C. Ask the patient specifically what foods she has difficulty swallowing D. Encourage the patient to drink more fluids to soften the food she eats

B. This is could be a sign of difficulty swallowing. Notify the physician and anticipate a referral to speech therapy for a swallow evaluation

You are going to perform a mouth assessment. Collect your supplies. Select all that apply. A. Sterile gloves B. Stethoscope C. Penlight D. Tongue blade E. Paper tape measure

C, D Penlight is needed for better visualization Tongue blade presses down tongue to see back of pharynx

You are performing a neck assessment and assess for symmetry and swelling. What assessment comes next? A. Inspection B. Palpation C. Auscultation D. Range of motion

D - Have the patient turn his head to assess ROM: turn neck side to side. Bend neck forward. Extend neck backwards. Bend neck toward each shoulder.

The patient reports that he has clear nasal drainage especially during the spring month. What is this nasal drainage called? A. Epistaxis B. Xerostomia C. Sinusitis D. Rhinorrhea

D. Rhinorrhea