Head and Neck

Which structures of the neck should the nurse palpate for smoothness and tenderness? Select all that apply. a. Scalp skin b. Hyoid bone c. Trachea d. Thyroid cartilage e. Cricoid cartilage

b, d, e Rationale: The nurse should palpate the hyoid bone for smoothness and tenderness. The nurse should palpate the thyroid cartilage for smoothness and tenderness. The nurse should palpate the cricoid cartilage for smoothness and tenderness.

Identify the indicated sutures of the adult skull. a. Coronal b. Lambdoid c. Squamous

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Label the fontanels at their locations on the diagram. a. Mastoid fontanel b. Posterior fontanel c. Sphenoid fontanel d. Anterior fontanel

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Label the indicated structures of the infant skull. a. Posterior fontanel b. Coronal suture c. Sagittal suture d. Lambdoid suture e. Anterior fontanel

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Label the skull bones at their locations on the diagram. a. Frontal bone b. Parietal bone c. Occipital bone d. Zygomatic bone

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Which question should the nurse ask a patient with a headache to assess aggravating and alleviating factors as part of the history of present illness? a. "Does your headache worsen with loud noises?" b. "How long has this headache been going on?" c. "When did the pain begin?" d. "Are you seeing any spots or floaters?"

a Rationale: The nurse should ask a patient with a headache about sensitivity to loud noises when assessing aggravating and alleviating factors as part of the history of present illness.

Match the abnormal finding with the relevant element of the head. Finding: a. Coarse, dry, brittle b. Asymmetrical c. Thickening Element of the head: 1. Hair 2. Salivary glands 3. Temporal arteries

a = 1 b = 2 c = 3

Match the condition with the abnormal neck assessment finding. Condition: a. Torticollis b. Thyroglossal duct cyst c. Branchial cleft cyst Finding: 1. Head tilted toward the sternocleidomastoid muscle 2. In neck midline 3. Mass along anteromedial border of sternocleidomastoid muscle

a = 1 b = 2 c = 3

How should the nurse describe the fontanels of a healthy infant on assessment? Select all that apply. a. Flat b. Soft c. Tense d. Hard e. Bulging f. Depressed

a, b Rationale: The nurse should describe the fontanels of a healthy infant as flat. The nurse should describe the fontanels of a healthy infant as soft.

When conducting thorough head and neck assessment of an infant, which a aspects of the scalp should the nurse assess by inspection? Select all that apply. a. Dilated scalp veins b. Scalp scaling or crusting c. Depressions of the skull d. Temperature of the skin e. Firmness of the fontanels

a, b Rationale: The nurse should inspect for dilated scalp veins during the head and neck assessment. The nurse should inspect for scalp scaling or crusting during the head and neck assessment.

Which aspects of the scalp should the nurse inspect as part of a thorough infant head and neck assessment? Select all that apply. a. Scaling b. Shape c. Movement d. Smoothness e. Temperature

a, b Rationale: The nurse should inspect the scalp for scaling or crusting during the infant head and neck assessment. The nurse should inspect the shape of the scalp and skull during the infant head and neck assessment.

Which findings would be considered abnormal on palpation of the head? Select all that apply. a. Slight depressions b. Asymmetrical salivary glands c. Thrill over temporal arteries d. Thick hair e. Nontender salivary glands

a, b, c Rationale: Depressions, even if slight, are an abnormal finding on palpation of the head. Salivary glands are expected to be symmetrical on palpation. Asymmetrical glands would be an abnormal finding. A thrill over the temporal arteries is an abnormal finding on palpation.

Which findings would be considered abnormal when the neck is assessed? Select all that apply. a. Edema b. Webbing c. Nuchal rigidity d. Midline placement of trachea e. Upward movement of the thyroid gland on swallowing

a, b, c Rationale: Edema of the neck is an abnormal finding and may be associated with infection. Webbing of the neck is an abnormal finding and may be associated with congenital abnormalities. Nuchal rigidity is an abnormal finding and may indicate meningeal irritation.

A 63-year-old patient reports a headache that began 3 days ago. The patient describes the headache as constant and severe. The patient denies photophobia or nasal discharge. The patient reports a personal and family history of migraine headaches. Which should the nurse document as part of the history of present illness? Select all that apply. a. Onset 3 days ago b. Constant and severe pain c. No photophobia or nasal discharge d. Family history of migraines e. Personal history of migraines

a, b, c Rationale: Onset of the headache is subjective data and is part of the history of present illness. Report of pain is subjective data and is part of the history of present illness. The patient's report of no photophobia and no nasal discharge is subjective data and is part of the history of present illness.

Which head assessment findings would be considered abnormal? Select all that apply. a. Tics b. Pallor c. Alopecia d. Symmetry of the head e. Slight asymmetry of the facial features

a, b, c Rationale: Tics are an abnormal finding on assessment of the head. Pallor, or an unhealthy pale appearance, is an abnormal finding on assessment of the head. Alopecia is an abnormal finding on assessment of the head.

During the head and face assessments, which features would be assessed by inspection? Select all that apply. a. Head position b. Facial features c. Tics and spasms d. Facial symmetry e. Facial skin thickness f. Skull size and shape

a, b, c, d, f Rationale: The nurse should inspect the head position during the head and face assessment. The nurse should inspect the facial features during the head and face assessment. The nurse should inspect for tics and spasms during the head and face assessment. The nurse should inspect facial symmetry during the head and face assessment. The nurse should inspect the skull size and shape during the head and face assessment.

Which features of the neck should the nurse inspect as part of a thorough assessment? Select all that apply. a. Fullness b. Symmetry c. Lymph nodes d. Alignment of trachea e. Masses, webbing, and skinfolds

a, b, d, e Rationale: The nurse should inspect for fullness of the neck during a thorough neck assessment. The nurse should inspect for symmetry of the neck during a thorough neck assessment. The nurse should inspect for alignment of the trachea during a thorough neck assessment. The nurse should inspect for masses, webbing, and skinfolds during a thorough neck assessment.

Which findings would be considered abnormal on examination of an infant's fontanels? Select all that apply. a. Bulging b. Depressed c. Some pulsation d. Posterior fontanel open at 1 month e. Anterior fontanel open at 2 years

a, b, e Rationale: Bulging fontanels are an abnormal finding. Depressed fontanels are an abnormal finding. The anterior fontanel would not be expected to be open at 2 years, as it typically closes by 12-15 months.

Which sutures separate the cranial bones in infants? Select all that apply. a. Sagittal b. Zygomatic c. Coronal d. Lambdoid e. Frontal

a, c, d Rationale: The sagittal suture separates the cranial bones in infants. The coronal suture separates the cranial bones in infants. The lambdoid suture separates the cranial bones in infants.

As part of the head and face assessment, which features should the nurse assess by palpation? Select all that apply. a. Hair distribution b. Skull shape c. Temporomandibular joint space d. Size and shape of the thyroid gland e. Symmetry and smoothness of the skull

a, c, d, e Rationale: Hair distribution is assessed by both inspection and palpation. The nurse should assess the temporomandibular joint space by palpation during the head and neck assessment. The nurse should assess the size and shape of the thyroid gland by palpation during the head and neck assessment. The nurse should assess the symmetry and smoothness of the skull by palpation during the head and neck assessment.

What questions should a nurse ask a patient complaining of headache when assessing history of present illness? Select all that apply. a. "Can you describe the pain to me?" b. "Are you under a lot of stress either at home or work?" c. "On a scale of 1 to 10 how severe is the pain?" d. "Is the pain worse in the morning?" e. "Where specifically is the pain?" f. "Does anyone in your family have similar headaches?"

a, c, d, e Rationale: It is important to assess the quality or character of pain when assessing history of present illness of a headache. It is important to assess the severity of pain when assessing history of present illness of a headache. It is important to assess if there is a pattern to the pain when assessing history of present illness of a headache. It is important to assess the location of pain when assessing history of present illness of a headache. a

An 82-year-old patient complains of sudden headache, difficulty opening the mouth, and pain in the neck. The nurse notes pinpoint pupils, increased ocular pressure, and green drainage from the eye. Which findings should the nurse document as history of present illness related to the head assessment? Select all that apply. a. Headache b. Pinpoint pupils c. Tenderness of the neck d. Green drainage from eye e. Increased ocular pressure f. Difficulty opening the mouth

a, c, f Rationale: A headache is part of the history of present illness related to the head assessment. Tenderness of the neck is part of the history of present illness related to the head assessment. Difficulty opening the mouth is part of the history of present illness related to the head assessment.

A 54-year-old female patient presents to the clinic concerned that she might be having a stroke. She reports symptoms started this morning and she sought help immediately. Her speech and cognition are intact, but she is complaining of a headache. The nurse notices upon inspection that her face is asymmetrical, with the right eyelid not closing completely, a drooping eyelid and corner of mouth, and a loss of the nasolabial fold on the affected side. What should the nurse document as objective data for the head and neck assessment? Select all that apply. a. Loss of nasolabial fold on affected side b. Rapid onset of symptoms c. Headache d. Asymmetrical face e. Right eyelid not closing completely f. Drooping eyelid and corner of mouth on affected side

a, d, e, f Rationale: Loss of nasolabial fold on affected side should be documented as objective data. Asymmetrical face should be documented as objective data. Right eyelid not closing completely should be documented as objective data. Drooping eyelid and corner of mouth on the affected side should be documented as objective data.

The nurse should choose which question to ask a patient a who reports riding their bicycle to work every day as part of social and personal history assessment of the head and neck? a. "Do you have issues with balance while riding your bike?" b. "Do you wear a helmet?" c. "Do you wear sunglasses and sunblock?" d. "Have you ever had a bicycle accident where you injured your head or neck?"

b Rationale: Because the patient reports riding a bicycle to work every day it is important to assess the use of helmet as part of the personal and social history assessment of the head and neck.

Which face bone is movable? a. Maxilla b. Mandible c. Hyoid d. Occipital bone

b Rationale: The mandible is a movable face bone.

Which finding should the nurse note as normal when assessing the face? a. Rough texture b. Variations in shape c. Palpable skin lesions d. Heterogenous skin color

b Rationale: Variations in facial shape are normal and based on race, gender, age, and build.

Which findings would be considered normal on palpation of the neck? Select all that apply. a. Palpable lymph nodes b. Firm thyroid gland tissue c. Right thyroid lobe slightly larger than left d. Movement of cricoid cartilage on swallowing e. A palpable thrill over the carotid arteries

b, c, d Rationale: The thyroid gland would be expected to be firm and pliable. The right lobe of the thyroid gland may be up to 25% larger than the left. This would be considered a normal finding. The hyoid, thyroid, and cricoid cartilage should move during swallowing. This would be considered a normal finding.

Which bones compose the face? Select all that apply. a. Hyoid b. Ethmoid c. Lacrimal d. Thyroid e. Zygomatic

b, c, e Rationale: The ethmoid bone is one of the bones that makes up the face. The lacrimal bone is one of the bones that makes up the face. The zygomatic bone is one of the bones that makes up the face.

As part of a thorough head and neck assessment, the nurse should assess which features of the infant head by palpation? Select all that apply. a. Skin color b. Suture lines c. Fontanels d. Neck muscle tone e. Skull depressions

b, c, e Rationale: The nurse should assess the suture lines by palpation during the infant head and neck assessment. The nurse should assess the fontanels by palpation during the infant head and neck assessment. The nurse should assess for skull depressions by palpation during the infant head and neck assessment.

What questions related to the history of present illness should a nurse ask a patient who complains of anterior neck swelling? Select all that apply. a. "Have you been experiencing stress at work or home?" b. "How long have you had this?" c. "Have you had radiation to the head and neck?" d. "Do you have any difficulty swallowing?" e. "Does anyone in your family have thyroid problems?"

b, d Rationale: Asking about onset and duration of the problem is part of the history of present illness. It is appropriate to ask about associated symptoms as part of the history of present illness.

Which finding should the nurse note as normal on inspection of the neck? a. Skinfolds b. Pulsations c. Symmetry of the muscles d. Slightly displaced trachea

c Rationale: The nurse should note symmetry of the sternocleidomastoid and trapezius muscles as normal on inspection of the neck.

The nurse notes that a 36-year-old patient has a mass in his neck at the midline. The patient reports a family history of lymphoma and a history of smoking two cigarettes a day. The patient complains of difficulty swallowing and pain when turning the head. Which should the nurse document as objective data related to the neck assessment? a. Difficulty swallowing b. Pain when turning head c. Mass in neck d. Family history of lymphoma

c Rationale: The patient's neck mass is objective data related to the neck assessment.

Which finding should the nurse note as abnormal when palpating the thyroid? Select all that apply. a. Right lobe may be larger than the left b. Tissue firm and pliable c. Palpable nodule d. Gland rises freely with swallowing e. Left lobe may be larger than the right

c, e Rationale: A palpable nodule on the thyroid gland is considered an abnormal finding and may require further evaluation. The right lobe of the thyroid gland may be up to 25% larger than the left.

A patient complains of hoarseness, throat pain, and difficulty swallowing. The nurse notes a bruit over the thyroid and neck swelling. Which information should the nurse document as objective data? Select all that apply. a. Hoarseness b. Throat pain c. Neck swelling d. Difficulty swallowing e. Bruit over the thyroid

c, e Rationale: The nurse's observation of neck swelling is objective data suggestive of thyroid disease. The nurse's observation of a bruit is objective data suggestive of thyroid disease.

Transillumination is a technique used to assess the head of infants under which circumstances? Select all that apply. a. The infant has a neck mass. b. The infant's oral mucosa appears dry. c. The infant has suspected intracranial lesions. d. The infant has suspected respiratory compromise. e. The infant has a rapidly increasing head circumference.

c, e Rationale: Transillumination is used to assess the head of an infant with suspected intracranial lesions. Transillumination is used to assess the head of an infant with a rapidly increasing head circumference.

Which finding should the nurse note as normal on palpation of the head? a. Tender salivary glands b. Distinguishable bones c. Thrill over temporal arteries d. Palpable ridge of sagittal fissure

d Rationale: A palpable sagittal fissure ridge would be normal finding.

Which finding should the nurse note as normal on inspection of the head? a. Head tilted to side b. Balding pattern in females c. Slight asymmetry in skull size d. Slight asymmetry in facial features

d Rationale: Slight asymmetry of facial features is a normal finding when inspecting the head.

Identify the function of the fontanels in the infant. a. Protect the brain from injury b. Provide moisture to the oral membranes c. Produce lymphocytes to fight infection d. Allow for skull expansion to accommodate brain growth

d Rationale: The fontanels allow the skull bones to move to accommodate rapid growth of the infant brain.

Which medical-surgical history question should the nurse ask a patient with headaches? a. "What have you been taking for your headache?" b. "How long have you experienced headaches?" c. "Have any of your siblings needed sinus surgery?" d. "Have you ever been diagnosed with migraines?"

d Rationale: The nurse should ask a patient with headaches about a diagnosis of migraines as part of the medical-surgical history.

What personal/social history question should the nurse ask the patient with neck pain? a. "What makes the pain worse?" b. "Have you had an injury to your neck?" c. "When did the pain begin?" d. "What type of physical activity or sports do you participate in?"

d Rationale: The nurse should assess physical activity or sports as part of the personal/social history examination.

Which information suggestive of thyroid condition would be documented under family history? a. Tachycardia b. Neck pain on palpation c. Spouse with Graves disease d. Father with Graves disease

d Rationale: The patient's father with Graves disease is family history suggestive of a thyroid condition.

Which finding should the nurse consider normal on assessment of the thyroid gland? a. Large lobes b. Nodules c. Fixed lobes d. Firm and pliable

d Rationale: The thyroid gland tissue should be firm and pliable.

The nurse should begin the examination of the head by assessment of which physical characteristics of the patient? Select all that apply. a. Inspection of Thyroid gland b. Inspection of Tracheal position c. Inspection of neck muscles d. Inspection of head position e. Inspection of facial features

d, e Rationale: The nurse should begin the head and neck examination with inspection of the head position. The nurse should begin the head and neck examination with inspection of the facial features.