Ch. 12 PrepU Practice Questions
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) Brain tumor b) Paget disease c) Acromegaly d) Parkinson disease
Acromegaly Explanation: The skull and facial bones are larger and thicker in acromegaly. Acorn-shaped enlarged skull bones are seen in Paget's disease. Brain tumor and Parkinson's disease would not change the shape, size, or configuration of the skull.
When palpating the neck, performing which of the following techniques will help differentiate lymph nodes from a band of muscles? a) Palpating for lateral movement when the client swallows a sip of water b) Observing for hypertrophy when the client turns the head against resistance c) Attempting to roll the structure up and down and side to side d) Applying pressure and assessing for induration
Attempting to roll the structure up and down and side to side Explanation: While lymph nodes may be rolled both up and down and side to side, muscles will not move in this manner. The other cited techniques do not differentiate between lymph nodes and muscles
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 c) Immediately notify the health care provider d) Ask the client about past history of hypothyroidism
Auscultate with the bell over the lateral lobes Explanation: If a nurse palpates an enlargement of the thyroid, auscultation should be performed with the bell of the stethoscope to assess for the presence of a bruit. A bruit is a soft, swishing sound produced because of an increase in blood flow through the thyroid arteries. The nurse should also ask the client about past history of thyroid problems, the findings must be documented, then the health care provider notified once assessment is complete to obtain further orders.
What would the nurse identify as a priority educational need for clients with chronic back problems. a) Ways to reduce the risk of falling b) Proper posture, bending, and lifting techniques c) To sleep in the semi-Fowler's position d) Which medications to take and when
Proper posture, bending, and lifting techniques Explanation: Patients with back problems need education about proper posture, bending, and lifting. There would not be an identified need to sleep in the semi-Fowler's position. The question did not identify any need regarding medication education. The question did not identify any fall risk issues
A community health nurse is attending a seminar on headaches. What would this nurse learn is a red flag for headaches? a) Pain centered behind the eyes b) Stiff neck c) Pain that is temporary d) Pain without new symptomatology
Stiff neck Explanation: Limitation of neck mobility may be from muscle tension/strain or cervical vertebral joint dysfunction.
A client comes to the trauma unit in respiratory distress following a motor vehicle accident. On examination, the nurse notices that the trachea is deviated from the midline. What does this finding indicate? a) Tension pneumothorax b) Severe neck fracture c) Cardiac tamponade d) Flail chest
Tension pneumothorax Explanation: Palpation of the thyroid gland reveals important landmarks of the trachea. Such landmarks are noted when assessing for tracheal deviation, which accompanies a potentially life-threatening condition called tension pneumothorax. A deviation of the trachea does not indicate cardiac tamponade, flail chest, or a severe neck fracture.
A nurse is going to inspect and palpate a client's head and neck. After asking the client to remove the wig, what should the nurse do next? a) Put on examination gloves b) Wash hands c) Instruct the client to report any discomfort d) Instruct the client to lie flat with feet together
Wash hands Explanation: If the client is wearing a wig or hairpiece, the nurse asks him or her to remove it. The nurse then washes the hands. The client is usually seated, facing the examiner. The nurse can instruct the client to report any discomfort as the nurse performs the different parts of the head and neck examination. The nurse would don gloves if the client has an open lesion or wound
A client reports right-sided temporal headache accompanied by nausea and vomiting. A nurse recognizes that which condition is likely to produce these symptoms? a) Migraine headache b) Tension headache c) Bell's palsy d) Temporal arteritis
a) Migraine headache
After teaching a group of students about risk factors for traumatic brain injury, the instructor determines that additional teaching is needed when the students identify which of the following? a) Contact sports b) Transportation accidents c) Female gender d) Firearm violence
c) Female gender
The nurse in an emergency department is caring for a minimally responsive 27-year-old victim of a motorcycle accident. The patient was not wearing a helmet. When assessing the patient's head and neck, the nurse should prioritize the assessment for which of the following? a) Strain b) Cyanosis c) Bleeding d) Pallor
Bleeding Explanation: Patients with acute head injuries and neurological changes must be quickly and accurately assessed by the health care team. Stabilization of the head and neck is essential to avoid further neurological injury. Any history of trauma to the head, neck, or both warrants a careful assessment of these structures for bleeding, swelling, loss of mobility, or pain.
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) Sternal notch b) Supraclavicular space c) Submental space d) Sternocleidomastoid muscle
Sternal notch Explanation: To palpate the trachea, the nurse would first place a finger in the sternal notch and then feel each side of the notch and palpate the tracheal rings.
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) Mobile b) Diameter: 0.75 cm c) Tender d) Discrete
Tender Explanation: A lymph node that is tender is an abnormal finding suggesting acute infection. Size less than 1 cm, mobile, and discrete indicate normal findings.
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 c) tonsillitis d) nasopharyngitis
a metastasis
While assessing an adult client's skull, the nurse observes that the client's skull and facial bones are larger and thicker than usual. The nurse should assess the client for a) acromegaly. b) Cushing syndrome. c) Paget disease. d) parotid gland enlargement.
acromegaly. Explanation: The skull and facial bones are larger and thicker in acromegaly.
What does the nurse assess the face for? (Select all that apply.) a) Involuntary movements b) Hair color c) Edema d) Asymmetry e) Affect
• Asymmetry • Edema • Involuntary movements Explanation: Note the patient's facial expression and contours. Observe for asymmetry, involuntary movements, edema, and masses.
A group of students are reviewing the structures of the head and neck in preparation for an examination. The students demonstrate understanding of the material when they identify that the face has how many bones? a) 18 b) 24 c) 14 d) 8
14 Explanation: The face has 14 bones: 2 maxilla, 2 zygomatic, 2 inferior conchae, 2 nasal, 2 lacrimal, 2 palatine, 1 vomer, and 1 mandible. The cranium has 8 bones.
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) A smoking cessation program b) Teaching about genetic screening c) Teaching about monthly self-examination d) A nutritional health program
A smoking cessation program Explanation: Tobacco use increases the risk of head and neck cancer. Eighty-five percent of head and neck cancers are linked to tobacco use. Self-examination is not a current recommendation. Inadequate nutrition is not a noted risk factor. Genetic predisposition is a risk factor, but genetic screening is not commonly available.
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) Irregular S1 and S2 rhythms in the thyroid c) An audible S3 sound at the site of the thyroid d) Audible referred breath sounds at the site of the thyroid
A sound of turbulent blood flow in the thyroid Explanation: A soft, blowing, swishing sound auscultated over the thyroid lobes is often heard in hyperthyroidism because of an increase in blood flow through the thyroid arteries. Breath sounds and heart sounds are atypical
At which location would a nurse palpate a client's submental lymph nodes? a) Behind the tip of the mandible b) Posterior base of the skull c) At the angle of the mandible d) Area behind the ears
Behind the tip of the mandible Explanation: The submental lymph nodes are located a few centimeters behind the tip of the mandible. The tonsillar nodes are located at the angle of the mandible at the anterior edge of the sternomastoid muscle. The occipital nodes are at the posterior base of the skull. The postauricular nodes are behind the ears.
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) Assess for dehydration b) Document a normal finding c) Get the baby to cry d) Call the physician
Document a normal finding Explanation: A bulging fontanel may be normal when an infant cries but otherwise needs further evaluation as a sign of possible increased intracranial pressure. Documenting normal findings would be the nurse's next action. It would be inappropriate to call the physician, assess for dehydration, or make the baby cry.
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) Domestic violence prevention b) Fall prevention c) Defensive driving d) Correct use of firearms
Fall prevention Explanation: The leading causes of traumatic brain injury are falls, motor vehicle accidents, strikes by or against objects, and assaults. Therefore the nurse would address measures related to fall prevention.
While the nurse is assessing a client for an unrelated health concern, the client experiences a sudden, severe headache with no known cause. He also complains of dizziness and trouble seeing out of one eye. What associated condition should the nurse suspect in this client? a) Hyperthyroidism b) Brain tumor c) Diabetes d) Impending stroke
Impending stroke Explanation: A sudden, severe headache with no known cause may be a sign of impending stroke, particularly if accompanied by sudden trouble seeing in one or both eyes or sudden trouble walking, dizziness, and loss of balance or coordination. Only impending stroke is associated with all of these symptoms. Diabetes is not associated with headache or the other symptoms. A tumor-related headache is aching and steady and not necessarily associated with sudden onset. Hyperthyroidism is associated with goiter, bruit, and sudden weight loss, but not with any of the symptoms listed.
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 between the top of the ear and the eye c) On each side of the client's face, anterior and inferior to the ears d) Bilaterally, parallel to and anterior to the sternomastoid muscle
Inferior to the mandible beneath the tongue Explanation: The submandibular glands are located inferior to the mandible underneath the base of the tongue. The parotid glands are located on each side of the face, anterior and inferior to the ears. The temporal artery is located between the top of the ear and the eye. The internal jugular and carotid arteries are located bilaterally parallel and anterior to the sternomastoid muscle.
A client presents to the emergency department with reports of neck pain and a sudden onset of a headache. Upon examination, the nurse finds that the client has an increased temperature and nuchal rigidity. The nurse recognizes these findings as most likely to be caused by what condition? a) Trigeminal neuralgia b) Migraine headache c) Meningeal inflammation d) Parkinson's disease
Meningeal inflammation Explanation: Meningeal inflammation is a likely cause of this condition which manifests as sudden headache, neck pain with stiffness, and fever. Migraine headaches are accompanied by nausea, vomiting, and sensitivity to noise or light and not by fever and neck stiffness. Trigeminal neuralgia is manifested by sharp, shooting, piercing facial pains that last from seconds to minutes. Parkinson's disease is not manifested by headache and neck pain.
When assessing the head and neck, the nurse should realize that variations in skull or neck shape or size relate most to what? a) Height and weight b) Gender c) Cultural background d) Ethnic background
Height and weight Explanation: Variations in cranium or neck shape or size relate more to height and weight than to specific racial or cultural background.
The nurse is caring for a patient who comes to the clinic reporting a lump by her ear. What are the symptoms of a cancerous lymph node? a) The node is fixed and rubbery. b) The node matches the node on the opposite side of the body. c) The node is less than 1 cm in size and feels boggy. d) The node is soft and moves freely.
The node is fixed and rubbery. Explanation: Lymph nodes larger than 1 cm, fixed, irregular, hard, or rubbery require emergency investigation. Such signs raise the possibility of cancer.
A female client visits the clinic and tells the nurse that she frequently experiences severe recurring headaches that sometimes last for several days and are accompanied by nausea and vomiting. The nurse determines that the type of headache the client is describing is a a) tension headache. b) tumor-related headache. c) cluster headache. d) migraine headache.
migraine headache. Explanation: The most common types of headaches are related to vascular (e.g., migraine), muscle contraction (tension), traction, or inflammatory causes.
A client presents to the health care clinic with reports of a stiff neck for the past three days. What objective information can the nurse obtain during the health history? a) Range of motion b) Thyroid size c) Neck tenderness d) Head position
Head position Explanation: While collecting history, the nurse would be able to inspect the client to see how what position the head was being held. Range of motion would require the nurse to give the client commands while trying to obtain other information. Neck tenderness and thyroid size would require the use of palpation, not inspection
Where should a nurse place the hands to palpate the submandibular lymph nodes? a) On the medial border of the mandible b) A few centimeters behind the tip of the mandible c) At the posterior base of the skull bone d) At the angle of the mandible on the anterior edge
On the medial border of the mandible Explanation: The submandibular lymph nodes can be palpated on the medial border of the mandibular bone. Tonsillar nodes are found at the angle of the mandible on the anterior edge of the sternomastoid muscle. The occipital nodes can be palpated at the posterior base of the skull bone. Submental lymph nodes can be palpated a few centimeters behind the tip of the mandible
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) Posterior cervical b) Submandibular c) Occipital d) Tonsillar
Posterior cervical Explanation: The group of nodes posterior to the sternocleidomastoid muscle is the posterior cervical chain. These are common in mononucleosis.
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) Multiple sex partners b) Smokeless tobacco use c) Recreational drug use d) Alcohol abuse
Smokeless tobacco use Explanation: Tobacco use increases the risk of head and neck cancer. The nurse would need to perform a thorough head and neck examination. Alcohol abuse, recreational drug use, or multiple sex partners are not risk factors associated with head and neck cancer.
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) Meningitis b) Migraine headache c) Temporomandibular joint dysfunction d) Trigeminal neuralgia
Trigeminal neuralgia Explanation: Trigeminal neuralgia is manifested by sharp, shooting, piercing facial pain that lasts from seconds to minutes. Migraine headache is characterized by pain around the eyes, temples, cheeks, or forehead. Meningitis would be manifested by sudden head and neck pain, with fever and neck stiffness. Temporomandibular joint dysfunction is manifested by limited range of motion, swelling, tenderness, or crepitation in the jaw area.
A 29-year-old computer programmer comes to the office for evaluation of a headache. The tightening sensation of moderate intensity is located all over the head. It used to last minutes, but this time it has lasted for 5 days. He denies photophobia and nausea. He spends several hours at a computer monitor/keyboard. He has tried over-the-counter medication; it has dulled the pain, but not taken it away. Based on this description, what is the most likely diagnosis? a) Cluster b) Tension c) Migraine d) Analgesic rebound
b) Tension
A client diagnosed with goiter has undergone a thyroidectomy. Which statement from the client indicates understanding of post-operative care teaching? a) I will complete the entire course of thyroid hormone replacement over six weeks. b) I must keep my follow up appointments to receive my thyroid hormone injections. c) I will take my thyroid hormone replacement medication once every week. d) I must take thyroid hormone replacement medication for the rest of my life.
I must take thyroid hormone replacement medication for the rest of my life. Explanation: After thyroidectomy, clients must be treated with exogenous thyroid hormone for the rest of their lives. Thyroid hormones are usually taken by mouth on a daily basis.
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) Ask the client about past history of hypothyroidism b) Auscultate with the bell over the lateral lobes c) Immediately notify the health care provider d) Document the findings in the nurse notes
Auscultate with the bell over the lateral lobes Explanation: If a nurse palpates an enlargement of the thyroid, auscultation should be performed with the bell of the stethoscope to assess for the presence of a bruit. A bruit is a soft, swishing sound produced because of an increase in blood flow through the thyroid arteries. The nurse should also ask the client about past history of thyroid problems, the findings must be documented, then the health care provider notified once assessment is complete to obtain further orders.
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 c) Cricoid cartilage, hyoid bone, tracheal rings, thyroid isthmus d) Hyoid bone, tracheal rings, cricoid cartilage, lobes of the thyroid gland
Hyoid bone, thyroid cartilage, cricoid cartilage, isthmus of the thyroid Explanation: The midline structures of the neck include (1) the mobile hyoid bone just below the mandible; (2) the thyroid cartilage, readily identified by the notch on the superior edge (larger in males than in females); (3) the cricoid cartilage; (4) the tracheal rings; and (5) the thyroid gland.
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) Percuss the client's thyroid. b) Auscultate the client's thyroid. c) Obtain a full set of vital signs. d) Perform a swallowing assessment.
Auscultate the client's thyroid. Explanation: The nurse should auscultate the thyroid only if an enlarged thyroid gland is identified during inspection or palpation. Vital signs are not indicated, and the thyroid is never percussed. A swallowing assessment is not likely necessary.
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) Ask the client about past history of hypothyroidism b) Document the findings in the nurse notes c) Immediately notify the health care provider d) Auscultate with the bell over the lateral lobes
Auscultate with the bell over the lateral lobes Explanation: If a nurse palpates an enlargement of the thyroid, auscultation should be performed with the bell of the stethoscope to assess for the presence of a bruit. A bruit is a soft, swishing sound produced because of an increase in blood flow through the thyroid arteries. The nurse should also ask the client about past history of thyroid problems, the findings must be documented, then the health care provider notified once assessment is complete to obtain further orders.
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) Ask the client about past history of hypothyroidism b) Auscultate with the bell over the lateral lobes c) Immediately notify the health care provider d) Document the findings in the nurse notes
Auscultate with the bell over the lateral lobes Explanation: If a nurse palpates an enlargement of the thyroid, auscultation should be performed with the bell of the stethoscope to assess for the presence of a bruit. A bruit is a soft, swishing sound produced because of an increase in blood flow through the thyroid arteries. The nurse should also ask the client about past history of thyroid problems, the findings must be documented, then the health care provider notified once assessment is complete to obtain further orders.
The nurse is assessing a client's parathyroid gland. Which is the most likely finding the nurse will encounter with hyperparathyroidism? a) Decreased serum calcium level on review of labwork. b) Enlarged posterior portion of thyroid gland. c) Unsymmetrical movement of thyroid gland when swallowing. d) Palpation of two or more enlarged parathyroid glands.
Decreased serum calcium level on review of labwork. Explanation: Parathyroid glands produce calcitonin, which moves calcium into the bones; therefore decreasing the serum calcium levles. In all patients, the thyroid should be symmetrical without discrete masses, nodularity, or tenderness. Inspection of the patient's neck while he or she swallows can sometimes reveal up-and-down movement of the thyroid gland. The thyroid gland is usually not palpable; if it is palpable, this means that the gland is enlarged, which would indicate a pathological condition. Conversely, if only the posterior portion of the thyroid gland is enlarged, it may not be palpable. Nurses must take care to gather thorough data in history taking that may identify symptoms of hypothyroid or hyperthyroid function, even in the absence of an enlarged thyroid gland. Two pairs of parathyroid glands are embedded in the thyroid lobes and produce the hormone calcitonin, which helps move calcium into bones. The parathyroid glands are usually not palpable
The nurse is assessing a client's parathyroid gland. Which is the most likely finding the nurse will encounter with hyperparathyroidism? a) Enlarged posterior portion of thyroid gland. b) Unsymmetrical movement of thyroid gland when swallowing. c) Decreased serum calcium level on review of labwork. d) Palpation of two or more enlarged parathyroid glands.
Decreased serum calcium level on review of labwork. Explanation: Parathyroid glands produce calcitonin, which moves calcium into the bones; therefore decreasing the serum calcium levles. In all patients, the thyroid should be symmetrical without discrete masses, nodularity, or tenderness. Inspection of the patient's neck while he or she swallows can sometimes reveal up-and-down movement of the thyroid gland. The thyroid gland is usually not palpable; if it is palpable, this means that the gland is enlarged, which would indicate a pathological condition. Conversely, if only the posterior portion of the thyroid gland is enlarged, it may not be palpable. Nurses must take care to gather thorough data in history taking that may identify symptoms of hypothyroid or hyperthyroid function, even in the absence of an enlarged thyroid gland. Two pairs of parathyroid glands are embedded in the thyroid lobes and produce the hormone calcitonin, which helps move calcium into bones. The parathyroid glands are usually not palpable.
The nurse is preparing to palpate the submandibular salivary glands. 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) Inferior to the mandible beneath the tongue c) On each side between the top of the ear and the eye d) Bilaterally, parallel to and anterior to the sternomastoid muscle
Inferior to the mandible beneath the tongue Explanation: The submandibular glands are located inferior to the mandible underneath the base of the tongue. The parotid glands are located on each side of the face, anterior and inferior to the ears. The temporal artery is located between the top of the ear and the eye. The internal jugular and carotid arteries are located bilaterally parallel and anterior to the sternomastoid muscle.
When documenting the findings from a physical examination of the head and neck, what will the nurse include when describing the client's head? a) Facial skin color b) Sclera color c) Nasal mucosa color d) Hair color
Hair color Explanation: When describing a client's head, the nurse should include 2 categories of findings, the client's hair color and the presence or absence of abnormalities of the skull. Sclera color is included in documentation of the eyes. Nasal mucosa color is included in documentation regarding the nose. Facial skin color is best included when documenting data regarding the skin
An 81-year-old client complains of neck pain and demonstrates decreased range of motion on examination. Which of the following causes should the nurse most suspect in this client? a) Injury to the sternomastoid b) Meningeal inflammation c) Arthritis d) Stress
Arthritis Explanation: Older clients who have arthritis or osteoporosis may experience neck pain and a decreased range of motion. Sudden head and neck pain seen with elevated temperature and neck stiffness may be a sign of meningeal inflammation. Stress and tension may increase neck pain. Neck pain may accompany muscular problems or cervical spinal cord problems.
A male college student presents to the student health clinic with reports of night-time headaches for the past two weeks. He denies nausea and photosensitivity but states he has noticed his eyes are tearing and his nose runs a lot. He is stressed because of final exams and confesses to drinking more alcohol than normal. The nurse recognizes these findings as indicative of what type of headache? a) Tension b) Cluster c) Migraine d) Stress
Cluster Explanation: Cluster headaches occur more often in young males, have a sudden onset and may be precipitated by ingestion of alcohol. The headaches typically occur in the evening, localized to one eye with radiation into the facial and temporal areas. The person may report tearing of the eye, or runny nose. Migraine headaches are accompanied by nausea, vomiting, and sensitivity to light and sound. Tension headaches occur more frequently in females and are usually a result of stress, anxiety, or depression
A female client describes headache symptoms that seem to indicate a migraine. Which of the following questions during the client interview would, if answered in the positive, tend to confirm the nurse's suspicion? a) "Does the headache occur in conjunction with tightening of neck muscles?" b) "Does the headache tend to occur when you are stressed?" c) "Does the headache tend to occur after a cold or sinusitis?" d) "Does the headache occur regularly with your menstrual cycle?"
"Does the headache occur regularly with your menstrual cycle?" Explanation: Eighteen percent of women have migraine headaches provoked by hormone fluctuations. None of the other types of headache have an onset associated with the menstrual cycle. Sinus headaches tend to occur following a cold or sinusitis. Tension headaches tend to occur with stress or anxiety and are associated with tightening of facial and neck muscles.
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) Trochlear (IV) b) Accessory (XI) c) Hypoglossal (XII) d) Abducens (VI)
Accessory (XI) Explanation: The eleventh cranial nerve is responsible for muscle movement that permits shrugging of the shoulders by the trapezium muscles and turning the head against resistance by the sternomastoid muscle. The abducens (VI) and trochlear (IV) nerves are involved with eye muscle movement. The hypoglossal (XII) nerve is involved with tongue muscles.
The nurse suspects an enlarged thyroid in a patient during the physical examination of the head and neck. What should the nurse first? a) Ask the client to lie down for further assessment b) Displace the trachea to the right. c) Ask the patient to sip and swallow water. d) Listen over the thyroid with a stethoscope.
Ask the patient to sip and swallow water. Explanation: In order to determine if the thyroid gland is enlarged, the first step in the physical assessment is to ask the client to sip some water, extend the neck and swallow. By doing so, the nurse can watch for upward movement of the thyroid gland and determine if the gland is enlarged. Once it confirmed that the thyroid gland is enlarged, it would be the next step for the nurse to listen over the lateral lobes with a stethoscope to detect a bruit. Displacing the trachea would not be part of the assessment; however, the nurse would need to inspect the trachea for deviations that may push it to one side. Assessment of the thyroid gland can be done while the client is sitting up from either an anterior or posterior approach. The assessment cannot be effectively done with the client lying down.
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) Behind the tip of the client's mandible c) On the area behind the client's ears d) At the base of the client's skull
Behind the tip of the client's mandible Explanation: The submental lymph nodes are located a few centimeters behind the tip of the mandible. The tonsillar nodes are located at the angle of the mandible, at the anterior edge of the sternomastoid muscle. The occipital nodes are at the posterior base of the skull. The postauricular nodes are behind the ears
An adult client comes to the ED with a new onset of pain in his neck and jaw. What system requires emergency assessment? a) Integumentary b) Nervous c) Cardiovascular d) Respiratory
Cardiovascular Explanation: Acute situations that need emergency assessment and intervention include head or neck injuries, neck pain (may be cardiac), enlarged hard nodes (which may indicate cancer), and thyrotoxicosis. The other options are, therefore, incorrect.
Which vessel is the nurse assessing if the major artery of the neck is being examined? a) Temporal b) Jugular c) Carotid d) Radial
Carotid Explanation: The common carotid artery exits the aorta and extends upward in the neck to branch into the internal and external carotid arteries. It is the major artery carrying blood to the brain. The internal jugular veins are located in the neck. The temporal artery is located between the top of the ear and the eye. The radial artery is located at the wrist
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? a) Cranial nerve V b) Cranial nerve VII c) Cranial nerve VIII d) Cranial nerve VI
Cranial nerve VII Explanation: Facial asymmetry may indicate inflammation of cranial nerve VII with Bell palsy.
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) A nonpalpable carotid pulse b) Tenderness of lymph nodes on palpation c) Decreased strength of temporal artery pulsations d) Increased size of a single thyroid nodule
Decreased strength of temporal artery pulsations Explanation: The strength of the pulsation of the temporal artery may be decreased in the older client. Enlargement of a single thyroid nodule suggests a malignancy and must be evaluated further. Carotid pulses should always be palpable in healthy clients, and tender lymph nodes are a pathologic finding in clients of any age
A nurse has performed a head and neck assessment of an adult patient and noted that the thyroid gland is not palpable. What is the nurse's most appropriate action? a) Refer the patient to the primary care provider promptly b) Perform a focused endocrine assessment c) Position the patient supine and reattempt palpation d) Document this as an expected assessment finding
Document this as an expected assessment finding Explanation: It is not unusual for the thyroid lobes to be non-palpable using the posterior approach.
A nurse performs palpation of a client's lymph nodes. Which finding should be reported to the health care provider? a) Soft consistency b) Round and 8mm in size c) Mobile from side to side d) Fixed to underlying tissue
Fixed to underlying tissue Explanation: Normally lymph nodes are round and soft, less than 1 cm in size, mobile from side to side, soft consistency, and nontender. A fixed lymph node may be seen in metastatic disease.
A nurse performs palpation of a client's lymph nodes. Which finding should be reported to the health care provider? a) Mobile from side to side b) Soft in consistency c) Round and 8 mm in size d) Fixed to underlying tissue
Fixed to underlying tissue Explanation: Normally lymph nodes are round and soft, less than 1 cm in size, mobile from side to side, soft in consistency, and nontender. A fixed lymph node may be seen in metastatic disease.
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) Have the client swallow water. b) Hyperextend the client's neck. c) Have the client hold his or her breath. d) Turn the client's head to the right.
Have the client hold his or her breath. Explanation: When auscultating the thyroid, the client should hold the breath to obscure any tracheal breath sounds during auscultation. The neck should be slightly extended, without being turned to any side. The client swallows water during inspection, and palpation of the thyroid gland but not during auscultation.
During your physical examination of the patient you note an enlarged tender tonsillar lymph node. What would you do? a) Look for a source such as infection in the area that it drains b) Assess for dietary changes c) Look for involvement of other regions of the body d) Assess for meningitis
Look for a source such as infection in the area that it drains Explanation: Knowledge of the lymphatic system is important to a sound clinical habit: whenever a malignant or inflammatory lesion is observed, look for involvement of the regional lymph nodes that drain it; whenever a node is enlarged or tender, look for a source such as infection in the area that it drains.
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) Masklike expression c) Drooping of one side d) Asymmetry of earlobes
Masklike expression Explanation: A client with Parkinson's disease often exhibits a masklike face. A sunken face with depressed eyes and hollow cheeks is typical of cachexia. Drooping of one side may suggest a stroke or Bell's palsy. Asymmetry of the earlobes occurs with parotid gland enlargement from an abscess or tumor.
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) Earlobes c) Preauricular nodes d) Nasolabial folds
Nasolabial folds Explanation: The nasolabial folds are ideal places to check facial features for symmetry. Inspection of the temporomandibular joint cannot elicit facial symmetry. Preauricular nodes are common head and neck lymph nodes that are not inspected but palpated. Earlobes are not an appropriate feature to use to determine facial symmetry.
Which of the following findings should the nurse document after assessing the thyroid gland of an older adult without abnormalities? a) Nodularity b) Bruits c) Tenderness d) Enlargement
Nodularity Explanation: If palpable, the older adult's thyroid gland may feel more nodular or irregular because of fibrotic changes that occur with aging. The thyroid also may be felt lower in the neck because of age-related structural changes.
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) Palpation b) Percussion c) Inspection d) Auscultation
Percussion Explanation: When examining the thyroid gland, the nurse inspects for enlargement and asymmetry; auscultates for bruits; and palpates for tumors, masses, size, and tenderness. Percussion does not provide meaningful data.
The nurse questions a client about any radiation therapy to the neck area based on the understanding about which of the following? a) Radiation therapy in that area can lead to enlarged lymph nodes. b) Radiation therapy has been linked to the development of thyroid cancer. c) The client may not be able to flex and extend his neck for the examination. d) The client may experience dizziness and light-headedness more easily.
Radiation therapy has been linked to the development of thyroid cancer. Explanation: The nurse asks about a history of radiation therapy because it has been linked to the development of thyroid cancer requiring the nurse to be thorough when examining the thyroid gland. Radiation therapy is not associated with enlarged lymph nodes, reduced range of motion, or dizziness and light-headedness.
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 further assessment of swallowing ability d) Referral for assessment of lymphatic system function
Referral for further assessment of thyroid function Explanation: A goiter (an enlarged thyroid gland) may appear as a large swelling at the base of the neck. This growth is not suggestive of impaired cranial nerve or lymphatic function, and it does not normally impair swallowing ability.
A client complains of pain, numbness, and tingling in the upper extremities for several weeks before coming to the clinic for evaluation. What is the nurse's best action? a) Suggest referral to orthopedic spine specialist. b) Ask client about medications taken for arthritis. c) Review the client's history for recent closed head injury. d) Teach neck exercises to be done daily.
Suggest referral to orthopedic spine specialist. Explanation: Pain, numbness, or tingling may indicate compression of spinal root nerves, requiring further evaluation, preferably by a spine specialist. Limited range of motion with pain is most indicative of arthritis, not spinal nerve root compression. Neck exercises do not relieve nerve compression; the client needs further evaluation first. Signs of head injury include changes in level of consciousness and orientation and behavior changes.
When examining the head, the nurse remembers that the anatomic regions of the cranium take their names from which of the following sources? a) Their anatomical positions b) Noted anatomists c) The underlying vascular network d) The underlying bones
The underlying bones Explanation: Regions of the head take their names from the underlying bones of the skull, not from the names of anatomists, anatomical positions, or vasculature.
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) Vision c) Hearing d) Neurologic status
Vision Explanation: A hard, thick, and tender temporal artery with absent pulsations suggests temporal arteritis, which can lead to blindness. Additional information about mental status, hearing, or neurologic status would not be needed based on this finding.
While assessing an older adult client's neck, the nurse observes that the client's trachea is pulled to the left side. The nurse should a) observe whether the client has difficulty swallowing water. b) refer the client to a physician for further evaluation. c) palpate the cricoid cartilage for smoothness. d) ask the client to flex his neck to the left side.
refer the client to a physician for further evaluation. Explanation: The trachea may be pulled to the affected side in cases of large atelectasis, fibrosis or pleural adhesions. The trachea is pushed to the unaffected side in cases of a tumor, enlarged thyroid lobe, pneumothorax, or with an aortic aneurysm
An older client visits the clinic accompanied by his daughter. The daughter tells the nurse that her father has been experiencing severe headaches that usually begin in the morning and become worse when he coughs. The client tells the nurse that he feels dizzy when he has the headaches. The nurse refers the client for further evaluation because these symptoms are characteristic of a a) tumor-related headache. b) tension headache. c) migraine headache. d) cluster headache.
tumor-related headache. Explanation: Tumor-related headaches have no prodromal stage; may be aggravated by coughing, sneezing, or sudden movements of the head.
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) Esophagus b) Sternocleidomastoid muscle c) Cricoid cartilage d) Hyoid bone e) Carotid artery
• Hyoid bone • Cricoid cartilage Explanation: Thyroid assessment begins with the identification of relevant landmarks, including the thyroid cartilage, the hyoid bone, and the cricoid cartilage. The sternocleidomastoid muscle, esophagus, and carotid arteries are not landmarked.
Risk factors for cancers of the neck include which of the following? Select all that apply. a) Male gender b) Alcohol consumption c) Tobacco use d) Improper diet e) Age older than 35 years
• Male gender • Alcohol consumption • Tobacco use Explanation: Risk factors for cancers of the neck include male gender, age older than 50 years, tobacco use, and alcohol consumption. Risk factors do not include age older than 35 years or an improper diet.
The nurse is performing an assessment of the neck and identifies tracheal deviation. What is the most appropriate response of the nurse? a) Document findings b) Palpate for thyroid c) Notify the health care provider d) Ask about recent injuries
• Notify the health care provider Explanation: Tracheal deviation is an emergency and the health care provider should be notified immediately. The client should be provided nursing care and further head and neck assessment along documentation can occur once emergency has subsided.
A nurse is caring for an adult client who has just undergone surgery to remove a thyroid tumor. The nurse is assessing for symptoms of hyperthyroidism. What are some of the symptoms of hypermetabolism? Select all that apply. a) Headache b) Tachycardia c) Anxiety d) Diarrhea e) Bradycardia
• Tachycardia • Diarrhea • Anxiety Explanation: Hyperthyroidism may present as an emergency, with symptoms of hypermetabolism in all systems. The most common sign is tachycardia, but other possibilities include diarrhea, anxiety, fever, weakness, and even psychosis, coma, or death. Nurses should recognize clients at greatest risk for this emergency state. Such clients include those with thyroid tumors and those who have undergone thyroid surgery. Signs of hypermetabolism do not include bradycardia or headache.
What are the bordering landmarks of the anterior triangle of the neck? (Mark all that apply.) a) The mandible b) The midline of the neck c) The sternomastoid d) The omohyoid muscle e) The clavicle
• The sternomastoid • The mandible • The midline of the neck Explanation: The anterior triangle is bordered by the mandible above, the sternomastoid laterally, and the midline of the neck medially.