FINAL EXAM: Head and neck NCLEX

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 regularly with you menstrual cycle?" 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 in conjunction with tightening of neck muscles?"

a. "does the headache occur regularly with you menstrual cycle?"

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. acute infection b. chronic infection c. cushing's disease d. metastatic disease

a. acute infection

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. arthritis b. meningeal inflammation c. injury to the sternomastoid d. stress

a. arthritis

A nurse performs palpation of a client's lymph nodes. Which finding should be reported to the health care provider? a. fixed to underlying tissue b. mobile from side to side c. round and 8 mm in size d. soft in consistency

a. fixed to underlying tissue

A nurse needs to assess a client who is experiencing chronic headache to determine how it is affecting her activities of daily living. Which of the following interventions should the nurse implement? a. headache impact test b. a mnemonic assessment tool c. family health history questionnaire d. auscultation

a. headache impact test

A nurse is performing a head and neck assessment on a client. Which area should the nurse inspect for facial symmetry? a. nasolabial folds b. preauricular nodes c. earlobes d. temporomandibular joint

a. nasolabial folds

Which area should the nurse inspect for facial symmetry when performing a head and neck assessment? a. nasolabial folds b. earlobe placement c. temporomandibular joint d. preauricular nodes

a. nasolabial folds

A nurse needs to palpate a client's submandibular lymph nodes. Where should the nurse place her hands to do this? a. on the medial border of the mandible b. at the posterior base of the skull bone c. at the angle of the mandible on the anterior edge of the sternomastoid muscle d. a few centimeters behind the tip of the mandible

a. on the medial border of the mandible

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. bells palsy b. Migraine headache c. tension headache d. temporal arteritis

b. Migraine headache

A nurse palpates an enlarged, hard, and non-tender left-sided supraclavicular lymph node in a client. Where should the nurse focus the physical assessment to obtain more data about this finding? a. upper extremities for changes in sensation, movement, and range of motion b. abdomen and thoracic area for changes associated with malignancy c. head and neck area for signs of infection or inflammation d. spinal cord area for signs of degeneration and decreased mobility

b. abdomen and thoracic area for changes associated with malignancy

During the physical examination of a client, a nurse notes that a client's trachea has been pushed toward the right side. The nurse recognizes that the pathophysiologic cause of this finding is related to what disease process? a. tuberculosis b. atelectasis c. bronchitis d. endocarditis

b. atelectasis

The nurse is palpating a client's neck as part of a physical assessment. Which of the following blood vessels should the nurse be especially careful to avoid bilaterally compressing during the assessment? a. external jugular vein b. carotid artery c. temporal artery d. internal jugular vein

b. carotid artery

A nurse is examining a client's goiter and explaining the characteristics and functions of the thyroid gland. Which of the following should the nurse mention? select all that apply. a. produces saliva b. consists of two lateral lobes c. covered mostly by the sternomastoid muscles d. largest endocrine gland in the body e. located anterior and inferior to the ears and behind the mandible f. produces hormones that increase the metabolic rate of most body cells

b. consists of two lateral lobes c. covered mostly by the sternomastoid muscles d. largest endocrine gland in the body f. produces hormones that increase the metabolic rate of most body cells

Which instruction to the client will help facilitate examination of the temporomandibular joint by the nurse? a. perform a chewing action b. open the mouth c. sit without moving d. sit upright

b. open the mouth

Upon inspection of a client with reports of a fever, the nurse notices that the client's earlobes are asymmetrical in appearance. The nurse recognizes that the most common cause for asymmetry of the earlobes is what condition? a. thyroid enlargement b. parotid enlargement c. acute pharyngitis d. bells palsy

b. parotid enlargement

During the physical examination of a 60 year old client, the nurse finds that the pulsation of the temporal artery is weak. What is an appropriate action by the nurse for this client? a. assess the client for a decrease in level of consciousness b. recognize the weakened pulsation as an age-related change c. check the blood pressure as it can be due to hypotension d. notify the health care provider for further diagnostic tests

b. recognize the weakened pulsation as an age-related change

While examining a client, the nurse observes that he appears to be nodding his head involuntarily. Which of the following conditions should the nurse additionally assess for, based on this finding? a. unilateral vision b. neurologic disorder c. aortic insufficiency d. paget's disease

c. aortic insufficiency

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. ask the client about past history of hypothyroidism c. auscultate with the bell over the lateral lobes d. immediately notify the health care provider

c. auscultate with the bell over the lateral lobes

While performing an examination of the head and neck, a nurse notices left-sided facial drooping. The nurse recognizes this as what condition? a. preauricular adenitis b. trigeminal neuralgia c. bells palsy d. temporomandibular joint syndrome

c. bells palsy

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. hyperextend the head, keeping midline alignment b. hyperextend the head to the side being examined c. flex the head toward the side being examined d. flex the head away from the side being examined

c. flex the head toward the side being examined

A client is having trouble turning her head to the side. Which of the following muscles should the nurse most suspect as being involved? a. masseter b. temporalis c. sternocleidomastoid d. trapezius

c.sternocleidomastoid

The nurse is palpating a client's cervical vertebrae. Which vertebra can be easily palpated when the neck is flexed and should help the nurse locate the other vertebra? a. C1 b. C5 c. C3 d. C7

d. C7

A nurse is preparing to examine a client from Southeast Asia who has been experiencing chronic headache. Which of the following should the nurse do in light of this client's cultural background? a. have a nurse who is the same sex as the client perform the examination b. palpate the client's feet before palpating the head c. avoid asking the client to remove her cloths for the examination d. ask permission before palpating the head and neck

d. ask permission before palpating the head and neck

A nurse is assessing a client with hyperthyroidism for the presence of a bruit. Which assessment technique should the nurse use? a. palpation b. percussion c. inspection d. auscultation

d. auscultation

Which risk factor for traumatic brain injury should a nurse include in a discussion about prevention fro a group of adolescents? a. falls occur more frequently in the younger population b. most firearm incidents are accidental c. females have twice the risk that males do d. concussions in sports and motor vehicle accidents cause the largest number of TBIs in teens

d. concussions in sports and motor vehicle accidents cause the largest number of TBIs in teens

A client presents to the health care clinic with reports of a stiff neck for the past 3 days. What objective information can the nurse obtain during the health history using inspection? a. thyroid size b. range of motion c. neck tenderness d. head position

d. head position

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. brain tumor b. diabetes c. hyperthyrodism d. impending stroke

d. impending stroke

In reviewing a client's health history, the nurse notes that the client has had a history of TMJ pain. The nurse recognizes that which of the following bones is involved in this dysfunction? a. maxilla b. parietal bone c. frontal bone d. mandible

d. mandible

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 neck stiffness. The nurse recognizes these findings as most likely to be caused by what condition? a. parkinson's disease b. trigeminal neuralgia c. migraine headache d. meningeal inflammation

d. meningeal inflammation

A client reports severe pain in the posterior region of the neck and difficulty turning the head to the right. What additional information should the nurse collect? a. stiffness in the right shoulder b. changes in sleeping habits c. difficulty with swallowing d. previous injuries to the head and neck

d. previous injuries to the head and neck