Health Assessment Chapter 12: Head and Neck, with basic Vision and Hearing Basics

Where is the temporal artery palpated? A) Above the cheek bone near the scalp line B) Just left of midline at the base of the neck C) Between the mandibular joint and the base of the ear D) Just left or right of the spine at the base of the skull

A) Above the cheek bone near the scalp line Explanation: The nurse palpates the temporal artery in the space above the cheek bone near the scalp line. The temporal artery is not found at midline at the base of the neck, between the mandibular joint and the base of the ear, or just left or right of the spine at the base of the skull.

Which of the following would the nurse suspect if assessment reveals a skull and facial bones that are larger and thicker than normal? A) Acromegaly B) Brain tumor C) Paget disease D) Parkinson disease

A) Acromegaly

A nurse is working with a client who has a history of headaches. When preparing to assess the client's temporomandibular joint (TMJ), the nurse should provide what instruction? A) "I'm going to press on several different places below and in front of your ear." B) "I'm going to put my fingers in front of your ears and ask you to open your mouth wide." C) "Turn so I can see the side of your face and then open your mouth wide like you're yawning." D) "When I place my hands on your cheeks, clench your teeth and then relax them."

B) "I'm going to put my fingers in front of your ears and ask you to open your mouth wide." Explanation: To assess the TMJ, place your index finger over the front of each ear as you ask the client to open her mouth. None of the other listed instructions facilitates this assessment.

A nurse is caring for a client admitted with neck pain. The client is febrile. What is the most likely medical diagnosis for this client? A) Migraine B) Meningitis C) Cervical fracture D) Measles

B) Meningitis

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) Audible referred breath sounds at the site of the thyroid B) An audible S3 sound at the site of the thyroid C) A sound of turbulent blood flow in the thyroid D) Irregular S1 and S2 rhythms in the thyroid

C) A sound of turbulent blood flow in the thyroid

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 for this finding is related to what disease process? A) Endocarditis B) Bronchitis C) Atelectasis D) Tuberculosis

C) Atelectasis

Assessment of an adult female client's face reveals a moon shape, increased hair distribution, and a reddened tone to the client's cheeks. What collaborative problem is most clearly suggested to the nurse by these assessment data? A) RC: Thyroid crisis B) RC: Cerebrovascular accident C) RC: Cushing's syndrome D) RC: Acromegaly

C) RC: Cushing's syndrome

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) Bell's palsy B) Tension headache C) Temporal arteritis D) Migraine headache

D) Migraine headache

The nurse is assessing the face of a client with a diagnosis of Parkinson's disease. What would the nurse most likely assess? A) Sunken face B) Drooping of one side C) Mask-like expression D) Asymmetry of earlobes

C) Mask-like expression

A young adult client has just had X-rays and computed tomography scanning of the head and neck following a mountain bicycling accident. All results are negative. What should the nurse assess for next? A) Range of motion of the neck B) Headache C) Shortness of breath D) Range of motion of the arms and shoulders

A) Range of motion of the neck

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? Select all that apply. A) Alcohol abuse B) Recreational drug use C) Smokeless tobacco use D) Multiple sex partners

A) Alcohol abuse B) Recreational drug use C) Smokeless tobacco use D) Multiple sex partners Explanation: Tobacco and alcohol use increases the risk of head and neck cancer. A more recently identified cause of head and neck cancer is exposure to human papillomavirus (HPV). People with multiple sexual partners and those who engage in oral sex are at increased risk of developing oral HPV-related cancer. For these reasons the nurse would need to perform a thorough head and neck examination.

A nurse is examining a client's neck and is preparing to palpate the thyroid gland. The nurse would most likely expect to palpate how many lobes? A) 1 B) 2 C) 3 D) 4

B) 2

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) parotid gland enlargement. B) acromegaly. C) Paget disease. D) Cushing syndrome.

B) acromegaly. Explanation: The skull and facial bones are larger and thicker in acromegaly.

A client complains of a headache over both temporal areas. What type of headache should the nurse suspect the client is experiencing? A) cluster B) tension C) migraine D) hypertensive

B) tension Explanation: Tension headaches often arise in the temporal areas. Cluster headaches typically occur behind the eyes. A throbbing, severe, unilateral headache that lasts 6-24 hours and is associated with photophobia, nausea, and vomiting suggests a migraine headache. Hypertensive is not a type of headache although individuals with hypertension may experience a headache upon arising in the morning.

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

C) 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.

A nursing instructor is teaching a group of students how to examine the thyroid gland. The instructor would determine that a student needs additional instruction when the student demonstrates which technique? A) Inspection B) Auscultation C) Palpation D) Percussion

D) 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 is not necessary.

A client seeks medical attention for sharp, shooting facial pain that lasts for several minutes at a time. For which health problem should the nurse assess this client? A) Cluster headache B) Tension headache C) Migraine headache D) Trigeminal neuralgia

D) Trigeminal neuralgia Explanation: Trigeminal neuralgia is manifested by sharp, shooting, piercing facial pain that lasts from seconds to minutes. The pain occurs over the divisions of the fifth trigeminal cranial nerve. A headache associated with a fever or high blood pressure is a cluster headache. Tension headaches are caused by tightening of facial and neck muscles. Migraine headaches are provoked by hormone fluctuations.

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) Temporomandibular joint C) Preauricular nodes E) Earlobes

A) 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.

On palpation, the nurse notes that a client's thyroid gland is diffusely enlarged. Which of the following health problems is associated with this finding? A) A tumor B) Hypothyroidism C) Graves' disease D) Nephrotic syndrome

C) Graves' disease Explanation: Graves' disease is associated with a diffusely enlarged thyroid. This finding is not normally consistent with neoplasm, hypothyroidism, or nephritic syndrome.

During your physical examination of the client you note an enlarged tender tonsillar lymph node. What would you do? A) Assess for meningitis B) Look for involvement of other regions of the body C) Look for a source such as infection in the area that it drains D) Assess for dietary changes

C) 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.

A 82 year old female presents with neck pain, decreased strength and sensation of the upper extremities. The nurse identifies that this could be related to what? A) Arthritic changes of the cervical spine B) Bacterial thyroiditis C) Cranial damage D) Muscle tension

A) Arthritic changes of the cervical spine Explanation: Arthritic changes in cervical spine may present in the older adults as neck pain, decreased strength and sensation of the upper extremities. Bacterial thyroiditis has neck swelling and cranial damage may manifest as headaches or tension of the muscles

A 57-year-old client reports, "I am having the worst headache I have ever experienced." Which action should the nurse perform next? A) Assess the client's blood pressure. B) Provide medication for pain relief. C) Inquire about family history of headaches. D) Review the client's medical record.

A) Assess the client's blood pressure. Explanation: Onset of headache after the age of 50 paired with the statement the client has made here is considered a "red flag." The nurse should suspect this is a secondary headache or arising from another condition. Markedly elevated blood pressure could be indicative of imminent danger to the client's life. Assessment of the blood pressure should be the nurse's first action.

Which vessel is the nurse assessing if the major artery of the neck is being examined? A) Carotid B) Jugular C) Temporal D) Radial

A) 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.

A nurse has performed a head and neck assessment of an adult client and noted that the thyroid gland is not palpable. What is the nurse's most appropriate action? A) Document this as an expected assessment finding B) Refer the client to the primary care provider promptly C) Perform a focused endocrine assessment D) Position the client supine and reattempt palpation

A) Document this as an expected assessment finding Explanation: It is not unusual for the thyroid lobes to be non-palpable using the posterior approach.

The nurse is discharging an adult client who received 18 staples for a head laceration received while mountain biking. What can the nurse focus on while doing discharge teaching? A) Encourage the use of safety equipment B) Encourage proper nutrition to promote healing C) Encourage the client to take a safety course D) Teach proper posture, bending, and lifting

A) Encourage the use of safety equipment

When talking to a client before starting the physical exam, the nurse notes that the client consistently tilts her head to one side. What would the nurse examine first? A) Hearing acuity B) Thyroid gland C) Mental status D) Lymph nodes

A) Hearing acuity

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.

A) Notify the healthcare provider immediately. Explanation: 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. A biopsy may be necessary for diagnosis; however the healthcare provider immediately. The temporal artery pulse can be palpated; but the carotid artery pulses should never be palpated simultaneously so that the client does not pass out from lack of blood flow to the brain.

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 assessment of lymphatic system function D) Referral for further assessment of swallowing ability

A) Referral for further assessment of thyroid function

The nurse is caring for a client 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 is less than 1 cm in size and feels boggy. C) The node is soft and moves freely. D) The node matches the node on the opposite side of the body.

A) 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.

An adult client visits the clinic and tells the nurse that she has had headaches recently that are intense and stabbing and often occur in the late evening. The nurse should suspect the presence of A) cluster headaches. B) migraine headaches. C) tension headaches. D) tumor-related headaches.

A) cluster headaches. Explanation: Other vascular headaches may be caused by fever or high blood pressure ("cluster headaches").

The nurse conducts the physical examination of a client with a diagnosis of chronic obstructive pulmonary disease. The nurse observes the point of maximal impulse (PMI) is located in the epigastric region. What condition explains this finding? A) right ventricular hypertrophy B) aortic stenosis C) aortic insufficiency D) orthopnea

A) right ventricular hypertrophy Explanation: Hypertrophy can cause an anatomical shift of the right ventricle, leading the PMI to be palpable in the epigastric region. Aortic stenosis denotes a narrowed valvular orifice, which obstructs blood flow. Aortic insufficiency is caused by a valve that fails to fully close, allowing blood to leak backward, creating a regurgitant murmur. Orthopnea describes shortness of breath that occurs when the client is lying down. This would not be the reason the PMI would shift to be heard in the epigastric region.

When palpating the neck, performing which of the following techniques will help differentiate lymph nodes from a band of muscles? A) Applying pressure and assessing for induration B) Attempting to roll the structure up and down and side to side C) Palpating for lateral movement when the client swallows a sip of water D) Observing for hypertrophy when the client turns the head against resistance

B) 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 is preparing to assess an adult client's carotid pulses. Which of the following actions would be contraindicated? A) Asking the client to flex his or her neck B) Compressing the arteries bilaterally C) Performing the examination while the client is seated D) Asking the client to swallow water

B) Compressing the arteries bilaterally Explanation: The nurse needs to avoid bilateral compression of the carotid blood vessels to prevent reducing the blood supply to the brain. The nurse does not need to avoid having the client flex the neck, ask the client to swallow water, or perform the exam while the client is seated.

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) Firearm violence B) Female gender C) Contact sports D) Transportation accidents

B) Female gender Explanation: Risk factors for traumatic brain injury include transportation accidents, violence (often firearms related), falls, male gender, failure to use protective equipment, and participation in contact sports.

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) Migraine headache B) Meningeal inflammation C) Trigeminal neuralgia D) Parkinson's disease

B) Meningeal inflammation

The nurse can best palpate the superficial cervical nodes, the deep cervical chain, and the supraclavicular nodes by first locating which muscle? A) Infraspinous B) Sternomastoid C) Trapezius D) Platysma

B) Sternomastoid Explanation: The superficial cervical nodes are in the area superficial to the sternomastoid muscle, whereas the deep cervical chain is deeply within and around it. The supraclavicular nodes lie deeply between the clavicles and sternomastoid muscle.

The nurse is preparing to assess a client's thyroid gland using the posterior approach. What direction should the nurse provide regarding the client's head? A) tilt the head back B) flex the neck forward C) turn the head towards the left shoulder D) turn the head towards the right shoulder

B) flex the neck forward Explanation: When assessing the thyroid gland from the posterior approach the client should flex the neck forward to relax the neck muscles. Tilting the head back would be used if assessing the thyroid gland using the anterior approach. Turning the head to the right or left shoulder would be done later in order to further assess the individual thyroid gland lobes.

The nurse is preparing to assess the neck of an adult client. To inspect movement of the client's thyroid gland, the nurse should ask the client to A) inhale deeply. B) swallow a small sip of water. C) cough deeply. D) flex the neck to each side.

B) swallow a small sip of water. Explanation: Ask the client to swallow a small sip of water. Observe the movement of the thyroid cartilage, thyroid gland.

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) Migraine headache B)Meningeal inflammation C) Trigeminal neuralgia D) Parkinson's disease

B)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, 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.

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

C) Ask permission before palpating the head and neck Explanation: Take care to consider cultural norms for touch when assessing the head. Some cultures (e.g., Southeast Asian) prohibit touching the head or touching the feet before touching the head. There is no need to avoid asking the client to remove clothes for the examination; removing clothing is not a particular concern related to this client's culture nor is it necessary for examination of the head and neck. Clients of certain conservative religious backgrounds may object to being assessed by a nurse of the opposite sex, but there is not enough information in this scenario to warrant such a concern.

Which assessment technique should a nurse use to assess for the presence of a bruit in a client with hyperthyroidism? A) Inspection B) Palpation C) Auscultation D) Percussion

C) Auscultation Explanation: A bruit is a soft, blowing, swishing sound auscultated over the thyroid lobes with the bell of the stethoscope that is often heard in hyperthyroidism because of an increase in blood flow through the thyroid arteries. A bruit can be elicited through auscultation in a client with hyperthyroidism. A bruit cannot be elicited through inspection, palpation, and percussion. Inspection can only reveal swelling of the neck and palpation can indicate only the enlarged mass.

A nurse has completed the assessment of an older adult client's head and neck and is now analyzing the assessment findings. Which finding should the nurse attribute to age-related physiological changes? A) Increased size of a single thyroid nodule B) A nonpalpable carotid pulse C) Decreased strength of temporal artery pulsations D) Tenderness of lymph nodes on palpation

C) 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.

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) Diabetes B) Brain tumor C) Impending stroke D) Hyperthyroidism

C) Impending stroke

The nurse assesses a client's submental lymph nodes. In which area of the client's head should the nurse palpate these lymph nodes? A) Superficial to the sternomastoid B) In front of the ear C) In the midline, a few centimeters behind the tip of the mandible D) At the angle of the mandible

C) In the midline, a few centimeters behind the tip of the mandible Explanation: The submental lymph nodes are located near the midline, a few centimeters behind the tip of the mandible. Superficial cervical lymph nodes are located superficial to the sternomastoid. The preauricular lymph nodes are located in front of the ear. The tonsillar lymph nodes are located near the mandible.

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) The client may not be able to flex and extend his neck for the examination. C) Radiation therapy has been linked to the development of thyroid cancer. D) The client may experience dizziness and light-headedness more easily.

C) 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.

While performing an examination of the head and neck, a nurse notices left-sided facial drooping. The nurse recognizes this as what condition? A) Trigeminal neuralgia B) Preauricular adenitis C) Temporomandibular joint syndrome D) Bell's palsy

D) Bell's palsy Explanation: One-sided facial drooping is present in Bell's palsy due to inflammation of the facial nerve. Trigeminal neuralgia causes shooting, piercing facial pains that occur over the divisions of the fifth cranial nerve. Preauricular adenitis is characterized by tenderness and swelling of the lymph nodes in front of the ears. Temporomandibular joint syndrome causes pain or crepitation with jaw movement.

The nurse in an emergency department is caring for a minimally responsive 27-year-old victim of a motorcycle accident. The client was not wearing a helmet. When assessing the client's head and neck, the nurse should prioritize the assessment for which of the following? A) Strain B) Cyanosis C) Pallor D) Bleeding

D) 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 client presents at the clinic for a routine check-up. The nurse notes that she is dressed in warm clothing even though the temperature outside is 73°F (22.8°C). The nurse also notes that the client has gained 10 pounds (4.5 kg) since her last visit 9 months ago. What might the nurse suspect? A)Effects of age-related changes B) Brain tumor C) Hyperthyroidism D) Hypothyroidism

D) Hypothyroidism Explanation: Intolerance to cold, preference for warm clothing and many blankets, and decreased sweating suggest hypothyroidism; the opposite symptoms, palpitations, and involuntary weight loss suggest hyperthyroidism.

Palpation of a 15-year-old boy's submandibular lymph nodes reveals them to be enlarged and tender. What is the nurse's most reasonable interpretation of this assessment finding? A) The boy requires assessment of his thyroid gland. B)There is an inflammatory response in the musculature of the boy's neck. C) The tissue underlying the nodes is infected. D) There is an infection in the area that these nodes drain.

D) There is an infection in the area that these nodes drain. Explanation: Whenever a lymph node is enlarged or tender, the nurse should assess for infection in the area that the particular nodes drain. Thyroid or muscular involvement is less likely, and infection does not likely underlie the nodes directly.