NURB 3060 Exam 4 - Ch 15 Head & Neck TEST REVIEW & PREPU QUESTIONS - FALL 2023

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) Acromegaly B) Brain tumor C) Paget disease D) Parkinson disease

A) Acromegaly

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

A) Hearing acuity

Which of the following findings should the nurse document after assessing the thyroid gland of an older adult without abnormalities? A) Nodularity B) Tenderness C) Enlargement D) Bruits

A) Nodularity

During a health history, a client reports complaints of headaches. Which of the following would lead the nurse to suspect that the client is experiencing cluster headaches? A) Pain radiating from eye to temporal region B) Throbbing and severe pain C) Report of ringing in the ears prior to headache D) Complaint of sensitivity to light

A) Pain radiating from eye to temporal region

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

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) Trigeminal neuralgia B) Migraine headache C) Meningitis D) Temporomandibular joint dysfunction

A) Trigeminal neuralgia

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) Abducens (VI) B) Accessory (XI) C) Hypoglossal (XII) D) Trochlear (IV)

B) Accessory (XI)

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

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) Sternocleidomastoid muscle B) Hyoid bone C) Cricoid cartilage D) Carotid artery E) Esophagus

B) Hyoid bone C) Cricoid cartilage

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.

A nurse is conducting a focused head and neck assessment of a client. When preparing to assess the client's thyroid gland, the nurse should be aware of which of the following principles? A) The thyroid gland is not normally palpable in female clients. B) Many clients have an additional (third) thyroid lobe. C) The thyroid gland is not normally palpable until clients are in their thirties or forties. D) Palpation creates a risk of rupturing the thyroid gland in some older adult clients.

B) Many clients have an additional (third) thyroid lobe.

The nurse is preparing to palpate a client's temporal artery. 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) On each side between the top of the ear and the eye C) Bilaterally, parallel to and anterior to the sternomastoid muscle D) Inferior to the lower jaw beneath the client's tongue

B) On each side between the top of the ear and the eye

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) Sternocleidomastoid muscle B) Sternal notch C) Submental space D) Supraclavicular space

B) Sternal notch

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

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

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) Obtain a full set of vital signs. B) Percuss the client's thyroid. C) Auscultate the client's thyroid. D) Perform a swallowing assessment.

C) Auscultate the client's thyroid.

A nurse is assessing the head and neck of an adult client. Which vertebra should the nurse identify as a landmark in order to locate the client's other vertebrae? A) C3 B) C5 C) C7 D) T2

C) C7

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) 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

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) Safe use of firearms B) Safe use of machinery C) Falls prevention D) Domestic violence prevention

C) Falls prevention

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) Drooping of one side C) Masklike expression D) Asymmetry of earlobes

C) Masklike expression

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

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) Alcohol abuse B) Recreational drug use C) Smokeless tobacco use D) Multiple sex partners

C) Smokeless tobacco use

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

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) Teaching about genetic screening B) A nutritional health program C) Teaching about monthly self-examination D) A smoking cessation program

D) A smoking cessation program

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) At the base of the client's skull C) On the area behind the client's ears D) Behind the tip of the client's mandible

D) Behind the tip of the client's mandible

When preparing to assess a client's thyroid gland, the nurse should ensure that which piece of equipment is readily available? A) Penlight B) Tongue depressor C) Centimeter-scale ruler D) Cup of water

D) Cup of water

A client describes her frequent headaches as being severe and lasting for days. The client's positive response to what question would most clearly suggest to the nurse that these headaches are migraines? A) Do they occur after you have been tense or anxious? B) When you consume alcohol, do you get a headache? C) Do you have any eye symptoms, such as tearing? D) Do you have any visual changes before the headache?

D) Do you have any visual changes before the headache?

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) Hyperextend the client's neck. B) Turn the client's head to the right. C) Have the client swallow water. D) Have the client hold his or her breath.

D) Have the client hold his or her breath.

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) Inspection B) Auscultation C) Palpation D) Percussion

D) Percussion

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) Hearing C) Neurologic status D) Vision

D) Vision

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 client to take a safety course b) Encourage the use of safety equipment c) Teach proper posture, bending, and lifting d) Encourage proper nutrition to promote healing

Encourage the use of safety equipment explanation: Nurses encourage use of appropriate safety equipment to reduce risk of head or neck trauma.

Headaches cause significant pain and distress to patients, but they are not associated with disease or major health problems. TRUE FALSE

FALSE

You should use the pads of your thumbs to palpate a patient's lymph nodes, palpating both sides simultaneously for comparison. FALSE TRUE

FALSE

True or False: In order to prevent head injuries, patients can install safety features in their home, such as grab bars in the bathroom and nonslip mats in the bathtub. TRUE FALSE

TRUE

During the health interview of the head and neck, a patient tells you about always feeling cold and preferring warm weather. What additional questions can you ask to learn more information about the patient's symptom? Select all that apply. a) "Do you use more blankets than others at home?" b) "Do you perspire less than others?" c) "Have you lost weight recently?" d) "Do you dress more warmly than other people?" e) "Do you perspire more than others?"

a) "Do you use more blankets than others at home?" b) "Do you perspire less than others?" e) "Do you dress more warmly than other people?"

During the health interview of the head and neck, a patient tells the nurse about always feeling cold and preferring warm weather. What additional questions can the nurse ask to learn more information about the patient's symptom? (Select all that apply.) a) "Do you use more blankets that others at home? b) "Have you lost weight recently?" c) "Do you dress more warmly than other people? d) "Do you perspire more than others?" e) "Do you perspire less than others?"

a) "Do you use more blankets that others at home? c) "Do you dress more warmly than other people? e) "Do you perspire less than others?" Explanation: Because the client complains of feeling cold and preferring warm weather, the nurse should focus additional questions to assess for hypothyroidism. These questions would include "Do you dress more warmly than other people?", "Do you use more blankets than others at home?", and "Do you perspire less than other?" The questions "Do you perspire more than others?" and "Have you lost weight recently?" would be appropriate to assess for hyperthyroidism.

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) 2 b) 4 c) 1 d) 3

a) 2 Explanation: The thyroid gland consists of two lateral lobes connected by an isthmus. Approximately one-third of the population has a third lobe that extends upward from the isthmus or from one of the two lobes.

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) Metastatic disease c) Cushing's disease d) Chronic infection

a) Acute infection Explanation: The lymph nodes are enlarged and tender in acute infections. Normally, lymph nodes are not sore or tender and are usually not palpable. Chronic infection causes the nodes to become confluent. In metastatic disease, the nodes enlarge and become fixed in place and are nontender. The lymph node findings may vary in Cushing's disease

Which assessment technique should a nurse use to assess for the presence of a bruit in a client with hyperthyroidism? a) Auscultation b) Inspection c) Percussion d) Palpation

a) 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

The nurse practitioner auscultates both lobes of a client's enlarged thyroid gland. Identification of what sound would tend to confirm a diagnosis of a toxic goiter? a) Bruit b) Gurgle c) Murmur d) Rush

a) Bruit explanation: If the thyroid is enlarged, either unilaterally or bilaterally, the nurse uses the bell of the stethoscope to auscultate over each lobe for a bruit. Bruits are most often found with a toxic goiter, hyperthyroidism, or thyrotoxicosis.

When auscultating a patient's carotid arteries, you are primarily listening for which abnormal finding? a) Bruits b) A thready pulse c) A bounding pulse d) Irregular heart rate

a) Bruits

When preparing to assess a client's thyroid gland, the nurse should ensure that which piece of equipment is readily available? a) Cup of water b) Tongue depressor c) Centimeter-scale ruler d) Penlight

a) Cup of water Explanation: When examining the thyroid gland, the client is asked to swallow so that each side of the gland can be felt. A cup of water would aid in swallowing. A penlight, tongue depressor, or ruler is not needed.

Which assessment findings of the head should you associate with a cerebrovascular accident (CVA)? (Select all that apply.) a) Facial weakness b) Erythema c) A "mask-like" face d) Drooping e) Unilateral paralysis

a) Facial weakness d) Drooping e) Unilateral paralysis

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) Mandible b) Parietal bone c) Maxilla d) Frontal bone

a) Mandible Explanation: The mandible (jaw bone) provides the structural support for the floor of the mouth and, with the temporal bone, forms the temporomandibular joint (TMJ). The other bones listed are part of the skull but are not associated with the TMJ.

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) Meningeal inflammation b) Parkinson's disease c) Trigeminal neuralgia d) Migraine headache

a) 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 palpate a client's submental lymph nodes. At what anatomic location should the nurse position his or her hands? a) Midline, under the chin b) At the base of the client's skull c) At the angle of the client's mandible d) On the area behind the client's ears

a) Midline, under the chin

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) Percussion b) Auscultation c) Inspection d) Palpation

a) 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.

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) Sternocleidomastoid b) Trapezius c) Temporalis d) Masseter

a) Sternocleidomastoid Explanation: The sternomastoid muscle rotates and flexes the head, whereas the trapezius muscle extends the head and moves the shoulders. The masseter and temporalis muscles are involved in raising and lowering the mandible during mastication (chewing).

Which of the following would the nurse document as an abnormal finding with lymph node assessment? a) Tender b) Diameter: 0.75 cm c) Mobile d) Discrete

a) 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.

When examining the head, the nurse remembers that the anatomic regions of the cranium take their names from which of the following sources? a) The underlying bones b) Noted anatomists c) The underlying vascular network d) Their anatomical positions

a) 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.

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) migraine headache. b) cluster headache. c) tension headache. d) tumor-related headache.

a) migraine headache. Explanation: The most common types of headaches are related to vascular (e.g., migraine), muscle contraction (tension), traction, or inflammatory causes.

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

b) Acromegaly

A client suffering from a headache complains of throbbing, severe, unilateral pain that feels worse when exposed to bright lights. The client also complains of nausea and vomiting. What is the nurse's best action? a) Administer narcotic pain medication b) Administer migraine medication c) Prepare the client for a spinal tap d) Administer medication for common cold

b) Administer migraine medication Explanation: A throbbing, severe, unilateral headache that lasts 6-24 hours and is associated with photophobia, nausea, and vomiting suggests migraine

A 66-year-old woman has come to the clinic with complaints of increasing fatigue over the last several months. She claims to frequently feel lethargic and listless and states that, "I can never seem to get warm, no matter what the thermostat is set at." How should the nurse proceed with assessment? a) Order tests to rule out an overactive thyroid gland. b) Assess the woman for hypothyroidism. c) Palpate the woman's parotid gland for enlargement. d) Assess for other signs and symptoms of Cushing's syndrome.

b) Assess the woman for hypothyroidism. Explanation: Fatigue, weakness, and cold sensitivity are symptoms of hypothyroidism. These symptoms are not associated with Cushing's syndrome, hyperthyroidism, or any of the disorders that result in parotid gland enlargement

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) Bell's palsy c) Preauricular adenitis d) Temporomandibular joint syndrome

b) 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

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) Asking the client to swallow water d) Performing the examination while the client is seated

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.

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) Hyoid bone, tracheal rings, cricoid cartilage, lobes of the thyroid gland d) Cricoid cartilage, hyoid bone, tracheal rings, thyroid isthmus

b) 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.

You should begin the assessment of a patient's head with which action? a) Palpating the patient's scalp b) Inspecting the patient's head for size and shape c) Inspecting the patient's face d) Palpating the patient's lymph nodes

b) Inspecting the patient's head for size and shape

Assessment of the head involves __________ and ____________. a) Headaches, head injury b) Inspection, palpation c) Percussion, auscultation

b) Inspection, palpation

When assessing the neck of a healthy adult, you expect the lymph nodes to be: a) Large, firm, and fixed b) Not palpable c) Hard, discrete, and nonmobile d) Soft and tender

b) Not palpable

A client reports sudden head and neck pain with stiffness, a new sensitivity to light, and has developed a fever. What is a priority action of the nurse? a) Document the findings. b) Notify the health care provider. c) Administer acetaminophen for the pain. d) Continue to monitor the client.

b) Notify the health care provider. explanation: Sudden head and neck pain seen with elevated temperature and neck stiffness may be a sign of meningeal inflammation. These findings need to be reported to the health care provider immediately in order for steps to be taken that will determine the cause of the meningeal inflammation, for example, bacterial or viral meningitis.

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

b) 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 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) Previous injuries to the head and neck c) Changes in sleeping habits d) Difficulty with swallowing

b) Previous injuries to the head and neck Explanation: Previous head or neck injuries may cause limitations in movement and chronic pain. Change in sleeping habits is too vague to be correct. The other two options may produce pain but not necessarily limit functioning

During the physical examination of the head and neck, you should ensure that a lymph node can move in which directions? Select all that apply. a) To the right b) Side to side c) Up and down d) The lymph node should not move e) To the left

b) Side to side c) Up and down

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 soft and moves freely. b) The node is fixed and rubbery. c) The node matches the node on the opposite side of the body. d) The node is less than 1 cm in size and feels boggy.

b) 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.

The nurse is preparing to perform a head and neck assessment of an adult client who has immigrated to the United States from Cambodia. The nurse should first: a) explain to the client why the assessment is necessary. b) ask the client if touching the head is permissible. c) determine whether the client desires a family member present. d) examine the lymph nodes of the neck before examining the head.

b) ask the client if touching the head is permissible. 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.

A client is brought to the emergency department via ambulance after experiencing difficulty speaking and weakness in the left arm and leg. The nurse understands that the client is most likely experiencing which of the following disorders? a) temporal arteritis b) cerebrovascular accident c) trigeminal neuralgia d) Bell palsy

b) cerebrovascular accident

Where is the temporal artery palpated? a) Between the mandibular joint and the base of the ear b) Just left of midline at the base of the neck c) Above the cheek bone near the scalp line d) Just left or right of the spine at the base of the skull

c) 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

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) Cushing's disease b) Metastatic disease c) Acute infection d) Chronic infection

c) Acute infection Explanation: The lymph nodes are enlarged and tender in acute infections. Normally, lymph nodes are not sore or tender and are usually not palpable.

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 vertebrae? a) C5 b) C1 c) C7 d) C3

c) C7 The cervical vertebrae (C1 through C7) are located in the posterior neck and support the cranium. The vertebra prominens is C7, which can easily be palpated when the neck is flexed. Using C7 as a landmark will help you to locate other vertebrae.

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) Temporal artery b) Internal jugular vein c) Carotid artery d) External jugular vein

c) Carotid artery Explanation: It is important to avoid bilaterally compressing the carotid arteries when assessing the neck, as bilateral compression can reduce the blood supply to the brain. Compression of the internal or external jugular veins would not be as significant as compressing the carotid arteries as doing so would not reduce blood supply to the brain. The temporal artery, a major artery, is located between the eye and the top of the ear, and would not be affected by palpation of the neck.

When palpating the lymph nodes of the neck, the nurse assesses for which of the following characteristics? a) Configuration, discreteness, temperature, colour b) Delineation, integrity, shape, colour c) Consistency, delineation, mobility, tenderness d) Congruency, induration, size, turgor

c) Consistency, delineation, mobility, tenderness Explanation: Parameters of lymph node assessment include size, shape, delinitation, mobility, consistency, and tenderness.

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) Position the patient supine and reattempt palpation c) Document this as an expected assessment finding d) Perform a focused endocrine assessment

c) 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) Teach proper posture, bending, and lifting b) Encourage the client to take a safety course c) Encourage the use of safety equipment d) Encourage proper nutrition to promote healing

c) Encourage the use of safety equipment Explanation: Nurses encourage use of appropriate safety equipment to reduce risk of head or neck trauma. There is no identified need to encourage proper nutrition to promote healing in this client. There is no identified need to teach proper posture, bending, and lifting with this client. Encouraging the client to take a safety course is not the primary focus of discharge teaching.

What is the most common type of hyperthyroidism? a) Moon face b) Cushing's syndrome c) Graves' disease d) Thyroid cancer

c) Graves' disease explanation: Graves' disease, the most common type of hyperthyroidism, is autoimmune and may also be genetic.

The four common complications found with assessment of the head are ______________, ______________, ______________, and _____________. a) Myxedema, Cushing's syndrome, scleroderma, Bell's palsy b) Acromegaly, brain tumor, Paget disease, Parkinson disease c) Headache, head injury, head and neck surgery, traumatic brain injury

c) Headache, head injury, head and neck surgery, traumatic brain injury

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) Impending stroke d) Diabetes

c) 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 assesses a client's submental lymph nodes. In which area of the client's head should the nurse palpate these lymph nodes? a) In front of the ear b) Superficial to the sternomastoid 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

A nurse is caring for a patient admitted with neck pain. The patient is febrile. What is the most likely medical diagnosis for this patient? a) Migraine b) Measles c) Meningitis d) Cervical fracture

c) Meningitis Explanation: Neck pain associated with fever and headache may signify serious illness such as meningitis and should be carefully evaluated.

Which area should the nurse inspect for facial symmetry when performing a head and neck assessment? a) Preauricular nodes b) Temporomandibular joint c) Nasolabial folds d) Earlobe placement

c) 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 cannot be inspected as they are very small. Earlobe placement is not an appropriate method to determine facial symmetry.

A patient has an open draining wound located on the underside of the chin. Which lymph nodes should the nurse assess in this patient? a) Tonsillar b) Superficial cervical c) Submental d) Preauricular

c) Submental Explanation: The submental lymph nodes are located near the region of the chin and should be assessed in the patient. Superficial cervical lymph nodes are located on the side of the neck and would not necessarily need to be assessed with the chin wound. The preauricular lymph nodes are located in front of the ear and would not necessarily need to be assessed with the chin wound. The tonsillar lymph nodes are located near the mandible and would not necessarily need to be assessed with the chin wound.

The nurse is assessing a client complaining of swelling in the neck. While palpating the neck, the nurse finds a 2-cm lump that is fixed and hard. Why does this finding require emergency investigation? a) This could be a sign of pneumothorax b) This could be a sign of an embolus c) This could be a sign of cancer d) This could be a sign of a parotid stone

c) This could be a sign of cancer Explanation: Lymphatics larger than 1 cm, fixed, irregular, or hard or rubbery require emergency investigation. Such signs raise the possibility of cancer. The signs and symptoms cited in the scenario do not indicate pneumothorax, embolus, or parotid stone.

The nurse is conducting discharge teaching to the caregiver of an older adult who was hospitalized following a fall at home. Which statement by the caregiver indicates a need for additional teaching by the nurse? a) "Certain medications can cause muscle weakness." b) "Standing up slowly is important because dizziness can cause falls." c) "Changes in vision such as decreased accommodation happen with aging." d) "Loss of sensation in the toes is an age-related change."

d) "Loss of sensation in the toes is an age-related change." Explanation: Numbness, tingling, or loss of sensation in the toes are not normal age-related findings and should be assessed immediately.

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) Muscle tension b) Cranial damage c) Bacterial thyroiditis d) Arthritic changes of the cervical spine

d) Arthritic changes of the cervical spine Correct Explanation: Arthritic changes in cervical spine may 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

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) Tuberculosis d) Atelectasis

d) Atelectasis

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) Obtain a full set of vital signs. b) Perform a swallowing assessment. c) Percuss the client's thyroid. d) Auscultate the client's thyroid.

d) 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 is assessing the head and neck of an adult client. Which vertebra should the nurse identify as a landmark in order to locate the client's other vertebrae? a) C3 b) T2 c) C5 d) C7

d) C7 Explanation: The vertebra prominens is C7, which can easily be palpated when the neck is flexed. Using C7 as a landmark helps the nurse to locate other vertebrae.

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

d) Compressing the arteries bilaterally

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) Hyperthyroidism c) Diabetes d) Impending stroke

d) 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.

Which of the following answers lists the inspection steps for assessing the head in the correct order? a) Inspect the 1) skin, 2) hair, 3) scalp, 4) whole head, and 5) face b) Inspect the 1) whole head, 2) hair, 3) scalp, 4) face, and 5) skin c) Inspect the 1) hair, 2) whole head, 3) scalp, 4) skin, and 5) face d) Inspect the 1) hair, 2) scalp, 3) whole head, 4) face, and 5) skin

d) Inspect the 1) hair, 2) scalp, 3) whole head, 4) face, and 5) skin

A 38-year-old accountant comes to the clinic for evaluation of a headache. The throbbing sensation is located in the right temporal region, and is an 8 on a pain scale of 1 to 10. It started a few hours ago, and she has noted nausea with sensitivity to light; she has had headaches like this in the past, usually less than one per week, but not as severe. She does not know of any inciting factors. There has been no change in the frequency of her headaches. She usually takes an over-the-counter analgesic, which results in resolution of the headache. Based on this description, what is the most likely diagnosis of the type of headache? a) Cluster b) Tension c) Analgesic rebound d) Migraine

d) Migraine explanation: This is a description of a common migraine (no aura). Distinctive features of a migraine include phono- and photophobia, nausea, resolution with sleep, and unilateral distribution. Only some of these features may be present.

A 73-year-old woman comes to the office for evaluation of new onset of tremors. She is not taking any medications, herbs, or supplements. She has no chronic medical conditions. She does not smoke or drink alcohol. She walks into the examination room with slow, shuffling steps. She has decreased facial mobility with a blunt expression without any changes in hair distribution on her face. Based on this description, what is the most likely reason for the client's symptoms? a) Nephrotic syndrome b) Cushing's syndrome c) Myxedema d) Parkinson's disease

d) Parkinson's disease Explanation: This is a typical description for a client with Parkinson's disease. Facial mobility is decreased, which results in a blunt expression or a "masked" appearance. The client also has decreased blinking and a characteristic stare with an upward gaze. Combined with the findings of slow movements and a shuffling gait, the diagnosis of Parkinson's is highly likely.

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) Headache b) Range of motion of the arms and shoulders c) Shortness of breath d) Range of motion of the neck

d) Range of motion of the neck Explanation: Musculoskeletal injury or disease can be confirmed with an X-ray, CT, or MRI. If test results are negative, the nurse should assess for complete range of motion of the neck, looking for any muscle tension, loss of mobility, or pain

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) There is an inflammatory response in the musculature of the boy's neck. b) The boy requires assessment of his thyroid gland. 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.

A woman brings her 1-month-old infant to the ED. She says the baby is not eating or drinking well. The nurse finds the fontanels are depressed slightly. Why does this require further assessment? a) This is a sign of a possible neurological disorder b) This could be a sign of increased intracranial pressure c) This could be a sign of physical abuse d) This could be a sign of dehydration

d) This could be a sign of dehydration

A client reports using pain medication and sitting in a dark room on the onset of a migraine headache. In which part of the subjective section of the physical examination should the nurse document this information? a) location b) treatment c) onset d) relieving factors

d) relieving factors explanation: Relieving factors includes anything the client subjectively reports they have tried to make the migraine go away.