PrepU Quiz 4
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
C7 Correct 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 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
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
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.
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
Impending stroke Correct 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.
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
Mandible Correct 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.
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
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.
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
Tender Correct 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 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
This could be a sign of dehydration
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.
migraine headache. Correct Explanation: The most common types of headaches are related to vascular (e.g., migraine), muscle contraction (tension), traction, or inflammatory causes.
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
2 Correct 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.
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
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) Acute infection b) Metastatic disease c) Cushing's disease d) Chronic infection
Acute infection Correct 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
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
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
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.
Assess the woman for hypothyroidism. Correct 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
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.
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
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
Auscultation Correct 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
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
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 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
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.
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
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 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
Consistency, delineation, mobility, tenderness Correct Explanation: Parameters of lymph node assessment include size, shape, delinitation, mobility, consistency, and tenderness.
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
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.
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
Hyoid bone, thyroid cartilage, cricoid cartilage, isthmus of the thyroid Correct 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.
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
Meningeal inflammation Correct 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 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
Meningitis Correct Explanation: Neck pain associated with fever and headache may signify serious illness such as meningitis and should be carefully evaluated.
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
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 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
Percussion Correct 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 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
Previous injuries to the head and neck Correct 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
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
Sternocleidomastoid Correct 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).
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
Submental Correct 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 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.
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.
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
There is an infection in the area that these nodes drain. Correct 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.
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.
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.
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
This could be a sign of cancer Correct 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.
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?"
• "Do you dress more warmly than other people? • "Do you use more blankets that others at home? • "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.