Chapter 9: Assessing the Head, Face, Mouth, and Neck

The major artery of the head that branches from within the external carotid artery and has a palpable pulse superior to the zygomatic arch is called the ____________________ artery.

temporal The temporal artery is palpable in front of each ear.

The nose is located centrally on the face and is composed of bone and cartilage. What structures are considered part of the anatomy of the nose? Select all that apply. 1. Septum 2. Turbinates 3. Nares 4. Adenoids 5. Tonsils 6. Epiglottis 7. Hyoid bone

1, 2, 3

You are using the anterior approach to palpate the thyroid gland. The purpose of palpating this gland is to assess which of the following? Select all that apply. 1. Smoothness 2. Swelling 3. Nodules 4. Tenderness 5. Size

1, 2, 3, 4, 5 All are correct

You are assessing a patient who has swelling of the face. Which of the following are normal findings when palpating the face? Select all that apply. 1. No tenderness 2. Temporal artery nontender 3. Temporomandibular joint (TMJ) has limited range of motion (ROM) 4. TMJ has no clicking sounds 5. Mouth opens on the average of 1 to 2 cm 6. Mouth moves laterally 3 to 6 cm

1, 2, 4 No tenderness is a normal finding. Temporal artery nontender is a normal finding. TMJ has no clicking sounds is a normal finding.

The patient is experiencing xerostomia (dry mouth). Identify the factors that may cause xerostomia. Select all that apply. 1. Medications 2. Pain 3. Systemic disease 4. Radiation therapy 5. Anxiety 6. Smoking 7. Gastroesophageal reflux 8. Dehydration

1, 3, 4, 5, 8

You are inspecting the neck of an older adult. What is the purpose of this assessment technique? Select all that apply. 1. To assess symmetry 2. To assess for tenderness 3. To assess for lumps 4. To assess range of motion 5. To assess for swelling

1, 4, 5 You palpate for tenderness, not inspect for tenderness. You palpate for lumps, not inspect for lumps.

You are assessing a patient and note that he has an enlarged head and face, hands, and feet. This syndrome is called: 1. Acromegaly. 2. Macrocephaly. 3. Microcephaly. 4. Parkinson's syndrome.

1. Acromegaly. Acromegaly is characterized by enlargement of the bones of the hands, feet, and face.

The nurse assesses the patient's face. What documentation indicates normal findings of this assessment? Select all that apply. 1. Face square 2. Asymmetry of the face structures 3. Nasolabial folds and palpebral fissures equal 4. Flat affect 5. No involuntary muscle movement 6. Skin smooth and clear 7. No edema 8. Masklike facial appearance

1. Face square 3. Nasolabial folds and palpebral fissures equal 5. No involuntary muscle movement 6. Skin smooth and clear 7. No edema

The nurse has inspected and palpated the nose during the patient's assessment. What documentation indicates normal findings? 1. Nose symmetrical without tenderness 2. Skin color red with nasal congestion 3. Nose tender and bruised 4. Nose symmetrical with deviated septum

1. Nose symmetrical without tenderness Nose symmetrical and nontender is a normal finding.

When inspecting and palpating the nose, the nurse assesses for which of the following? 1. Symmetry, septum alignment, color, swelling, and tenderness 2. Symmetry, color, moisture, lesions, and pain 3. Symmetry, movable, pain, lesions, and septum alignment 4. Symmetry, pain, bleeding, moisture, lesions, and tenderness

1. Symmetry, septum alignment, color, swelling, and tenderness

What is the purpose of assessing the patency of the nose? 1. To assess for nasal passageway occlusion 2. To assess for tenderness, inflammation, or deviation 3. To assess appearance and symmetry 4. To assess for normal size and shape

1. To assess for nasal passageway occlusion The purpose of assessing the patency of the nose is to assess for nasal passage occlusion.

The patient is complaining of a sinus headache and nasal congestion. What technique is used to assess the sinuses? Select all that apply. 1. Inspection 2. Palpation 3. Percussion 4. Auscultation

2, 3 Inspection does not assess the maxillary and frontal sinuses & You cannot auscultate for sinus tenderness.

You are inspecting and assessing a patient's teeth. What will you be assessing? Select all that apply. 1. Buccal mucosa 2. Color of teeth 3. Tooth decay 4. Malocclusion 5. Tongue

2, 3, 4 The buccal mucosa and the tongue are not part of inspecting the teeth

The patient reports a chronic sore throat, chronic hoarseness, and dysphagia. What diagnostic tests would you expect the health-care provider to order for further evaluation? Select all that apply. 1. Computed tomography (CT) scan 2. Swallowing evaluation 3. Throat culture 4. Fiberoptic endoscopic evaluation of swallowing (FEES) 5. Magnetic resonance imaging (MRI) 6. Modified barium swallow (MBS) study

2, 3, 4, 6

You are using the anterior approach to palpating the thyroid gland. What are normal findings? Select all that apply. 1. Variations of firmness 2. Palpable lobes 3. Nonpalpable lobes 4. Small nodules 5. Nontender

2, 3, 5 The thyroid gland lateral lobes may or may not be palpable. The thyroid gland should be non-tender.

The nurse is inspecting and palpating the patient's head. What is the nurse specifically assessing? Select all that apply. 1. Voluntary movement of the tongue 2. Size and shape of the head 3. Configuration 4. Range of motion 5. Movement 6. Palpating for masses or depressions 7. Palpating the head for moisture

2, 3, 5, 6

You are providing patient education on dental health. The patient states that he has been using the same toothbrush for the past year and has not seen a dentist in 2 years. The nurse should educate the patient with which of the following statements? Select all that apply. 1. Toothbrushes should be replaced every 6 months. 2. Have a dental examination twice per year. 3. Brush all tooth surfaces for at least 60 seconds. 4. Place your toothbrush at a 90-degree angle to the gums. 5. Floss at least once a day, preferably more often. 6. Brush your tongue to remove bacteria.

2, 5, 6 The American Dental Association (2016) recommends dental examinations twice per year, flossing at least once a day, and brushing your tongue to remove bacteria.

You are inspecting the buccal mucosa of a 70-year-old male patient. Which of the following instructions should you give to this patient? 1. "Hold your mouth open until I tell you that I am finished." 2. "Please remove your dentures so that I can assess the gums of your mouth." 3. "Let me know if you have xerostomia and I will give you a cup of water to drink." 4. "I will be using a penlight to look in your mouth."

2. "Please remove your dentures so that I can assess the gums of your mouth." If the patient has full or partial dentures, have him remove the dentures for inspection and palpation of gum area.

A patient comes to the emergency room stating that he woke up this morning with swollen lips. He reports that he has just started a new medication for his allergies. What is the name of this condition? 1. Anaphylaxis 2. Angioedema 3. Herpes simplex 4. Angular cheilitis

2. Angioedema Angioedema is edema of the lips, usually related to an allergic reaction.

The patient states that she has frequent headaches. The patient explains that the headaches are stabbing pain on one side of the face or sometimes occur behind one eye. The headaches occur most often in the early morning. What type of headache is this patient describing? 1. Migraine 2. Cluster 3. Sinus 4. Tension

2. Cluster

What are you assessing on the center of the forehead just above the eyes? 1. Sphenoid sinuses 2. Frontal sinuses 3. Maxillary sinuses 4. Ethmoid sinuses

2. Frontal sinuses

You are assessing a 32-year-old man's mouth. Using a penlight, you inspect the mouth and note that the he has red, bleeding gums. What is the name of this abnormal finding? 1. Aphthous stomatitis 2. Gingivitis 3. Gingival hyperplasia 4. Periodontal disease

2. Gingivitis The patient's gums will be red, swollen, and bleeding.

You are performing a mouth assessment and are going to inspect and palpate the tongue. What equipment will you need? 1. Gown and gloves 2. Gloves and sterile gauze 3. Goggles and penlight 4. Penlight and gloves

2. Gloves and sterile gauze

A 37-year-old female presents to the community health clinic complaining of a severe sore throat and swollen glands. You have already inspected the rising of the soft palate and uvula. Prior to using the tongue depressor to assess the oropharynx, which of the following should the nurse do first? 1. Ask the patient to open her mouth real wide. 2. Moisten the tongue blade with warm water. 3. Ask the patient to say "ahh." 4. Assess for swollen glands.

2. Moisten the tongue blade with warm water. A moistened tongue blade may help to decrease the chances of the patient gagging.

The student nurse is explaining the technique of palpating the face to the instructor. The instructor identifies that further teaching is necessary when the student nurse makes which of the following statements? 1. Using the finger pads of both hands, gently palpate the face for tenderness and swelling. 2. Place your fingers in back of the earlobes and below the eyes and palpate the temporal arteries simultaneously by each ear. 3. Place your fingertips in front of each ear at the zygomatic arch and ask the patient to open and close his or her mouth. 4. Assess for any clicking sounds or decreased range of motion (ROM) of the jaw, including temporomandibular joint (TMJ) disorder .

2. Place your fingers in back of the earlobes and below the eyes and palpate the temporal arteries simultaneously by each ear.

The purpose of inspecting the thyroid gland is to assess: 1. Tenderness and size. 2. Size and mobility. 3. Position within the neck and nodules. 4. Mobility and tenderness.

2. Size and mobility. The nurse would inspect the thyroid for size and mobility as the patient swallows.

The nasal labial folds and the palpebral fissures of the face are measured to assess for: 1. Appearance of the face. 2. Symmetry of the face. 3. Edema of the face. 4. Involuntary movements of the face.

2. Symmetry of the face. The nasal labial folds and the palpebral fissures are measured to assess for the symmetry of the face (cranial nerve VII).

A college student goes to the on-campus health clinic complaining of a severe sore throat and difficulty swallowing. You put on gloves and with the aid of a penlight assess her pharynx. You see that her throat is very red, her tonsils have white purulent spots, and the tonsils are almost touching her uvula. What objective data would you document? 1. Throat is red, tonsils are enlarged 2. Throat is red, tonsils are 3+ with multiple white spots 3. Reports painful sore throat, swollen glands, and dysphagia 4. Painful sore throat, white spots on tonsils, enlarged tonsils 3+

2. Throat is red, tonsils are 3+ with multiple white spots This is objective data documenting what the nurse assesses.

The patient is diagnosed with a neurological disorder. During the assessment of this patient's head, what abnormal assessment findings would the nurse expect to find? 1. Tenderness and swelling of the head 2. Tremors, tics, or jerking movements of the head 3. A mass or lesions on the skull 4. Depression of the skull

2. Tremors, tics, or jerking movements of the head Neurological disorders cause involuntary movements such as tremors, tics, or jerking movements of the head.

The adult skull is made up of ________ bones and _________ cranial bones.

22; 8 The adult skull is made up of 22 bones and 8 cranial bones.

Cancers of the larynx and pharynx are most common in which racial or ethnic groups? 1. Latinos and Asians 2. Asians and Italians 3. Caucasians and African Americans 4. African Americans and Latinos

3. Caucasians and African Americans

The patient is sticking out their tongue. What are you assessing? 1. Mouth range of motion 2. Jaw range of motion 3. Dorsal surface of the tongue 4. Ventral surface of the tongue

3. Dorsal surface of the tongue

The aide reports to the nurse that the patient coughs when he drinks liquids and appears to be having difficulty swallowing solid foods. The medical term for difficulty swallowing is: 1. Xerostomia. 2. Dysphasia. 3. Dysphagia. 4. Bruxism.

3. Dysphagia. Xerostomia is a dry mouth. Dysphasia is difficulty speaking. Dysphagia is difficulty swallowing. Bruxism is grinding of teeth.

You are assessing this patient's tongue and note that patches on the tongue are missing papillae. What is the name of this condition? 1. Atrophic glossitis 2. Hairy tongue 3. Geographic tongue 4. Leukoplakia

3. Geographic tongue

You are preparing to assess the head, face, mouth, and neck of a patient. Choose your equipment. Select all that apply. 1. Face shield 2. Goggles 3. Gloves 4. Gauze 5. Penlight 6. Stethoscope 7. Tongue blade 8. Cup of water

3. Gloves 4. Gauze 5. Penlight 6. Stethoscope 7. Tongue blade 8. Cup of water

You are inspecting the trachea. Where will you place your right index finger to start the assessment for tracheal deviation?1. Below the cricoid cartilage 2. Below the thyroid isthmus 3. In the sternal notch 4. To the right and left of the trachea

3. In the sternal notch You will gently place your right index finger in the sternal notch and then slip your finger off to each side, noting distance from the sternomastoid muscle.

When you are gently feeling the upper part of the mouth on a patient with your index finger, What technique are you performing? 1. Inspecting the upper dentition 2. Inspecting and palpating the dorsal surface of the tongue 3. Palpating the soft and hard palates 4. Inspecting and palpating the soft palate only

3. Palpating the soft and hard palates

Which statement best describes the function of the neck? 1. The neck is formed by seven cervical vertebrae, muscles, and ligaments to support the head. 2. The major muscles supporting the neck are the sternocleidomastoid and trapezius muscles. 3. The neck protects the nerves that carry sensory and motor impulses from the brain to the body. 4. The neck protects the thyroid gland in the anterior portion of the neck.

3. The neck protects the nerves that carry sensory and motor impulses from the brain to the body.

Which of the following statements is true concerning the anatomy and physiology of the mouth? 1. Stensen ducts are located in the lower oral cavity and drain saliva. 2. The hard palate is the largest and strongest bone of the face. 3. The soft palate is responsible for closing off the nasal passages during the act of swallowing. 4. Gingiva is the mucous membrane epithelium lining inside of the mouth.

3. The soft palate is responsible for closing off the nasal passages during the act of swallowing.

The nurse is preparing to begin the physical assessment on a young adult starting with assessing the head, face, and neck. Order the following in the correct sequence (1-5). (Enter the number of each step in the proper sequence. Do not use punctuation or spaces. Example: 1234.) ____1. Auscultation ____2. Inspection ____3. Palpation ____4. Explain procedure ____5. Document findings

4, 2, 3, 1, 5 The nurse explains the procedure to the patient, assesses by inspection, then palpation, and then auscultation. Findings are documented last.

You are using the posterior approach to palpate the thyroid gland. Where will you place your finger pads? 1. At the level of the thyroid isthmus 2. Below the thyroid isthmus 3. Above the cricoid cartilage 4. Below the cricoid cartilage

4. Below the cricoid cartilage

The patient has a history of chronic sinus infections for the past 2 years. What diagnostic test would you expect the health-care provider to order to provide detailed imaging of the sinuses? 1. X-ray of the face 2. X-ray of the sinuses 3. Nasal culture of sinus drainage 4. Computed tomography (CT) scan of the sinuses

4. Computed tomography (CT) scan of the sinuses This scan may help to diagnose infection, nasal polyps, birth defects, or abnormalities of the sinuses

What cranial nerve assesses the position of the tongue? 1. Cranial nerve I 2. Cranial nerve III 3. Cranial nerve X 4. Cranial nerve XII

4. Cranial nerve XII Hypoglossal nerve is cranial nerve XII

A patient comes to the urgent care center with a nosebleed. During the focused health history, the patient states that this is the first time she has ever had a nosebleed and is scared. You assess her nose and observe blood coming from the right nostril. What should the nurse do to try to stop the bleeding? 1. Have the patient apply pressure with an ice pack and tilt her head back. 2. Hold pressure on the nares by pinching the nostrils tightly for 10 minutes. 3. Have the patient lean forward and press on the bridge of the nose for 5 minutes. 4. Instruct the patient to sit up, lean forward, and pinch the nostrils for 10 to 15 minutes.

4. Instruct the patient to sit up, lean forward, and pinch the nostrils for 10 to 15 minutes. Instruct the patient to sit up, lean forward, and pinch the nostrils for 10 to 15 minutes.

Which bone of the face is considered the largest and strongest bone? 1. Frontal bone 2. Cranial bone 3. Cranial vault 4. Mandible

4. Mandible The jaw bone (mandible) is the largest and strongest bone of the face.

What statement is true concerning the sinuses of the patient? 1. Frontal sinuses are between the eyes, deeper in the skull, and not visible for examination. 2. Ethmoid sinuses are behind the nasal cavity, deeper in the skull, and not visible for examination. 3. Sphenoid sinuses are above the eyes in the center of the forehead. 4. Maxillary sinuses are the largest and located in the cheekbones below the eyes.

4. Maxillary sinuses are the largest and located in the cheekbones below the eyes.

A patient comes to the outpatient clinic complaining of jaw pain and asks the nurse what might be some causes. The nurse explains to the patient that jaw pain is related to: 1. Temporomandibular joint (TMJ) disorder, teeth grinding, or temporal arteritis. 2. TMJ disorder, xerostomia, allergies, or goiter. 3. TMJ disorder, rhinorrhea, sinusitis, or epistaxis. 4. TMJ disorder, teeth grinding, or cardiac conditions.

4. TMJ disorder, teeth grinding, or cardiac conditions.

The patient reports that she is feeling tired all the time and has been gaining weight. She thinks that her face is "puffy." You assess the thyroid gland and find it to be enlarged. The health-care provider suspects the patient has hypothyroidism. You expect that the health-care provider will order which of the following blood work to assess the thyroid gland? 1. Triiodothyronine (T3) 2. Thyroid-stimulating hormone (TSH) only 3. Thyroid-stimulating hormone (TSH) and free thyroxine (Free T4) 4. Thyroid-stimulating hormone (TSH), free thyroxine (Free T4), and triiodothyronine (T3)

4. Thyroid-stimulating hormone (TSH), free thyroxine (Free T4), and triiodothyronine (T3) Thyroid-stimulating hormone (TSH), free thyroxine (Free T4), and triiodothyronine (T3) tests are used to differentiate thyroid malfunction.

The left lobe of the thyroid gland is auscultated for a ________________.

bruit A bruit is a vascular sound heard with the presence of turbulent blood flow. It is usually heard in the presence of hyperthyroidism.

The purpose of inspecting and palpating the head is to assess the ____________________ and ____________________ of the head.

size; shape Assess the size and shape of the head for any abnormalities.