Deck 13: Head, Neck, and Related Lymphatics

Question 1

Reviewing a client's record, the nurse notes that the client has a goiter. Which priority question should the nurse include in the focused interview?

A) "Where do you purchase your medication?"
B) "What type of salt do you use in your diet?"
C) "Do you work around chemicals?"
D) "How long have you had this problem?"

Answer 1

"What type of salt do you use in your diet?"

Question 2

A client has a history of palpable submental lymph nodes. Which anatomical area should the nurse assess?

A) At the base of the skull.
B) Behind the ear over the outer surface of the mastoid bone.
C) At the junction of the posterior and lateral walls of the pharynx at the angle of the jaw.
D) Behind the tip of the mandible at the midline.

Answer 2

Behind the tip of the mandible at the midline.

Question 3

The nurse is assessing the client's neck. Which should the nurse recognize is an abnormal finding?

A) The client's carotid arteries are visibly pulsating.
B) The neck is symmetrical.
C) The tracheal cartilage does not move when the client swallows.
D) The thyroid has no palpable nodules.

Answer 3

The tracheal cartilage does not move when the client swallows.

Question 4

A client tells the nurse that they experience daily headaches. Which should the nurse include in the assessment? Select all that apply.

A) "Rate your pain on a scale from 0 to 10, with 0 being no pain and 10 the worst."
B) "Daily headaches are not of any concern."
C) "Is there anything that relieves the pain, like resting or medication?"
D) "Is the pain sharp, dull, steady, or throbbing?"
E) "Have you had a recent cold or infection?"

Question 5

Which best describes the function of the axis?

A) Carries the skull.
B) Denotes the first cervical vertebrae.
C) Allows for movement of the skull.
D) Connects the skull to the vertebrae.

Question 6

The nurse suspects a client has a concussion. Which findings should the nurse expect to support the suspicion?

A) Enlarged lymph nodes.
B) Headache.
C) Blurred vision.
D) Temporal bruits.

Question 7

The nurse is auscultating the temporal artery and hears a soft blowing sound. Which term should the nurse use to document the findings?

A) Bruit.
B) Murmur.
C) Stenosis.
D) Occlusion.

Question 8

A client asks the nurse why their lymph node is enlarged. Which response should the nurse provide the client?

A) "Sometimes, enlarged lymph nodes indicate an infection."
B) "All of your lymph nodes should be easily palpable."
C) "The lymph system is making antibiotics to fight infection."
D) "An enlarged lymph node is an abnormal finding."

Question 9

The nurse is teaching a client with a history of migraines about avoiding foods that are rich in tyramine. Which foods should the nurse include in the teaching? Select all that apply.

A) Nuts.
B) Avocados.
C) Corn.
D) Eggs.
E) Onions.

Question 10

The nurse is obtaining a focused head and neck interview on a client. Which should the nurse ask the client to assess their internal environment?

A) "Do you use any home remedies?"
B) "Have you ever had irradiation to your neck?"
C) "Have you been exposed to chemicals in the work place?"
D) "Does anyone smoke in the home environment?"

Question 11

The client has an enlarged lymph node in front of the right ear. Which should the nurse document the finding as?

A) Right-sided occipital lymph node enlarged.
B) Right-sided submaxillary lymph node enlarged.
C) Right-sided deep cervical lymph node enlarged.
D) Right-sided preauricular lymph node enlarged.

Question 12

The nurse auscultates a bruit in the left temporal artery. Which should the nurse understand is the initial contributing factor to the assessment finding?

A) Increased blood flow.
B) Narrowing of the vessel.
C) Decreased blood flow.
D) Dilated arterial vessel.

Question 13

A client asks why they are being asked about tobacco products during a head and neck assessment. Which response should the nurse recognize the primary reason for the question?

A) The use of tobacco results in enlarged lymph nodes.
B) The use of tobacco may cause headaches.
C) The use of tobacco contributes to decreased sense of taste.
D) The use of tobacco may cause a loss of the sense of smell.

Question 14

A client tells the nurse they are experiencing headaches. Which question should the nurse ask the client that best encourages a detailed description?

A) "How long does a typical headache last?"
B) "Do you experience any nausea or vomiting with the headache?"
C) "What seems to relieve the symptoms?"
D) "Do you feel that the headache is triggered by a specific event?"

Question 15

A client tells the nurse they do not understand how they got Bell's Palsy. Which information should the nurse include in the response? Select all that apply.

A) "One of your cranial nerves has been affected."
B) "This is usually caused by a virus."
C) "This is a temporary disorder."
D) "This is related to a possible stroke."
E) "This condition is related to an autoimmune disorder."

Question 16

The nurse is preparing to perform a head and neck assessment on a client with Parkinson's disease. Which finding should the nurse anticipate?

A) Exophthalmos.
B) Facial paralysis.
C) Enlargement of the head.
D) Mask-like expression.

Question 17

The nurse observes involuntary facial muscle movement on a client. Which cranial nerve should the nurse evaluate?

A) Cranial nerve III.
B) Cranial nerve VI.
C) Cranial nerve VII.
D) Cranial nerve IV.

Question 18

The nurse is preparing to assess a client that is experiencing TMJ discomfort. Which should the nurse be concerned with? Select all that apply.

A) Difficulty swallowing.
B) Difficulty speaking.
C) Difficulty chewing.
D) Decreased tongue motion.
E) Impaired ability to slide the upper jaw.

Question 19

A client asks why the nurse is looking at their jugular veins and arteries. Which response should the nurse provide? Select all that apply.

A) I am looking for pulsation.
B) I am looking for distension.
C) I am evaluating placement.
D) I am evaluating the pulse rate.

Question 20

The nurse is preparing to instruct a client to take a drink of water during a head and neck assessment. Which statement should the nurse provide the client?

A) "I am preparing to assess your temporomandibular joint."
B) "I am preparing to assess your lymph nodes."
C) "I am preparing to assess your temporal artery."
D) "I am preparing to assess your trachea."

Question 21

The nurse is preparing to palpate the submental lymph node. Which anatomical location should the nurse palpate?

A) Under the chin.
B) At the base of the skull.
C) Behind the tip at the mandible midline.
D) At the junction of the posterior and lateral walls of the pharynx at the angle of the jaw.

Question 22

A client tells the nurse they are experiencing sudden intermittent headaches after seeing "flashes of light" and experiencing nausea. Which should the nurse suspect the client is experiencing?

A) Migraine headaches.
B) Cluster headaches.
C) Tension headaches.
D) Increased intracranial pressure.

Question 23

A client tells the nurse they have been experiencing "severe headaches intermittently over the past 3 days" that are accompanied with unilateral pain over the right side of their face and nasal congestion. Which should the nurse suspect the client is experiencing?

A) Cluster headache.
B) Classic migraine.
C) Tension headache.
D) Hydrocephalus.

Question 24

The nurse is examining a client's neck. Which techniques should the nurse use to palpate the trachea? Select all that apply.

A) Palpate while the client is swallowing.
B) Slide the thumb and index finger upward on each side of the trachea.
C) Palpate the midline of the neck to feel the cricoid cartilage.
D) Ask the client to open and close their mouth.
E) Stand behind the client and ask them to turn their head slightly to the right.

Question 25

The nurse is planning care for a client with hypothyroidism. Which should the nurse recognize is a priority nursing diagnosis?

A) Risk for constipation related to metabolic imbalance.
B) Activity intolerance related to fatigue.
C) Risk for injury related to confusion and lethargy.
D) Altered nutrition, less than body requirements.

Question 26

The nurse is preparing to assess an adult client suspected of having hyperthyroidism. Which assessment findings does the nurse anticipate? Select all that apply.

A) Blood pressure: 162/92 mmHg.
B) Apical pulse: 120 bpm.
C) Respiratory rate of 14 breaths per minute.
D) Constricted pupils.
E) Temperature of 100.1°F

Question 27

A client with hypothyroidism tells the nurse they have forgotten to take their medication for the past several days. Which should the nurse assess the client for?

A) Headache.
B) Constipation.
C) Exophthalmos.
D) Cardiac dysrhythmias.

Question 28

The nurse assessing a newborn notes an enlarged head with visible prominent scalp veins. Which should the nurse suspect the newborn is experiencing?

A) Craniosynostosis.
B) Hydrocephalus.
C) Acromegaly.
D) Fetal alcohol syndrome.

Question 29

The nurse is preparing to assess a client with cluster headaches. Which statement made by the client should the nurse recognize supports the diagnosis?

A) "I see flashing lights before my headache starts."
B) "Before I get my headaches, I experience mood changes."
C) "I wake up at night with pain in the side of my face."
D) "My headaches start gradually and the pain is steady."

Question 30

The nurse is preparing to assess a client's thyroid. Which information should the nurse provide the client prior to the assessment?

A) "Please lie down while I assess your thyroid gland."
B) "When I assess your thyroid gland, you can expect to feel strong pressure."
C) "I will stand behind you while palpating your thyroid gland."
D) "Please chew this mint so that I can assess your thyroid gland."

Question 31

The nurse is preparing to assess a client's lymph nodes. Which technique should the nurse use?

A) Assessing each side separately.
B) Applying gentle, circular pressure.
C) Applying strong, deep pressure.
D) Attempting to push the nodes into the muscle.