Deck 14: Head, Neck, and Related Lymphatics

Question 1

Which country has decreased their population's risk of developing thyroid disease by adding iodine to salt?

A) India.
B) United States.
C) Australia.
D) China.

Answer 1

United States.

Question 2

The nurse is auscultating the temporal artery and hears a soft blowing sound. Which term will the nurse use when documenting this finding?

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

Answer 2

Bruit.

Question 3

The nurse is conducting a seminar regarding cultural implications for physical assessment. A client of which ethnicity might prohibit the nurse from examining the head?

A) Caucasian from the United States.
B) African American.
C) Mexican American.
D) Cambodian American.

Answer 3

Cambodian American.

Question 4

The nurse is performing an assessment of the client's head and neck. The client requests information about the assessment of her lymph nodes. Which response by the nurse is the most appropriate?

A) "Sometimes, enlarged lymph nodes indicate an infection."
B) "All of your lymph nodes should be easily palpable."
C) "The lymph system makes antibiotics to treat infection."
D) "When one lymph node is identified as being enlarged, this is always an abnormal finding."

Question 5

A client complains of daily headaches. Which items will the nurse include in the focused interview for this client to learn more about the client's headaches?

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 6

The nurse is assessing the client's neck. Which finding is considered an abnormality?

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.

Question 7

The nurse is assessing the function of the client's cranial nerves. The nurse finds that the client is unable to demonstrate the ability to chew. Which cranial nerve is not functioning properly based on this assessment finding?

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

Question 8

The client is complaining of pain in the temporomandibular joint. During the nurse's assessment of this client, which pieces of information does the nurse expect to find?.

A) The client has been under a great deal of stress due to a recent divorce.
B) The client has developed hypothyroidism.
C) The client has lost tooth enamel due to nighttime teeth grinding.
D) The client has developed hypotension.
E) The client has developed severe tension headaches.

Question 9

The nurse is palpating an adult client's neck and does not note any palpable lymph nodes. Which conclusion by the nurse is appropriate based on this data?

A) This finding indicates an infection.
B) This finding is considered normal.
C) This finding necessitates a referral to an ear, nose, and throat specialist.
D) This finding indicates the need for further assessment to determine the malformation.

Question 10

The pregnant client, who just entered the third trimester of pregnancy, develops hypertension and is diagnosed with preeclampsia. Which assessment data does the nurse anticipate for this client?

A) Dehydration.
B) Complaints of increasing headaches.
C) Decreased reproductive hormone levels.
D) Lack of protein excretion in client's urine.

Question 11

The nurse notes the client's thyroid gland is enlarged during the physical assessment. While reviewing the client's history, the nurse notes that the client has a history of a goiter. Based on this information, which question is the priority during 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?"

Question 12

Which information is true regarding the assessment of the thyroid or thyroid function in an infant or child?

A) To accurately assess thyroid function, the nurse should assess the child's growth and development in comparison to others in the child's age group.
B) The thyroid gland is easily palpable in an infant.
C) Assess the child for abnormal hair growth because this may indicate thyroid dysfunction.
D) Assess the child for melasma because this will indicate thyroid dysfunction.

Question 13

The pediatric nurse is conducting physical assessments during a shift in the outpatient clinic. Which findings are considered abnormal?

A) The 2-week-old newborn whose fontanels are slightly pulsing.
B) The 2-year-old child's anterior fontanel remains unclosed.
C) The 1-month-old infant's posterior fontanel has closed.
D) The 10-month-old infant's anterior fontanel is shaped like a triangle.
E) The 6-month-old infant's anterior fontanel is soft and flat.

Question 14

The client has an enlarged lymph node in front of the right ear. Which phrase will the nurse use to document this finding in the medical record?

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 15

During a focused interview of a client, the nurse learns about an open lesion on the client's head that has not healed in several months. Which conclusion is appropriate for the nurse to make based on this data?

A) The client may have a thyroid disease.
B) The client may have a malignancy.
C) The client may be pregnant.
D) The client may have meningitis.

Question 16

The nurse assesses the client's temporomandibular joint after the client's states chronic pain in this location. Which manifestations would the nurse anticipate as a result of this chronic pain?

A) The client has developed migraine headaches.
B) The client is unable to chew well and has lost weight since the pain began.
C) The client exhibits difficulty speaking clearly and enunciating words.
D) The client has developed hyperparathyroidism.
E) The client has developed torticollis.

Question 17

The nurse is assessing the client's head and neck. The nurse provides the client with a glass of water. Which structure is the nurse assessing while observing the client drinking the water?

A) Temporomandibular joint.
B) Lymph nodes.
C) Temporal artery.
D) Trachea.

Question 18

The nurse is performing a physical examination on a 2-day-old newborn and notes flattened areas on each side of the head. The mother expresses concern about the infant's appearance. Which response by the nurse is appropriate?

A) "The baby will likely need a neurologic evaluation."
B) "The baby will need plastic surgery."
C) "This is normal and will resolve in a few days."
D) "What shape is your husband's head?"

Question 19

The nurse is assessing the client's neck. Where is the axis located?

A) A.
B) B.
C) C.
D) D.

Question 20

The nurse is assessing the 1-month-old infant's fontanels and notes they are sunken. Based on this data, which conclusion is most appropriate?

A) Infection.
B) Thyroid disease.
C) Dehydration.
D) Fetal Alcohol Syndrome.

Question 21

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

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 22

The nurse is planning care for an older adult client. Which topic will the nurse include in the teaching session when discussing thyroid function?

A) Eliminating the use of alcohol.
B) Monitoring of hormone levels annually.
C) Providing information about congenital abnormalities.
D) Educating about birth control options.

Question 23

The nurse is assessing a client who reports the occurrence of sudden, intermittent headaches for the past several months. The client states that the headaches come after seeing flashes of lights and experiencing nausea. Based on this data, which diagnosis does the nurse anticipate for this client?

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

Question 24

The nurse is preparing to assess an adult client. The focus of the exam will be on the head and neck. Which statement by the nurse is appropriate when preparing the client for the thyroid examination?

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 25

The nurse is examining a client's neck. Which techniques are appropriate when palpating the trachea?

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 her mouth.
E) Stand behind the client and ask her to turn her head slightly to the right.

Question 26

The nurse is assessing an infant diagnosed with Down syndrome. During the physical assessment, which data does the nurse anticipate?

A) Slanted eyes.
B) Cleft palate and lip.
C) Protruding tongue.
D) Shortened neck.
E) Drooping eyelids.

Question 27

Which action by the nurse is appropriate when palpating the client's lymph nodes during the physical assessment?

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

Question 28

Which location would the nurse use for palpation when assessing the submental lymph node during a physical assessment?

A) A.
B) B.
C) C.
D) D.

Question 29

The nurse is auscultating the thyroid gland and notes a bruit. Which conclusion by the nurse is appropriate based on this assessment finding?

A) Stenosis of the thyroid artery.
B) A normal finding.
C) Indicates increased blood flow.
D) Occurs with hypothyroidism.

Question 30

During a focused assessment and interview regarding the client's head and neck, the client reveals the occurrence of severe headaches intermittently over a three-day period. The client denies any aura, but admits to severe and unilateral pain over the right side of the face along with nasal congestion. Which diagnosis does the nurse anticipate based on this assessment data?

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

Question 31

The nurse is assessing a newborn and notes an enlarged head with prominent scalp veins visible. Based on this data, which diagnosis does the nurse suspect?

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

Question 32

The client presents with unilateral facial paralysis and the nurse suspects Bell's palsy. After client teaching, which client statement would indicate the need for further education?

A) "This may have occurred as a result of a viral infection."
B) "This will probably disappear on its own in several weeks."
C) "The onset of Bell's palsy is very slow and the effects can linger for several months."
D) "Your cranial nerve VII is not functioning appropriately."

Question 33

The nurse is preparing an educational seminar about Healthy People 2020. Which topics will the nurse include in the educational seminar?

A) The parents of a newborn should be educated about the clinical manifestations associated with hyperthyroidism.
B) Thyroid disease more frequently affects males versus females.
C) Immigrants may have an increased risk of disorders related to thyroid function.
D) Depression in older adults may be linked to hypothyroidism.
E) The iodine added to some medications can be linked to hypothyroidism in the clients who use these medications.

Question 34

While assessing a client, the nurse notes the client is irritable, anxious, and has lost 12 pounds over the last two months. The client's eyes appear to bulge from their sockets. Based on this data, which assessment findings does the nurse anticipate for this client?

A) Blood pressure: 162/92 mmHg.
B) Apical pulse: 120.
C) Respiratory rate is 10 breaths per minute
D) Pupils: constricted.
E) Client complains of feeling very warm.