Deck 12: Head, Neck Related Lymphatics

Question 1

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.The nurse suspects that which of the following cranial nerves is not functioning properly?
1)Cranial nerve III
2)Cranial nerve V
3)Cranial nerve VII
4)Cranial nerve VI

Answer 1

2

Question 2

During a focused interview of a client,the nurse learns about an open lesion on theclient's head that hasn't healed in several months.What might this indicate to the nurse?
1)The client may have a thyroid disease.
2)The client may have a malignancy.
3)The client may be pregnant.
4)The client may have meningitis.

Answer 2

2

Question 3

The nurse is assessing the client's neck.Draw an "X" over the location of the axis.

Answer 3

Question 4

The pregnant female has entered her third trimester.The client has developed hypertension and has been diagnosed with preeclampsia.Which of the following would the nurse also expect to find during the assessment of this client?
1)Dehydration
2)Complaints of increasing headaches
3)Decreased reproductive hormone levels
4)Lack of protein excretion in client's urine

Question 5

The nurse is auscultating the temporal artery and hears a soft blowing sound.How would the nurse correctly document this finding?
1)Bruit
2)Murmur
3)Stenosis
4)Occlusion

Question 6

The nurse is assessing the client's neck.Which of the following findings is abnormal?
1)The client's carotid arteries are visibly pulsating.
2)The neck is symmetrical.
3)The tracheal cartilage does not move when the client swallows.
4)The thyroid has no palpable nodules.

Question 7

The nurse is assessing the client's temporomandibular joint.The client complains of chronic pain at this site.Which of the following may have occurred as a result of this condition?
1)The client has developed migraine headaches.
2)The client is unable to chew well and has lost weight since the pain began.
3)The client exhibits difficulty speaking clearly and enunciating words.
4)The client has developed hyperparathyroidism.
5)The client has developed torticollis.

Question 8

The nurse is performing a physical examination on a 2-day-old infant and notes flattened areas on each side of the head.The mother expresses concern about the infant's appearance.Which of the following responses would be appropriate for the nurse?
1)"The baby will likely need a neurologic evaluation."
2)"The baby will need plastic surgery."
3)"This is normal and will resolve in a few days."
4)"What shape is your husband's head?"

Question 9

The client has an enlarged lymph node in front of his right ear.In which of the following ways should the nurse accurately document this finding?
1)Right-sided occipital lymph node enlarged
2)Right-sided submaxillary lymph node enlarged
3)Right-sided deep cervical lymph node enlarged
4)Right-sided preauricular lymph node enlarged

Question 10

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 of the following is the best response?
1)"Sometimes,enlarged lymph nodes indicate an infection."
2)"All of your lymph nodes should be easily palpable."
3)"The lymph system makes antibiotics to treat infection."
4)"When one lymph node is identified as being enlarged,this is always an abnormal finding."

Question 11

The nurse is palpating an adult client's neck and does not note any palpable lymph nodes.The nurse understands that this is:
1)probably due to an infection.
2)a normal finding in adults.
3)reason for referral to an ear,nose,and throat specialist.
4)cause to inspect for further malformations.

Question 12

Which of the following information is true regarding the assessment of the thyroid or thyroid function in an infant or child?
1)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.
2)The thyroid gland is easily palpable in an infant.
3)Assess the child for abnormal hair growth because this may indicate thyroid dysfunction.
4)Assess the child for melasma because this will indicate thyroid dysfunction.

Question 13

Which of the following findings is normal regarding assessment of the fontanels?
1)The nurse notes that the 2-week-old infant's fontanels are slightly pulsing.
2)The 2-year-old child's anterior fontanel remains unclosed.
3)The 1-month-old infant's posterior fontanel has closed.
4)The 10-month-old infant's anterior fontanel is shaped like a triangle.

Question 14

The client is complaining of pain in his temporomandibular joint.During the nurse's assessment of this client,which of the following pieces of information does the nurse expect to find?
1)The client has been under a great deal of stress due to a recent divorce.
2)The client has developed hypothyroidism.
3)The client has lost tooth enamel due to nighttime teeth grinding.
4)The client has developed hypotension.
5)The client has developed severe tension headaches.

Question 15

Which of the following countries have decreased their population's risk of developing thyroid disease by adding iodine to salt?
1)India
2)United States
3)Australia
4)China

Question 16

The nurse finds the client's thyroid gland is enlarged during the physical assessment.The client states that she has had a history of a goiter in the past.Which of the following questions is a priority to ask during the focused interview?
1)"Where do you purchase your medication?"
2)"What type of salt do you use in your diet?"
3)"Do you work around chemicals?"
4)"How long have you had this problem?"

Question 17

The nurse is assessing the client's head and neck.The nurse provides the client with a glass of water.Which of the following structures will the nurse most likely need to assess as the client drinks?
1)Temporomandibular joint
2)Lymph nodes
3)Temporal artery
4)Trachea

Question 18

The client is preparing to examine the client's head.Which of the following clients may prohibit the nurse from performing this portion of the exam?
1)Caucasian from the United States
2)African American
3)Mexican American
4)Native American Indian

Question 19

A client complains of daily headaches.Which of the following would the nurse include in the focused interview?
1)"Rate your pain on a scale from 0 to 10,with 0 being no pain and 10 the worst."
2)"Tell me exactly where the pain is located."
3)"Is there anything that relieves the pain,like resting or medication?"
4)"Is the pain sharp,dull,steady,or throbbing?"
5)"Have you had a recent cold or infection?"

Question 20

The nurse is assessing the 1-month-old infant's fontanels.The infant's fontanels are sunken.What may this indicate to the nurse?
1)Infection
2)Thyroid disease
3)Dehydration
4)Fetal Alcohol Syndrome

Question 21

The nurse is assessing the client.The client is irritable,anxious,and has lost 12 pounds over the last 2 months.The client's eyes appear to bulge from their sockets.Which of the following pieces of information does the nurse expect to find during the assessment of this client?
1)Blood pressure: 162/92
2)Apical pulse: 120
3)Respiratory rate: 11
4)Pupils: constricted
5)Client complains of feeling very warm.

Question 22

The nurse needs to palpate the submental lymph node on a client.Draw an arrow to the spot where the nurse would palpate.

Question 23

The nurse is assessing an infant diagnosed with Down syndrome.Which of the following characteristics would the nurse expect to find during the examination?
1)Slanted eyes
2)Cleft palate and lip
3)Protruding tongue
4)Shortened neck
5)Drooping eyelids

Question 24

The nurse is assessing a client with complaints of sudden,intermittent headaches for the past several months.The client states that the headaches come after seeing flashes of lights and experiencing nausea.The nurse would suspect which of the following disorders?
1)Migraine headaches
2)Cluster headaches
3)Tension headaches
4)Increased intracranial pressure

Question 25

The nurse is planning care for a client with hypothyroidism.Which of the following would be the priority nursing diagnosis for this client?
1)Risk for constipation related to metabolic imbalance
2)Activity intolerance related to fatigue
3)Risk for injury related to confusion and lethargy
4)Altered nutrition,less than body requirements

Question 26

The nurse is demonstrating palpation of the lymph nodes to a nursing student.Which of the following methods would be correct for the nurse to use during this examination?
1)First on one side,then on the other
2)Gentle,circular pressure
3)Strong,deep pressure
4)Always attempt to push the nodes into the muscle.

Question 27

The nurse is auscultating the thyroid gland and notes a bruit.Which of the following would the nurse associate with this finding?
1)Indicates stenosis of the thyroid artery.
2)Is a normal finding.
3)Indicates increased blood flow.
4)Occurs with hypothyroidism.

Question 28

The nurse is assessing a newborn infant and notes that the infant's head is enlarged with prominent scalp veins visible.The nurse would correctly document this finding as which of the following?
1)Craniosynostosis
2)Hydrocephalus
3)Acromegaly
4)Fetal alcohol syndrome

Question 29

During a focused assessment and interview regarding the client's head and neck,the client states that she is currently suffering from a severe headache that has occurred intermittently over the course of 3 days.The client denies any aura.The pain is severe and unilateral over the right side of her face.Also,the client is complaining of nasal congestion.Which of the following is the most likely diagnosis?
1)Cluster headache
2)Classic migraine
3)Tension headache
4)Hydrocephalus

Question 30

The nurse is preparing an educational seminar about Healthy People 2020.The inclusion of which of the following topics in this presentation are unexpected and indicate that the nurse requires further education?
1)The parents of a newborn should be educated about the clinical manifestations associated with hyperthyroidism.
2)Thyroid disease more frequently affects males than females.
3)Immigrants may have an increased risk of disorders related to thyroid function.
4)Depression in older adults may be linked to hypothyroidism.
5)The iodine added to some medications can be linked to hypothyroidism in the clients who use these medications.

Question 31

The nurse is preparing a teaching plan regarding thyroid function for the older adult.Which of the following would the nurse include in this teaching?
1)Eliminating the use of alcohol
2)Annual monitoring of hormone levels
3)Information about congenital abnormalities
4)Information on birth control

Question 32

The client presents with unilateral facial paralysis and the nurse suspects Bell's palsy.Which of the following statement by the nurse to the client may indicate that the nurse requires further education about Bell's palsy?
1)"This may have occurred as a result of a viral infection."
2)"This will probably disappear on its own in several weeks."
3)"The onset of Bell's palsy is very slow and the effects can linger for several months."
4)"Your cranial nerve VII is not functioning appropriately."

Question 33

The nurse is examining a client's neck.Which of the following would the nurse use as the correct method to palpate the trachea?
1)Palpate while the client is swallowing.
2)Slide the thumb and index finger upward on each side of the trachea.
3)Palpate the midline of the neck to feel the cricoid cartilage.
4)Ask the client to open and close her mouth.
5)Stand behind the client and ask her to turn her head.