Question 1

The nurse notices that an infant has a large,soft lump on the side of his head and that his mother is very concerned.She tells the nurse that she noticed the lump approximately 8 hours after her baby's birth and that it seems to be getting bigger.One possible explanation for this is:

Accepted Answer

A cephalhematoma is a subperiosteal hemorrhage that is the result of birth trauma.It is soft,fluctuant,and well defined over one cranial bone.It appears several hours after birth and gradually increases in size.

Question 2

A visitor from Poland who does not speak English seems to be somewhat apprehensive about the nurse examining his neck.He would probably be more comfortable with the nurse examining his thyroid gland from:

Accepted Answer

Examining this patient's thyroid gland from the back may be unsettling for him.It would be best to examine his thyroid gland using the anterior approach,asking him to tip his head forward and to the right and then to the left.

Question 3

While performing a well-child assessment on a 5 year old,the nurse notes the presence of palpable,bilateral,cervical,and inguinal lymph nodes.They are approximately 0.5 cm in size,round,mobile,and nontender.The nurse suspects that this child:

Accepted Answer

Palpable lymph nodes are normal in children until puberty when the lymphoid tissue begins to atrophy.Lymph nodes may be up to 1 cm in size in the cervical and inguinal areas but are discrete,movable,and nontender.

Question 4

During an examination,the nurse knows that the best way to palpate the lymph nodes in the neck is described by which statement?

Accepted Answer

Using gentle pressure is recommended because strong pressure can push the nodes into the neck muscles.Palpating with both hands to compare the two sides symmetrically is usually most efficient.

Question 5

During an assessment of an infant,the nurse notes that the fontanels are depressed and sunken.The nurse suspects which condition?

Accepted Answer

Depressed and sunken fontanels occur with dehydration or malnutrition.Mental retardation and rickets have no effect on the fontanels.Increased intracranial pressure would cause tense or bulging and possibly pulsating fontanels.

Question 6

When examining children affected with Down syndrome (trisomy 21),the nurse looks for the possible presence of:

Accepted Answer

With the chromosomal aberration trisomy 21,also known as Down syndrome,head and face characteristics may include upslanting eyes with inner epicanthal folds,a flat nasal bridge,a small broad flat nose,a protruding thick tongue,ear dysplasia,a short broad neck with webbing,and small hands with a single palmar crease.

Question 7

During an examination of a female patient,the nurse notes lymphadenopathy and suspects an acute infection.Acutely infected lymph nodes would be:

Accepted Answer

Acutely infected lymph nodes are bilateral,enlarged,warm,tender,and firm but freely movable.Unilaterally enlarged nodes that are firm and nontender may indicate cancer.

Question 8

The nurse has just completed a lymph node assessment on a 60-year-old healthy female patient.The nurse knows that most lymph nodes in healthy adults are normally:

Accepted Answer

Most lymph nodes are nonpalpable in adults.The palpability of lymph nodes decreases with age.Normal nodes feel movable,discrete,soft,and nontender.

Question 9

The physician reports that a patient with a neck tumor has a tracheal shift.The nurse is aware that this means that the patient's trachea is:

Accepted Answer

The trachea is pushed to the unaffected side with an aortic aneurysm,a tumor,unilateral thyroid lobe enlargement,or a pneumothorax.The trachea is pulled to the affected side with large atelectasis,pleural adhesions,or fibrosis.Tracheal tug is a rhythmic downward pull that is synchronous with systole and occurs with aortic arch aneurysm.

Question 10

During an admission assessment,the nurse notices that a male patient has an enlarged and rather thick skull.The nurse suspects acromegaly and would further assess for:

Accepted Answer

Acromegaly is excessive secretion of growth hormone that creates an enlarged skull and thickened cranial bones.Patients will have elongated heads,massive faces,prominent noses and lower jaws,heavy eyebrow ridges,and coarse facial features.Exophthalmos is associated with hyperthyroidism.Bowed long bones and an acorn-shaped cranium result from Paget disease.

Question 11

A patient visits the clinic because he has recently noticed that the left side of his mouth is paralyzed.He states that he cannot raise his eyebrow or whistle.The nurse suspects that he has:

Accepted Answer

With an upper motor neuron lesion,as with a CVA,the patient will have paralysis of lower facial muscles,but the upper half of the face will not be affected owing to the intact nerve from the unaffected hemisphere.The person is still able to wrinkle the forehead and close the eyes.(See Table 13-4,Abnormal Facial Appearances with Chronic Illnesses,for descriptions of the other responses.)

Question 12

During a well-baby checkup,a mother is concerned because her 2-month-old infant cannot hold her head up when she is pulled to a sitting position.Which response by the nurse is appropriate?

Accepted Answer

Head control is achieved by 4 months when the baby can hold the head erect and steady when pulled to a vertical position.The other responses are not appropriate.

Question 13

A woman comes to the clinic and states,"I've been sick for so long! My eyes have gotten so puffy,and my eyebrows and hair have become coarse and dry." The nurse will assess for other signs and symptoms of:

Accepted Answer

Myxedema (hypothyroidism)is a deficiency of thyroid hormone that,when severe,causes a nonpitting edema or myxedema.The patient will have a puffy edematous face,especially around the eyes (periorbital edema); coarse facial features; dry skin; and dry,coarse hair and eyebrows.(See Table 13-4,Abnormal Facial Appearances with Chronic Illnesses,for descriptions of the other responses.)

Question 14

During an examination of a 3-year-old child,the nurse notices a bruit over the left temporal area.The nurse should:

Accepted Answer

Bruits are common in the skull in children under 4 or 5 years of age and in children with anemia.They are systolic or continuous and are heard over the temporal area.

Question 15

The nurse suspects that a patient has hyperthyroidism,and the laboratory data indicate that the patient's T? and T? hormone levels are elevated.Which of these findings would the nurse most likely find on examination?

Accepted Answer

T? and T? are thyroid hormones that stimulate the rate of cellular metabolism,resulting in tachycardia.With an enlarged thyroid gland as in hyperthyroidism,the nurse might expect to find diffuse enlargement (goiter)or a nodular lump but not an atrophied gland.Dyspnea and constipation are not findings associated with hyperthyroidism.

Question 16

During an examination of a patient in her third trimester of pregnancy,the nurse notices that the patient's thyroid gland is slightly enlarged.No enlargement had been previously noticed.The nurse suspects that the patient:

Accepted Answer

The thyroid gland enlarges slightly during pregnancy because of hyperplasia of the tissue and increased vascularity.

Question 17

The nurse is performing an assessment on a 7-year-old child who has symptoms of chronic watery eyes,sneezing,and clear nasal drainage.The nurse notices the presence of a transverse line across the bridge of the nose,dark blue shadows below the eyes,and a double crease on the lower eyelids.These findings are characteristic of:

Accepted Answer

Chronic allergies often develop chronic facial characteristics and include blue shadows below the eyes,a double or single crease on the lower eyelids,open-mouth breathing,and a transverse line on the nose.

Question 18

A patient's thyroid gland is enlarged,and the nurse is preparing to auscultate the thyroid gland for the presence of a bruit.A bruit is a __________ sound that is heard best with the __________ of the stethoscope.

Accepted Answer

If the thyroid gland is enlarged,then the nurse should auscultate it for the presence of a bruit,which is a soft,pulsatile,whooshing,blowing sound heard best with the bell of the stethoscope.

Question 19

A mother brings in her newborn infant for an assessment and tells the nurse that she has noticed that whenever her newborn's head is turned to the right side,she straightens out the arm and leg on the same side and flexes the opposite arm and leg.After observing this on examination,the nurse tells her that this reflex is:

Accepted Answer

By 2 weeks,the infant shows the tonic neck reflex when supine and the head is turned to one side (extension of same arm and leg,flexion of opposite arm and leg).The tonic neck reflex disappears between 3 and 4 months of age.

Question 20

During an examination,the nurse finds that a patient's left temporal artery is tortuous and feels hardened and tender,compared with the right temporal artery.The nurse suspects which condition?

Accepted Answer

With temporal arteritis,the artery appears more tortuous and feels hardened and tender.These assessment findings are not consistent with the other responses.

Quiz 13: Head, Face, and Neck, Including Regional Lymphatics