Question 1

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?

Accepted Answer

The symptoms described, including irritability, anxiety, weight loss, and bulging eyes, are indicative of hyperthyroidism, particularly Graves' disease. High blood pressure (A) and an elevated apical pulse (B) are common in hyperthyroidism due to the increased metabolism and sympathetic nervous system activity. Feeling very warm (E) is also a symptom of hyperthyroidism, as the increased metabolism generates more heat.

Question 2

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

Accepted Answer

The answer of The nurse needs to palpate the submental...

Question 3

The nurse is assessing an infant diagnosed with Down syndrome.Which of the following characteristics would the nurse expect to find during the examination?

Accepted Answer

Slanted eyes, protruding tongue, and a shortened neck are all characteristic physical features of infants with Down syndrome. Cleft palate and lip and drooping eyelids may be present in some cases, but they are not as consistently associated with the condition.

Question 4

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?

Accepted Answer

The symptoms of sudden, intermittent headaches that are accompanied by flashes of lights and nausea are characteristic of migraine headaches. Cluster headaches typically occur in cyclical patterns, tension headaches are usually described as a constant ache or pressure, and increased intracranial pressure can cause a range of symptoms including headaches but is not typically intermittent and accompanied by flashes of lights and nausea.

Question 5

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

Accepted Answer

Activity intolerance related to fatigue is the priority nursing diagnosis for a client with hypothyroidism because fatigue is a primary symptom of hypothyroidism that significantly affects the client's daily functioning and quality of life.

Question 6

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?

Accepted Answer

The nurse should use gentle, circular pressure during palpation of lymph nodes. This allows for proper detection of any abnormalities, while minimizing discomfort or potential injury to the patient. The nurse should also palpate both sides of the body, comparing any differences in size or consistency of the lymph nodes. Strong, deep pressure should be avoided, and the nurse should not attempt to push the nodes into the muscle.

Question 7

The nurse is auscultating the thyroid gland and notes a bruit.Which of the following would the nurse associate with this finding?

Accepted Answer

A bruit heard over the thyroid gland indicates increased blood flow, which can occur in conditions such as hyperthyroidism, thyroiditis, or thyroid cancer. It is not a normal finding and does not indicate stenosis of the thyroid artery or occur with hypothyroidism.

Question 8

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?

Accepted Answer

Enlargement of the infant's head with visible scalp veins is a characteristic finding in infants with hydrocephalus. They may also have a bulging fontanelle, irritability, lethargy, and vomiting. Craniosynostosis is premature closure of one or more cranial sutures and does not necessarily present with an enlarged head. Acromegaly is a disorder of excessive growth hormone production that occurs after closure of the growth plates and is unlikely in a newborn infant. Fetal alcohol syndrome does not typically present with an enlarged head.

Question 9

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?

Accepted Answer

The severe, unilateral pain over the right side of the face and the presence of nasal congestion suggest a cluster headache. Classic migraines often have an aura and tension headaches do not typically cause nasal congestion. Hydrocephalus may cause headaches, but it would be necessary to gather additional information to make a definitive diagnosis.

Question 10

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?

Accepted Answer

The answer of The nurse is preparing an educational seminar...

Question 11

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?

Accepted Answer

Older adults may experience changes in thyroid function and should have their hormone levels checked annually to monitor for any abnormalities. Eliminating alcohol may be beneficial for overall health, but it is not specifically related to thyroid function. Information about congenital abnormalities and birth control are not relevant to older adults and their thyroid function.

Question 12

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?

Accepted Answer

The statement "The onset of Bell's palsy is very slow and the effects can linger for several months" is incorrect. The onset of Bell's palsy is typically sudden and the effects can last for several weeks to several months. The nurse should be educated on the correct information regarding Bell's palsy.

Question 13

The nurse is examining a client's neck.Which of the following would the nurse use as the correct method to palpate the trachea?

Accepted Answer

The answer of The nurse is examining a client's neck.Which...

Quiz 12: Head, Neck Related Lymphatics