Chapter 12 My Nursing Test Banks

DAmico/Barbarito Health & Physical Assessment in Nursing, 2/e
Chapter 12

Question 1

Type: MCMA

The nurse is assessing the clients temporomandibular joint. The client complains of chronic pain at this site. Which of the following may have occurred as a result of this condition?

Standard Text: Select all that apply.

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.

Correct Answer: 2,3,5

Rationale 1: The client has developed migraine headaches. Clients who have pain at the temporomandibular joint will have difficulty moving this joint adequately. This can result in difficulty speaking, problems chewing food, and weight loss. Clients with temporomandibular joint pain are more likely to develop cluster or tension headaches.

Rationale 2: The client is unable to chew well and has lost weight since the pain began. Clients who have pain at the temporomandibular joint will have difficulty moving this joint adequately. This can result in difficulty speaking, problems chewing food, and weight loss.

Rationale 3: The client exhibits difficulty speaking clearly and enunciating words. Clients who have pain at the temporomandibular joint will have difficulty moving this joint adequately. This can result in difficulty speaking, problems chewing food, and weight loss.

Rationale 4: The client has developed hyperparathyroidism. Clients who have pain at the temporomandibular joint will have difficulty moving this joint adequately. This can result in difficulty speaking, problems chewing food, and weight loss. Pain at the site of temporomandibular joint is not associated with hyperparathyroidism.

Rationale 5: The client has developed torticollis. Clients who have pain at the temporomandibular joint will have difficulty moving this joint adequately. This can result in difficulty speaking, problems chewing food, and weight loss. The client with temporomandibular joint pain can also develop painful muscle spasms in the neck called torticollis.

Global Rationale: Clients who have pain at the temporomandibular joint will have difficulty moving this joint adequately. This can result in difficulty speaking, problems chewing food, and weight loss. Clients with temporomandibular joint pain are more likely to develop cluster or tension headaches than migraine headaches. Pain at the site of temporomandibular joint is not associated with hyperparathyroidism. The client with temporomandibular joint pain can also develop painful muscle spasms in the neck called torticollis.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 12.1: Identify the anatomy and physiology of the structures of the head and neck.

Question 2

Type: HOTSPOT

The nurse is assessing the clients neck. Draw an X over the location of the axis.

Screen Shot 2015-09-24 at 11.58.44 AM

Rationale : The neck is formed by the seven cervical vertebrae, ligaments, and muscles, which support the cranium. The second cervical vertebra is commonly referred to as the axis. The axis allows for movement of the head.

Global Rationale:

Cognitive Level: Remembering

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 12.1: Identify the anatomy and physiology of the structures of the head and neck.

Question 3

Type: MCSA

The nurse is performing an assessment of the clients 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.

Correct Answer: 1

Rationale 1: The lymph nodes are part of the lymphatic system and provide the body with protection against infection. It is true that sometimes when the nurse is able to palpate enlarged lymph nodes this indicates that the client has developed an infection.

Rationale 2: Lymph nodes should not be palpable.

Rationale 3: The lymph system does not make antibiotics; it makes antibodies and lymphocytes to protect the client from infection.

Rationale 4: It is not necessarily abnormal to be able to palpate one enlarged lymph node.

Global Rationale: The head and neck are supplied by a large number of lymph nodes. The lymph nodes are part of the lymphatic system and provide the body with protection against infection. It is true that sometimes when the nurse is able to palpate enlarged lymph nodes this indicates that the client has developed an infection. Lymph nodes should not be palpable. The lymph system does not make antibiotics; it makes antibodies and lymphocytes to protect the client from infection. It is not necessarily abnormal to be able to palpate one enlarged lymph node.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 12.1: Identify the anatomy and physiology of the structures of the head and neck.

Question 4

Type: MCSA

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 infants 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 husbands head?

Correct Answer: 3

Rationale 1: The infant will not require a neurologic evaluation because this is a normal finding.

Rationale 2: The infants head will take on a more normal round shape in several days so plastic surgery is not required.

Rationale 3: Infants born by vaginal delivery experience molding, which is shaping of the head as it passes through the vaginal canal. This will resolve in several days.

Rationale 4: The shape of the infants head is normal after birth and is unrelated to the shape of the fathers head.

Global Rationale: Infants born by vaginal delivery experience molding, which is shaping of the head as it passes through the vaginal canal. This will resolve in several days. The infant will not require a neurologic evaluation because this is a normal finding. The infants head will take on a more normal round shape in several days. The shape of the infants head is normal after birth and is unrelated to the shape of the fathers head.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 12.1: Identify the anatomy and physiology of the structures of the head and neck.

Question 5

Type: MCSA

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

Correct Answer: 4

Rationale 1: The occipital lymph nodes are located at the base of the skull.

Rationale 2: The submaxillary lymph nodes are located in the medial border of the mandible.

Rationale 3: The deep cervical lymph nodes are located behind and inferior to the sternocleidomastoid muscle.

Rationale 4: The preauricular lymph node is located in front of the ear.

Global Rationale: The occipital lymph nodes are located at the base of the skull. The submaxillary lymph nodes are located in the medial border of the mandible. The deep cervical lymph nodes are located behind and inferior to the sternocleidomastoid muscle. The preauricular lymph node is located in front of the ear.

Cognitive Level: Understanding

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 12.1: Identify the anatomy and physiology of the structures of the head and neck.

Question 6

Type: MCSA

Which of the following findings is normal regarding assessment of the fontanels?

1. The nurse notes that the 2-week-old infants fontanels are slightly pulsing.

2. The 2-year-old childs anterior fontanel remains unclosed.

3. The 1-month-old infants posterior fontanel has closed.

4. The 10-month-old infants anterior fontanel is shaped like a triangle.

Correct Answer: 1

Rationale 1: The nurse may note that there are slight pulsations noted in the infants fontanels.

Rationale 2: The anterior fontanel should be fully closed by 18 months of age.

Rationale 3: The posterior fontanel should close at approximately 2 months of age.

Rationale 4: The anterior fontanel should be shaped like a diamond. The posterior fontanel should be shaped like a triangle.

Global Rationale: The nurse may note that there are slight pulsations noted in the infants fontanels. The anterior fontanel should be fully closed by 18 months of age. The posterior fontanel should close at approximately 2 months of age. The anterior fontanel should be shaped like a diamond. The posterior fontanel should be shaped like a triangle.

Cognitive Level: Understanding

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 12.1: Identify the anatomy and physiology of the structures of the head and neck.

Question 7

Type: MCSA

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 childs growth and development in comparison to others in the childs 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.

Correct Answer: 1

Rationale 1: The best way to assess thyroid function in an infant or child is to assess his growth and development in comparison to other people in his age group

Rationale 2: The thyroid gland is difficult to palpate in an infant.

Rationale 3: Long facial hair is usually seen in older women who are making less reproductive hormones.

Rationale 4: Melasma is found in pregnant women. Melasma occurs when the pregnant female develops large, blotchy, pigmented areas on her face.

Global Rationale: The best way to assess thyroid function in an infant or child is to assess his growth and development in comparison to other people in his age group. Laboratory tests can also help the clinician determine thyroid function. The thyroid gland is difficult to palpate in an infant. Long facial hair is usually seen in older women who are making less reproductive hormones. Melasma is found in pregnant women. Melasma occurs when the pregnant female develops large, blotchy, pigmented areas on her face.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 12.1: Identify the anatomy and physiology of the structures of the head and neck.

Question 8

Type: MCSA

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 clients urine

Correct Answer: 2

Rationale 1: Preeclampsia is associated with fluid retention, not dehydration.

Rationale 2: Preeclampsia is associated with hypertension, fluid retention, complaints of headaches, increased hormone levels, and an increase amount of urinary protein excretion.

Rationale 3: Preeclampsia is associated with increased hormone levels.

Rationale 4: Preeclampsia is associated with an increased amount of urinary protein excretion.

Global Rationale: This pregnant client has developed preeclampsia. This condition occurs after 20 weeks gestation. It is associated with hypertension, fluid retention, complaints of headaches, increased hormone levels, and an increase amount of urinary protein excretion. Preeclampsia is important to identify because it can result in restricted blood flow to the placenta and may harm the developing fetus.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 12.1: Identify the anatomy and physiology of the structures of the head and neck.

Question 9

Type: MCSA

The client is preparing to examine the clients 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

Correct Answer: 4

Rationale 1: Touching the head is not a cultural taboo for this group.

Rationale 2: Touching the head is not a cultural taboo for this group.

Rationale 3: Touching the head is not a cultural taboo for this group.

Rationale 4: The cultural groups who may prohibit a thorough examination of their heads are Native Americans, people from Southeast Asia, and some Latino cultures.

Global Rationale: Some cultural groups believe that the touching of another persons head is inappropriate and this type of examination would be unwelcome. They believe that the soul or spirit resides within their heads.

Cognitive Level: Understanding

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 12.1: Identify the anatomy and physiology of the structures of the head and neck.

Question 10

Type: MCMA

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

Standard Text: Select all that apply.

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.

Correct Answer: 1,3,5

Rationale 1: The client has been under a great deal of stress due to a recent divorce. Stress can produce unconscious jaw clenching that can result in temporomandibular joint pain.

Rationale 2: The client has developed hypothyroidism. Temporomandibular joint pain is not associated with hypothyroidism. Perhaps, the client with hyperthyroidism may experience more stress related to sympathetic nervous system stimulation and this could possibly result in teeth grinding and temporomandibular joint pain.

Rationale 3: The client has lost tooth enamel due to nighttime teeth grinding. Some clients with temporomandibular joint pain grind their teeth at night and wear down their tooth enamel.

Rationale 4: The client has developed hypotension. Temporomandibular joint pain is not associated with hypotension. The client with stress may develop hypertension and temporomandibular joint pain.

Rationale 5: The client has developed severe tension headaches. Clients with temporomandibular joint pain are more prone to tension headaches.

Global Rationale: Stress can produce unconscious jaw clenching that can result in temporomandibular joint pain. Some clients with temporomandibular joint pain grind their teeth at night and wear down their tooth enamel. Clients with temporomandibular joint pain are more prone to tension headaches. Temporomandibular joint pain is not associated with hypothyroidism. Perhaps, the client with hyperthyroidism may experience more stress related to sympathetic nervous system stimulation and this could possibly result in teeth grinding and temporomandibular joint pain. Temporomandibular joint pain is not associated with hypotension. The client with stress may develop hypertension and temporomandibular joint pain.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 12.1: Identify the anatomy and physiology of the structures of the head and neck.

Question 11

Type: MCSA

Which of the following countries have decreased their populations risk of developing thyroid disease by adding iodine to salt?

1. India

2. United States

3. Australia

4. China

Correct Answer: 2

Rationale 1: People who live in India and China have a higher risk of developing thyroid disease related to iodine deficiencies.

Rationale 2: The use of iodized salt has reduced iodine defiencies and thyroid problems for people who live in the United States.

Rationale 3: Australia, some areas in Eastern Europe, and South America have trouble with iodine deficiency due to their soil, which is typically poor in iodine.

Rationale 4: People who live in India and China have a higher risk of developing thyroid disease related to iodine deficiencies.

Global Rationale: Thyroid problems are common in areas where iodine is limited. The use of iodized salt has reduced iodine defiencies and thyroid problems for people who live in the United States. People who live in India and China have a higher risk of developing thyroid disease related to iodine deficiencies. Australia, some areas in Eastern Europe, and South America have trouble with iodine deficiency due to their soil, which is typically poor in iodine.

Cognitive Level: Remembering

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 12.1: Identify the anatomy and physiology of the structures of the head and neck.

Question 12

Type: MCSA

During a focused interview of a client, the nurse learns about an open lesion on theclients head that hasnt 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.

Correct Answer: 2

Rationale 1: This finding doesnt necessarily indicate the client has a thyroid problem.

Rationale 2: Wounds or lesions that do not heal, swellings, or masses should be assessed because this finding may indicate the client has a malignancy.

Rationale 3: Pregnancy does not make the body less likely to heal.

Rationale 4: This particular client does not exhibit symptoms of meningitis such as complaints of a stiff neck and headache.

Global Rationale: Wounds or lesions that do not heal, swellings, or masses should be assessed because this finding may indicate the client has a malignancy. This finding doesnt necessarily indicate the client has a thyroid problem. Pregnancy does not make the body less likely to heal. This particular client does not exhibit symptoms of meningitis such as complaints of a stiff neck and headache.

Cognitive Level: Understanding

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 12.2: Develop questions to be used when completing the focused interview.

Question 13

Type: MCMA

A client complains of daily headaches. Which of the following would the nurse include in the focused interview?

Standard Text: Select all that apply.

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?

Correct Answer: 1,2,3,4,5

Rationale 1: Rate your pain on a scale from 0 to 10, with 0 being no pain and 10 the worst. The nurse should gather as much information about the clients pain as possible. The nurse should gather information about the pains intensity.

Rationale 2: Tell me exactly where the pain is located. The nurse should gather as much information about the clients pain as possible. The nurse should gather information about the pains location.

Rationale 3: Is there anything that relieves the pain, like resting or medication? The nurse should determine if there is anything that helps alleviate the clients pain, such as resting, medication, or exercise.

Rationale 4: Is the pain sharp, dull, steady, or throbbing? It is important to assess the character of the pain.

Rationale 5: Have you had a recent cold or infection? Sometimes headaches can be associated with recent colds or infections.

Global Rationale: The nurse should gather as much information about the clients pain as possible. The nurse should gather information about the pains location, intensity, character, and location. The nurse should determine if there is anything that helps alleviate the clients pain, such as resting, medication, or exercise. Sometimes headaches can be associated with recent colds or infections.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 12.2: Develop questions to be used when completing the focused interview.

Question 14

Type: MCSA

The nurse finds the clients 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?

Correct Answer: 2

Rationale 1: Although this question is important to gain general information, the nurse needs to assess whether the client is indeed using iodized salt, especially regarding the clients past history and present symptomatology.

Rationale 2: Thyroid disease is common where iodine is limited and deficient amounts of iodine can cause a goiter to develop. Use of iodized salt in the U.S. has generally eliminated iodine deficiencies.

Rationale 3: Although this question is important to gain general information, the nurse needs to assess whether the client is indeed using iodized salt, especially regarding the clients past history and present symptomatology.

Rationale 4: Although this question is important to gain general information, the nurse needs to assess whether the client is indeed using iodized salt, especially regarding the clients past history and present symptomatology.

Global Rationale: Thyroid disease is common where iodine is limited and deficient amounts of iodine can cause a goiter to develop. Use of iodized salt in the U.S. has generally eliminated iodine deficiencies. Although the other questions are important to gain general information, the nurse needs to assess whether the client is indeed using iodized salt, especially regarding the clients past history and present symptomatology.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 12.2: Develop questions to be used when completing the focused interview.

Question 15

Type: MCSA

The nurse is assessing the 1-month-old infants fontanels. The infants fontanels are sunken. What may this indicate to the nurse?

1. Infection

2. Thyroid disease

3. Dehydration

4. Fetal Alcohol Syndrome

Correct Answer: 3

Rationale 1: Infection would result in bulging fontanels.

Rationale 2: Thyroid disease would not necessarily alter the state of the fontanels.

Rationale 3: Sunken or depressed fontanels in an infant can indicate dehydration.

Rationale 4: Fetal Alcohol Syndrome results in specific facial malformations.

Global Rationale: Sunken or depressed fontanels in an infant can indicate dehydration. Infection would result in bulging fontanels. Thyroid disease would not necessarily alter the state of the fontanels. Fetal Alcohol Syndrome results in specific facial malformations.

Cognitive Level: Understanding

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 12.2: Develop questions to be used when completing the focused interview.

Question 16

Type: MCSA

The nurse is assessing the clients 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

Correct Answer: 4

Rationale 1: The temporomandibular joint should be inspected and palpated.

Rationale 2: The lymph nodes are inspected and palpated.

Rationale 3: The temporal artery can be inspected and palpated.

Rationale 4: The nurse will ask the client to drink from the glass of water when the nurse is ready to assess the hyoid bone, tracheal cartilage, and thyroid as the client swallows.

Global Rationale: Physical assessment of the head and neck requires the use of inspection, palpation, and auscultation. The nurse will ask the client to drink from the glass of water when the nurse is ready to assess the hyoid bone, tracheal cartilage, and thyroid as the client swallows. The temporomandibular joint should be inspected and palpated. The lymph nodes are inspected and palpated. The temporal artery can be inspected and palpated.

Cognitive Level: Understanding

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 12.3: Describe the techniques required for assessment of the head and neck.

Question 17

Type: MCSA

The nurse is assessing the clients neck. Which of the following findings is abnormal?

1. The clients 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.

Correct Answer: 3

Rationale 1: It is normal to note that a clients carotid arteries visibly pulse during inspection of the neck.

Rationale 2: The neck should be smooth and symmetrical.

Rationale 3: The tracheal cartilage should move when the client swallows.

Rationale 4: The thyroid should be free of any nodules and this would be noted during palpation.

Global Rationale: It is normal to note that a clients carotid arteries visibly pulse during inspection of the neck. The neck should be smooth and symmetrical. The thyroid should be free of any nodules and this would be noted during palpation. The tracheal cartilage should move when the client swallows.

Cognitive Level: Understanding

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 12.3: Describe the techniques required for assessment of the head and neck.

Question 18

Type: MCSA

The nurse is assessing the function of the clients 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

Correct Answer: 2

Rationale 1: Cranial nerve III assists with controlling the movement of the eyes.

Rationale 2: Cranial nerve V stimulates the movement needed for chewing, which is also known as mastication.

Rationale 3: Cranial nerve VII is responsible for controlling the clients facial movements.

Rationale 4: Cranial nerve VI assists with controlling the movement of the eyes.

Global Rationale: Cranial nerve III assists with controlling the movement of the eyes. Cranial nerve V stimulates the movement needed for chewing, which is also known as mastication. Cranial nerve VII is responsible for controlling the clients facial movements. Cranial nerve VI assists with controlling the movement of the eyes.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 12.4: Differentiate normal from abnormal findings in physical assessment of the head, neck, and related structures.

Question 19

Type: MCSA

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

Correct Answer: 1

Rationale 1: A bruit can be heard through the bell of the stethoscope as a soft, blowing sound and is indicative of narrowing of the vessel. This is an abnormal sound.

Rationale 2: The sound described is not a murmur, which is heard when auscultating the heart.

Rationale 3: Stenosis is a medical diagnosis and the nurse should not document any conclusive diagnoses from assessment findings.

Rationale 4: When a vessel is occluded, there is no associated sound because blood is not flowing through the vessel.

Global Rationale: A bruit can be heard through the bell of the stethoscope as a soft, blowing sound and is indicative of narrowing of the vessel. This is an abnormal sound. The sound described is not a murmur, which is heard when auscultating the heart, and the nurse should not document any conclusive diagnoses from assessment findings. Stenosis is a medical diagnosis. When an artery is stenosed, it can create a bruit. When a vessel is occluded, there is no associated sound because blood is not flowing through the vessel.

Cognitive Level: Understanding

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 12.4: Differentiate normal from abnormal findings in physical assessment of the head, neck, and related structures.

Question 20

Type: MCSA

The nurse is palpating an adult clients 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.

Correct Answer: 2

Rationale 1: Lymph nodes of the head and neck are non-palpable in adults. If an infection were present, the lymph nodes of the surrounding area may be tender and possibly enlarged.

Rationale 2: The lymph nodes that are located in the adult clients neck should not be able to be palpated.

Rationale 3: There is no reason to refer the client to a specialist or to inspect the client for further malformations in the neck because it is normal to be unable to palpate lymph nodes.

Rationale 4: There is no reason to refer the client to a specialist or to inspect the client for further malformations in the neck because it is normal to be unable to palpate lymph nodes.

Global Rationale: Lymph nodes of the head and neck are nonpalpable in adults. If an infection were present, the lymph nodes of the surrounding area may be tender and possibly enlarged. The lymph nodes that are located in the adult clients neck should not be able to be palpated. There is no reason to refer the client to a specialist or to inspect the client for further malformations in the neck because it is normal to be unable to palpate lymph nodes.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 12.4: Differentiate normal from abnormal findings in physical assessment of the head, neck, and related structures.

Question 21

Type: MCMA

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

Standard Text: Select all that apply.

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.

Correct Answer: 1,2,3

Rationale 1: Palpate while the client is swallowing. The nurse should confirm that the hyoid bone and tracheal cartilages move up when the client swallows.

Rationale 2: Slide the thumb and index finger upward on each side of the trachea. The nurse should use his thumb and index finger to identify the thyroid cartilage as he slides these fingers up the clients neck.

Rationale 3: Palpate the midline of the neck to feel the cricoid cartilage. The trachea should be midline. The C rings are also called cricoid cartilage.

Rationale 4: Ask the client to open and close her mouth. The client should be asked to open and close her mouth during inspected and palpation of the temporomandibular joint.

Rationale 5: Stand behind the client and ask her to turn her head. The range of motion of the clients neck can be partially assessed in this manner.

Global Rationale: The nurse should use his thumb and index finger to identify the thyroid cartilage as he slides these fingers up the clients neck. The nurse should confirm that the hyoid bone and tracheal cartilages move up when the client swallows. The trachea should be midline. The C rings are also called cricoid cartilage. The client should be asked to open and close her mouth during inspected and palpation of the temporomandibular joint. The range of motion of the clients neck can be partially assessed by standing behind the client and asking her to turn her head.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 12.4: Differentiate normal from abnormal findings in physical assessment of the head, neck, and related structures.

Question 22

Type: HOTSPOT

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

Screen Shot 2015-09-24 at 12.09.57 PM

Rationale : The submental lymph node is just below the chin and should be palpated with one hand.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 12.4: Differentiate normal from abnormal findings in physical assessment of the head, neck, and related structures.

Question 23

Type: MCSA

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

Correct Answer: 2

Rationale 1: While confusion, lethargy, and constipation are commonly associated with hypothyroidism, these are conditions that are not present according to the nursing diagnosis statement and therefore do not carry the same priority as those that are actually present.

Rationale 2: Feeling tired, exhausted, and not having enough energy to perform even small tasks is a typical complaint from clients suffering from hypothyroidism.

Rationale 3: While confusion, lethargy, and constipation are commonly associated with hypothyroidism, these are conditions that are not present according to the nursing diagnosis statement and therefore do not carry the same priority as those that are actually present.

Rationale 4: Typically, the client with hypothyroidism, though he may not have an appetite, may be gaining weight.

Global Rationale: Feeling tired, exhausted, and not having enough energy to perform even small tasks is a typical complaint from clients suffering from hypothyroidism. While confusion, lethargy, and constipation are commonly associated with hypothyroidism, these are conditions that are not present according to the nursing diagnosis statement and therefore do not carry the same priority as those that are actually present. Typically, the client with hypothyroidism, though he may not have an appetite, may be gaining weight.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 12.4: Differentiate normal from abnormal findings in physical assessment of the head, neck, and related structures.

Question 24

Type: MCSA

The client presents with unilateral facial paralysis and the nurse suspects Bells palsy. Which of the following statement by the nurse to the client may indicate that the nurse requires further education about Bells 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 Bells palsy is very slow and the effects can linger for several months.

4. Your cranial nerve VII is not functioning appropriately.

Correct Answer: 3

Rationale 1: Bells palsy is believed to occur as a result of viral infection.

Rationale 2: The condition usually resolves spontaneously after several weeks.

Rationale 3: The onset is sudden and there arent lingering effects after the condition resolves in several weeks after onset.

Rationale 4: Cranial nerve VII is not functioning appropriately as a result of the viral infection. This results in the unilateral facial paralysis associated with the condition.

Global Rationale: Bells palsy is believed to occur as a result of viral infection. The condition usually resolves spontaneously after several weeks. The onset is sudden and there arent lingering effects after the condition resolves in several weeks after onset. Cranial nerve VII is not functioning appropriately as a result of the viral infection. This results in the unilateral facial paralysis associated with the condition.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 12.4: Differentiate normal from abnormal findings in physical assessment of the head, neck, and related structures.

Question 25

Type: MCSA

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.

Correct Answer: 3

Rationale 1: A bruit does not indicate stenosis, which is when blood flow is restricted through a blood vessel.

Rationale 2: This is not a normal finding.

Rationale 3: If the thyroid is enlarged, blood flows through the arteries at an accelerated rate, producing a soft, rushing sound and is detected with the bell of the stethoscope as a bruit.

Rationale 4: Hypothyroidism can produce a smaller than normal thyroid gland and decreased blood flow.

Global Rationale: If the thyroid is enlarged, blood flows through the arteries at an accelerated rate, producing a soft, rushing sound and is detected with the bell of the stethoscope as a bruit. A bruit does not indicate stenosis, which is when blood flow is restricted through a blood vessel. This is not a normal finding. Hypothyroidism can produce a smaller than normal thyroid gland and decreased blood flow.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 12.4: Differentiate normal from abnormal findings in physical assessment of the head, neck, and related structures.

Question 26

Type: MCSA

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.

Correct Answer: 2

Rationale 1: Nodes should be palpated on both sides simultaneously for comparison.

Rationale 2: Palpation of the lymph nodes should be done by exerting gentle, circular pressure using the fingerpads of both hands.

Rationale 3: Strong, deep pressure can push the nodes into the muscle and underlying structures, making them difficult to find.

Rationale 4: It is not appropriate to exhibit enough pressure to push the lymph nodes into the clients neck muscles because it makes it more difficult to find the lymph nodes.

Global Rationale: Palpation of the lymph nodes should be done by exerting gentle, circular pressure using the fingerpads of both hands. Strong, deep pressure can push the nodes into the muscle and underlying structures, making them difficult to find. Nodes should be palpated on both sides simultaneously for comparison. It is not appropriate to exhibit enough pressure to push the lymph nodes into the clients neck muscles because it makes it more difficult to find the lymph nodes.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 12.4: Differentiate normal from abnormal findings in physical assessment of the head, neck, and related structures.

Question 27

Type: MCSA

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

Correct Answer: 1

Rationale 1: Migraine headaches are often preceded by an aura during which the client may feel depressed, restless, or irritable; see spots or flashes of light; and feel nausea.

Rationale 2: Cluster headaches come in waves over a period of time and then disappear and reappear.

Rationale 3: Tension headaches occur gradually.

Rationale 4: The headache associated with increased intracranial pressure is usually sudden and severe and is not intermittent.

Global Rationale: Migraine headaches are often preceded by an aura during which the client may feel depressed, restless, or irritable; see spots or flashes of light; and feel nausea. Cluster headaches come in waves over a period of time and then disappear and reappear. Tension headaches occur gradually. Neither cluster nor tension headaches are precipitated by an aura. The headache associated with increased intracranial pressure is usually sudden and severe and is not intermittent.

Cognitive Level: Understanding

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 12.4: Differentiate normal from abnormal findings in physical assessment of the head, neck, and related structures.

Question 28

Type: MCSA

During a focused assessment and interview regarding the clients 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

Correct Answer: 1

Rationale 1: Cluster headaches can occur over time. They have no associated aura. They are often unilateral and can be excruciating. Nasal congestion is commonly associated with this type of headache.

Rationale 2: Migraine headaches are associated with an aura, nausea, tremors, and vertigo.

Rationale 3: Tension headaches are also known as a muscle contraction headache. The onset for tension headaches is gradual and the pain is steady.

Rationale 4: Hydrocephalus is not a type of headache.

Global Rationale: Cluster headaches can occur over time. They have no associated aura. They are often unilateral and can be excruciating. Nasal congestion is commonly associated with this type of headache. Migraine headaches are associated with an aura, nausea, tremors, and vertigo. Tension headaches are also known as a muscle contraction headache. The onset for tension headaches is gradual and the pain is steady. Hydrocephalus is not a type of headache.

Cognitive Level: Understanding

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 12.4: Differentiate normal from abnormal findings in physical assessment of the head, neck, and related structures.

Question 29

Type: MCSA

The nurse is assessing a newborn infant and notes that the infants 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

Correct Answer: 2

Rationale 1: Craniosynostosis is early closure of the sutures, which causes head elongation.

Rationale 2: Hydrocephalus is enlargement of the head caused by inadequate drainage of cerebrospinal fluid.

Rationale 3: Acromegaly is enlargement of the skull and cranial bones due to increased growth hormone, which would not be the cause in an infant. Acromegaly is usually found in adult clients.

Rationale 4: Fetal alcohol syndrome causes specific types of facial deformities such as a small head circumference, small widely spaced eyes, and a flat mid-facial area.

Global Rationale: Hydrocephalus is enlargement of the head caused by inadequate drainage of cerebrospinal fluid. Craniosynostosis is early closure of the sutures, which causes head elongation. Acromegaly is enlargement of the skull and cranial bones due to increased growth hormone, which would not be the cause in an infant. Acromegaly is usually found in adult clients. Fetal alcohol syndrome causes specific types of facial deformities such as a small head circumference, small widely spaced eyes, and a flat mid-facial area.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 12.4: Differentiate normal from abnormal findings in physical assessment of the head, neck, and related structures.

Question 30

Type: MCMA

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

Standard Text: Select all that apply.

1. Slanted eyes

2. Cleft palate and lip

3. Protruding tongue

4. Shortened neck

5. Drooping eyelids

Correct Answer: 1,3,4

Rationale 1: Slanted eyes: An associated characteristic of a client with Down syndrome is slanted eyes.

Rationale 2: Cleft palate and lip: Down syndrome is not associated with a cleft palate and lip.

Rationale 3: Protruding tongue: An associated characteristic of a client with Down syndrome is a protruding tongue.

Rationale 4: Shortened neck: An associated characteristic of a client with Down syndrome is a shortened neck.

Rationale 5: Drooping eyelids: Down syndrome is not associated with drooping eyelids.

Global Rationale: Associated characteristics of a client with Down syndrome are slanted eyes, a protruding tongue, and a shortened neck. Cleft palate and lip and drooping eyelids are not characteristics associated with Down syndrome.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 12.4: Differentiate normal from abnormal findings in physical assessment of the head, neck, and related structures.

Question 31

Type: MCSA

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

Correct Answer: 2

Rationale 1: The ingestion of alcohol is not necessarily associated with thyroid function.

Rationale 2: Production of thyroid hormone decreases with age, and older adults, regardless of gender, should have annual thyroid screening and monitoring of thyroid hormone levels.

Rationale 3: Education about congenital abnormalities is most appropriate to teach to a pregnant woman with risk factors associated with these types of problems.

Rationale 4: Birth control education is probably less appropriate to teach to an older adult client.

Global Rationale: The ingestion of alcohol is not necessarily associated with thyroid function. Production of thyroid hormone decreases with age, and older adults, regardless of gender, should have annual thyroid screening and monitoring of thyroid hormone levels. Education about congenital abnormalities is most appropriate to teach to a pregnant woman with risk factors associated with these types of problems. Birth control education is probably less appropriate to teach to an older adult client.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 12. 5: Describe developmental, psychosocial, cultural, and environmental variations in assessment techniques and findings.

Question 32

Type: MCMA

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?

Standard Text: Select all that apply.

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.

Correct Answer: 1,2,5

Rationale 1: The parents of a newborn should be educated about the clinical manifestations associated with hyperthyroidism. Parents of newborns should be educated about the clinical manifestations associated with hypothyroidism. Hypothyroidism in newborns is a very serious condition and may even be fatal.

Rationale 2: Thyroid disease more frequently affects males than females. Women are more likely to develop thyroid disease. Women are advised to have thyroid screening diagnostic tests performed if they have a family history of the disease.

Rationale 3: Immigrants may have an increased risk of disorders related to thyroid function. Iodine deficiency leads to thyroid dysfunction and may occur more often in immigrant populations.

Rationale 4: Depression in older adults may be linked to hypothyroidism. Older adults with depression should be evaluated for hypothyroidism.

Rationale 5: The iodine added to some medications may be linked to hypothyroidism in the clients who use these medications. Medications with iodine can increase the clients risk of developing hyperthyroidism, not hypothyroidism.

Global Rationale: Parents of newborns should be educated about the clinical manifestations associated with hypothyroidism. Hypothyroidism in newborns is a very serious condition and may even be fatal. Women are more likely to develop thyroid disease. Women are advised to have thyroid screening diagnostic tests performed if they have a family history of the disease. Iodine deficiency leads to thyroid dysfunction and may occur more often in immigrant populations. Older adults with depression should be evaluated for hypothyroidism. Medications with iodine can increase the clients risk of developing hyperthyroidism, not hypothyroidism.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 12.6: Discuss the objectives related to the overall health of the head, neck, and related lymphatics as presented in Healthy People 2020.

Question 33

Type: MCMA

The nurse is assessing the client. The client is irritable, anxious, and has lost 12 pounds over the last 2 months. The clients 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?

Standard Text: Select all that apply.

1. Blood pressure: 162/92

2. Apical pulse: 120

3. Respiratory rate: 11

4. Pupils: constricted

5. Client complains of feeling very warm.

Correct Answer: 1,2,5

Rationale 1: Blood pressure: 162/92. When the sympathetic nervous system is stimulated due to hyperthyroidism, the clients blood pressure will increase. This blood pressure is increased.

Rationale 2: Apical pulse: 120. When the sympathetic nervous system is stimulated due to hyperthyroidism, the clients heart rate will increase. A normal heart rate for an adult client is 60100 beats per minute.

Rationale 3: Respiratory rate: 11. The client with hyperthyroidism will demonstrate an increased respiratory rate. A normal respiratory rate is 1220 per minute.

Rationale 4: Pupils: constricted. The client with hyperthyroidism will demonstrate pupil dilation.

Rationale 5: Client complains of feeling very warm. When the sympathetic nervous system is stimulated due to hyperthyroidism, the clients body temperature will increase.

Global Rationale: When the sympathetic nervous system is stimulated due to hyperthyroidism, the clients blood pressure, heart rate, and body temperature will increase. This blood pressure and heart rate are increased. Complaints of feeling warm are related to increased body temperature. The client with hyperthyroidism will demonstrate an increased respiratory rate. A normal respiratory rate is 1220 per minute. The client with hyperthyroidism will demonstrate pupil dilation.

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 12.7: Apply critical thinking in selected simulations related to physical assessment of the head, neck, and related structures.

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