NURSING HEALTH ASSESSMENT 3rd Edition By Dillon – Test Bank

 

 

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Sample Test

Chapter 03: Assessing the Head, Face, and Neck

 

Multiple Choice

Identify the choice that best completes the statement or answers the question.

 

____    1.   The nurse is assessing the patient’s turbinates. Which is an expected finding?

1)	Dry and pink
2)	Moist and pink
3)	Dry and dark red
4)	Moist and dark red

 

 

____    2.   The nurse is assessing the patient’s soft palate and notes erythema. Which is the possible reason for this finding?

1)	Congenital defect
2)	Cleft palate
3)	Infection
4)	Trauma

 

 

____    3.   During a patient assessment, the nurse suspects that the patient may have cardiovascular disease. Which assessment finding supports the nurse’s suspicion?

1)	Facial edema
2)	Jaw pain
3)	Facial spasm
4)	Temporal pain

 

 

____    4.   Which cluster of assessment findings would the nurse expect to find in association with acute bacterial sinusitis?

1)	Inflamed nasal mucosa; yellow drainage on posterior pharynx; perforated septum
2)	Yellow drainage on the posterior pharynx; pale and boggy nasal mucosa; fever
3)	Pale, boggy nasal mucosa; fever; perforated septum
4)	Inflamed nasal mucosa; yellow drainage on the posterior pharynx; fever

 

 

____    5.   Which disease process is associated with tender, palpable cervical nodes along with painful vesicles?

1)	Herpes simplex virus
2)	Hyperthyroidism
3)	Temporal arteritis
4)	Allergic rhinitis

 

 

____    6.   The nurse is conducting a head, face, and neck assessment for a toddler-age patient. Which finding is expected for a patient of this age?

1)	Anterior fontanel 2 cm open
2)	Posterior fontanel 2 cm open
3)	Anterior fontanel open, posterior fontanel closed
4)	Anterior and posterior fontanels closed

 

 

____    7.   Which male patient is likely to have the least facial hair?

1)	Chinese American
2)	African American
3)	Irish American
4)	Hispanic

 

 

____    8.   A patient presents to the emergency department complaining of headache. Which is the priority question when assessing this patient’s symptoms?

1)	“Have you been diagnosed with temporomandibular joint (TMJ) syndrome?”
2)	“Have you had any recent trauma or injury?”
3)	“How often do you experience migraines?”
4)	“Have you recently experienced any neck strain?”

 

 

____    9.   The nurse is assessing the head, face, and neck of a patient and notes a painless area of white, adherent mucosal thickening on the left buccal mucosa. The patient admits to being a smoker. Which is the most likely diagnosis for this patient?

1)	Erythroplakia
2)	Leukoplakia
3)	Herpes simplex virus
4)	Candidiasis

 

 

____  10.   The patient has a lobulated, bony growth noted midline on the hard palate that is covered with mucosa consistent with that of the surrounding areas. Based on this data, which diagnosis does the nurse anticipate?

1)	Oral cancer
2)	Frenulumitis
3)	Torus palatinus
4)	Kaposi sarcoma

 

 

____  11.   While examining the throat, the nurse notes that the patient’s tonsils bilaterally extend beyond the anterior pillars and almost to the uvula. Which is an appropriate grade based on this data?

1)	Grade 1 +
2)	Grade 2 +
3)	Grade 3 +
4)	Grade 4 +

 

 

____  12.   Which structure, if located on the floor of the mouth, would be considered an abnormal finding?

1)	Frenulum
2)	Wharton duct
3)	Stensen duct
4)	Uvula

 

 

____  13.   Which group of cervical nodes is palpable under the tip of the chin?

1)	Submandibular
2)	Submaxillary
3)	Tonsillar
4)	Submental

 

 

____  14.   During a neck exam, the nurse identifies a 1.5-cm hard, nonpainful anterior cervical node with an irregular surface. Based on this data, which does the nurse suspect?

1)	Infection
2)	Allergy
3)	Malignancy
4)	Edema

 

 

____  15.   The nurse is conducting a neck assessment. Which instructions should be given to the patient when palpating the left thyroid lobe?

1)	Ask the patient to lean the neck to the right side.
2)	Ask the patient to take a sip of water.
3)	Ask the patient to hold her or his breath.
4)	Ask the patient to hyperextend the neck.

 

 

____  16.   Upon assessment, the nurse notes the patient has an enlarged thyroid. Which action is most appropriate?

1)	Document this as a normal finding
2)	Prepare the patient for the diagnosis of cancer
3)	Notify the healthcare provider
4)	Further assess for tenderness and nodules

 

 

____  17.   The nurse is providing care to a patient with allergic rhinitis. Which is an unexpected finding during the physical assessment?

1)	Pale and boggy mucosa
2)	Tender, palpable cervical nodes
3)	Periorbital puffiness
4)	History of allergic disorders

 

 

____  18.   A student is rushed to the school health clinic because of a nosebleed. The towel being held to the student’s nose is saturated with blood. When the towel is removed, the bleeding continues in large quantities and is deep red. Which is the priority for the nurse to determine during the assessment process?

1)	Whether the classroom environment is particularly dry
2)	History of sinusitis symptoms or exposure
3)	History of trauma before the onset of bleeding
4)	Family history of nosebleeds

 

 

____  19.   The patient is complaining of a severe sore throat. Upon assessment the nurse notes the patient has a fever; large, tender cervical lymph nodes; a deeply inflamed pharynx with exudate; and a diffuse sandpaper-like rash. Based on this data, which diagnosis does the nurse suspect?

1)	Mononucleosis
2)	Streptococcal pharyngitis
3)	Viral pharyngitis
4)	Candida albicans

 

 

____  20.   The nurse is assessing a pregnant patient. Which clinical manifestation does the nurse anticipate for this patient?

1)	Enlarged cervical lymph nodes
2)	Palatal petechiae
3)	Pharyngitis
4)	Nasal stuffiness

 

 

____  21.   The nurse conducts an oral examination for a patient and notes a precancerous lesion. Which term will the nurse use when documenting this finding?

1)	Herpes simplex
2)	Cheilitis
3)	Leukoplakia
4)	Cheilosis

 

 

____  22.   The nurse is conducting a neck assessment for a patient. The nurse inspects the neck in a neutral straight position. Which other assessment of the neck is appropriate?

1)	In a flexed position
2)	As the patient swallows
3)	In a lateral position
4)	As the patient holds his or her breath

 

 

____  23.   To palpate the thyroid gland, the isthmus of the thyroid is located directly below which structure?

1)	Thyroid cartilage
2)	Hyoid bone
3)	Cricoid cartilage
4)	Tracheal rings

 

 

____  24.   To facilitate palpation of the thyroid gland, which will the nurse ask the patient to do?

1)	Hyperextend the neck
2)	Swallow
3)	Cough
4)	Extend the neck

 

 

____  25.   Which statement is true concerning the thyroid gland?

1)	The thyroid gland is usually not palpable.
2)	The thyroid gland is always palpable.
3)	The thyroid gland is more likely palpable in overweight patients.
4)	The thyroid gland is never palpable.

 

 

Completion

Complete each statement.

 

26.  During an assessment of a school-age patient the nurse expects the sinuses may be underdeveloped because sinuses do not fully develop until the age of ____________________.

 

27.  A preschool-age patient is diagnosed with a sinus infection. Tetracycline is prescribed by the healthcare provider. The nurse questions this prescription because patients younger than ____________________ years may develop enamel hypoplasia as a result of this medication.

 

28.  When assessing an adult patient’s mouth who has not had the wisdom teeth removed the nurse anticipates the patient will have ____________________ teeth.

 

29.  The nurse is assessing an older adolescent patient who has had the wisdom teeth removed. The nurse anticipates that this patient will have ____________________ teeth.

 

30.  During the assessment of a preschool-age patient, the nurse expects the patient to have ____________________ teeth.

 

31.  The nurse is assessing a patient’s tongue mobility by assessing cranial nerve (CN) ____________________.

 

Multiple Response

Identify one or more choices that best complete the statement or answer the question.

 

____  32.   The nurse notes bulging fontanels when assessing an infant’s head. Which are likely causes for this assessment finding? Select all that apply.

1)	Dehydration
2)	Hydrocephalus
3)	Increased intracranial pressure
4)	Temporal arteritis
5)	TMJ syndrome

 

 

____  33.   The nurse is assessing a patient who experienced a cerebrovascular accident (CVA) 24 hours ago. The patient does not have a gag reflex. Which conclusions by the nurse are appropriate based on this data? Select all that apply.

1)	Damage to cranial nerve IX
2)	Damage to cranial nerve X
3)	Risk for aspiration
4)	Potential malignancy
5)	Herpes simplex virus

 

 

____  34.   Which actions by the nurse are appropriate when auscultating the thyroid during a physical assessment? Select all that apply.

1)	Using the diaphragm of the stethoscope
2)	Using the bell of the stethoscope
3)	Asking the patient to take deep breaths
4)	Asking the patient to hold the breath
5)	Using the finger pads for palpation

 

 

____  35.   Which muscles allow for movement, eating, and communication? Select all that apply.

1)	Facial
2)	Mouth
3)	Neck
4)	Carotid
5)	Jugular

 

 

____  36.   The nurse is assessing an older adult patient. Which findings does the nurse anticipate during the assessment process? Select all that apply.

1)	The appearance of gum hypertrophy.
2)	The development of gum disease.
3)	A decrease in salivation.
4)	An increase in the sense of smell.
5)	An increase in the sense of taste.

 

 

____  37.   The nurse is conducting a health history on a patient who presents with epistaxis. Which questions are appropriate by the nurse? Select all that apply.

1)	“Have you had similar congestion before?”
2)	“When is the congestion at its worst?”
3)	“At what age did you have your first nosebleed?”
4)	“Can you describe a typical nosebleeding episode?’
5)	“Do you have a personal or family history of hypertension?”

 

Chapter 03: Assessing the Head, Face, and Neck

Answer Section

 

MULTIPLE CHOICE

 

1.    ANS:  2

Chapter number and title: 3, Assessing the Head, Face, and Neck

Chapter learning objective: N/A

Chapter page reference: 88

Integrated Processes: Nursing Process: Evaluation

Client Need: Health Promotion and Maintenance

Cognitive level: Comprehension [Understanding]

Concept: Assessment, Oxygenation

Difficulty: Easy

	Feedback
1	Turbinates should not be dry and pink.
2	The turbinates are bony conchae (folds) of the internal nasal walls that increase the surface area for air to be filtered, warmed, and humidified before entering the lungs. The turbinates should be pink and moist.
3	Turbinates should not be dry and dark red.
4	Turbinates should not be moist and dark red.

 

 

PTS:   1                    CON:  Assessment | Oxygenation

 

2.    ANS:  3

Chapter number and title: 3, Assessing the Head, Face, and Neck

Chapter learning objective: N/A

Chapter page reference: 100

Integrated Processes: Nursing Process: Evaluation

Client Need: Physiological Integrity: Physiological Adaptation

Cognitive level: Knowledge [Remembering]

Concept: Assessment, Oxygenation

Difficulty: Easy

	Feedback
1	Perforation of the palate could indicate a congenital defect, cleft palate, trauma, or drug use.
2	Perforation of the palate could indicate a congenital defect, cleft palate, trauma, or drug use.
3	The soft palate is posterior to the hard palate and elevates when swallowing to prevent food and saliva from entering the nasopharynx. Erythema, exudate, or lesions indicate an infectious process.
4	Perforation of the palate could indicate a congenital defect, cleft palate, trauma, or drug use.

 

 

PTS:   1                    CON:  Assessment | Oxygenation

 

3.    ANS:  2

Chapter number and title: 3, Assessing the Head, Face, and Neck

Chapter learning objective: N/A

Chapter page reference: 82

Integrated Processes: Nursing Process: Assessment

Client Need: Physiological Integrity: Physiological Adaptation

Cognitive level: Comprehension [Understanding]

Concept: Perfusion

Difficulty: Easy

	Feedback
1	Facial edema can reflect fluid retention.
2	Infarct or ischemia pain may radiate to the jaw or throat.
3	Facial spasm is not indicative of cardiovascular disease.
4	Temporal pain is not indicative of cardiovascular disease.

 

 

PTS:   1                    CON:  Perfusion

 

4.    ANS:  4

Chapter number and title: 3, Assessing the Head, Face, and Neck

Chapter learning objective: N/A

Chapter page reference: 88

Integrated Processes: Nursing Process: Assessment

Client Need: Physiological Integrity: Physiological Adaptation

Cognitive level: Analysis [Analyzing]

Concept: Oxygenation, Infection

Difficulty: Difficult

	Feedback
1	A perforated septum is not an expected finding with acute bacterial sinusitis.
2	Pale and boggy nasal mucosa are not an expected finding with acute bacterial sinusitis.
3	Although fever is expected with acute bacterial sinusitis, the other two symptoms listed are not expected.
4	Symptoms of acute sinusitis are mucopurulent nasal discharge, postnasal drainage, cough, fever, inflammation of the mucosa, tenderness over sinuses, periorbital swelling, and facial pain.

 

 

PTS:   1                    CON:  Oxygenation | Infection

 

5.    ANS:  1

Chapter number and title: 3, Assessing the Head, Face, and Neck

Chapter learning objective: N/A

Chapter page reference: 103

Integrated Processes: Nursing Process: Assessment

Client Need: Physiological Integrity: Physiological Adaptation

Cognitive level: Knowledge [Remembering]

Concept: Infection

Difficulty: Easy

	Feedback
1	Tender, enlarged lymph nodes and clustered, small (3- to 4-mm) vesicles on the mucosa characterize the herpes simplex virus. Vesicles rupture and form ulcers. Also, there is severe pain, fever, and history of previous episodes.
2	These symptoms do not indicate hyperthyroidism.
3	These symptoms do not indicate temporal arteritis.
4	These symptoms do not indicate allergic rhinitis.

 

 

PTS:   1                    CON:  Infection

 

6.    ANS:  4

Chapter number and title: 3, Assessing the Head, Face, and Neck

Chapter learning objective: N/A

Chapter page reference: 101

Integrated Processes: Nursing Process: Assessment

Client Need: Health Promotion and Maintenance

Cognitive level: Knowledge [Remembering]

Concept: Development

Difficulty: Easy

	Feedback
1	The anterior fontanel is expected to be closed by this time.
2	The posterior fontanel is expected to be closed by this time.
3	Both fontanels are expected to be closed by this time.
4	The fontanels (anterior, posterior, anterolateral, and posterolateral), which are the openings between the skull bones, remain open for growth, but close by 18 to 24 months of age.

 

 

PTS:   1                    CON:  Development

 

7.    ANS:  1

Chapter number and title: 3, Assessing the Head, Face, and Neck

Chapter learning objective: N/A

Chapter page reference: 74

Integrated Processes: Nursing Process: Assessment

Client Need: Health Promotion and Maintenance

Cognitive level: Knowledge [Remembering]

Concept: Assessment, Diversity

Difficulty: Easy

	Feedback
1	Cultural variations are noted in skin textures and hair growth patterns. Chinese Americans normally have little facial hair.
2	Cultural variations are noted in skin textures and hair growth patterns. African Americans may develop facial pseudofolliculitis (razor bumps).
3	Cultural variations are noted in skin textures and hair growth patterns. An Irish American patient is not expected to have little facial hair.
4	Cultural variations are noted in skin textures and hair growth patterns. An Hispanic patient is not expected to have little facial hair.

 

 

PTS:   1                    CON:  Assessment | Diversity

 

8.    ANS:  2

Chapter number and title: 3, Assessing the Head, Face, and Neck

Chapter learning objective: N/A

Chapter page reference: 74

Integrated Processes: Nursing Process: Assessment

Client Need: Physiological Integrity: Physiological Adaptation

Cognitive level: Analysis [Analyzing]

Concept: Neurologic Regulation

Difficulty: Moderate

	Feedback
1	A patient who presents with jaw pain should be asked whether they are diagnosed with TMJ.
2	Appropriate questions to ask for any patient who presents with a headache is to determine how long the pain has been going on and whether the patient has experienced a recent head trauma or injury.
3	Although it may be appropriate to ask the patient how often they experience migraines, the priority is to determine whether the patient recently experience head trauma or injury.
4	Asking about neck strain is more appropriate if the patient presents with neck pain.

 

 

PTS:   1                    CON:  Neurologic Regulation

 

9.    ANS:  2

Chapter number and title: 3, Assessing the Head, Face, and Neck

Chapter learning objective: N/A

Chapter page reference: 92

Integrated Processes: Nursing Process: Evaluation

Client Need: Physiological Integrity: Physiological Adaptation

Cognitive level: Application [Applying]

Concept: Cellular Regulation

Difficulty: Moderate

	Feedback
1	Erythroplakia is a red precancerous lesion.
2	When oral lesions are painless, they may be caused by secondary syphilis, leukoplakia (a precancerous lesion), or a malignancy.
3	Herpes simplex virus may cause a painful lesion.
4	Candidiasis is a fungal infection that causes white patches to appear on the tongue and cheeks.

 

 

PTS:   1                    CON:  Cellular Regulation

 

10.  ANS:  3

Chapter number and title: 3, Assessing the Head, Face, and Neck

Chapter learning objective: N/A

Chapter page reference: 93

Integrated Processes: Nursing Process: Evaluation

Client Need: Health Promotion and Maintenance

Cognitive level: Application [Applying]

Concept: Digestion

Difficulty: Moderate

	Feedback
1	These findings do not indicate oral cancer, frenulumitis, or Kaposi sarcoma.
2	These findings do not indicate oral cancer, frenulumitis, or Kaposi sarcoma.
3	Torus palatinus, a bony, mucosa-covered projection on the hard palate, and torus mandible, a similar growth on the floor of mouth, are normal variations.
4	These findings do not indicate oral cancer, frenulumitis, or Kaposi sarcoma.

 

 

PTS:   1                    CON:  Digestion

 

11.  ANS:  2

Chapter number and title: 3, Assessing the Head, Face, and Neck

Chapter learning objective: N/A

Chapter page reference: 99

Integrated Processes: Nursing Process: Evaluation

Client Need: Physiological Integrity: Physiological Adaptation

Cognitive level: Application [Applying]

Concept: Inflammation

Difficulty: Moderate

	Feedback
1	This is not a description of a grade 1 +.
2	Specific tonsil grades are described based on tonsil enlargement. A patient with a grade 2 + has tonsils that extend to just beyond the arches.
3	This is not a description of a grade 3 +.
4	This is not a description of a grade 4 +.

 

 

PTS:   1                    CON:  Inflammation

 

12.  ANS:  3

Chapter number and title: 3, Assessing the Head, Face, and Neck

Chapter learning objective: N/A

Chapter page reference: 93

Integrated Processes: Nursing Process: Assessment

Client Need: Physiological Integrity: Physiological Adaptation

Cognitive level: Knowledge [Remembering]

Concept: Digestion

Difficulty: Moderate

	Feedback
1	The frenulum is located between the submandibular glands.
2	Wharton ducts, openings for the submandibular glands, are located on either side of the frenulum.
3	Stensen ducts, openings for the parotid glands, are located on the buccal mucosa at the point of the second molars.
4	The uvula is located between the tonsils.

 

 

PTS:   1                    CON:  Digestion

 

13.  ANS:  4

Chapter number and title: 3, Assessing the Head, Face, and Neck

Chapter learning objective: N/A

Chapter page reference: 101

Integrated Processes: Nursing Process: Assessment

Client Need: Health Promotion and Maintenance

Cognitive level: Knowledge [Remembering]

Concept: Assessment

Difficulty: Easy

	Feedback
1	The submandibular/submaxillary nodes are located under the jaw.
2	The submandibular/submaxillary nodes are located under the jaw.
3	The tonsillar nodes are located at the angle of the jaw.
4	Submental nodes are located under the tip of the chin.

 

 

PTS:   1                    CON:  Assessment

 

14.  ANS:  3

Chapter number and title: 3, Assessing the Head, Face, and Neck

Chapter learning objective: N/A

Chapter page reference: 106

Integrated Processes: Nursing Process: Evaluation

Client Need: Physiological Integrity: Physiological Adaptation

Cognitive level: Comprehension [Understanding]

Concept: Cellular Regulation

Difficulty: Difficult

	Feedback
1	Tender nodes may be present with infection.
2	Allergies and edema do not usually affect nodes.
3	Malignancy is characterized as an enlarged, irregular, hard, nontender, immobile node.
4	Allergies and edema do not usually affect nodes.

 

 

PTS:   1                    CON:  Cellular Regulation

 

15.  ANS:  2

Chapter number and title: 3, Assessing the Head, Face, and Neck

Chapter learning objective: N/A

Chapter page reference: 100

Integrated Processes: Nursing Process: Assessment

Client Need: Health Promotion and Maintenance

Cognitive level: Application [Applying]

Concept: Assessment

Difficulty: Moderate

	Feedback
1	The nurse does not ask the patient to lean the neck to the right side.
2	To palpate the thyroid, use an anterior or a posterior approach. The patient is often asked to swallow water to enhance palpation of the thyroid gland, which moves during the act of swallowing.
3	The nurse does not ask the patient to hold the breath.
4	The nurse does not ask the patient to hyperextend the neck.

 

 

PTS:   1                    CON:  Assessment

 

16.  ANS:  4

Chapter number and title: 3, Assessing the Head, Face, and Neck

Chapter learning objective: N/A

Chapter page reference: 105

Integrated Processes: Nursing Process: Planning

Client Need: Physiological Integrity: Physiological Adaptation

Cognitive level: Comprehension [Understanding]

Concept: Cellular Regulation, Inflammation, Infection

Difficulty: Moderate

	Feedback
1	These are not normal findings.
2	The findings are not normal, but it is premature to prepare the patient for a possible diagnosis of cancer.
3	The nurse would assess this patient further before notifying the healthcare provider.
4	A patient who presents with an enlarged thyroid gland will require further assessment of signs and symptoms, including assessing for tenderness and nodules. The nurse would notify the healthcare provider, but not until further assessment has been conducted.

 

 

PTS:   1                    CON:  Cellular Regulation | Inflammation | Infection

 

17.  ANS:  2

Chapter number and title: 3, Assessing the Head, Face, and Neck

Chapter learning objective: N/A

Chapter page reference: 106

Integrated Processes: Nursing Process: Assessment

Client Need: Physiological Integrity, Physiological Adaptation

Cognitive level: Application [Applying]

Concept: Inflammation

Difficulty: Difficult

	Feedback
1	Pale, boggy mucosa is an expected finding for allergic rhinitis.
2	Tender, palpable cervical nodes are not expected for a patient experiencing allergies.
3	Periorbital puffiness is an expected finding for allergic rhinitis.
4	A history of allergic disorders is an expected finding for allergic rhinitis.

 

 

PTS:   1                    CON:  Inflammation

 

18.  ANS:  3

Chapter number and title: 3, Assessing the Head, Face, and Neck

Chapter learning objective: N/A

Chapter page reference: 75

Integrated Processes: Nursing Process: Assessment

Client Need: Physiological Integrity: Physiological Adaptation

Cognitive level: Synthesis [Creating]

Concept: Inflammation

Difficulty: Difficult

	Feedback
1	Although a dry environment can cause epistaxis, this is not the priority.
2	Although a history of sinusitis can cause epistaxis, this is not the priority.
3	History of present illness or injury takes precedence in an emergency situation.
4	Although a history of family nosebleeds is an appropriate question to ask, this is not the priority.

 

 

PTS:   1                    CON:  Inflammation

 

19.  ANS:  2

Chapter number and title: 3, Assessing the Head, Face, and Neck

Chapter learning objective: N/A

Chapter page reference: 99

Integrated Processes: Nursing Process: Evaluation

Client Need: Physiological Integrity: Physiological Adaptation

Cognitive level: Analysis [Analyzing]

Concept: Infection

Difficulty: Difficult

	Feedback
1	The nurse would suspect mononucleosis with lymph node enlargement.
2	Strep pharyngitis has the same symptoms as viral pharyngitis with the addition of increased fever, dysphagia, abdominal pain, nausea and/or vomiting, headache, increased exudates, and sandpaper rash.
3	Strep pharyngitis has the same symptoms as viral pharyngitis with the addition of increased fever, dysphagia, abdominal pain, nausea and/or vomiting, headache, increased exudates, and sandpaper rash.
4	Candida albicans is a fungal infection that does not present with these symptoms.

 

 

PTS:   1                    CON:  Infection

 

20.  ANS:  4

Chapter number and title: 3, Assessing the Head, Face, and Neck

Chapter learning objective: N/A

Chapter page reference: 81

Integrated Processes: Nursing Process: Assessment

Client Need: Health Promotion and Maintenance

Cognitive level: Application [Applying]

Concept: Pregnancy

Difficulty: Moderate

	Feedback
1	Enlarged cervical lymph nodes, palatal petechiae, and pharyngitis are not expected findings during pregnancy.
2	Enlarged cervical lymph nodes, palatal petechiae, and pharyngitis are not expected findings during pregnancy.
3	Enlarged cervical lymph nodes, palatal petechiae, and pharyngitis are not expected findings during pregnancy.
4	Pregnant patients often experience nasal stuffiness during the pregnancy.

 

 

PTS:   1                    CON:  Pregnancy

 

21.  ANS:  3

Chapter number and title: 3, Assessing the Head, Face, and Neck

Chapter learning objective: N/A

Chapter page reference: 92

Integrated Processes: Communication and Documentation

Client Need: Physiological Integrity: Physiological Adaptation

Cognitive level: Application [Applying]

Concept: Cellular Regulation, Communication

Difficulty: Moderate

	Feedback
1	Herpes simplex, cheilitis, and cheilosis are not appropriate terms when documenting this finding.
2	Herpes simplex, cheilitis, and cheilosis are not appropriate terms when documenting this finding.
3	The term used to document a precancerous lesion is leukoplakia.
4	Herpes simplex, cheilitis, and cheilosis are not appropriate terms when documenting this finding.

 

 

PTS:   1                    CON:  Cellular Regulation | Communication

 

22.  ANS:  2

Chapter number and title: 3, Assessing the Head, Face, and Neck

Chapter learning objective: N/A

Chapter page reference: 100

Integrated Processes: Nursing Process: Assessment

Client Need: Health Promotion and Maintenance

Cognitive level: Application [Applying]

Concept: Assessment

Difficulty: Moderate

	Feedback
1	Having the patient flex and lateral bend is useful in assessing range of motion of the neck.
2	Inspect neck from neutral position, when hyperextended, and when the patient swallows water.
3	Having the patient flex and lateral bend is useful in assessing range of motion of the neck.
4	Having the patient hold the breath is important when assessing the carotid arteries for bruits.

 

 

PTS:   1                    CON:  Assessment

 

23.  ANS:  3

Chapter number and title: 3, Assessing the Head, Face, and Neck

Chapter learning objective: N/A

Chapter page reference: 100

Integrated Processes: Nursing Process: Assessment

Client Need: Health Promotion and Maintenance

Cognitive level: Knowledge [Remembering]

Concept: Assessment

Difficulty: Easy

	Feedback
1	The isthmus does not lie below the thyroid cartilage.
2	The isthmus does not lie below the hyoid bone.
3	The isthmus, which connects the two lobes, lies below the cricoid cartilage.
4	The isthmus does not lie below the tracheal rings.

 

 

PTS:   1                    CON:  Assessment

 

24.  ANS:  2

Chapter number and title: 3, Assessing the Head, Face, and Neck

Chapter learning objective: N/A

Chapter page reference: 100

Integrated Processes: Nursing Process: Assessment

Client Need: Health Promotion and Maintenance

Cognitive level: Application [Applying]

Concept: Assessment

Difficulty: Moderate

	Feedback
1	Extending and hyperextending the neck is useful in assessing range of motion of the neck.
2	The thyroid gland moves with swallowing. Have the patient drink water while palpating the gland to facilitate palpation.
3	Having the patient cough is useful in testing cranial nerves (CNs) IX and X.
4	Extending and hyperextending the neck is useful in assessing range of motion of the neck.

 

 

PTS:   1                    CON:  Assessment

 

25.  ANS:  1

Chapter number and title: 3, Assessing the Head, Face, and Neck

Chapter learning objective: N/A

Chapter page reference: 104

Integrated Processes: Nursing Process: Assessment

Client Need: Health Promotion and Maintenance

Cognitive level: Knowledge [Remembering]

Concept: Assessment

Difficulty: Easy

	Feedback
1	The thyroid gland is usually nonpalpable.
2	The thyroid gland is usually nonpalpable. However the edge of the gland may be felt in very thin or pregnant patients.
3	The likelihood of palpating the thyroid increases with very thin patients, not overweight patients.
4	The thyroid gland is usually nonpalpable, but some tissue may be palpable in very thin or pregnant patients.

 

 

PTS:   1                    CON:  Assessment

 

COMPLETION

 

26.  ANS:

7

Feedback: Sinuses are not fully developed until the age of 7.

 

Chapter number and title: 3, Assessing the Head, Face, and Neck

Chapter learning objective: N/A

Chapter page reference: 74

Integrated Processes: Nursing Process: Assessment

Client Need: Health Promotion and Maintenance

Cognitive level: Knowledge [Remembering]

Concept: Assessment

Difficulty: Easy

 

PTS:   1                    CON:  Assessment

 

27.  ANS:

7

Feedback: Tetracycline is associated with enamel hypoplasia and permanent yellow-gray to brown tooth discoloration in children younger than the age of 8 and in offspring of pregnant patients.

 

 

Chapter number and title: 3, Assessing the Head, Face, and Neck

Chapter learning objective: N/A

Chapter page reference: 78

Integrated Processes: Nursing Process: Implementation

Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies

Cognitive level: Knowledge [Remembering]

Concept: Nursing Process, Medication

Difficulty: Easy

 

PTS:   1                    CON:  Nursing Process | Medication

 

28.  ANS:

32

Feedback: The adult patient who has not had the wisdom teeth removed is expected to have 32 teeth.

 

Chapter number and title: 3, Assessing the Head, Face, and Neck

Chapter learning objective: N/A

Chapter page reference: 96

Integrated Processes: Nursing Process: Assessment

Client Need: Health Promotion and Maintenance

Cognitive level: Knowledge [Remembering]

Concept: Assessment

Difficulty: Easy

 

PTS:   1                    CON:  Assessment

 

29.  ANS:

28

Feedback: An older adolescent patient who has had the wisdom teeth removed is expected to have 28 teeth.

 

Chapter number and title: 3, Assessing the Head, Face, and Neck

Chapter learning objective: N/A

Chapter page reference: 96

Integrated Processes: Nursing Process: Assessment

Client Need: Health Promotion and Maintenance

Cognitive level: Knowledge [Remembering]

Concept: Assessment

Difficulty: Easy

 

PTS:   1                    CON:  Assessment

 

30.  ANS:

20

Feedback: A preschool-age patient is expected to have 20 teeth.

 

Chapter number and title: 3, Assessing the Head, Face, and Neck

Chapter learning objective: N/A

Chapter page reference: 96

Integrated Processes: Nursing Process: Assessment

Client Need: Health Promotion and Maintenance

Cognitive level: Knowledge [Remembering]

Concept: Assessment

Difficulty: Easy

 

PTS:   1                    CON:  Assessment

 

31.  ANS:

XII

Feedback: The nurse assesses tongue mobility when testing CN XII.

 

Chapter number and title: 3, Assessing the Head, Face, and Neck

Chapter learning objective: N/A

Chapter page reference: 97

Integrated Processes: Nursing Process: Assessment

Client Need: Health Promotion and Maintenance

Cognitive level: Comprehension [Understanding]

Concept: Assessment

Difficulty: Easy

 

PTS:   1                    CON:  Assessment

 

MULTIPLE RESPONSE

 

32.  ANS:  2, 3

Chapter number and title: 3, Assess the Head, Face, and Neck

Chapter learning objective: N/A

Chapter page reference: 101

Integrated Processes: Nursing Process: Assessment

Client Need: Physiological Integrity: Physiological Adaptation

Cognitive level: Comprehension [Understanding]

Concept: Assessment

Difficulty: Easy

 

	Feedback
1.	This is incorrect. Dehydration will cause sunken, not bulging, fontanels.
2.	This is correct. Hydrocephalus is one condition that can cause bulging fontanels.
3.	This is correct. Increased intracranial pressure is one condition that can cause bulging fontanels.
4.	This is incorrect. Temporal arteritis causes facial tenderness, not a bulging fontanel.
5.	This is incorrect. TMJ syndromes causes facial tenderness, not a bulging fontanel.

 

 

PTS:   1                    CON:  Assessment

 

33.  ANS:  1, 2, 3

Chapter number and title: 3, Assessing the Head, Face, and Neck

Chapter learning objective: N/A

Chapter page reference: 103

Integrated Processes: Nursing Process: Evaluation

Client Need: Physiological Integrity: Physiological Adaptation

Cognitive level: Application [Applying]

Concept: Assessment

Difficulty: Moderate

 

	Feedback
1.	This is correct. A patient who does not have a gag reflex has damage to cranial nerve IX.
2.	This is correct. A patient who does not have a gag reflex has damage to cranial nerve X.
3.	This is correct. A patient who does not have a gag reflex is at risk for aspiration.
4.	This is incorrect. Areas of induration and thickening of the tongue indicate malignancy. A lack of a gag reflex is the result of the CVA and damage to the cranial nerves.
5.	This is incorrect. Vesicles that appear on the tongue would indicate herpes simplex virus.

 

 

PTS:   1                    CON:  Assessment

 

34.  ANS:  2, 4

Chapter number and title: 3, Assessing the Head, Face, and Neck

Chapter learning objective: N/A

Chapter page reference: 106

Integrated Processes: Nursing Process: Assessment

Client Need: Health Promotion and Maintenance

Cognitive level: Application [Applying]

Concept: Assessment

Difficulty: Moderate

 

	Feedback
1.	This is incorrect. The diaphragm of the stethoscope is not used to auscultate the thyroid.
2.	This is correct. The bell of the stethoscope is used to auscultate the thyroid.
3.	This is incorrect. The patient is asked to take deep breaths when auscultating the lung fields, not the thyroid.
4.	This is correct. The patient is asked to hold the breath when auscultating the thyroid.
5.	This is incorrect. Palpation does not occur during auscultation of the thyroid.

 

 

PTS:   1                    CON:  Assessment

 

35.  ANS:  1, 2, 3

Chapter number and title: 3, Assessing the Head, Face, and Neck

Chapter learning objective: N/A

Chapter page reference: 73

Integrated Processes: Teaching and Learning

Client Need: Health Promotion and Maintenance

Cognitive level: Knowledge [Remembering]

Concept: Assessment

Difficulty: Easy

 

	Feedback
1.	This is correct. Facial muscles allow for movement, eating, and communication.
2.	This is correct. Mouth muscles allow for movement, eating, and communication.
3.	This is correct. Neck muscles allow for movement, eating, and communication.
4.	This is incorrect. The carotid is a major cardiovascular vessel that provides blood supply to the brain. It is not a muscle.
5.	This is incorrect. The jugular is a major cardiovascular vessel that provides blood supply to the brain. It is not a muscle.

 

 

PTS:   1                    CON:  Assessment

 

36.  ANS:  2, 3

Chapter number and title: 3, Assessing the Head, Face, and Neck

Chapter learning objective: N/A

Chapter page reference: 74

Integrated Processes: Nursing Process: Assessment

Client Need: Health Promotion and Maintenance

Cognitive level: Comprehension [Understanding]

Concept: Assessment

Difficulty: Easy

 

	Feedback
1.	This is incorrect. Gum hypertrophy is an expected finding during pregnancy, not for the older adult patient.
2.	This is correct. Many older adults develop gum disease with the aging process.
3.	This is correct. Many older adults experience a decrease in salivation with the aging process.
4.	This is incorrect. A decrease sense of smell is expected when assessing the older adult patient.
5.	This is incorrect. A decrease sense of taste is expected when assessing the older adult patient.

 

 

PTS:   1                    CON:  Assessment

 

37.  ANS:  3, 4, 5

Chapter number and title: 3, Assessing the Head, Face, and Neck

Chapter learning objective: N/A

Chapter page reference: 75

Integrated Processes: Nursing Process: Assessment

Client Need: Physiological Integrity: Physiological Adaptation

Cognitive level: Application [Applying]

Concept: Assessment

Difficulty: Moderate

 

	Feedback
1.	This is incorrect. The nurse would ask the patient if they have experienced congestion in the past if the patient presents with nasal congestion, not epistaxis.
2.	This is incorrect. The nurse would ask when the congestion is at its worst for a patient who presents with nasal congestion, not epistaxis.
3.	This is correct. For a patient who presents with epistaxis, a nosebleed, it is important to determine at what age the nosebleeds began.
4.	This is correct, For a patient who presents with epistaxis, a nosebleed, it is important for the nurse to ask the patient to describe a typical nosebleeding episode.
5.	This is correct. For a patient who presents with epistaxis, a nosebleed, it is important to determine whether there is a personal or family history of hypertension. Hypertension can increase the risk of epistaxis.

 

 

PTS:   1                    CON:  Assessment

 

Chapter 03: Assessing the Head, Face, and Neck

 

Multiple Choice

Identify the choice that best completes the statement or answers the question.

 

____    1.   The nurse is assessing the patient’s turbinates. Which is an expected finding?

1)	Dry and pink
2)	Moist and pink
3)	Dry and dark red
4)	Moist and dark red

 

 

____    2.   The nurse is assessing the patient’s soft palate and notes erythema. Which is the possible reason for this finding?

1)	Congenital defect
2)	Cleft palate
3)	Infection
4)	Trauma

 

 

____    3.   During a patient assessment, the nurse suspects that the patient may have cardiovascular disease. Which assessment finding supports the nurse’s suspicion?

1)	Facial edema
2)	Jaw pain
3)	Facial spasm
4)	Temporal pain

 

 

____    4.   Which cluster of assessment findings would the nurse expect to find in association with acute bacterial sinusitis?

1)	Inflamed nasal mucosa; yellow drainage on posterior pharynx; perforated septum
2)	Yellow drainage on the posterior pharynx; pale and boggy nasal mucosa; fever
3)	Pale, boggy nasal mucosa; fever; perforated septum
4)	Inflamed nasal mucosa; yellow drainage on the posterior pharynx; fever

 

 

____    5.   Which disease process is associated with tender, palpable cervical nodes along with painful vesicles?

1)	Herpes simplex virus
2)	Hyperthyroidism
3)	Temporal arteritis
4)	Allergic rhinitis

 

 

____    6.   The nurse is conducting a head, face, and neck assessment for a toddler-age patient. Which finding is expected for a patient of this age?

1)	Anterior fontanel 2 cm open
2)	Posterior fontanel 2 cm open
3)	Anterior fontanel open, posterior fontanel closed
4)	Anterior and posterior fontanels closed

 

 

____    7.   Which male patient is likely to have the least facial hair?

1)	Chinese American
2)	African American
3)	Irish American
4)	Hispanic

 

 

____    8.   A patient presents to the emergency department complaining of headache. Which is the priority question when assessing this patient’s symptoms?

1)	“Have you been diagnosed with temporomandibular joint (TMJ) syndrome?”
2)	“Have you had any recent trauma or injury?”
3)	“How often do you experience migraines?”
4)	“Have you recently experienced any neck strain?”

 

 

____    9.   The nurse is assessing the head, face, and neck of a patient and notes a painless area of white, adherent mucosal thickening on the left buccal mucosa. The patient admits to being a smoker. Which is the most likely diagnosis for this patient?

1)	Erythroplakia
2)	Leukoplakia
3)	Herpes simplex virus
4)	Candidiasis

 

 

____  10.   The patient has a lobulated, bony growth noted midline on the hard palate that is covered with mucosa consistent with that of the surrounding areas. Based on this data, which diagnosis does the nurse anticipate?

1)	Oral cancer
2)	Frenulumitis
3)	Torus palatinus
4)	Kaposi sarcoma

 

 

____  11.   While examining the throat, the nurse notes that the patient’s tonsils bilaterally extend beyond the anterior pillars and almost to the uvula. Which is an appropriate grade based on this data?

1)	Grade 1 +
2)	Grade 2 +
3)	Grade 3 +
4)	Grade 4 +

 

 

____  12.   Which structure, if located on the floor of the mouth, would be considered an abnormal finding?

1)	Frenulum
2)	Wharton duct
3)	Stensen duct
4)	Uvula

 

 

____  13.   Which group of cervical nodes is palpable under the tip of the chin?

1)	Submandibular
2)	Submaxillary
3)	Tonsillar
4)	Submental

 

 

____  14.   During a neck exam, the nurse identifies a 1.5-cm hard, nonpainful anterior cervical node with an irregular surface. Based on this data, which does the nurse suspect?

1)	Infection
2)	Allergy
3)	Malignancy
4)	Edema

 

 

____  15.   The nurse is conducting a neck assessment. Which instructions should be given to the patient when palpating the left thyroid lobe?

1)	Ask the patient to lean the neck to the right side.
2)	Ask the patient to take a sip of water.
3)	Ask the patient to hold her or his breath.
4)	Ask the patient to hyperextend the neck.

 

 

____  16.   Upon assessment, the nurse notes the patient has an enlarged thyroid. Which action is most appropriate?

1)	Document this as a normal finding
2)	Prepare the patient for the diagnosis of cancer
3)	Notify the healthcare provider
4)	Further assess for tenderness and nodules

 

 

____  17.   The nurse is providing care to a patient with allergic rhinitis. Which is an unexpected finding during the physical assessment?

1)	Pale and boggy mucosa
2)	Tender, palpable cervical nodes
3)	Periorbital puffiness
4)	History of allergic disorders