Deck 3: Assessing the Head, Face, and Neck

Question 1

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

A) Ask the patient to lean the neck to the right side.
B) Ask the patient to take a sip of water.
C) Ask the patient to hold her or his breath.
D) Ask the patient to hyperextend the neck.

Answer 1

Ask the patient to take a sip of water.

Question 2

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

A) Chinese American
B) African American
C) Irish American
D) Hispanic

Answer 2

Chinese American

Question 3

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?

A) Infection
B) Allergy
C) Malignancy
D) Edema

Answer 3

Malignancy

Question 4

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?

A) Erythroplakia
B) Leukoplakia
C) Herpes simplex virus
D) Candidiasis

Question 5

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?

A) Mononucleosis
B) Streptococcal pharyngitis
C) Viral pharyngitis
D) Candida albicans

Question 6

The nurse is assessing the patient's turbinates. Which is an expected finding?

A) Dry and pink
B) Moist and pink
C) Dry and dark red
D) Moist and dark red

Question 7

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

A) Congenital defect
B) Cleft palate
C) Infection
D) Trauma

Question 8

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?

A) Whether the classroom environment is particularly dry
B) History of sinusitis symptoms or exposure
C) History of trauma before the onset of bleeding
D) Family history of nosebleeds

Question 9

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

A) Enlarged cervical lymph nodes
B) Palatal petechiae
C) Pharyngitis
D) Nasal stuffiness

Question 10

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?

A) Grade 1 +
B) Grade 2 +
C) Grade 3 +
D) Grade 4 +

Question 11

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?

A) Oral cancer
B) Frenulumitis
C) Torus palatinus
D) Kaposi sarcoma

Question 12

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

A) Submandibular
B) Submaxillary
C) Tonsillar
D) Submental

Question 13

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

A) Frenulum
B) Wharton duct
C) Stensen duct
D) Uvula

Question 14

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

A) Document this as a normal finding
B) Prepare the patient for the diagnosis of cancer
C) Notify the healthcare provider
D) Further assess for tenderness and nodules

Question 15

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

A) "Have you been diagnosed with temporomandibular joint (TMJ) syndrome?"
B) "Have you had any recent trauma or injury?"
C) "How often do you experience migraines?"
D) "Have you recently experienced any neck strain?"

Question 16

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?

A) Anterior fontanel 2 cm open
B) Posterior fontanel 2 cm open
C) Anterior fontanel open, posterior fontanel closed
D) Anterior and posterior fontanels closed

Question 17

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

A) Pale and boggy mucosa
B) Tender, palpable cervical nodes
C) Periorbital puffiness
D) History of allergic disorders

Question 18

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

A) Inflamed nasal mucosa; yellow drainage on posterior pharynx; perforated septum
B) Yellow drainage on the posterior pharynx; pale and boggy nasal mucosa; fever
C) Pale, boggy nasal mucosa; fever; perforated septum
D) Inflamed nasal mucosa; yellow drainage on the posterior pharynx; fever

Question 19

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

A) Herpes simplex virus
B) Hyperthyroidism
C) Temporal arteritis
D) Allergic rhinitis

Question 20

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

A) Facial edema
B) Jaw pain
C) Facial spasm
D) Temporal pain

Question 21

Which statement is true concerning the thyroid gland?

A) The thyroid gland is usually not palpable.
B) The thyroid gland is always palpable.
C) The thyroid gland is more likely palpable in overweight patients.
D) The thyroid gland is never palpable.

Question 22

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

A) The appearance of gum hypertrophy.
B) The development of gum disease.
C) A decrease in salivation.
D) An increase in the sense of smell.
E) An increase in the sense of taste.

Question 23

During the assessment of a preschool-age patient, the nurse expects the patient to have ________________teeth.

Question 24

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

A) Using the diaphragm of the stethoscope
B) Using the bell of the stethoscope
C) Asking the patient to take deep breaths
D) Asking the patient to hold the breath
E) Using the finger pads for palpation

Question 25

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.

Question 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 ____________________.

Question 27

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

A) Hyperextend the neck
B) Swallow
C) Cough
D) Extend the neck

Question 28

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

A) Facial
B) Mouth
C) Neck
D) Carotid
E) Jugular

Question 29

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.

A) Damage to cranial nerve IX
B) Damage to cranial nerve X
C) Risk for aspiration
D) Potential malignancy
E) Herpes simplex virus

Question 30

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.

A) "Have you had similar congestion before?"
B) "When is the congestion at its worst?"
C) "At what age did you have your first nosebleed?"
D) "Can you describe a typical nosebleeding episode?'
E) "Do you have a personal or family history of hypertension?"

Question 31

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

A) Herpes simplex
B) Cheilitis
C) Leukoplakia
D) Cheilosis

Question 32

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

Question 33

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

Question 34

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

Question 35

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?

A) In a flexed position
B) As the patient swallows
C) In a lateral position
D) As the patient holds his or her breath

Question 36

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

A) Thyroid cartilage
B) Hyoid bone
C) Cricoid cartilage
D) Tracheal rings

Question 37

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

A) Dehydration
B) Hydrocephalus
C) Increased intracranial pressure
D) Temporal arteritis
E) TMJ syndrome