Exam 3

Question 1

What structure prevents food from entering the lungs?
Uvula
Hard palate
Palatine tonsils
Epiglottis

Answer 1

Epiglottis
The epiglottis prevents food from entering the lungs.

Question 2

The ossicles of the middle ear include which small bones?

Select all that apply.

Tympanic
Malleus
Stapes
Incus
Maxilla

Answer 2

Malleus
The malleus is an ossicle of the middle ear.

Correct

Stapes
The stapes is an ossicle of the middle ear.

Correct

Incus
The incus is an ossicle of the middle ear.

Question 3

As part of the history of present illness, which questions should the nurse ask a patient presenting with a nosebleed to learn more about the potential predisposing factors?

Select all that apply.

“Are you experiencing any nasal congestion or fever?”
“Have you been struck in the nose recently?”
“Have you noticed your nasal passages feeling dry?”
“When did the nosebleed start?”
“How long do the nosebleeds last when you have them?”

Answer 3

“Are you experiencing any nasal congestion or fever?”
The nurse should ask a patient with a nosebleed about a concurrent upper respiratory tract infection as part of the history of present illness to learn about predisposing factors.

Correct

“Have you been struck in the nose recently?”
The nurse should ask a patient with a nosebleed about any recent nasal trauma as part of the history of present illness to learn about predisposing factors.

Correct

“Have you noticed your nasal passages feeling dry?”
The nurse should ask a patient with a nosebleed about exposure to dry air as part of the history of present illness to learn about predisposing factors.

Question 4

Which questions should the nurse ask a patient who has difficulty swallowing as part of the history of present illness?

Select all that apply.

“When did you first notice the difficulty swallowing?”
“When you try to swallow liquid, does it come out of your nose?”
“Do you cough or have a choking sensation when you swallow?”
“Have you ever been diagnosed with acid reflux or esophageal problems?”
“How many cigarettes do you smoke daily?”

Answer 4

“When did you first notice the difficulty swallowing?”
The nurse should ask a patient with difficulty swallowing about the onset of symptoms as part of the history of present illness.

Correct

“When you try to swallow liquid, does it come out of your nose?”
The nurse should ask a patient with difficulty swallowing about associated symptoms and severity of the problem as part of the history of present illness.

Correct

“Do you cough or have a choking sensation when you swallow?”
The nurse should ask a patient with difficulty swallowing about associated symptoms and severity of the problem, such as coughing or choking, as part of the history of present illness.

Question 5

Choose which medical-surgical history questions to ask a patient presenting with ear pain.

Select all that apply.

“Did your parents have tubes put in their ears as children?”
“Did you experience frequent ear infections during childhood?”
“Have you ever been diagnosed with labyrinthitis?”
“Do you clean your ears with cotton-tipped applicators?”
“Do you use ear drops for the pain?”

Answer 5

“Did you experience frequent ear infections during childhood?”
The nurse should ask a patient with ear pain about a childhood history of frequent ear infections as part of the medical-surgical history.

Correct

“Have you ever been diagnosed with labyrinthitis?”
The nurse should ask a patient with ear pain about a past diagnosis of labyrinthitis as part of the medical-surgical history.

Question 6

When gathering medical-surgical history about a patient who presents with postnasal drip, which conditions should the nurse ask about?

Select all that apply.

Headaches
Thyroid disease
Seasonal allergies
Recurrent sinusitis
Chronic postnasal drip

Answer 6

Seasonal allergies
The nurse should ask a patient with postnasal drip about the onset or diagnosis of seasonal allergies as part of the medical-surgical history.

Correct

Recurrent sinusitis
The nurse should ask a patient with postnasal drip about a diagnosis of chronic sinusitis as part of the medical-surgical history.

Correct

Chronic postnasal drip
The nurse should ask a patient with postnasal drip about a diagnosis of chronic postnasal drip as part of the medical-surgical history.

Question 7

Which question about environmental exposure should the nurse ask a patient presenting with hearing loss as part of the personal/social history?
Hot, dry air
Air pollutants
Dust and allergens
Loud, continuous noises

Answer 7

Loud, continuous noises
The nurse should ask a patient with hearing loss about exposure to loud, continuous noises as part of the personal/social history.

Question 8

Which features of the buccal mucosa should be inspected as part of a thorough ears, nose, and throat examination?

Select all that apply.

Color
Masses
Swelling
Symmetry
Ulcerations

Answer 8

Color
The nurse should inspect the buccal mucosa for color.

Correct

Swelling
The nurse should inspect the buccal mucosa for swelling.

Correct

Symmetry
The nurse should inspect the buccal mucosa for symmetry.

Correct

Ulcerations
The nurse should inspect the buccal mucosa for ulcerations.

Question 9

When inspecting the nasal septum, which features should the nurse assess?

Select all that apply.

Crusting
Bleeding
Alignment
Perforation
Tenderness

Answer 9

Crusting
The nurse should assess the nasal septum for crusting.

Correct

Bleeding
The nurse should assess the nasal septum for bleeding.

Correct

Alignment
The nurse should assess the nasal septum for alignment.

Correct

Perforation
The nurse should assess the nasal septum for perforation.

Question 10

In which ways should the nurse evaluate a young child’s hearing?

Select all that apply.

Use the Snellen E chart or HOVT chart.
Whisper words with meaning to the child.
Have the child repeat phrases the nurse yells.
Inspect the tympanic membrane for perforations.
Ask the child to perform tasks using a soft voice.

Answer 10

Whisper words with meaning to the child.
The nurse should assess a child’s hearing by whispering words with meaning to the child.

Correct

Ask the child to perform tasks using a soft voice.
The nurse should assess a child’s hearing by asking the child to perform tasks using a soft voice.

Question 11

To assist in the examination of the soft palate of a young child, what question should the nurse ask the patient?
“Do you brush your own teeth?”
“Can you pant like a puppy?”
“Can you take a deep breath?”
“Did you have any surgeries on your mouth when you were a baby?”

Answer 11

“Can you pant like a puppy?”
Having the child pant causes the palate to rise during the ear, nose, and throat assessment.

Question 12

Which finding should the nurse note as normal when assessing the mouth and throat of an infant?
Adherent white patches on the buccal mucosa
Epstein pearls
Persistent drooling after age 6 months not associated with teething
Presence of natal teeth

Answer 12

Epstein pearls
Pearl-like retention cysts on gums are normal finding in an infant up to 2 months old.

Question 13

Which finding is expected when assessing the tonsils?
Dark red tonsils
Hypertrophied tonsils
Exudate on the tonsils
Crypts with food particles

Answer 13

Crypts with food particles
The tonsils may have crypts with debris or food particles found within them.

Question 14

Which mouth and oropharynx assessment finding is expected for the child?
Mottled teeth
Deciduous teeth
Black or grey teeth
Caries on upper incisors

Answer 14

Deciduous teeth
Deciduous teeth are a normal finding in children and erupt between 6 and 24 months of age.

Question 15

Which age-related finding is expected in a 55-year-old patient?
Hearing loss
Loss of vision
Loss of sense of smell
Decrease in sense of taste

Answer 15

Decrease in sense of taste
The sense of taste begins to deteriorate at 50 years of age, and some loss of taste would be expected in a 55-year-old patient.

Question 16

Which ear assessment findings would be considered abnormal?

Select all that apply.

Vertigo
Tinnitus
Darwin tubercle
Preauricular pits
Hearing loss

Answer 16

Vertigo
Vertigo is an abnormal finding and may be associated with Meniere disease.

Correct

Tinnitus
Tinnitus is an abnormal finding and may be associated with Meniere disease.

Correct

Hearing loss
Hearing loss is an abnormal finding and may be associated with Meniere disease.

Question 17

Which nose assessment findings should be considered abnormal?

Select all that apply.

Noisy breathing or occlusion
Patient unable to smell
Perforated or deviated septum
Deviation of uvula
Hyperemia, rhinorrhea, and edema of mucosa

Answer 17

Noisy breathing or occlusion
Noisy breathing or occlusion is an abnormal finding in an assessment of the nose.

Correct

Patient unable to smell
Patient unable to smell is an abnormal finding in an assessment of the nose.

Correct

Perforated or deviated septum
Perforated or deviated septum is an abnormal finding in an assessment of the nose.

Correct

Hyperemia, rhinorrhea, and edema of mucosa
Hyperemia, rhinorrhea, and edema of mucosa are abnormal findings and may indicate cocaine use.

Question 18

Which nasal assessment findings, suggestive of inhaled cocaine abuse, are considered abnormal?

Select all that apply.

Hyperemia
Polyps
Rhinorrhea
Clear nasal discharge
Edema of the nasal mucosa

Answer 18

Hyperemia
Hyperemia is an abnormal finding suggestive of cocaine abuse.

Correct

Rhinorrhea
Rhinorrhea is an abnormal finding suggestive of cocaine abuse.

Correct

Edema of the nasal mucosa
Edema of the nasal mucosa is an abnormal finding suggestive of cocaine abuse.

Question 19

Match the conditions with the associated abnormal mouth and throat assessment findings.
Enlarged anterior cervical lymph nodes; swollen tonsils
Select an answer
Displaced tonsil and uvula associated with sore throat radiating to the ear
Select an answer
Firm, nonmobile mass with cervical lymphadenopathy
Select an answer
Deep pockets between the teeth and gingiva
Select an answer

Answer 19

Enlarged anterior cervical lymph nodes; swollen tonsils Acute pharyngitis
Displaced tonsil and uvula associated with sore throat radiating to the ear Peritonsillar abscess
Firm, nonmobile mass with cervical lymphadenopathy Oral cancer
Deep pockets between the teeth and gingiva Periodontal disease

Question 20

When the sinuses are assessed, which findings should be considered abnormal?

Select all that apply.

Pain
Swelling
Tenderness
Opaque glow on transillumination
Dim red glow on transillumination

Answer 20

Pain
Pain on palpation of the sinuses is an abnormal finding and may indicate infection or obstruction.

Correct

Swelling
Swelling of the sinuses is an abnormal finding and may indicate infection or obstruction.

Correct

Tenderness
Tenderness on palpation of the sinuses is an abnormal finding and may indicate infection or obstruction.

Correct

Opaque glow on transillumination
An opaque glow on transillumination is an abnormal finding and may indicate infection or obstruction.

Question 21

The nurse is caring for a patient with complaints of hoarseness, sore throat, and difficulty swallowing. The nurse notes redness in the oropharynx and swollen tonsils. Which information suggestive of tonsillitis should the nurse document as history of present illness?

Select all that apply.

Hoarseness
Sore throat
Swollen tonsils
Difficulty swallowing
Redness of the oropharynx

Answer 21

Hoarseness
The patient’s hoarseness is part of the history of present illness suggestive of tonsillitis.

Correct

Sore throat
The patient’s sore throat is part of the history of present illness suggestive of tonsillitis.

Correct

Difficulty swallowing
The patient’s difficulty swallowing is part of the history of present illness suggestive of tonsillitis.

Question 22

During ear assessment of a 62-year-old patient, the nurse notes a buildup of cerumen and irritation in the ear canal. The patient reports a family history of Meniere disease and complains of muffled hearing. Which subjective assessment information should be documented as a part of the family history related to the ear assessment?
Muffled hearing
Buildup of cerumen
Irritation of the ear canal
History of Meniere disease

Answer 22

History of Meniere disease
The patient’s family history of Meniere disease is family history data related to the ear assessment.

Question 23

A patient presents with a complaint of impaired smell and nasal stuffiness. The patient reports use of intranasal cocaine and oral tobacco products. The nurse notes inflamed oral and nasal mucosa. Which subjective information should the nurse document as a part of the personal/social history related to the ear, nose, and throat (ENT) assessment?

Select all that apply.

Nasal stuffiness
Oral tobacco use
Impaired smell
Intranasal cocaine use
Inflamed oral mucosa

Answer 23

Oral tobacco use
The patient’s oral tobacco use is part of the personal/social history related to the ENT assessment.

Correct

Intranasal cocaine use
The patient’s intranasal cocaine use is part of the personal/social history related to the ENT assessment.

Question 24

A patient complains of hoarseness, throat pain, and difficulty swallowing. The nurse notes a bruit over the thyroid and neck swelling. Which information should the nurse document as objective data?

Select all that apply.

Hoarseness
Throat pain
Neck swelling
Difficulty swallowing
Bruit over the thyroid

Answer 24

Neck swelling
The nurse’s observation of neck swelling is objective data suggestive of thyroid disease.

Correct

Bruit over the thyroid
The nurse’s observation of a bruit is objective data suggestive of thyroid disease.

Question 25

Which eye structure is known as the “white” of the eye?
Iris
Sclera
Cornea
Conjunctiva

Answer 25

Sclera
The sclera is known as the “white” of the eye.

Question 26

Distributes tears over the eye surface
Select an answer
Protects from foreign bodies and desiccation
Select an answer
Produces tears that moisten the eye
Select an answer

Answer 26

Distributes tears over the eye surface Eyelid
Protects from foreign bodies and desiccation Conjunctiva
Produces tears that moisten the eye Lacrimal gland

Question 27

Match the nerve with the relevant function in the eye.
Innervates the lateral rectus muscle
Select an answer
Innervates the superior oblique muscle
Select an answer
Elevates and retracts the eyelid
Select an answer

Answer 27

Innervates the lateral rectus muscle Abducens nerve
Innervates the superior oblique muscle Trochlear nerve
Elevates and retracts the eyelid Oculomotor nerve

Question 28

Which cranial nerve is responsible for elevation of the eyelid?
Cranial nerve III
Cranial nerve V
Cranial nerve IV
Cranial nerve X

Answer 28

Cranial nerve III
Cranial nerve III is responsible for eye movement by elevating and retracting the upper eyelid.

Question 29

The nurse should ask a patient with a red eye which questions about associated symptoms as part of the history of present illness?

Select all that apply.

“Do you have pain in or around the eye?”
“Have you tried using eye drops?”
“Do you have any vision loss?”
“Do you have seasonal allergies?”
“Do you wear contact lenses?”

Answer 29

“Do you have pain in or around the eye?”
The nurse should ask the patient with a red eye about the presence of pain when assessing associated symptoms as part of the history of present illness.

Correct

“Do you have any vision loss?”
The nurse should ask the patient with a red eye about vision loss when assessing associated symptoms as part of the history of present illness.

Question 30

Which question related to family history should a nurse ask a patient with a red eye?
“Do you have pain in or around the eye?”
“Have you had eye surgery?”
“Do you have any vision loss?”
“Do you have seasonal allergies?”
“Has anyone in your family had glaucoma?”

Answer 30

“Has anyone in your family had glaucoma?”
The nurse should ask the patient with a red eye about a family history of glaucoma.

Question 31

The nurse should ask a patient who reports halos around lights which questions as part of the past medical history?

Select all that apply.

“Do you have pain in or around the eye?”
“Have you been treated for glaucoma?”
“Are you having trouble seeing?”
“Do you have seasonal allergies?”
“How long has this been going on?”

Answer 31

“Have you been treated for glaucoma?”
The nurse should ask the patient with halos around lights about a history of glaucoma as part of past medical history.

Correct

“Do you have seasonal allergies?”
The nurse should ask the patient with halos around lights about a history of seasonal allergies as part of past medical history.

Question 32

Match the examination with the type of vision it tests.
Near vision
Select an answer
Peripheral vision
Select an answer
Central vision
Select an answer

Answer 32

Near vision Rosenbaum pocket screener
Peripheral vision Confrontation test
Central vision Snellen chart

Question 33

For which features should the nurse inspect the orbital area?

Select all that apply.

Edema
Puffiness
Tenderness
Temperature
Sagging tissue

Answer 33

Edema
The nurse should inspect the orbital area for edema.

Correct

Puffiness
The nurse should inspect the orbital area for puffiness.

Correct

Sagging tissue
The nurse should inspect the orbital area for sagging tissue.

Question 34

For which features should the nurse inspect during assessment of the sclera?

Select all that apply.

Visual acuity
Corneal abrasions
Color of the sclera
Eyelid fasciculations
Presence of senile hyaline plaque

Answer 34

Color of the sclera
The nurse should inspect the color of the sclera.

Correct

Presence of senile hyaline plaque
The nurse should inspect for the presence of senile hyaline plaques.

Question 35

Which finding is expected when both eyes are examined for light reactivity?
Slow bilateral reactivity
No reaction in either eye
Brisk bilateral reactivity
Reactivity in the illuminated eye only

Answer 35

Brisk bilateral reactivity
Brisk bilateral reactivity is expected; that is, the pupil in the nonilluminated eye will constrict.

Question 36

Which age-related color change is expected on assessment of the sclera of an older adult?
Red
White
Blue
Yellow

Answer 36

Yellow
Although a yellow sclera may indicate liver disease, it is also a common age-related finding in older adults.

Question 37

What findings are expected when assessing the iris and pupils of the eyes?

Select all that apply.

Both pupils constrict when a light is shone directly into one eye.
When testing accommodation, the pupils constrict when looking at the far object.
Both pupils are the same size.
One pupil constricts more rapidly than the other.
Both pupils have notched edges.

Answer 37

Both pupils constrict when a light is shone directly into one eye.
As a consensual response to light, both pupils should constrict simultaneously.

Correct

Both pupils are the same size.
Both pupils are expected to be the same size.

Question 38

When examining the eyes, which finding is indicative of cataracts?
In the affected eye the pupil dilates more slowly than the unaffected eye
Shallow anterior chamber in the affected eye
Cobblestone appearance of the conjunctivae in the affected eye
Cloudiness of the lens in the affected eye

Answer 38

Cloudiness of the lens in the affected eye
Cloudiness of the lens is found with cataracts.

Question 39

When performing the ophthalmoscopic examination, which finding of the blood vessels is abnormal?
Venules smaller than arterioles
Branching of vessels away from the optic disc
Smooth crossing of the vessels
Possible venous pulsations

Answer 39

Venules smaller than arterioles
Arterioles are smaller than venules in a ratio of 2:3 or 3:5.

Question 40

When performing the ophthalmoscopic examination, which finding of the optic discs is abnormal?
Sharp well-defined disc margin
About 1.5 mm in diameter
Cupping of the disc
Yellow to creamy pink in color

Answer 40

Cupping of the disc
Cupping of the disc is associated with glaucoma and is an abnormal finding.

Question 41

During the eye assessment, the nurse notes a visual acuity of 20/70 and periorbital swelling. The patient complains of blurred vision and has had recent eye surgery. Which history of present illness information should the nurse document as a part of the eye assessment?
Eye surgery
Blurred vision
Periorbital swelling
20/70 visual acuity

Answer 41

Blurred vision
Blurred vision is part of the history of present illness related to the eye assessment.

Question 42

The nurse assesses an older adult patient who reports lack of access to food and poor intake over the past month. The nurse notes sunken eyes and loose, wrinkled eyelids. Which information suggestive of poor nutrition should the nurse document as objective data?

Select all that apply.

Sunken eyes
Loose eyelids
Poor food intake
Wrinkled eyelids
Lack of access to food

Answer 42

Sunken eyes
The patient’s sunken eyelids are objective data suggestive of poor nutrition.

Correct

Loose eyelids
The patient’s loose eyelids are objective data suggestive of poor nutrition.

Correct

Wrinkled eyelids
The patient’s wrinkled eyelids are objective data suggestive of poor nutrition.

Question 43

A patient with a history of hypertension complains of impaired vision and eye discomfort. The nurse notes hemorrhages in the eye and increased ocular pressure. Which information related to the eye assessment should the nurse document as objective data?

Select all that apply.

Hypertension
Impaired vision
Eye discomfort
Eye hemorrhages
Increased ocular pressure

Answer 43

Eye hemorrhages
The patient’s eye hemorrhages, as observed by the nurse, are objective data related to the eye assessment.

Correct

Increased ocular pressure
The patient’s increased ocular pressure, as observed by the nurse, is objective data related to the eye assessment.

Question 44

Which face bone is movable?
Maxilla
Mandible
Hyoid
Occipital bone

Answer 44

Mandible
The mandible is a movable face bone.

Question 45

Which sutures separate the cranial bones in infants?

Select all that apply.

Sagittal
Zygomatic
Coronal
Lambdoid
Frontal

Answer 45

Sagittal
The sagittal suture separates the cranial bones in infants.

Correct

Coronal
The coronal suture separates the cranial bones in infants.

Correct

Lambdoid
The lambdoid suture separates the cranial bones in infants.

Question 46

What questions related to the history of present illness should a nurse ask a patient who complains of anterior neck swelling?

Select all that apply.

“Have you been experiencing stress at work or home?”
“How long have you had this?”
“Have you had radiation to the head and neck?”
“Do you have any difficulty swallowing?”
“Does anyone in your family have thyroid problems?”

Answer 46

“How long have you had this?”
Asking about onset and duration of the problem is part of the history of present illness.

Correct

“Do you have any difficulty swallowing?”
It is appropriate to ask about associated symptoms as part of the history of present illness.

Question 47

The nurse should choose which question to ask a patient who reports riding their bicycle to work every day as part of social and personal history assessment of the head and neck?
“Do you have issues with balance while riding your bike?”
“Do you wear a helmet?”
“Do you wear sunglasses and sunblock?”
“Have you ever had a bicycle accident where you injured your head or neck?”

Answer 47

“Do you wear a helmet?”
Because the patient reports riding a bicycle to work every day it is important to assess the use of helmet as part of the personal and social history assessment of the head and neck.

Question 48

What questions should a nurse ask a patient complaining of headache when assessing history of present illness?

Select all that apply.

“Can you describe the pain to me?”
“Are you under a lot of stress either at home or work?”
“On a scale of 1 to 10 how severe is the pain?”
“Is the pain worse in the morning?”
“Where specifically is the pain?”
“Does anyone in your family have similar headaches?”

Answer 48

“Can you describe the pain to me?”
It is important to assess the quality or character of pain when assessing history of present illness of a headache.

Correct

“On a scale of 1 to 10 how severe is the pain?”
It is important to assess the severity of pain when assessing history of present illness of a headache.

Correct

“Is the pain worse in the morning?”
It is important to assess if there is a pattern to the pain when assessing history of present illness of a headache.

Correct

“Where specifically is the pain?”
It is important to assess the location of pain when assessing history of present illness of a headache.

Question 49

During the head and face assessments, which features would be assessed by inspection?

Select all that apply.

Head position
Facial features
Tics and spasms
Facial symmetry
Facial skin thickness
Skull size and shape

Answer 49

Head position
The nurse should inspect the head position during the head and face assessment.

Correct

Facial features
The nurse should inspect the facial features during the head and face assessment.

Correct

Tics and spasms
The nurse should inspect for tics and spasms during the head and face assessment.

Correct

Facial symmetry
The nurse should inspect facial symmetry during the head and face assessment.

Correct

Skull size and shape
The nurse should inspect the skull size and shape during the head and face assessment.

Question 50

Which features of the neck should the nurse inspect as part of a thorough assessment?

Select all that apply.

Fullness
Symmetry
Lymph nodes
Alignment of trachea
Masses, webbing, and skinfolds

Answer 50

Fullness
The nurse should inspect for fullness of the neck during a thorough neck assessment.

Correct

Symmetry
The nurse should inspect for symmetry of the neck during a thorough neck assessment.

Correct

Alignment of trachea
The nurse should inspect for alignment of the trachea during a thorough neck assessment.

Correct

Masses, webbing, and skinfolds
The nurse should inspect for masses, webbing, and skinfolds during a thorough neck assessment.

Question 51

Which features would the nurse assess by palpation during a head and neck assessment?

Select all that apply.

Hair distribution
Facial expression
Temporomandibular joint space
Size and shape of the thyroid gland
Symmetry and smoothness of the skull

Answer 51

Hair distribution
Hair distribution is assessed by both inspection and palpation.

Correct

Temporomandibular joint space
The nurse would assess the temporomandibular joint space by palpation during the head and neck assessment.

Correct

Size and shape of the thyroid gland
The nurse would assess the size and shape of the thyroid gland by palpation during the head and neck assessment.

Correct

Symmetry and smoothness of the skull
The nurse would assess the symmetry and smoothness of the skull by palpation during the head and neck assessment.

Question 52

Which aspects of the scalp should the nurse inspect as part of a thorough infant head and neck assessment?

Select all that apply.

Scaling
Shape
Movement
Smoothness
Temperature

Answer 52

Scaling
The nurse should inspect the scalp for scaling or crusting during the infant head and neck assessment.

Correct

Shape
The nurse should inspect the shape of the scalp and skull during the infant head and neck assessment.

Question 53

As part of a thorough head and neck assessment, the nurse should assess which features of the infant head by palpation?

Select all that apply.

Skin color
Suture lines
Fontanels
Neck muscle tone
Skull depressions

Answer 53

Suture lines
The nurse should assess the suture lines by palpation during the infant head and neck assessment.

Correct

Fontanels
The nurse should assess the fontanels by palpation during the infant head and neck assessment.

Correct

Skull depressions
The nurse should assess for skull depressions by palpation during the infant head and neck assessment.

Question 54

Transillumination is a technique used to assess the head of infants under which circumstances?

Select all that apply.

The infant has a neck mass.
The infant’s oral mucosa appears dry.
The infant has suspected intracranial lesions.
The infant has suspected respiratory compromise.
The infant has a rapidly increasing head circumference.

Answer 54

The infant has suspected intracranial lesions.
Transillumination is used to assess the head of an infant with suspected intracranial lesions.

Correct

The infant has a rapidly increasing head circumference.
Transillumination is used to assess the head of an infant with a rapidly increasing head circumference.

Question 55

Which finding should the nurse note as normal on inspection of the head?
Head tilted to side
Balding pattern in females
Slight asymmetry in skull size
Slight asymmetry in facial features

Answer 55

Slight asymmetry in facial features
Slight asymmetry of facial features is a normal finding when inspecting the head.

Question 56

Which findings would be considered normal on palpation of the neck?

Select all that apply.

Palpable lymph nodes
Firm thyroid gland tissue
Right thyroid lobe slightly larger than left
Movement of cricoid cartilage on swallowing
A palpable thrill over the carotid arteries

Answer 56

Firm thyroid gland tissue
The thyroid gland would be expected to be firm and pliable.

Correct

Right thyroid lobe slightly larger than left
The right lobe of the thyroid gland may be up to 25% larger than the left. This would be considered a normal finding.

Correct

Movement of cricoid cartilage on swallowing
The hyoid, thyroid, and cricoid cartilage should move during swallowing. This would be considered a normal finding.

Question 57

Which finding should the nurse note as normal when assessing the face?
Rough texture
Variations in shape
Palpable skin lesion
Heterogeneous skin color

Answer 57

Variations in shape
Variations in facial shape are normal and based on race, gender, age, and build.

Question 58

Which finding should the nurse note as abnormal when palpating the thyroid?

Select all that apply.

Right lobe may be larger than the left
Tissue firm and pliable
Palpable nodule
Gland rises freely with swallowing
Left lobe may be larger than the right

Answer 58

Palpable nodule
A palpable nodule on the thyroid gland is considered an abnormal finding and may require further evaluation.

Correct

Left lobe may be larger than the right
The right lobe of the thyroid gland may be up to 25% larger than the left.

Question 59

Which finding should the nurse consider normal on assessment of the thyroid gland?
Large lobes
Nodules
Fixed lobes
Firm and pliable

Answer 59

Firm and pliable
The thyroid gland tissue should be firm and pliable.

Question 60

Which head assessment findings would be considered abnormal?

Select all that apply.

Tics
Pallor
Alopecia
Symmetry of the head
Slight asymmetry of the facial features

Answer 60

Tics
Tics are an abnormal finding on assessment of the head.

Correct

Pallor
Pallor, or an unhealthy pale appearance, is an abnormal finding on assessment of the head.

Correct

Alopecia
Alopecia is an abnormal finding on assessment of the head.

Question 61

Match the condition with the abnormal neck assessment finding.
Head tilted toward the sternocleidomastoid muscle
Select an answer
fin neck midline
Select an answer
Mass along anteromedial border of sternocleidomastoid muscle
Select an answer

Answer 61

Head tilted toward the sternocleidomastoid muscle Torticollis
fin neck midline Thyroglossal duct cyst
Mass along anteromedial border of sternocleidomastoid muscle Branchial cleft cyst

Question 62

Match the abnormal finding with the relevant element of the head.
Coarse, dry, brittle
Select an answer
Asymmetrical
Select an answer
Thickening
Select an answer

Answer 62

Match the abnormal finding with the relevant element of the head.

Coarse, dry, brittle Hair
Asymmetrical Salivary Glands
Thickening Temporal arteries

Question 63

An 82-year-old patient complains of sudden headache, difficulty opening the mouth, and pain in the neck. The nurse notes pinpoint pupils, increased ocular pressure, and green drainage from the eye. Which findings should the nurse document as history of present illness related to the head assessment?

Select all that apply.

Headache
Pinpoint pupils
Tenderness of the neck
Green drainage from eye
Increased ocular pressure
Difficulty opening the mouth

Answer 63

Headache
A headache is part of the history of present illness related to the head assessment.

Correct

Tenderness of the neck
Tenderness of the neck is part of the history of present illness related to the head assessment.

Correct

Difficulty opening the mouth
Difficulty opening the mouth is part of the history of present illness related to the head assessment.

Question 64

A patient complains of hoarseness, throat pain, and difficulty swallowing. The nurse notes a bruit over the thyroid and neck swelling. Which information should the nurse document as objective data?

Select all that apply.

Hoarseness
Throat pain
Neck swelling
Difficulty swallowing
Bruit over the thyroid

Answer 64

Neck swelling
The nurse’s observation of neck swelling is objective data suggestive of thyroid disease.

Correct

Bruit over the thyroid
The nurse’s observation of a bruit is objective data suggestive of thyroid disease.

Question 65

A 54-year-old female patient presents to the clinic concerned that she might be having a stroke. She reports symptoms started this morning and she sought help immediately. Her speech and cognition are intact, but she is complaining of a headache. The nurse notices upon inspection that her face is asymmetrical, with the right eyelid not closing completely, a drooping eyelid and corner of mouth, and a loss of the nasolabial fold on the affected side. What should the nurse document as objective data for the head and neck assessment?

Select all that apply.

Loss of nasolabial fold on affected side
Rapid onset of symptoms
Headache
Asymmetrical face
Right eyelid not closing completely
Drooping eyelid and corner of mouth on affected side

Answer 65

Loss of nasolabial fold on affected side
Loss of nasolabial fold on affected side should be documented as objective data.

Correct

Asymmetrical face
Asymmetrical face should be documented as objective data.

Correct

Right eyelid not closing completely
Right eyelid not closing completely should be documented as objective data.

Correct

Drooping eyelid and corner of mouth on affected side
Drooping eyelid and corner of mouth on the affected side should be documented as objective data.