Exam 3 Flashcards
What structure prevents food from entering the lungs?
Uvula
Hard palate
Palatine tonsils
Epiglottis
Epiglottis
The epiglottis prevents food from entering the lungs.
The ossicles of the middle ear include which small bones?
Select all that apply.
Tympanic Malleus Stapes Incus Maxilla
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.
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?”
“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.
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?”
“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.
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?”
“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.
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
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.
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
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.
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
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.
When inspecting the nasal septum, which features should the nurse assess?
Select all that apply.
Crusting Bleeding Alignment Perforation Tenderness
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.
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.
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.
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?”
“Can you pant like a puppy?”
Having the child pant causes the palate to rise during the ear, nose, and throat assessment.
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
Epstein pearls
Pearl-like retention cysts on gums are normal finding in an infant up to 2 months old.
Which finding is expected when assessing the tonsils?
Dark red tonsils
Hypertrophied tonsils
Exudate on the tonsils
Crypts with food particles
Crypts with food particles
The tonsils may have crypts with debris or food particles found within them.
Which mouth and oropharynx assessment finding is expected for the child?
Mottled teeth
Deciduous teeth
Black or grey teeth
Caries on upper incisors
Deciduous teeth
Deciduous teeth are a normal finding in children and erupt between 6 and 24 months of age.
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
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.
Which ear assessment findings would be considered abnormal?
Select all that apply.
Vertigo Tinnitus Darwin tubercle Preauricular pits Hearing loss
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.
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
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.
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
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.
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
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
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
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.
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
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.
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
History of Meniere disease
The patient’s family history of Meniere disease is family history data related to the ear assessment.
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
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.
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
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.
Which eye structure is known as the “white” of the eye?
Iris
Sclera
Cornea
Conjunctiva
Sclera
The sclera is known as the “white” of the eye.
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
Distributes tears over the eye surface Eyelid
Protects from foreign bodies and desiccation Conjunctiva
Produces tears that moisten the eye Lacrimal gland
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
Innervates the lateral rectus muscle Abducens nerve
Innervates the superior oblique muscle Trochlear nerve
Elevates and retracts the eyelid Oculomotor nerve
Which cranial nerve is responsible for elevation of the eyelid?
Cranial nerve III
Cranial nerve V
Cranial nerve IV
Cranial nerve X
Cranial nerve III
Cranial nerve III is responsible for eye movement by elevating and retracting the upper eyelid.
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?”
“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.
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?”
“Has anyone in your family had glaucoma?”
The nurse should ask the patient with a red eye about a family history of glaucoma.
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?”
“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.
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
Near vision Rosenbaum pocket screener
Peripheral vision Confrontation test
Central vision Snellen chart
For which features should the nurse inspect the orbital area?
Select all that apply.
Edema Puffiness Tenderness Temperature Sagging tissue
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.
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
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.
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
Brisk bilateral reactivity
Brisk bilateral reactivity is expected; that is, the pupil in the nonilluminated eye will constrict.
Which age-related color change is expected on assessment of the sclera of an older adult?
Red
White
Blue
Yellow
Yellow
Although a yellow sclera may indicate liver disease, it is also a common age-related finding in older adults.
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.
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.
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
Cloudiness of the lens in the affected eye
Cloudiness of the lens is found with cataracts.
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
Venules smaller than arterioles
Arterioles are smaller than venules in a ratio of 2:3 or 3:5.
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
Cupping of the disc
Cupping of the disc is associated with glaucoma and is an abnormal finding.
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
Blurred vision
Blurred vision is part of the history of present illness related to the eye assessment.
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
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.
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
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.
Which face bone is movable?
Maxilla
Mandible
Hyoid
Occipital bone
Mandible
The mandible is a movable face bone.
Which sutures separate the cranial bones in infants?
Select all that apply.
Sagittal Zygomatic Coronal Lambdoid Frontal
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.
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?”
“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.
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?”
“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.
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?”
“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.
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
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.
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
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.
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
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.
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
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.
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
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.
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.
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.
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
Slight asymmetry in facial features
Slight asymmetry of facial features is a normal finding when inspecting the head.
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
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.
Which finding should the nurse note as normal when assessing the face?
Rough texture
Variations in shape
Palpable skin lesion
Heterogeneous skin color
Variations in shape
Variations in facial shape are normal and based on race, gender, age, and build.
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
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.
Which finding should the nurse consider normal on assessment of the thyroid gland?
Large lobes
Nodules
Fixed lobes
Firm and pliable
Firm and pliable
The thyroid gland tissue should be firm and pliable.
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
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.
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
Head tilted toward the sternocleidomastoid muscle Torticollis
fin neck midline Thyroglossal duct cyst
Mass along anteromedial border of sternocleidomastoid muscle Branchial cleft cyst
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
Match the abnormal finding with the relevant element of the head.
Coarse, dry, brittle Hair Asymmetrical Salivary Glands Thickening Temporal arteries
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
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.
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
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.
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
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.
