head and neck assessment

Question 1

Anatomy of the head

Answer 1

cranial bones are joined by immovable sutures in adults. only mandible is movable

Question 2

Cranial bones

Answer 2

frontal, parietal, temporal, occipital, ethmoid, sphenoid

Question 3

sutures

Answer 3

sagittal, coronal, lambdoid, squamosal

Question 4

Facial bones

Answer 4

maxilla, zygomatic, lacrimal, palatine, vomer, mandible, nasal, inferior conchae

Question 5

Anterior triangle of the neck

Answer 5

hyoid bone, trachea, larynx, major blood vessels, thyroid gland

Question 6

Muscles and landmarks in the neck

Answer 6

sternocleidomastoid rotates and flexes head. trapezius extends head, moves shoulders, 11th cranial nerve.

Question 7

Lymph nodes of the neck

Answer 7

preauricular, posterior auricular, occipital, superficial cervical, deep cervical chain, posterior cervical, tonsillar, submental, submandibular, supraclavicular

Question 8

What happens when a nurse notices an enlarged lymph node?

Answer 8

need to know where receives drainage from

Question 9

Preauricular nodes

Answer 9

in front of ear

Question 10

Posterior auricular nodes

Answer 10

lie superficial to the mastoid process

Question 11

Occipital nodes

Answer 11

at the base of the skull

Question 12

Superficial cervical nodes

Answer 12

overlay the sternocleidomastoid muscle

Question 13

Deep cervical chain nodes

Answer 13

deep to the sternocleidomastoid

Question 14

Posterior cervical nodes

Answer 14

appear in the posterior triangle along the edge of the trapezius muscle.

Question 15

Tonsillar nodes

Answer 15

angle of mandible

Question 16

Submandibular nodes

Answer 16

found halfway between the angle of the mandible and its tip

Question 17

Submental nodes

Answer 17

midline under the chin

Question 18

Supraclavicular nodes

Answer 18

located just above and behind the clavicle, at the sternocleidomastoid muscle

Question 19

Inspect the head

Answer 19

size - microcephaly, acromegaly. shape, configuration

Question 20

Inspect the face

Answer 20

symmetry, features, movement, expression, skin condition

Question 21

Palpate the head

Answer 21

note consistency, temporal artery, TMJ - swelling, tenderness, crepitation (crackling sound)

Question 22

Inspect neck (slightly extended)

Answer 22

position, symmetry, lumps, masses, movements - swallowing water observe thyroid, normal rom. cervical vertebrae (look down), see c7

Question 23

Palpate neck

Answer 23

trachea - midline, thyroid gland - midline (from the back), swallowing right/left separate

Question 24

Auscultate neck

Answer 24

if enlarged thyroid, use bell, hold breath

Question 25

When palpating lymph nodes what are you looking for?

Answer 25

swelling, enlargement, tenderness

Question 26

Headaches

Answer 26

sinus, cluster, tension, migraine, tumor related

Question 27

Sinus headaches

Answer 27

deep constant throbbing (front of face)

Question 28

Cluster headaches

Answer 28

stabbing pain (ex: behind eye)

Question 29

Tension headaches

Answer 29

dull, tight, diffuse (forehead)

Question 30

Migraine

Answer 30

nausea, vomiting, light/sound sensitivity

Question 31

COLDSPA

Answer 31

character, onset, locations, duration, severity, pattern, associated factors (other symptoms)

Question 32

Using Coldspa, Which question would be next after asking the patient how long the headaches lasts?
a. “Rate your pain on a scale of 1-10”
b. “Where does it hurt now?”
c. “When did it start?”
d. “Describe the pain, is it dull, tight, or sharp?”

Answer 32

a

Question 33

Which data below, collected by the nurse during a head and neck assessment would be considered abnormal (select all that apply)?
a. Trachea midline
b. Palpable Submandibular lymph node
c. Tender Tonsillar lymph node
d. Thyroid is midline
e. TMJ crepitus with movement
f. C7 visible when patient flexes neck
g. Auscultating the Thyroid and notes bruits

Answer 33

b, c, e, g

Question 34

OLDCARTS

Answer 34

Onset, location/radiation, duration, character, aggravating factors, relieving factors, timing, severity

Question 35

What is the order of assessing the neck?

Answer 35

Inspection, palpation, and auscultation.

Question 36

What is the order of assessing the head and face?

Answer 36

Inspection of head and face, palpatation