Head, Face, and Chapter 13 Neck, Including Regional Lymphatics

Question 1

1. A physician tells the nurse that a patient’s vertebra prominens is tender and asks the nurse to reevaluate the area in 1 hour. The area of the body the nurse will assess is:
   a. Just above the diaphragm.
   b. Just lateral to the knee cap.
   c. At the level of the C7 vertebra.
   d. At the level of the T11 vertebra.

Answer 1

ANS: C

The C7 vertebra has a long spinous process, called the vertebra prominens, which is palpable when the head is flexed.

Question 2

2. A mother brings her 2-month-old daughter in for an examination and says, “My daughter rolled over against the wall, and now I have noticed that she has this spot that is soft on the top of her head. Is something terribly wrong?” The nurse’s best response would be:
   a. “Perhaps that could be a result of your dietary intake during pregnancy.”
   b. “Your baby may have craniosynostosis, a disease of the sutures of the brain.”
   c. “That ‘soft spot’ may be an indication of cretinism or congenital hypothyroidism.”
   d. “That ‘soft spot’ is normal, and actually allows for growth of the brain during the first year of your baby’s life.”

Answer 2

ANS: D
Membrane-covered “soft spots” allow for growth of the brain during the first year of life. They gradually ossify; the triangular-shaped posterior fontanel is closed by 1 to 2 months, and the diamond-shaped anterior fontanel closes between 9 months and 2 years.

Question 3

3. The nurse notices that a patient’s palpebral fissures are not symmetric. On examination, the nurse may find that damage has occurred to which cranial nerve (CN)?
   a. III
   b. V
   c. VII
   d. VIII

Answer 3

ANS: C
Facial muscles are mediated by CN VII; asymmetry of palpebral fissures may be attributable to damage to CN VII (Bell palsy).

Question 4

4. A patient is unable to differentiate between sharp and dull stimulation to both sides of her face. The nurse suspects:
   a. Bell palsy.
   b. Damage to the trigeminal nerve.
   c. Frostbite with resultant paresthesia to the cheeks.
   d. Scleroderma.

Answer 4

ANS: B

Facial sensations of pain or touch are mediated by CN V, which is the trigeminal nerve. Bell palsy is associated with CN VII damage. Frostbite and scleroderma are not associated with this problem.

Question 5

5. When examining the face of a patient, the nurse is aware that the two pairs of salivary glands that are accessible to examination are the ___________ and ___________ glands.
   a. Occipital; submental
   b. Parotid; jugulodigastric
   c. Parotid; submandibular
   d. Submandibular; occipital

Answer 5

ANS: C
Two pairs of salivary glands accessible to examination on the face are the parotid glands, which are in the cheeks over the mandible, anterior to and below the ear; and the submandibular glands, which are beneath the mandible at the angle of the jaw. The parotid glands are normally nonpalpable.

Question 6

6. A patient comes to the clinic complaining of neck and shoulder pain and is unable to turn her head. The nurse suspects damage to CN ______ and proceeds with the examination by _____________.
   a. XI; palpating the anterior and posterior triangles
   b. XI; asking the patient to shrug her shoulders against resistance
   c. XII; percussing the sternomastoid and submandibular neck muscles
   d. XII; assessing for a positive Romberg sign

Answer 6

ANS: B
The major neck muscles are the sternomastoid and the trapezius. They are innervated by CN XI, the spinal accessory. The innervated muscles assist with head rotation and head flexion, movement of the shoulders, and extension and turning of the head.

Question 7

7. When examining a patient’s CN function, the nurse remembers that the muscles in the neck that are innervated by CN XI are the:
   a. Sternomastoid and trapezius.
   b. Spinal accessory and omohyoid.
   c. Trapezius and sternomandibular.
   d. Sternomandibular and spinal accessory.

Answer 7

ANS: A

The major neck muscles are the sternomastoid and the trapezius. They are innervated by CN XI, the spinal accessory.

Question 8

8. A patient’s laboratory data reveal an elevated thyroxine (T4) level. The nurse would proceed with an examination of the _____ gland.
   a. Thyroid
   b. Parotid
   c. Adrenal
   d. Parathyroid

Answer 8

ANS: A
The thyroid gland is a highly vascular endocrine gland that secretes T4 and triiodothyronine (T3). The other glands do not secrete T4.

Question 9

9. A patient says that she has recently noticed a lump in the front of her neck below her “Adam’s apple” that seems to be getting bigger. During the assessment, the finding that leads the nurse to suspect that this may not be a cancerous thyroid nodule is that the lump (nodule):

a. Is tender.
b. Is mobile and not hard.
c. Disappears when the patient smiles.
d. Is hard and fixed to the surrounding structures.

Answer 9

ANS: B
Painless, rapidly growing nodules may be cancerous, especially the appearance of a single nodule in a young person. However, cancerous nodules tend to be hard and fixed to surrounding structures, not mobile.

Question 10

10. The nurse notices that a patient’s submental lymph nodes are enlarged. In an effort to identify the cause of the node enlargement, the nurse would assess the patient’s:
    a. Infraclavicular area.
    b. Supraclavicular area.
    c. Area distal to the enlarged node.
    d. Area proximal to the enlarged node.

Answer 10

ANS: D
When nodes are abnormal, the nurse should check the area into which they drain for the source of the problem. The area proximal (upstream) to the location of the abnormal node should be explored.

Question 11

11. The nurse is aware that the four areas in the body where lymph nodes are accessible are the:
    a. Head, breasts, groin, and abdomen.
    b. Arms, breasts, inguinal area, and legs.
    c. Head and neck, arms, breasts, and axillae.
    d. Head and neck, arms, inguinal area, and axillae.

Answer 11

ANS: D
Nodes are located throughout the body, but they are accessible to examination only in four areas: head and neck, arms, inguinal region, and axillae.

Question 12

12. A mother brings her newborn in for an assessment and asks, “Is there something wrong with my baby? His head seems so big.” Which statement is true regarding the relative proportions of the head and trunk of the newborn?
    a. At birth, the head is one fifth the total length.
    b. Head circumference should be greater than chest circumference at birth.
    c. The head size reaches 90% of its final size when the child is 3 years old.
    When the anterior fontanel closes at 2 months, the head will be more proportioned to the
    d. body.

Answer 12

ANS: B
The nurse recognizes that during the fetal period, head growth predominates. Head size is greater than chest circumference at birth, and the head size grows during childhood, reaching 90% of its final size when the child is age 6 years.

Question 13

13. A patient, an 85-year-old woman, is complaining about the fact that the bones in her face have become more noticeable. What explanation should the nurse give her?
    a. Diets low in protein and high in carbohydrates may cause enhanced facial bones.
    Bones can become more noticeable if the person does not use a dermatologically approved
    b. moisturizer.
    c. More noticeable facial bones are probably due to a combination of factors related to aging,
    such as decreased elasticity, subcutaneous fat, and moisture in her skin.
    d. Facial skin becomes more elastic with age. This increased elasticity causes the skin to be
    more taught, drawing attention to the facial bones.

Answer 13

ANS: C
The facial bones and orbits appear more prominent in the aging adult, and the facial skin sags, which is attributable to decreased elasticity, decreased subcutaneous fat, and decreased moisture in the skin.

Question 14

14. A patient reports excruciating headache pain on one side of his head, especially around his
    eye, forehead, and cheek that has lasted approximately to 2 hours, occurring once or twice each day. The nurse should suspect:
    a. Hypertension.
    b. Cluster headaches.
    c. Tension headaches.
    d. Migraine headaches.

Answer 14

ANS: B
Cluster headaches produce pain around the eye, temple, forehead, and cheek and are unilateral and always on the same side of the head. They are excruciating and occur once or twice per day
and last to 2 hours each.

Question 15

15. A patient complains that while studying for an examination he began to notice a severe headache in the frontotemporal area of his head that is throbbing and is somewhat relieved when he lies down. He tells the nurse that his mother also had these headaches. The nurse suspects that he may be suffering from:
    a. Hypertension.
    b. Cluster headaches.
    c. Tension headaches.
    d. Migraine headaches.

Answer 15

ANS:C
Migraine headaches tend to be supraorbital, retroorbital, or frontotemporal with a throbbing quality. They are severe in quality and are relieved by lying down. Migraines are associated with a family history of migraine headaches.

Question 16

16. A 19-year-old college student is brought to the emergency department with a severe headache he describes as, “Like nothing I’ve ever had before.” His temperature is 40° C, and he has a stiff neck. The nurse looks for other signs and symptoms of which problem?
    a. Head injury
    b. Cluster headache
    c. Migraine headache
    d. Meningeal inflammation

Answer 16

ANS: D
The acute onset of neck stiffness and pain along with headache and fever occurs with meningeal inflammation. A severe headache in an adult or child who has never had it before is a red flag. Head injury and cluster or migraine headaches are not associated with a fever or stiff neck.

Question 17

17. During a well-baby checkup, the nurse notices that a 1-week-old infant’s face looks small compared with his cranium, which seems enlarged. On further examination, the nurse also notices dilated scalp veins and downcast or “setting sun” eyes. The nurse suspects which condition?
    a. Craniotabes
    b. Microcephaly
    c. Hydrocephalus
    d. Caput succedaneum

Answer 17

ANS: C
Hydrocephalus occurs with the obstruction of drainage of cerebrospinal fluid that results in excessive accumulation, increasing intracranial pressure, and an enlargement of the head. The face looks small, compared with the enlarged cranium, and dilated scalp veins and downcast or
“setting sun” eyes are noted. Craniotabes is a softening of the skull’s outer layer. Microcephaly is an abnormally small head. A caput succedaneum is edematous swelling and ecchymosis of the presenting part of the head caused by birth trauma.

Question 18

18. The nurse needs to palpate the temporomandibular joint for crepitation. This joint is located just below the temporal artery and anterior to the:
    a. Hyoid bone.
    b. Vagus nerve.
    c. Tragus.
    d. Mandible.

Answer 18

ANS: C

The temporomandibular joint is just below the temporal artery and anterior to the tragus.

Question 19

19. A patient has come in for an examination and states, “I have this spot in front of my ear lobe on my cheek that seems to be getting bigger and is tender. What do you think it is?” The nurse notes swelling below the angle of the jaw and suspects that it could be an inflammation of his:
    a. Thyroid gland.
    b. Parotid gland.
    c. Occipital lymph node.
    d. Submental lymph node.

Answer 19

ANS: B
Swelling of the parotid gland is evident below the angle of the jaw and is most visible when the head is extended. Painful inflammation occurs with mumps, and swelling also occurs with abscesses or tumors. Swelling occurs anterior to the lower ear lobe.

Question 20

20. A male patient with a history of acquired immunodeficiency syndrome (AIDS) has come in for an examination and he states, “I think that I have the mumps.” The nurse would begin by examining the:
    a. Thyroid gland.
    b. Parotid gland.
    c. Cervical lymph nodes.
    d. Mouth and skin for lesions.

Answer 20

ANS: B
The parotid gland may become swollen with the onset of mumps, and parotid enlargement has been found with human immunodeficiency virus (HIV).

Question 21

21. The nurse suspects that a patient has hyperthyroidism, and the laboratory data indicate that the patient’s T4 and T3 hormone levels are elevated. Which of these findings would the nurse most likely find on examination?
    a. Tachycardia
    b. Constipation
    c. Rapid dyspnea
    d. Atrophied nodular thyroid gland

Answer 21

ANS: A
T4 and T3 are thyroid hormones that stimulate the rate of cellular metabolism, resulting in tachycardia. With an enlarged thyroid gland as in hyperthyroidism, the nurse might expect to find diffuse enlargement (goiter) or a nodular lump but not an atrophied gland. Dyspnea and constipation are not findings associated with hyperthyroidism.

Question 22

22. A visitor from Poland who does not speak English seems to be somewhat apprehensive about the nurse examining his neck. He would probably be more comfortable with the nurse examining his thyroid gland from:

a. Behind with the nurse’s hands placed firmly around his neck.
b. The side with the nurse’s eyes averted toward the ceiling and thumbs on his neck.
The front with the nurse’s thumbs placed on either side of his trachea and his head tilted
c. forward.
The front with the nurse’s thumbs placed on either side of his trachea and his head tilted
d. backward.

Answer 22

ANS: C
Examining this patient’s thyroid gland from the back may be unsettling for him. It would be best to examine his thyroid gland using the anterior approach, asking him to tip his head forward and to the right and then to the left.

Question 23

23. A patient’s thyroid gland is enlarged, and the nurse is preparing to auscultate the thyroid gland for the presence of a bruit. A bruit is a __________ sound that is heard best with the __________ of the stethoscope.
    a. Low gurgling; diaphragm
    b. Loud, whooshing, blowing; bell
    c. Soft, whooshing, pulsatile; bell
    d. High-pitched tinkling; diaphragm

Answer 23

ANS: C
If the thyroid gland is enlarged, then the nurse should auscultate it for the presence of a bruit, which is a soft, pulsatile, whooshing, blowing sound heard best with the bell of the stethoscope.

Question 24

24. The nurse notices that an infant has a large, soft lump on the side of his head and that his mother is very concerned. She tells the nurse that she noticed the lump approximately 8 hours after her baby’s birth and that it seems to be getting bigger. One possible explanation for this is:
    a. Hydrocephalus.
    b. Craniosynostosis.
    c. Cephalhematoma.
    d. Caput succedaneum.

Answer 24

ANS: C
A cephalhematoma is a subperiosteal hemorrhage that is the result of birth trauma. It is soft, fluctuant, and well defined over one cranial bone. It appears several hours after birth and gradually increases in size.

Question 25

25. A mother brings in her newborn infant for an assessment and tells the nurse that she has noticed that whenever her newborn’s head is turned to the right side, she straightens out the arm and leg on the same side and flexes the opposite arm and leg. After observing this on examination, the nurse tells her that this reflex is:

a. Abnormal and is called the atonic neck reflex.
b. Normal and should disappear by the first year of life.
Normal and is called the tonic neck reflex, which should disappear between 3 and 4 months
c. of age.
Abnormal. The baby should be flexing the arm and leg on the right side of his body when
d. the head is turned to the right.

Answer 25

ANS: C
By 2 weeks, the infant shows the tonic neck reflex when supine and the head is turned to one side (extension of same arm and leg, flexion of opposite arm and leg). The tonic neck reflex disappears between 3 and 4 months of age.

Question 26

26. During an admission assessment, the nurse notices that a male patient has an enlarged and rather thick skull. The nurse suspects acromegaly and would further assess for:
    a. Exophthalmos.
    b. Bowed long bones.
    c. Coarse facial features.
    d. Acorn-shaped cranium.

Answer 26

ANS: C
Acromegaly is excessive secretion of growth hormone that creates an enlarged skull and thickened cranial bones. Patients will have elongated heads, massive faces, prominent noses and lower jaws, heavy eyebrow ridges, and coarse facial features. Exophthalmos is associated with hyperthyroidism. Bowed long bones and an acorn-shaped cranium result from Paget disease.

Question 27

27. When examining children affected with Down syndrome (trisomy 21), the nurse looks for the possible presence of:
    a. Ear dysplasia.
    b. Long, thin neck.
    c. Protruding thin tongue.
    d. Narrow and raised nasal bridge.

Answer 27

ANS: A
With the chromosomal aberration trisomy 21, also known as Down syndrome, head and face characteristics may include upslanting eyes with inner epicanthal folds, a flat nasal bridge, a small broad flat nose, a protruding thick tongue, ear dysplasia, a short broad neck with webbing, and small hands with a single palmar crease.

Question 28

28. A patient visits the clinic because he has recently noticed that the left side of his mouth is paralyzed. He states that he cannot raise his eyebrow or whistle. The nurse suspects that he has:
    a. Cushing syndrome.
    b. Parkinson disease.
    c. Bell palsy.
    d. Experienced a cerebrovascular accident (CVA) or stroke.

Answer 28

ANS: D
With an upper motor neuron lesion, as with a CVA, the patient will have paralysis of lower facial muscles, but the upper half of the face will not be affected owing to the intact nerve from the unaffected hemisphere. The person is still able to wrinkle the forehead and close the eyes. (See Table 13-4, Abnormal Facial Appearances with Chronic Illnesses, for descriptions of the other responses.)

Question 29

29. A woman comes to the clinic and states, “I’ve been sick for so long! My eyes have gotten so puffy, and my eyebrows and hair have become coarse and dry.” The nurse will assess for other signs and symptoms of:
    a. Cachexia.
    b. Parkinson syndrome.
    c. Myxedema.
    d. Scleroderma.

Answer 29

ANS: C
Myxedema (hypothyroidism) is a deficiency of thyroid hormone that, when severe, causes a nonpitting edema or myxedema. The patient will have a puffy edematous face, especially around the eyes (periorbital edema); coarse facial features; dry skin; and dry, coarse hair and eyebrows. (See Table 13-4, Abnormal Facial Appearances with Chronic Illnesses, for descriptions of the other responses.)

Question 30

30. During an examination of a female patient, the nurse notes lymphadenopathy and suspects an acute infection. Acutely infected lymph nodes would be:
    a. Clumped.
    b. Unilateral.
    c. Firm but freely movable.
    d. Firm and nontender.

Answer 30

ANS: C

Acutely infected lymph nodes are bilateral, enlarged, warm, tender, and firm but freely movable. Unilaterally enlarged nodes that are firm and nontender may indicate cancer.

Question 31

31. The physician reports that a patient with a neck tumor has a tracheal shift. The nurse is aware that this means that the patient’s trachea is:
    a. Pulled to the affected side.
    b. Pushed to the unaffected side.
    c. Pulled downward.
    d. Pulled downward in a rhythmic pattern.

Answer 31

ANS: B
The trachea is pushed to the unaffected side with an aortic aneurysm, a tumor, unilateral thyroid lobe enlargement, or a pneumothorax. The trachea is pulled to the affected side with large atelectasis, pleural adhesions, or fibrosis. Tracheal tug is a rhythmic downward pull that is synchronous with systole and occurs with aortic arch aneurysm.

Question 32

32. During an assessment of an infant, the nurse notes that the fontanels are depressed and sunken. The nurse suspects which condition?
    a. Rickets
    b. Dehydration
    c. Mental retardation
    d. Increased intracranial pressure

Answer 32

ANS: B
Depressed and sunken fontanels occur with dehydration or malnutrition. Mental retardation and rickets have no effect on the fontanels. Increased intracranial pressure would cause tense or bulging and possibly pulsating fontanels.

Question 33

33. The nurse is performing an assessment on a 7-year-old child who has symptoms of chronic watery eyes, sneezing, and clear nasal drainage. The nurse notices the presence of a transverse line across the bridge of the nose, dark blue shadows below the eyes, and a double crease on the lower eyelids. These findings are characteristic of:
    a. Allergies.
    b. Sinus infection.
    c. Nasal congestion.
    d. Upper respiratory infection.

Answer 33

ANS: A
Chronic allergies often develop chronic facial characteristics and include blue shadows below the eyes, a double or single crease on the lower eyelids, open-mouth breathing, and a transverse line on the nose.

Question 34

34. While performing a well-child assessment on a 5 year old, the nurse notes the presence of palpable, bilateral, cervical, and inguinal lymph nodes. They are approximately 0.5 cm in size, round, mobile, and nontender. The nurse suspects that this child:
    a. Has chronic allergies.
    b. May have an infection.
    c. Is exhibiting a normal finding for a well child of this age.
    d. Should be referred for additional evaluation.

Answer 34

ANS: C
Palpable lymph nodes are normal in children until puberty when the lymphoid tissue begins to atrophy. Lymph nodes may be up to 1 cm in size in the cervical and inguinal areas but are discrete, movable, and nontender.

Question 35

35. The nurse has just completed a lymph node assessment on a 60-year-old healthy female patient. The nurse knows that most lymph nodes in healthy adults are normally:
    a. Shotty.
    b. Nonpalpable.
    c. Large, firm, and fixed to the tissue.
    d. Rubbery, discrete, and mobile.

Answer 35

ANS: B
Most lymph nodes are nonpalpable in adults. The palpability of lymph nodes decreases with age. Normal nodes feel movable, discrete, soft, and nontender.

Question 36

36. During an examination of a patient in her third trimester of pregnancy, the nurse notices that the patient’s thyroid gland is slightly enlarged. No enlargement had been previously noticed. The nurse suspects that the patient:
    a. Has an iodine deficiency.
    b. Is exhibiting early signs of goiter.
    c. Is exhibiting a normal enlargement of the thyroid gland during pregnancy.
    d. Needs further testing for possible thyroid cancer.

Answer 36

ANS: C

The thyroid gland enlarges slightly during pregnancy because of hyperplasia of the tissue and increased vascularity.

Question 37

37. During an examination, the nurse knows that the best way to palpate the lymph nodes in the neck is described by which statement?
    a. Using gentle pressure, palpate with both hands to compare the two sides.
    b. Using strong pressure, palpate with both hands to compare the two sides.
    c. Gently pinch each node between one’s thumb and forefinger, and then move down the neck muscle.
    d. Using the index and middle fingers, gently palpate by applying pressure in a rotating pattern.

Answer 37

ANS: A
Using gentle pressure is recommended because strong pressure can push the nodes into the neck muscles. Palpating with both hands to compare the two sides symmetrically is usually most efficient.

Question 38

38. During a well-baby checkup, a mother is concerned because her 2-month-old infant cannot hold her head up when she is pulled to a sitting position. Which response by the nurse is appropriate?
    a. “Head control is usually achieved by 4 months of age.”
    b. “You shouldn’t be trying to pull your baby up like that until she is older.”
    c. “Head control should be achieved by this time.”
    d. “This inability indicates possible nerve damage to the neck muscles.”

Answer 38

ANS: A
Head control is achieved by 4 months when the baby can hold the head erect and steady when pulled to a vertical position. The other responses are not appropriate.

Question 39

39. During an examination of a 3-year-old child, the nurse notices a bruit over the left temporal area. The nurse should:
    a. Continue the examination because a bruit is a normal finding for this age.
    b. Check for the bruit again in 1 hour.
    c. Notify the parents that a bruit has been detected in their child.
    d. Stop the examination, and notify the physician.

Answer 39

ANS: A
Bruits are common in the skull in children under 4 or 5 years of age and in children with anemia. They are systolic or continuous and are heard over the temporal area.

Question 40

40. During an examination, the nurse finds that a patient’s left temporal artery is tortuous and feels hardened and tender, compared with the right temporal artery. The nurse suspects which condition?
    a. Crepitation
    b. Mastoiditis
    c. Temporal arteritis
    d. Bell palsy

Answer 40

ANS: C
With temporal arteritis, the artery appears more tortuous and feels hardened and tender. These assessment findings are not consistent with the other responses.

Question 41

MULTIPLE RESPONSE

1. The nurse is assessing a 1-month-old infant at his well-baby checkup. Which assessment findings are appropriate for this age? Select all that apply.
   a. Head circumference equal to chest circumference
   b. Head circumference greater than chest circumference
   c. Head circumference less than chest circumference
   d. Fontanels firm and slightly concave
   e. Absent tonic neck reflex
   f. Nonpalpable cervical lymph nodes

Answer 41

ANS: B, D, F

An infant’s head circumference is larger than the chest circumference. At age 2 years, both measurements are the same. During childhood, the chest circumference grows to exceed the head circumference by 5 to 7 cm. The fontanels should feel firm and slightly concave in the infant, and they should close by age 9 months. The tonic neck reflex is present until between 3 and 4 months of age, and cervical lymph nodes are normally nonpalpable in an infant.