Head, Neck, Mouth, Nose, Throat and Sinus

Question 1

Glands to know

Answer 1

Parotid and the Sublingual and Submandibular

Question 2

Developmental Considerations

Answer 2

In infants, cranial bones are soft and separated by a membraneous space, which allows brain to expand
Closed by 9-24 months of age
Head size is greater than chest circumference

Question 3

Subjective data collection

Answer 3

Headache
Head injury
Dizziness
Neck Pain
Past medical history
Family history 
Past surgeries

Question 4

Objective Data Inspection

Answer 4

General size - Normocephalic
Facial Expressions- appropriateness, look for ptosis of the eyelids
Check for facial symmetry (features and movement)
Position of head (midline, erect and still)
Inspect hair for lesions, scabs, parasites, nits or scaliness)
Range of motion

Question 5

Objective Data: Palpation

Answer 5

Head/skull: palpate for shape

Question 6

Objective data for lymph nodes

Answer 6

Normal nodes feel movable and soft

If the nodes are enlarged, check the area they drain for the source of the problem

Question 7

Lymph nodes: Palpation

Answer 7

Use gentle circular notion with pads of fingers
Easily palpable nodes are not found in adults
Nodes are normally small, movable, less than a centimeter in diameter
Note: location, size, consistency, shape, tenderness, movability, or fixation

Question 8

Best way to palpate the thyroid

Answer 8

Posterior approach is easiest
Move behind pt
Bend head slightly forward and to right
Use fingers of your left hand to push trachea to right
You should not be able to palpate the normal adult thyroid!

Ask client to swallow and note movement of thyroid
Note enlargement or nodules
Note size, shape, consistency, and presence of nodules
If thyroid is enlarged, auscultate for bruit. (normally absent)
Pregnant females may have slightly enlarged thyroid glands.

Question 9

If thyroid gland is enlarged, what do you do next?

Answer 9

Auscultate for a bruit: soft, whooshing, blowing sound

Question 10

If there is no bruit sound, does that mean your thyroid gland is fine and okay?

Answer 10

No, not neccessarily. The presence of a bruit is abnormal, but its absence does not mean thyroid gland is totally fine

Question 11

Talk about the nose …

Answer 11

Nares widen into vestibules, nose has rich blood supply, contains cilia that traps dust and debris, numerous nasal hairs to filter air

Question 12

Describe sinuses

Answer 12

Air filled extensions of the nasal cavity within the bones of the skull. Lined by ciliated mucous membranes

Question 13

Developmental Considerations

Answer 13

Salivation begins at 3 months of age and infant drools until swallowing is learned
Teeth begin to erupt in children by 6-24 months. Twenty deciduous teeth (temporary) and begin to loose by age 6 through age 12
Pregnant women- increase estrogen levels cause increase vascularity in nasal area

Question 14

Subjective data for nose

Answer 14

Nasal discharge
Frequent Colds 
Sinus Pain 
Trauma 
Snoring 
Allergies
Stuffiness
 Altered smell 
Epistaxis

Question 15

Subjective for Mouth and Throat

Answer 15

Sore or lesions 
Self Care Practices 
SOre Throat 
Altered Taste 
Bleeding Gums 
Smoking and Alcohol use 
Toothache
Hoarseness
Dysphagia
Dysphasia

Question 16

Objective Data Inspection for Mouth and Throat

Answer 16

Soft palate should be continuous with hard palate note lesions, ulcerations, pain, or discharge
Uvula should be midline and soft palate rise with saying ”ah”- CN IX and X
Depress tongue with a tongue blade scan the posterior wall for color, exudate, or lesions including tonsils

Question 17

Inspecting the Tonsils

Answer 17

1+  Visible
2+  Half between tonsillar pillars and uvula
3+  Touching the uvula
4+  Touching each other
Normal is +1 to +2

Question 18

Nose Inspection

Answer 18

Midline, inspect for deformities, assymmetry

Question 19

The C1 vertebrae that helps support the cranium is known as the _____________ while the C2 vertebrae is known as the ________________.

Answer 19

atlas ; axis

Question 20

Coronal, Sagittal and Lamboid sutures are each unions of which bones?

Answer 20

Coronal is the union between the frontal and parietal bones

Sagittal is union between two parietal bones

Lamboid is union between parietal bones and occipital bone.

Question 21

What are palpebral fissues ?

Answer 21

These are the openings between the eyelids. They should be equal bilaterally.

Question 22

What are the nasolabial folds ?

Answer 22

These are the creases which extend from the nose to the corner of the mouth should be symmetric.

Question 23

Parotid glands are what ?

Answer 23

The largest of the salivary glands- they are in the cheek over the mandible and are not normally palpable.

Question 24

Where can you palpate the temporal artery?

Answer 24

Anterior to the ear. The temporal artery lies superior to the temporalis muscle.

Question 25

The major neck muscles are …………

they are innervated by what cranial nerve?

Answer 25

the trapezius and sternomastoid muscles

Innervated by the spinal accessory cranial nerve (XI)

Question 26

The greatest supply of lymph nodes are in the ____________

Answer 26

head and the neck
such as the preauricular (in front of the ears)
the submandibular (below the mandible)
the supraclavicular (above the clavicle)
and more

Question 27

What to ask about headaches ?

Answer 27

any unusually frequent or unusually severe headaches ?

Question 28

Subjective data collection for head, face and neck

Answer 28

1. Headache
2. Head injury
3. Dizziness
4. neck pain
5. lumps or swelling
6. head or neck surgeries
   family history of head/neck cancers/thyroid problems

Question 29

the thyroid cartilage is called the ____________ in males.

Answer 29

Adam’s apple

Question 30

What is the TMJ?

Answer 30

The temporomandibular joint - it should be palpated as client opens mouth

Question 31

Tracheal deviation - when is the trachea pulled toward the affected (diseased side)?

Answer 31

WIth large atelectasis, pleural adhesions or fibrosis

Question 32

When is the trachea pulled toward the unaffected (or healthy side)

Answer 32

with an aortic aneurysm, a tumor, unilateral thyroid lobe enlargement and pneumothorax

Question 33

What do normal lymph nodes feel like?

Answer 33

movable, discrete, soft and non tender.

Question 34

if nodes are enlarged, what should I do?

Answer 34

Check the area they drain for the source of the problem

Question 35

What is lymphadenopathy?

Answer 35

Enlargement of lymph node greater than 1 cm that can be caused by infection , allergy or neoplasm

Question 36

There are how many groups of lymph nodes in the face and neck?

Answer 36

10 groups of lymph nodes

1. Preauricular
2. Posterior Auricular
3. Occipital
4. Submental
5. Submandibular
6. Jugulodigastric
7. Superficial cervical
8. Deep cervical chain
9. Posterior cervical
10. Supraclavicular

Question 37

Are lymph nodes easily palpable in adults ?

Answer 37

the answer is no,

Question 38

If the thyroid gland is enlarged, what should one do?

Answer 38

Auscultate it with the bell of stethoscope for the presence of a bruit indicating hyperplasia of the thyroid.
The bruit is not present normally

Question 39

Pregnant women may have slightly enlarged thyroid glands. True or False?

Answer 39

True

Question 40

The newborn infants head size should be 2 cm larger than chest circumference. True or false?

At what age are both measurements the same

Answer 40

True

By age 2 both measurements, head size and chest circumference are the same.
During childhood, chest circumference grows to exceed head circumference by 5-7 meters

Question 41

Caput Succedaneum is what ?

Answer 41

This is a edematous swelling and ecchymosis (discoloration of the skin) of the presenting part of the head caused by birth trauma , which gradually resolves during the first few days of life and needs no treatment

Question 42

What are some nursing diagnoses related to the head and neck?

Answer 42

Self-care deficit
Body image disturbance R/T scalp dryness
Risk for impaired skin integrity R/T pruritus (severe itching of the skin)

Question 43

What are sinuses ?

Answer 43

These are air filled extensions of the nasal cavity within the bones of the skull. They are lined by ciliated mucous membranes.
frontal, ethmoid and maxillary sinuses

Question 44

The uvula is an extension of the _________

Answer 44

soft palate

Question 45

When does salivation begin ?

Answer 45

At 3 months of age and infant drools until swallowing is learned

Question 46

When do teeth begin to erupt in children?

Answer 46

By 6-24 months. 20 teeth are normally in place by 2 1/2 years of age. Teeth begin to be lost at age 6 until 12 years of age

Question 47

Pregnant women have increased what in the nasal area because of high estrogen levels?

Answer 47

Increased vascularity

Question 48

Newborns are ____________ breathers so it is important to determine the patency of their nares.

Answer 48

nose

Question 49

The soft palate should be _____________ with the hard palate .

Answer 49

continuous

Question 50

What is the inspection grading for tonsils ?

Answer 50

1+  Visible
2+  Half between tonsillar pillars and uvula
3+  Touching the uvula
4+  Touching each other
Normal is +1 to +2

Question 51

Nursing diagnoses for mouth, nose and throat

Answer 51

Altered oral mucous membrane
Impaired swallowing
Pain
Sensory/perceptual alterations: olfactory
Sensory/perceptual alterations: gustatory

Question 52

What is nystagmus ?

Answer 52

Involuntary movement of the eyes. .. known as dancing eyes

Question 53

What is pneumothorax?

Answer 53

A collapsed lung

Question 54

What is hyperplasia ?

Answer 54

the enlargement of an organ or tissue caused by an increase in the reproduction rate of its cells

Question 55

What is neoplasm ?

Answer 55

new and abnormal growth of new tissue