Head, neck, nose, mouth, and throat

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 is 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.”

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 fontanelle is closed by 1 to 2 months, and the diamond-shaped anterior fontanel closes between 9 months and 2 years.

When examining the face of a patient, the nurse is aware that the two pairs of salivary glands that are accessible for examination are the ___________ and ___________ glands.

a. Occipital; submental

b. Parotid; jugulodigastric

c. Parotid; submandibular

d. Submandibular; occipital

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

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

ANS: A

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

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 assessment, the nurse suspects a noncancerous finding as the lump:

a. Is singular and firm.

b. Consists of multiple nodules.

c. Disappears when the patient smiles.

d. Is hard and fixed to the surrounding structures.

ANS: B

Multiple nodules usually indicate inflammation or a multinodular goitre, rather than a neoplasm. Any rapidly enlarging or firm nodule should be further investigated. Painless, rapidly growing nodules may be cancerous, especially the appearance of a single nodule in a young person. Cancerous nodules tend to be hard and fixed to surrounding structures.

A patient who is 7 months pregnant is at the clinic for her routine checkup. During assessment the nurse notes that the patient’s thyroid is palpable. The nurse will:

a. Refer the patient to a thyroid specialist.

b. Send the patient for laboratory tests for thyroid hormones.

c. Document the findings as normal.

d. Ask a colleague to check the findings.

ANS: C

Usually the normal adult thyroid is not palpable. However, the thyroid gland may be palpable normally during pregnancy.

The nurse notices that a patient’s submental lymph nodes are enlarged. To identify the cause of the enlargement of the patient’s nodes, the nurse assesses the:

a. Infraclavicular area.

b. Supraclavicular area.

c. Area distal to the enlarged node.

d. Area proximal to the enlarged node.

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.

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.

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.

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.

d. When the anterior fontanelle closes at 2 months, the head will be more proportionate to the body.

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 6 years of age.

A patient, an 85-year-old woman, is concerned that the bones in her face have become more noticeable. The nurse tells her that:

a. Diets low in protein and high in carbohydrates may cause enhanced facial bones.

b. Bones can become more noticeable if the person does not use a dermatologically approved moisturizer.

c. More noticeable facial bones are probably caused by 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.

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.

A patient reports to the nurse that he has been experiencing excruciating headache pain on one side of his head, especially around his eye, forehead, and cheek that lasts approximately one-half to 2 hours, occurring once or twice each day. The nurse suspects that he is having:

a. Hypertension.

b. Cluster headaches.

c. Tension headaches.

d. Migraine headaches.

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 one-half to 2 hours each

A patient is concerned that while studying for an examination he began to notice a severe headache in the left front and side of his head that was throbbing and was relieved when he lay 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.

ANS: D

Migraine headaches tend to be supraorbital, retro-orbital, 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.

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.

ANS: C

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

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.

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 tumours. Swelling occurs anterior to the lower ear lobe.

A male patient with a history of 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.

ANS: B

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

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.

c. The front with the nurse’s thumbs placed on either side of his trachea and his head tilted forward.

d. The front with the nurse’s thumbs placed on either side of his trachea and his head tilted backward.

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

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

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.

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.

c. Normal and is called the tonic neck reflex, which should disappear between 3 and 4 months of age.

d. Abnormal and the baby should be flexing the arm and leg on the right side of his body when the head is turned to the right.

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.

When examining children affected with Down’s syndrome (trisomy 21), the nurse looks for the possible presence of:

a. Misshapen ears.

b. Long, thin neck.

c. Thin tongue sticking out

d. Narrow and raised nasal bridge.

ANS: A

With the chromosomal aberration trisomy 21, also known as Down’s syndrome, head and face characteristics may include upslanting eyes with inner epicanthal folds (small folds of skin at the inner corners), a flat nasal bridge, a small broad flat nose, a protruding thick tongue, ear dysplasia (misshapen ears), a short broad neck with webbing, and small hands with a single palmar crease. (See Table 14-2.)

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.

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.

The physician reports that a patient with a neck tumour 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.

ANS: B

The trachea is pushed to the unaffected side with an aortic aneurysm, a tumour, 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

During an assessment of an infant, the nurse notes that the fontanelles are depressed and sunken. The nurse suspects which condition?

a. Rickets

b. Dehydration

c. Mental retardation

d. Increased intracranial pressure

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 fontanelles.

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.

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

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 documents that the child:

a. Has chronic allergies.

b. Has an infection.

c. Has normal findings for a 5-year-old child.

d. Should be referred for additional evaluation.

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

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.

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

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 recognizes that the patient:

a. Has an iodine deficiency.

b. Is exhibiting early signs of goitre.

c. Is exhibiting a normal enlargement of the thyroid gland during pregnancy.

d. Needs further testing for possible thyroid cancer.

ANS: C

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

During an examination, the nurse knows that the best way to palpate the lymph nodes in the neck is by:

a. Using gentle pressure and palpating with both hands to compare the two sides.

b. Using strong pressure and palpating with both hands to compare the two sides.

c. Gently pinching each node between one’s thumb and forefinger and then moving down the neck muscle.

d. Using the index and middle fingers and gently palpating by applying pressure in a rotating pattern.

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

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.”

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.

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.

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

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’s palsy

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.