Question 1

The nurse is aware that all of the areas in the body where lymph nodes are accessible for examination are the:

Accepted Answer

Nodes are located throughout the body but are accessible for examination only in the head and neck,arms,axillae,and inguinal region.

Question 2

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 will be:

Accepted Answer

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

Question 3

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 starts the examination by:

Accepted Answer

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 4

An 85-year-old female patient is complaining about the fact that the bones in her face have become more noticeable.What explanation should the nurse provide?

Accepted Answer

The facial bones and orbits appear more prominent in the older adult,and the facial skin sags as a result of decreased elasticity,subcutaneous fat,and moisture in the skin.

Question 5

When examining the face,the nurse is aware that the two pairs of salivary glands that are accessible to examination are the _____ glands.

Accepted Answer

Two pairs of salivary glands accessible to examination on the face are the parotid glands in the cheeks over the mandible,anterior to and below the ear,and the submandibular glands,beneath the mandible at the angle of the jaw.The parotid glands are not normally palpable.

Question 6

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:

Accepted Answer

When nodes are abnormal,check the area they drain for the source of the problem.Explore the area proximal (upstream)to the location of the abnormal node.

Question 7

During a well-baby checkup,the nurse notices that a 1-week-old infant's face looks small,compared with an enlarged cranium.On further examination,the nurse also notes dilated scalp veins and downcast,or "setting sun," eyes.What condition does the nurse suspect?

Accepted Answer

Hydrocephalus occurs when cerebrospinal fluid drainage is obstructed,resulting in excessive accumulation,increasing intracranial pressure,and enlargement of the head.The face looks small compared with the enlarged cranium,and dilated scalp veins and downcast,or "setting sun," eyes are also present.

Question 8

The muscles in the neck that are innervated by CN XI are the:

Accepted Answer

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

Question 9

A patient has come in for an examination and states,"I have this spot on my cheek here in front of my ear lobe.The spot seems to be getting bigger and is very 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:

Accepted Answer

Swelling of the parotid gland is seen below the angle of the jaw,especially when the head is extended.Painful inflammation occurs with mumps;abscesses or tumours also cause swelling,which is present anterior to the lower ear lobe.

Question 10

A mother brings her newborn in for an assessment and asks,"Is there something wrong with my baby? His head seems so big." Which of the following does the nurse know about the relative proportions of the head and trunk in the newborn?

Accepted Answer

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 at 6 years.

Question 11

A 19-year-old community 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 his neck is stiff.What do these signs and symptoms suggest?

Accepted Answer

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 such a headache before is a red flag.

Question 12

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 reassures the nurse that this may not be a cancerous thyroid nodule is that the lump (nodule):

Accepted Answer

Mobile nodules that are not hard are in all probability noncancerous.A painless,rapidly growing nodule,especially a single nodule in a young person,should be considered suspicious.Also,cancerous nodules tend to be hard and are fixed to surrounding structures.

Question 13

A patient's laboratory data reveal an elevated thyroxine level.The nurse would examine the:

Accepted Answer

The thyroid gland is a highly vascular endocrine gland that secretes thyroxine (T₄)and triiodothyronine (T₃).

Question 14

A mother brings her 2-month-old daughter in for an examination and says,"My daughter rolled over and hit her head on the wall,and now I have noticed that she has this spot that is soft on the top of her head.Is there something terribly wrong?" The nurse's response would be:

Accepted Answer

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

Question 15

A patient presents with excruciating pain on one side of his head,especially around his eye,forehead,and cheek,that occurs once or twice each day and lasts about 30 minutes to 2 hours.The nurse suspects:

Accepted Answer

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 30 minutes to 2 hours each time.

Question 16

The nurse notices that a patient's palpebral fissures are not symmetrical.On examination,the nurse may find that there has been damage to:

Accepted Answer

Facial muscles are mediated by CN VII;asymmetry of palpebral fissures may be due to CN VII damage.

Question 17

A patient is unable to differentiate between sharp and dull stimulation to both sides of her face.The nurse suspects:

Accepted Answer

Facial sensations of pain or touch are mediated by CN V,the trigeminal nerve.

Question 18

A male patient with acquired immunodeficiency syndrome (AIDS)has come in for an examination and says,"I think that I have the mumps." The nurse would begin by examining the:

Accepted Answer

The parotid gland may become swollen with the onset of mumps,and parotid enlargement has been found in AIDS.

Question 19

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

Accepted Answer

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

Question 20

A patient reports a severe throbbing headache in the frontotemporal area of his head that he experienced while studying for an examination,He says that the headache was somewhat relieved when he lay down.He tells the nurse that his mother also used to get these headaches.The nurse suspects that he may be suffering from:

Accepted Answer

Migraine headaches tend to be supraorbital,retro-orbital,or frontotemporal.They are of a severe throbbing quality and are relieved to an extent when the affected person lies down.Migraines are associated with family history.

Quiz 14: Head and Neck, including Regional Lymphatic System