NUR 505 Chapter 10: Head and Neck Test Bank—Nursing (GRADED A) | TOP RATED PAPER

Chapter 10: Head and Neck Test Bank—Nursing MULTIPLE CHOICE 1. Which cranial nerves innervate the face? a. II and V b. III and VI c. V and VII d. VIII and IX ANS: C Facial nerves are con trolled by cranial nerves V and VII; cranial nerves II, III, and VI control the eyes, cranial nerve VIII deals with hearing, and cranial nerve IX deals with swallowing. DIF: Cognitive Level: Remembering (Knowledge) REF: p. 185 OBJ: Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 2. The parotid, submandibular, and sublingual salivary glands: a. impair carbohydrate digestion. b. inhibit dental caries. c. lubricate nasal surfaces. d. promote dry mouth. ANS: B These glands function together to secrete saliva, which moistens the mouth, aids in carbohydrate breakdown, and prevents cavities. DIF: Cognitive Level: Understanding (Comprehension) REF: p. 185 OBJ: Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 3. Mr. Black is a 44-year-old patient who presents to the clinic with complaints of neck pain that he thinks is from his job involving computer data entry. As the examiner, you are checking the range of motion in his neck and note that the greatest degree of cervical mobility is at: a. C1 to C2. b. C2 to C3. c. C3 to C4. d. C4 to C5. ANS: D C4 to C5 and C5 to C6 are the cervical vertebrae with the greatest movement. The types of movement includes flexion, extension, and hyperflexion, as well as horizontal movements of lateral flexion and rotation. DIF: Cognitive Level: Applying (Application) REF: p. 185 OBJ: Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 4. In examining the neck of a 34-year-old female patient, you note that the uppermost ridge of the tracheal cartilage is at the: a. cricoid. b. hyoid. c. thyroid. d. sternocleidomastoid. ANS: A The walls of the trachea are supported by nine cartilages. The cricoid cartilage is the most superior cartilage and is ring-shaped. The hyoid bone sits just below the mandible, the thyroid gland is not a part of this region but rather lies across, and the sternocleidomastoid muscles are on the lateral side of the neck. DIF: Cognitive Level: Remembering (Knowledge) REF: p. 185 OBJ: Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 5. Mrs. Britton brings her 16-year-old son in with a complaint that he is not developing correctly into adolescence. Which structures disproportionately enlarge in the male during adolescence? a. Coronal sutures b. Hyoid and cricoid cartilages c. Mandible and maxilla bones d. Nose and thyroid cartilages ANS: D In adolescent males, the nose enlarges and the thyroid cartilage becomes the largest component of the anterior larynx, known as the Adam’s apple. DIF: Cognitive Level: Remembering (Knowledge) REF: p. 186 OBJ: Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 6. Spaces between the cranial bones accommodate: a. brain growth. b. cartilage formation. c. muscular expansion. d. nerve regeneration. ANS: A The suture lines, the spaces between the cranial bones, allow for brain growth and later fuse after growth is complete. DIF: Cognitive Level: Remembering (Knowledge) REF: p. 186 OBJ: Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 7. When examining the skull of a 4-month-old baby, you should normally find: a. closure of the anterior fontanel. b. closure of the posterior fontanel. c. ossification of all sutures. d. overlap of cranial bones. ANS: B At 2 months of age, the posterior fontanel should be closed or ossified with the anterior fontanel, a larger fontanel, closing at 24 months. The only time the cranial bones should overlap is at a vaginal birth as a result of pressure within the birth canal. DIF: Cognitive Level: Remembering (Knowledge) REF: p. 186 OBJ: Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 8. The brown or tan pigmentation on the forehead, nose, and malar prominence of some pregnant women is called: a. hormonal acne. b. erythema. c. alopecia. d. chloasma. ANS: D Chloasma—brown-tan facial pigmentation during pregnancy—will fade after delivery. Hormonal acne and erythema do not result in brown or tan pigmentation, and alopecia is loss of hair. DIF: Cognitive Level: Remembering (Knowledge) REF: p. 197 OBJ: Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 9. Which of the following is an expected change in the assessment of the thyroid during pregnancy? a. Palpation of the gland becomes difficult. b. A bruit is auscultated. c. Inspection reveals a goiter. d. The gland is tender on palpation. ANS: B During pregnancy, the thyroid gland hypertrophies (not to the point of a goiter), palpation is easier and, because the gland also has increased vascularity, bruits are common. It is an abnormal finding for the thyroid to feel fibrotic, tender, or smaller. DIF: Cognitive Level: Applying (Application) REF: p. 197 OBJ: Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 10. Mr. Mathews is a 47-year-old patient who presents for a routine physical examination. On examination, you noted a bruit heard over the thyroid. This is suggestive of: a. hypothyroidism. b. hyperthyroidism. c. thyroid cancer. d. thyroid cyst. ANS: B Because of hypermetabolic states such as hyperthyroidism, a bruit may be heard as a result of the increased blood flow to the area. Auscultating a bruit is not symptomatic of hypothyroidism, cancer, or a cyst. A nodule is more indicative of cancer. DIF: Cognitive Level: Applying (Application) REF: p. 194 OBJ: Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 11. Ms. Galvan is a 22-year-old secretary who comes to the clinic with headaches of 6 weeks’ duration. She tells the office assistant about her heavy schedule, including part-time work and evening classes. Her vital signs are normal. Which information is most appropriate to Ms. Galvan’s history? a. Current medications b. Elimination patterns c. Immunization status d. Previous pregnancies ANS: A Some current medications, such as birth control pills, nitroglycerin, antihypertensives, antiseizure drugs, and some diabetic drugs, can be headache triggers. Withdrawal of headache medication can also trigger headaches. DIF: Cognitive Level: Analyzing (Analysis) REF: p. 188 OBJ: Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 12. Observation during history taking is the best way to examine for: a. head position. b. scalp lice. c. thyroid size. d. tracheal alignment. ANS: A Head position as well as facial features are best observed when talking to the patient during the history. Scalp lice, thyroid size, and tracheal alignment are best assessed by palpation and closer physical observation. DIF: Cognitive Level: Applying (Application) REF: p. 189 OBJ: Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 13. During a head and neck assessment of a neonate, it is important to screen for: a. the presence of torticollis. b. signs and symptoms of cerebral palsy. c. uneven movement of the eyes. d. unilateral movement of the tongue. ANS: A Torticollis is usually caused by constraint of the newborn in utero or injury during vaginal delivery. The other symptoms may be difficult to discern because of the infant’s lack of fine motor skills and control of voluntary muscle groups. During a head and neck assessment of a neonate, it is not important to screen for signs and symptoms of cerebral palsy, uneven movement of the eyes, or unilateral movement of the tongue. DIF: Cognitive Level: Applying (Application) REF: p. 195 OBJ: Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 14. To detect bruits in the head and neck region, you should place the bell of the stethoscope: a. above the temporal and sagittal regions. b. below the eyes and on the coronal suture. c. near the zygomatic and nasal areas. d. on the temporal region and below the occiput. ANS: D Vascular abnormalities of the head and neck may cause audible bruits and are best heard over the eyes, in the temporal area, and below the occiput. These are all areas of major blood supply to the head. DIF: Cognitive Level: Understanding (Comprehension) REF: p. 192 OBJ: Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 15. During a physical examination of a 30-year-old Chinese man, you notice a slight asymmetry of his face. The cranial nerve examination is normal. Your best action is to: a. ask the patient if this characteristic runs in his family. b. perform monofilament testing on the face. c. consult with the physician regarding the laboratory tests needed. d. record the finding in the patient’s chart. ANS: D It is not abnormal to have some slight asymmetry of the face that does not require further questioning, tests, or unnecessary laboratory work, but it does require a notation in the chart that could be referenced for future concerns. DIF: Cognitive Level: Applying (Application) REF: p. 189 OBJ: Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 16. A bruit, or blowing sound, over the skull or temporal region of an adult indicates a: a. degenerative change. b. hyperthyroid storm. c. skull fracture. d. vascular anomaly. ANS: D Temporal bruits can indicate a vascular anomaly such as an arterial obstruction, aneurysm, or vascular neoplasm. Audible bruits are not associated with degenerative changes or skull fracture. Hyperthyroid storm would cause tachycardia and palpations but not usually a bruit. DIF: Cognitive Level: Analyzing (Analysis) REF: p. 192 OBJ: Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 17. Spasmodic muscular contractions of the head, face, or neck are called: a. torticollis. b. tics. c. dimpling. d. webbing. ANS: B Tics, by definition, are spasmodic, repetitive contractions of the muscles of the face, head, or neck. DIF: Cognitive Level: Remembering (Knowledge) REF: p. 189 OBJ: Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 18. Coarse, dry, and brittle hair is associated with which metabolic disorder? a. Hypothyroidism b. Diabetes mellitus c. Addison disease d. Cushing syndrome ANS: A Hypothyroidism affects hair texture, resulting in coarse, dry, and brittle changes. DIF: Cognitive Level: Remembering (Knowledge) REF: p. 192 OBJ: Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 19. An inconsequential finding on the head of an adult is a palpable: a. embryonic remnant. b. posterior fontanel. c. sagittal suture ridge. d. skull indentation. ANS: C The sites of fusion on the skull are not generally palpable after 6 months of age; however, if the sagittal suture line is felt in an adult, it is not significant. An embryonic remnant is associated with branchial cleft cyst, not the head. The posterior fontanel should not be palpable after fusion. A skull indentation may indicate a skull fracture. DIF: Cognitive Level: Remembering (Knowledge) REF: p. 192 OBJ: Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 20. Which is the best way to position a patient’s neck for palpation of the thyroid? a. Flexed away from the side being examined b. Flexed directly forward c. Flexed toward the side being examined d. Hyperextended directly backward ANS: C The patient should be positioned so that the sternocleidomastoid muscle is relaxed and the thyroid is easier to palpate. This is done by having the patient flex the neck slightly forward and laterally toward the side being examined. DIF: Cognitive Level: Applying (Application) REF: p. 194 OBJ: Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 21. A stethoscope is used in a head and neck examination to assess: a. intracranial fluid. b. pulsating fontanels. c. skull bone development. d. thyroid vascular sounds. ANS: D Although the skull is not routinely auscultated, the neck is auscultated using the bell of the stethoscope at the thyroid gland to screen for states of hypermetabolism that have increased with blood supply and produce bruits. DIF: Cognitive Level: Understanding (Comprehension) REF: p. 194 OBJ: Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 22. Tracheal tug suggests the presence of a(n): a. enlarged thyroid. b. swallowing disorder. c. aortic aneurysm. d. thoracic carcinoma. ANS: C When palpating the trachea, an ominous sign of an aortic aneurysm is a tugging sensation in sync with the pulse of the patient. DIF: Cognitive Level: Understanding (Comprehension) REF: p. 193 OBJ: Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 23. The thyroid gland should: a. be slightly left of midline. b. have a clear vascular sound. c. move when the patient swallows. d. tug with each heartbeat. ANS: C It is a normal finding for the thyroid gland to move with swallowing; however, being off center may indicate a nodular growth or enlargement. The thyroid gland should not be slightly left of midline. Vascular sounds indicate hypermetabolic states such as hyperthyroidism, and a tug with each heartbeat is a sign of an aortic aneurysm. DIF: Cognitive Level: Understanding (Comprehension) REF: p. 194 OBJ: Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 24. You are palpating a patient’s thyroid and find that its broadest dimension measures 4 cm. The right lobe is 25% larger than the left. These data would indicate: a. a congenital anomaly. b. a multinodular goiter. c. a normal thyroid gland. d. thyroiditis. ANS: C The situation described is most likely a normal finding; the right lobe of the thyroid gland is typically 25% larger than the left and measures 4 cm. The other choices produce enlargements beyond these normal findings. DIF: Cognitive Level: Analyzing (Analysis) REF: p. 194 OBJ: Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 25. The correct way to transilluminate an infant’s skull is to: a. hold the light 18 inches from the skull. b. move the light toward and then away from the head. c. place the light firmly against the skull. d. shine the light inside the infant’s mouth. ANS: C The correct technique for transillumination of the infant’s skull is to place the light source tightly against the skull so that no light escapes. DIF: Cognitive Level: Applying (Application) REF: p. 196 OBJ: Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 26. The most common form of birth trauma of the scalp is: a. caput succedaneum. b. cephalohematoma. c. cranial bossing. d. torticollis. ANS: A Caput succedaneum, as a result of birth trauma, results in swelling of the scalp. The swelling can cross the suture lines. A cephalohematoma is a hematoma under the skull, and cranial bossing is compensatory growth of the skull related to craniosynostosis. Torticollis involves the neck. DIF: Cognitive Level: Understanding (Comprehension) REF: p. 194 OBJ: Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 27. Which of the following is true regarding caput succedaneum? a. It is a subperiosteal collection of blood. b. It is firm and its edges are well defined. c. It develops several days after delivery. d. It is seen over the presenting part of the head. ANS: D Caput succedaneum is seen over the presenting part of the head during delivery as the skull passes through the pelvis; the scalp usually feels edematous to touch, which fades after a few days. DIF: Cognitive Level: Remembering (Knowledge) REF: p. 194 OBJ: Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 28. Which of the following is true regarding a cephalohematoma? a. It is bound by suture lines. b. The affected part feels soft. c. It is obvious at birth. d. The margins are poorly defined. ANS: A The condition is subperiosteal, under the bone, and contained by the margins of the suture lines; it does not cross the suture line. It is often unnoticed at birth and typically feels firm, with its edges well defined. DIF: Cognitive Level: Understanding (Comprehension) REF: p. 195 OBJ: Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 29. Nuchal rigidity is most commonly associated with: a. thyroiditis. b. meningeal irritation. c. Down syndrome. d. cranial nerve V damage. ANS: B Stiffness and inability to flex the neck, or nuchal rigidity, constitute a classic symptom of meningeal irritation. DIF: Cognitive Level: Applying (Application) REF: p. 193 OBJ: Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 30. When noting a bulging fontanel with marked pulsations in a 6-month-old, you suspect: a. normal development. b. congenital anomaly. c. increased intracranial pressure. d. fever response to a viral infection. ANS: C A bulging fontanel with pulsations suggests increased intracranial pressure. A normal fontanel feels slightly depressed, with mild pulsations. DIF: Cognitive Level: Applying (Application) REF: p. 195 OBJ: Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 31. Which type of headache usually occurs at night, is precipitated by alcohol consumption, and occurs more often in men than in women? a. Classic migraine b. Temporal arteritis c. Cluster d. Hypertensive ANS: C Cluster headaches usually occur at night; they are associated with alcohol consumption and occur more often in men. DIF: Cognitive Level: Understanding (Comprehension) REF: p. 198 OBJ: Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 32. A 29-year-old woman presents to the urgent care center with a history of a severe headache of 2 hours’ duration. She describes it as bandlike and constricting. In interviewing the woman about her complaint, you would ask: a. whether she has experienced increased tearfulness. b. the date of her last menstrual period. c. whether these headaches started in childhood. d. whether she is particularly stressed or overworked. ANS: D This woman is describing a tension headache, which feels bandlike and constricting. Tension headaches are associated with stress, so you should inquire about her stress level. Increased tearfulness is common with cluster headaches, and migraines are associated with menstrual periods. You would not need to ask whether these headaches started in childhood. DIF: Cognitive Level: Analyzing (Analysis) REF: p. 198 OBJ: Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 33. Mr. Johnson presents with a freely movable cystic mass in the midline of the high neck region, at the base of the tongue. This is most likely a: a. parotid gland tumor. b. branchial cleft cyst. c. Stensen duct stone. d. thyroglossal duct cyst. ANS: D A thyroglossal duct cyst presents as a freely movable mass at the base of the tongue. A parotid gland tumor occurs in the ear and cheek bone area. A branchial cleft cyst occurs in the lateral neck area. A Stensen duct stone occurs in the parotid duct. DIF: Cognitive Level: Understanding (Comprehension) REF: p. 195 OBJ: Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 34. Moist skin with fine hair, prominent eyes, lid retraction, and a staring expression are characteristics associated with: a. Cushing syndrome. b. Graves disease. c. myxedema. d. systemic lupus erythematosus. ANS: B Skin problems, along with changes in hair, protruding eyes, and a glazed look, are symptoms associated with Graves disease or hyperthyroidism. Myxedema is a condition of hypothyroidism. Cushing syndrome is characterized by plump skin around the face, and lupus usually presents with a rash around the face. DIF: Cognitive Level: Understanding (Comprehension) REF: p. 202 OBJ: Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 35. You are examining Ms. L, age 78 years. You find a sunken appearance of her eyes, cheeks, and temporal areas. Her skin is dry, and her nose appears sharp. This description of Ms. L’s facies is associated with: a. cutis laxa syndrome. b. Hurler syndrome. c. old age. d. terminal illness. ANS: D In the late stages of terminal illness, the face may appear sunken, facial bones will be more visible, and the skin will be dry. This is referred to as hippocratic facies. Cutis laxa syndrome is a rare condition in which the skin loses its elasticity and sags all over. Hurler syndrome is marked by an enlarged skull and short neck. The description of Ms. L’s facies is not a common finding of old age. DIF: Cognitive Level: Understanding (Comprehension) REF: p. 189 OBJ: Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 36. Which of the following findings would be consistent with fetal alcohol syndrome (FAS)? a. Corneal clouding b. Eye slanting c. Mild ptosis d. Symmetric, bulging fontanels ANS: C With FAS, classic findings include poorly formed or flat philtrum, widespread eyes with inner epicanthal folds and mild ptosis, hirsute forehead, short nose, relatively thin upper lip, and small eye openings. Corneal clouding is seen with Hurler syndrome, eye slanting is seen in Down syndrome, and bulging fontanels are seen in hydrocephalus. DIF: Cognitive Level: Understanding (Comprehension) REF: p. 191 OBJ: Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 37. What structure is located in the upper third of the sternocleidomastoid muscle? a. Branchial cleft cyst b. Cricoid cartilage c. Lacrimal duct d. Thyroid gland ANS: A The branchial cleft cyst is a remnant of development during the embryologic stage and is located around the upper third of the sternocleidomastoid muscle. Cricoid cartilage is located at the trachea, below the epiglottis. The lacrimal duct is where tears drain. The thyroid gland is located at the anterior part of the neck. DIF: Cognitive Level: Remembering (Knowledge) REF: pp. 195-196 OBJ: Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 38. Which of the following is a chronic autoimmune disorder? a. Microcephaly b. Hashimoto disease c. Salivary gland tumor d. Down syndrome ANS: B Hashimoto disease is a chronic autoimmune thyroid disease that commonly affects children and women 30 to 50 years of age. DIF: Cognitive Level: Understanding (Comprehension) REF: p. 202 OBJ: Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 39. The premature union of cranial sutures that involves the shape of the head without mental retardation is: a. craniosynostosis. b. encephalocele. c. microcephaly. d. myxedema. ANS: A In patients with craniosynostosis, the cranial sutures fuse prematurely, causing a misshapen head, but mental retardation is not involved. Encephalocele and microcephaly involve mental retardation. Myxedema is a condition of hyperthyroidism. DIF: Cognitive Level: Understanding (Comprehension) REF: p. 203 OBJ: Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 40. Mr. Donaldson is a 64-year-old patient with complaints of headaches. As the examiner, you are palpating his head during your physical examination. Which of the following would be your first step? a. Palpate the patient’s hair, noting texture, color, and distribution. b. Palpate the temporomandibular joint. c. Palpate the skull from front to back. d. Palpate the temporal artery. ANS: C Palpate the skull in a gentle rotary movement first, progressing systematically from front to back. DIF: Cognitive Level: Understanding (Comprehension) REF: p. 192 OBJ: Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation COMPLETION 1. The trapezius and sternocleidomastoid muscles and the clavicle form a landmark called the triangle. ANS: posterior Anatomically, the trapezius, sternocleidomastoid muscles and clavicle comprise what is referred to as the posterior triangle, which includes the posterior cervical lymph nodes. The anterior triangle is adjacent to the posterior triangle, formed by the medial borders of the sternocleidomastoid muscles and the mandible. The relationship of neck muscles to each other and to adjacent bones creates the anatomic landmarks known as triangles. DIF: Cognitive Level: Remembering (Knowledge) REF: p. 185 OBJ: Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 2. The medial borders of the sternocleidomastoid muscles and the mandible form the triangle. ANS: anterior The anterior triangle is adjacent to the posterior triangle, formed by the medial borders of the sternocleidomastoid muscles and the mandible. The trapezius, sternocleidomastoid muscles, and clavicle form the posterior triangle. The relationship of neck muscles to each other and to adjacent bones creates the anatomic landmarks known as triangles. DIF: Cognitive Level: Remembering (Knowledge) REF: p. 185 OBJ: Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 3. The largest endocrine gland in the body lies in the triangle. ANS: anterior The thyroid gland is the largest endocrine gland and lies within the anterior triangle. The posterior triangle contains cervical lymph nodes, and the lateral and medial triangles are not anatomic landmarks. DIF: Cognitive Level: Remembering (Knowledge) REF: p. 185 OBJ: Nursing process—assessment MSC: Physiologic Integrity: Physiological Adaptation 4. Closure of the anterior skull fontanel should occur by . ANS: 24 months of age The anterior fontanel can remain palpable until 24 months, at which time it closes. DIF: Cognitive Level: Remembering (Knowledge) REF: p. 186 OBJ: Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation Show Less