Health & Physical Assessment in Nursing, 4e (Fenske/Watkins/Saunders/D'Amico/Barbarito)

Chapter 13 Head, Neck, and Related Lymphatics

1. The nurse is preparing to assess a client that is experiencing TMJ discomfort. Which should the nurse be concerned with? Select all that apply.

1. Difficulty swallowing.

2. Difficulty speaking.

3. Difficulty chewing.

4. Decreased tongue motion.

5. Impaired ability to slide the upper jaw.

Page Ref: 211

Cognitive Level: Applying

Client Need & Sub: Physiological Adaptation; Alterations in Body Systems

Standards: QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essentials Competencies: I.1. Integrate theories and concepts from liberal education into nursing practice. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 13.6: Identify abnormal findings in the physical assessment of the head, neck, and related lymphatics.

MNL Learning Outcome: 13.4: Differentiate normal and abnormal variations of the head, neck, and related lymphatics observed during physical assessment.

1. Which best describes the function of the axis?

1. Carries the skull.

2. Denotes the first cervical vertebrae.

3. Allows for movement of the skull.

4. Connects the skull to the vertebrae.

Page Ref: 212

Cognitive Level: Remembering

Client Need & Sub: Health Promotion and Maintenance; Health Screening

Standards: QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essentials Competencies: I.1. Integrate theories and concepts from liberal education into nursing practice. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 13.1: Describe the anatomy and physiology of the head, neck, and related lymphatics.

MNL Learning Outcome: 13.1: Consider the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of the head, neck, and related lymphatics.

1. A client asks the nurse why their lymph node is enlarged. Which response should the nurse provide the client?

1. "Sometimes, enlarged lymph nodes indicate an infection."

2. "All of your lymph nodes should be easily palpable."

3. "The lymph system is making antibiotics to fight infection."

4. "An enlarged lymph node is an abnormal finding."

Page Ref: 214

Cognitive Level: Applying

Client Need & Sub: Health Promotion and Maintenance; Health Promotion/Disease Prevention

Standards: QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essentials Competencies: I.1. Integrate theories and concepts from liberal education into nursing practice. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 13.6: Identify abnormal findings in the physical assessment of the head, neck, and related lymphatics.

MNL Learning Outcome: 13.1: Consider the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of the head, neck, and related lymphatics.

1. A client has a history of palpable submental lymph nodes. Which anatomical area should the nurse assess?

1. At the base of the skull.

2. Behind the ear over the outer surface of the mastoid bone.

3. At the junction of the posterior and lateral walls of the pharynx at the angle of the jaw.

4. Behind the tip of the mandible at the midline.

Page Ref: 214

Cognitive Level: Applying

Client Need & Sub: Health Promotion and Maintenance; Health Promotion/Disease Prevention

Standards: QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essentials Competencies: I.1. Integrate theories and concepts from liberal education into nursing practice. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 13.1: Describe the anatomy and physiology of the head, neck, and related lymphatics.

MNL Learning Outcome: 13.1: Consider the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of the head, neck, and related lymphatics.

1. The client has an enlarged lymph node in front of the right ear. Which should the nurse document the finding as?

1. Right-sided occipital lymph node enlarged.

2. Right-sided submaxillary lymph node enlarged.

3. Right-sided deep cervical lymph node enlarged.

4. Right-sided preauricular lymph node enlarged.

Page Ref: 215

Cognitive Level: Understanding

Client Need & Sub: Health Promotion and Maintenance; Health Promotion/Disease Prevention

Standards: QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essentials Competencies: I.1. Integrate theories and concepts from liberal education into nursing practice. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 13.5: Generate the appropriate documentation to describe the assessment of the head, neck, and related lymphatics.

MNL Learning Outcome: 13.1: Consider the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of the head, neck, and related lymphatics.

1. The nurse auscultates a bruit in the left temporal artery. Which should the nurse understand is the initial contributing factor to the assessment finding?

1. Increased blood flow.

2. Narrowing of the vessel.

3. Decreased blood flow.

4. Dilated arterial vessel.

Page Ref: 222

Cognitive Level: Applying

Client Need & Sub: Physiological Adaptation; Alterations in Body Systems

Standards: QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essentials Competencies: I.1. Integrate theories and concepts from liberal education into nursing practice. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Nursing Diagnosis

Learning Outcome: 13.6: Identify abnormal findings in the physical assessment of the head, neck, and related lymphatics.

MNL Learning Outcome: 13.4: Differentiate normal and abnormal variations of the head, neck, and related lymphatics observed during physical assessment.

1. A client tells the nurse they do not understand how they got Bell's Palsy. Which information should the nurse include in the response? Select all that apply.

1. "One of your cranial nerves has been affected."

2. "This is usually caused by a virus."

3. "This is a temporary disorder."

4. "This is related to a possible stroke."

5. "This condition is related to an autoimmune disorder."

Page Ref: 228

Cognitive Level: Analyzing

Client Need & Sub: Physiological Adaptation; Alterations in Body Systems

Standards: QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essentials Competencies: I.1. Integrate theories and concepts from liberal education into nursing practice. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Nursing Diagnosis

Learning Outcome: 13.6: Identify abnormal findings in the physical assessment of the head, neck, and related lymphatics.

MNL Learning Outcome: 13.4: Differentiate normal and abnormal variations of the head, neck, and related lymphatics observed during physical assessment.

1. The nurse is teaching a client with a history of migraines about avoiding foods that are rich in tyramine. Which foods should the nurse include in the teaching? Select all that apply.

1. Nuts.

2. Avocados.

3. Corn.

4. Eggs.

5. Onions.

Page Ref: 288

Cognitive Level: Applying

Client Need & Sub: Physiological Adaptation; Alterations in Body Systems

Standards: QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essentials Competencies: I.1. Integrate theories and concepts from liberal education into nursing practice. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 13.6: Identify abnormal findings in the physical assessment of the head, neck, and related lymphatics.

MNL Learning Outcome: 13.4: Differentiate normal and abnormal variations of the head, neck, and related lymphatics observed during physical assessment.

1. A client asks why the nurse is looking at their jugular veins and arteries. Which response should the nurse provide? Select all that apply.

1. I am looking for pulsation.

2. I am looking for distension.

3. I am evaluating placement.

4. I am evaluating the pulse rate.

Page Ref: 223

Cognitive Level: Analyzing

Client Need & Sub: Health Promotion and Maintenance; Health Screening

Standards: QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essentials Competencies: I.1. Integrate theories and concepts from liberal education into nursing practice. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 13.4: Outline the techniques for assessment of the head, neck, and related lymphatics.

MNL Learning Outcome: 13.3: Utilize the appropriate techniques and tools for physical assessment of the head, neck, and related lymphatics.

1. The nurse observes involuntary facial muscle movement on a client. Which cranial nerve should the nurse evaluate?

1. Cranial nerve III.

2. Cranial nerve VI.

3. Cranial nerve VII.

4. Cranial nerve IV.

Page Ref: 222

Cognitive Level: Analyzing

Client Need & Sub: Physiological Adaptation; Alterations in Body Systems

Standards: QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essentials Competencies: I.1. Integrate theories and concepts from liberal education into nursing practice. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 13.6: Identify abnormal findings in the physical assessment of the head, neck, and related lymphatics.

MNL Learning Outcome: 13.3: Utilize the appropriate techniques and tools for physical assessment of the head, neck, and related lymphatics.

1. The nurse is obtaining a focused head and neck interview on a client. Which should the nurse ask the client to assess their internal environment?

1. "Do you use any home remedies?"

2. "Have you ever had irradiation to your neck?"

3. "Have you been exposed to chemicals in the work place?"

4. "Does anyone smoke in the home environment?"

Page Ref: 220

Cognitive Level: Applying

Client Need & Sub: Health Promotion and Maintenance; Health Screening

Standards: QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Environmental health; health promotion/disease prevention (e.g., transmission of disease, disease patterns, epidemiological principles); chronic disease management; healthcare systems; transcultural approaches to health; and family dynamics | Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 13.3: Determine which questions about the head, neck, and related lymphatics to use for the focused interview.

MNL Learning Outcome: 13.2: Plan questions about the head, neck, and related lymphatics for the focused interview.

1. A client tells the nurse they are experiencing headaches. Which question should the nurse ask the client that best encourages a detailed description?

1. "How long does a typical headache last?"

2. "Do you experience any nausea or vomiting with the headache?"

3. "What seems to relieve the symptoms?"

4. "Do you feel that the headache is triggered by a specific event?"

Page Ref: 219

Cognitive Level: Applying

Client Need & Sub: Physiological Adaptation; Alterations in Body Systems

Standards: QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Environmental health; health promotion/disease prevention (e.g., transmission of disease, disease patterns, epidemiological principles); chronic disease management; healthcare systems; transcultural approaches to health; and family dynamics. | Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 13.3: Determine which questions about the head, neck, and related lymphatics to use for the focused interview.

MNL Learning Outcome: 13.2: Plan questions about the head, neck, and related lymphatics for the focused interview.

1. A client tells the nurse that they experience daily headaches. Which should the nurse include in the assessment? Select all that apply.

1. "Rate your pain on a scale from 0 to 10, with 0 being no pain and 10 the worst."

2. "Daily headaches are not of any concern."

3. "Is there anything that relieves the pain, like resting or medication?"

4. "Is the pain sharp, dull, steady, or throbbing?"

5. "Have you had a recent cold or infection?"

Page Ref: 231

Cognitive Level: Applying

Client Need & Sub: Physiological Adaptation; Alterations in Body Systems

Standards: QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Environmental health; health promotion/disease prevention (e.g., transmission of disease, disease patterns, epidemiological principles); chronic disease management; healthcare systems; transcultural approaches to health; and family dynamics | Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 13.2: Identify the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of the head, neck, and related lymphatics.

MNL Learning Outcome: 13.2: Plan questions about the head, neck, and related lymphatics for the focused interview.

1. Reviewing a client's record, the nurse notes that the client has a goiter. Which priority question should the nurse include in the focused interview?

1. "Where do you purchase your medication?"

2. "What type of salt do you use in your diet?"

3. "Do you work around chemicals?"

4. "How long have you had this problem?"

Page Ref: 231-232

Cognitive Level: Applying

Client Need & Sub: Physiological Integrity; Physiological Adaptation

Standards: QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 13.3: Determine which questions about the head, neck, and related lymphatics to use for the focused interview.

MNL Learning Outcome: 13.2: Plan questions about the head, neck, and related lymphatics for the focused interview.

1. A client asks why they are being asked about tobacco products during a head and neck assessment. Which response should the nurse recognize the primary reason for the question?

1. The use of tobacco results in enlarged lymph nodes.

2. The use of tobacco may cause headaches.

3. The use of tobacco contributes to decreased sense of taste.

4. The use of tobacco may cause a loss of the sense of smell.

Page Ref: 219

Cognitive Level: Applying

Client Need & Sub: Health Promotion and Maintenance; Health Screening

Standards: QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essentials Competencies: I.1. Integrate theories and concepts from liberal education into nursing practice. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 13.2: Identify the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of the head, neck, and related lymphatics.

MNL Learning Outcome: 13.2: Plan questions about the head, neck, and related lymphatics for the focused interview.

1. The nurse is preparing to instruct a client to take a drink of water during a head and neck assessment. Which statement should the nurse provide the client?

1. "I am preparing to assess your temporomandibular joint."

2. "I am preparing to assess your lymph nodes."

3. "I am preparing to assess your temporal artery."

4. "I am preparing to assess your trachea."

Page Ref: 224

Cognitive Level: Applying

Client Need & Sub: Health Promotion and Maintenance; Health Screening

Standards: QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essentials Competencies: I.1. Integrate theories and concepts from liberal education into nursing practice. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 13.4: Outline the techniques for assessment of the head, neck, and related lymphatics.

MNL Learning Outcome: 13.3: Utilize the appropriate techniques and tools for physical assessment of the head, neck, and related lymphatics.

1. The nurse is assessing the client's neck. Which should the nurse recognize is an abnormal finding?

1. The client's carotid arteries are visibly pulsating.

2. The neck is symmetrical.

3. The tracheal cartilage does not move when the client swallows.

4. The thyroid has no palpable nodules.

Page Ref: 223

Cognitive Level: Applying

Client Need & Sub: Physiological Adaptation; Alterations in Body Systems

Standards: QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essentials Competencies: I.1. Integrate theories and concepts from liberal education into nursing practice. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 13.6: Identify abnormal findings in the physical assessment of the head, neck, and related lymphatics.

MNL Learning Outcome: 13.4: Differentiate normal and abnormal variations of the head, neck, and related lymphatics observed during physical assessment.

1. The nurse suspects a client has a concussion. Which findings should the nurse expect to support the suspicion?

1. Enlarged lymph nodes.

2. Headache.

3. Blurred vision.

4. Temporal bruits.

Page Ref: 218

Cognitive Level: Applying

Client Need & Sub: Physiological Adaptation; Alterations in Body Systems

Standards: QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essentials Competencies: I.1. Integrate theories and concepts from liberal education into nursing practice. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Nursing Diagnosis

Learning Outcome: 13.2: Identify the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of the head, neck, and related lymphatics.

MNL Learning Outcome: 13.4: Differentiate normal and abnormal variations of the head, neck, and related lymphatics observed during physical assessment.

1. The nurse is auscultating the temporal artery and hears a soft blowing sound. Which term should the nurse use to document the findings?

1. Bruit.

2. Murmur.

3. Stenosis.

4. Occlusion.

Page Ref: 222

Cognitive Level: Applying

Client Need & Sub: Physiological Adaptation; Alterations in Body Systems

Standards: QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essentials Competencies: I.1. Integrate theories and concepts from liberal education into nursing practice. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Nursing Diagnosis

Learning Outcome: 13.5: Generate the appropriate documentation to describe the assessment of the head, neck, and related lymphatics.

MNL Learning Outcome: 13.4: Differentiate normal and abnormal variations of the head, neck, and related lymphatics observed during physical assessment.

1. The nurse is preparing to perform a head and neck assessment on a client with Parkinson's disease. Which finding should the nurse anticipate?

1. Exophthalmos.

2. Facial paralysis.

3. Enlargement of the head.

4. Mask-like expression.

Page Ref: 230

Cognitive Level: Applying

Client Need & Sub: Physiological Adaptation; Alterations in Body Systems

Standards: QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essentials Competencies: I.1. Integrate theories and concepts from liberal education into nursing practice. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Nursing Diagnosis

Learning Outcome: 13.6: Identify abnormal findings in the physical assessment of the head, neck, and related lymphatics.

MNL Learning Outcome: 13.4: Differentiate normal and abnormal variations of the head, neck, and related lymphatics observed during physical assessment.

1. The nurse is examining a client's neck. Which techniques should the nurse use to palpate the trachea? Select all that apply.

1. Palpate while the client is swallowing.

2. Slide the thumb and index finger upward on each side of the trachea.

3. Palpate the midline of the neck to feel the cricoid cartilage.

4. Ask the client to open and close their mouth.

5. Stand behind the client and ask them to turn their head slightly to the right.

Page Ref: 223

Cognitive Level: Applying

Client Need & Sub: Health Promotion and Maintenance; Techniques of Physical Assessment

Standards: QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essentials Competencies: I.1. Integrate theories and concepts from liberal education into nursing practice. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 13.4: Outline the techniques for assessment of the head, neck, and related lymphatics.

MNL Learning Outcome: 13.3: Utilize the appropriate techniques and tools for physical assessment of the head, neck, and related lymphatics.

1. The nurse is preparing to palpate the submental lymph node. Which anatomical location should the nurse palpate?

1. Under the chin.

2. At the base of the skull.

3. Behind the tip at the mandible midline.

4. At the junction of the posterior and lateral walls of the pharynx at the angle of the jaw.

Page Ref: 214

Cognitive Level: Understanding

Client Need & Sub: Health Promotion and Maintenance; Techniques of Physical Assessment

Standards: QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essentials Competencies: I.1. Integrate theories and concepts from liberal education into nursing practice. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 13.1: Describe the anatomy and physiology of the head, neck, and related lymphatics.

MNL Learning Outcome: 13.1: Consider the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of the head, neck, and related lymphatics.

1. The nurse is planning care for a client with hypothyroidism. Which should the nurse recognize is a priority nursing diagnosis?

1. Risk for constipation related to metabolic imbalance.

2. Activity intolerance related to fatigue.

3. Risk for injury related to confusion and lethargy.

4. Altered nutrition, less than body requirements.

Page Ref: 231

Cognitive Level: Applying

Client Need & Sub: Physiological Adaptation; Alterations in Body Systems

Standards: QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essentials Competencies: I.1. Integrate theories and concepts from liberal education into nursing practice. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Nursing Diagnosis

Learning Outcome: 13.6: Identify abnormal findings in the physical assessment of the head, neck, and related lymphatics.

MNL Learning Outcome: 13.4: Differentiate normal and abnormal variations of the head, neck, and related lymphatics observed during physical assessment.

1. The nurse is preparing to assess a client with cluster headaches. Which statement made by the client should the nurse recognize supports the diagnosis?

1. "I see flashing lights before my headache starts."

2. "Before I get my headaches, I experience mood changes."

3. "I wake up at night with pain in the side of my face."

4. "My headaches start gradually and the pain is steady."

Page Ref: 231

Cognitive Level: Analyzing

Client Need & Sub: Physiological Adaptation; Alterations in Body Systems

Standards: QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essentials Competencies: I.1. Integrate theories and concepts from liberal education into nursing practice. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 13.6: Identify abnormal findings in the physical assessment of the head, neck, and related lymphatics.

MNL Learning Outcome: 13.4: Differentiate normal and abnormal variations of the head, neck, and related lymphatics observed during physical assessment.

1. A client with hypothyroidism tells the nurse they have forgotten to take their medication for the past several days. Which should the nurse assess the client for?

1. Headache.

2. Constipation.

3. Exophthalmos.

4. Cardiac dysrhythmias.

Page Ref: 231

Cognitive Level: Applying

Client Need & Sub: Physiological Adaptation; Alterations in Body Systems

Standards: QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essentials Competencies: I.1. Integrate theories and concepts from liberal education into nursing practice. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Nursing Diagnosis

Learning Outcome: 13.2: Identify the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of the head, neck, and related lymphatics.

MNL Learning Outcome: 13.4: Differentiate normal and abnormal variations of the head, neck, and related lymphatics observed during physical assessment.

1. The nurse is preparing to assess a client's lymph nodes. Which technique should the nurse use?

1. Assessing each side separately.

2. Applying gentle, circular pressure.

3. Applying strong, deep pressure.

4. Attempting to push the nodes into the muscle.

Page Ref: 225

Cognitive Level: Applying

Client Need & Sub: Health Promotion and Maintenance; Techniques of Physical Assessment

Standards: QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essentials Competencies: I.1. Integrate theories and concepts from liberal education into nursing practice. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 13.4: Outline the techniques for assessment of the head, neck, and related lymphatics.

MNL Learning Outcome: 13.3: Utilize the appropriate techniques and tools for physical assessment of the head, neck, and related lymphatics.

1. A client tells the nurse they are experiencing sudden intermittent headaches after seeing "flashes of light" and experiencing nausea. Which should the nurse suspect the client is experiencing?

1. Migraine headaches.

2. Cluster headaches.

3. Tension headaches.

4. Increased intracranial pressure.

Page Ref: 231

Cognitive Level: Applying

Client Need & Sub: Physiological Adaptation; Alterations in Body Systems

Standards: QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essentials Competencies: I.1. Integrate theories and concepts from liberal education into nursing practice. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Nursing Diagnosis

Learning Outcome: 13.6: Identify abnormal findings in the physical assessment of the head, neck, and related lymphatics.

MNL Learning Outcome: 13.4: Differentiate normal and abnormal variations of the head, neck, and related lymphatics observed during physical assessment.

1. A client tells the nurse they have been experiencing "severe headaches intermittently over the past 3 days" that are accompanied with unilateral pain over the right side of their face and nasal congestion. Which should the nurse suspect the client is experiencing?

1. Cluster headache.

2. Classic migraine.

3. Tension headache.

4. Hydrocephalus.

Page Ref: 231

Cognitive Level: Applying

Client Need & Sub: Physiological Adaptation; Alterations in Body Systems

Standards: QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essentials Competencies: I.1. Integrate theories and concepts from liberal education into nursing practice. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Nursing Diagnosis

Learning Outcome: 13.6: Identify abnormal findings in the physical assessment of the head, neck, and related lymphatics.

MNL Learning Outcome: 13.4: Differentiate normal and abnormal variations of the head, neck, and related lymphatics observed during physical assessment.

1. The nurse assessing a newborn notes an enlarged head with visible prominent scalp veins. Which should the nurse suspect the newborn is experiencing?

1. Craniosynostosis.

2. Hydrocephalus.

3. Acromegaly.

4. Fetal alcohol syndrome.

Page Ref: 230

Cognitive Level: Applying

Client Need & Sub: Physiological Adaptation; Alterations in Body Systems

Standards: QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essentials Competencies: I.1. Integrate theories and concepts from liberal education into nursing practice. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Nursing Diagnosis

Learning Outcome: 13.6: Identify abnormal findings in the physical assessment of the head, neck, and related lymphatics.

MNL Learning Outcome: 13.4: Differentiate normal and abnormal variations of the head, neck, and related lymphatics observed during physical assessment.

1. The nurse is preparing to assess an adult client suspected of having hyperthyroidism. Which assessment findings does the nurse anticipate? Select all that apply.

1. Blood pressure: 162/92 mmHg.

2. Apical pulse: 120 bpm.

3. Respiratory rate of 14 breaths per minute.

4. Constricted pupils.

5. Temperature of 100.1°F

Page Ref: 231

Cognitive Level: Analyzing

Client Need & Sub: Physiological Adaptation; Alterations in Body Systems

Standards: QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essentials Competencies: I.1. Integrate theories and concepts from liberal education into nursing practice. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Nursing Diagnosis

Learning Outcome: 13.6: Identify abnormal findings in the physical assessment of the head, neck, and related lymphatics.

MNL Learning Outcome: 13.4: Differentiate normal and abnormal variations of the head, neck, and related lymphatics observed during physical assessment.

1. The nurse is preparing to assess a client's thyroid. Which information should the nurse provide the client prior to the assessment?

1. "Please lie down while I assess your thyroid gland."

2. "When I assess your thyroid gland, you can expect to feel strong pressure."

3. "I will stand behind you while palpating your thyroid gland."

4. "Please chew this mint so that I can assess your thyroid gland."

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Cognitive Level: Applying

Client Need & Sub: Health Promotion and Maintenance; Techniques of Physical Assessment

Standards: QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essentials Competencies: I.1. Integrate theories and concepts from liberal education into nursing practice. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Nursing Assessment

Learning Outcome: 13.4: Outline the techniques for assessment of the head, neck, and related lymphatics.

MNL Learning Outcome: 13.3: Utilize the appropriate techniques and tools for physical assessment of the head, neck, and related lymphatics.