Question

1.Using inspection and palpation, the nurse determines that the client's head is round,symmetric and appropriate size...

1.Using inspection and palpation, the nurse determines that the client's head is round,symmetric and appropriate size related to body size. How will the nurse document this finding?

A.
Acromegaly

B.
Megalomaniac

C.
Microcephaly

D.
Normocephalic
2 What is the nursing priority when enlarged, tender lymph nodes are palpated in the neck?

A.
Refer the patient to an oncologist because it is probably lymphoma

B.
Palpate the lymph nodes in the axila

C.
Ask the patient about the family history of cancer

D.
Check the area that the lymph node drains for the source of the problem
3. What technique is used to palpate the lymph nodes in the neck?

A.
Palpate several groups of lymph nodes at the same time

B.
Use firm pressure to identify each lymph node

C.
Use a gentle circular motion of your finger pads

D.
Have the patient raise chin up while you palpate the lymph nodes
4. Which topics will the include when obtaining subjective data regarding the head, face and the neck? (Select all that apply.)

A.
Dizziness

B.
Childhood illnesses

C.
Neck pain

D.
Problems hearing

E.
Headache

F.
Lumps or swelling
5. The nurse palpates an enlarged lymph node in the neck. What will be included in the documentation of this finding? (Select all that apply.)

A.
location

B.
shape

C.
consistency

D.
size

E.
tenderness

F.
mobility
6. A 42 year old female patient come to the clinic with complaints of pain behind the right ear. The nurse notes that the right side of the face is paralyzed including inability to wrinkle forehead, raise eyebrow, close eye, whistle or show teeth. The nurse suspects:

A.
Myxedema

B.
Parkinson syndrome

C.
Hyperthyroidism

D.
Bell's palsy (cranial nerve VII paralysis)
7. The nurse is assessing facial symmetry of a 76 year old female patient. The nurse notes paralysis of the lower facial muscles on one side of the face. What does the nurse suspect?

A.
Stroke

B.
Scleroderma

C.
Torticollis

D.
Cushing syndrome
8. How will the nurse assess for visible thyroid enlargement?

A.
Note any enlargement in a line from the outer corner of the eye to the lobule of the ear

B.
Note a lump or diffuse enlargement of the thyroid at the base of the neck

C.
Have the patient shrug his shoulders and turn head side to side as you observe the neck.

D.
Observe the area under the chin when the head is extended
9. The nurse is inspecting the face for symmetry. What structures will be included in the assessment? (Select all that apply.)

A.
temporomadibular joint

B.
palpebral fissures (eye lids)

C.
nasolabial folds

D.
sides of mouth

E.
eyebrows

Homework Answers

Answer #1

1. Ans- D Normocephalic

2. Ans - B Palpate the lymph nodes in axilla

3. Ans - B use firm pressure to identify each lymph nodes

4.ans- A Dizziness

B Childhood illness

C Neck pain

D Problems Hearing

E . Headache

F lumps and swellling

5. Ans A Location

B shape

C consistency

D size

E tenderness

F mobility

6. Ans - D Bell' s palsy( cranial nerveVll paralysis)

7. Ans - A Stroke

8.Ans- B Note a lump or diffuse enlargement of the thyroid at the base of the neck.

9. Ans- B Palpebral fissures ( eye lids)

C nasolabial folds

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