Head/neck
You’re performing a head-to-toe assessment on a patient. While palpating the lymph nodes of the neck, the patient reports tenderness behind the ear. When you document the findings of the head-to-toe assessment, you will note that the patient felt tenderness at which lymph node site?
A. Preauricular
B. Submandibular
C. Superficial cervical
D. Postauricular
D. Postauricular
A client has sought care because he is concerned that a mole on his scalp may be evidence of skin cancer. Which finding would the nurse identify as being most suggestive of melanoma?
a) Solid, dark brown color
b) Asymmetric, irregular borders
c) Diameter of 3 mm
d) Flat with silvery scales
b) Asymmetric, irregular borders
A nurse is integrating health promotion education into the assessment of a client's mouth, nose, and throat. What interview question is most likely to identify a risk factor for oral cancer?
a) “Would you say that you're prone to getting mouth ulcers?”
b) “Do you brush and floss daily?”
c) “Do you use tobacco, whether smoking or chewing?”
d) “How often do you usually go to the dentist in a year?”
c) “Do you use tobacco, whether smoking or chewing?”
The nurse is preparing to auscultate a client's lungs after completing thoracic inspection, palpation, and percussion. How should the nurse best prepare for this assessment technique?
a) Keep the client's shirt or gown in place to maintain privacy.
b) Begin with the bell of the stethoscope on the client's anterior chest.
c) Tell the client that you will be asking them to breathe as quickly and deeply as possible.
d) Place the diaphragm on the client's posterior chest wall.
d) Place the diaphragm on the client's posterior chest wall.
A nurse assesses a client's capillary refill and finds it to be less than 2 seconds. What should the nurse do next?
a) Document this finding as normal.
b) Recheck in 5 minutes after elevating the arm.
c) Reassess after applying warm compresses.
d) Refer the client for medical follow-up.
a) Document this finding as normal.
Where should the nurse inspect for facial symmetry when performing a head and neck assessment?
a. nasolabial folds
b. earlobe placement
c. temporomandibular joint
d. preauricular notes
a. nasolabial folds
A nurse is assessing a 49-year-old client who questions the nurse's need to know about sunburns he experienced as a child. How should the nurse best explain the rationale for this subjective assessment?
a) Repeated sunburns in childhood may explain the presence of some of your moles.
b) This is one of the assessments we use to determine whether your parents took good care of your skin when you were young.
c) When you burn your skin as a child, it makes your skin more sensitive and slower to heal when you're older.
d) Having bad sunburns when you're a child puts you at risk for skin cancer later in life.
d) Having bad sunburns when you're a child puts you at risk for skin cancer later in life.
A client complains of the inability to concentrate at work and daily frontal headaches for the past two weeks. What additional assessment data does the nurse need to collect?
a. presence of a cough?
b. recent dental work?
c. presence of sinus congestion?
d. recent head trauma?
c. presence of sinus congestion?
The nurse is assessing the apices of the client's lungs. The nurse should locate them at which position?
a) At the level of the diaphragm
b) Near the level of the eighth rib
c) Slightly above the clavicle
d) At about the tenth rib
c) Slightly above the clavicle
During a client's vascular assessment, the nurse is palpating the pulse just under the client's inguinal ligament. The nurse is assessing which pulse?
a) Temporal
b) Brachial
c) Popliteal
d) Femoral
d) Femoral
Upon examination of the head and neck of a client, a nurse notes that the submandibular nodes are tender and enlarged. The nurse should assess the client for further findings related to what condition?
a. acute infection
b. chronic infection
c. Cushing's disease
d. metastatic disease
a. acute infection
Which of the following, if obtained during the health history, would alert the nurse to a possible risk factor for ear-related problems?
a) Frequent use of acetaminophen (Tylenol)
b) Frequent use of cotton-tipped applicators
c) Preference for showers rather than baths
d) Inadequate hygiene practices
b) Frequent use of cotton-tipped applicators
The nurse is preparing the client for an assessment of the mouth, throat, nose, and sinuses. How should the nurse position the client for proper examination?
a. have the client assume a lying position
b. ask the client to sit with the head erect and at the nurses' eye level
c. have the client sit and tilt head slightly backward
d. have the client in a semi-recumbent position with the chin lifted
b. ask the client to sit with the head erect and at the nurses' eye level
The nurse is preparing to perform a respiratory assessment of an older adult patient and understands the effects of aging on respiration. What does the nurse expect to find during this patient’s assessment?
a) Decreased lung elasticity
b) Increased respiratory strength
c) Decreased aspiration risk
d) Increased cough reflexes
a) Decreased lung elasticity
An older adult client presents with cramping-type leg pain when walking, which is relieved by rest. The client also has cool, pale feet and capillary refill in the toes of 4 to 6 seconds. What would the nurse suspect?
a) Arterial insufficiency
b) Musculoskeletal weakness
c) Venous insufficiency
d) Diabetic neuropathy
a) Arterial insufficiency
During the physical examination of a 60 year old client, the nurse finds that the pulsations of the temporal artery is weak. What is an appropriate action by the nurse for this client?
a. assess the client for a decrease in level of consciousness
b. recognize the weakened pulsation as an age-related change
c. check the blood pressure as it can be due to hypotension
d. notify the health care provider for further diagnostic tests
b. recognize the weakened pulsation as an age-related change
After having a client perform a Romberg test, what finding would indicate to the nurse that the test is negative?
a) Client moves the feet apart during the test
b) Client sways slightly during the test
c) Client maintains the position during the test
d) Client keeps his or her eyes closed during the test
c) Client maintains the position during the test
Which of the following statement regartding the risk of cancer of the oral cavity is true?
a. oral cavity cancer is more prevalent in women than men
b. most are detected in the fifth and sixth decades of life
c. oral cancer does not increase the risk of other cancers
d. smokeless tobacco carries less risk of oral cancer than cigarettes
b. most are detected in the fifth and sixth decades of life
The nurse auscultates a patient's lungs. Which of the following breath sounds would be documented as normal?
a) Rhonchi
b) Vesicular
c) Crackles
d) Wheezes
b) Vesicular
The clinic nurse is reviewing the medication history of a 39-year-old female client. Which medication would the nurse identify as a potential risk factor for thrombophlebitis?
a) A beta-adrenergic blocker
b) A selective serotonin reuptake inhibitor (SSRI)
c) An oral contraceptive
d) An anti-lipid agent
c) An oral contraceptive
The nurse is assessing a client with hyperthyroidism for the presence of a bruit. Which assessment technique should the nurse use?
a. palpation
b. percussion
c. inspection
d. auscultation
d. auscultation
A nurse shines a light into one of the client's eyes during an ocular exam and the pupil of the other eye constricts. The nurse interprets this as which of the following?
a) Direct reflex
b) Optic chiasm
c) Consensual response
d) Accommodation
c) Consensual response
The nasal mucosa of a client with rhinitis would be:
a. pink and moist
b. grey with green mucous
c. blue and swollen
d. bright red and swollen
d. bright red and swollen
The provider is assessing a patient's thoracic expansion. The assessment technique used is?
a) Inspection
b) Palpation
c) Percussion
d) Auscultation
b) Palpation
Examination of a patient in a supine position reveals distended jugular veins from the base of the neck to the angle of the jaw. This finding indicates:
a. decreased venous return.
b. increased central venous pressure.
c. increased pulmonary artery capillary pressure.
d. left-sided heart failure.
b. increased central venous pressure.