NURSING HEALTH ASSESSMENT 3rd Edition By Dillon
NURSING HEALTH ASSESSMENT 3rd Edition By Dillon
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Chapter 03: Assessing the Head, Face, and Neck
Complete Chapter Questions With Answers
Sample Questions Are Posted Below
Multiple Choice
Identify the choice that best completes the statement or answers the question.
____ 1. The nurse is assessing the patient’s turbinates. Which is an expected finding?
| 1) | Dry and pink |
| 2) | Moist and pink |
| 3) | Dry and dark red |
| 4) | Moist and dark red |
____ 2. The nurse is assessing the patient’s soft palate and notes erythema. Which is the possible reason for this finding?
| 1) | Congenital defect |
| 2) | Cleft palate |
| 3) | Infection |
| 4) | Trauma |
____ 3. During a patient assessment, the nurse suspects that the patient may have cardiovascular disease. Which assessment finding supports the nurse’s suspicion?
| 1) | Facial edema |
| 2) | Jaw pain |
| 3) | Facial spasm |
| 4) | Temporal pain |
____ 4. Which cluster of assessment findings would the nurse expect to find in association with acute bacterial sinusitis?
| 1) | Inflamed nasal mucosa; yellow drainage on posterior pharynx; perforated septum |
| 2) | Yellow drainage on the posterior pharynx; pale and boggy nasal mucosa; fever |
| 3) | Pale, boggy nasal mucosa; fever; perforated septum |
| 4) | Inflamed nasal mucosa; yellow drainage on the posterior pharynx; fever |
____ 5. Which disease process is associated with tender, palpable cervical nodes along with painful vesicles?
| 1) | Herpes simplex virus |
| 2) | Hyperthyroidism |
| 3) | Temporal arteritis |
| 4) | Allergic rhinitis |
Answer Section
MULTIPLE CHOICE
Chapter number and title: 3, Assessing the Head, Face, and Neck
Chapter learning objective: N/A
Chapter page reference: 88
Integrated Processes: Nursing Process: Evaluation
Client Need: Health Promotion and Maintenance
Cognitive level: Comprehension [Understanding]
Concept: Assessment, Oxygenation
Difficulty: Easy
| Feedback | |
| 1 | Turbinates should not be dry and pink. |
| 2 | The turbinates are bony conchae (folds) of the internal nasal walls that increase the surface area for air to be filtered, warmed, and humidified before entering the lungs. The turbinates should be pink and moist. |
| 3 | Turbinates should not be dry and dark red. |
| 4 | Turbinates should not be moist and dark red. |
PTS: 1 CON: Assessment | Oxygenation
Chapter number and title: 3, Assessing the Head, Face, and Neck
Chapter learning objective: N/A
Chapter page reference: 100
Integrated Processes: Nursing Process: Evaluation
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive level: Knowledge [Remembering]
Concept: Assessment, Oxygenation
Difficulty: Easy
| Feedback | |
| 1 | Perforation of the palate could indicate a congenital defect, cleft palate, trauma, or drug use. |
| 2 | Perforation of the palate could indicate a congenital defect, cleft palate, trauma, or drug use. |
| 3 | The soft palate is posterior to the hard palate and elevates when swallowing to prevent food and saliva from entering the nasopharynx. Erythema, exudate, or lesions indicate an infectious process. |
| 4 | Perforation of the palate could indicate a congenital defect, cleft palate, trauma, or drug use. |
PTS: 1 CON: Assessment | Oxygenation
Chapter number and title: 3, Assessing the Head, Face, and Neck
Chapter learning objective: N/A
Chapter page reference: 82
Integrated Processes: Nursing Process: Assessment
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive level: Comprehension [Understanding]
Concept: Perfusion
Difficulty: Easy
| Feedback | |
| 1 | Facial edema can reflect fluid retention. |
| 2 | Infarct or ischemia pain may radiate to the jaw or throat. |
| 3 | Facial spasm is not indicative of cardiovascular disease. |
| 4 | Temporal pain is not indicative of cardiovascular disease. |
PTS: 1 CON: Perfusion
Chapter number and title: 3, Assessing the Head, Face, and Neck
Chapter learning objective: N/A
Chapter page reference: 88
Integrated Processes: Nursing Process: Assessment
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive level: Analysis [Analyzing]
Concept: Oxygenation, Infection
Difficulty: Difficult
| Feedback | |
| 1 | A perforated septum is not an expected finding with acute bacterial sinusitis. |
| 2 | Pale and boggy nasal mucosa are not an expected finding with acute bacterial sinusitis. |
| 3 | Although fever is expected with acute bacterial sinusitis, the other two symptoms listed are not expected. |
| 4 | Symptoms of acute sinusitis are mucopurulent nasal discharge, postnasal drainage, cough, fever, inflammation of the mucosa, tenderness over sinuses, periorbital swelling, and facial pain. |
PTS: 1 CON: Oxygenation | Infection
Chapter number and title: 3, Assessing the Head, Face, and Neck
Chapter learning objective: N/A
Chapter page reference: 103
Integrated Processes: Nursing Process: Assessment
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive level: Knowledge [Remembering]
Concept: Infection
Difficulty: Easy
| Feedback | |
| 1 | Tender, enlarged lymph nodes and clustered, small (3- to 4-mm) vesicles on the mucosa characterize the herpes simplex virus. Vesicles rupture and form ulcers. Also, there is severe pain, fever, and history of previous episodes. |
| 2 | These symptoms do not indicate hyperthyroidism. |
| 3 | These symptoms do not indicate temporal arteritis. |
| 4 | These symptoms do not indicate allergic rhinitis. |
PTS: 1 CON: Infection
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