NUR 504 Exam 4 Questions & Verified Answers | Head-to-Toe
Health Assessment, Nose & Sinus Examination, Olfactory
Receptors, Rhinitis, Allergies, Pharyngitis, Oral Assessment,
Smoking Effects, Geriatric Changes & Pediatric Dentition |
Complete Exam Review
Section 1: The Head, Face, and Neck Assessment
1. A 45-year-old patient presents with a chief complaint of a "pounding headache" that has
been persistent for three days. During the health history, which of the following questions is
most important for the nurse to ask first?
A. "Have you tried any over-the-counter medications for this?"
B. "Can you describe the location and quality of the pain?"
C. "Do you have a family history of migraines?"
D. "Have you experienced any recent head trauma?"
Correct Answer: D. "Have you experienced any recent head trauma?"
Rationale: When a patient presents with a new, persistent headache, the priority is to rule
out life-threatening causes. Asking about recent head trauma is a critical screening question for
a potential subdural or epidural hematoma, which requires immediate medical intervention.
While the other questions are important for a full assessment, assessing for trauma is the
highest priority.
2. During the physical assessment of the head and face, the nurse is preparing to palpate the
temporomandibular joint (TMJ). The correct technique is to:
A. Place the tips of the index fingers in front of the tragus of each ear and ask the patient to
open and close their mouth.
B. Place the palms of the hands on the patient's cheeks and ask them to clench their teeth.
C. Palpate the mastoid process behind the ear while the patient turns their head.
D. Apply pressure to the zygomatic arches while the patient opens their mouth wide.
Correct Answer: A. Place the tips of the index fingers in front of the tragus of each ear and
ask the patient to open and close their mouth.
Rationale: This is the standard technique for assessing the TMJ. Placing the fingertips in
front of the tragus allows the nurse to feel for crepitus, tenderness, or limited range of motion
as the jaw opens and closes. Options B, C, and D are incorrect techniques for assessing the TMJ.
,3. A nurse is assessing a patient's thyroid gland. Which instruction should the nurse give to
the patient to best facilitate palpation of the thyroid isthmus?
A. "Please turn your head to the right."
B. "Please swallow a sip of water."
C. "Please take a deep breath and hold it."
D. "Please open your mouth and say 'ah'."
Correct Answer: B. "Please swallow a sip of water."
Rationale: Swallowing causes the thyroid gland to rise and become more prominent,
making it easier to palpate. The nurse should stand behind the patient, place fingers on either
side of the trachea, and ask the patient to swallow. This allows for assessment of the isthmus
and lobes as they move upward.
4. Which of the following findings would be considered an abnormal assessment of the head
and neck in an adult?
A. A midline trachea.
B. Symmetrical facial features at rest.
C. A fixed, non-tender, hard lymph node in the supraclavicular area.
D. A thyroid gland that is not palpable.
Correct Answer: C. A fixed, non-tender, hard lymph node in the supraclavicular area.
Rationale: A fixed, hard, non-tender lymph node, especially in the supraclavicular area
(Virchow's node), is a classic warning sign for malignancy (e.g., from the stomach, lungs, or
breasts). A midline trachea, symmetrical face, and a non-palpable thyroid are all normal findings
in many adults.
5. During a head and neck assessment, the nurse notes that a patient's neck is flexed forward
and the chin is touching the chest. What is this finding called?
A. Torticollis
B. Nuchal rigidity
C. Opisthotonus
D. Ankylosis
Correct Answer: B. Nuchal rigidity
Rationale: Nuchal rigidity, or stiffness of the neck, is a key sign of meningeal irritation, often
seen in meningitis. While a patient can flex their neck, it is painful and resistance is met.
Torticollis is a wryneck (twisting). Opisthotonus is an arching of the back. Ankylosis is joint
stiffness.
,6. A nurse is performing a head-to-toe assessment on a new admission. When assessing the
head, the nurse should include which of the following? (Select All That Apply)
A. Inspecting for symmetry of facial features.
B. Palpating the skull for deformities or tenderness.
C. Assessing the function of cranial nerve V (Trigeminal).
D. Auscultating the carotid arteries for bruits.
E. Observing for involuntary facial movements (tics).
Correct Answers: A, B, C, E
Rationale: A comprehensive head assessment includes inspection (symmetry, tics),
palpation (skull), and neurological screening for cranial nerves (CN V and VII are key for the
face). Auscultating the carotid arteries is part of the neck assessment, not the head assessment.
7. A patient reports a "whooshing" sound in their right ear that is synchronous with their
heartbeat. What is the most appropriate term for this finding, and what should the nurse do
next?
A. Tinnitus; reassure the patient it is a common finding.
B. Vertigo; perform a Romberg test.
C. Pulsatile tinnitus; auscultate the neck and head for a bruit.
D. Presbycusis; refer the patient to an audiologist.
Correct Answer: C. Pulsatile tinnitus; auscultate the neck and head for a bruit.
Rationale: Pulsatile tinnitus, a sound synchronous with the heartbeat, can be a sign of
vascular abnormality such as an arteriovenous malformation or carotid stenosis. Auscultating
for a bruit is the immediate next step. Non-pulsatile tinnitus is more common and often benign.
8. Which cranial nerve is responsible for the motor function of the muscles of mastication,
and how is it assessed?
A. CN V (Trigeminal); assessed by having the patient clench their teeth.
B. CN VII (Facial); assessed by having the patient smile.
C. CN IX (Glossopharyngeal); assessed by having the patient swallow.
D. CN XII (Hypoglossal); assessed by having the patient move their tongue.
Correct Answer: A. CN V (Trigeminal); assessed by having the patient clench their teeth.
Rationale: The trigeminal nerve (CN V) has a motor component that innervates the muscles
of mastication (masseter, temporalis, pterygoids). Clenching the teeth while the nurse palpates
the masseter and temporalis muscles assesses this function. CN VII controls facial expression.
9. The nurse is assessing an older adult patient and notes a unilateral, painless, hard, fixed
lymph node in the cervical chain. The patient states, "I've had that for a few months." What is
, the nurse's priority action?
A. Document the finding and re-evaluate in one week.
B. Ask the patient about recent colds or sore throats.
C. Notify the healthcare provider immediately.
D. Perform range-of-motion exercises on the patient's neck.
Correct Answer: C. Notify the healthcare provider immediately.
Rationale: A hard, fixed, painless lymph node that has been present for months is highly
suspicious for malignancy. The nurse's priority is to report this finding to the provider for further
investigation (e.g., biopsy, imaging). Re-evaluating in a week or asking about colds is
inappropriate given the high suspicion for a serious condition.
10. A patient is admitted with a suspected basilar skull fracture. Which of the following signs
would the nurse expect to find during the head assessment? (Select All That Apply)
A. Battle's sign (ecchymosis behind the ear)
B. Raccoon eyes (periorbital ecchymosis)
C. Nuchal rigidity
D. Otorrhea (CSF leak from the ear)
E. Rhinorrhea (CSF leak from the nose)
Correct Answers: A, B, D, E
Rationale: Battle's sign, Raccoon eyes, Otorrhea, and Rhinorrhea are all classic signs of a
basilar skull fracture. Nuchal rigidity is a sign of meningeal irritation (e.g., meningitis) and is not
a specific sign of a basilar skull fracture, though it can occur if meningitis develops as a
complication.
11. A nurse is assessing a patient who has a history of temporomandibular joint (TMJ)
disorder. Which assessment finding is most consistent with this condition?
A. A smooth, non-tender jaw movement.
B. A clicking or popping sound upon opening the mouth.
C. Inability to open the mouth more than 1 cm.
D. Swelling over the mastoid process.
Correct Answer: B. A clicking or popping sound upon opening the mouth.
Rationale: Crepitus (clicking/popping) and pain with jaw movement are hallmark signs of
TMJ dysfunction. While limited opening (trismus) can occur in severe cases, crepitus is the most
common and specific finding.
12. The nurse is performing a physical assessment on a 70-year-old patient. Which of the
following age-related changes to the head and neck is expected?
Health Assessment, Nose & Sinus Examination, Olfactory
Receptors, Rhinitis, Allergies, Pharyngitis, Oral Assessment,
Smoking Effects, Geriatric Changes & Pediatric Dentition |
Complete Exam Review
Section 1: The Head, Face, and Neck Assessment
1. A 45-year-old patient presents with a chief complaint of a "pounding headache" that has
been persistent for three days. During the health history, which of the following questions is
most important for the nurse to ask first?
A. "Have you tried any over-the-counter medications for this?"
B. "Can you describe the location and quality of the pain?"
C. "Do you have a family history of migraines?"
D. "Have you experienced any recent head trauma?"
Correct Answer: D. "Have you experienced any recent head trauma?"
Rationale: When a patient presents with a new, persistent headache, the priority is to rule
out life-threatening causes. Asking about recent head trauma is a critical screening question for
a potential subdural or epidural hematoma, which requires immediate medical intervention.
While the other questions are important for a full assessment, assessing for trauma is the
highest priority.
2. During the physical assessment of the head and face, the nurse is preparing to palpate the
temporomandibular joint (TMJ). The correct technique is to:
A. Place the tips of the index fingers in front of the tragus of each ear and ask the patient to
open and close their mouth.
B. Place the palms of the hands on the patient's cheeks and ask them to clench their teeth.
C. Palpate the mastoid process behind the ear while the patient turns their head.
D. Apply pressure to the zygomatic arches while the patient opens their mouth wide.
Correct Answer: A. Place the tips of the index fingers in front of the tragus of each ear and
ask the patient to open and close their mouth.
Rationale: This is the standard technique for assessing the TMJ. Placing the fingertips in
front of the tragus allows the nurse to feel for crepitus, tenderness, or limited range of motion
as the jaw opens and closes. Options B, C, and D are incorrect techniques for assessing the TMJ.
,3. A nurse is assessing a patient's thyroid gland. Which instruction should the nurse give to
the patient to best facilitate palpation of the thyroid isthmus?
A. "Please turn your head to the right."
B. "Please swallow a sip of water."
C. "Please take a deep breath and hold it."
D. "Please open your mouth and say 'ah'."
Correct Answer: B. "Please swallow a sip of water."
Rationale: Swallowing causes the thyroid gland to rise and become more prominent,
making it easier to palpate. The nurse should stand behind the patient, place fingers on either
side of the trachea, and ask the patient to swallow. This allows for assessment of the isthmus
and lobes as they move upward.
4. Which of the following findings would be considered an abnormal assessment of the head
and neck in an adult?
A. A midline trachea.
B. Symmetrical facial features at rest.
C. A fixed, non-tender, hard lymph node in the supraclavicular area.
D. A thyroid gland that is not palpable.
Correct Answer: C. A fixed, non-tender, hard lymph node in the supraclavicular area.
Rationale: A fixed, hard, non-tender lymph node, especially in the supraclavicular area
(Virchow's node), is a classic warning sign for malignancy (e.g., from the stomach, lungs, or
breasts). A midline trachea, symmetrical face, and a non-palpable thyroid are all normal findings
in many adults.
5. During a head and neck assessment, the nurse notes that a patient's neck is flexed forward
and the chin is touching the chest. What is this finding called?
A. Torticollis
B. Nuchal rigidity
C. Opisthotonus
D. Ankylosis
Correct Answer: B. Nuchal rigidity
Rationale: Nuchal rigidity, or stiffness of the neck, is a key sign of meningeal irritation, often
seen in meningitis. While a patient can flex their neck, it is painful and resistance is met.
Torticollis is a wryneck (twisting). Opisthotonus is an arching of the back. Ankylosis is joint
stiffness.
,6. A nurse is performing a head-to-toe assessment on a new admission. When assessing the
head, the nurse should include which of the following? (Select All That Apply)
A. Inspecting for symmetry of facial features.
B. Palpating the skull for deformities or tenderness.
C. Assessing the function of cranial nerve V (Trigeminal).
D. Auscultating the carotid arteries for bruits.
E. Observing for involuntary facial movements (tics).
Correct Answers: A, B, C, E
Rationale: A comprehensive head assessment includes inspection (symmetry, tics),
palpation (skull), and neurological screening for cranial nerves (CN V and VII are key for the
face). Auscultating the carotid arteries is part of the neck assessment, not the head assessment.
7. A patient reports a "whooshing" sound in their right ear that is synchronous with their
heartbeat. What is the most appropriate term for this finding, and what should the nurse do
next?
A. Tinnitus; reassure the patient it is a common finding.
B. Vertigo; perform a Romberg test.
C. Pulsatile tinnitus; auscultate the neck and head for a bruit.
D. Presbycusis; refer the patient to an audiologist.
Correct Answer: C. Pulsatile tinnitus; auscultate the neck and head for a bruit.
Rationale: Pulsatile tinnitus, a sound synchronous with the heartbeat, can be a sign of
vascular abnormality such as an arteriovenous malformation or carotid stenosis. Auscultating
for a bruit is the immediate next step. Non-pulsatile tinnitus is more common and often benign.
8. Which cranial nerve is responsible for the motor function of the muscles of mastication,
and how is it assessed?
A. CN V (Trigeminal); assessed by having the patient clench their teeth.
B. CN VII (Facial); assessed by having the patient smile.
C. CN IX (Glossopharyngeal); assessed by having the patient swallow.
D. CN XII (Hypoglossal); assessed by having the patient move their tongue.
Correct Answer: A. CN V (Trigeminal); assessed by having the patient clench their teeth.
Rationale: The trigeminal nerve (CN V) has a motor component that innervates the muscles
of mastication (masseter, temporalis, pterygoids). Clenching the teeth while the nurse palpates
the masseter and temporalis muscles assesses this function. CN VII controls facial expression.
9. The nurse is assessing an older adult patient and notes a unilateral, painless, hard, fixed
lymph node in the cervical chain. The patient states, "I've had that for a few months." What is
, the nurse's priority action?
A. Document the finding and re-evaluate in one week.
B. Ask the patient about recent colds or sore throats.
C. Notify the healthcare provider immediately.
D. Perform range-of-motion exercises on the patient's neck.
Correct Answer: C. Notify the healthcare provider immediately.
Rationale: A hard, fixed, painless lymph node that has been present for months is highly
suspicious for malignancy. The nurse's priority is to report this finding to the provider for further
investigation (e.g., biopsy, imaging). Re-evaluating in a week or asking about colds is
inappropriate given the high suspicion for a serious condition.
10. A patient is admitted with a suspected basilar skull fracture. Which of the following signs
would the nurse expect to find during the head assessment? (Select All That Apply)
A. Battle's sign (ecchymosis behind the ear)
B. Raccoon eyes (periorbital ecchymosis)
C. Nuchal rigidity
D. Otorrhea (CSF leak from the ear)
E. Rhinorrhea (CSF leak from the nose)
Correct Answers: A, B, D, E
Rationale: Battle's sign, Raccoon eyes, Otorrhea, and Rhinorrhea are all classic signs of a
basilar skull fracture. Nuchal rigidity is a sign of meningeal irritation (e.g., meningitis) and is not
a specific sign of a basilar skull fracture, though it can occur if meningitis develops as a
complication.
11. A nurse is assessing a patient who has a history of temporomandibular joint (TMJ)
disorder. Which assessment finding is most consistent with this condition?
A. A smooth, non-tender jaw movement.
B. A clicking or popping sound upon opening the mouth.
C. Inability to open the mouth more than 1 cm.
D. Swelling over the mastoid process.
Correct Answer: B. A clicking or popping sound upon opening the mouth.
Rationale: Crepitus (clicking/popping) and pain with jaw movement are hallmark signs of
TMJ dysfunction. While limited opening (trismus) can occur in severe cases, crepitus is the most
common and specific finding.
12. The nurse is performing a physical assessment on a 70-year-old patient. Which of the
following age-related changes to the head and neck is expected?
