!NSG 303 EXAM 3 QUESTIONS UPDATED AND CORRECT
ANSWERS UPDATED QUESTIONS AND CORRECT
ANSWERS
Question:
1. The nurse is palpating a client's neck as part of a physical assessment. Which of the following
blood vessels should the nurse be especially careful to avoid bilaterally compressing during the
assessment?
-Internal jugular vein -External jugular vein -Carotid artery -Temporal artery
Answer:
-Carotid artery
Question:
2. A nurse palpates a client's cervical lymph nodes and notes the following findings: cervical lymph
nodes 0.6 inches (1.5 cm) in diameter (enlarged), painful, and mobile. What is the bestaction of the
nurse?
-Ask the client if they have a history of cancer.
-Ask the client if they have experienced any other signs or symptoms.
-Document findings as normal.
-Notify the health care provider.
Answer:
-Ask the client if they have experienced any oth-er signs or symptoms.
Question:
3. The nurse is discharging an adult client who received 18 staples for a head laceration received
while moun-tain biking. What can the nurse focus on while doing discharge teaching?
-Encourage proper nutrition to promote healing -Encourage the client to take a safety course
-Encourage the use of safety equipment -Teach proper posture, bending, and lifting
Answer:
-Encourage the use of safety equipment
Question:
4. A nurse is preparing to examine a client from Southeast Asia who has been experiencing chronic
headaches. Which of the following should the nurse do in light of this client's cultural background?
-Ask permission before palpating the head and neck -Palpate the client's feet before palpating the
head -Have a nurse who is the same sex as the client per-form the examination -Avoid asking the
client to remove their clothes for the examination
Answer:
-Ask permission before palpating the head and neck
Question:
5. A client is being admitted with a diagnosis of temporal arteritis. The nurse expects which of the
following findings on assessment?
-The temporal artery is elastic, red, and tender.
-The temporal artery is hard, thick, and tender.
-There is sensitivity to light and some loss of vision.
-There is asymmetry of the face with pain.
, Answer:
-The temporal artery is hard, thick, and tender.
Question:
6. While assessing the head and neck of an adult client, the client tells the nurse that they have been
experi-encing sharp shooting facial pains that last from 10 to 20 seconds but are occurring more
frequently. The nurse should refer the client for possible -cancerous lesions. -inner ear disease.
-trigeminal neuralgia. -arterial occlusion.
Answer:
-trigeminal neuralgia
Question:
7. 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?
-Chronic infection -Acute infection -Cushing's disease -Metastatic disease
Answer:
-Acute infection
Question:
8. Palpation of a 15-year-old client's submandibular lymph nodes reveals them to be enlarged and
tender. What is the nurse's most reasonable interpretation of this assessment finding?
-The tissue underlying the nodes is infected.
-There is an infection in the area that these nodes drain.
-The client requires assessment of their thyroid gland.
-There is an inflammatory response in the muscula-ture of the client's neck.
Answer:
-There is an infection in the area that these nodes drain.
Question:
9. The nurse is using the Headache Impact Test with a client who reports frequent headaches. What is
the primary purpose of this assessment tool?
-Identify triggers that cause headache episodes.
-Measure the client's pain tolerance level.
-Determine how headaches affect daily functioning.
-Differentiate the specific type of headache disorder.
Answer:
-Determine how headaches affect daily functioning.
Question:
10. A client reports using pain medication and sitting in a dark room on the onset of a migraine
headache. In which part of the subjective section of the physical examination should the nurse
document this informa-tion?
-onset -relieving factors -treatment -location
Answer:
-relieving factors
,Question:
11. A client presents to the emergency department with reports of neck pain and a sudden onset of a
headache. Upon examination, the nurse finds that the client has an increased temperature and neck
stiff-ness. The nurse recognizes these findings as most likely to be caused by what condition?
-Meningeal inflammation -Migraine headache -Trigeminal neuralgia -Parkinson's disease
Answer:
-Meningeal inflammation
Question:
12. During the physical examination of a client, a nurse notes that a client's trachea has been pushed
toward the right side. The nurse recognizes that the patho-physiologic cause for this finding is related
to what disease process?
-Endocarditis -Bronchitis -Tuberculosis -Atelectasis
Answer:
-Atelectasis
Question:
13. A 38-year-old accountant comes to the clinic for evalu-ation of a headache. The throbbing
sensation is locat-ed in the right temporal region, and is an 8 on a pain scale of 1 to 10. It started a few
hours ago, and they have noted nausea with sensitivity to light; they have had headaches like this in
the past, usually less than one per week, but not as severe. They do not know of any inciting factors.
There has been no change in the frequency of their headaches. They usually takes an over-the-counter
analgesic, which results in resolu-tion of the headache. Based on this description, what is the most
likely diagnosis of the type of headache?
-Migraine -Cluster -Tension -Analgesic rebound
Answer:
-Migraine
Question:
14. An adult client visits the clinic and tells the nurse that they have had headaches recently that are
intense and stabbing and often occur in the late evening. The nurse should suspect the presence of
-tension headaches. -cluster headaches. -tumor-related headaches. -migraine headaches.
Answer:
-cluster headaches.
Question:
15. A client reports recurring headaches that are worse when first waking in the morning and with
coughing or sneezing. What would be the nurse's most appro-priate action?
-Ask the health care provider for an order for an MRI -Perform a focused assessment -Prepare the
client for a spinal tap -Perform a generalized assessment
Answer:
-Perform a focused as-sessment
Question:
16. A female client asks a nurse why it seems like their headaches are more severe and longer in
duration than male friends who also have migraines. What is the best response by the nurse?
-"The severity of migraines is usually related to genet-ics." -"There is no difference in how migraines
affect males and females." -"Hormones affect the severity of migraine headaches." -"People
, experience different symptoms with mi-graines."
Answer:
-"Hormones affect the severity of migraine headaches.
Question:
17. During the nurse's physical examination of the client they note an enlarged tender tonsillar lymph
node. What would they do?
-Look for a source such as infection in the area that it drains -Look for involvement of other regions
of the body -Assess for dietary changes -Assess for meningitis
Answer:
-Look for a source such as infection in the area that it drains
Question:
18. The nurses assesses the thyroid gland of a client with recent weight loss. On auscultation, a low,
soft, rush-ing sound is heard over the lateral lobes. Which con-dition is most likely?
-Hashimoto thyroiditis -benign tumor -hyperthyroidism -thyroid cyst
Answer:
-hyperthyroidism
Question:
19. A 29-year-old computer programmer comes to the of-fice for evaluation of a headache. The
tightening sen-sation of moderate intensity is located all over their head. It used to last minutes, but
this time it has lasted for 5 days. They deny photophobia and nausea. They spend several hours at a
computer monitor/keyboard. They have tried over-the-counter medication; it has dulled the pain, but
not taken it away. Based on this description, what is the most -Tension -Migraine -Analgesic rebound
-Cluster
Answer:
-Tension
Question:
20. A client reports a unilateral headache near the scalp line and double vision. The nurse palpates the
space above the cheekbone near the scalp line on the affect-ed side, and the client reports tenderness
on palpa-tion. What is the nurse's next action?
-Administer intravenous pain medication.
-Prepare the client for a temporal artery biopsy.
-Palpate the carotid pulses bilaterally at the same time.
-Notify the health care provider immediately.
Answer:
-Notify the health care provider immediately.
Question:
21. While assessing an adult client's skull, the nurse ob-serves that the client's skull and facial bones
are larger and thicker than usual. The nurse should assess the client for -acromegaly. -Cushing
syndrome. -Paget disease. -parotid gland enlargement.
Answer:
-acromegaly
ANSWERS UPDATED QUESTIONS AND CORRECT
ANSWERS
Question:
1. The nurse is palpating a client's neck as part of a physical assessment. Which of the following
blood vessels should the nurse be especially careful to avoid bilaterally compressing during the
assessment?
-Internal jugular vein -External jugular vein -Carotid artery -Temporal artery
Answer:
-Carotid artery
Question:
2. A nurse palpates a client's cervical lymph nodes and notes the following findings: cervical lymph
nodes 0.6 inches (1.5 cm) in diameter (enlarged), painful, and mobile. What is the bestaction of the
nurse?
-Ask the client if they have a history of cancer.
-Ask the client if they have experienced any other signs or symptoms.
-Document findings as normal.
-Notify the health care provider.
Answer:
-Ask the client if they have experienced any oth-er signs or symptoms.
Question:
3. The nurse is discharging an adult client who received 18 staples for a head laceration received
while moun-tain biking. What can the nurse focus on while doing discharge teaching?
-Encourage proper nutrition to promote healing -Encourage the client to take a safety course
-Encourage the use of safety equipment -Teach proper posture, bending, and lifting
Answer:
-Encourage the use of safety equipment
Question:
4. A nurse is preparing to examine a client from Southeast Asia who has been experiencing chronic
headaches. Which of the following should the nurse do in light of this client's cultural background?
-Ask permission before palpating the head and neck -Palpate the client's feet before palpating the
head -Have a nurse who is the same sex as the client per-form the examination -Avoid asking the
client to remove their clothes for the examination
Answer:
-Ask permission before palpating the head and neck
Question:
5. A client is being admitted with a diagnosis of temporal arteritis. The nurse expects which of the
following findings on assessment?
-The temporal artery is elastic, red, and tender.
-The temporal artery is hard, thick, and tender.
-There is sensitivity to light and some loss of vision.
-There is asymmetry of the face with pain.
, Answer:
-The temporal artery is hard, thick, and tender.
Question:
6. While assessing the head and neck of an adult client, the client tells the nurse that they have been
experi-encing sharp shooting facial pains that last from 10 to 20 seconds but are occurring more
frequently. The nurse should refer the client for possible -cancerous lesions. -inner ear disease.
-trigeminal neuralgia. -arterial occlusion.
Answer:
-trigeminal neuralgia
Question:
7. 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?
-Chronic infection -Acute infection -Cushing's disease -Metastatic disease
Answer:
-Acute infection
Question:
8. Palpation of a 15-year-old client's submandibular lymph nodes reveals them to be enlarged and
tender. What is the nurse's most reasonable interpretation of this assessment finding?
-The tissue underlying the nodes is infected.
-There is an infection in the area that these nodes drain.
-The client requires assessment of their thyroid gland.
-There is an inflammatory response in the muscula-ture of the client's neck.
Answer:
-There is an infection in the area that these nodes drain.
Question:
9. The nurse is using the Headache Impact Test with a client who reports frequent headaches. What is
the primary purpose of this assessment tool?
-Identify triggers that cause headache episodes.
-Measure the client's pain tolerance level.
-Determine how headaches affect daily functioning.
-Differentiate the specific type of headache disorder.
Answer:
-Determine how headaches affect daily functioning.
Question:
10. A client reports using pain medication and sitting in a dark room on the onset of a migraine
headache. In which part of the subjective section of the physical examination should the nurse
document this informa-tion?
-onset -relieving factors -treatment -location
Answer:
-relieving factors
,Question:
11. A client presents to the emergency department with reports of neck pain and a sudden onset of a
headache. Upon examination, the nurse finds that the client has an increased temperature and neck
stiff-ness. The nurse recognizes these findings as most likely to be caused by what condition?
-Meningeal inflammation -Migraine headache -Trigeminal neuralgia -Parkinson's disease
Answer:
-Meningeal inflammation
Question:
12. During the physical examination of a client, a nurse notes that a client's trachea has been pushed
toward the right side. The nurse recognizes that the patho-physiologic cause for this finding is related
to what disease process?
-Endocarditis -Bronchitis -Tuberculosis -Atelectasis
Answer:
-Atelectasis
Question:
13. A 38-year-old accountant comes to the clinic for evalu-ation of a headache. The throbbing
sensation is locat-ed in the right temporal region, and is an 8 on a pain scale of 1 to 10. It started a few
hours ago, and they have noted nausea with sensitivity to light; they have had headaches like this in
the past, usually less than one per week, but not as severe. They do not know of any inciting factors.
There has been no change in the frequency of their headaches. They usually takes an over-the-counter
analgesic, which results in resolu-tion of the headache. Based on this description, what is the most
likely diagnosis of the type of headache?
-Migraine -Cluster -Tension -Analgesic rebound
Answer:
-Migraine
Question:
14. An adult client visits the clinic and tells the nurse that they have had headaches recently that are
intense and stabbing and often occur in the late evening. The nurse should suspect the presence of
-tension headaches. -cluster headaches. -tumor-related headaches. -migraine headaches.
Answer:
-cluster headaches.
Question:
15. A client reports recurring headaches that are worse when first waking in the morning and with
coughing or sneezing. What would be the nurse's most appro-priate action?
-Ask the health care provider for an order for an MRI -Perform a focused assessment -Prepare the
client for a spinal tap -Perform a generalized assessment
Answer:
-Perform a focused as-sessment
Question:
16. A female client asks a nurse why it seems like their headaches are more severe and longer in
duration than male friends who also have migraines. What is the best response by the nurse?
-"The severity of migraines is usually related to genet-ics." -"There is no difference in how migraines
affect males and females." -"Hormones affect the severity of migraine headaches." -"People
, experience different symptoms with mi-graines."
Answer:
-"Hormones affect the severity of migraine headaches.
Question:
17. During the nurse's physical examination of the client they note an enlarged tender tonsillar lymph
node. What would they do?
-Look for a source such as infection in the area that it drains -Look for involvement of other regions
of the body -Assess for dietary changes -Assess for meningitis
Answer:
-Look for a source such as infection in the area that it drains
Question:
18. The nurses assesses the thyroid gland of a client with recent weight loss. On auscultation, a low,
soft, rush-ing sound is heard over the lateral lobes. Which con-dition is most likely?
-Hashimoto thyroiditis -benign tumor -hyperthyroidism -thyroid cyst
Answer:
-hyperthyroidism
Question:
19. A 29-year-old computer programmer comes to the of-fice for evaluation of a headache. The
tightening sen-sation of moderate intensity is located all over their head. It used to last minutes, but
this time it has lasted for 5 days. They deny photophobia and nausea. They spend several hours at a
computer monitor/keyboard. They have tried over-the-counter medication; it has dulled the pain, but
not taken it away. Based on this description, what is the most -Tension -Migraine -Analgesic rebound
-Cluster
Answer:
-Tension
Question:
20. A client reports a unilateral headache near the scalp line and double vision. The nurse palpates the
space above the cheekbone near the scalp line on the affect-ed side, and the client reports tenderness
on palpa-tion. What is the nurse's next action?
-Administer intravenous pain medication.
-Prepare the client for a temporal artery biopsy.
-Palpate the carotid pulses bilaterally at the same time.
-Notify the health care provider immediately.
Answer:
-Notify the health care provider immediately.
Question:
21. While assessing an adult client's skull, the nurse ob-serves that the client's skull and facial bones
are larger and thicker than usual. The nurse should assess the client for -acromegaly. -Cushing
syndrome. -Paget disease. -parotid gland enlargement.
Answer:
-acromegaly
