Ch 10 PrepU: The Head and Neck

A client describes headaches as severe and lasting for days. Which question would be most appropriate to use to determine if these headaches are migraines?

"Do you have any visual changes before the headache?"

A nurse is examining a client's neck and is preparing to palpate the thyroid gland. The nurse would most likely expect to palpate how many lobes?

2

A client's recent weight loss and diarrhea has been attributed to hyperthyroidism. When auscultating the client's thyroid gland, what assessment finding is most consistent with this diagnosis?

A sound of turbulent blood flow in the thyroid

A nurse palpates an enlarged and tender left sided supraclavicular lymph node in a client. Where should the nurse focus the physical assessment to obtain more data about this finding?

Abdomen and thoracic area for changes associated with malignancy

A client suffering from a headache complains of throbbing, severe, unilateral pain that feels worse when exposed to bright lights. The client also complains of nausea and vomiting. What is the nurse's best action?

Administer migraine medication

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

A 66-year-old woman has come to the clinic with complaints of increasing fatigue over the last several months. She claims to frequently feel lethargic and listless and states that, "I can never seem to get warm, no matter what the thermostat is set at." How should the nurse proceed with assessment?

Assess the woman for hypothyroidism.

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 pathophysiological cause for this finding is related to what disease process?

Atelectasis

When palpating the neck, performing which of the following techniques will help differentiate lymph nodes from a band of muscles?

Attempting to roll the structure up and down and side to side

Which vessel is the nurse assessing if the major artery of the neck is being examined?

Carotid

A nurse is preparing to assess an adult client's carotid pulses. Which of the following actions would be contraindicated?

Compressing the arteries bilaterally

When examining a client's thyroid gland, the nurse ensures that which equipment is readily available?

Cup of water

When preparing to assess a client's thyroid gland, the nurse should ensure that which piece of equipment is readily available?

Cup of water

When assessing an adult client experiencing diarrhea, the nurse notes a round "moon" face, a buffalo hump at the nape of the neck, and a velvety discoloration around the neck. What is the possible cause of these signs?

Cushing's syndrome

A nurse has completed the assessment of an older adult client's head and neck and is now analyzing the assessment findings. Which finding should the nurse attribute to age-related physiological changes?

Decreased strength of temporal artery pulsations

The nurse is discharging an adult client who received 18 staples for a head laceration received while mountain biking. What can the nurse focus on while doing discharge teaching?

Encourage the use of safety equipment

The nurse is preparing to palpate a client's trachea. Which technique should the nurse use?

Facing patient with hands around base of neck

A nurse is preparing a presentation for a local community group about preventing traumatic brain injury. The nurse would discuss which measure as prevention of the leading cause?

Fall prevention

After teaching a group of students about risk factors for traumatic brain injury, the instructor determines that additional teaching is needed when the students identify which of the following?

Female gender

A nurse performs palpation of a client's lymph nodes. Which finding should be reported to the health care provider?

Fixed to underlying tissue

What is the most common type of hyperthyroidism?

Graves disease

On palpation, the nurse notes that a client's thyroid gland is diffusely enlarged. Which of the following health problems is associated with this finding?

Graves' disease

A client presents at the clinic for a routine check-up. The nurse notes that she is dressed in warm clothing even though the temperature outside is 73°F (22.8°C). The nurse also notes that the client has gained 10 pounds (4.5 kg) since her last visit 9 months ago. What might the nurse suspect?

Hypothyroidism

During your physical examination of the client you note an enlarged tender tonsillar lymph node. What would you do?

Look for a source such as infection in the area that it drains

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 nuchal rigidity. The nurse recognizes these findings as most likely to be caused by what condition?

Meningeal inflammation

A 38-year-old accountant comes to the clinic for evaluation of a headache. The throbbing sensation is located in the right temporal region, and is an 8 on a pain scale of 1 to 10. It started a few hours ago, and she has noted nausea with sensitivity to light; she has had headaches like this in the past, usually less than one per week, but not as severe. She does not know of any inciting factors. There has been no change in the frequency of her headaches. She usually takes an over-the-counter analgesic, which results in resolution of the headache. Based on this description, what is the most likely diagnosis of the type of headache?

Migraine

Which risk factor for traumatic brain injury should a nurse include in a discussion about prevention for a group of adolescents?

Modes of transportation are the leading cause

An older adult presents at the clinic with reports of a painful neck. On palpation, the nurse notes a hard, nonmovable mass, approximately 20 mm, that is painful to touch. The area seems to have several nodes matted together. How would the nurse chart this last finding?

Nodes are delimited on palpation

A nurse documents which of the following as a normal finding when examining the thyroid gland of an older adult client?

Nodularity

A client complains of a unilateral headache near the scalp line and double vision. The nurse palpates the space above the cheekbone near the scalp line on the affected side, and the client complains of tenderness on palpation. What is the nurse's next action?

Notify the healthcare provider immediately.

The nurse is preparing to palpate a client's temporal artery. The nurse would place the hands at which location?

On each side between the top of the ear and the eye

Where should a nurse place the hands to palpate the submandibular lymph nodes?

On the medial border of the mandible

During a health history, a client reports complaints of headaches. What would lead the nurse to suspect that the client is experiencing cluster headaches?

Pain radiating from eye to temporal region

A nurse is providing care at an inner-city shelter, and a man who frequents the shelter presents with a significant frontal growth that is located midline at the base of his neck. The nurse should recognize the need for what referral?

Referral for further assessment of thyroid function

A client is having trouble turning her head to the side. Which of the following muscles should the nurse most suspect as being involved?

Sternocleidomastoid

A nurse has completed an assessment of a client's lymph nodes. Which of the following data would the nurse document as an abnormal finding?

Tender

A 29-year-old computer programmer comes to the office for evaluation of a headache. The tightening sensation of moderate intensity is located all over the head. It used to last minutes, but this time it has lasted for 5 days. He denies photophobia and nausea. He spends several hours at a computer monitor/keyboard. He has tried over-the-counter medication; it has dulled the pain, but not taken it away. Based on this description, what is the most likely diagnosis?

Tension

When examining the head, the nurse remembers that the anatomic regions of the cranium take their names from which of the following sources?

The underlying bones

Palpation of a 15-year-old boy's submandibular lymph nodes reveals them to be enlarged and tender. What is the nurse's most reasonable interpretation of this assessment finding?

There is an infection in the area that these nodes drain.

A client seeks medical attention for sharp, shooting facial pain that lasts for several minutes at a time. For which health problem should the nurse assess this client?

Trigeminal neuralgia

During the health history, a client describes recent episodes of intermittent facial pain lasting several minutes. The nurse should recognize that this complaint is suggestive of what health problem?

Trigeminal neuralgia

While assessing an adult client's skull, the nurse observes that the client's skull and facial bones are larger and thicker than usual. The nurse should assess the client for

acromegaly

A female client visits the clinic and tells the nurse that she frequently experiences severe recurring headaches that sometimes last for several days and are accompanied by nausea and vomiting. The nurse determines that the type of headache the client is describing is a

migraine headache.

A client is experiencing pain around the eye that radiates to the face and temporal area. Which image diagrams this client's pain?

only eye

The nurse is preparing to assess the neck of an adult client. To inspect movement of the client's thyroid gland, the nurse should ask the client to

swallow a small sip of water.

A client visits the clinic and tells the nurse that he is depressed because of a recent job loss. He complains of dull, aching, tight, and diffuse headaches that have lasted for several days. The nurse should recognize that these are symptoms of

tension headaches.

While assessing the head and neck of an adult client, the client tells the nurse that she has been experiencing sharp shooting facial pains that last from 10 to 20 seconds but are occurring more frequently. The nurse should refer the client for possible

trigeminal neuralgia.