ch 12: head and neck
A female client asks a nurse why it seems like her headaches are more severe and longer in duration than male friends who also have migraines. What is the best response by the nurse?
"Hormones affect the severity of migraine headaches."
characteristics of cluster headaches
- Frequent - Short - High intensity - 10X more common in men vs. women
subjective data for head and neck
- headache - injury - dizziness - neck pain, limitation of ROM - lumps or swelling - history of head/neck surgery - family history - lifestyle
When to worry about lymph nodes
- larger than 1c, - fixed, hard, rubbery nodules
sutures
Areas where the cranial bones have joined together
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 stiffness. The nurse recognizes these findings as most likely to be caused by what condition?
Meningeal inflammation
Lymph nodes of the neck
Preauricular Postauricular Tonsillar Occipital Submandibular Submental Superficial cervical Posterior cervical Deep cervical Supraclavicular
thyroid gland secretes
T3 and T4
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?
The thyroid gland consists of two lateral lobes
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
submandibular gland
a salivary gland inside the lower jaw on either side that produces
The lymph nodes are enlarged and tender in ? Normally, lymph nodes are not
acute infections. Normally, lymph nodes are not sore or tender and are usually not palpable.
how to test that facial muscles are symmetriclal and working well?
ask pt to smile, raise eyebrows, blink, open jaw
bruit
blowing, swooshing sound heard through a stethoscope when an artery is partially occluded
shape pf thyroid
butterfly 2 lobes
Neck vertebrae
c1-c7
blood supplied to head through
carotid arteries
assess face for
color, symmetry, masses, lesions
head made of
cranium and facial skeletons
lymphadenopathy
enlarged lymph nodes, a good thing shows immune system is working
temporal artery supplies blood to the
face
stabilization of head and neck is essential to avoid
further neurological injury
Hypothyroidism more common in
in pt over 60
characteristics of migraines
last 4-72 hours, unilateral, pulsating, moderate to severe intensity, aggravated by routine physical activity, there are triggers, associated with nausea/vomiting, photophobia/phonophobia (aura)
Fever + Headache
meningitis
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.
characteristics of tension heachaches
most common, bilateral, pressing or tightening, gradual
to palpate thyroid
o Instruct the person to swallow a sip of water, the thyroid gland and cartilage should rise as the person swallows o Palpate as the person is swallowing o Enlarged thyroid gland is called a goiter Do not palpate if visibly enlarged, a bruit may be auscultated if the thyroid is enlarged
sublingual gland
salivary gland under the tongue
parotid gland
salivary gland within the cheek, just anterior to the ear
assess the head for
size and shape, depressions, lumps
blood supply for neck lies under the
sternocleidomastoid
major muscles of the neck
sternocleidomastoid and trapezius
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?
The strength of the pulsation of the temporal artery may be decreased in the older client.
A nurse is teaching nursing students about the risks associated with developing head and neck cancers. The nurse determines student understanding when the students make which of the following statements?
Tobacco use increases the risk of head and neck cancer. Eighty-five percent of head and neck cancers are linked to tobacco use
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?
Whenever a lymph node is enlarged or tender, the nurse should assess for infection in the area that the particular nodes drain.
major facial muscles enable
chewing, speaking, smiling and frowning
cranial nerve 5 does what
supplies motor and sensory
assess the neck for
symmetry, range of motion, masses/swelling
