CH. 15 Head and Neck

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.

A client presents at the emergency room reporting "the worst headache I have ever had." What are critical nursing behaviors for this client? (Select all that apply.)

• Physical examination for neurologic changes • Focused history

The nurse would expect to assess which symptoms in a patient complaining of migraine headaches? Select all the apply.

• photophobia • throbbing • recurrent

During the health interview of the head and neck, the patient tells the nurse about having a lump in the neck. Which question would the nurse ask to assess manifestations associated with this lump?

"Do you have difficulty swallowing?

A nurse palpates an elderly client's thyroid and detects an enlargement over the right lateral lobe. What action should the nurse take first?

Auscultate with the bell over the lateral lobes

A male college student presents to the student health clinic with reports of night-time headaches for the past 2 weeks. He denies nausea or photosensitivity but states that he has noticed his eyes are tearing and his nose runs a lot. He is stressed because of final exams and confesses to drinking more alcohol than normal. The nurse recognizes these findings as indicative of what type of headache?

Cluster

When conduction a generalized assessment of a new client, for what would the nurse inspect the neck?

Limitations in movement

A nurse is caring for a patient admitted with neck pain. The patient is febrile. What is the most likely medical diagnosis for this patient?

Meningitis

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

When assessing a patient with Graves disease, how would you expect the thyroid gland to be?

Soft

The nurse is performing a physical examination and notes an enlarged left supraclavicular lymph node. The nurse understands that this could be indicative of

a metastasis

The nurse does a health history. The patient states he has lost 30 pounds in the last couple months without really trying. The patient also states he feels warm all the time and sometimes feels like he has heart palpitations. The nurse would anticipate orders to evaluate the patient for

hyperthyroidism

The nurse is assessing a client complaining of swelling in the neck. While palpating the neck, the nurse finds a 2-cm lump that is fixed and hard. Why does this finding require emergency investigation?

This could be a sign of cancer Lymphatics larger than 1 cm, fixed, irregular, or hard or rubbery require emergency investigation

Primary headaches are more worrisome than secondary headaches.

false

The nurse is palpating a client's cervical vertebrae. Which vertebra can be easily palpated when the neck is flexed and should help the nurse locate the other vertebrae?

C7

A nurse needs to examine a client's thyroid as part of the head and neck assessment. How should the nurse instruct the client to position his head to best facilitate this exam?

Flex the head toward the side being examined To correctly examine the thyroid, the nurse should stand behind the client and ask him to lower the chin and turn the head toward the side being examined. This action helps to relax the client's neck muscles.

A nurse palpates an enlarged, hard, and nontender 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 Normally, these lymph nodes should not be palpable. An enlarged, hard, nontender left-sided supraclavicular node may be an indication of malignancy of the abdomen or thorax.

During the physical examination the head and neck, the nurse palpates several nodules on the patient's thyroid gland. What would this finding suggest to the nurse?

Metabolic process An enlarged thyroid gland with two or more nodules suggests a metabolic rather than a neoplastic disease process. Diffuse enlargement of the thyroid gland is seen in Graves' disease and endemic goiter. A single nodule palpated on the thyroid gland is suspicious for a malignancy.

A young adult client has just had X-rays and computed tomography scanning of the head and neck following a mountain bicycling accident. All results are negative. What should the nurse assess for next?

Range of motion of the neck

A 73-year-old woman comes to the office for evaluation of new onset of tremors. She is not taking any medications, herbs, or supplements. She has no chronic medical conditions. She does not smoke or drink alcohol. She walks into the examination room with slow, shuffling steps. She has decreased facial mobility with a blunt expression without any changes in hair distribution on her face. Based on this description, what is the most likely reason for the client's symptoms?

Parkinson's disease