Ch. 15 Prep U

D. Parkinson's disease

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? A. Nephrotic syndrome B. Myxedema C. Cushing's syndrome D. Parkinson's disease

D. characteristic symptoms

A nurse asks the client to describe the pain associated with a headache by rating the pain on a scale from 1 to 10. This subjective data should be documented in which section of the assessment? A. relieving factors B. location C. associated manifestations D. characteristic symptoms

A. Fixed to underlying tissue

A nurse performs palpation of a client's lymph nodes. Which finding should be reported to the health care provider? A. Fixed to underlying tissue B. Round and 8 mm in size C. Soft in consistency D. Mobile from side to side

C. Arthritis

An 81-year-old client complains of neck pain and demonstrates decreased range of motion on examination. Which of the following causes should the nurse most suspect in this client? A. Stress B. Injury to the sternomastoid C. Arthritis D. Meningeal inflammation

B. tumor-related headache.

An older client visits the clinic accompanied by his daughter. The daughter tells the nurse that her father has been experiencing severe headaches that usually begin in the morning and become worse when he coughs. The client tells the nurse that he feels dizzy when he has the headaches. The nurse refers the client for further evaluation because these symptoms are characteristic of a A. migraine headache. B. tumor-related headache. C. tension headache. D. cluster headache.

C. malignancy

As the nurse palpates the lymph nodes of the neck, hard and fixed nodes are noted in the supra-clavicular region. This finding is consistent with which condition? A. inflammation B. hypothyroidism C. malignancy D. enlargement

A. Laboratory tests

In addition to noting the physical characteristics of the thyroid gland, which of the following signs would be most important to consider in determining if the client has hypothyroidism? A. Laboratory tests B. Increased blood pressure C. Increased heart rate D. Feeling anxious

C. Shape of the lips D. Shape of the nose E. Shape of the eyes

Nursing students are learning about assessment of the head and neck. What cultural considerations would the students learn to assess in relation to this area? (Select all that apply.) A. Shape of the ears B. Shape of the chin C. Shape of the lips D. Shape of the nose E. Shape of the eyes

A. False

The frontal sinuses are the only ones readily accessible to clinical examination. A. False B. True

C. C7

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? A. C3 B. C1 C. C7 D. C5

D. Hyoid bone, thyroid cartilage, cricoid cartilage, isthmus of the thyroid

When identifying the midline structures of the neck from the mandible to the sternal notch, the nurse notes the structures in what order? A. Thyroid cartilage, thyroid isthmus, cricoid cartilage, hyoid bone B. Cricoid cartilage, hyoid bone, tracheal rings, thyroid isthmus C. Hyoid bone, tracheal rings, cricoid cartilage, lobes of the thyroid gland D. Hyoid bone, thyroid cartilage, cricoid cartilage, isthmus of the thyroid

A. Open the mouth

Which instruction to the client will help facilitate examination of the temporomandibular joint by the nurse? A. Open the mouth B. Sit upright C. Sit without moving D. Perform a chewing action

A. Tension

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? A. Tension B. Cluster C. Migraine D. Analgesic rebound

B. Migraine

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? A. Cluster B. Migraine C. Analgesic rebound D. Tension

C. Assess the client's blood pressure.

A 57-year-old client reports, "I am having the worst headache I have ever experienced." Which action should the nurse perform next? A. Provide medication for pain relief. B. Review the client's medical record. C. Assess the client's blood pressure. D. Inquire about family history of headaches.

B. Assess the woman for hypothyroidism.

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? A. Palpate the woman's parotid gland for enlargement. B. Assess the woman for hypothyroidism. C. Assess for other signs and symptoms of Cushing's syndrome. D. Order tests to rule out an overactive thyroid gland.

C. Arthritic changes of the cervical spine

A 82 year old female presents with neck pain, decreased strength and sensation of the upper extremities. The nurse identifies that this could be related to what? A. Bacterial thyroiditis B. Cranial damage C. Arthritic changes of the cervical spine D. Muscle tension

D. Tension pneumothorax

A client comes to the trauma unit in respiratory distress following a motor vehicle accident. On examination, the nurse notices that the trachea is deviated from the midline. What does this finding indicate? A. Cardiac tamponade B. Flail chest C. Severe neck fracture D. Tension pneumothorax

A. tension

A client complains of a headache over both temporal areas. What type of headache should the nurse suspect the client is experiencing? A. tension B. cluster C. hypertensive D. migraine

D. Notify the healthcare provider immediately.

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? A. Palpate the carotid pulses bilaterally at the same time. B. Prepare the client for a temporal artery biopsy. C. Administer intravenous pain medication. D. Notify the healthcare provider immediately.

B. Perform a focused assessment

A client complains of recurring headaches that are worse when first waking in the morning and with coughing or sneezing. What would be the nurse's most appropriate action? A. Ask the doctor for an order for an MRI B. Perform a focused assessment C. Prepare the client for a spinal tap D. Perform a generalized assessment

A. acute bacterial sinusitis

A client reports experiencing chronic headache after a recent upper respiratory tract infection. On physical examination, the nurse notes tenderness when palpating over the sinuses. Which condition is likely? A. acute bacterial sinusitis B. allergic rhinitis C. rhinitis medicamentosa D. epistaxis

A. Migraine headache

A client reports right-sided temporal headache accompanied by nausea and vomiting. A nurse recognizes that which condition is likely to produce these symptoms? A. Migraine headache B. Tension headache C. Temporal arteritis D. Bell's palsy

A. Previous injuries to the head and neck

A client reports severe pain in the posterior region of the neck and difficulty turning the head to the right. What additional information should the nurse collect? A. Previous injuries to the head and neck B. Difficulty with swallowing C. Changes in sleeping habits D. Stiffness in the right shoulder

C. relieving factors

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 information? A. onset B. treatment C. relieving factors D. location

B. Acute bacterial rhinosinusitis

A client seeks medical attention for pain when touching the area of the frontal sinuses. Which should the nurse consider as the reason for this client's symptom? A. Oropharyngitis B. Acute bacterial rhinosinusitis C. Eye infection D. Acute otitis media

B. tension headaches.

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 A. cluster headaches. B. tension headaches. C. tumor-related headaches. D. migraine headaches.

C. Assess the client regarding characteristics of the pain.

A client with a cervical spine injury reports chronic pain. What would be the most appropriate initial nursing intervention for this client? A. Discuss pharmacologic interventions. B. Educate the client regarding cervical spine pain. C. Assess the client regarding characteristics of the pain. D. Work with medical team to evaluate possible surgery.

A. Stiff neck

A community health nurse is attending a seminar on headaches. What would this nurse learn is a red flag for headaches? A. Stiff neck B. Pain that is temporary C. Pain without new symptomatology D. Pain centered behind the eyes

C. A large amount of exudate in the sinuses

A nurse finds crepitus when palpating over a client's maxillary sinuses. Which of the following should the nurse most suspect in this client? A. Obstruction of the nostril by a foreign object B. A perforated septum C. A large amount of exudate in the sinuses D. Normal, air-filled sinuses

B. Document this as an expected assessment finding

A nurse has performed a head and neck assessment of an adult client and noted that the thyroid gland is not palpable. What is the nurse's most appropriate action? A. Perform a focused endocrine assessment B. Document this as an expected assessment finding C. Position the client supine and reattempt palpation D. Refer the client to the primary care provider promptly

C. Document this as an expected assessment finding

A nurse has performed a head and neck assessment of an adult client and noted that the thyroid gland is not palpable. What is the nurse's most appropriate action? A. Position the client supine and reattempt palpation B. Refer the client to the primary care provider promptly C. Document this as an expected assessment finding D. Perform a focused endocrine assessment

D. Meningitis

A nurse is caring for a client admitted with neck pain. The client is febrile. What is the most likely medical diagnosis for this client? A. Measles B. Cervical fracture C. Migraine D. Meningitis

B. Red, swollen, with purulent discharge

A nurse is examining the nose of a client diagnosed with an upper respiratory tract infection. Which characteristics of the nasal mucosa should the nurse expect to find during assessment of a client with an upper respiratory tract infection? A. Pale pink, swollen, with watery exudate B. Red, swollen, with purulent discharge C. Dark pink, moist, & free of discharge D. Bluish gray, swollen, with watery exudate

B. Ask permission before palpating the head and neck

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? A. Palpate the client's feet before palpating the head B. Ask permission before palpating the head and neck C. Have a nurse who is the same sex as the client perform the examination D. Avoid asking the client to remove her clothes for the examination

B. Cranial nerve XII (hypoglossal)

A nurse is working with a client who has an impaired ability to move the tongue. He explains that he was in an automobile accident many years ago and suffered nerve damage that resulted in this condition. Which nerve should the nurse suspect was damaged in this client? A. Cranial nerve X (vagus) B. Cranial nerve XII (hypoglossal) C. Cranial nerve VII (facial) D. Cranial nerve I (olfactory)

C. Headache Impact Test

A nurse needs to assess a client who is experiencing chronic headache to determine how it is affecting her activities of daily living. Which of the following interventions should the nurse implement? A. Family health history questionnaire B. Auscultation C. Headache Impact Test D. A mnemonic assessment tool

C. Auscultate with the bell over the lateral lobes

A nurse palpates an elderly client's thyroid and detects an enlargement over the right lateral lobe. What action should the nurse take first? A. Document the findings in the nurse notes B. Immediately notify the health care provider C. Auscultate with the bell over the lateral lobes D. Ask the client about past history of hypothyroidism

B. Atelectasis

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 pathophysiologic cause for this finding is related to what disease process? A. Bronchitis B. Atelectasis C. Tuberculosis D. Endocarditis

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

During your physical examination of the client you note an enlarged tender tonsillar lymph node. What would you do? A. Look for a source such as infection in the area that it drains B. Look for involvement of other regions of the body C. Assess for meningitis D. Assess for dietary changes

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

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? A. The boy requires assessment of his thyroid gland. B. There is an infection in the area that these nodes drain. C. The tissue underlying the nodes is infected. D. There is an inflammatory response in the musculature of the boy's neck.

D. Educating them about not drinking and driving

Teenagers doing community service following arrest for driving under the influence are working at the rehabilitation hospital with clients who have paraplegia. These clients have been paralyzed by drunk drivers. How would the nurses who care for these clients best use the time spent with these teenagers? A. Teaching them how to turn these clients every 2 hours B. Keeping the shelves restocked C. Fulfilling the court requirements D. Educating them about not drinking and driving

A. In the midline, a few centimeters behind the tip of the mandible

The nurse assesses a client's submental lymph nodes. In which area of the client's head should the nurse palpate these lymph nodes? A. In the midline, a few centimeters behind the tip of the mandible B. In front of the ear C. At the angle of the mandible D. Superficial to the sternomastoid

B. hyperthyroidism

The nurse does a health history. The client states he has lost 30 pounds in the last couple months without really trying. The client also states he feels warm all the time and sometimes feels like he has heart palpitations. The nurse would anticipate orders to evaluate the client for A. hypernatremia B. hyperthyroidism C. hyperbilirubinemia D. hyperproteinemia

D. Encourage the use of safety equipment

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? A. Encourage proper nutrition to promote healing B. Encourage the client to take a safety course C. Teach proper posture, bending, and lifting D. Encourage the use of safety equipment

B. a metastasis

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. tonsillitis B. a metastasis C. nasopharyngitis D. a goiter

D. preauricular

The nurse is planning to assess a client's lymph nodes. Which set of nodes should the nurse assess first? A. supraclavicular B. superficial cervical C. submental D. preauricular

C. Always use seat belts.

The nurse is planning to instruct a group of adolescents on ways to prevent traumatic brain injuries. What should be included in these instructions? A. Avoid risky activities such as snowboarding B. Use of guns should be supervised by an adult C. Always use seat belts. D. Wear nonslip shoes in the house.

A. flex the neck forward

The nurse is preparing to assess a client's thyroid gland using the posterior approach. What direction should the nurse provide regarding the client's head? A. flex the neck forward B. tilt the head back C. turn the head towards the right shoulder D. turn the head towards the left shoulder

B. sit in an upright position.

The nurse is preparing to assess the lymph nodes of an adult client. The nurse should instruct the client to A. stand upright in front of the nurse. B. sit in an upright position. C. lie in a supine position. D. lie in a side-lying position.

D. Bruit

The nurse practitioner auscultates both lobes of a client's enlarged thyroid gland. Identification of what sound would tend to confirm a diagnosis of a toxic goiter? A. Murmur B. Rush C. Gurgle D. Bruit

A. Ask the client to sip and swallow water.

The nurse suspects an enlarged thyroid in a client during the physical examination of the head and neck. What should the nurse do first? A. Ask the client to sip and swallow water. B. Displace the trachea to the right. C. Ask the client to lie down for further assessment D. Listen over the thyroid with a stethoscope.

A. red cheeks

The nurse suspects that a client has Cushing's syndrome. What assessment finding did the nurse use to make this clinical determination? A. red cheeks B. elongated prominent forehead C. swelling around the eyes D. mask-like face

C. hyperthyroidism

The nurses assesses the thyroid gland of a client with recent weight loss. On auscultation, a low, soft, rushing sound is heard over the lateral lobes. Which condition is most likely? A. Hashimoto thyroiditis B. thyroid cyst C. hyperthyroidism D. benign tumor

A. frenulum.

The tongue is attached to the hyoid bone and styloid process of the temporal bone and is connected to the floor of the mouth by the A. frenulum. B. mandible. C. soft palate. D. gums.

B. Acute infection

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? A. Chronic infection B. Acute infection C. Metastatic disease D. Cushing's disease

D. Parotid enlargement

Upon inspection of a client with reports of a fever, the nurse notices that the client's earlobes are asymmetrical in appearance. The nurse recognizes that the most common cause for the asymmetry of the earlobes is what condition? A. Bell's palsy B. Thyroid enlargement C. Acute pharyngitis D. Parotid enlargement

A. Oropharynx

What is the common channel for the respiratory and digestive systems? A. Oropharynx B. Sinuses C. Frenulum D. Nares

B. Graves' disease

What is the most common type of hyperthyroidism? A. Cushing's syndrome B. Graves' disease C. Thyroid cancer D. Moon face

A. Age older than 50 years B. Tobacco use E. Male gender

What risk factors should the nurse include in a discussion on the occurrence of neck cancer? (Select all that apply.) A. Age older than 50 years B. Tobacco use C. Female gender D. Coffee drinker E. Male gender

B. Hyoid bone

What structure is found midline in the tracheal area just beneath the mandible? A. Cricoid cartilage B. Hyoid bone C. Thyroid cartilage D. Adam's apple

A. Hair color

When documenting the findings from a physical examination of the head and neck, what will the nurse include when describing the client's head? A. Hair color B. Facial skin color C. Nasal mucosa color D. Sclera color

D. The underlying bones

When examining the head, the nurse remembers that the anatomic regions of the cranium take their names from which of the following sources? A. Their anatomical positions B. The underlying vascular network C. Noted anatomists D. The underlying bones

C. Consistency, delineation, mobility, tenderness

When palpating the lymph nodes of the neck, the nurse assesses for which of the following characteristics? A. Delineation, integrity, shape, color B. Configuration, discreteness, temperature, color C. Consistency, delineation, mobility, tenderness D. Congruency, induration, size, turgor

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

When palpating the neck, performing which of the following techniques will help differentiate lymph nodes from a band of muscles? A. Palpating for lateral movement when the client swallows a sip of water B. Applying pressure and assessing for induration C. Observing for hypertrophy when the client turns the head against resistance D. Attempting to roll the structure up and down and side to side

D. to observe the movement of the thyroid gland

When the nurse is preparing to assess the thyroid gland of a client with suspected hypothyroidism, why is it important to bring a cup of water to the physical examination? A. to prevent further dehydration B. to promote the nurse-client relationship C. to assist the client to feel more comfortable D. to observe the movement of the thyroid gland

C. Above the cheek bone near the scalp line

Where is the temporal artery palpated? A. Between the mandibular joint and the base of the ear B. Just left of midline at the base of the neck C. Above the cheek bone near the scalp line D. Just left or right of the spine at the base of the skull

A. Smokeless tobacco use B. Recreational drug use C. Multiple sex partners D. Alcohol abuse

Which factor, if present in a client's lifestyle and health practices assessment, would alert the nurse to the need for performing a more thorough head and neck assessment? Select all that apply. A. Smokeless tobacco use B. Recreational drug use C. Multiple sex partners D. Alcohol abuse

B. A woman whose headaches come on suddenly and are somewhat relieved by a quiet, dark room

Which of the following clients is most likely to be diagnosed with migraine headaches? A. A man whose headaches are accompanied by severe light sensitivity but an absence of nausea B. A woman whose headaches come on suddenly and are somewhat relieved by a quiet, dark room C. A man who has sought care for treatment of his episodic headaches that occur several times each day D. A woman who complains of recurrent headaches near the end of her workday spent at a computer station

D. trigeminal neuralgia.

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 A. inner ear disease. B. cancerous lesions. C. arterial occlusion. D. trigeminal neuralgia.

D. Impending stroke

While the nurse is assessing a client for an unrelated health concern, the client experiences a sudden, severe headache with no known cause. He also complains of dizziness and trouble seeing out of one eye. What associated condition should the nurse suspect in this client? A. Brain tumor B. Hyperthyroidism C. Diabetes D. Impending stroke

A. Hoarseness

You are caring for a client in the outpatient clinic with suspicion of cancer due to recent weight losses for unidentifiable reasons. The client a 25-year history of smoking. You perform an assessment and ask the client about symptoms related to laryngeal cancer. What is an early symptom associated with laryngeal cancer? A. Hoarseness B. Dysphagia C. Alopecia D. Dyspnea

B. Laryngeal cancer

Your client has a history of hoarseness lasting longer than 2 weeks. The client is now complaining of feeling a lump in their throat. What would you suspect this client has? A. Laryngeal polyps B. Laryngeal cancer C. Cancer of the pharynx D. Cancer of the tonsils