Chapter 10 The Head & Neck

The nurse is conducting discharge teaching to the caregiver of an older adult who was hospitalized following a fall at home. Which statement by the caregiver indicates a need for additional teaching by the nurse?

"Loss of sensation in the toes is an age-related change."

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

Which of the following would the nurse suspect if assessment reveals a skull and facial bones that are larger and thicker than normal?

Acromegaly

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 teaching nursing students about the difference between a general routine screening and a focused specialty assessment. The nurse determines understanding when the student nurses identify which of the following as part of a focused specialty assessment? Select all that apply.

Assess signs of trigeminal neuralgia. Assess thyroid dysfunction. Determine the type of headache a client is experiencing.

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?

Bruit

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

A nurse is providing care for a client who experienced a head injury and who just moved to the United States from Southeast Asia. What cultural nursing consideration should the nurse take into account when performing an assessment on clients from different cultures?

Consider cultural norms.

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

Cup of water

What does the nurse assess the face for? (Select all that apply.)

Edema Involuntary movements Asymmetry

The nurse notes that a client's trachea is pushed to the right side of the neck. What health problem could this client be experiencing? Select all that apply.

Enlarged thyroid lobe Tumor Pneumothorax Aortic aneurysm

The nurse detects enlarged, tender, preauricular nodes in a client. Which of the following would the nurse need to examine for possible infection?

Eyes

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

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

The nurse feels a small mass in the neck of a client. It is mobile in both the up-and-down and side-to-side directions. Which of the following is the nurse most likely feeling?

Lymph node

Which type of vessels filter pathogens from the body and drain the fluid that has moved outside of the circulation back into the vessels?

Lymphatic

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?

Meningitis

A client reports right-sided temporal headache accompanied by nausea and vomiting. A nurse recognizes that which condition is likely to produce these symptoms?

Migraine headache

A client arrives in the emergency department by ambulance after falling down his front steps. The nurse notes two soft lumps, approximately 3 cm in diameter, on the side of his head. What would the nurse identify these as?

Pilar cysts

A nurse is providing discharge teaching to a client newly diagnosed with migraine headaches. What should the nurse include in the teaching?

Resting may help relieve the headache.

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

During the health history, a client reports complaints of intermittent facial pain lasting several minutes. The nurse would suspect which of the following?

Trigeminal neuralgia

A client reports having a headache. The nurse performs a specialized focused assessment and notes the following: client rates pain 10 on a scale of 1 to 10 (10 being the worst), nauseated and vomited, reporting sensitivity to noise and light. The nurse determines that the client is most likely experiencing which of the following types of headache?

migraine

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.

The nurse is preparing to assess the lymph nodes of an adult client. The nurse should instruct the client to

sit in an upright position.

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

Concussions in sports and motor vehicle accidents cause the largest number of TBIs in teens.

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

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 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

A client is being assessed for a headache. Symptoms include throbbing and severe pain lasting for the last 8 hours. The client also has a history of vomiting with the headache. What type of headache could these findings indicate?

Migraine

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

Assessment of an adult female client's face reveals a moon shape, increased hair distribution, and a reddened tone to the client's cheeks. What collaborative problem is most clearly suggested to the nurse by these assessment data?

RC: Cushing's syndrome

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 Pilar cysts

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 hard, thick, and tender.

A nurse performs a comprehensive assessment on a client. The nurse observes the following findings: enlarged hands, feet, and facial features (nose, ears). Which of the following disorders do these findings indicate?

acromegaly

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.