Chapter 15: Assessing Head and 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? "Standing up slowly is important because dizziness can cause falls." "Loss of sensation in the toes is an age-related change." "Certain medications can cause muscle weakness." "Changes in vision such as decreased accommodation happen with aging."
"Loss of sensation in the toes is an age-related change."
Where is the temporal artery palpated? Above the cheek bone near the scalp line Just left of midline at the base of the neck Between the mandibular joint and the base of the ear Just left or right of the spine at the base of the skull
Above the cheek bone near the scalp line Chapter 15: Assessing Head and Neck - Page 280
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? Rush Gurgle Murmur Bruit
Bruit Chapter 15: Assessing Head and Neck - Page 288-293
An anatomy and physiology instructor is discussing the lymphatic system of the head and neck. Why would the instructor emphasize the importance of the drainage pattern of the lymph? Nurses need to follow lymph patterns to track the course of a disease. The drainage pattern can help the nurse understand why the disease is spreading. Enlargement of a node may be a sign of pathology that is distant from that node. The drainage pattern may help pinpoint a fluid or electrolyte imbalance.
Enlargement of a node may be a sign of pathology that is distant from that node. Chapter 15: Assessing Head and Neck - Page 288, 292
What is the most common type of hyperthyroidism? Graves' disease Cushing's syndrome Moon face Thyroid cancer
Graves' disease Chapter 15: Assessing Head and Neck - Page 292
A client reports right-sided temporal headache accompanied by nausea and vomiting. A nurse recognizes that which condition is likely to produce these symptoms? Bell's palsy Tension headache Temporal arteritis Migraine headache
Migraine headache Chapter 15: Assessing Head and Neck - Page 299
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. Administer intravenous pain medication. Palpate the carotid pulses bilaterally at the same time. Prepare the client for a temporal artery biopsy.
Notify the healthcare provider immediately. Chapter 15: Assessing Head and Neck - Page 295
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 Headache Shortness of breath Range of motion of the arms and shoulders
Range of motion of the neck Chapter 15: Assessing Head and Neck - Page 292
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? Parkinson disease Cushing syndrome scleroderma acromegaly
acromegaly Chapter 15: Assessing Head and Neck - Page 300
A client reports slight swelling and tightness at the base of their neck. The nurse palpates the client's throat and neck and determines the thyroid gland is enlarged. What medical term will the nurse use when charting this finding? hyperthyroidism hypothyroidism iodine deficiency goiter
goiter Chapter 15: Assessing Head and Neck - Page 284
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? Ask the doctor for an order for an MRI Perform a focused assessment Prepare the client for a spinal tap Perform a generalized assessment
Perform a focused assessment Chapter 15: Assessing Head and Neck - Page 297-300
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? Previous injuries to the head and neck Difficulty with swallowing Changes in sleeping habits Stiffness in the right shoulder
Previous injuries to the head and neck Chapter 15: Assessing Head and Neck - Page 285-286
What are the bordering landmarks of the anterior triangle of the neck? (Mark all that apply.) The sternomastoid The mandible The midline of the neck The omohyoid muscle The clavicle
The sternomastoid The mandible The midline of the neck Chapter 15: Assessing Head and Neck - Page 280-281
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 This could be a sign of pneumothorax This could be a sign of an embolus This could be a sign of a parotid stone
This could be a sign of cancer Chapter 15: Assessing Head and Neck - Page 283-284
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 parotid gland enlargement. acromegaly. Paget disease. Cushing syndrome.
acromegaly. Chapter 15: Assessing Head and Neck - Page 300
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? hyperthyroidism thyroid cyst Hashimoto thyroiditis benign tumor
hyperthyroidism Chapter 15: Assessing Head and Neck - Page 283, 287
The nurse assesses a client with noisy breathing including a gasping sound with respiration. The nurse notes tracheal deviation from the usual midline position. Which conditions should the nurse assess for further? Select all that apply. mediastinal mass atelectasis pneumothorax goiter inflammation of preauricular node
mediastinal mass atelectasis pneumothorax goiter Chapter 15: Assessing Head and Neck - Page 292
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? onset location treatment relieving factors
relieving factors Chapter 15: Assessing Head and Neck - Page 284
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? Meningeal inflammation Stress Injury to the sternomastoid Arthritis
Arthritis Chapter 15: Assessing Head and Neck - Page 292
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? C1 C3 C5 C7
C7 Chapter 15: Assessing Head and Neck - Page 281
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 Encourage proper nutrition to promote healing Encourage the client to take a safety course Teach proper posture, bending, and lifting
Encourage the use of safety equipment Chapter 15: Assessing Head and Neck - Page 288
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? Diabetes Brain tumor Impending stroke Hyperthyroidism
Impending stroke Chapter 15: Assessing Head and Neck - Page 284
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? Metastatic disease Chronic infection Acute infection Cushing's disease
Acute infection Chapter 15: Assessing Head and Neck - Page 296
A client with a cervical spine injury reports chronic pain. What would be the most appropriate initial nursing intervention for this client? Work with medical team to evaluate possible surgery. Discuss pharmacologic interventions. Educate the client regarding cervical spine pain. Assess the client regarding characteristics of the pain.
Assess the client regarding characteristics of the pain. Chapter 15: Assessing Head and Neck - Page 283
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? Migraine Cluster Tension Stress
Cluster Chapter 15: Assessing Head and Neck - Page 298
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? Myxedema Cushing's syndrome Scleroderma Bell's palsy
Cushing's syndrome Chapter 15: Assessing Head and Neck - Page 297,300
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? Tension Migraine Cluster Analgesic rebound
Migraine Chapter 15: Assessing Head and Neck - Page 297-300
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? Cushing's syndrome Nephrotic syndrome Myxedema Parkinson's disease
Parkinson's disease Chapter 15: Assessing Head and Neck - Page 297, 301
The nurse is preparing to perform a head and neck assessment of an adult client who has immigrated to the United States from Cambodia. The nurse should first explain to the client why the assessment is necessary. ask the client if touching the head is permissible. determine whether the client desires a family member present. examine the lymph nodes of the neck before examining the head.
ask the client if touching the head is permissible. Chapter 15: Assessing Head and Neck - Page 288
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? characteristic symptoms associated manifestations relieving factors location
characteristic symptoms Chapter 15: Assessing Head and Neck - Page 283-284