Chapter 15 Assessing Head / Neck Prep U
The nurse suspects an enlarged thyroid in a client during the physical examination of the head and neck. What should the nurse do first?
Ask the client to sip and swallow water
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?
Atelectasis
Where is the temporal artery palpated?
Above the cheek bone near the scalp line
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?
Acute infection
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?
Arthritic changes of the cervical spine
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?
Ask permission before palpating the head and neck
A client with a cervical spine injury reports chronic pain. What would be the most appropriate initial nursing intervention for this client?
Assess the client regarding characteristics of the pain
A 57-year-old client reports, "I am having the worst headache I have ever experienced." Which action should the nurse perform next?
Assess the client's blood pressure.
The nurse notes unilateral facial drooping and reports the finding immediately to the healthcare provider. The client is diagnosed with Bell palsy. The nurse should include assessment of which affected cranial nerve in the client's head and neck assessment?
Cranial nerve VII
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?
Document this as an expected assessment finding
A nurse performs palpation of a client's lymph nodes. Which finding should be reported to the health care provider?
Fixed to underlying tissue
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?
Headache Impact Test
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?
Impending stroke
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 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.
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
A client is having trouble turning her head to the side. Which of the following muscles should the nurse most suspect as being involved?
Sternocleidomastoid
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?
There is an infection in the area that these nodes drain.
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
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
acromegaly
The nurse is planning to assess an adult client's thyroid gland. The nurse should plan to
approach the client posteriorly.
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?
arthritis
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
ask the client if touching the head is permissible.
A nurse is assessing a client with hyperthyroidism for the presence of a bruit. Which assessment technique should the nurse use?
auscultation
What structure is found midline in the tracheal area just beneath the mandible?
hyoid bone
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
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?
hyperthyroidism
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
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
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 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 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 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?
relieving factors
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?
tension
A client complains of a headache over both temporal areas. What type of headache should the nurse suspect the client is experiencing?
tension
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.
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
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
What is the most common type of hyperthyroidism?
Graves disease
On palpation, the nurse notes that a client's thyroid gland is diffusely enlarged. Which of the following health problems is associated with this finding?
Graves' disease
When assessing the head and neck, the nurse should realize that variations in skull or neck shape or size relate most to what?
Height and weight
A client diagnosed with goiter has undergone a thyroidectomy. Which statement from the client indicates understanding of post-operative care teaching?
I must take thyroid hormone replacement medication for the rest of my life
The nurse assesses a client's submental lymph nodes. In which area of the client's head should the nurse palpate these lymph nodes?
In the midline, a few centimeters behind the tip of the mandible
During a neck assessment, where would the nurse focus palpation of the thyroid isthmus?
Just below the cricoid cartilage
When conducting a generalized assessment of a new client, what would the nurse focus upon when inspecting the neck?
Limitations in movement
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
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
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
When examining the head, the nurse remembers that the anatomic regions of the cranium take their names from which of the following sources?
The underlying bones
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
An adult client visits the clinic and tells the nurse that she has had headaches recently that are intense and stabbing and often occur in the late evening. The nurse should suspect the presence of
cluster headaches
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?
malignancy
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
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?
perform a focused assessment
The nurse assesses an adult client's head and neck. While examining the carotid arteries, the nurse assesses each artery individually to prevent:
reduction of the blood supply to the brain.
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.
- Alcohol abuse - Recreational drug use - Smokeless tobacco use - Multiple sex partners
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 nurse should ask about or assess which associated factors when a client complains of cluster headaches? Select all that apply.
- rhinorrhea - ptosis - miosis - lacrimation
The nurse would expect to assess which symptoms in a client complaining of migraine headaches? Select all the apply.
- throbbing - photophobia - recurrent
Which of the following clients is most likely to be diagnosed with migraine headaches?
A woman whose headaches come on suddenly and are somewhat relieved by a quiet, dark room
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?
Assess the woman for hypothyroidism.
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
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.
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
