Chapter 15: Assessing the Head and Neck

A nurse needs to palpate a client's submental lymph nodes. Where should the nurse place her hands to do this? A.) A few centimeters behind the tip of the mandible B.) on the medial border of the mandible C.) at the posterior base of the skull D.) at the angle of the mandible on the anterior edge of the sternocleidomastoid

A few centimeters behind the tip of the mandible

While examining a client, the nurse observes that he appears to be nodding his head involuntarily. Which of the following conditions should the nurse additionally assess for, based on this finding? A.) unilateral vision B.) aortic insufficiency C.) pagets disease D.) neurological disorder

Aortic insufficiency

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

The nurse is palpating a client's neck as part of a physical assessment. Which of the following blood vessels should the nurse be especially careful to avoid bilaterally compressing during the assessment?

Carotid artery

A nurse performs palpation of the client's lymph nodes. Which finding should be reported to the health care provider?

Fixed to underlying tissue

A client presents to the health care clinic with the reports of a stiff neck for the past 3 days. What objective information can the nurse obtain during the health history inspection?

Head position

A client presents to the health care clinic with reports of a 12-pound unintentional weight loss despite being hungry all the time, profuse sweating, and swelling around the anterior neck area. The client states that she does not have insurance and cannot afford to see a regular health care provider. What nursing diagnosis can the nurse confirm from this data?

Health seeking behaviors

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.) impending stroke B.) brain tumor C.) diabetes D.) hyperthyroidism

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

Which area should the nurse inspect for facial symmetry when performing a head and neck assessment?

Nasolabial folds -smile lines

Which instruction to the client will help facilitate examination of the temporomandibular joint by the nurse?

Open the mouth

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?

Parotid enlargement

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

During the physical examination of a 60-year old client, the nurse finds that the pulsation of the temporal artery is weak. What is an appropriate action by the nurse for this client?

Recognize the weakened pulsation as an age-related change

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

While performing an examination of the head and neck, the client complains of shooting facial pains. the nurse identifies that the client reports pain over the fifth cranial nerve. The nurse recognizes this as what condition? A.) temporal joint syndrome B.) bells palsy C.) preauricular adenitis D.) trigeminal neuralgia

trigeminal neuralgia

A female client describes headache symptoms that seem to indicate a migraine. Which of the following questions during the client interview would, if answered in the positive, tend to confirm the nurse's suspicion?

"Does the headache occur regularly with your menstrual cycle?"

A nurse is examining a client's goiter and explaining the characteristics and functions of the thyroid gland. Which of the following should the nurse mention? Select all that apply.

-Consists of two lateral lobes -Largest endocrine gland in the body -Produces hormones that increase the metabolic rate of most body cells -Covered mostly by the sternomastoid muscles

A nurse palpates an elderly client's thyroid and detects an enlargement over the right lateral lobe. What order of action should the nurse take? A.) auscultate with the bell over the lateral lobes B.) immediately notify the provider C.) ask the client about past history of hypothyroidism D.) document findings in the nurse notes

1 - auscultate with the bell over the lateral lobes 2 - ask the client about past history of hypothyroidism 3 - document findings in the nurse notes 4 - notify the provider

A nurse palpates an enlarged, hard, and non-tender left-sided supravascular 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

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

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.) Meningeal inflammation B.) stress C.) injury to sternomastoid D.) arthritis

Arthritis

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 nurse is assessing a client with hyperthyroidism for the presence of a bruit. Which assessment technique should the nurse use?

Auscultation

While performing an examination of the head and neck, a nurse notices left-sided facial drooping. The nurse recognizes this as what condition? A.) temporal joint syndrome B.) bells palsy C.) preauricular adenitis D.) trigeminal neuralgia

Bell's Palsy

A 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 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

A nurse needs to examine 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 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 history questionnaire B.) a mneumonic assessment tool C.) auscultation D.) headache impact test

Headache Impact Test

Reviewing a client's health history, the nurse notes that the client has had a history of TMJ pain. The nurse recognizes that which of the following bones is involved in this dysfunction? A.) Parietal bone B.) Mandible C.) Maxilla D.) Frontal Bone

Mandible

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 nurse needs to palpate a client's submandibular lymph nodes. Where should the nurse place her hands to do this? A.) A few centimeters behind the tip of the mandible B.) on the medial border of the mandible C.) at the posterior base of the skull D.) at the angle of the mandible on the anterior edge of the sternocleidomastoid

On the medial border of the mandible

A nurse needs to palpate a client's tonsillar lymph nodes. Where should the nurse place her hands to do this? A.) A few centimeters behind the tip of the mandible B.) on the medial border of the mandible C.) at the posterior base of the skull D.) at the angle of the mandible on the anterior edge of the sternocleidomastoid

at the angle of the mandible on the anterior edge of the sternocleidomastoid

A nurse needs to palpate a client's occipital lymph nodes. Where should the nurse place her hands to do this? A.) A few centimeters behind the tip of the mandible B.) on the medial border of the mandible C.) at the posterior base of the skull D.) at the angle of the mandible on the anterior edge of the sternocleidomastoid

at the posterior base of the skull

While the nurse is assessing a client the client complaines of an aching steady headache. What associated condition should the nurse suspect in this client? A.) impending stroke B.) brain tumor C.) diabetes D.) hyperthyroidism

brain tumor

While examining a client, the nurse observes that he appears to be horizontally jerking his head involuntarily. Which of the following conditions should the nurse additionally assess for, based on this finding? A.) unilateral vision B.) aortic insufficiency C.) pagets disease D.) neurological disorder

neurological disorder

While examining a client, the nurse observes that his head is acorn shaped and his skull bone is enlarged. Which of the following conditions should the nurse additionally assess for, based on this finding? A.) unilateral vision B.) aortic insufficiency C.) pagets disease D.) neurological disorder

pagets disease

While performing an examination of the head and neck, the nurse notices the lymph nodes in front of the ear are swollen, and the client complains of tenderness. The nurse recognizes this as what condition? A.) temporal joint syndrome B.) bells palsy C.) preauricular adenitis D.) trigeminal neuralgia

preauricular adenitis

While examining a client, the nurse observes that he appears to be tilting his head to one side. Which of the following conditions should the nurse additionally assess for, based on this finding? A.) unilateral vision B.) aortic insufficiency C.) pagets disease D.) neurological disorder

unilateral vision (hearing deficiency)