Chapter 15 assessment
Where is the temporal artery palpated?
Above the cheek bone near the scalp line
The nurse is planning to instruct a group of adolescents on ways to prevent traumatic brain injuries. What should be included in these instructions?
Always use seat belts.
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.
While performing an examination of the head and neck, a nurse notices left sided facial drooping. The nurse recognizes this as what condition?
Bell's palsy
A 63-year-old man comes to the ED with a new onset of pain in his neck and jaw. What system requires emergency assessment?
Cardiovascular
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 palpating the lymph nodes of the neck, the nurse assesses for which of the following characteristics?
Consistency, delineation, mobility, tenderness
A 64-year-old patient is admitted to the hospital with severe diarrhea. When assessing the patient, the nurse notes a round "moon" face, a buffalo hump at the nape of the neck, and a velvety discoloration around the neck. What are these signs indicative of?
Cushing's syndrome
Primary headaches are more worrisome than secondary headaches.
False
A nurse performs palpation of a client's lymph nodes. Which finding should be reported to the health care provider?
Fixed to underlying tissue
When identifying the midline structures of the neck from the mandible to the sternal notch, the nurse notes the structures in what order?
Hyoid bone, thyroid cartilage, cricoid cartilage, isthmus of the thyroid
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 normal assessment of the neck would include palpation of the thyroid isthmus. Where would the nurse find the isthmus?
Just below the cricoid cartilage
The nurse assesses an enlarged thyroid in a patient during the physical examination of the head and neck. What should the nurse do next?
Listen over the thyroid with a stethoscope.
During the physical examination the head and neck, the nurse palpates several nodules on the patient's thyroid gland. What would this finding suggest to the nurse?
Metabolic process
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 nurse is performing a head and neck assessment on a client. Which area should the nurse inspect for facial symmetry?
Nasolabial folds
A college student presents with a sore throat, fever, and fatigue for several days. Exudates are on her enlarged tonsils. A careful lymphatic examination reveals some scattered small mobile lymph nodes just behind her sternocleidomastoid muscles bilaterally. What group of nodes is this?
Posterior cervical
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
A nurse needs to palpate a client's submandibular lymph nodes. Where should the nurse place her hands to do this?
On the medial border of the mandible
Which instruction to the client will help facilitate examination of the temporomandibular joint by the nurse?
Open the mouth
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
A clinic patient 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
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
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 is assessing a patient complaining of swelling in his neck. While palpating his 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
During the health interview of the head and neck, the patient tells the nurse about having a lump in the neck. Which question would the nurse ask to assess manifestations associated with this lump?
"Do you have difficulty swallowing?
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 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
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
When palpating the neck, performing which of the following techniques will help differentiate lymph nodes from a band of muscles?
Attempting to roll the structure up and down and side to side
The APRN notes that the thyroid gland is enlarged and auscultates both lobes of the thyroid. For what is the APRN listening?
Bruit
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 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 male college student presents to the student health clinic with reports of night-time headaches for the past two weeks. He denies nausea and photosensitivity but states 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
Teenagers doing community service following arrest for driving under the influence are working at the rehabilitation hospital with patients who have paraplegia. These patients have been paralyzed by drunk drivers. How would the nurses who care for these patients best use the time spent with these teenagers?
Educating them about not drinking and driving
The nurse is discharging a 26-year-old man who received 18 staples for a head laceration he got while mountain biking. What can the nurse focus on while doing discharge teaching?
Encourage the use of safety equipment
Flex the head toward the side being examinedA 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 the head in order to best facilitate this exam?
Flex the head toward the side being examined
On palpation, the nurse notes that a client's thyroid gland is diffusely enlarged. Which of the following health problems would the nurse want to rule out?
Graves' disease
What is the most common type of hyperthyroidism?
Graves' disease
When documenting the findings from a physical examination of the head and neck, what will the nurse include when describing the patient's head?
Hair color
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
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 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 nuchal rigidity. The nurse recognizes these findings as most likely to be caused by what condition?
Meningeal inflammation
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 nurse palpates an elderly client's thyroid and detects an enlargement over the right lateral lobe. What action should the nurse take first?
Auscultate with the bell over the lateral lobes
Which risk factor for traumatic brain injury should a nurse include in a discussion about prevention for a group of adolescents?
Modes of transportation are the leading cause
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
The nurse would expect to assess which symptoms in a patient complaining of migraine headaches? Select all the apply.
• throbbing • photophobia • recurrent
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.
A patient with hypothyroidism is admitted to the medical unit. The nurse would expect to assess which signs/symptoms? Select all that apply.
• lethargy • constipation • cool skin • lower systolic blood pressure
A patient with a cervical spine injury has chronic pain. What would be the most appropriate initial nursing intervention for this patient?
Assess characteristics
A client presents to the health care clinic with reports of a stiff neck for the past 3 days. What objective information can the nurse obtain during the health history using inspection?
Head position
A client presents to the health care clinic with reports of a stiff neck for the past three days. What objective information can the nurse obtain during the health history?
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
An 81-year-old man presents at the clinic with reports of a painful neck. On palpation, the nurse notes a hard, nonmovable mass, approximately 20 mm, that is painful to touch. The area seems to have several nodes matted together. How would the nurse chart this last finding?
Nodes are delimited on palpation
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 patient has an open draining wound located on the underside of the chin. Which lymph nodes should the nurse assess in this patient?
Submental
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
