Chapter 15 Assessment: Assessing the head and neck

A nurse assesses a young adult client who lost consciousness after a head-to-head collision while playing football. Which question should the nurse ask in order to determine characteristic symptoms of the head trauma?

"Do you have a history of seizures?" - this can be the reason this collisions started or it can be a result of the collision.

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.

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

What is atelectasis?

A collapse of closure of a lung, which results in unequal pressure in the chest cavity and causes the trachea to get pushed to one side.

A nurse visits an older adult client at home in order to conduct a risk assessment for falls. Which factors would most likely increase the risk for falls for this client? Select all that apply.

A throw rug in the dining room, bathtubs in all bathrooms, a television cord that runs across the floor.

Where is the temporal artery palpated?

Above the cheekbone, near the scalp line.

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.

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.

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.

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 assessment technique should a nurse use to assess for the presence of a bruit in a client with hyperthyroidism?

Auscultation. Which is listening with stethoscope.

The nurse practitioner notes that the thyroid gland is enlarged and auscultates both lobes of the thyroid. For what is the nurse practitioner listening?

Bruit.

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

When palpating the lymph nodes of the neck, the nurse assesses for which of the following characteristics?

Consistency, delineation, mobility, & tenderness. (Have they moved and do they hurt?)

What should the nurse do when he/she finds an enlarged node?

Find out where the node drains from and assess that region for nay abnormalities.

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

What is the most common type of hyperthyroidism?

Graves disease. Enlarged thyroid and causes overproduction of TSH.

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 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

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.

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.

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

Where is the thyroid isthmus?

Just below the cricoid cartilage

When conducting a generalized assessment of a new client, for what would the nurse inspect the neck?

Limitations in movement. (looking for meningitis?)

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

In 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?

Mandible. TMJ stands for temporomandibular joint.

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. The neck pain associated with the headaches is the combination you should look for with meningitis.

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 headaches.

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

An older adult 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

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.

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

Open Mouth.

What is acromegaly?

Overproduction of growth hormone by a benign tumor in the pituitary gland.

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.

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

What does febrile mean?

Showing signs of fever.

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.

Which lymph nodes are closer to the ear, the superficial cervical or the deep cervical?

Superior cervical lymph nodes are found above the deep cervical. Deep cervical are found about midway down the sternomastoid muscle.

Where are your submandibular lymph nodes?

They are under your jaw line.

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. The fact that it is fixed and hard is a cancerous sign.

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. A chronic pain condition affecting the trigeminal nerve in the face.

During the physical examination of a client, a nurse detects a thick and tender temporal artery. Which additional assessment should the nurse perform to rule out the possibility of temporal arteritis?

Vision acuity. Vision acuity = clarity in vision, which implies that with temporal arteritis, your vision gets less sharp. You can get double vision, loss of vision, throbbing headache...etc.

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

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.

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

migraine

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

Name a health situation that causes your earlobes to be asymmetrical?

parotid enlargement (Looks like one of your cheeks is swollen)

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

Where are the tonsils lymph nodes?

right in front of the ear lobes.

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.

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. signs to look for, intense and stabbing.

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. The nurse also notes that the patient has gained 10 pounds since her last visit 9 months ago. What might the nurse suspect?

Hypothyroidism.

What is a bruit?

It is an abnormal sound from turbulence in a blood vessel, most likely caused by a narrowing in the artery. Bruits are bad, and a way to remember this is because bruit starts with "B".

A nurse is caring for a patient admitted with neck pain. The patient is febrile. What is the most likely medical diagnosis for this patient?

Meningitis. Neck pain and fever combo could indicate 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;

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.

The nurse suspects that a client has Cushing's syndrome. What assessment finding did the nurse use to make this clinical determination?

red cheeks