CoursePoint Chapter 12: Head and Neck Assessment, with Vision and Hearing Basics
A client describes headaches as severe and lasting for days. Which question would be most appropriate to use to determine if these headaches are migraines?
"Do you have any visual changes before the headache?"
A client describes their frequent headaches as being severe and lasting for days. The client's positive response to what question would most clearly suggest to the nurse that these headaches are migraines?
"Do you have any visual changes before the headache?"
A nurse is working with a client who has a history of headaches. When preparing to assess the client's temporomandibular joint (TMJ), the nurse should provide what instruction?
"I'm going to put my fingers in front of your ears and ask you to open your mouth wide."
A client 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 -low systolic blood pressure
The nurse is performing a physical examination and notes an enlarged left supraclavicular lymph node. The nurse understands that this could be indicative of:
A Metastasis
A community health nurse is planning a health promotion campaign that will focus on cancer prevention. Which educational intervention should the nurse select in order to most influence participants' risks of head and neck cancers?
A smoking cessation program
Tension Headache
A tension headache usually presents with stress, anxiety, or tension and is located in the frontal, temporal, or occipital region.
Where is the temporal artery palpated?
Above the cheek bone near the scalp line
A male client can neither turn his head against resistance nor shrug his shoulders. The nurse documents a deficit in the functioning of which cranial nerve?
Accessory (XI)
A nurse is palpating the head and neck of a newly referred client. Which of the following would the nurse suspect if assessment reveals that the client's skull and facial bones are larger and thicker than normal?
Acromegaly
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
A nurse palpates a client's cervical lymph nodes and notes the following findings: cervical lymph nodes .6 inches (1.5 cm) in diameter (enlarged), painful, and mobile. What is the best action of the nurse?
Ask the client if they have experienced any other signs or symptoms.
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
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.
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.
A nurse is assessing a client with hyperthyroidism for the presence of a bruit. Which assessment technique should the nurse use?
Auscultation
At which location would a nurse palpate a client's submental lymph nodes?
Behind the tip of the mandible
A client admitted to the hospital for a gastrointestinal bleed is now experiencing right-sided facial weakness. The nurse assesses the client and determines no other neurological deficits exist. The nurse determines the client is most likely exhibiting signs of which of the following disorders?
Bell's Palsy
Bell's Palsy
Bell's palsy is a one sided facial paralysis caused by inflammation of the facial nerve.
A nurse is assessing the head and neck of an adult client. Which vertebra should the nurse identify as a landmark in order to locate the client's other vertebrae?
C7
A client is brought to the emergency department via ambulance after experiencing difficulty speaking and weakness in the left arm and leg. The nurse understands that the client is most likely experiencing which of the following disorders?
Cerebrovascular Accident
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 7 (VII)
A nurse has completed the assessment of an older adult client's head and neck and is now analyzing the assessment findings. Which finding should the nurse attribute to age-related physiological changes?
Decreased strength of temporal artery pulsations
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.
True or False: The thyroid is normally smooth, rubbery, and non-movable.
False
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 top of the mandible
The nurse is preparing to palpate the submandibular salivary glands. The nurse would place the hands at which location?
Inferior to the mandible beneath the tongue.
What does location mean?
Location helps determine what part of the client's head the pain is localized within or where it radiates.
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
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
The nurse is assessing the face of a client with a diagnosis of Parkinson's disease. What would the nurse most likely assess?
Mask-like expression. One of the main symptoms of Parkinson disease (PD) is diminished facial expressivity or "masked facies," which refers to the expressionless appearance of individuals with the disorder.
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 headaches are usually located around the eyes, temples, cheeks, and forehead. They are often accompanied by nausea and vomiting.
When preparing to provide education regarding the prevention of head injuries from motor vehicle accidents, the nurse should be sure to include which point?
Mobile phones should only be used if there is a hands-free option available.
Question 15 of 20 A nurse is teaching nursing students about the risks associated with developing head and neck cancers. The nurse determines student understanding when the students make which of the following statements?
Most head and neck cancers are linked to smoking.
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.
The nurse is preparing to palpate a client's temporal artery. The nurse would place the hands at which location?
On each side between the top of the ear and the eye
Where should a nurse place the hands to palpate the submandibular lymph nodes?
On the medial border of the mandible.
What is onset mean?
Onset refers to when the migraine started.
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 nursing educator is evaluating a colleague's examination of a client's thyroid gland. The educator would determine that the nurse needs additional instruction when the nurse demonstrates which technique?
Percussion
A nursing instructor is teaching a group of students how to examine the thyroid gland. The instructor would determine that a student needs additional instruction when the student demonstrates which technique?
Percussion
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 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 nurse is providing discharge teaching to a client newly diagnosed with migraine headaches. What should the nurse include in the teaching?
Resting may help relieve the headache.
The nurse is preparing to assess the lymph nodes of an adult client. The nurse should instruct the client to
Sit in an upright position.
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
A community health nurse is attending a seminar on headaches. What would this nurse learn is a red flag for headaches?
Stiff Neck
Temporal Arteritis
Temporal arteritis produces pain around the temple but no nausea or vomiting.
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
A client is being admitted with a diagnosis of temporal arteritis. The nurse expects which of the following findings on assessment?
The temporal artery is hard, thick, and tender.
A nurse is examining a client's neck and is preparing to palpate the thyroid gland. The nurse would most likely expect to palpate how many lobes?
The thyroid gland consists of two lateral lobes.
When the nurse is preparing to assess the thyroid gland of a client with suspected hypothyroidism, why is it important to bring a cup of water to the physical examination?
To observe the movement of the thyroid gland
What does treatment mean?
Treatment refers to any assessment, support, or care the client has received from various health care providers.
True or False: Neck pain may be cardiac.
True
True or False: Thyroid problems can affect appetite, sleep, and other daily processes.
True
An older client visits the clinic accompanied by his daughter. The daughter tells the nurse that her father has been experiencing severe headaches that usually begin in the morning and become worse when he coughs. The client tells the nurse that he feels dizzy when he has the headaches. The nurse refers the client for further evaluation because these symptoms are characteristic of a:
Tumor-Related Headache
A __________may be present with hyperthyroidism or thyrotoxicosis.
bruit
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?
goiter
Structures of the head and neck also include the trachea, thyroid, and __________.
lymphatics
The neck __________, sternocleidomastoid muscle, thyroid, and isthmus are inspected in the neck.
muscles
The nurse is performing an assessment of the neck and identifies tracheal deviation. What is the most appropriate response of the nurse?
-Notify the Healthcare provider
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 seeks medical attention for sharp, shooting facial pain that lasts for several minutes at a time. For which health problem should the nurse assess this client?
Trigeminal Neuralgia
True or False: Common symptoms of the head and neck include pain and limited neck movement.
True
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 -Smokeless Tobacco Use -Recreational Drug Use -Multiple Sexual Partners
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
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
A client's recent weight loss and diarrhea has been attributed to hyperthyroidism. When auscultating the client's thyroid gland, what assessment finding is most consistent with this diagnosis?
A sound of turbulent blood flow in the thyroid gland
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?
Acromegaly
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 client suffering from a headache complains of throbbing, severe, unilateral pain that feels worse when exposed to bright lights. The client also complains of nausea and vomiting. What is the nurse's best action?
Administer migraine medication
The nurse is assessing the head and neck of a 51-year-old male client. Following inspection and palpation of the client's thyroid gland, the nurse determines that the gland is enlarged. What is the next action that the nurse should perform?
Auscultate the client's thyroid
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 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.
After teaching a group of students about risk factors for traumatic brain injury, the instructor determines that additional teaching is needed when the students identify which of the following?
Female Gender
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
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 documents which of the following as a normal finding when examining the thyroid gland of an older adult client?
Nodularity
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
Assessment of an adult female client's face reveals a moon shape, increased hair distribution, and a reddened tone to the client's cheeks. What collaborative problem is most clearly suggested to the nurse by these assessment data?
RC: Cushing's Syndrome
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 ne328xt?
Range of motion of the neck
What are relieving factors?
Relieving factors includes anything the client subjectively reports they have tried to make the migraine go away.
A client comes to the trauma unit in respiratory distress following a motor vehicle accident. On examination, the nurse notices that the trachea is deviated from the midline. What does this finding indicate?
Tension Pneumothorax
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.
True or False: Fontanelles in the newborn should be flat.
True
A nurse is going to inspect and palpate a client's head and neck. After asking the client to remove the wig, what should the nurse do next?
Wash hands
If the thyroid is enlarged, either unilaterally or bilaterally, auscultate over each lobe for a ______ using the bell of the stethoscope.
bruit
Common diagnoses/hypotheses for the head and neck include activity ____________, fatigue, chronic pain, and knowledge deficit.
intolerance
A female client asks a nurse why it seems like her headaches are more severe and longer in duration than male friends who also have migraines. What is the best response by the nurse?
"Hormones affect the severity of migraine headaches."
The nurse is preparing to assess the neck of an adult client. To inspect movement of the client's thyroid gland, the nurse should ask the client to
Swallow a small sip of water
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 Headache
A group of students are reviewing the structures of the head and neck in preparation for an examination. The students demonstrate understanding of the material when they identify that the face has how many bones?
14
The nurse in an emergency department is caring for a minimally responsive 27-year-old victim of a motorcycle accident. The client was not wearing a helmet. When assessing the client's head and neck, the nurse should prioritize the assessment for which of the following?
Bleeding
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 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