HA - Ch. 11, 12 & 15

Where is the temporal artery palpated?

Above the cheek bone near the scalp line

The nurse assesses the frontal sinus where?

Above the eyes

When assessing a client, the nurse notes a brownish ridge along the gum line. This finding would be considered normal in a client from what background?

African American

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 health interview, the nurse notes that a client is a mouth breather. The client denies nasal congestion and has a healthy body mass index. What would be most important for the nurse to assess?

Checking for a deviated nasal septum

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 Explanation: Facial asymmetry may indicate inflammation of cranial nerve VII with Bell palsy.

What is the most common type of hyperthyroidism?

Graves' disease

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

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 Explanation: A client with Parkinson's disease often exhibits a mask-like face.

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

You are caring for a client diagnosed with enlarged adenoids. What condition is produced by enlarged adenoids?

Noisy breathing Explanation: Enlarged adenoids may produce nasal obstruction, noisy breathing, snoring, and a nasal quality to the voice. Incrustation of the mucous membranes in the trachea and the main bronchus occurs during the postoperative period following a tracheostomy. The long-term and short-term complications of tracheostomy include airway obstruction. These are caused by hardened secretions and erosion of the trachea.

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

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 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 nurse should assist a client to assume what position to best assess the mouth, nose, and sinuses?

Sitting with the head erect and at the eye level of the nurse

The client comes to the clinic with complaints of a sore throat, difficulty swallowing, malaise, and anorexia. Upon examination, the nurse notes a red throat with enlargement of the tonsils and jaw and neck lymph nodes. Which condition does the nurse suspect the client has?

Strep throat

The nurse is providing health education to an elderly client with dysphagia following a recent ischemic stroke. What would be most appropriate for the nurse to include?

Thoroughly chew small amounts of food with each mouthful.

During the health history, a client describes recent episodes of intermittent facial pain lasting several minutes. The nurse should recognize that this complaint is suggestive of what health problem?

Trigeminal neuralgia

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

Difficulty talking

aphasia

Rosenmuller fossa is the most common site of

nasopharyngeal cancer.

Asymmetry of the earlobes occurs with

parotid gland enlargement from an abscess or tumor.

Trigeminal neuralgia is manifested by

sharp, shooting, piercing facial pain that lasts from seconds to minutes.

Meningitis is manifested by

sudden head and neck pain, with fever and neck stiffness.

Enlarged palatine tonsils are an indicator of

tonsillitis.

Brown spots on the chewing surface of teeth is an indication of

tooth decay

The ventral surface of the tongue is the

underside portion of the tongue.

Aortic insufficiency is caused by a

valve that fails to fully close, allowing blood to leak backward, creating a regurgitant murmur.

Risk factors associated with oropharyngeal cancer (9)

-using tobacco products (including cigarettes, cigars, pipes, and smokeless and chewing tobacco) heavy alcohol use -chewing betel nuts (but not high consumption of cashew nuts) -infection with a certain type of human papillomavirus -being exposed to sunlight (lip cancer only) -being male -fair skin -poor oral hygiene -poor diet/nutrition -a weakened immune system.

1) The third cranial nerve is involved with ______ 2)The sixth cranial nerve is involved with

1) 3rd cranial nerve - eye muscle movement 2) 6th cranial nerve - lateral eye movement

A loss of taste discrimination occurs with a defect of

Acranial nerve VII (facial)

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 Explanation: Atelectasis can cause the trachea to be pushed to one side from its midline position.

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

Auscultation

The nurse is inspecting Wharton's ducts. The nurse would expect to find these at which location?

Either side of frenulum on floor of the mouth

During the health interview, a client reports an occasional blockage in the upper portion of the nasal passage. The nurse understands the most pronounced effect this would have on the client would be what?

Impaired sense of smell Explanation: Receptors for cranial nerve I (olfactory) are located in the upper part of the nasal cavity and septum. Blockage would decrease the ability to smell.

A client complains of a headache over both temporal areas. What type of headache should the nurse suspect the client is experiencing?

Tension

The nurse assesses a client and palpates a temporal artery that is hard, thick, and tender with absent pulsations. The nurse would gather additional information related to which aspect of health?

Vision

The nasal cavities have a vascular and ciliated mucous lining. What is the purpose of the vascular and ciliated mucous lining of the nasal cavities?

Warm and humidify inspired air

You are teaching a physiology class for pre-nursing students. A student asks what the purpose of the upper airway is in regard to the lower airway. What would be your best answer?

Warm the inspired air

The submandibular glands open under the tongue through openings called

Wharton ducts. Explanation: The submandibular glands, located in the lower jaw, open under the tongue on either side of the frenulum through openings called Wharton's ducts.

A decrease in tongue strength is noted on examination of a client. The nurse interprets this as indicating a problem with which cranial nerve?

XII Decreased tongue strength may occur with a defect of the twelfth cranial nerve.

A decreased ability to taste is associated with

an upper respiratory infection or lesion of the facial nerve.

The uvula is located at the

back of the mouth, midline of the soft palate.

During the act of swallowing, the soft palate and uvula elevate to

block the nasal cavity, preventing food from entering the respiratory system.

Stenson's ducts are located on the

buccal mucosa across from the second upper molars

A sunken face with depressed eyes and hollow cheeks is typical of

cachexia

Cyanotic lips are often seen in cases of ____ or _____. Pallor around the lips is a finding in clients with ____ and ____.

cold or hypoxia anemia and shock

Difficulty hearing or occasional dizziness is associated with

ear and vestibular problems.

Angular cheilitis is the presence of

fissures at the edges of the mouth.

The tongue is attached to the hyoid bone and styloid process of the temporal bone and is connected to the floor of the mouth by the

frenulum

The eighth cranial nerve is involved with

hearing and equilibrium

A bifid uvula is a common finding

in Native Americans.

Temporomandibular joint dysfunction is manifested by

limited range of motion, swelling, tenderness, or crepitation in the jaw area.

Actinic cheilitis affects the

lower lip and is characterized by scales, thickening, and eversion of the lip tissue.

Aortic stenosis denotes a

narrowed valvular orifice, which obstructs blood flow.

Migraine headaches are characterized by

pain around the eyes, temples, cheeks, or forehead.

Odynophagia is

painful swallowing

Orthopnea describes

shortness of breath that occurs when the client is lying down.

Receptors of cranial nerve I (olfactory) are located in ________ and a related to ________

the nose; these receptors are related to the sense of smell.

A nurse examines a client with complaints of a sore throat and finds that the tonsils are enlarged and touching one another. Using a grading scale of 1+ to 4+, how should the nurse appropriately document the tonsils?

4+

Which genetic disorder would the nurse ask about when conducting a family history regarding upper respiratory illness?

Cystic fibrosis

The client has experienced a stroke and has dysphagia. The nurse knows this is what?

Difficulty swallowing

During the physical examination of the mouth, the nurse identifies vesicular eruptions along the client's lips and surrounding skin. The nurse would document this finding as being:

Herpes simplex

An emergency department nurse is caring for a young child with intractable nose bleeds. What is the most common site of epistaxis?

Kiesselbach plexus Explanation: Kiesselbach plexus is the most common site of epistaxis.

A nurse is assessing the mouth of an older client. Which of the following findings is common among older adults?

Receding and ischemic gums Explanation: The gums recede, become ischemic, and undergo fibrotic changes as a person ages.

A client who is semiconscious is brought to the emergency department of a health care facility after being rescued from a fire. Which finding of the lips supports the diagnosis of carbon monoxide poisoning?

Reddish

A client who is taking antibiotics for a sinus infection presents with a white coating on the tongue and complains of a burning sensation on the tongue. Which instructions are most appropriate for this client?

Rinse mouth with antifungal medication as prescribed.

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

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. -Observe the movement of the thyroid cartilage, thyroid gland.

The nurse notes thrush on the palate of a client. The most appropriate question the nurse should ask is

"Have you been on antibiotics recently?"

A nurse examines a client with complaints of a sore throat and finds that the tonsils are just visible. Using a grading scale of 1+ to 4+, how should the nurse appropriately document the tonsils?

1+

The nurse's assessment reveals that a male client can neither turn his head against resistance nor shrug his shoulders. The nurse should document a potential deficit in the functioning of which cranial nerve?

Accessory (XI) Explanation: The eleventh cranial nerve is responsible for muscle movement that permits shrugging of the shoulders by the trapezium muscles and turning the head against resistance by the sternomastoid muscle. The abducens (VI) and trochlear (IV) nerves are involved with eye muscle movement. The hypoglossal (XII) nerve is involved with tongue muscles.

A client presents to the health care clinic with reports of a 3-day history of fever, sore throat, and trouble swallowing. The nurse notes that the client is febrile, with a temperature of 101.5°F, tonsils are 2+ and red, and transillumination of the sinuses is normal. Which nursing diagnosis should the nurse confirm based on this data?

Acute pain

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

Alcohol abuse Recreational drug use Smokeless tobacco use Multiple sex partners Explanation: Tobacco and alcohol use increases the risk of head and neck cancer. A more recently identified cause of head and neck cancer is exposure to human papillomavirus (HPV). People with multiple sexual partners and those who engage in oral sex are at increased risk of developing oral HPV-related cancer. For these reasons the nurse would need to perform a thorough head and neck examination.

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

The nurse is interviewing an adult client in the context of a focused mouth, nose, sinus, and throat assessment. After asking the client about his history of environmental allergies, the client states, "I'm pretty sure that I'm allergic to something, but I'm not exactly sure what triggers my allergies." What would the nurse do next?

Ask the client about the timing of his allergy symptoms. Explanation: Pollens cause seasonal rhinitis, whereas dust and other environmental allergens may cause rhinitis year round.

A client arrives complaining of nasal congestion, drainage of a thick, yellow discharge from the nose, difficulty breathing through the nose, headache, and pressure in the forehead. The nurse suspects sinusitis. Which of the following risk factors should the nurse assess for in this client?

Asthma Explanation: This client shows symptoms of sinusitis. Risk factors for sinusitis include a nasal passage abnormality, aspirin sensitivity, cystic fibrosis, chronic obstructive pulmonary disease (COPD), an immune system disorder, hay fever, asthma, and regular exposure to pollutants such as cigarette smoke.

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 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

A nurse is working with a client who has an impaired ability to move the tongue. He explains that he was in an automobile accident many years ago and suffered nerve damage that resulted in this condition. Which nerve should the nurse suspect was damaged in this client?

Cranial nerve XII (hypoglossal) Explanation: Decreased tongue strength may occur with a defect of the twelfth cranial nerve—hypoglossal—or with a shortened frenulum that limits motion

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 Explanation: It is not unusual for the thyroid lobes to be non-palpable using the posterior approach.

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

A mother of a client complains of getting no sleep because of excessive snoring from the client every night. The nurse is reviewing with the mother what causes the snoring. Based on this information, what is the best response to the mother of the client about the cause of snoring?

Enlargement of the adenoids Explanation: Enlargement of the adenoids can cause snoring or obstruction of the upper airway.

A client diagnosed with Sjogren syndrome should be given which instructions?

Eye drops and sucking on hard candy may used to relieve dryness Explanation: Sjogren syndrome is a chronic inflammatory disorder characterized by decreased lacrimal and salivary gland secretion. Eye drops and hard candy can provide relief from dryness.

A client has a sore throat and difficulty swallowing that has lasted for months. There are no lesions on the lips. The nurse suspects that the client may have oropharyngeal cancer. Which of the following are risk factors the nurse should assess for in this client?

Frequent pipe smoking Heavy use of alcohol

Tonsillar grading

Grade 1+ - the tonsils are just visible Grade 2+ - tonsils are midway between the tonsillar pillars and the uvula Grade 3+ - tonsils touch the uvula, and tonsils that are Grade 4+ - so enlarged that they touch each other are

A nurse is assessing an adult client's neck. Which of the following would be most appropriate when auscultating the client's thyroid gland for bruits?

Have the client hold his or her breath. Explanation: When auscultating the thyroid, the client should hold the breath to obscure any tracheal breath sounds during auscultation. The neck should be slightly extended.

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

When talking to a client before starting the physical exam, the nurse notes that the client consistently tilts her head to one side. What would the nurse examine first?

Hearing acuity Explanation: A head tilted to one side may indicate unilateral vision or hearing deficiency, which should be ruled out before proceeding with the examination.

The nurse is planning instructions for a client with a broken nose. What teaching will be included to address the alterations in nasal function? (Select all that apply.) How to breathe through the mouth Importance to increase oral fluids Safety measures because of a loss of smell Expect a sore throat and difficulty swallowing Remind that the voice may sound different

How to breathe through the mouth Importance to increase oral fluids Safety measures because of a loss of smell Remind that the voice may sound different

A staff educator from the hospital is providing an event for the hospital staff. The educator is talking about health promotion activities for people with diseases of the nose, mouth, throat, and sinuses. What would the educator include in the presentation?

How to reduce periodontal disease Explanation: Major risk reduction and health promotion goals in assessment of the nose, sinuses, mouth, and throat are related to various issues, including tobacco use, obstructive sleep apnea, oral health, and cancer. Health goals include reducing periodontal disease.

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 Explanation: Intolerance to cold, preference for warm clothing and many blankets, and decreased sweating suggest hypothyroidism; the opposite symptoms, palpitations, and involuntary weight loss suggest hyperthyroidism.

A child presents to the health care facility with new onset of a foul-smelling, purulent drainage from the right nare. The mother states that no other signs of an upper respiratory tract infection are present. What is an appropriate action by the nurse?

Inspect the nostrils with an otoscope Explanation: Because the drainage is unilateral, the most likely cause is a foreign body obstruction. The nurse should inspect the nostrils for patency and the presence of a foreign body. It is not a normal finding in children to have unilateral foul-smelling drainage from the nose.

Which finding, if noted when inspecting a client's mouth, would require immediate follow-up? Thrush Leukoplakia Koplik spots Canker sore

Leukoplakia Explanation: Leukoplakia is a precancerous lesion that requires immediate follow-up. Although thrush, which indicates a candidal infection; Koplik spots, which are an early sign of measles; and canker sores, which are associated with adrenocortical insufficiency, are abnormal findings, the evidence of leukoplakia is serious and needs immediate evaluation.

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 Explanation: Meningeal inflammation is a likely cause of this condition which manifests as sudden headache, neck pain with stiffness, and fever.

A nurse is providing care at an inner-city shelter, and a man who frequents the shelter presents with a significant frontal growth that is located midline at the base of his neck. The nurse should recognize the need for what referral?

Referral for further assessment of thyroid function Explanation: A goiter (an enlarged thyroid gland) may appear as a large swelling at the base of the neck. This growth is not suggestive of impaired cranial nerve or lymphatic function, and it does not normally impair swallowing ability.

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

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. Explanation: Whenever a lymph node is enlarged or tender, the nurse should assess for infection in the area that the particular nodes drain. Thyroid or muscular involvement is less likely, and infection does not likely underlie the nodes directly.

The nurse conducts the physical examination of a client with a diagnosis of chronic obstructive pulmonary disease. The nurse observes the point of maximal impulse (PMI) is located in the epigastric region. What condition explains this finding?

right ventricular hypertrophy Explanation: Hypertrophy can cause an anatomical shift of the right ventricle, leading the PMI to be palpable in the epigastric region.