Head & Neck Chapter 10
Where is the temporal artery palpated? -Above the cheek bone near the scalp line -Just left of midline at the base of the neck -Between the mandibular joint and the base of the ear -Just left or right of the spine at the base of the skull
Above the cheek bone near the scalp line -The nurse palpates the temporal artery in the space above the cheek bone near the scalp line. -The temporal artery is not found at midline at the base of the neck, between the mandibular joint and the base of the ear, or just left or right of the spine at the base of the skull.
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? -Metastatic disease -Chronic infection -Acute infection -Cushing's disease
Acute infection -The lymph nodes are enlarged and tender in acute infections. -Normally, lymph nodes are not sore or tender and are usually not palpable. -Chronic infection causes the nodes to become confluent. -In metastatic disease, the nodes enlarge and become fixed in place and are nontender. -The lymph node findings may vary in Cushing's disease.
A client with a cervical spine injury reports chronic pain. What would be the most appropriate initial nursing intervention for this client? -Work with medical team to evaluate possible surgery. -Discuss pharmacologic interventions. -Educate the client regarding cervical spine pain. -Assess the client regarding characteristics of the pain.
Assess the client regarding characteristics of the pain. -The first step would be for the nurse to assess characteristics of the pain. -Surgery or pharmacologic interventions would be considered by the whole health care team after more information was gathered. -While education is an appropriate intervention, it would not be addressed initially but rather after pain management interventions were implemented.
A client describes her 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 they occur after you have been tense or anxious?" -"When you consume alcohol, do you get a headache?" -"Do you have any eye symptoms, such as tearing?" -"Do you have any visual changes before the headache?"
"Do you have any visual changes before the headache?" -A typical migraine headache has prodromal symptoms that may include visual disturbances, vertigo, tinnitus, and/or numbness or tingling of the fingers and toes. -Asking about being tense or anxious would be appropriate to assess for a tension headache. -Asking about alcohol or tearing would be appropriate for a cluster headache.
The nurse is preparing to palpate a client's trachea. Which technique should the nurse use?
-The thumbs are located at the base of the neck when palpating the trachea. -The fingers are on either side of the neck when palpating the thyroid gland. -The fingers are located right beneath the ears when palpating the tonsillar nodes. -The fingers are located near to the chin when palpating the submandibular nodes.
The nurse assesses the client's pulses to be normal. These would be documented how? -0 -1+ -2+ -3+
2+ -Absent pulses are 0. -Weak pules are 1+. -Normal pulses are 2+. -Increased pulses are 3+.
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 -A woman who complains of recurrent headaches near the end of her workday spent at a computer station -A man who has sought care for treatment of his episodic headaches that occur several times each day -A man whose headaches are accompanied by severe light sensitivity but an absence of nausea
A woman whose headaches come on suddenly and are somewhat relieved by a quiet, dark room -The hallmarks of migraine headaches include a rapid onset, nausea, and relief by the removal of light and sound stimuli. -Sustained muscle activity associated with typing and driving often precedes tension headaches. -Cluster headaches, not migraines, are episodic over the course of a day.
Which assessment technique should a nurse use to assess for the presence of a bruit in a client with hyperthyroidism? -Inspection -Palpation -Auscultation -Percussion
Auscultation -A bruit is a soft, blowing, swishing sound auscultated over the thyroid lobes with the bell of the stethoscope that is often heard in hyperthyroidism because of an increase in blood flow through the thyroid arteries. -A bruit can be elicited through auscultation in a client with hyperthyroidism. -A bruit cannot be elicited through inspection, palpation, and percussion. -Inspection can only reveal swelling of the neck and palpation can indicate only the enlarged mass.
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? -C3 -C5 -C7 -T2
C7 -The vertebra prominens is C7, which can easily be palpated when the neck is flexed. -Using C7 as a landmark helps the nurse to locate other vertebrae.
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? -Migraine -Cluster -Tension -Stress
Cluster -Cluster headaches occur more often in young males, have a sudden onset, and may be precipitated by ingestion of alcohol. The headaches typically occur in the evening and are localized to the eyes, with radiation into the facial and temporal areas. The person may report tearing of the eye or runny nose. -Migraine headaches are accompanied by nausea, vomiting, and sensitivity to light and sound. -Tension headaches occur more frequently in females and are usually a result of stress, anxiety, or depression.
A nurse is preparing to assess an adult client's carotid pulses. Which of the following actions would be contraindicated? -Asking the client to flex his or her neck -Compressing the arteries bilaterally -Performing the examination while the client is seated -Asking the client to swallow water
Compressing the arteries bilaterally -The nurse needs to avoid bilateral compression of the carotid blood vessels to prevent reducing the blood supply to the brain. -The nurse does not need to avoid having the client flex the neck, ask the client to swallow water, or perform the exam while the client is seated.
When preparing to assess a client's thyroid gland, the nurse should ensure that which piece of equipment is readily available? -Penlight -Tongue depressor -Centimeter-scale ruler -Cup of water
Cup of water -When examining the thyroid gland, the client is asked to swallow so that each side of the gland can be felt. -A cup of water would aid in swallowing. -A penlight, tongue depressor, or ruler is not needed.
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 -Encourage proper nutrition to promote healing -Encourage the client to take a safety course -Teach proper posture, bending, and lifting
Encourage the use of safety equipment -Nurses encourage use of appropriate safety equipment to reduce risk of head or neck trauma. -There is no identified need to encourage proper nutrition to promote healing in this client. -There is no identified need to teach proper posture, bending, and lifting with this client. -Encouraging the client to take a safety course is not the primary focus of discharge teaching.
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? -Hyperextend the head, keeping midline alignment -Hyperextend the head to the side being examined -Flex the head toward the side being examined -Flex the head away from the side being examined
Flex the head toward the side being examined To correctly examine the thyroid, the nurse should stand behind the client and ask him to lower the chin and turn the head toward the side being examined. This action helps to relax the client's neck muscles.
What is the most common type of hyperthyroidism? -Graves' disease -Cushing's syndrome -Moon face -Thyroid cancer
Graves' disease -Graves' disease, the most common type of hyperthyroidism, is autoimmune and may also be genetic. -Cushing's syndrome, moon face, and thyroid cancer are not the most common types of hyperthyroidism.
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 -Thyroid gland -Mental status -Lymph nodes
Hearing acuity -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 would not need to evaluate the thyroid gland, mental status, or lymph nodes based on this finding.
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. -I will complete the entire course of thyroid hormone replacement over six weeks. -I must keep my follow up appointments to receive my thyroid hormone injections. -I will take my thyroid hormone replacement medication once every week.
I must take thyroid hormone replacement medication for the rest of my life. -After thyroidectomy, clients must be treated with exogenous thyroid hormone for the rest of their lives. -Thyroid hormones are usually taken by mouth on a daily basis.
The nurse is preparing to palpate the submandibular salivary glands. The nurse would place the hands at which location? -On each side of the client's face, anterior and inferior to the ears -On each side between the top of the ear and the eye -Bilaterally, parallel to and anterior to the sternomastoid muscle -Inferior to the mandible beneath the tongue
Inferior to the mandible beneath the tongue -The submandibular glands are located inferior to the mandible underneath the base of the tongue. -The parotid glands are located on each side of the face, anterior and inferior to the ears. -The temporal artery is located between the top of the ear and the eye. -The internal jugular and carotid arteries are located bilaterally parallel and anterior to the sternomastoid muscle.
The nurse is assessing the face of a client with a diagnosis of Parkinson's disease. What would the nurse most likely assess? -Sunken face -Drooping of one side -Mask-like expression -Asymmetry of earlobes
Mask-like expression -A client with Parkinson's disease often exhibits a masklike face. -A sunken face with depressed eyes and hollow cheeks is typical of cachexia. -Drooping of one side may suggest a stroke or Bell's palsy. -Asymmetry of the earlobes occurs with parotid gland enlargement from an abscess or tumor.
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? -Tension -Migraine -Cluster -Analgesic rebound
Migraine -This is a description of a common migraine (no aura). -Distinctive features of a migraine include phono- and photophobia, nausea, resolution with sleep, and unilateral distribution. ---> Only some of these features may be present.
A client reports right-sided temporal headache accompanied by nausea and vomiting. A nurse recognizes that which condition is likely to produce these symptoms? -Bell's palsy -Tension headache -Temporal arteritis -Migraine headache
Migraine headache -Migraine headaches are usually located around the eyes, temples, cheeks, and forehead. -They are often accompanied by nausea and vomiting. Bell's palsy is a one sided facial paralysis caused by inflammation of the facial nerve. -A tension headache usually presents with stress, anxiety, or tension and is located in the frontal, temporal, or occipital region. -Temporal arteritis produces pain around the temple but no nausea or vomiting.
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. -Administer intravenous pain medication. -Palpate the carotid pulses bilaterally at the same time. -Prepare the client for a temporal artery biopsy.
Notify the healthcare provider immediately. -Temporal arteritis is a painful inflammation of the temporal artery. ----Clients report severe unilateral headache sometimes accompanied by visual disturbances. This condition needs immediate care. A biopsy may be necessary for diagnosis; however the healthcare provider immediately. -The temporal artery pulse can be palpated; but the carotid artery pulses should never be palpated simultaneously so that the client does not pass out from lack of blood flow to the brain.
Which instruction to the client will help facilitate examination of the temporomandibular joint by the nurse? -Open the mouth -Sit upright -Sit without moving -Perform a chewing action
Open the mouth -While performing the assessment of the temporomandibular joint, the nurse should ask the client to open the mouth. ----This gives an easy access to the joint. -Telling the client to sit upright and not move helps in performing the overall examination; however, it does not contribute to the examination of the temporomandibular joint. -Telling the client to perform a chewing action is not appropriate.
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: Thyroid crisis -RC: Cerebrovascular accident -RC: Cushing's syndrome -RC: Acromegaly
RC: Cushing's syndrome -Cushing's syndrome may present with a moon-shaped face with reddened cheeks and increased facial hair. -This cluster of signs is not characteristic of CVA, thyroid disease, or acromegaly.
What finding upon assessment would indicate the client is experiencing shock? -Systolic blood pressure 50 -Heart rate 100 -Respiratory rate 24 -Temperature 99.5 F
Systolic blood pressure 50 -A systolic blood pressure of 50 would indicate the client is experiencing shock. -All other vital signs, while elevated do not indicate shock
Which of the following would the nurse document as an abnormal finding with lymph node assessment? -Diameter: 0.75 cm -Mobile -Tender -Discrete
Tender -A lymph node that is tender is an abnormal finding suggesting acute infection. -Size less than 1 cm, mobile, and discrete indicate normal findings.
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? -The boy requires assessment of his thyroid gland. -There is an inflammatory response in the musculature of the boy's neck. -The tissue underlying the nodes is infected. -There is an infection in the area that these nodes drain.
There is an infection in the area that these nodes drain. -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.
During the health history, a client reports complaints of intermittent facial pain lasting several minutes. The nurse would suspect which of the following? -Trigeminal neuralgia -Migraine headache -Meningitis -Temporomandibular joint dysfunction
Trigeminal neuralgia -Trigeminal neuralgia is manifested by sharp, shooting, piercing facial pain that lasts from seconds to minutes. -Migraine headache is characterized by pain around the eyes, temples, cheeks, or forehead. -Meningitis would be manifested by sudden head and neck pain with fever and neck stiffness. -Temporomandibular joint dysfunction is manifested by limited range of motion, swelling, tenderness, or crepitation in the jaw area.
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 -tonsillitis -nasopharyngitis -a goiter
a metastasis
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 -parotid gland enlargement. -acromegaly. -Paget disease. -Cushing syndrome.
acromegaly. The skull and facial bones are larger and thicker in acromegaly.
