Health Assessment Chapter 15- Assessing the Head and Neck

Migraine

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

tension

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

Arthritic changes of the cervical spine

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 Bacterial thyroiditis Cranial damage Muscle tension

lethargy constipation cool skin lower systolic blood pressure

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 lower systolic blood pressure weight loss

Stiff neck

A community health nurse is attending a seminar on headaches. What would this nurse learn is a red flag for headaches? Stiff neck Pain centered behind the eyes Pain that is temporary Pain without new symptomatology

Nodes are delimited on palpation

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 feel matted together on palpation Nodes are delimited on palpation Nodes appear grown together on palpation Nodes are demarcated on palpation

hyperthyroidism

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 thyroid cyst Hashimoto thyroiditis benign tumor

Consistency, delineation, mobility, tenderness

When palpating the lymph nodes of the neck, the nurse assesses for which of the following characteristics? Congruency, induration, size, turgor Delineation, integrity, shape, color Consistency, delineation, mobility, tenderness Configuration, discreteness, temperature, color

Above the cheek bone near the scalp line

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

characteristic symptoms

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 associated manifestations relieving factors location

Meningitis

A nurse is caring for a client admitted with neck pain. The client is febrile. What is the most likely medical diagnosis for this client? Migraine Meningitis Cervical fracture Measles

Fixed to underlying tissue

A nurse performs palpation of a client's lymph nodes. Which finding should be reported to the health care provider? Mobile from side to side Soft in consistency Fixed to underlying tissue Round and 8 mm in size

malignancy

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 inflammation enlargement hypothyroidism

Recognize the weakened pulsation as an age-related change

During the physical examination of a 65-year-old client, the nurse finds that the pulsation of the temporal artery is weak. What is an appropriate action by the nurse for this client? Recognize the weakened pulsation as an age-related change Check the blood pressure as it can be due to hypotension Notify the health care provider for further diagnostic tests Assess the client for a decrease in level of consciousness

Atelectasis

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? Endocarditis Bronchitis Atelectasis Tuberculosis

Laboratory tests

In addition to noting the physical characteristics of the thyroid gland, which of the following signs would be most important to consider in determining if the client has hypothyroidism? Increased heart rate Increased blood pressure Laboratory tests Feeling anxious

Graves' disease

On palpation, the nurse notes that a client's thyroid gland is diffusely enlarged. Which of the following health problems is associated with this finding? A tumor Hypothyroidism Graves' disease Nephrotic syndrome

d. There is an infection in the area that these nodes drain.

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? a. The boy requires assessment of his thyroid gland. b. There is an inflammatory response in the musculature of the boy's neck. c. The tissue underlying the nodes is infected. d. There is an infection in the area that these nodes drain.

In the midline, a few centimeters behind the tip of the mandible

The nurse assesses a client's submental lymph nodes. In which area of the client's head should the nurse palpate these lymph nodes? A. Superficial to the sternomastoid B. In front of the ear C. In the midline, a few centimeters behind the tip of the mandible D. At the angle of the mandible

Has the lump changed? When did you first notice the lump? How recently have you consumed alcohol?

The nurse is conducting a physical examination of a client who reports finding a lump in the neck. Which of the following questions should be included in when the nurse is collecting subjective data? (Select all that apply). When did you first notice the lump? How recently have you consumed alcohol? Do you have family members that experience lumps? Has the lump changed? Is it painful to touch?

Male gender Age older than 50 years Tobacco use

What risk factors should the nurse include in a discussion on the occurrence of neck cancer? (Select all that apply.) Female gender Male gender Coffee drinker Tobacco use Age older than 50 years

Hyoid bone

What structure is found midline in the tracheal area just beneath the mandible? Cricoid cartilage Hyoid bone Thyroid cartilage Adam's apple

Lymphatic

Which type of vessels filter pathogens from the body and drain the fluid that has moved outside of the circulation back into the vessels? Lymphatic Arteries Veins Aortic

Tension

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 Migraine Cluster Analgesic rebound

Document this as an expected assessment finding

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 Refer the client to the primary care provider promptly Perform a focused endocrine assessment Position the client supine and reattempt palpation

Headache Impact Test

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? A mnemonic assessment tool Headache Impact Test Auscultation Family health history questionnaire

Bruit

The nurse practitioner auscultates both lobes of a client's enlarged thyroid gland. Identification of what sound would tend to confirm a diagnosis of a toxic goiter? Rush Gurgle Murmur Bruit

The underlying bones

When examining the head, the nurse remembers that the anatomic regions of the cranium take their names from which of the following sources? Noted anatomists The underlying bones Their anatomical positions The underlying vascular network

Attempting to roll the structure up and down and side to side

When palpating the neck, performing which of the following techniques will help differentiate lymph nodes from a band of muscles? a. Applying pressure and assessing for induration b. Attempting to roll the structure up and down and side to side c. Palpating for lateral movement when the client swallows a sip of water d. Observing for hypertrophy when the client turns the head against resistance

Nasolabial folds

Which area should the nurse inspect for facial symmetry when performing a head and neck assessment? Nasolabial folds Temporomandibular joint Preauricular nodes Earlobe placement

acromegaly.

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.

Perform a focused assessment

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? Ask the doctor for an order for an MRI Perform a focused assessment Prepare the client for a spinal tap Perform a generalized assessment

a. I must take thyroid hormone replacement medication for the rest of my life.

A client diagnosed with goiter has undergone a thyroidectomy. Which statement from the client indicates understanding of post-operative care teaching? a. I must take thyroid hormone replacement medication for the rest of my life. b. I will complete the entire course of thyroid hormone replacement over six weeks. c. I must keep my follow up appointments to receive my thyroid hormone injections. d. I will take my thyroid hormone replacement medication once every week.

Range of motion of the neck

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 next? Range of motion of the neck Headache Shortness of breath Range of motion of the arms and shoulders

cluster 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. migraine headaches. tension headaches. tumor-related headaches.

preauricular

The nurse is planning to assess a client's lymph nodes. Which set of nodes should the nurse assess first? submental preauricular supraclavicular superficial cervical

Cranial nerve VII (facial)

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 V (vagus) Cranial nerve VI (abducens) Cranial nerve VII (facial) Cranial nerve VIII (vestibulocochlear)

Previous injuries to the head and neck

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 Difficulty with swallowing Changes in sleeping habits Stiffness in the right shoulder

Assess the client regarding characteristics of the pain.

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.

Arthritis

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? Meningeal inflammation Stress Injury to the sternomastoid Arthritis

Hypothyroidism 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 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? Effects of age-related changes Brain tumor Hyperthyroidism Hypothyroidism

Posterior cervical

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? Submandibular Tonsillar Occipital Posterior cervical

Cardiovascular

An adult client comes to the ED with a new onset of pain in his neck and jaw. What system requires emergency assessment? Integumentary Respiratory Nervous Cardiovascular

red cheeks

The nurse suspects that a client has Cushing's syndrome. What assessment finding did the nurse use to make this clinical determination? red cheeks mask-like face swelling around the eyes elongated prominent forehead

Prodrome Is there a prodrome of unusual feelings such as euphoria, craving for food, fatigue, or dizziness?

A 16-year-old white female is brought to the clinic by her mother with a chief complaint of a severe headache lasting more than 24 hours. The mother states, "Just before the headache started my daughter was craving food. I couldn't feed her enough." What is this called? Aura Prodrome Neurologic onset Aberrant sign

Assess the client's blood pressure. Onset of headache after the age of 50 paired with the statement the client has made here is considered a "red flag." The nurse should suspect this is a secondary headache or arising from another condition.

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. Provide medication for pain relief. Inquire about family history of headaches. Review the client's medical record.

relieving factors

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? onset location treatment relieving factors

Auscultate with the bell over the lateral lobes

A nurse palpates an elderly client's thyroid and detects an enlargement over the right lateral lobe. What action should the nurse take first? Immediately notify the health care provider Document the findings in the nurse notes Auscultate with the bell over the lateral lobes Ask the client about past history of hypothyroidism

Encourage the use of safety equipment

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

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.

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.

tension headaches.

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 cluster headaches. tumor-related headaches. migraine headaches. tension headaches.

Fatigue, cold intolerance, and constipation. The client's lab values are consistent with hypothyroidism. Fatigue, cold intolerance, constipation, depression, anorexia, dry skin, brittle and coarse hair, menstrual irregularities, and weight gain are all symptoms of hypothyroidism. All other symptoms in the answer options are indicative of hyperthyroidism.

A client's lab results reveal thyroid stimulating hormone level of 7.0 mU/L; Free T4 0.5 ng/dl; Total T3 60 ng/dl; and Total T4 3mdmg/dl. Based on these lab results what symptoms should the nurse expect the client to reveal? Fatigue, cold intolerance, and constipation. Weight loss, rapid pulse, heat intolerance. Palpitations, limp hair, and sweating. Muscle weakness, increased metabolic rate, and anxiety.

A large endocrine gland in the body d. Produces hormones that increase the metabolic rate of most body cells e. Consists of two lateral lobes f. Covered mostly by the sternomastoid muscles

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 about the thyroid gland? Select all that apply. a. A large endocrine gland in the body b. Located anterior and inferior to the ears and behind the mandible c. Produces saliva d. Produces hormones that increase the metabolic rate of most body cells e. Consists of two lateral lobes f. Covered mostly by the sternomastoid muscles

Impaired comfort related to possible neck injury

An older adult client is admitted to the hospital after a fall during which the client's head was injured. While performing the admission assessment, the nurse finds a large ecchymosis over the C7-T1 area. The client reports tenderness on palpation and movement. What would be an appropriate nursing diagnosis for this client? Impaired skin integrity related to bed rest Impaired range of motion related to injury Immobility related to bed rest Impaired comfort related to possible neck injury

tumor-related headache.

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... migraine headache. cluster headache. tension headache. tumor-related headache.

metastasis

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

flex the neck forward When assessing the thyroid gland from the posterior approach the client should flex the neck forward to relax the neck muscles. Tilting the head back would be used if assessing the thyroid gland using the anterior approach. Turning the head to the right or left shoulder would be done later in order to further assess the individual thyroid gland lobes.

The nurse is preparing to assess a client's thyroid gland using the posterior approach. What direction should the nurse provide regarding the client's head? tilt the head back flex the neck forward turn the head towards the left shoulder turn the head towards the right shoulder

b. ask the client if touching the head is permissible.

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... a. explain to the client why the assessment is necessary. b. ask the client if touching the head is permissible. c. determine whether the client desires a family member present. d. examine the lymph nodes of the neck before examining the head.

rhinorrhea ptosis miosis lacrimation

The nurse should ask about or assess which associated factors when a client complains of cluster headaches? Select all that apply. rhinorrhea (runny nose) ptosis (drooping eye) miosis (small pupil) lacrimation (tears) photophobia (light sensitivity)

Ask the client to sip and swallow water.

The nurse suspects an enlarged thyroid in a client during the physical examination of the head and neck. What should the nurse do first? Displace the trachea to the right. Listen over the thyroid with a stethoscope. Ask the client to sip and swallow water. Ask the client to lie down for further assessment

a. A woman whose headaches come on suddenly and are somewhat relieved by a quiet, dark room

Which of the following clients is most likely to be diagnosed with migraine headaches? a. A woman whose headaches come on suddenly and are somewhat relieved by a quiet, dark room b. A woman who complains of recurrent headaches near the end of her workday spent at a computer station c. A man who has sought care for treatment of his episodic headaches that occur several times each day d. A man whose headaches are accompanied by severe light sensitivity but an absence of nausea

parotid gland enlargement.

While assessing an adult client's head and neck, the nurse observes asymmetry in front of the client's ear lobes. The nurse refers the client to the physician because the nurse suspects the client is most likely experiencing a/an enlarged thyroid. lymph node abscess. neurologic disorder. parotid gland enlargement.