Health Assessment PrepU Ch. 10 (Head and Neck)

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?" Explanation: A typical migraine headache has prodromal symptoms that may include visual disturbances, vertigo, tinnitus, and/or numbness or tingling of the fingers and toes. <wbr />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.

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." Explanation: To assess the TMJ, place your index finger over the front of each ear as you ask the client to open her mouth. None of the other listed instructions facilitates this assessment.

The nurse assesses the client's pulses to be normal. These would be documented how?

2+ Explanation: Normal pulses are 2+. Absent pulses are 0. Weak pules are 1+. Increased pulses are 3+.

Where is the temporal artery palpated?

Above the cheek bone near the scalp line Explanation: 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?

Acute infection Explanation: 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 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 Explanation: Arthritic changes in cervical spine may present in the older adults as neck pain, decreased strength and sensation of the upper extremities. Bacterial thyroiditis has neck swelling and cranial damage may manifest as headaches or tension of the muscles

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 Explanation: Older clients who have arthritis or osteoporosis may experience neck pain and a decreased range of motion. Sudden head and neck pain seen with elevated temperature and neck stiffness may be a sign of meningeal inflammation. Stress and tension may increase neck pain. Neck pain may accompany muscular problems or cervical spinal cord problems.

A 66-year-old woman has come to the clinic with complaints of increasing fatigue over the last several months. She claims to frequently feel lethargic and listless and states that, "I can never seem to get warm, no matter what the thermostat is set at." How should the nurse proceed with assessment?

Assess the woman for hypothyroidism. Explanation: Fatigue, weakness, and cold sensitivity are symptoms of hypothyroidism. These symptoms are not associated with Cushing's syndrome, hyperthyroidism, or any of the disorders that result in parotid gland enlargement.

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 pathophysiological 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. Endocarditis is an infection in the muscle of the heart which does not cause the trachea to shift. Bronchitis is an inflammation of the mucous membrane of the bronchial tubes. Tuberculosis is an infection in the lungs. Both bronchitis and tuberculosis are not responsible for the tracheal shift.

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 Explanation: If a nurse palpates an enlargement of the thyroid, auscultation should be performed with the bell of the stethoscope to assess for the presence of a bruit. A bruit is a soft, swishing sound produced because of an increase in blood flow through the thyroid arteries. The nurse should also ask the client about past history of thyroid problems, the findings must be documented, then the health care provider notified once assessment is complete to obtain further orders.

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

Auscultation Explanation: 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?

C7 Explanation: 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.

Which vessel is the nurse assessing if the major artery of the neck is being examined?

Carotid Explanation: The common carotid artery exits the aorta and extends upward in the neck to branch into the internal and external carotid arteries. It is the major artery carrying blood to the brain. The internal jugular veins are located in the neck. The temporal artery is located between the top of the ear and the eye. The radial artery is located at the wrist.

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

Consistency, delineation, mobility, tenderness Explanation: Parameters of lymph node assessment include size, shape, delimitation, mobility, consistency, and tenderness.

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 Explanation: 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.

The nurse prepares to assess the anterior triangle of a client's neck. Where should the nurse palpate this area on the diagram?

Explanation: The anterior triangle is located in the area below the mandible, lateral to the sternocleidomastoid muscle and medial to the midline of the neck.

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?

Graves' disease Explanation: Graves' disease is associated with a diffusely enlarged thyroid. This finding is not normally consistent with neoplasm, hypothyroidism, or nephritic syndrome.

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 Explanation: The Headache Impact Test may be used to assess the impact of headache on a client's activities of daily living. A mnemonic assessment tool is used to assess for the character, onset, location, duration, severity, pattern, and associated factors of pain. It does not assess for the effect of pain on the client's activities of daily living. Auscultation is use of a stethoscope to assess the client's blood pressure, heart sounds, or respiration. The family health history portion of the interview is used to assess for health conditions of family members that might help shed light on the client's chief complaint.

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 would not need to evaluate the thyroid gland, mental status, or lymph nodes based on this finding.

A nurse is performing a head and neck assessment of a client who is newly admitted to the hospital unit. When preparing to assess the client's thyroid gland, what landmarks should the nurse first identify? Select all that apply.

Hyoid bone Cricoid cartilage Explanation: Thyroid assessment begins with the identification of relevant landmarks, including the thyroid cartilage, the hyoid bone, and the cricoid cartilage. The sternocleidomastoid muscle, esophagus, and carotid arteries are not landmarked.

What structure is found midline in the tracheal area just beneath the mandible?

Hyoid bone Explanation: Important landmarks for the head and neck region are in the tracheal area. The usually palpable U-shaped hyoid bone is located midline just beneath the mandible. The large thyroid cartilage consists of two flat, plate-like structures joined together at an angle and with a small, sometimes palpable notch at the superior edge. Usually more prominent in males, the thyroid cartilage is also called the "Adam's apple." The palpable cricoid cartilage is a ringed structure just inferior to the thyroid cartilage.

What nursing diagnosis would be most appropriate for a client admitted with heart failure?

Ineffective tissue perfusion Explanation: Heart failure can cause ineffective tissue perfusion which can lead to fatigue, pain and activity intolerance. Impaired gas exchange would be more appropriate for respiratory disorders

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 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 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. Migraine headaches are accompanied by nausea, vomiting, and sensitivity to noise or light and not by fever and neck stiffness. Trigeminal neuralgia is manifested by sharp, shooting, piercing facial pains that last from seconds to minutes. Parkinson's disease is not manifested by headache and neck pain.

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 Explanation: Meningeal inflammation is a likely cause of this condition, which manifests as sudden headache, neck pain with stiffness, and fever. Migraine headaches are accompanied by nausea, vomiting, and sensitivity to noise or light, not by fever and neck stiffness. Trigeminal neuralgia is manifested by sharp, shooting, piercing facial pains that last from seconds to minutes. Parkinson's disease is not manifested by headache and neck pain.

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?

Meningitis Explanation: Neck pain associated with fever and headache may signify serious illness such as meningitis and should be carefully evaluated.

A client is being assessed for a headache. Symptoms include throbbing and severe pain lasting for the last 8 hours. The client also has a history of vomiting with the headache. What type of headache could these findings indicate?

Migraine Explanation: A throbbing, severe, unilateral headache that lasts 6 to 24 hours and is associated with photophobia, nausea, and vomiting suggests migraine. The scenario does not indicate tension, cluster, or benign headaches.

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 headache Explanation: 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.

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 Explanation: All modes of transportation, such as motor vehicle & bicycles, are the leading cause of traumatic brain injuries for people age 5 to 64 years. Males have twice the risk of females. Firearm injuries are high in the violence category and two thirds are suicidal in intent. Fall occur most frequently in the over 65 years of age population.

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. Explanation: 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 Explanation: 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.

During a health history, a client reports complaints of headaches. What would lead the nurse to suspect that the client is experiencing cluster headaches?

Pain radiating from eye to temporal region Explanation: Cluster headaches are typically localized in the eye and orbit and radiate to the facial and temporal regions. Throbbing severe pain, reports of ringing in the ears prior to the headache, and sensitivity to light suggest migraine headache.

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 Explanation: Earlobe asymmetry can be due to parotid gland enlargement caused by an abscess or tumor. Bell's palsy is a neurologic condition that may cause drooping of one side of the face. Acute pharyngitis causes swelling in the throat, which is not usually visible on the outside of the face. Thyroid enlargement affects the neck and has no effect on the symmetry of the earlobes.

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 Explanation: When examining the thyroid gland, the nurse inspects for enlargement and asymmetry; auscultates for bruits; and palpates for tumors, masses, size, and tenderness. Percussion does not provide meaningful data.

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.

When assessing a client with Graves disease, how would you expect the thyroid gland to be?

Soft Explanation: Soft in Graves disease; firm in Hashimoto thyroiditis, malignancy. Benign and malignant nodules, tenderness in thyroiditis.

What finding upon assessment would indicate the client is experiencing shock?

Systolic blood pressure 50 Explanation: A systolic blood pressure of 50 would indicate the client is experiencing shock. All other vital signs, while elevated do not indicate shock

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

When examining the head, the nurse remembers that the anatomic regions of the cranium take their names from which of the following sources?

The underlying bones Explanation: Regions of the head take their names from the underlying bones of the skull, not from the names of anatomists, anatomical positions, or vasculature.

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.

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 Explanation: Trigeminal neuralgia is manifested by sharp, shooting, piercing facial pain that lasts from seconds to minutes. The pain occurs over the divisions of the fifth trigeminal cranial nerve. A headache associated with a fever or high blood pressure is a cluster headache. Tension headaches are caused by tightening of facial and neck muscles. Migraine headaches are provoked by hormone fluctuations.

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

tension Explanation: Tension headaches often arise in the temporal areas. Cluster headaches typically occur behind the eyes. A throbbing, severe, unilateral headache that lasts 6-24 hours and is associated with photophobia, nausea, and vomiting suggests a migraine headache. Hypertensive is not a type of headache although individuals with hypertension may experience a headache upon arising in the morning.

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. Explanation: Tumor-related headaches have no prodromal stage; may be aggravated by coughing, sneezing, or sudden movements of the head.