NUR 1068 Health Assessment Ch 15- assessing head and neck

During a physical examination of the head and neck, a client reports frequently feeling cold. What additional questions should the nurse ask for more information about the client's symptoms? (Select all that apply.)

"Do you dress more warmly than other people? "Do you use more blankets that others at home? "Do you perspire less than others?"

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

Where is the temporal artery palpated?

Above the cheek bone near the scalp line

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

The nurse is planning to instruct a group of adolescents on ways to prevent traumatic brain injuries. What should be included in these instructions?

Always use seat belts.

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

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 client with a cervical spine injury reports chronic pain. What would be the most appropriate initial nursing intervention for this client?

Assess the client regarding characteristics of the pain.

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

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

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

Which of the following cranial nerves has only sensory function?

CN I - 1 the olfactory nerve, relays smell

Which of the following cranial nerves has only sensory function?

CN II - 2 the optic nerve, conveys sight

Which of the following cranial nerves has only motor function?

CN III - 3 the oculomotor nerve, helps the eye move, while allowing pupillary constriction, accommodation, as well as eyelid opening.

Which of the following cranial nerves has only motor function?

CN IV - 4 the trochlear nerve, innervates the superior oblique muscle, helping the eye rotate medially

Which of the following cranial nerves has both sensory and motor function?

CN IX - 9 the glossopharyngeal nerve conveys the sensation of taste from the posterior tongue, and senses carotid pressure. It has the motor functions of allowing swallowing and innervating the stylopharyngeus muscle

Which of the following cranial nerves has both sensory and motor function?

CN V - 5 the trigeminal nerve conveys facial sensation and anterior tongue somatosensation. It also has motor function to allow mastication

Which of the following cranial nerves has only motor function?

CN VI - 6 the abducens nerve innervates the lateral rectus. This helps the eye abduct and move laterally

Which of the following cranial nerves has both sensory and motor function?

CN VII - 7 the facial nerve conveys the sensation of taste from the anterior tongue. It also has motor function of facial movement, eyelid closing, movement of the stapedius muscle, lacrimation and salivation

Which of the following cranial nerves has only sensory function?

CN VIII - 8 the vestibulocochlear nerve, propagates the sensation of sound, but also helps sense balance

Which of the following cranial nerves has both sensory and motor function?

CN X - 10 the vagus nerve senses taste from the epiglottis and monitors aortic arch receptors. It has motor functions of allowing swallowing, soft palate elevation, talking and coughing

Which of the following cranial nerves has only motor function?

CN XI - 11 the accessory nerve which helps the motor functions of shoulder shrugging and head turning.

Which of the following cranial nerves has only motor function?

CN XII - 12 the hypoglossal nerve, allows tongue movement

Which risk factor for traumatic brain injury (TBI) should a nurse include in a discussion about prevention for a group of adolescents?

Concussions in sports and motor vehicle accidents cause the largest number of TBIs in teens.

Consistency, delineation, mobility, tenderness

Consistency, delineation, mobility, tenderness

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

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

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

Tell whether the following statement is true or false. The axis is the first of the seven cervical vertebrae.

False. The axis is the second of the seven cervical vertebrae.

Is the following statement true or false? The skull, which is the framework of a head, has two subsections: the cranium and cervical vertebrae.

False. The skull has two subsections: the cranium and the face.

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.

A nurse performs palpation of a client's lymph nodes. Which finding should be reported to the health care provider?

Fixed to underlying tissue

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

What is the most common type of hyperthyroidism?

Graves' disease

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

Hyoid bone

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

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.

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 comfort related to possible neck injury

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

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

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

In reviewing a client's health history, the nurse notes that the client has had a history of TMJ pain. The nurse recognizes that which of the following bones is involved in this dysfunction?

Mandible

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

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?

Migraine

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

A nurse is performing a head and neck assessment on a client. Which area should the nurse inspect for facial symmetry?

Nasolabial folds

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.

Which instruction to the client will help facilitate examination of the temporomandibular joint by the nurse?

Open the mouth

Which bone belongs to the face?

Palatine. Palatine is a facial bone that gives shape to the face. Parietal, temporal, and sphenoid are bones of the cranium

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

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 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?

Perform a focused assessment

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 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

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 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 assessing an elderly woman who reports lethargy and weakness. During the examination, the nurse notices that the client's face is drooping slightly on the right side. Why does this finding require emergency intervention?

The client could be experiencing a stroke

The nurse is caring for a client who comes to the clinic reporting a lump by her ear. What are the symptoms of a cancerous lymph node?

The node is fixed and rubbery.

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

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.

The nurse is planning to assess an adult client's thyroid gland. The nurse should plan to

approach the client posteriorly.

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

ask the client if touching the head is permissible.

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

The nurse should ask about or assess which associated factors when a client complains of cluster headaches? Select all that apply.

lacrimation rhinorrhea ptosis miosis

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

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

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

parotid gland enlargement.

The nurse suspects that a client has Cushing's syndrome. What assessment finding did the nurse use to make this clinical determination?

red cheeks

The nurse assesses an adult client's head and neck. While examining the carotid arteries, the nurse assesses each artery individually to prevent:

reduction of the blood supply to the brain.

While assessing an older adult client's neck, the nurse observes that the client's trachea is pulled to the left side. The nurse should

refer the client to a physician for further evaluation.

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

tension