Prep U: ch 15 head & neck

A nurse has performed a head and neck assessment of an adult patient 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 patient to the primary care provider promptly -Perform a focused endocrine assessment -Position the patient supine and reattempt palpation

-Document this as an expected assessment finding

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

Arthritic changes of the cervical spine

A client with a cervical spine injury has 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 -Chronic pain related to cervical spine injury -Assess characteristics

Assess characteristics

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

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

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

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 VIII (8) -Cranial nerve VII (7) -Cranial nerve VI (6) -Cranial nerve V (5)

Cranial nerve VII (7)

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. The nurse also notes that the patient has gained 10 pounds since her last visit 9 months ago. What might the nurse suspect? -Effects of age-related changes -Brain tumor -Hyperthyroidism -Hypothyroidism

Hypothyroidism

A client diagnosed with goiter has undergone a thyroidectomy. Which statement from the client indicates understanding of post-operative care teaching? -I must keep my follow up appointments to receive my thyroid hormone injections. -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 will take my thyroid hormone replacement medication once every week.

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

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? -Brain tumor -Diabetes -Impending stroke -Hyperthyroidism

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? Superficial to the sternomastoid In front of the ear In the midline, a few centimeters behind the tip of the mandible At the angle of the mandible

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

During your physical examination of the patient you note an enlarged tender tonsillar lymph node. What would you do? -Assess for meningitis -Look for involvement of other regions of the body -Look for a source such as infection in the area that it drains -Assess for dietary changes

Look for a source such as infection in the area that it drains

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? -Migraine headache -Meningeal inflammation -Trigeminal neuralgia -Parkinson's disease

Meningeal inflammation

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

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

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

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

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 Trapezius Masseter Temporalis

Sternocleidomastoid

The nurse is assessing a client complaining of swelling in the neck. While palpating the neck, the nurse finds a 2-cm lump that is fixed and hard. Why does this finding require emergency investigation? -This could be a sign of cancer -This could be a sign of pneumothorax -This could be a sign of an embolus -This could be a sign of a parotid stone

This could be a sign of cancer

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 nurse is palpating a client's neck as part of a physical assessment. Which of the following blood vessels should the nurse be especially careful to avoid bilaterally compressing during the assessment? Internal jugular vein Carotid artery External jugular vein Temporal artery

carotid

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

characteristic symptoms

Primary headaches are more worrisome than secondary headaches. True False

false

A client has an edematous face, hands, and legs. Which health problem should the nurse suspect this client is experiencing? -scleroderma -hypothyroidism -hyperthyroidism -Cushing's syndrome

hypothyroidism (fat)

The nurse feels a small mass in the neck of a client. It is mobile in both the up-and-down and side-to-side directions. Which of the following is the nurse most likely feeling? -Cancer -Lymph node -Deep scar -Muscle

lymph node

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

posterior cervical

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

relieving factors

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 -nhale deeply. -swallow a small sip of water. -cough deeply. -flex the neck to each side.

swallow a small sip of water.

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.

tesnsion

While assessing the head and neck of an adult client, the client tells the nurse that she has been experiencing sharp shooting facial pains that last from 10 to 20 seconds but are occurring more frequently. The nurse should refer the client for possible -cancerous lesions. -arterial occlusion. -inner ear disease. -trigeminal neuralgia.

trigeminal neuralgia

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

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 -Endocarditis -Tuberculosis -Bronchitis

Atelectasis

Teenagers doing community service following arrest for driving under the influence are working at the rehabilitation hospital with clients who have paraplegia. These clients have been paralyzed by drunk drivers. How would the nurses who care for these clients best use the time spent with these teenagers? -Educating them about not drinking and driving -Teaching them how to turn these patients every 2 hours -Fulfilling the court requirements -Keeping the shelves restocked

Educating them about not drinking and driving

A nurse is performing a head and neck assessment on a client. Which area should the nurse inspect for facial symmetry? -Nasolabial folds -Temporomandibular joint -Preauricular nodes -Earlobes

Nasolabial folds

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.

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

goiter

What is the most common type of hyperthyroidism? Graves' disease Cushing's syndrome Moon face Thyroid cancer

graves, goiter, bulging eyes,

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

hyoid bone

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? -thyroid cyst -Hashimoto thyroiditis -benign tumor -hyperthyroidism

hyperthyroidism

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

meningitis

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

tension

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 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? C1 C3 C5 C7

C7

A female client describes headache symptoms that seem to indicate a migraine. Which of the following questions during the client interview would, if answered in the positive, tend to confirm the nurse's suspicion? -"Does the headache occur regularly with your menstrual cycle?" -"Does the headache tend to occur after a cold or sinusitis?" -"Does the headache tend to occur when you are stressed?" -"Does the headache occur in conjunction with tightening of neck muscles?"

"Does the headache occur regularly with your menstrual cycle?"

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

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? -Order tests to rule out an overactive thyroid gland. -Assess for other signs and symptoms of Cushing's syndrome. -Palpate the woman's parotid gland for enlargement. -Assess the woman for hypothyroidism.

Assess the woman for hypothyroidism.

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

Consistency, delineation, mobility, tenderness

The nurse is planning to assess an adult client's thyroid gland. The nurse should plan to -ask the client to raise the chin. -approach the client posteriorly. -turn the client's neck slightly backward. -place the fingers above the cricoid cartilage.

approach the client posteriorly.

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? -Stress -Injury to the sternomastoid -Meningeal inflammation -Arthritis

arthritis

A female client visits the clinic and tells the nurse that she frequently experiences severe recurring headaches that sometimes last for several days and are accompanied by nausea and vomiting. The nurse determines that the type of headache the client is describing is a -cluster headache. -migraine headache. -tension headache. -tumor-related headache.

migraine headache.

The nurse is performing an assessment of the neck and identifies tracheal deviation. What is the most appropriate response of the nurse? select all apply -Notify the health care provider -Ask about recent injuries -Palpate for thyroid -Document findings

notify the health care provider

Which instruction to the client will help facilitate examination of the temporomandibular joint by the nurse? Ask the client to: -perform a chewing action -sit upright -open the mouth -sit without moving

open the mouth

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 -Analgesic rebound -Migraine -Cluster

tension headache