PrepU ch.15 assessing head and neck

The client is having a thyroid crisis. What symptoms would the nurse assess for? Select all that apply. -Tachypnea -Nausea -Neck swelling -Bradycardia -Anxiety

-Tachypnea -Nausea -Anxiety Explanation: Clients experiencing a thyroid crisis may present with tachypnea, tachycardia, nausea, vomiting, diarrhea, abdominal pain and anxiety. Neck swelling may be related to hypothyroidism or acute bacterial thyroiditis. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 15: Assessing Head and Neck, p. 287. Chapter 15: Assessing Head and Neck - Page 287

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? a.Aura b.Prodrome c.Neurologic onset d.Aberrant sign

b. Prodrome Explanation: Is there a prodrome of unusual feelings such as euphoria, craving for food, fatigue, or dizziness? Is there an aura with neurologic symptoms, such as change in vision or numbness or weakness in an arm or leg? Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018.

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? a.This could be a sign of cancer b.This could be a sign of pneumothorax c.This could be a sign of an embolus d.This could be a sign of a parotid stone

a. This could be a sign of cancer Explanation: Lymphatics larger than 1 cm, fixed, irregular, or hard or rubbery require emergency investigation. Such signs raise the possibility of cancer. The signs and symptoms cited in the scenario do not indicate pneumothorax, embolus, or parotid stone. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 15: Assessing Head and Neck, p. 290. Chapter 15: Assessing Head and Neck - Page 290

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? a.onset b.location c.treatment d.relieving factors

d. relieving factors Explanation: Relieving factors includes anything the client subjectively reports they have tried to make the migraine go away. Onset refers to when the migraine started. Location helps determine what part of the client's head the pain is localized within or where it radiates. Treatment refers to any assessment, support, or care the client has received from various health care providers. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 15: Assessing Head and Neck, p. 283. Chapter 15: Assessing Head and Neck - Page 283

The nurse is planning to instruct a group of adolescents on ways to prevent traumatic brain injuries. What should be included in these instructions? a.Always use seat belts. b.Wear nonslip shoes in the house. c.Avoid risky activities such as snowboarding d.Use of guns should be supervised by an adult

a. Always use seat belts. Explanation: The third leading cause of traumatic brain injury is motor vehicle crashes. When instructing a group of adolescents on ways to prevent traumatic brain injuries, the most important thing for the nurse to include would be to always use seat belts. Wearing nonslip shoes in the house is a more appropriate teaching point for adults over 65 years of age. Instead of teaching adolescents to avoid risky activities such as snowboarding; they should be reminded to always wear a helmet. Adolescents should not be encouraged to use firearms. Instead, they should ensure that the responsible adult has stored the bullets and firearm in separate locations. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 15: Assessing Head and Neck, p. 288. Chapter 15: Assessing Head and Neck - Page 288

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? a.Educating them about not drinking and driving b.Teaching them how to turn these clients every 2 hours c.Fulfilling the court requirements d.Keeping the shelves restocked

a. Educating them about not drinking and driving Explanation: Education for high-risk groups about not driving while under the influence or sleepy is critical. The nurses working with these clients would not spend time with the teenagers teaching them how to turn the clients, fulfilling court requirements, or keeping the shelves restocked. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 15: Assessing Head and Neck, p. 288. Chapter 15: Assessing Head and Neck - Page 288

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? a.Encourage the use of safety equipment b.Encourage proper nutrition to promote healing c.Encourage the client to take a safety course d.Teach proper posture, bending, and lifting

a. 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. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 15: Assessing Head and Neck, p. 286. Chapter 15: Assessing Head and Neck - Page 286

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? a.Notify the healthcare provider immediately. b.Administer intravenous pain medication. c.Palpate the carotid pulses bilaterally at the same time. d.Prepare the client for a temporal artery biopsy.

a. 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. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 15: Assessing Head and Neck, p. 298. Chapter 15: Assessing Head and Neck - Page 298

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... a.migraine headache. b.cluster headache. c.tension headache. d.tumor-related headache.

a. migraine headache. Explanation: The most common types of headaches are related to vascular (e.g., migraine), muscle contraction (tension), traction, or inflammatory causes. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 15: Assessing Head and Neck, pp. 299-300. Chapter 15: Assessing Head and Neck - Page 299-300

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

a. red cheeks Explanation: The increased adrenal cortisol production of Cushing syndrome produces a round or "moon" face with red cheeks. A mask-like face is associated with Parkinson's disease. Swelling around the eyes is associated with nephrotic syndrome. An elongated prominent forehead is associated with acromegaly. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 15: Assessing Head and Neck, p. 301. Chapter 15: Assessing Head and Neck - Page 301

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? a.Internal jugular vein b.Carotid artery c.External jugular vein d.Temporal artery

b. Carotid artery Explanation: It is important to avoid bilaterally compressing the carotid arteries when assessing the neck, as bilateral compression can reduce the blood supply to the brain. Compression of the internal or external jugular veins would not be as significant as compressing the carotid arteries as doing so would not reduce blood supply to the brain. The temporal artery, a major artery, is located between the eye and the top of the ear, and would not be affected by palpation of the neck. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 15: Assessing Head and Neck, p. 282. Chapter 15: Assessing Head and Neck - Page 282

When assessing an adult client experiencing diarrhea, the nurse notes a round "moon" face, a buffalo hump at the nape of the neck, and a velvety discoloration around the neck. What is the possible cause of these signs? a.Myxedema b.Cushing's syndrome c.Scleroderma d.Bell's palsy

b. Cushing's syndrome Explanation: Cushing's syndrome, excessive production of exogenous ACTH, can result in a round "moon" facies, fat deposits at the nape of the neck, "buffalo hump," and sometimes a velvety discoloration around the neck (acanthosis nigracans). The scenario does not describe signs and symptoms demonstrated by a client with myxedema, scleroderma, or Bell's palsy. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 15: Assessing Head and Neck, p. 301. Chapter 15: Assessing Head and Neck - Page 301

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.

b. ask the client if touching the head is permissible. Explanation: Take care to consider cultural norms for touch when assessing the head. Some cultures (e.g., Southeast Asian) prohibit touching the head or touching the feet before touching the head. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 15: Assessing Head and Neck, p. 288. Chapter 15: Assessing Head and Neck - Page 288

While examining a client, the nurse observes that he appears to be nodding his head involuntarily. Which of the following conditions should the nurse additionally assess for, based on this finding? a.Neurologic disorder b.Aortic insufficiency c.Unilateral vision d.Paget's disease

b. b. Aortic insufficiency Explanation: An involuntary nodding movement may be seen in clients with aortic insufficiency. Neurologic disorders may cause a horizontal jerking movement. Head tilted to one side may indicate unilateral vision or hearing deficiency or shortening of the sternomastoid muscle. Acorn-shaped, enlarged skull bones are seen in Paget's disease of the bone. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 15: Assessing Head and Neck, p. 290. Chapter 15: Assessing Head and Neck - Page 290

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... a.inhale deeply. b.swallow a small sip of water. c.cough deeply. d.flex the neck to each side.

b. swallow a small sip of water. Explanation: Ask the client to swallow a small sip of water. Observe the movement of the thyroid cartilage, thyroid gland. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 15: Assessing Head and Neck, p. 292. Chapter 15: Assessing Head and Neck - Page 292

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? a.Metastatic disease b.Chronic infection c.Acute infection d.Cushing's disease

c. 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. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 15: Assessing Head and Neck, p. 296. Chapter 15: Assessing Head and Neck - Page 296

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

c. Consistency, delineation, mobility, tenderness Explanation: Parameters of lymph node assessment include size, shape, delimitation, mobility, consistency, and tenderness. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 15: Assessing Head and Neck, p. 296. Chapter 15: Assessing Head and Neck - Page 296

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

c. In the midline, a few centimeters behind the tip of the mandible Explanation: The submental lymph nodes are located near the midline, a few centimeters behind the tip of the mandible. Superficial cervical lymph nodes are located superficial to the sternomastoid. The preauricular lymph nodes are located in front of the ear. The tonsillar lymph nodes are located near the mandible. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 15: Assessing Head and Neck, p. 295. Chapter 15: Assessing Head and Neck - Page 295

During a neck assessment, where would the nurse focus palpation of the thyroid isthmus? a.Just above the thyroid cartilage b.Between the thyroid and the cricoid cartilages c.Just below the cricoid cartilage d.In front of the sternocleidomastoid muscle

c. Just below the cricoid cartilage Explanation: Just below the cricoid cartilage, the isthmus of the thyroid should be palpable as a smooth rubbery band that rises and falls with swallowing. The other options do not accurately describe the location of the isthmus. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 15: Assessing Head and Neck, p. 282. Chapter 15: Assessing Head and Neck - Page 282

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? a.Effects of age-related changes b.Brain tumor c.Hyperthyroidism d.Hypothyroidism

d. Hypothyroidism Explanation: 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. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 15: Assessing Head and Neck, p. 287. Chapter 15: Assessing Head and Neck - Page 287