PrepU - Chapter 15 - Health Assessment

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?

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.

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?

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

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

The most common types of headaches are related to vascular (e.g., migraine), muscle contraction (tension), traction, or inflammatory causes.

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?"

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 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 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?

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.

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?

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.

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?

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.

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?

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.

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

Trigeminal neuralgia (tic douloureux) is manifested by sharp, shooting, piercing facial pains that last from seconds to minutes. Pain occurs over the divisions of the fifth trigeminal cranial nerve (the ophthalmic, maxillary, and mandibular areas).

Primary headaches are more worrisome than secondary headaches.

false

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

Normally lymph nodes are round and soft, less than 1 cm in size, mobile from side to side, soft in consistency, and nontender. A fixed lymph node may be seen in metastatic disease.

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?

Musculoskeletal injury or disease can be confirmed with an X-ray, CT, or MRI. If test results are negative, the nurse should assess for complete range of motion of the neck, looking for any muscle tension, loss of mobility, or pain. According to the scenario, the nurse would not assess for headache, shortness of breath, or ROM of the arms and shoulders next.

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 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?

This is a description of a common migraine (no aura). Distinctive features of a migraine include phono- and photophobia, nausea, resolution with sleep, and unilateral distribution. Only some of these features may be present.

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 include having the client rate the level of pain as this provides information about the severity. This subjective information is categorized as a characteristic symptom. Information about anything else that the client may be experiencing during the headache (for example, nausea or blurred vision) should be documented in associated manifestations. Relieving factors provides information about anything that the client has attempted to relieve the symptoms. The location provides subjective information about where the headache is localized and pain radiates.

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?

Characteristics such as pain that is worse in the morning on awakening and precipitated or made worse by straining or sneezing (potentially elevated intracranial pressure) versus pain that is worse as the day progresses (more likely tension) indicate a need for a more focused assessment. Other listed options are not the most appropriate action for the nurse to take.

A client presents at the emergency room reporting "the worst headache I have ever had." What are critical nursing behaviors for this client? (Select all that apply.)

A client with severe headaches may be unable to provide a complete history, but a focused history and physical examination looking for neurologic changes are critical nursing behaviors. Nursing behaviors do not include MRIs, CT scans, or EEGs

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?

A sudden, severe headache with no known cause may be a sign of impending stroke, particularly if accompanied by sudden trouble seeing in one or both eyes or sudden trouble walking, dizziness, and loss of balance or coordination. Only impending stroke is associated with all of these symptoms. Diabetes is not associated with headache or the other symptoms. A tumor-related headache is aching and steady and not necessarily associated with sudden onset. Hyperthyroidism is associated with goiter, bruit, and sudden weight loss, but not with any of the symptoms listed.

A client diagnosed with goiter has undergone a thyroidectomy. Which statement from the client indicates understanding of post-operative care teaching?

After thyroidectomy, clients must be treated with exogenous thyroid hormone for the rest of their lives. Thyroid hormones are usually taken by mouth on a daily basis.

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

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.

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?

An involuntary nodding movement may be seen in patients 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.

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 in cervical spine may 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

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 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. Neither bronchitis nor tuberculosis is responsible for the tracheal shift.

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 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

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?

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 patients, fulfilling court requirements, or keeping the shelves restocked.

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?

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.

What is the most common type of hyperthyroidism?

Graves' disease, the most common type of hyperthyroidism, is autoimmune and may also be genetic. Cushing's syndrome, moon face, and thyroid cancer are not the most common types of hyperthyroidism.

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

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?

Hyperthyroidism

The nurse practitioner notes that the thyroid gland is enlarged and auscultates both lobes of the thyroid. For what is the nurse practitioner listening?

If the thyroid is enlarged, either unilaterally or bilaterally, the nurse uses the bell of the stethoscope to auscultate over each lobe for a bruit. Bruits are most often found with a toxic goiter, hyperthyroidism, or thyrotoxicosis. Rush and gurgle are distracters for this question. A murmur is assessed during a cardiac assessment.

During your physical examination of the patient you note an enlarged tender tonsillar lymph node. What would you do?

Knowledge of the lymphatic system is important to a sound clinical habit: whenever a malignant or inflammatory lesion is observed, look for involvement of the regional lymph nodes that drain it; whenever a node is enlarged or tender, look for a source such as infection in the area that it drains.

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 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.

When preparing to provide education regarding the prevention of head injuries from motor vehicle accidents, the nurse should be sure to include which point?

Mobile phones should only be used if there is a hands-free option available.

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 head or neck injuries may cause limitations in movement and chronic pain. Change in sleeping habits is too vague to be correct. The other two options may produce pain but not necessarily limit functioning.

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

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

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?

The cervical vertebrae (C1 through C7) are located in the posterior neck and support the cranium. The vertebra prominens is C7, which can easily be palpated when the neck is flexed. Using C7 as a landmark will help you to locate other vertebrae.

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

The first step would be for the nurse to assess characteristics of the pain. Surgery or pharmacologic interventions would be considered by the whole health care team after more information was gathered. Option C represents a nursing diagnosis, not an intervention.

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

The skull and facial bones are larger and thicker in acromegaly.

The nurse assesses a client's submental lymph nodes. In which area of the client's head should the nurse palpate these lymph nodes?

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.

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

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?

This is a typical description for a client with Parkinson's disease. Facial mobility is decreased, which results in a blunt expression or a "masked" appearance. The client also has decreased blinking and a characteristic stare with an upward gaze. Combined with the findings of slow movements and a shuffling gait, the diagnosis of Parkinson's is highly likely.

While the nurse is obtaining a client's health history regarding the head and neck,the client tells the nurse about having a lump in the neck. In order to assess for associated manifestations of this problem, which of the following questions should the nurse ask next?

To assess manifestations associated with the lump in the neck, the nurse would ask if the patient has difficulty swallowing. Asking how long the client has experienced discomfort from the lump is associated with duration. Asking when the patient first noticed the lump assesses the onset of the lump. Asking if there is there more than one lump assesses the location of the lump.

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?

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.

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

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.

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

rhinorrhea ptosis miosis lacrimation