Ch15: head and neck
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 Injury to the sternomastoid Stress Meningeal inflammation
Arthritis
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 C7 C5
C7
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 acromegaly. Paget disease. Cushing syndrome. parotid gland enlargement.
acromegaly
A client is brought to the emergency department via ambulance after experiencing difficulty speaking and weakness in the left arm and leg. The nurse understands that the client is most likely experiencing which of the following disorders? temporal arteritis Bell palsy trigeminal neuralgia cerebrovascular accident
cerebrovascular accident
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. tension headaches. migraine headaches. tumor-related headaches.
tension headaches. Tension headaches are dull, tight, and diffuse.
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 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.
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 Muscle tension Cranial damage
Arthritic changes of the cervical spine 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
A client with a cervical spine injury reports chronic pain. What would be the most appropriate initial nursing intervention for this client? Educate the client regarding cervical spine pain. Assess the client regarding characteristics of the pain. Work with medical team to evaluate possible surgery. Discuss pharmacologic interventions.
Assess the client regarding characteristics of the pain.
When palpating the neck, performing which of the following techniques will help differentiate lymph nodes from a band of muscles? Attempting to roll the structure up and down and side to side Applying pressure and assessing for induration 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 While lymph nodes may be rolled both up and down and side to side, muscles will not move in this manner. The other cited techniques do not differentiate between lymph nodes and muscles.
A nurse is assessing a client with hyperthyroidism for the presence of a bruit. Which assessment technique should the nurse use? Inspection Palpation Percussion Auscultation
Auscultation
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 Encourage proper nutrition to promote healing Teach proper posture, bending, and lifting Encourage the client to take a safety course
Encourage the use of safety equipment
An anatomy and physiology instructor is discussing the lymphatic system of the head and neck. Why would the instructor emphasize the importance of the drainage pattern of the lymph? Nurses need to follow lymph patterns to track the course of a disease. The drainage pattern may help pinpoint a fluid or electrolyte imbalance. The drainage pattern can help the nurse understand why the disease is spreading. Enlargement of a node may be a sign of pathology that is distant from that node.
Enlargement of a node may be a sign of pathology that is distant from that node.
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? Nephrotic syndrome A tumor Hypothyroidism Graves' disease
Graves' disease
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? Family health history questionnaire A mnemonic assessment tool Auscultation Headache Impact Test
Headache Impact Test
What structure is found midline in the tracheal area just beneath the mandible? Cricoid cartilage Hyoid bone Thyroid cartilage Adam's apple
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? Cricoid cartilage, hyoid bone, tracheal rings, thyroid isthmus Hyoid bone, tracheal rings, cricoid cartilage, lobes of the thyroid gland Thyroid cartilage, thyroid isthmus, cricoid cartilage, hyoid bone Hyoid bone, thyroid cartilage, cricoid cartilage, isthmus of the thyroid
Hyoid bone, thyroid cartilage, cricoid cartilage, isthmus of the thyroid
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 Superficial to the sternomastoid At the angle of the mandible In front of the ear
In the midline, a few centimeters behind the tip of the mandible
What risk factors should the nurse include in a discussion on the occurrence of neck cancer? (Select all that apply.) Male gender Coffee drinker Age older than 50 years Tobacco use Female gender
Male gender Age older than 50 years Tobacco use Risk factors for neck cancers include male gender, age older than 50 years, tobacco use, and alcohol consumption. For clients with such risk factors, nurses should especially emphasize teaching related to smoking prevention or cessation. Risk factors do not include female gender or being a coffee drinker.
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 Temporal arteritis Bell's palsy Tension headache
Migraine headache 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.
A nurse is performing a head and neck assessment on a client. Which area should the nurse inspect for facial symmetry? Nasolabial folds Earlobes Preauricular nodes Temporomandibular joint
Nasolabial folds
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? Bell's palsy Thyroid enlargement Parotid enlargement Acute pharyngitis
Parotid enlargement 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 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 ne328xt? Shortness of breath Range of motion of the arms and shoulders Range of motion of the neck Headache
ROM of neck 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.
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 Temporalis Trapezius Masseter
Sternocleidomastoid The sternomastoid muscle rotates and flexes the head, whereas the trapezius muscle extends the head and moves the shoulders. The masseter and temporalis muscles are involved in raising and lowering the mandible during mastication (chewing).
A community health nurse is attending a seminar on headaches. What would this nurse learn is a red flag for headaches? Pain centered behind the eyes Pain without new symptomatology Pain that is temporary Stiff neck
Stiff neck
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? Analgesic rebound Tension Migraine Cluster
Tension
A client comes to the trauma unit in respiratory distress following a motor vehicle accident. On examination, the nurse notices that the trachea is deviated from the midline. What does this finding indicate? Tension pneumothorax Severe neck fracture Flail chest Cardiac tamponade
Tension pneumothorax
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 soft and moves freely. The node is fixed and rubbery. The node matches the node on the opposite side of the body. The node is less than 1 cm in size and feels boggy.
The node is fixed and rubbery. Lymph nodes larger than 1 cm, fixed, irregular, hard, or rubbery require emergency investigation. Such signs raise the possibility of cancer.
What are the bordering landmarks of the anterior triangle of the neck? (Mark all that apply.) The omohyoid muscle The sternomastoid The clavicle The mandible The midline of the neck
The sternomastoid The mandible 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 The underlying vascular network Their anatomical positions Noted anatomists
The underlying bones
The nurse does a health history. The client states he has lost 30 pounds in the last couple months without really trying. The client also states he feels warm all the time and sometimes feels like he has heart palpitations. The nurse would anticipate orders to evaluate the client for hyperbilirubinemia hyperthyroidism hypernatremia hyperproteinemia
hyperthyroidism
The nurse assesses an adult client's head and neck. While examining the carotid arteries, the nurse assesses each artery individually to prevent: decreased pulse pressure. rapid rise in the client's pulse rate. premature ventricular heart sound. reduction of the blood supply to the brain.
reduction of the blood supply to the brain.
A client complains of a headache over both temporal areas. What type of headache should the nurse suspect the client is experiencing? migraine tension cluster hypertensive
tension
A client reports sharp, shooting, piercing facial pains that last from seconds to minutes. The nurse identifies these as signs and symptoms of which of the following disorders? Bell palsy tic douloureux stroke hyperthyroidism
tic douloureux 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). Signs and symptoms of hyperthyroidism include goiter, increased heart rate and blood pressure, increased appetite, loss of weight, heat intolerance. Bell palsy affects cranial nerve VII, affects one side of the face, and is not painful. A stroke may cause a facial droop that is not painful.
Which of the following clients is most likely to be diagnosed with migraine headaches? 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 woman whose headaches come on suddenly and are somewhat relieved by a quiet, dark room The hallmarks of migraine headaches include a rapid onset, nausea, and relief by the removal of light and sound stimuli. Sustained muscle activity associated with typing and driving often precedes tension headaches. Cluster headaches, not migraines, are episodic over the course of a day.
An adult client comes to the ED with a new onset of pain in his neck and jaw. What system requires emergency assessment? Respiratory Integumentary Nervous Cardiovascular
Cardiovascular
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? Palpate the carotid pulses bilaterally at the same time. Administer intravenous pain medication. Notify the healthcare provider immediately. Prepare the client for a temporal artery biopsy.
Notify the healthcare provider immediately.
When palpating the lymph nodes of the neck, the nurse assesses for which of the following characteristics? Delineation, integrity, shape, color Configuration, discreteness, temperature, color Congruency, induration, size, turgor Consistency, delineation, mobility, tenderness
Consistency, delineation, mobility, tenderness Parameters of lymph node assessment include size, shape, delineation, mobility, consistency, and tenderness.
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 Assess for meningitis Assess for dietary changes Look for involvement of other regions of the body
Look for a source such as infection in the area that it drains
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.
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. ask the client to flex his neck to the left side. observe whether the client has difficulty swallowing water. palpate the cricoid cartilage for smoothness.
refer the client to a physician for further evaluation.
A nurse is providing care for a client who experienced a head injury and who just moved to the United States from Southeast Asia. What cultural nursing consideration should the nurse take into account when performing an assessment on clients from different cultures? Treat all clients the same despite culture. Consider cultural norms. Follow hospital policy. Explain U.S. norms because they are in the United States.
Consider cultural norms.
A client reports having a headache. The nurse performs a specialized focused assessment and notes the following: client rates pain 10 on a scale of 1 to 10 (10 being the worst), nauseated and vomited, reporting sensitivity to noise and light. The nurse determines that the client is most likely experiencing which of the following types of headache? sinus tension cluster migraine
migraine Migraine headaches are accompanied by nausea, vomiting, and sensitivity to noise or light. A sinus headache is deep, constant, throbbing pain, with pressure-like pain in one specific area of face or head (e.g., behind eyes) and the face being tender to the touch. A cluster headache has stabbing pain and may be accompanied by tearing, eyelid drooping, reddened eye, or runny nose. A tension headache is dull, tight, and diffuse.
The nurse suspects an enlarged thyroid in a client during the physical examination of the head and neck. What should the nurse do first? Listen over the thyroid with a stethoscope. Ask the client to lie down for further assessment Displace the trachea to the right. Ask the client to sip and swallow water.
Ask the client to sip and swallow water.
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? Refer the client to the primary care provider promptly Document this as an expected assessment finding Position the client supine and reattempt palpation Perform a focused endocrine assessment
Document this as an expected assessment finding
A nurse performs palpation of a client's lymph nodes. Which finding should be reported to the health care provider? Soft in consistency Fixed to underlying tissue Mobile from side to side Round and 8 mm in size
Fixed to underlying tissue
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? Effects of age-related changes Hyperthyroidism Hypothyroidism Brain tumor
Hypothyroidism
The nurse is performing a physical examination and notes an enlarged left supraclavicular lymph node. The nurse understands that this could be indicative of nasopharyngitis a goiter tonsillitis a metastasis
a metastasis 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.
The nurse is planning to assess a client's lymph nodes. Which set of nodes should the nurse assess first? supraclavicular preauricular submental superficial cervical
preauricular The lymph nodes in front of the ear, or preauricular, are usually palpated first. The submental nodes are under the chin. The supraclavicular nodes are located near the clavicle and sternocleidomastoid muscle. The superficial cervical nodes are located superficial to the sternocleidomastoid muscle.
A nurse is teaching nursing students about the risks associated with developing head and neck cancers. The nurse determines student understanding when the students make which of the following statements? "Chewing tobacco does not cause cancer." "Asbestosis does not cause head and neck cancers." "Most head and neck cancers are linked to smoking." "Alcohol plays a very little role in head and neck cancers."
"Most head and neck cancers are linked to smoking."
Which risk factor for traumatic brain injury (TBI) should a nurse include in a discussion about prevention for a group of adolescents? Most firearm incidents are accidental. Females have twice the risk that males do. Concussions in sports and motor vehicle accidents cause the largest number of TBIs in teens. Falls occur more frequently in the younger population.
Concussions in sports and motor vehicle accidents cause the largest number of TBIs in teens.
A nurse palpates an elderly client's thyroid and detects an enlargement over the right lateral lobe. What action should the nurse take first? Document the findings in the nurse notes Ask the client about past history of hypothyroidism Auscultate with the bell over the lateral lobes Immediately notify the health care provider
Auscultate with the bell over the lateral lobes 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.
A client admitted to the hospital for a gastrointestinal bleed is now experiencing right-sided facial weakness. The nurse assesses the client and determines no other neurological deficits exist. The nurse determines the client is most likely exhibiting signs of which of the following disorders? cranial nerve V dysfunction Bell palsy cranial nerve XII dysfunction trigeminal neuralgia
Bell palsy Signs and symptoms of Bell palsy include unilateral facial weakness (cranial nerve VII). Cranial nerve V (trigeminal) controls temporal and masseter muscles. Cranial nerve XII controls tongue movement. Trigeminal neuralgia involves cranial nerve V.
Teenagers doing community service following arrest for driving under the influence and 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 Keeping the shelves restocked Teaching them how to turn these clients every 2 hours Fulfilling the court requirements
Educating them about not drinking and driving
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? Cervical fracture Measles Meningitis Migraine
Meningitis
A client reports sudden head and neck pain with stiffness, a new sensitivity to light, and has developed a fever. What is a priority action of the nurse? Continue to monitor the client. Notify the health care provider. Document the findings. Administer acetaminophen for the pain.
Notify the health care provider. Sudden head and neck pain seen with elevated temperature and neck stiffness may be a sign of meningeal inflammation. These findings need to be reported to the health care provider immediately in order for steps to be taken that will determine the cause of the meningeal inflammation, for example, bacterial or viral meningitis. The nurse may administer acetaminophen for the pain, but this is not a priority. The nurse will document the findings and continue to monitor the client but notifying the health care provider is the priority action that is needed to ensure the safety of the client and others.
A nurse palpates a client's cervical lymph nodes and notes the following findings: cervical lymph nodes .6 inches (1.5 cm) in diameter (enlarged), painful, and mobile. What is the best action of the nurse? Notify the health care provider. Ask the client if they have a history of cancer. Ask the client if they have experienced any other signs or symptoms. Document findings as normal.
Ask the client if they have experienced any other signs or symptoms. Normally, lymph nodes are either not palpable or they may feel like very small beads. If the nodes become overwhelmed by microorganisms, as happens with an infection such as mononucleosis, they swell and become painful. Lymph nodes greater than 6 inches (1.5 cm) in diameter is an abnormal finding and requires further assessment. If cancer metastasizes to the lymph nodes, they may enlarge but will not be painful. The nurse would further assess the client for other signs or symptoms before notifying the health care provider.
The nurse practitioner auscultates both lobes of a client's enlarged thyroid gland. Identification of what sound would tend to confirm a diagnosis of a toxic goiter? Murmur Gurgle Bruit Rush
Bruit 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. A murmur is assessed during a cardiac assessment.
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? Parkinson's disease Meningeal inflammation Trigeminal neuralgia Migraine headache
Meningeal inflammation
The nurse suspects that a client has Cushing's syndrome. What assessment finding did the nurse use to make this clinical determination? elongated prominent forehead mask-like face red cheeks swelling around the eyes
red cheeks 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.
The nurse is conducting discharge teaching to the caregiver of an older adult who was hospitalized following a fall at home. Which statement by the caregiver indicates a need for additional teaching by the nurse? "Loss of sensation in the toes is an age-related change." "Standing up slowly is important because dizziness can cause falls." "Changes in vision such as decreased accommodation happen with aging." "Certain medications can cause muscle weakness."
"Loss of sensation in the toes is an age-related change."
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 examine the lymph nodes of the neck before examining the head. determine whether the client desires a family member present. explain to the client why the assessment is necessary. ask the client if touching the head is permissible.
ask the client if touching the head is permissible. 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.
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 migraine headache. cluster headache. tension headache. tumor-related headache.
tumor-related headache. Tumor-related headaches have no prodromal stage; may be aggravated by coughing, sneezing, or sudden movements of the head.
The nurse is planning to assess an adult client's thyroid gland. The nurse should plan to turn the client's neck slightly backward. place the fingers above the cricoid cartilage. ask the client to raise the chin. approach the client posteriorly.
approach the client posteriorly. To palpate the thyroid, use a posterior approach. Stand behind the client and ask the client to lower the chin to the chest and turn the neck slightly to the right.
A nurse is providing care to an 86-year-old client. The nurse identifies which of the following finding(s) as a normal age-related head and neck change? Select all that apply. smooth thyroid lumbar stiffness cervical curvature of the spine decreased temporal pulse decreased range of motion of the neck
cervical curvature of the spine decreased temporal pulse decreased range of motion of the neck Normal age-related changes in older clients include decreased range of motion in the neck due to arthritis, increased cervical curvature, decreased temporal pulse, and nodular (not smooth) thyroid. The lumbar is the lower back and is not related to changes in the neck and head.
A client reports slight swelling and tightness at the base of their neck. The nurse palpates the client's throat and neck and determines the thyroid gland is enlarged. What medical term will the nurse use when charting this finding? hypothyroidism iodine deficiency hyperthyroidism goiter
goiter
A nurse performs a comprehensive assessment on a client. The nurse observes the following findings: enlarged hands, feet, and facial features (nose, ears). Which of the following disorders do these findings indicate? Cushing syndrome acromegaly scleroderma Parkinson disease
acromegaly
An adult client visits the clinic and tells the nurse that she has had headaches recently that are intense and stabbing and often occur in the late evening. The nurse should suspect the presence of cluster headaches. migraine headaches. tension headaches. tumor-related headaches.
cluster headaches.
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? Tuberculosis Bronchitis Endocarditis Atelectasis
Atelectasis
In addition to noting the physical characteristics of the thyroid gland, which of the following signs would be most important to consider in determining if the client has hypothyroidism? Increased heart rate Increased blood pressure Feeling anxious Laboratory tests
Laboratory tests In order to determine the presence of hypothyroidism, laboratory tests to determine blood levels of the TSH, FT4 and FT1 are needed to ensure correct diagnosis of this condition. The presence of tachycardia, increased blood pressure and anxiety are signs associated with hyperthyroidism.
A female client asks a nurse why it seems like her headaches are more severe and longer in duration than male friends who also have migraines. What is the best response by the nurse? "People experience different symptoms with migraines." "The severity of migraines is usually related to genetics." "There is no difference in how migraines affect males and females." "Hormones affect the severity of migraine headaches."
"Hormones affect the severity of migraine headaches."
A nurse palpates an enlarged, hard, and nontender left-sided supraclavicular lymph node in a client. Where should the nurse focus the physical assessment to obtain more data about this finding? Abdomen and thoracic area for changes associated with malignancy Head and neck area for signs of infection or inflammation Upper extremities for changes in sensation, movement, and range of motion Spinal cord area for signs of degeneration and decreased mobility
Abdomen and thoracic area for changes associated with malignancy
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 Chronic infection Metastatic disease Cushing's disease
Acute infection 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.
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 Hyperthyroidism Impending stroke Diabetes
Impending stroke 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 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? Analgesic rebound Cluster Tension Migraine
Migraine 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.
When preparing to provide education regarding the prevention of head injuries from motor vehicle accidents, the nurse should be sure to include which point? Refrain from taking any medication prior to operating a motor vehicle. A car seat should only be installed in the front if there are passenger airbags available. Helmets can obscure vision when riding all-terrain vehicles and should be avoided. Mobile phones should only be used if there is a hands-free option available.
Mobile phones should only be used if there is a hands-free option available. Only hands-free mobile phones can be used when driving, and text messaging is prohibited due to the risk for distraction. Small children should only sit in the back of the motor vehicle, especially if there is a passenger side airbag. Only medications with side effects such as fainting or dizziness should be avoided. Helmets should always be worn when riding motorcycles, all-terrain vehicles, motorized scooters, bicycles, horses, and snowmobiles.
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? Stiffness in the right shoulder Difficulty with swallowing Previous injuries to the head and neck Changes in sleeping habits
Previous injuries to the head and neck 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.
A family member of a client recovering from a traumatic brain injury asks the nurse what safeguards can be put in place at home to prevent future head injuries. What should the nurse instruct this family member? (Select all that apply.) Remove extension cords from high traffic areas Avoid the use of throw rugs Avoid taking medications that cause faintness Always sit to have a shower Use rails on stairs
Remove extension cords from high traffic areas Avoid the use of throw rugs Use rails on stairs To avoid traumatic head injuries, the nurse should instruct the family member to use the rails when ascending and descending the stairs. Extension cords pose a tripping hazard and should be concealed or kept in areas that are not frequently used. Throw rugs are a tripping hazard and are best removed. It is not necessary to encourage the client to always sit in the shower. Instead, the nurse should recommend that grab bars or non-slip mats be used in the shower. Medications with side effects that cause faintness may be prescribed and necessary to effectively treat the client. The nurse should not recommend that the client avoid taking these medications. Rather, the nurse should offer client teaching to ensure precautions are taken moving from sitting to standing.
