Chapter 14/15 - Head and Neck
An older adult client is admitted to the hospital after a fall during which the client's head was injured. While performing the admission assessment, the nurse finds a large ecchymosis over the C7-T1 area. The client reports tenderness on palpation and movement. What would be an appropriate nursing diagnosis for this client?
Impaired comfort related to possible neck injury Diagnosis of a cervical spine injury is challenging and, in many cases, goes undiagnosed, especially in those lacking adequate health insurance. Clients at risk include those following a fall or collision and those with osteoporosis, advanced arthritis, cancer, or degenerative bone disease. The scenario does not indicate that the client is on bed rest or that the client has a limited range of motion.
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
tumor-related headache.
What does the nurse assess the face for? (Select all that apply.)
Asymmetry Edema Involuntary movements
An adult client is admitted to the hospital with severe diarrhea. When assessing the client, the nurse notes a round "moon" face, a buffalo hump at the nape of the neck, and a velvety discoloration around the neck. What are these signs indicative of?
Cushing's syndrome
A client presents to the health care clinic with reports of a stiff neck for the past three days. What objective information can the nurse obtain during the health history?
Head position While collecting history, the nurse would be able to inspect the client to see how what position the head was being held. Range of motion would require the nurse to give the client commands while trying to obtain other information. Neck tenderness and thyroid size would require the use of palpation, not inspection.
A client diagnosed with goiter has undergone a thyroidectomy. Which statement from the client indicates understanding of post-operative care teaching?
I must take thyroid hormone replacement medication for the rest of my life.
A normal assessment of the neck would include palpation of the thyroid isthmus. Where would the nurse find the isthmus?
Just below the cricoid cartilage
Which risk factor for traumatic brain injury should a nurse include in a discussion about prevention for a group of adolescents?
Modes of transportation are the leading cause All modes of transportation, such as motor vehicle & bicycles, are the leading cause of traumatic brain injuries for people age 5 to 64 years. Males have twice the risk of females. Firearm injuries are high in the violence category and two thirds are suicidal in intent. Fall occur most frequently in the over 65 years of age population.
An older adult presents at the clinic with reports of a painful neck. On palpation, the nurse notes a hard, nonmovable mass, approximately 20 mm, that is painful to touch. The area seems to have several nodes matted together. How would the nurse chart this last finding?
Nodes are delimited on palpation Usually, no lymph nodes are palpable in the adult. If a node is palpable, it is important to describe the following characteristics: location—which lymphatic chain and where along that chain is the node; size—in mm or cm; consistency—how hard or soft is the node; mobility—it should be freely movable; delimitation—there should not be any matting together of lymph nodes. The other options are distracters for the question.
A nurse palpates an elderly client's thyroid and detects an enlargement over the right lateral lobe. What action should the nurse take first?
Auscultate with the bell over the lateral lobes
The nurse is assessing a client's parathyroid gland. Which is the most likely finding the nurse will encounter with hyperparathyroidism?
Decreased serum calcium level on review of labwork.
A client presents to the health care clinic with reports of a stiff neck for the past 3 days. What objective information can the nurse obtain during the health history using inspection?
Head position
Upon inspection of a client with reports of a fever, the nurse notices that the client's earlobes are asymmetrical in appearance. The nurse recognizes that the most common cause for the asymmetry of the earlobes is what condition?
Parotid enlargement
A young adult client has just had X-rays and computed tomography scanning of the head and neck following a mountain bicycling accident. All results are negative. What should the nurse assess for next?
Range of motion of the neck
A client visits the outpatient center with a complaint of sudden head and neck pain and stiffness. The client's oral temperature is 37.7 °C (100 °F). The nurse suspects the client is experiencing symptoms of
The most common types of headaches are related to vascular (e.g., migraine), muscle contraction (tension), traction, or inflammatory causes.
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
A client has an edematous face, hands, and legs. Which health problem should the nurse suspect this client is experiencing?
hypothyroidism
A patient with hypothyroidism is admitted to the medical unit. The nurse would expect to assess which signs/symptoms? Select all that apply.
lethargy constipation cool skin lower systolic blood pressure
As the nurse palpates the lymph nodes of the neck, hard and fixed nodes are noted in the supra-clavicular region. This finding is consistent with which condition?
malignancy Hard or fixed nodes, particularly in the supra-clavicular region of the neck, suggest a malignancy. This could even be a possible metastasis of a thoracic or abdominal malignancy. Although inflamed or enlarged nodes may be tender on palpation, the node should still be mobile. In hypothyroidism, the thyroid gland may be enlarged, but discovering hard or fixed nodes warrants further assessment for malignancy.
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?
"Do you have difficulty swallowing? 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.
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 The supraclavicular lymph nodes are located by hooking the fingers over the clavicles and feeling deeply between the clavicles and the sternomastoid muscles. Normally, these lymph nodes should not be palpable. An enlarged, hard, nontender left-sided supraclavicular node may be an indication of malignancy of the abdomen or thorax. Enlarged, hard, and nontender supraclavicular nodes would not affect sensation, movement, or range of motion. Infection or inflammation in the head and neck region most often enlarges the nodes closest to the site affected, such as preauricular or postauricular with ear infections. Degeneration within the spinal cord does not affect lymph nodes.
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?
Aortic insufficiency 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 male college student presents to the student health clinic with reports of night-time headaches for the past 2 weeks. He denies nausea or photosensitivity but states that he has noticed his eyes are tearing and his nose runs a lot. He is stressed because of final exams and confesses to drinking more alcohol than normal. The nurse recognizes these findings as indicative of what type of headache?
Cluster headaches occur more often in young males, have a sudden onset, and may be precipitated by ingestion of alcohol. The headaches typically occur in the evening and are localized to the eyes, with radiation into the facial and temporal areas. The person may report tearing of the eye or runny nose. Migraine headaches are accompanied by nausea, vomiting, and sensitivity to light and sound. Tension headaches occur more frequently in females and are usually a result of stress, anxiety, or depression.
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?
Enlargement of a node may be a sign of pathology that is distant from that node. It is important to understand the drainage patterns of the lymphatics because enlargement of a node may be a sign of pathology that is not directly adjacent to that node.
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?
Headache Impact Test
When conducting a generalized assessment of a new client, for what would the nurse inspect the neck?
Limitations in movement
A client has an edematous face, hands, and legs. Which health problem should the nurse suspect this client is experiencing?
Manifestations of hypothyroidism include an edematous face, hands, and legs. Manifestations of scleroderma include a hardening face with thinning facial skin. Manifestations of hyperthyroidism include warm, smooth, moist skin and exophthalmos. Manifestations of Cushing's syndrome include a moon-shaped face with reddened cheeks and increased facial hair.
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.
A client complains of pain, numbness, and tingling in the upper extremities for several weeks before coming to the clinic for evaluation. What is the nurse's best action?
Suggest referral to orthopedic spine specialist. Pain, numbness, or tingling may indicate compression of spinal root nerves, requiring further evaluation, preferably by a spine specialist. Limited range of motion with pain is most indicative of arthritis, not spinal nerve root compression. Neck exercises do not relieve nerve compression; the client needs further evaluation first. Signs of head injury include changes in level of consciousness and orientation and behavior changes.
The nurse is performing an assessment of the neck and identifies tracheal deviation. What is the most appropriate response of the nurse?
Tracheal deviation is an emergency and the health care provider should be notified immediately. The client should be provided nursing care and further head and neck assessment along documentation can occur once emergency has subsided.
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
A nurse is examining a client's goiter and explaining the characteristics and functions of the thyroid gland. Which of the following should the nurse mention? Select all that apply.
Largest endocrine gland in the body Produces hormones that increase the metabolic rate of most body cells Consists of two lateral lobes Covered mostly by the sternomastoid muscles
Which type of vessels filter pathogens from the body and drain the fluid that has moved outside of the circulation back into the vessels?
Lymphatic
The nurse is presenting an educational event for a local civic group about the risk factors for neck cancer. What would the nurse list? (Select all that apply.)
Male gender Tobacco use Age older than 50 years
The nurse is planning to assess an adult client's thyroid gland. The nurse should plan to
approach the client posteriorly. Explanation: 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 performing a head and neck assessment on a client. Which area should the nurse inspect for facial symmetry?
Nasolabial folds The nasolabial folds are ideal places to check facial features for symmetry. Inspection of the temporomandibular joint cannot elicit facial symmetry. Preauricular nodes are common head and neck lymph nodes that are not inspected but palpated. Earlobes are not an appropriate feature to use to determine facial symmetry.
The client is having a thyroid crisis. What symptoms would the nurse assess for? Select all that apply.
Clients experiencing a thyroid crisis may present with tachpnea, tachycardia, nausea, vomiting, diarrhea, abdominal pain and anxiety. Neck swelling may be related to hypothyroidism or acute bacterial thyroiditis.
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 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 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 low, soft, rushing sound is a systolic or continuous bruit commonly heard in hyperthyroidism. A bruit is not commonly auscultated in Hashimoto thyroiditis. Identifying characteristics of this condition include enlarged, firm, and rubbery thyroid glands with no bruit. Thyroid cysts and benign malignancies would not have a low, soft, rushing sound that can be auscultated.
The nurse is preparing to assess a client's thyroid gland using the posterior approach. What direction should the nurse provide regarding the client's head?
flex the neck forward When assessing the thyroid gland from the posterior approach the client should flex the neck forward to relax the neck muscles. Tilting the head back would be used if assessing the thyroid gland using the anterior approach. Turning the head to the right or left shoulder would be done later in order to further assess the individual thyroid gland lobes.
A client's lab results reveal thyroid stimulating hormone level of 7.0 mU/L; Free T4 0.5 ng/dl; Total T3 60 ng/dl; and Total T4 3mdmg/dl. Based on these lab results what symptoms should the nurse expect the client to reveal?
The client's lab values are consistent with hypothyroidism. Fatigue, cold intolerance, constipation, depression, anorexia, dry skin, brittle and coarse hair, menstrual irregularities, and weight gain are all symptoms of hypothyroidism. All other symptoms in the answer options are indicative of hyperthyroidism.
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.)
Use rails on stairs Remove extension cords from high traffic areas Avoid the use of throw rugs. 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.
The nurse assesses a client with noisy breathing including a gasping sound with respiration. The nurse notes tracheal deviation from the usual midline position. Which conditions should the nurse assess for further? Select all that apply.
mediastinal mass atelectasis pneumothorax goiter A mediastinal mass is any large mass of the lung, bronchi or pleural cavity, benign or malignant, that can cause a shift of the trachea from the normal midline position. Atelectasis refers to the diminished lung volume from either a blockage or inability to inflate the lungs fully. The decreased pressure associated with this problem could shift the trachea. Pneumothorax is a part or complete collapse of the lung due to abnormal air entry to the pleural space causing lung compression. This leads to little or no expansion of the lungs on inspiration. As a result, the trachea shifts. A goiter is an enlargement of the thyroid gland. The enlargement can impede upon the trachea shifting it from the midline position. The preauricular node is located in the front of the ear. Its location is not near the trachea.
A client presents to the health care clinic with reports of a 12-pound unintentional weight loss despite being hungry all the time, profuse sweating, and swelling around the anterior neck area. The client states she does not have insurance and cannot afford to see a regular health care provider. What nursing diagnosis can the nurse confirm from this data?
Health Seeking Behaviors The client has expressed the desire to seek assistance for her health issues even though she cannot afford a regular health care provider. There is not data to support Imbalanced Nutrition because the client state she is hungry all the time. More data needs to be collected about how much the client is eating. Major defining characteristics for Ineffective Health Maintenance do not exist even thought the client does not have insurance because she is at the health care clinic. To confirm the diagnosis of Alteration in Fluid Balance, the nurse needs to perform further assessment.
A 57-year-old client reports, "I am having the worst headache I have ever experienced." Which action should the nurse perform next?
Onset of headache after the age of 50 paired with the statement the client has made here is considered a "red flag." The nurse should suspect this is a secondary headache or arising from another condition. Markedly elevated blood pressure could be indicative of imminent danger to the client's life. Assessment of the blood pressure should be the nurse's first action.
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
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 is experiencing pain around the eye that radiates to the face and temporal area. Which image diagrams this client's pain?
A cluster headache is localized in the eye and orbit and radiates to the facial and temporal regions. A sinus headache occurs along the eyebrows and below the cheek bone. A tension headache is usually located in the frontal, temporal, or occipital region. A migraine headache is usually located around eyes, temples, cheeks, or forehead and may affect only one side of the face.
A nurse palpates an enlarged and tender 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
A nurse needs to examine a client's thyroid as part of the head and neck assessment. How should the nurse instruct the client to position the head in order to best facilitate this exam?
Flex the head toward the side being examined
While the nurse is assessing a client for an unrelated health concern, the client experiences a sudden, severe headache with no known cause. He also complains of dizziness and trouble seeing out of one eye. What associated condition should the nurse suspect in this client?
Impending stroke 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 nurse is caring for an adult client who has just undergone surgery to remove a thyroid tumor. The nurse is assessing for symptoms of hyperthyroidism. What are some of the symptoms of hypermetabolism? Select all that apply. Headache Diarrhea Tachycardia Anxiety
Tachycardia Diarrhea Anxiety Hyperthyroidism may present as an emergency, with symptoms of hypermetabolism in all systems. The most common sign is tachycardia, but other possibilities include diarrhea, anxiety, fever, weakness, and even psychosis, coma, or death. Nurses should recognize clients at greatest risk for this emergency state. Such clients include those with thyroid tumors and those who have undergone thyroid surgery. Signs of hypermetabolism do not include bradycardia or headache.
A 29-year-old computer programmer comes to the office for evaluation of a headache. The tightening sensation of moderate intensity is located all over the head. It used to last minutes, but this time it has lasted for 5 days. He denies photophobia and nausea. He spends several hours at a computer monitor/keyboard. He has tried over-the-counter medication; it has dulled the pain, but not taken it away. Based on this description, what is the most likely diagnosis?
Tension
The nurse 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 preparing to palpate a client's trachea. Which technique should the nurse use?
The thumbs are located at the base of the neck when palpating the trachea. The fingers are on either side of the neck when palpating the thyroid gland. The fingers are located right beneath the ears when palpating the tonsillar nodes. The fingers are located near to the chin when palpating the submandibular nodes.
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
The nurse is conducting a physical examination of a client who reports finding a lump in the neck. Which of the following questions should be included in when the nurse is collecting subjective data? (Select all that apply). When did you first notice the lump? Has the lump changed? Is it painful to touch? How recently have you consumed alcohol?
When did you first notice the lump? How recently have you consumed alcohol? Has the lump changed? Asking the client when the lump was first noticed is included in the subjective data set in the onset section. Asking the client if alcohol has recently been consumed is included in the subjective data set in associated manifestations section. Asking the client whether the lump has changed is included in the subjective data set in the characteristic symptoms section. Assessing for familial experience with the client's chief complaint would be included in health history. The objective examination would provide the nurse with information regarding the experience of pain from the lump.
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
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.
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
The nurse would expect to assess which symptoms in a patient complaining of migraine headaches? Select all the apply.
throbbing photophobia recurrent
