Chapter 15- Assessing Head and Neck

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

tension Tension headaches are dull, tight, and diffuse.

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.

When assessing a client with Graves disease, how would you expect the thyroid gland to be?

Soft in Graves disease; firm in Hashimoto thyroiditis, malignancy. Benign and malignant nodules, tenderness in thyroiditis.

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

Which area should the nurse inspect for facial symmetry when performing a head and neck assessment?

nasal labial folds

The nurse suspects that a client has Cushing's syndrome. What assessment finding did the nurse use to make this clinical determination?

red cheeks

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. The trachea may be pulled to the affected side in cases of large atelectasis, fibrosis or pleural adhesions. The trachea is pushed to the unaffected side in cases of a tumor, enlarged thyroid lobe, pneumothorax, or with an aortic aneurysm.

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

swallow a small sip of water. Ask the client to swallow a small sip of water. Observe the movement of the thyroid cartilage, thyroid gland.

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.

When identifying the midline structures of the neck from the mandible to the sternal notch, the nurse notes the structures in what order?

Hyoid bone, thyroid cartilage, cricoid cartilage, isthmus of the thyroid

The nurse is performing a physical examination and notes an enlarged left supraclavicular lymph node. The nurse understands that this could be indicative of

metastasis

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?

node is fixed and rubbery

A community health nurse is attending a seminar on headaches. What would this nurse learn is a red flag for headaches?

stiff neck Limitation of neck mobility may be from muscle tension/strain or cervical vertebral joint dysfunction.

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?

C7

What does the nurse assess the face for? (Select all that apply.)

Note the client's facial expression and contours. Observe for asymmetry, involuntary movements, edema, and masses.

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

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

The nurse is planning to assess an adult client's thyroid gland. The nurse should plan to

approach the client posteriorly

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?

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 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

migraine

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

When examining the head, the nurse remembers that the anatomic regions of the cranium take their names from which of the following sources?

underlying bones

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 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.

When conducting a generalized assessment of a new client, what would the nurse focus upon when inspecting the neck?

During inspection of the neck, the nurse observes for lesions and limitations in movement. The nurse cannot assess strain, vertebral injury, or lymph node enlargement by inspection. The other options are incorrect because they are related to a focused inspection assessment.

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.

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 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 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 Palpation of the thyroid gland reveals important landmarks of the trachea. Such landmarks are noted when assessing for tracheal deviation, which accompanies a potentially life-threatening condition called tension pneumothorax. A deviation of the trachea does not indicate cardiac tamponade, flail chest, or a severe neck fracture.

Which area should the nurse inspect for facial symmetry when performing a head and neck assessment?

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 cannot be inspected as they are very small. Earlobe placement is not an appropriate method to determine facial symmetry.

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?

There is an infection in the area that these nodes drain. 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.

An adult client comes to the ED with a new onset of pain in his neck and jaw. What system requires emergency assessment?

cardiac Acute situations that need emergency assessment and intervention include head or neck injuries, neck pain (may be cardiac), enlarged hard nodes (which may indicate cancer), and thyrotoxicosis. The other options are, therefore, incorrect.

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?

parkinsons

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

A nurse needs to palpate a client's submandibular lymph nodes. Where should the nurse place her hands to do this?

On the medial border of the mandible The submandibular lymph nodes can be palpated on the medial border of the mandibular bone. Tonsillar nodes are found at the angle of the mandible on the anterior edge of the sternomastoid muscle. The occipital nodes can be palpated at the posterior base of the skull bone. Submental lymph nodes can be palpated a few centimeters behind the tip of the mandible.

The nurse is planning to assess a client's lymph nodes. Which set of nodes should the nurse assess first?

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 client complains of a headache over both temporal areas. What type of headache should the nurse suspect the client is experiencing?

tension Tension headaches often arise in the temporal areas. Cluster headaches typically occur behind the eyes. A throbbing, severe, unilateral headache that lasts 6-24 hours and is associated with photophobia, nausea, and vomiting suggests a migraine headache. Hypertensive is not a type of headache although individuals with hypertension may experience a headache upon arising in the morning.

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 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.

Where is the temporal artery palpated?

Above the cheek bone near the scalp line

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

Assess the client regarding characteristics of the pain. 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. While education is an appropriate intervention, it would not be addressed initially but rather after pain management interventions were implemented.

A 57-year-old client reports, "I am having the worst headache I have ever experienced." Which action should the nurse perform next?

Assess the client's blood pressure. 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.

A nurse is assessing a client with hyperthyroidism for the presence of a bruit. Which assessment technique should the nurse use?

Auscultation A bruit is a soft, blowing, swishing sound auscultated over the thyroid lobes with the bell of the stethoscope that is often heard in clients with hyperthyroidism because of an increase in blood flow through the thyroid arteries. A bruit can be elicited through auscultation in a client with hyperthyroidism. A bruit cannot be elicited through inspection, palpation, or percussion. Inspection can only reveal swelling of the neck and palpation can indicate only the enlarged mass.

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.

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?

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.

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

During a neck assessment, where would the nurse focus palpation of the thyroid isthmus?

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.

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 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.

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 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.

The nurse suspects an enlarged thyroid in a client during the physical examination of the head and neck. What should the nurse do first?

In order to determine if the thyroid gland is enlarged, the first step in the physical assessment is to ask the client to sip some water, extend the neck and swallow. By doing so, the nurse can watch for upward movement of the thyroid gland and determine if the gland is enlarged. Once it confirmed that the thyroid gland is enlarged, it would be the next step for the nurse to listen over the lateral lobes with a stethoscope to detect a bruit. Displacing the trachea would not be part of the assessment; however, the nurse would need to inspect the trachea for deviations that may push it to one side. Assessment of the thyroid gland can be done while the client is sitting up from either an anterior or posterior approach. The assessment cannot be effectively done with the client lying down.

During the physical examination of a 65-year-old client, the nurse finds that the pulsation of the temporal artery is weak. What is an appropriate action by the nurse for this client?

Recognize the weakened pulsation as an age-related change The nurse should consider the weakened pulse as an age-related change. The temporal arteries may have weak pulsation due to a decrease in the strength of the pulsation in old age. The nurse may check the blood pressure, but it is not the most appropriate action. The nurse may inform the physician, but the condition is not due to any underlying pathology. Decrease in the blood flow to the temporal artery will not affect the level of consciousness.

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?

The Headache Impact Test may be used to assess the impact of headache on a client's activities of daily living. A mnemonic assessment tool is used to assess for the character, onset, location, duration, severity, pattern, and associated factors of pain. It does not assess for the effect of pain on the client's activities of daily living. Auscultation is use of a stethoscope to assess the client's blood pressure, heart sounds, or respiration. The family health history portion of the interview is used to assess for health conditions of family members that might help shed light on the client's chief complaint.

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

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.

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?

graves

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?

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.

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 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.

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?

hypothyroidism

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 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.

What is the most common type of hyperthyroidism?

Grave's disease-diffuse toxic goiter that can occur at any age 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.

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 tumor 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.

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 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.