Chapter 15: Assessing Head and Neck

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 Migraine Tension

Migraine Explanation: 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. (Chapter 15: Assessing Head and Neck - Page 299-300)

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 tumor-related headaches. cluster headaches. migraine headaches. tension headaches.

tension headaches. Explanation: Tension headaches are dull, tight, and diffuse. (Chapter 15: Assessing Head and Neck - Page 299-300)

What is the most common type of hyperthyroidism? Thyroid cancer Moon face Graves' disease Cushing's syndrome

Graves' disease Explanation: 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. (Chapter 15: Assessing Head and Neck - Page 287)

A nurse is preparing to examine a client from Southeast Asia who has been experiencing chronic headaches. Which of the following should the nurse do in light of this client's cultural background? Have a nurse who is the same sex as the client perform the examination Ask permission before palpating the head and neck Avoid asking the client to remove her clothes for the examination Palpate the client's feet before palpating the head

Ask permission before palpating the head and neck Explanation: Take care to consider cultural norms for touch when assessing the head. Some cultures (e.g., Southeast Asian) prohibit touching the head or touching the feet before touching the head. There is no need to avoid asking the client to remove clothes for the examination; removing clothing is not a particular concern related to this client's culture nor is it necessary for examination of the head and neck. Clients of certain conservative religious backgrounds may object to being assessed by a nurse of the opposite sex, but there is not enough information in this scenario to warrant such a concern. (Chapter 15: Assessing Head and Neck - Page 295)

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 parotid gland enlargement. Paget disease. acromegaly. Cushing syndrome.

acromegaly. Explanation: The skull and facial bones are larger and thicker in acromegaly. (Chapter 15: Assessing Head and Neck - Page 289)

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 tension headache. tumor-related headache. migraine headache. cluster headache

migraine headache. Explanation: The most common types of headaches are related to vascular (e.g., migraine), muscle contraction (tension), traction, or inflammatory causes. (Chapter 15: Assessing Head and Neck - Page 299-300)

While assessing an adult client's head and neck, the nurse observes asymmetry in front of the client's ear lobes. The nurse refers the client to the physician because the nurse suspects the client is most likely experiencing a/an lymph node abscess. parotid gland enlargement. neurologic disorder. enlarged thyroid.

parotid gland enlargement. Explanation: Asymmetry in front of the earlobes occurs with parotid gland enlargement from an abscess or tumor. (Chapter 15: Assessing Head and Neck - Page 290)

A client reports using pain medication and sitting in a dark room on the onset of a migraine headache. In which part of the subjective section of the physical examination should the nurse document this information? treatment onset location relieving factors

relieving factors Explanation: Relieving factors includes anything the client subjectively reports they have tried to make the migraine go away. Onset refers to when the migraine started. Location helps determine what part of the client's head the pain is localized within or where it radiates. Treatment refers to any assessment, support, or care the client has received from various health care providers. (Chapter 15: Assessing Head and Neck - Page 283)

The nurse is preparing to assess the lymph nodes of an adult client. The nurse should instruct the client to lie in a supine position. stand upright in front of the nurse. lie in a side-lying position. sit in an upright position.

sit in an upright position. Explanation: Have the client remain seated upright. Then palpate the lymph nodes with your fingerpads in a slow walking, gentle, circular motion. (Chapter 15: Assessing Head and Neck - Page 296)

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? C5 C7 C1 C3

C7 Explanation: 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. (Chapter 15: Assessing Head and Neck - Page 281)