Chapter 15: Assessing Head & Neck

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

tension

While performing an examination of the head and neck, a nurse notices left-sided facial drooping. The nurse recognizes this as what condition?

Bell's palsy

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 than others at home? Do you perspire less than others?

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

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?

Hormones affect the severity of migraine headaches

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

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

cardiovascular

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 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 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

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

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

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 cm 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, Tobacco use, Age older than 50 y

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 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

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?

headache

A client presents to the emergency department with reports of neck pain and a sudden onset of a headache. Upon examination, the nurse finds that the client has an increased temperature and neck stiffness. The nurse recognizes these findings as most likely to be caused by what condition?

meningeal inflammation

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?

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?

notify HCP

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

relieving factors

The nurse is assessing an elderly woman who reports lethargy and weakness. During the examination, the nurse notices that the client's face is drooping slightly on the right side. Why does this finding require emergency intervention?

the client could be experiencing stroke

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

The nurse in a community health clinic is preparing to assess the thyroid gland of a 22-year-old female client.

Position self to complete the assessment: stand behind the client Identify landmarks by palpation: identify thyroid and cricoid cartilages and thyroid isthmus Displace the thyroid gland for palpation: ask the client to swallow

Which of the following clients is most likely to be diagnosed with migraine headaches?

a woman whose headaches come on suddenly and are somewhat relieved by a quiet, dark room

A 66-year-old woman has come to the clinic with complaints of increasing fatigue over the last several months. She claims to frequently feel lethargic and listless and states that, "I can never seem to get warm, no matter what the thermostat is set at." How should the nurse proceed with assessment?

assess for hypothyroidism

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

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

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

auscultation

When palpating the lymph nodes of the neck, the nurse assesses for which of the following characteristics?

consistency, delineation, mobility, tenderness

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

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

A client complains of recurring headaches that are worse when first waking in the morning and with coughing or sneezing. What would be the nurse's most appropriate action?

perform a focused assessment

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

The nurse assesses an adult client's head and neck. While examining the carotid arteries, the nurse assesses each artery individually to prevent:

reduction of the blood supply to the brain

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

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

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

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 headached

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

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

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

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

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