Chapter 15 - Assessing head and neck - health assessment

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 injury to the head or neck

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

Where is the temporal artery palpated?

Above the cheek bone near the scalp line

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 instruct a group of adolescents on ways to prevent traumatic brain injuries. What should be included in these instructions?

Always use seat belts

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 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?

Ask permission before palpating the head and neck

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 toughing the head is permissible

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 pathophysiological cause for this finding is related to what disease process?

Atelectasis

Which assessment technique should a nurse use to assess for the presence of a bruit in a client with hyperthyroidism?

Auscultation

The nurse practitioner notes that the thyroid gland is enlarged and auscultates both lobes of the thyroid. For what is the nurse practitioner listening?

Bruit

The nurse is palpating a client's neck as part of a physical assessment. Which of the following blood vessels should the nurse be especially careful to avoid bilaterally compressing during the assessment?

Carotid artery

Which risk factor for traumatic brain injury (TBI) should a nurse include in a discussion about prevention for a group of adolescents?

Concussions in sports and motor vehicle accidents cause the largest number of TBI's in teens

The nurse notes unilateral facial drooping and reports the finding immediately to the healthcare provider. The client is diagnosed with Bell palsy. The nurse should include assessment of which affected cranial nerve in the client's head and neck assessment?

Cranial nerve VII

Teenagers doing community service following arrest for driving under the influence 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

What is the most common type of hyperthyroidism?

Grave's disease

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 that 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 nurse does a health history. The patient states he has lost 30 pounds in the last couple months without really trying. The patient also states he feels warm all the time and sometimes feels like he has heart palpitations. The nurse would anticipate orders to evaluate the patient fo

Hyperthyroidism

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

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 sideline, a few centimeters behind the tip of the mandible

During your physical examination of the patient 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

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

In reviewing a client's health history, the nurse notes that the client has had a history of TMJ pain. The nurse recognizes that which of the following bones is involved in this dysfunction?

Mandible

What activity is known to aggravate a tension headache?

Mandible

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 nuchal rigidity. The nurse recognizes these findings as most likely to be caused by what condition?

Meningeal Inflammation

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 patient admitted with neck pain. The patient is febrile. What is the most likely medical diagnosis for this patient?

Meningitis

A client is being assessed for a headache. Symptoms include throbbing and severe pain lasting for the last 8 hours. The client also has a history of vomiting with the headache. What type of headache could these findings indicate?

Migraine

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 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 headache

A female client visits the clinic and tells the nurse that she wants to "stay healthy." The nurse observes that the client has diffuse neck enlargement, is perspiring, and is quite fidgety. The client tells the nurse that she is "hungry all the time, but I have lost weight." A priority nursing diagnosis for the client is

Migraine headache

Where should a nurse place the hands to palpate the submandibular lymph nodes?

On the medial border of the mandible

Which instruction to the client will help facilitate examination of the temporomandibular joint by the nurse

Open the mouth

Which instruction to the client will help facilitate examination of the temporomandibular joint by the nurse?

Open the mouth

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?

Parkinson's disease

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

The nurse is preparing to assess the lymph nodes of an adult client. The nurse should instruct the client to

Sit in an upright position

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

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 a referral to orthopedic spine specialist

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

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 headaches

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 a stroke

The nurse is caring for a patient who comes to the clinic reporting a lump by her ear. What are the symptoms of a cancerous lymph node?

The node is fixed and rubbery

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

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

While assessing the head and neck of an adult client, the client tells the nurse that she has been experiencing sharp shooting facial pains that last from 10 to 20 seconds but are occurring more frequently. The nurse should refer the client for possible

Trigeminal neuralgia

During the physical examination of a client, a nurse detects a thick and tender temporal artery. Which additional assessment should the nurse perform to rule out the possibility of temporal arteritis?

Vision Acuity

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.

-Tachycardia -Diarrhea -Anxiety

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 client suffering from a headache complains of throbbing, severe, unilateral pain that feels worse when exposed to bright lights. The client also complains of nausea and vomiting. What is the nurse's best action?

Administer migraine medication

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?

Arthritis

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?

Asses the women for hypothyroidism

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

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

Consistency, delineation, mobility, tenderness

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

When assessing the head and neck, the nurse should realize that variations in skull or neck shape or size relate most to what?

Height and weight

A client has an edematous face, hands, and legs. Which health problem should the nurse suspect this client is experiencing?

Hypothyroidism

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. The nurse also notes that the patient has gained 10 pounds since her last visit 9 months ago. What might the nurse suspect?

Hypothyroidism

The nurse feels a small mass in the neck of a client. It is mobile in both the up-and-down and side-to-side directions. Which of the following is the nurse most likely feeling?

Lymph node

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

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

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

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

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

A female client visits the clinic and tells the nurse that she wants to "stay healthy." The nurse observes that the client has diffuse neck enlargement, is perspiring, and is quite fidgety. The client tells the nurse that she is "hungry all the time, but I have lost weight." A priority nursing diagnosis for the client is

Health-seeking behaviors related to verbalization of wanting to stay healthy and concerns over weight loss.

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

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

Red cheeks

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

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