Chapter 15 Health Assess

Which is the largest endocrine gland in the body?

Thyroid gland

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

approach the client posteriorly

what is the most common form of hyperthyroidism?

Graves disease

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. I will take my thyroid hormone replacement medication once every week. I must keep my follow up appointments to receive my thyroid hormone injections. I will complete the entire course of thyroid hormone replacement over six weeks.

I must take thyroid hormone replacement medication for the rest of my life.

most common lymph nodes:

preauricular postauricular tonsillar occipital submandibular submental superficial cervical posterior cervical deep cervical supraclavicular

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? Avoid asking the client to remove her clothes for the examination Have a nurse who is the same sex as the client perform the examination Palpate the client's feet before palpating the head Ask permission before palpating the head and neck

Ask permission before palpating the head and neck

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

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 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

what are the muscles that allow movement and support the neck and head?

The sternocleidomastoid and the trapezius

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 tissue underlying the nodes is infected. There is an inflammatory response in the musculature of the boy's neck. The boy requires assessment of his thyroid gland.

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

what do lymph nodes do?

Trap pathogens for destruction by white blood cells... filter lymph

which facial bone is moveable?

mandible- has free movement (up, down and sideways) at the temporomandibular joint)

What does the thyroid gland do?

produces thyroid hormones that increase the metabolic rate of most body cells

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 flex the neck to each side. swallow a small sip of water. cough deeply. inhale deeply.

swallow a small sip of water.

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? Paget's disease Unilateral vision Neurologic disorder Aortic insufficiency

Aortic insufficiency

A client is brought to the emergency department via ambulance after experiencing difficulty speaking and weakness in the left arm and leg. The nurse understands that the client is most likely experiencing which of the following disorders?

Cerebrovascular accident

When palpating the lymph nodes of the neck, the nurse assesses for which of the following characteristics? Congruency, induration, size, turgor Delineation, integrity, shape, color Consistency, delineation, mobility, tenderness Configuration, discreteness, temperature, color

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 client to take a safety course Encourage the use of safety equipment Teach proper posture, bending, and lifting Encourage proper nutrition to promote healing

Encourage the use of safety equipment

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 the health care provider. Administer acetaminophen for the pain. Continue to monitor the client. Document the findings.

Notify the health care provider.

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

A nurse is providing discharge teaching to a client newly diagnosed with migraine headaches. What should the nurse include in the teaching?

Resting may help relieve the headache.

A nurse is assessing a patient and detects enlarged lymph nodes, what else does the nurse need to know about the enlarged lymph node?

Where does the lymph receive drainage from. This will help the nurse know where to assess for abnormality in that area which may be producing abnormal drainage into the lymph node.

A nurse visits an older adult client at home in order to conduct a risk assessment for falls. Which factors would most likely increase the risk for falls for this client? Select all that apply. bathtubs in all bathrooms a throw rug in the dining room a television cord runs across the floor missing window guards no gate at the top and bottom of the stairs

bathtubs in all bathrooms a throw rug in the dining room a television cord runs across the floor

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

It is important never to bilaterally compress the _______

carotid arteries. This can reduce blood supply to the brain

Cushing's syndrome

caused by prolonged exposure to high levels of cortisol

When assessing an adult client experiencing diarrhea, the nurse notes a round "moon" face, a buffalo hump at the nape of the neck, and a velvety discoloration around the neck. What is the possible cause of these signs?

cushing's

8 cranial bones

frontal, parietal, temporal, occipital, sphenoid, ethmoid

14 face bones

maxilla 2, zygomatic 2, inferior conchae 2, nasal 2, lacrimal 2, palatine 2, vomer, mandible

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 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

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. decreased pulse pressure. premature ventricular heart sound. rapid rise in the client's pulse rate.

reduction of the blood supply to the brain.

A client's recent weight loss and diarrhea has been attributed to hyperthyroidism. When auscultating the client's thyroid gland, what assessment finding is most consistent with this diagnosis?

sound of turbulent blood flow in the thyroid

What does the 11th cranial nerve do?

the 11th cranial nerve is responsible for muscle movement that permits shrugging of the shoulders by the trapezius muscles and turning the head against resistance by the sternomastoid.

what is located bilaterally, parallel and anterior to the sternomastoid muscles?

the internal jugular veins and the carotid arteries

A client reports sharp, shooting, piercing facial pains that last from seconds to minutes. The nurse identifies these as signs and symptoms of which of the following disorders?

trigeminal neuralgia or tic douloureux

If healthy lymph nodes are palpable, though typically they are not, what might they feel like?

very small beads

what causes lymph node enlargement

when the node becomes overwhelmed by microorganisms (ex: mononucleosis), they swell and become painful

A client describes their frequent headaches as being severe and lasting for days. The client's positive response to what question would most clearly suggest to the nurse that these headaches are migraines? "Do you have any visual changes before the headache?" "When you consume alcohol, do you get a headache?" "Do they occur with nausea?" "Do you have any eye pain?"

"Do you have any visual changes before the headache?"

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? Effects of age-related changes Brain tumor Hyperthyroidism Hypothyroidism

Hypothyroidism

the neck is composed of...

muscles, ligaments, and cervical vertebrae

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. Avoid risky activities such as snowboarding. Wear nonslip shoes in the house. Use of guns should be supervised by an adult.

Always use seat belts.

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? Parkinson's disease Meningeal inflammation Trigeminal neuralgia Migraine headache

Meningeal inflammation

Teenagers doing community service following arrest for driving under the influence and 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? Fulfilling the court requirements Teaching them how to turn these clients every 2 hours Keeping the shelves restocked Educating them about not drinking and driving

Educating them about not drinking and driving

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