Health Assessment Chapter 15

sublingual gland

a salivary gland on either side of the tongue

The nurse assesses an adult client's head and neck. While examining the carotid arteries, the nurse assesses each artery individually to prevent a a. reduction of the blood supply to the brain b. rapid rise in the client's pulse rate c. premature ventricular heart sound d. decreased pulse pressure

a. reduction of the blood supply to the brain

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 a. parotid gland enlargement b. acromegaly c. Paget disease d. cushing syndrome

b. acromegaly

vertebra prominens

cervical vertebra (C7) that can be easily palpated when the neck is flexed

An older client visits the clinic accompanied by his daughter. The daughter tells the nurse that her father has been experiencing sever headaches that usually beginin 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 futher evalus=ation because these symptoms are characteristic of a a. migraine headache b. cluster headache c. tension headache d. tumor-related headache

d. tumor-related headache

cricoid cartilage

ring-like cartilage forming the lower and back part of the larynx

cranial nerve XI

spinal accessory nerve-contraction of trapezius and sternocleidomastoid muscles.

trachea

the air passage extending from the throat and larynz to the main bronchi

thyroid gland

the largest of the endocrine glands, situated in the front and sides of the neck just below the thyroid cartilage

Parotid gland

the largest of the three main parts of salivary glands, located on either side of the face, just below and in front of the ears

adam's apple

the thyroid cartlage located just above the cricoid cartilage

hyoid bone

a horseshoe-shaped bone at the base of the tongue; the only bone in the body not directly attached to another bone

THe nurse is preparing to perform a head and neck assessment of an adult client who has immigrated to the US for Cambodia. The nurse should first a. explain to the client why the assessment is necessary b. ask the client if touching the head is permissible c. determine whether the client desires a family member present d. examine the lymph nodes of the neck before examining the head

b. ask the client if touching the head is permissible

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 a. cluster headaches b. migraine headaches c. tensio headaches d. tumor-related headaches

a. cluster headaches

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 a. migraine headache b. cluster headache c. tension headache d. tumor-related headache

a. migraine headache

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 a. ask the client to flex his neck to the left side b. observe whether the client has difficulty swallowing water c. refer the client to a physician for further evaluation d. palpate the cricoid cartilage for smoothness

c. refer the client to a physician for further evaluation

trapezius and sternocleidomastoid

paired muscles that allow movement and provide support to the 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 a. cluster headaches b. tumor-related headaches c. migraine headaches d. tension headaches

d. tension headaches

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 occuring more frequently. The nurse should refer the client for possible a. cancerous lesions b. arterial occlusion c. inner ear disease d. trigeminal neuralgia

d. trigeminal neuralgia

The nurse is planning to assess an adult client's thyroid gland. The nurse should plan to a. ask the client to raise the chin b. approach the client posteriorly c. turn the client's neck slightly backward d. place the fingers above the cricoid cartilage

b. approach the client posteriorly

A client visits the outpatient center with a complaint of sudden head and neck pain and stiffness. The client's oral temperature is 37.7C (100F). The nurse suspects the client is experiencing symptoms of a. migraine headache b. meingeal irritation c. trigeminal neuralgia d. otitis media

b. meingeal irritation

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

b. swallow a small sip of water

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 perpiring, and is quite fidgety. The client tells the nurse that she is "hungry all the time, but I have lost weight." A priority nursing dagnosis for the client is a. imbalanced nutrition: less than body requirements related to excessive energy level and nervousness b. ineffective health maintenance related to increased metabolism, diaphoresis, and hunger c. health-seeking behaviors related to verbalization of wanting to stay healthy and concers over weight loss d. thyroid dysfunction related to neck swelling, perpiration, and fidgeting and concern over weight loss

c. health-seeking behaviors related to verbalization of wanting to stay healthy and concers over weight loss

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

d. parotid gland enlargement

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

d. sit in an upright position