n114 c 15

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

tension

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.

When the nurse is preparing to assess the thyroid gland of a client with suspected hypothyroidism, why is it important to bring a cup of water to the physical examination?

to observe the movement of the thyroid gland

examining the head ,the nurse remembers that the anatomic regions of the cranium take their names from which >

underlying bones

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?

vii

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

Attempting to roll the structure up and down and side to side

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

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

Which factor, if present in a client's lifestyle and health practices assessment, would alert the nurse to the need for performing a more thorough head and neck assessment? Select all that apply.

Alcohol abuse Recreational drug use Smokeless tobacco use Multiple sex partners

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

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 suspects an enlarged thyroid in a client during the physical examination of the head and neck. What should the nurse do first?

Ask the client to sip and swallow water.

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 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 the woman for hypothyroidism.

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

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

Auscultation

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

A nurse performs palpation of a client's lymph nodes. Which finding should be reported to the health care provider?

Fixed to underlying tissue

What is the most common type of hyperthyroidism?

Graves disease

What structure is found midline in the tracheal area just beneath the mandible?

Hyoid bone

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

During a neck assessment, where would the nurse focus palpation of the thyroid isthmus?

Just below the cricoid cartilage

In addition to noting the physical characteristics of the thyroid gland, which of the following signs would be most important to consider in determining if the client has hypothyroidism?

Laboratory tests

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

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 years

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

When preparing to provide education regarding the prevention of head injuries from motor vehicle accidents, the nurse should be sure to include which point?

Mobile phones should only be used if there is a hands-free option available

An older adult presents at the clinic with reports of a painful neck. On palpation, the nurse notes a hard, nonmovable mass, approximately 20 mm, that is painful to touch. The area seems to have several nodes matted together. How would the nurse chart this last finding?

Nodes are delimited on palpation

During the physical examination of a 65-year-old client, the nurse finds that the pulsation of the temporal artery is weak. What is an appropriate action by the nurse for this client?

Recognize the weakened pulsation as an age-related change

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

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 performing a physical examination and notes an enlarged left supraclavicular lymph node. The nurse understands that this could be indicative of

a metastasis

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

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

approach the client posteriorly.

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 57-year-old cl rep worst headache ever xp, Next act

ass cl bp

phys exam of cli, nurse notes cl. traches pushed R, recognizes the pathophys cause is related to dz

atelectasis

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

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

palp= cl thyr gl =enlarged, health probl ass?

graves dz

ass cl w chr headache 2 determ affect adl, interv implemented?

headache impact test

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

ht and wt

id midline struct of neck from mandible to sternal notch, the nurse notes the struct in what order>

hyoid bone, thyroid cart, cricoid cart, isthmus of thyr

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

ass a cl 4 unrel health conc, cl xp a sudden, sev headache w no cause. dizzy and trouble seeing out of 1 eye. assoc condit should nurse suspect

impending stroke

As the nurse palpates the lymph nodes of the neck, hard and fixed nodes are noted in the supra-clavicular region. This finding is consistent with which condition?

malignancy

The nurse assesses a client with noisy breathing including a gasping sound with respiration. The nurse notes tracheal deviation from the usual midline position. Which conditions should the nurse assess for further? Select all that apply

mediastinal mass atelectasis pneumothorax goiter

A nurse is performing a head and neck assessment on a client. Which area should the nurse inspect for facial symmetry?

nasolabial folds

The nurse is planning to assess a client's lymph nodes. Which set of nodes should the nurse assess first?

preauricular

A 16-year-old white female is brought to the clinic by her mother with a chief complaint of a severe headache lasting more than 24 hours. The mother states, "Just before the headache started my daughter was craving food. I couldn't feed her enough." What is this called?

prodrome

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 conducts the physical examination of a client with a diagnosis of chronic obstructive pulmonary disease. The nurse observes the point of maximal impulse (PMI) is located in the epigastric region. What condition explains this finding?

right ventricular hypertrophy

A community health nurse is attending a seminar on headaches. What would this nurse learn is a red flag for headaches?

stiff neck

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?

Range of motion of the neck

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

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

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

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

open the mouth

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 nurse has performed a head and neck assessment of an adult client and noted that the thyroid gland is not palpable. What is the nurse's most appropriate action?

Document this as an expected assessment finding

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

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.

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

refer the client to a physician for further evaluation.

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

A client comes to the trauma unit in respiratory distress following a motor vehicle accident. On examination, the nurse notices that the trachea is deviated from the midline. What does this finding indicate?

tension pneumothorax

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

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's lab results reveal thyroid stimulating hormone level of 7.0 mU/L; Free T4 0.5 ng/dl; Total T3 60 ng/dl; and Total T4 3mdmg/dl. Based on these lab results what symptoms should the nurse expect the client to reveal?

Fatigue, cold intolerance, and constipation.

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?

Notify the healthcare provider immediately.

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 presents at the emergency room reporting "the worst headache I have ever had." What are the critical initial nursing interventions for this client? (Select all that apply.)

Physical examination for neurologic changes Conducting a focused history interview

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 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

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 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.

When conducting a generalized assessment of a new client, what would the nurse focus upon when inspecting the neck

Limitations in movement

The nurses assesses the thyroid gland of a client with recent weight loss. On auscultation, a low, soft, rushing sound is heard over the lateral lobes. Which condition is most likely?

hyperthyroidism

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

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

parotid gland enlargement

A college student presents with a sore throat, fever, and fatigue for several days. Exudates are on her enlarged tonsils. A careful lymphatic examination reveals some scattered small mobile lymph nodes just behind her sternocleidomastoid muscles bilaterally. What group of nodes is this?

post cervical

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?

sign of cancer

A 29-year-old computer programmer comes to the office for evaluation of a headache. The tightening sensation of moderate intensity is located all over the head. It used to last minutes, but this time it has lasted for 5 days. He denies photophobia and nausea. He spends several hours at a computer monitor/keyboard. He has tried over-the-counter medication; it has dulled the pain, but not taken it away. Based on this description, what is the most likely diagnosis?

tension

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 headache.

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

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

A male college student presents to the student health clinic with reports of night-time headaches for the past 2 weeks. He denies nausea or photosensitivity but states that he has noticed his eyes are tearing and his nose runs a lot. He is stressed because of final exams and confesses to drinking more alcohol than normal. The nurse recognizes these findings as indicative of what type of headache?

cluster

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

cluster headaches