PREP U - head and neck
A community health nurse is attending a seminar on headaches. What would this nurse learn is a red flag for headaches?
- pain centered behind the eyes - pain that is temporary - pain that is temporary **neck pain
The nurse is assessing the head and neck of a 51-year-old male client. Following inspection and palpation of the client's thyroid gland, the nurse determines that the gland is enlarged. What is the next action that the nurse should perform?
Ascultate the thyroid
Nurse notes the trachea is pushed to the right side. What is this disease?
Atelactasis
When identifying the midline structures of the neck from the mandible to the sternal notch, the nurse notes the structures in what order?
Hyoid bone, thyroid cartilage, cricoid cartilage, isthmus of the thyroid
Patient with weak, bilateral pulses. What does this indicate?
Hypovolemia
A normal assessment of the neck would include palpation of the thyroid isthmus. Where would the nurse find the isthmus?
Just above the thyroid cartilage Between the thyroid and the cricoid cartilages **Just below the cricoid cartilage In front of the sternocleidomastoid muscle
Upon inspection the nurse notes asymmetrical earlobes. What causes this?
Parotid enlargment
practitioner notes enlarged thyroid gland and auscultates both lobes. what is she listening for
a bruit
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 mastastasis
enlarged and tender supraclavicular nodes. where should she focus the assessment?
abdomen and thoracic area for changes with malignancy
where would you palpate the submental nodes
behind tip of the mandible
Client with heart failure most likely has
ineffective tissue disease
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 to physician for further assessment
What type of lighting should the nurse use during the physical exam of the thyroid
tangential lighting
A client complains of a headache over both temporal areas. What type of headache should the nurse suspect the client is experiencing?
tension
The thyroid gland is usually larger in women than in men. True or false
true
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
a tumor- related headache
Parkinsons disease patients will exhibit:
mask- like expression `
Upon assessment, the nurse finds the client's systolic blood pressure to be 88; heart rate of 121 and a lactate level of 2.3. The nurse recognizes the client is experiencing what?
**Severe sepsis Increased intracranial pressure Cardiac dysrhythmias Surgical site infection
Patient reports neck pain and sudden onset of headache. Client has an increased temperature and nuchal rigidity. What condition?
Meningeal inflammation
patient with intermittent facial pains lasting for several minutes. These findings are suggestive of what
Trigeminal neuralgia
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?
a sound of turbulent blood flow in the thyroid
A community health nurse is planning a health promotion campaign that will focus on cancer prevention. Which educational intervention should the nurse select in order to most influence participants' risks of head and neck cancers?
a smoking cessation program
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
The nurse is preparing to palpate the submandibular salivary glands. The nurse would place the hands at which location?
On each side of the client's face, anterior and inferior to the ears On each side between the top of the ear and the eye Bilaterally, parallel to and anterior to the sternomastoid muscle **Inferior to the mandible beneath the tongue
nurse detects enlarged, tender, preauricle nodes. which would nurse examine for infection?
eyes
Examining the clients thyroid. How should the nurse position the client?
flex toward side being examined
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
What structure is found midline in tracheal area beneath the mandible?
hyoid bone
A client has an edematous face, hands, and legs. Which health problem should the nurse suspect this client is experiencing?
hypothyroidism