PrepU Review Questions, Chapter 15

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 in cervical spine may may present in the older adults as neck pain, decreased strength and sensation of the upper extremities.

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

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, excessive production of exogenous ACTH, can result in a round "moon" facies, fat deposits at the nape of the neck, "buffalo hump," and sometimes a velvety discoloration around the neck (acanthosis nigra).

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

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?

Lymphatics larger than 1 cm, fixed, irregular, or hard or rubbery require emergency investigation. Such signs raise the possibility of cancer

A client visits the outpatient center with a complaint of sudden head and neck pain and stiffness. The client's oral temperature is 37.7 °C (100 °F). The nurse suspects the client is experiencing symptoms of

Migraine Headache

A client presents to the health care clinic with reports of a stiff neck for the past three days. What objective information can the nurse obtain during the health history?

While collecting history, the nurse would be able to inspect the client to see how what position the head was being held.

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. The trachea may be pulled to the affected side in cases of large atelectasis, fibrosis or pleural adhesions.