Chap. 15: head&neck assessment

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? Cranial damage Arthritic changes of the cervical spine Muscle tension Bacterial thyroiditis

Arthritic changes of the cervical spine Arthritic changes in cervical spine may may present in the older adults as neck pain, decreased strength and sensation of the upper extremities. Bacterial thyroiditis has neck swelling and cranial damage may manifest as headaches or tension of the muscles

During the physical examination of a client, a nurse notes that a client's trachea has been pushed toward the right side. The nurse recognizes that the pathophysiologic cause for this finding is related to what disease process? Endocarditis Bronchitis Atelectasis Tuberculosis

Atelectasis

A nurse performs palpation of a client's lymph nodes. Which finding should be reported to the health care provider? Round and 8 mm in size Fixed to underlying tissue Soft in consistency Mobile from side to side

Fixed to underlying tissue

What structure is found midline in the tracheal area just beneath the mandible? Cricoid cartilage Hyoid bone Thyroid cartilage Adam's apple

Hyoid bone

During your physical examination of the patient 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

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? Deep scar Lymph node Muscle Cancer

Lymph node

what type of headache involves unilateral pain?

migraine and cluster

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

preauricular

Types of Headaches: (3 types here)

-Tension-Type headache -Migraine headaches -Cluster headaches

Which of the following clients is most likely to be diagnosed with migraine headaches? A woman whose headaches come on suddenly and are somewhat relieved by a quiet, dark room A woman who complains of recurrent headaches near the end of her workday spent at a computer station A man whose headaches are accompanied by severe light sensitivity but an absence of nausea A man who has sought care for treatment of his episodic headaches that occur several times each day

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

A nurse is caring for an adult client who has just undergone surgery to remove a thyroid tumor. The nurse is assessing for symptoms of hyperthyroidism. What are some of the symptoms of hypermetabolism? Select all that apply. Bradycardia Anxiety Headache Tachycardia Diarrhea

Anxiety Tachycardia Diarrhea Hyperthyroidism may present as an emergency, with symptoms of hypermetabolism in all systems. The most common sign is tachycardia, but other possibilities include diarrhea, anxiety, fever, weakness, and even psychosis, coma, or death. Nurses should recognize clients at greatest risk for this emergency state. Such clients include those with thyroid tumors and those who have undergone thyroid surgery. Signs of hypermetabolism do not include bradycardia or headache.

A nurse has performed a head and neck assessment of an adult patient and noted that the thyroid gland is not palpable. What is the nurse's most appropriate action? Position the patient supine and reattempt palpation Refer the patient to the primary care provider promptly Document this as an expected assessment finding Perform a focused endocrine assessment

Document this as an expected assessment finding

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? Brain tumor Hyperthyroidism Diabetes Impending stroke

Impending stroke

A client reports right-sided temporal headache accompanied by nausea and vomiting. A nurse recognizes that which condition is likely to produce these symptoms? Tension headache Migraine headache Bell's palsy Temporal arteritis

Migraine headache

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 provider 911

Upon inspection of a client with reports of a fever, the nurse notices that the client's earlobes are asymmetrical in appearance. The nurse recognizes that the most common cause for the asymmetry of the earlobes is what condition? Thyroid enlargement Parotid enlargement Acute pharyngitis Bell's palsy

Parotid enlargement Earlobe asymmetry can be due to parotid gland enlargement caused by an abscess or tumor.

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? Headache Range of motion of the arms and shoulders Shortness of breath Range of motion of the neck

Range of motion in neck. Acute situations that need emergency assessment and intervention include head or neck injuries, neck pain (may be cardiac), enlarged hard nodes (which may indicate cancer), and thyrotoxicosis. The other options are, therefore, incorrect.

A community health nurse is attending a seminar on headaches. What would this nurse learn is a red flag for headaches? Stiff neck Pain without new symptomatology Pain that is temporary Pain centered behind the eyes

Stiff neck

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? Migraine Tension Analgesic rebound Cluster

Tension

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? Flail chest Cardiac tamponade Severe neck fracture Tension pneumothorax

Tension pneumothorax

Tender and enlarged lymph nodes suggest:

an acute infection; non-tender and enlarged=cancer

abnormal finding for lymph node.

anything fixed and non-mobile.

The nurse has just completed a lymph node assessment on a 60-year-old healthy female patient. The nurse knows that most lymph nodes in healthy adults are normally:a. Shotty.b. Nonpalpable.c. Large, firm, and fixed to the tissue.d. Rubbery, discrete, and mobile.

b. Nonpalpable. childrens would be larger until puberty

A 57-year-old client reports, "I am having the worst headache I have ever experienced." Which action should the nurse perform next? Assess the client's blood pressure. Provide medication for pain relief. Review the client's medical record. Inquire about family history of headaches.

Assess the client's blood pressure. Onset of headache after the age of 50 paired with the statement the client has made here is considered a "red flag." The nurse should suspect this is a secondary headache or arising from another condition. Markedly elevated blood pressure could be indicative of imminent danger to the client's life. Assessment of the blood pressure should be the nurse's first action.

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

Consistency, delineation, mobility, tenderness

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? Increased blood pressure Feeling anxious Laboratory tests Increased heart rate

Laboratory tests

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 Scheduling a computerized tomography (CT) scan Scheduling a magnetic resonance imaging (MRI) scan Conducting a focused history interview Scheduling an electroencephalography (EEG)

Physical examination for neurologic changes Conducting a focused history interview

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

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

The nurse suspects an enlarged thyroid in a patient during the physical examination of the head and neck. What should the nurse do first? Listen over the thyroid with a stethoscope. Displace the trachea to the right. Ask the patient to sip and swallow water. Ask the client to lie down for further assessment

Ask the patient to sip and swallow water. In order to determine if the thyroid gland is enlarged, the first step in the physical assessment is to ask the client to sip some water, extend the neck and swallow. By doing so, the nurse can watch for upward movement of the thyroid gland and determine if the gland is enlarged. Once it confirmed that the thyroid gland is enlarged, it would be the next step for the nurse to listen over the lateral lobes with a stethoscope to detect a bruit. Displacing the trachea would not be part of the assessment; however, the nurse would need to inspect the trachea for deviations that may push it to one side. Assessment of the thyroid gland can be done while the client is sitting up from either an anterior or posterior approach. The assessment cannot be effectively done with the client lying down.

A client with a cervical spine injury reports chronic pain. What would be the most appropriate initial nursing intervention for this client? Educate the client regarding cervical spine pain. Discuss pharmacologic interventions. Work with medical team to evaluate possible surgery. Assess the client regarding characteristics of the pain.

Assess the client regarding characteristics of the pain.

When palpating the neck, performing which of the following techniques will help differentiate lymph nodes from a band of muscles? Palpating for lateral movement when the client swallows a sip of water Observing for hypertrophy when the client turns the head against resistance Applying pressure and assessing for induration Attempting to roll the structure up and down and side to side

Attempting to roll the structure up and down and side to side While lymph nodes may be rolled both up and down and side to side, muscles will not move in this manner. The other cited techniques do not differentiate between lymph nodes and muscles.

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 Changes in sleeping habits Difficulty with swallowing Stiffness in the right shoulder

Previous injuries to the head and neck

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?

posterior cervical

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

swallow a small sip of water.