Chapter 12: Head and Neck, with Basic Vision and Hearing Basics
The nurse recognizes that which client is at greatest risk for the development of skin cancer?
55-year-old male who lived in California for 20 years
The nurse's assessment reveals that a male client can neither turn his head against resistance nor shrug his shoulders. The nurse should document a potential deficit in the functioning of which cranial nerve?
Accessory (XI)
Which of the following would the nurse suspect if assessment reveals a skull and facial bones that are larger and thicker than normal?
Acromegaly
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
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
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
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
Which assessment technique should a nurse use to assess for the presence of a bruit in a client with hyperthyroidism?
Auscultation
Which vessel is the nurse assessing if the major artery of the neck is being examined?
Carotid
A nurse observes the presence of hirsutism on a female client. The nurse should perform further assessment on this client for findings associated with which disease process?
Cushing's disease
The nurse is assessing a client's parathyroid gland. Which is the most likely finding the nurse will encounter with hyperparathyroidism?
Decreased serum calcium level on review of lab work.
A nurse has completed the assessment of an older adult client's head and neck and is now analyzing the assessment findings. Which finding should the nurse attribute to age-related physiological changes?
Decreased strength of temporal artery pulsations
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 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
What is the most common type of hyperthyroidism?
Graves' disease
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
When talking to a client before starting the physical exam, the nurse notes that the client consistently tilts her head to one side. What would the nurse examine first?
Hearing acuity
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.
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
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
The nurse is assessing the face of a client with a diagnosis of Parkinson's disease. What would the nurse most likely assess?
Mask-like expression
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 nuchal rigidity. The nurse recognizes these findings as most likely to be caused by what condition?
Meningeal inflammation
A client reports right-sided temporal headache accompanied by nausea and vomiting. A nurse recognizes that which condition is likely to produce these symptoms?
Migraine headache
A nurse is performing a head and neck assessment on a client. Which area should the nurse inspect for facial symmetry?
Nasolabial folds
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.
The nurse is preparing to palpate a client's temporal artery. The nurse would place the hands at which location?
On each side between the top of the ear and the eye
Where should a nurse place the hands to palpate the submandibular lymph nodes?
On the medial border of the mandible
Which instruction to the client will help facilitate examination of the temporomandibular joint by the nurse?
Open the mouth
Assessment of an adult female client's face reveals a moon shape, increased hair distribution, and a reddened tone to the client's cheeks. What collaborative problem is most clearly suggested to the nurse by these assessment data?
RC: Cushing's syndrome
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
A nurse is providing care at an inner-city shelter, and a man who frequents the shelter presents with a significant frontal growth that is located midline at the base of his neck. The nurse should recognize the need for what referral?
Referral for further assessment of thyroid function
A community health nurse is attending a seminar on headaches. What would this nurse learn is a red flag for headaches?
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?
Tension
When examining the head, the nurse remembers that the anatomic regions of the cranium take their names from which of the following sources?
The underlying bones
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.
A woman brings her 1-month-old infant to the ED. She says the baby is not eating or drinking well. The nurse finds the fontanels are depressed slightly. Why does this require further assessment?
This could be a sign of dehydration
A client seeks medical attention for sharp, shooting facial pain that lasts for several minutes at a time. For which health problem should the nurse assess this client?
Trigeminal neuralgia
A client reports that he might have shingles. Which type of lesion would the nurse most likely assess?
Vesicle
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 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
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
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 client complains of a headache over both temporal areas. What type of headache should the nurse suspect the client is experiencing?
tension
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 nurse is caring for a client admitted with neck pain. The client is febrile. What is the most likely medical diagnosis for this client?
Meningitis
A 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 in an emergency department is caring for a minimally responsive 27-year-old victim of a motorcycle accident. The client was not wearing a helmet. When assessing the client's head and neck, the nurse should prioritize the assessment for which of the following?
Bleeding
A nurse is assessing the head and neck of an adult client. Which vertebra should the nurse identify as a landmark in order to locate the client's other vertebrae?
C7
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 is preparing to assess an adult client's carotid pulses. Which of the following actions would be contraindicated?
Compressing the arteries bilaterally
After teaching a group of students about risk factors for traumatic brain injury, the instructor determines that additional teaching is needed when the students identify which of the following?
Female gender
On palpation, the nurse notes that a client's thyroid gland is diffusely enlarged. Which of the following health problems is associated with this finding?
Graves' disease
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
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
A nursing educator is evaluating a colleague's examination of a client's thyroid gland. The educator would determine that the nurse needs additional instruction when the nurse demonstrates which technique?
Percussion
A nursing instructor is teaching a group of students how to examine the thyroid gland. The instructor would determine that a student needs additional instruction when the student demonstrates which technique?
Percussion
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
During the health history, a client describes recent episodes of intermittent facial pain lasting several minutes. The nurse should recognize that this complaint is suggestive of what health problem?
Trigeminal neuralgia
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.
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
The nurse is palpating a client's neck as part of a physical assessment. Which of the following blood vessels should the nurse be especially careful to avoid bilaterally compressing during the assessment?
Carotid artery