Chapter 15-Assessing Head and Neck

While the nurse is obtaining a client's health history regarding the head and neck, the client tells the nurse about having a lump in the neck. In order to assess for associated manifestations of this problem, which of the following questions should the nurse ask next?

"Do you have difficulty swallowing?

A female client describes headache symptoms that seem to indicate a migraine. Which of the following questions during the client interview would, if answered in the positive, tend to confirm the nurse's suspicion?

"Does the headache occur regularly with your menstrual cycle?"

Nursing students are learning about assessment of the head and neck. What cultural considerations would the students learn to assess in relation to this area? (Select all that apply.)

-Shape of the lips -Shape of the nose -Shape of the eyes

A family member of a client recovering from a traumatic brain injury asks the nurse what safeguards can be put in place at home to prevent future head injuries. What should the nurse instruct this family member? (Select all that apply.)

-Use rails on stairs -Remove extension cords from high traffic areas -Avoid the use of throw rugs.

A nurse visits an older adult client at home in order to conduct a risk assessment for falls. Which factors would most likely increase the risk for falls for this client? Select all that apply.

-a throw rug in the dining room -bathtubs in all bathrooms -a television cord runs across the floor

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

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

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

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

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 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 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.

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.

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?

Atelectasis

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

While performing an examination of the head and neck, a nurse notices left sided facial drooping. The nurse recognizes this as what condition?

Bell's palsy

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

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

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

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

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

Fixed to underlying tissue

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

What is the most common type of hyperthyroidism?

Graves' disease

When documenting the findings from a physical examination of the head and neck, what will the nurse include when describing the client's head?

Hair color

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 the tracheal area just beneath the mandible?

Hyoid bone

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

A client presents at the clinic for a routine checkup. 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

A client diagnosed with goiter has undergone a thyroidectomy. Which statement from the client indicates understanding of postoperative care teaching?

I must take thyroid hormone replacement medication for the rest of my life.

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

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 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 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

A nurse is examining a client's goiter and explaining the characteristics and functions of the thyroid gland. Which of the following should the nurse mention? Select all that apply.

Largest endocrine gland in the body-Produces hormones that increase the metabolic rate of most body cells-Consists of two lateral lobes-Covered mostly by the sternomastoid muscles

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 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

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 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 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

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

The nurse is performing an assessment of the neck and identifies tracheal deviation. What is the most appropriate response of the nurse?

Notify the health care provider

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.

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

Open the mouth

A 73 year old woman comes to the office for evaluation of new onset of tremors. She is not taking any medications, herbs, or supplements. She has no chronic medical conditions. She does not smoke or drink alcohol. She walks into the examination room with slow, shuffling steps. She has decreased facial mobility with a blunt expression without any changes in hair distribution on her face. Based on this description, what is the most likely reason for the client's symptoms?

Parkinson's disease

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?

Parotid enlargement

A client 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 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

A young adult client has just had Xrays 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

During the physical examination of a 65year 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

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.

The nurse is assessing a client complaining of swelling in the neck. While palpating the neck, the nurse finds a 2cm lump that is fixed and hard. Why does this finding require emergency investigation?

This could be a sign of cancer

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 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 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

The nurse is preparing to assess a client's thyroid gland using the posterior approach. What direction should the nurse provide regarding the client's head?

flex the neck forward

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

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

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 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 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.

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

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.