Chapter 15: Assessing Head and Neck

The nurse is conducting discharge teaching to the caregiver of an older adult who was hospitalized following a fall at home. Which statement by the caregiver indicates a need for additional teaching by the nurse? A. "Loss of sensation in the toes is an age-related change." B. "Certain medications can cause muscle weakness." C. "Standing up slowly is important because dizziness can cause falls." "D. Changes in vision such as decreased accommodation happen with aging."

"Loss of sensation in the toes is an age-related change."

The nurse in a community health clinic is preparing to assess the thyroid gland of a 22-year-old female client. Position self to complete the assessment Identify landmarks by palpation Displace the thyroid gland for palpation

1. Position self to complete the assessment: Stand behind the client 2. Identify landmarks by palpation: Identify thyroid and cricoid cartilages and thyroid isthmus 3. Displace the thyroid gland for palpation: Ask the client to swallow

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

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

A nurse performs a comprehensive assessment on a client. The nurse observes the following findings: enlarged hands, feet, and facial features (nose, ears). Which of the following disorders do these findings indicate? A. Cushing syndrome B. scleroderma C. acromegaly D. Parkinson disease

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? A. Cushing's disease B. Metastatic disease C. Acute infection D. Chronic infection

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? A. Cranial damage B. Bacterial thyroiditis C. Arthritic changes of the cervical spine D. Muscle tension

Arthritic changes of the cervical spine

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? A. Have a nurse who is the same sex as the client perform the examination B. Avoid asking the client to remove her clothes for the examination C. Palpate the client's feet before palpating the head D. Ask permission before palpating the head and neck

Ask permission before palpating the head and neck

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

Assess the client regarding characteristics of the pain.

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? A. Order tests to rule out an overactive thyroid gland. B. Assess the woman for hypothyroidism. C. Palpate the woman's parotid gland for enlargement. D. Assess for other signs and symptoms of Cushing's syndrome.

Assess the woman for hypothyroidism.

What does the nurse assess the face for? (Select all that apply.) Asymmetry Involuntary movements Hair color Edema Affect

Asymmetry Involuntary movements Edema

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? A. Atelectasis B. Bronchitis C.Endocarditis D. Tuberculosis

Atelectasis

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

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? A. Auscultate with the bell over the lateral lobes B. Immediately notify the health care provider C. Document the findings in the nurse notes D. Ask the client about past history of hypothyroidism

Auscultate with the bell over the lateral lobes

A nurse is assessing a client with hyperthyroidism for the presence of a bruit. Which assessment technique should the nurse use? A. Inspection B. Palpation C. Auscultation D. Percussion

Auscultation

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? A. C1 B. C3 C. C7 D. C5

C7

When assessing an adult client experiencing diarrhea, the nurse notes a round "moon" face, a buffalo hump at the nape of the neck, and a velvety discoloration around the neck. What is the possible cause of these signs? A. Myxedema B. Bell's palsy C. Scleroderma D. Cushing's syndrome

Cushing's syndrome

Teenagers doing community service following arrest for driving under the influence and are working at the rehabilitation hospital with clients who have paraplegia. These clients have been paralyzed by drunk drivers. How would the nurses who care for these clients best use the time spent with these teenagers? A. Keeping the shelves restocked B. Fulfilling the court requirements C. Teaching them how to turn these clients every 2 hours D. Educating them about not drinking and driving

Educating them about not drinking and driving

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? A. Encourage the use of safety equipment B. Encourage proper nutrition to promote healing C. Teach proper posture, bending, and lifting D. Encourage the client to take a safety course

Encourage the use of safety equipment

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? A. turn the head towards the right shoulder B. tilt the head back C. flex the neck forward D. turn the head towards the left shoulder

Flex the neck forward

A client reports slight swelling and tightness at the base of their neck. The nurse palpates the client's throat and neck and determines the thyroid gland is enlarged. What medical term will the nurse use when charting this finding? A. hyperthyroidism B. hypothyroidism C. goiter D. iodine deficiency

Goiter

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? A. A tumor B. Hypothyroidism C. Nephrotic syndrome D. Graves' disease

Grave's Disease

What is the most common type of hyperthyroidism? A. Cushing's syndrome B. Moon face C. Graves' disease D. Thyroid cancer

Grave's Disease It is an autoimmune disorder in which an antibody over-stimulates the thyroid, prompting too much production of thyroid hormone. It is most common in young to middle-aged women and tends to run in families.

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? A. Auscultation B. A mnemonic assessment tool C. Headache Impact Test D. Family health history questionnaire

Head Impact Test

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

Hyoid bone

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? A. Hypothyroidism B. Effects of age-related changes C. Hyperthyroidism D. Brain tumor

Hypothyroidism

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? A. Hyperthyroidism B. Impending stroke C. Brain tumor D. Diabetes

Impeding 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? A. Superficial to the sternomastoid B. At the angle of the mandible C. In the midline, a few centimeters behind the tip of the mandible D. In front of the ear

In the midline, a few centimeters behind the tip of the mandible

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

Migraine Headache

A female client visits the clinic and tells the nurse that she frequently experiences severe recurring headaches that sometimes last for several days and are accompanied by nausea and vomiting. The nurse determines that the type of headache the client is describing is a A. migraine headache. B. cluster headache. C. tension headache. D. tumor-related headache.

Migraine headache

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? A. Myxedema B. Cushing's syndrome C. Parkinson's disease D. Nephrotic syndrome

Parkison'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? A. Bell's palsy B. Parotid enlargement C. Acute pharyngitis D. Thyroid enlargement

Parotid Enlargement

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? A. Acute pharyngitis B. Bell's palsy C. Thyroid enlargement D. Parotid enlargement

Parotid enlargement

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

Preauricular

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? A. Stiffness in the right shoulder B. Previous injuries to the head and neck C. Changes in sleeping habits D. Difficulty with swallowing

Previous injuries to the head and neck

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 ne328xt? A. Headache B. Shortness of breath C. Range of motion of the arms and shoulders D. Range of motion of the neck

Range of motion of the neck

A nurse is preparing to perform a comprehensive assessment on a new client with a long history of Parkinson disease. Which sign(s) and symptom(s) should the nurse expect? Select all that apply. A. Rigidity B. shuffling gait C. tremors at rest D. expressionless face E. quick, smooth movements

Rigidity shuffling gait tremors at rest expressionless face

A client is having trouble turning her head to the side. Which of the following muscles should the nurse most suspect as being involved? A. Trapezius B. Sternocleidomastoid C. Masseter D. Temporalis

Sternocleidomastoid The sternomastoid muscle rotates and flexes the head, whereas the trapezius muscle extends the head and moves the shoulders.

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

Stiff neck. Limitation of neck mobility may be from muscle tension/strain or cervical vertebral joint dysfunction.

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? A. The tissue underlying the nodes is infected. B. There is an infection in the area that these nodes drain. C. There is an inflammatory response in the musculature of the boy's neck. D. The boy requires assessment of his thyroid gland.

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

The nurse is planning to assess an adult client's thyroid gland. The nurse should plan to A. turn the client's neck slightly backward. B. ask the client to raise the chin. C. place the fingers above the cricoid cartilage. D. approach the client posteriorly.

approach the client posteriorly

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

assess the client's blood pressure

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? Hashimoto thyroiditis benign tumor thyroid cyst hyperthyroidism

hyperthyroidism The low, soft, rushing sound is a systolic or continuous bruit commonly heard in hyperthyroidism.

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? A. Ask the doctor for an order for an MRI B. Perform a focused assessment C. Prepare the client for a spinal tap D. Perform a generalized assessment

performed a focused assessment

The nurse assesses an adult client's head and neck. While examining the carotid arteries, the nurse assesses each artery individually to prevent: A. decreased pulse pressure. B. reduction of the blood supply to the brain. C. premature ventricular heart sound. D. rapid rise in the client's pulse rate.

reduction of the blood supply to the brain.

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 A. refer the client to a physician for further evaluation. B. ask the client to flex his neck to the left side. C. palpate the cricoid cartilage for smoothness. D. observe whether the client has difficulty swallowing water.

refer the client to a physician for further evaluation.

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 A. cluster headaches. B. migraine headaches. C. tension headaches. D. tumor-related headaches.

tension headaches