HA Head and Neck questions

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?

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

Considerations for older clients

- pulsation of the temporal artery may be decreased - cervical curvature may increase due to kyphosis of the spine - Clients who have arthritis or osteoporosis may experience neck pain and decreased ROM - Older clients have decreased flexion, extension, lateral bending, and ROM due to arthritis

The nurse is planning to instruct a group of adolescents on ways to prevent traumatic brain injuries. What should be included in these instructions?

Always use seat belts. explanation: The third leading cause of traumatic brain injury is motor vehicle crashes. When instructing a group of adolescents on ways to prevent traumatic brain injuries, the most important thing for the nurse to include would be to always use seat belts. Wearing nonslip shoes in the house is a more appropriate teaching point for adults over 65 years of age. Instead of teaching adolescents to avoid risky activities such as snowboarding; they should be reminded to always wear a helmet. Adolescents should not be encouraged to use firearms. Instead, they should ensure that the responsible adult has stored the bullets and firearm in separate locations.

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. explanation: Fatigue, weakness, and cold sensitivity are symptoms of hypothyroidism. These symptoms are not associated with Cushing's syndrome, hyperthyroidism, or any of the disorders that result in parotid gland enlargement.

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?

Cushing's syndrome

Sinus headache

Deep, constant throbbing pain, in one area of the face or head. Face is tender when palpated. Onset: with or after cold, sinusitis, or acute febrile illness with purulent

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?

Educating them about not drinking and driving

Altered Thyroid Function

Increased sensitivity to cold Constipation Depression Fatigue Heavier menstrual periods Pale, dry skin Thin, brittle hair or nails Weakness Unintentional weight gain

Hypoid bone is used to find

Its used to find the thyroid

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 explanation: Neck pain associated with fever and headache may signify serious illness such as meningitis and should be carefully evaluated.

Cushing's syndrome

Moon face appearance and buffalo hump

Bell's Palsy

One sided paralysis Can't wrinkle brow, raise brow, close eye, whistle, show teeth, or smile

migraine headache

a headache characterized by throbbing pain on one side of the head onset: can have a prodromal stage (visual disturbances such as vertigo, tinnitus, numbness and tingling of digits)

hydrocephalus

abnormal accumulation of fluid (CSF) in the brain

tension headache

across the forehead and can last days, months or years Onset: may occur with stress, anxiety, depression

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. explanation: Take care to consider cultural norms for touch when assessing the head. Some cultures (e.g., Southeast Asian) prohibit touching the head or touching the feet before touching the head

Hypothyroidism

cold weight gain scaly dry skin thick nails puffy eyes constipation Menorhagia (heavy periods) Lethargy Myxedema

A nurse is providing care to an 86-year-old client. The nurse identifies which of the following finding(s) as a normal age-related head and neck change? Select all that apply.

decreased range of motion of the neck cervical curvature of the spine decreased temporal pulse explanation: Normal age-related changes in older clients include decreased range of motion in the neck due to arthritis, increased cervical curvature, decreased temporal pulse, and nodular (not smooth) thyroid.

deep cervical lymph nodes

deep under the sternomastoid muscle

Paget's disease of bone

deincrease bone resorption and formation, which softens, thickens, and deforms bone.

acromegaly

excessive growth hormone causing an increase in bone density and size

submandibular nodes

found halfway between the angle of the mandible and its tip

Torticollis

head tilt due to shortening or spasm of one sternomastoid muscle

Preauricular node

in front of the ear

supraclavicular nodes

located just above and behind the clavicle, at the sternomastoid muscle

submental nodes

midline under the chin

tumor related headache

occurs in the morning

superficial cervical lymph nodes

overlying the sternomastoid muscle

cluster headache

pain is in and around one eye onset: sudden onset may be precipitated by ETOH (ethyl alcohol)

Stroke or CVA (Facial appearance)

paralysis of lower facial muscles Able to wrinkle brow and close the eyes

postauricular node

pertaining to behind the ear

A shifted trachea could indicate

pneumothorax or collapsed lung

posterior cervical nodes

posterior to the sternocleidomastoid muscle

hyperthyrodism

proptosis: enlargement of the eye sudden weight loss goiter (enlarged thyroid) tremor anxiety, nervousness, irritability increased sensitivity to heat fatigue muscle weakness

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. explanation:Ask the client to swallow a small sip of water. Observe the movement of the thyroid cartilage, thyroid gland.

when palpating the thyroid use

the balls of your fingers

do children have lymph systems that are more palpable?

yes

is a normal thyroid hard to palpate

yes