Head, Neck, Eyes, Ears, Mouth, ETC.

32

-A client with Parkinson's disease often exhibits a masklike face. A sunken face with depressed eyes and hollow cheeks is typical of cachexia. Drooping of one side may suggest a stroke or Bell's palsy. Asymmetry of the earlobes occurs with parotid gland enlargement from an abscess or tumor.

40

-Failure of the Romberg test may indicate dysfunction in the vestibular portion of the inner ear, semicircular canals, and vestibule.

When examining the mouth of an adult client with recent cognitive changes, the nurse notes a distinct bluish-black line along the client's gum line. Which action should be the nurse's priority?

A bluish-black line along the gum line is seen in lead poisoning. Therefore the nurse needs to refer the client for further evaluation. Phenytoin therapy can lead to gingival hyperplasia. Smoking may cause yellowish or brown teeth or a yellow-brown coating on the tongue. The finding is not suggestive of inadequate mouth care. However, information about proper mouth care would be important for any client, regardless of the findings.

42

A client with acute otitis media would have a red, bulging eardrum with absent light reflex. A pearly, translucent membrane with no bulging is a normal finding in the tympanic membrane. A yellowish, bulging membrane with bubbles is seen in serous otitis media. A gray, translucent membrane with retraction is a normal finding in the tympanic membrane.

28

A cyst on the ear would present as a fluid-filled sac. A tophus is a hard nodule composed of uric acid crystals. Redness and bulging of the eardrum is characteristic of otitis media with effusion. Swelling of the external ear canal with inflammation or infection would be referred to as an edematous ear.

The nurse examines a client and assesses a temporal artery that is hard, thick, and tender with absent pulsations. The nurse would gather additional information related to which area?

A hard, thick, and tender temporal artery with absent pulsations suggests temporal arteritis, which can lead to blindness. Additional information about mental status, hearing, or neurologic status would not be needed based on this finding.

33

A soft, blowing, swishing sound auscultated over the thyroid lobes is often heard in hyperthyroidism because of an increase in blood flow through the thyroid arteries. Breath sounds and heart sounds are atypical.

48

A sudden, severe headache with no known cause may be a sign of impending stroke, particularly if accompanied by sudden trouble seeing in one or both eyes or sudden trouble walking, dizziness, and loss of balance or coordination. Only impending stroke is associated with all of these symptoms. Diabetes is not associated with headache or the other symptoms. A tumor-related headache is aching and steady and not necessarily associated with sudden onset. Hyperthyroidism is associated with goiter, bruit, and sudden weight loss, but not with any of the symptoms listed.

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// The hallmarks of migraine headaches include a rapid onset, nausea, and relief by the removal of light and sound stimuli. Sustained muscle activity associated with typing and driving often precedes tension headaches. Cluster headaches, not migraines, are episodic over the course of a day.

An alternate pathway that bypasses the external and middle ear is called what?

An alternate pathway, known as bone conduction, bypasses the external and middle ear and is used for testing purposes.

7

Asking the client to say "aaah" and instructing him or her to open the mouth wide makes the uvula more clear for observation. The nurse should depress the client's tongue slightly off center to prevent the gag reflex during observation of the uvula. Depressing the back of the tongue would elicit the gag reflex. Having the client stick out the tongue would not provide a clear view of the uvula.

47

Atelectasis can cause the trachea to be pushed to one side from its midline position. Endocarditis is an infection in the muscle of the heart, which does not cause the trachea to shift. Bronchitis is an inflammation of the mucous membrane of the bronchial tubes. Tuberculosis is an infection in the lungs. Neither bronchitis nor tuberculosis is responsible for the tracheal shift.

11

Brown spots on the chewing surface on the teeth may indicate tooth decay, which also may cause pain with chewing. Clients who smoke or drink large quantities of coffee or tea may have a brownish tint to the teeth. Trouble chewing would indicate missing or malocclusion of the teeth.

18

Causes of hearing disorders are many and include genetics, infections, injuries to head or ear, ototoxic drugs, aging, and loud noises.

A male college student presents to the student health clinic with reports of night-time headaches for the past two weeks. He denies nausea and photosensitivity but states he has noticed his eyes are tearing and his nose runs a lot. He is stressed because of final exams and confesses to drinking more alcohol than normal. The nurse recognizes these findings as indicative of what type of headache?

Cluster headaches occur more often in young males, have a sudden onset and may be precipitated by ingestion of alcohol. The headaches typically occur in the evening, localized to one eye with radiation into the facial and temporal areas. The person may report tearing of the eye, or runny nose. Migraine headaches are accompanied by nausea, vomiting, and sensitivity to light and sound. Tension headaches occur more frequently in females and are usually a result of stress, anxiety, or depression.

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?

Cushing's syndrome may present with a moon-shaped face with reddened cheeks and increased facial hair. This cluster of signs is not characteristic of CVA, thyroid disease, or acromegaly.

34

Dietary recommendations for this bleeding disorder include decreasing foods high in salicylates, such as red wine, spices, chocolate, coffee, and some fruits. Provide education about supplements with antiplatelet activity, such as garlic, ginger, ginseng, gingko, and vitamin E. A vegetable omelet would be the most appropriate food choice since it doesn't contain salicylates or antiplatelet supplements.

56

Dizziness, hypotension and confusion may put the client at risk for falls. Palpitations and diaphoresis does not increase fall risk.

A nurse practitioner is assessing the tympanic membrane of a client who has come to the clinic. What would the nurse practitioner expect to visualize if the client has a normal otoscopic evaluation?

During visualization of the normal tympanic membrane, it is intact and translucent and the short process of the malleus is visible. The nurse practitioner would not expect to see the stapes or the head of the incus.

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?

Earlobe asymmetry can be due to parotid gland enlargement caused by an abscess or tumor. Bell's palsy is a neurologic condition that may cause drooping of one side of the face. Acute pharyngitis causes swelling in the throat, which is not usually visible on the outside of the face. Thyroid enlargement affects the neck and has no effect on the symmetry of the earlobes.

64

Earlobe asymmetry can be due to parotid gland enlargement. In this case, the client may have mumps as parotid enlargement is accompanied by fever. It can also be due to an abscess or tumor. Bell's palsy is a neurologic condition that may cause drooping of one side of the face. Acute pharyngitis causes swelling in the throat which is not usually visible on the outside of the face. Thyroid enlargement affects the neck and has no effect on the symmetry of the earlobes.

36

Facial asymmetry may indicate inflammation of cranial nerve VII with Bell palsy.

A 52-year-old patient fails the Romberg test. The nurse explains that this might indicate a dysfunction in what part of the ear?

Failure of the Romberg test may indicate dysfunction in the vestibular portion of the inner ear, semicircular canals, and vestibule.

12

Frontal or maxillary sinuses are tender to palpation in clients with allergies or acute bacterial rhinosinusitis. If the client has a large amount of exudate, you may feel crepitus upon palpation over the maxillary sinuses, which are located in the upper jaw. The ethmoidal and sphenoidal sinuses are smaller, located deeper in the skull, and are not accessible for examination.

On palpation, the nurse notes that a client's thyroid gland is diffusely enlarged. Which of the following health problems would the nurse want to rule out?

Graves' disease is associated with a diffusely enlarged thyroid. This finding is not normally consistent with neoplasm, hypothyroidism, or nephritic syndrome.

57

Heart failure can cause ineffective tissue perfusion which can lead to fatigue, pain and activity intolerance. Impaired gas exchange would be more appropriate for respiratory disorders

4

If a nurse palpates an enlargement of the thyroid, auscultation should be performed with the bell of the stethoscope to assess for the presence of a bruit. A bruit is a soft, swishing sound produced because of an increase in blood flow through the thyroid arteries. The nurse should also ask the client about past history of thyroid problems, the findings must be documented, then the health care provider notified once assessment is complete to obtain further orders.

A nurse palpates an elderly client's thyroid and detects an enlargement over the right lateral lobe. What action should the nurse take first?

If a nurse palpates an enlargement of the thyroid, auscultation should be performed with the bell of the stethoscope to assess for the presence of a bruit. A bruit is a soft, swishing sound produced because of an increase in blood flow through the thyroid arteries. The nurse should also ask the client about past history of thyroid problems, the findings must be documented, then the health care provider notified once assessment is complete to obtain further orders.

1

If palpable, the older adult's thyroid gland may feel more nodular or irregular because of fibrotic changes that occur with aging. The thyroid also may be felt lower in the neck because of age-related structural changes.

3

Important landmarks for the head and neck region are in the tracheal area. The usually palpable U-shaped hyoid bone is located midline just beneath the mandible. The large thyroid cartilage consists of two flat, plate-like structures joined together at an angle and with a small, sometimes palpable notch at the superior edge. Usually more prominent in males, the thyroid cartilage is also called the "Adam's apple." The palpable cricoid cartilage is a ringed structure just inferior to the thyroid cartilage.

6

In the Rinne test, the examiner shifts the stem of a vibrating tuning fork between two positions to test air conduction of sound and bone conduction of sound. The whisper test involves covering the untested ear and, whispering from a distance of 1 or 2 feet from the unoccluded ear, and the ability of the patient to repeat what was whispered. The watch tick test relies on the ability of the patient to perceive the high-pitched sound made by a watch held at the patient's auricle. The Weber's test uses bone conduction to test lateralization of sound.

14

Inability to breathe through the nose may indicate sinus congestion, obstruction, or a deviated septum. It would not be necessary to ask if the client experiences dry mouth often; the client would most likely answer yes. Tonsillar inflammation would most likely be unrelated to the client's breathing through the mouth. A focused respiratory assessment is not necessarily required, since mouth breathing does not usually affect respiratory function.

The nurse is reviewing a client's electronic health record before assessing her mouth. Which diagnosis would the nurse recognize as an indication for immediate medical follow-up?

Leukoplakia is a precancerous lesion that requires immediate follow-up. Thrush, gingivitis, and canker sores are abnormal findings, but the evidence of leukoplakia is serious and needs immediate evaluation and treatment.

The nurse understands that malocclusion may be related to what?

Malocclusion may occur with tooth loss. Rhinitis and sinusitis included infection or drainage. Parotid duct occlusion occurs in the mouth.

24

Meniere's disease is a disorder of the inner ear that can lead to dizzy spells (vertigo) and hearing loss. In most cases, Meniere's disease affects only one ear. Meniere's disease can occur at any age, but it usually starts between young and middle-aged adulthood

22

Normally lymph nodes are round and soft, less than 1 cm in size, mobile from side to side, soft consistency, and nontender. A fixed lymph node may be seen in metastatic disease

26

Nystagmus is a vision condition in which the eyes make repetitive, uncontrolled movements. These movements often result in reduced vision and depth perception and can affect balance and coordination. These involuntary eye movements can occur from side to side, up and down, or in a circular pattern

49

Older clients who have arthritis or osteoporosis may experience neck pain and a decreased range of motion. Sudden head and neck pain seen with elevated temperature and neck stiffness may be a sign of meningeal inflammation. Stress and tension may increase neck pain. Neck pain may accompany muscular problems or cervical spinal cord problems.

61

Otitis media is a group of inflammatory diseases of the middle ear. The two main types are acute otitis media (AOM) and otitis media with effusion (OME). AOM is an infection of rapid onset that usually presents with ear pain. In young children this may result in pulling at the ear, increased crying, and poor sleep

9

Paralysis of cranial nerve X (vagus) often causes the uvula to deviate to one side and the palate to fail to rise. A bifid or split uvula is a common finding in the Native American population. A cerebrovascular accident may cause asymmetrical or loss of movement of the uvula. Infection of the tonsils does not cause a deviation of the uvula and failure of the palate to rise.

58

Part the hair in several places and look for scaliness, lumps, nevi, or other lesions. Redness and scaling may indicate seborrheic dermatitis, psoriasis; soft lumps of pilar cysts (wens); pigmented nevi.

A client arrives in the emergency department by ambulance after falling down his front steps. The nurse notes two soft lumps, approximately 3 cm in diameter, on the side of his head. What would the nurse identify these as?

Part the hair in several places and look for scaliness, lumps, nevi, or other lesions. Redness and scaling may indicate seborrheic dermatitis, psoriasis; soft lumps of pilar cysts (wens); pigmented nevi.

62

Pilar cysts are flesh-colored bumps that can develop on the surface of the skin. They're sometimes called trichilemmal cysts or wens. These are benign cysts, meaning they typically aren't cancerous. Although pilar cysts aren't necessarily a cause for concern, you may find them uncomfortable

29

Placing the tuning fork on the mastoid bone is one part of the Rinne's test, which assesses the normal pathways for sound to travel to the inner ear. Equilibrium is assessed with the Romberg test. Multiple sources of assessment data are used to determine whether hearing loss is caused by degeneration of nerves in the inner ear or repeated ear infections.

53

Pollens cause seasonal rhinitis, whereas dust and other environmental allergens may cause rhinitis year round. Transillumination and otoscopic examination will not help identify the cause of the client's allergy symptoms. Similarly, the response of the allergies to antihistamines will not determine the ultimate cause of the symptoms.

50

Presbycusis often begins with a loss of high-frequency sounds (woman's voice) followed later by the loss of low-frequency sounds. The bass speakers, his son's voice, and the engine starting would all have lower-frequency sounds than his wife's voice.

43

Primary headaches are more worrisome than secondary headaches FALSE

8

Putting on gloves and retracting the client's lips and cheeks is a technique used to examine the gums and teeth. The correct technique to examine the sides of the tongue is to use a square gauze pad to hold the client's tongue to each side. Using a penlight and tongue depressor to retract the lips helps in visualization of buccal mucosa. Sticking the tongue out between the lips only allows visualization of the anterior portion of the tongue.

The nurse is conducting a comprehensive health assessment of an adult Hispanic man. Which of the following abnormal findings would be most likely in this client?

Rates of gingivitis (inflammation with bleeding of the gums) are high among Hispanics, American Indians, Alaskan Natives, and adults of low socioeconomic classes. Gingivitis may progress to periodontal disease with a loss of connective tissue and bone. Hispanic men are not at risk for bifid uvula, oral cancer, or sinus infection.

41

Rhinorrhea (thin, watery, clear nasal drainage) may indicate chronic allergy, which is the primary area for assessment and will yield the most pertinent information. Dysphagia would suggest a problem with the throat. Nosebleeds may be seen with overuse of nasal sprays, excessively dry mucosa , hypertension, leukemia, and other blood disorders. Tonsillar enlargement may be associated with tonsillitis.

16

Temporal arteritis is a painful inflammation of the temporal artery. Clients report severe unilateral headache sometimes accompanied by visual disturbances. This condition needs immediate care. A biopsy may be necessary for diagnosis; however the healthcare provider immediately. The temporal artery pulse can be palpated; but the carotid artery pulses should never be palpated simultaneously so that the client does not pass out from lack of blood flow to the brain.

19

Tension headaches often arise in the temporal areas. Cluster headaches typically occur behind the eyes. A throbbing, severe, unilateral headache that lasts 6-24 hours and is associated with photophobia, nausea, and vomiting suggests a migraine headache. Hypertensive is not a type of headache although individuals with hypertension may experience a headache upon arising in the morning.

71

Tension headaches often arise in the temporal areas. Cluster headaches typically occur behind the eyes. A throbbing, severe, unilateral headache that lasts 6-24 hours and is associated with photophobia, nausea, and vomiting suggests a migraine headache. Hypertensive is not a type of headache although individuals with hypertension may experience a headache upon arising in the morning.

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?

The Headache Impact Test may be used to assess the impact of headache on a client's activities of daily living. A mnemonic assessment tool is used to assess for the character, onset, location, duration, severity, pattern, and associated factors of pain. It does not assess for the effect of pain on the client's activities of daily living. Auscultation is use of a stethoscope to assess the client's blood pressure, heart sounds, or respiration. The family health history portion of the interview is used to assess for health conditions of family members that might help shed light on the client's chief complaint.

35

The Kiesselbach plexus is the most common site for anterior nosebleeds.

Upon assessment, the nurse finds the client's systolic blood pressure to be 88; heart rate of 121 and a lactate level of 2.3. The nurse recognizes the client is experiencing what?

The client is experiencing severe sepsis, the blood pressure is low, with an elevated heart rate and an elevated lactate level. There is no evidence of increased intracranial pressure, cardiac dysrhythmias or a surgical site infection.

15

The client should remain NPO until evaluated by speech therapy. Occupational therapists do not specialize in swallowing assessments. Physical therapy does not need to be cancelled and should be continued. The nurse, not the nursing assistant, is responsible for assessment. (NPO=nothing by mouth)

During an examination of the oral cavity, which technique by the nurse is appropriate to examine the sides of the tongue?

The correct technique to examine the sides of the tongue is to use a square gauze pad to hold the client's tongue to each side. Using a penlight and tongue depressor to retract the lips helps in visualization of buccal mucosa. Putting on gloves and retracting the client's lips and cheeks is a technique used to examine the gums and teeth. Sticking the tongue out between the lips only allows visualization of the anterior portion of the tongue.

face

The face has 14 bones: 2 maxilla, 2 zygomatic, 2 inferior conchae, 2 nasal, 2 lacrimal, 2 palatine, 1 vomer, and 1 mandible. The cranium has 8 bones

59

The frontal sinuses (above the eyes) and the maxillary sinuses (in the upper jaw) are accessible to examination by the nurse.

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?

The group of nodes posterior to the sternocleidomastoid muscle is the posterior cervical chain. These are common in mononucleosis.

5

The hallmarks of migraine headaches include a rapid onset, nausea, and relief by the removal of light and sound stimuli. Sustained muscle activity associated with typing and driving often precedes tension headaches. Cluster headaches, not migraines, are episodic over the course of a day.

45

The midline structures of the neck include (1) the mobile hyoid bone just below the mandible; (2) the thyroid cartilage, readily identified by the notch on the superior edge (larger in males than in females); (3) the cricoid cartilage; (4) the tracheal rings; and (5) the thyroid gland.

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

The most common types of headaches are related to vascular (e.g., migraine), muscle contraction (tension), traction, or inflammatory causes.

13

The nurse should auscultate the thyroid only if an enlarged thyroid gland is identified during inspection or palpation. Vital signs are not indicated, and the thyroid is never percussed. A swallowing assessment is not likely necessary.

A nurse examines a client with complaints of a sore throat and finds that the tonsils are just visible. Using a grading scale of 1+ to 4+, how should the nurse appropriately document the tonsils?

The nurse should document the tonsillar grading as 1+ because the tonsils are just visible. Grade 2 tonsils are midway between the tonsillar pillars and the uvula. Tonsils that touch the uvula are graded 3+, and tonsils that are so enlarged that they touch each other are graded 4+.

65

The nurse should document the tonsillar grading as 2+ because the tonsils are midway between the tonsillar pillars and the uvula. Grade 1 tonsils are ones which are visible. Tonsils that touch the uvula are graded 3+, and tonsils that are so enlarged that they touch each other are graded 4+.

Hypothyroidism in the older adult can be difficult to diagnose. What are some of the reasons it is difficult to diagnose? Select all that apply.

The older adult with hypothyroidism often lacks the classic symptoms seen in younger clients. Contributing factors include subtler onset, chronic diseases, and the idea that typical signs and symptoms (fatigue, cold intolerance, constipation, or depression) may be attributed to aging. Hypothyroidism in older adults is not difficult to diagnose because of elderly communication deficits or denial of problems.

A client reports a 20 pack per year history of cigarette smoking. To assess this client for cancer, where should the nurse inspect the tongue?

The sides of the tongue are the most common area for carcinoma to occur. Tobacco use is the most common risk factor for the development of cancer of the oral cavity. The nurse should inspect all surfaces of the tongue & buccal mucosa for the presence of oral cancer.

20

The submandibular glands are located inferior to the mandible underneath the base of the tongue. The parotid glands are located on each side of the face, anterior and inferior to the ears. The temporal artery is located between the top of the ear and the eye. The internal jugular and carotid arteries are located bilaterally parallel and anterior to the sternomastoid muscle.

62

The submental lymph nodes are located a few centimeters behind the tip of the mandible. The tonsillar nodes are located at the angle of the mandible at the anterior edge of the sternomastoid muscle. The occipital nodes are at the posterior base of the skull. The postauricular nodes are behind the ears

2

The submental lymph nodes are located a few centimeters behind the tip of the mandible. The tonsillar nodes are located at the angle of the mandible at the anterior edge of the sternomastoid muscle. The occipital nodes are at the posterior base of the skull. The postauricular nodes are behind the ears.

30

The supraclavicular lymph nodes are located by hooking the fingers over the clavicles and feeling deeply between the clavicles and the sternomastoid muscles. Normally, these lymph nodes should not be palpable. An enlarged, hard, nontender left-sided supraclavicular node may be an indication of malignancy of the abdomen or thorax. Enlarged, hard, and nontender supraclavicular nodes would not affect sensation, movement, or range of motion. Infection or inflammation in the head and neck region most often enlarges the nodes closest to the site affected, such as preauricular or postauricular with ear infections. Degeneration within the spinal cord does not affect lymph nodes

66

The thyroid gland is usually larger in women than in men TRUE

23

This is a classic description of benign positional vertigo, which is episodic and lasts a few seconds to minutes. Continuous vertigo is symptomatic of vestibular neuronitis. Also, there is no tinnitus or sensorineural hearing loss, as occurs with Meniere's disease and acoustic neuroma. The nurse may choose to learn about Hallpike maneuvres, which are helpful in the evaluation of vertigo.

A client reports the onset of tinnitus. What question should the nurse ask the client to further assess this condition?

Tinnitus is the feeling of ringing in the ears and may be associated with excessive wax buildup, high blood pressure, or certain ototoxic medications, such as antibiotics. Cleaning the ear with cotton-tipped applicators places the client at risk for ear damage. Ear infections can cause loss of hearing. Not hearing the p hone ring may be a sign of hearing loss.

A client has sought care at the clinic, telling the nurse, "This ringing in my ears has gone on for weeks, and it's driving me crazy." The patient denies exposure to excessive noise levels. What would the nurse ask next?

Tinnitus may be associated with certain ototoxic medications. There is not usually a family history of this problem. Cerumen buildup can contribute, but hygiene is not a common etiology of tinnitus. The client's overall perception of health is important but is less likely to explain why he is experiencing tinnitus.

68

To assess the TMJ, place your index finger over the front of each ear as you ask the client to open her mouth. None of the other listed instructions facilitates this assessment

37

Tonsils are graded based on size: T1: tonsils are visible; T2: tonsils are between the tonsillar pillars and the uvula; T3: tonsils are touching the uvula; T4: tonsils are touching each other.

69

Tonsils that touch the uvula are identified as 3+. Tonsils that are visible are graded as 1+; tonsils midway between tonsillar pillars and uvula are 2+; tonsils that touch each other are 4+

46

Tophi are deposits of uric acid crystals and are generally painless; they are a common physical assessment finding in clients diagnosed with gout. Cerumen is a normal finding during assessment of the ear canal. Its presence does not necessarily indicate that inflammation is present. Pain when the nurse pulls gently on the auricle in preparation for an otoscopic examination of the ear canal is a characteristic finding in clients with otitis externa. Air bubbles in the middle ear may be visualized with the otoscope; however, these do not indicate a problem involving the ear canal. Aural tenderness or pain is not usually associated with middle ear disorders.

44

Torus palatinus is relatively common and benign but can go unnoticed by clients for many years. The appearance of a bony mass can be concerning. Leukoplakia is a white lesion on the mucosal surfaces corresponding to chronic mechanical or chemical irritation. It can be premalignant. Thrush is usually painful and seen in immunosuppressed clients or those taking inhaled steroids for COPD or asthma. Kaposi's sarcoma is usually seen in HIV-positive people; these lesions are classically deep purple

60

Trigeminal neuralgia is manifested by sharp, shooting, piercing facial pain that lasts from seconds to minutes. The pain occurs over the divisions of the fifth trigeminal cranial nerve. A headache associated with a fever or high blood pressure is a cluster headache. Tension headaches are caused by tightening of facial and neck muscles. Migraine headaches are provoked by hormone fluctuations.

25

Vestibular neuritis is a condition that causes vertigo and dizziness. It results from inflammation of your vestibular nerve, a nerve in the ear that sends information to your brain about balance

When inspecting the tympanic membrane, which of the following structures does the nurse expect to identify?

Visualization of the tympanic membrane using an otoscope includes inspection of the cone of light, the short process of the malleus, and the handle of the maleus. The cochlea, vestibule, and stapes (part of the ossicles) are not normally visualizable.

The emergency department nurse notes a clear, watery discharge from the client's ear following a bicycle accident. Which of the following actions should the nurse do next?

Watery drainage may suggest cerebrospinal fluid, for which the client should be referred immediately for further evaluation. Tophi and postauricular cysts would be visible on inspection and are not associated with drainage. Repositioning the patient is not a priority, due to the potential severity of the client's injury.

52

When examining the thyroid gland, the nurse inspects for enlargement and asymmetry; auscultates for bruits; and palpates for tumors, masses, size, and tenderness. Percussion does not provide meaningful data.

10

While performing the assessment of the temporomandibular joint, the nurse should ask the client to open the mouth. This gives an easy access to the joint. Telling the client to sit upright and not move helps in performing the overall examination; however, it does not contribute to the examination of the temporomandibular joint. Telling the client to perform a chewing action is not appropriate.0

39

Whitish, curd-like patches that scrape off over reddened mucosa and bleed easily indicate "thrush" (Candida albicans) infection.

55

With the Weber test, lateralization of sound to the good ear suggests sensorineural hearing loss because of the limited perception of sound due to nerve damage in the affected ear, making sound seem louder in the unaffected ear. Lateralization to the poor ear suggests conductive hearing loss.

67

new onset of a foul smelling purulent drainage from the right are: Because the drainage is unilateral, the most likely cause is a foreign body obstruction. The nurse should inspect the nostrils for patency and the presence of a foreign body. It is not a normal finding in children to have unilateral foul-smelling drainage from the nose. This child will not need an antibiotic, thus the nurse does not need to assess for allergies to medication. Blowing the nose may or may not dislodge the object and may cause further trauma to the nare

normal finding when examining the thyroid of an older adult client

nodularity: If palpable, the older adult's thyroid gland may feel more nodular or irregular because of fibrotic changes that occur with aging. The thyroid also may be felt lower in the neck because of age-related structural changes

54

noticed white spots on boy's tympanic membrane: White spots on the tympanic membrane indicate scarring from previous infections. Therefore the nurse would ask the mother about a history of previous ear infections. A bluish or dark red color to the membrane would suggest skull trauma. Impacted cerumen would prevent the nurse from viewing the tympanic membrane. A red, bulging eardrum and a distorted, diminished, or absent light reflex would suggest acute otitis media.

17

older patient has severe headaches that begin in the morning and become worse when he coughs, he feels dizzy when he has the headaches: Tumor-related headaches have no prodromal stage; may be aggravated by coughing, sneezing, or sudden movements of the head.

38

patient frequently experiences severe recurring headaches that sometimes last for several days and are accompanied by nausea and vomiting: The most common types of headaches are related to vascular (e.g., migraine), muscle contraction (tension), traction, or inflammatory causes.

21

patient has chronic pain with a cervical spine injury: The first step would be for the nurse to assess characteristics of the pain. Surgery or pharmacologic interventions would be considered by the whole health care team after more information was gathered. While education is an appropriate intervention, it would not be addressed initially but rather after pain management interventions were implemented.

70

red flag for headaches: Limitation of neck mobility may be from muscle tension/strain or cervical vertebral joint dysfunction.

51

the eleventh cranial nerve is responsible for muscle movement that permits shrugging of the shoulders by the trapezium muscles and turning the head against resistance by the sternomastoid muscle. The abducens (VI) and trochlear (IV) nerves are involved with eye muscle movement. The hypoglossal (XII) nerve is involved with tongue muscles.

31

tobacco use increases the risk of head and neck cancer. The nurse would need to perform a thorough head and neck examination. Alcohol abuse, recreational drug use, or multiple sex partners are not risk factors associated with head and neck cancer.

27

typical tension headache: tightening sensation of moderate intensity is located all over the head, used to last minutes, but this time it has lasted for 5 days, no photophobia or nausea, OTC meds dull the pain but don't take it away