Health assessment Ch. 10

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

What finding upon assessment would indicate the client is experiencing shock? a. Temperature 99.5 F b. Heart rate 100 c. Systolic blood pressure 50 d. Respiratory rate 24

c Systolic blood pressure 50 A systolic blood pressure of 50 would indicate the client is experiencing shock. All other vital signs, while elevated do not indicate shock

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? a. Parkinson's disease b. Migraine headache c. Trigeminal neuralgia d. Meningeal inflammation

d. Meningeal inflammation Meningeal inflammation is a likely cause of this condition, which manifests as sudden headache, neck pain with stiffness, and fever. Migraine headaches are accompanied by nausea, vomiting, and sensitivity to noise or light, not by fever and neck stiffness. Trigeminal neuralgia is manifested by sharp, shooting, piercing facial pains that last from seconds to minutes. Parkinson's disease is not manifested by headache and neck pain.

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 a. flex the neck to each side. b. cough deeply. c. swallow a small sip of water. d. inhale deeply.

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

Which risk factor for traumatic brain injury should a nurse include in a discussion about prevention for a group of adolescents? a. Falls occur more frequently in the younger population b. Females have twice the risk that males do c. Most firearm incidents are accidental d. Modes of transportation are the leading cause

d. Modes of transportation are the leading cause All modes of transportation, such as motor vehicle & bicycles, are the leading cause of traumatic brain injuries for people age 5 to 64 years. Males have twice the risk of females. Firearm injuries are high in the violence category and two thirds are suicidal in intent. Fall occur most frequently in the over 65 years of age population.

A client describes headaches as severe and lasting for days. Which question would be most appropriate to use to determine if these headaches are migraines? a. "Do you have any visual changes before the headache?" b. "When you consume alcohol, do you get a headache?" c. "Do you have any eye symptoms, such as tearing?" d. "Do they occur after you have been tense or anxious?"

a. "Do you have any visual changes before the headache?" A typical migraine headache has prodromal symptoms that may include visual disturbances, vertigo, tinnitus, and/or numbness or tingling of the fingers and toes. Asking about being tense or anxious would be appropriate to assess for a tension headache. Asking about alcohol or tearing would be appropriate for a cluster headache.

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. Acute infection b. Chronic infection c. Metastatic disease d. Cushing's disease

a. Acute infection The lymph nodes are enlarged and tender in acute infections. Normally, lymph nodes are not sore or tender and are usually not palpable. Chronic infection causes the nodes to become confluent. In metastatic disease, the nodes enlarge and become fixed in place and are nontender. The lymph node findings may vary in Cushing's disease.

Which factor, if present in a client's lifestyle and health practices assessment, would alert the nurse to the need for performing a more thorough head and neck assessment? Select all that apply. a. Alcohol abuse b. Recreational drug use c. Multiple sex partners d. Smokeless tobacco use

a. Alcohol abuse b. Recreational drug use c. Smokeless tobacco use d. Multiple sex partners Tobacco and alcohol use increases the risk of head and neck cancer. A more recently identified cause of head and neck cancer is exposure to human papillomavirus (HPV). People with multiple sexual partners and those who engage in oral sex are at increased risk of developing oral HPV-related cancer. For these reasons the nurse would need to perform a thorough head and neck examination.

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. Ask permission before palpating the head and neck b. Avoid asking the client to remove her clothes for the examination c. Palpate the client's feet before palpating the head d. Have a nurse who is the same sex as the client perform the examination

a. Ask permission before palpating the head and neck 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. There is no need to avoid asking the client to remove clothes for the examination; removing clothing is not a particular concern related to this client's culture nor is it necessary for examination of the head and neck. Clients of certain conservative religious backgrounds may object to being assessed by a nurse of the opposite sex, but there is not enough information in this scenario to warrant such a concern.

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. Teach proper posture, bending, and lifting c. Encourage the client to take a safety course d. Encourage proper nutrition to promote healing

a. Encourage the use of safety equipment Nurses encourage use of appropriate safety equipment to reduce risk of head or neck trauma. There is no identified need to encourage proper nutrition to promote healing in this client. There is no identified need to teach proper posture, bending, and lifting with this client. Encouraging the client to take a safety course is not the primary focus of discharge teaching.

During the health history, a client reports complaints of intermittent facial pain lasting several minutes. The nurse would suspect which of the following? a. Trigeminal Neuralgia b. Migraine c. Meningitis d. Temporomandibular Joint Dysfunction

a. Trigeminal Neuralgia Trigeminal neuralgia is manifested by sharp, shooting, piercing facial pain that lasts from seconds to minutes. Migraine headache is characterized by pain around the eyes, temples, cheeks, or forehead. Meningitis would be manifested by sudden head and neck pain with fever and neck stiffness. Temporomandibular joint dysfunction is manifested by limited range of motion, swelling, tenderness, or crepitation in the jaw area.

A nurse is preparing to assess an adult client's carotid pulses. Which of the following actions would be contraindicated? a. Asking the client to swallow water b. Compressing the arteries bilaterally c. Performing the examination while the client is seated d. Asking the client to flex his or her neck

b. Compressing the arteries bilaterally The nurse needs to avoid bilateral compression of the carotid blood vessels to prevent reducing the blood supply to the brain. The nurse does not need to avoid having the client flex the neck, ask the client to swallow water, or perform the exam while the client is seated.

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? a. Thyroid gland b. Hearing acuity c. Mental status d. Lymph nodes

b. Hearing acuity A head tilted to one side may indicate unilateral vision or hearing deficiency, which should be ruled out before proceeding with the examination. The nurse would not need to evaluate the thyroid gland, mental status, or lymph nodes based on this finding.

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? a. Cluster b. Migraine c. Analgesic rebound d. Tension

b. Migraine This is a description of a common migraine (no aura). Distinctive features of a migraine include phono- and photophobia, nausea, resolution with sleep, and unilateral distribution. Only some of these features may be present.

The nurse is preparing to palpate a client's temporal artery. The nurse would place the hands at which location? a. On each side of the client's face, anterior and inferior to the ears b. On each side between the top of the ear and the eye c. Bilaterally, parallel to and anterior to the sternomastoid muscle d. Inferior to the lower jaw beneath the client's tongue

b. On each side between the top of the ear and the eye The temporal artery is located between the top of the ear and the eye. 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 internal jugular and carotid arteries are located bilaterally, parallel and anterior to the sternomastoid muscle.

Which instruction to the client will help facilitate examination of the temporomandibular joint by the nurse? a. Sit upright b. Open the Mouth c. Perform chewing action d. Do not move

b. Open the Mouth 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.

A nurse has completed an assessment of a client's lymph nodes. Which of the following data would the nurse document as an abnormal finding? a. Diameter: 0.75 cm b. Tender c. Discrete d. Mobile

b. Tender A lymph node that is tender is an abnormal finding suggesting acute infection. Size less than 1 cm, mobile, and discrete indicate normal findings.

What nursing diagnosis would be most appropriate for a client admitted with heart failure? a. Risk for denial b. Acute pain c. Ineffective tissue perfusion d. Impaired gas exchange

c. Ineffective tissue disorder 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

Where is the temporal artery palpated? a. Just left or right of the spine at the base of the skull b. Just left of midline at the base of the neck c. Between the mandibular joint and the base of the ear d. Above the cheek bone near the scalp line

d. Above the cheek bone near the scalp line The nurse palpates the temporal artery in the space above the cheek bone near the scalp line. The temporal artery is not found at midline at the base of the neck, between the mandibular joint and the base of the ear, or just left or right of the spine at the base of the skull.

Which assessment technique should a nurse use to assess for the presence of a bruit in a client with hyperthyroidism? a. Palpation b. Percussion c. Inspection d. Auscultation

d. Auscultation A bruit is a soft, blowing, swishing sound auscultated over the thyroid lobes with the bell of the stethoscope that is often heard in hyperthyroidism because of an increase in blood flow through the thyroid arteries. A bruit can be elicited through auscultation in a client with hyperthyroidism. A bruit cannot be elicited through inspection, palpation, and percussion. Inspection can only reveal swelling of the neck and palpation can indicate only the enlarged mass.

The nurse practitioner notes that the thyroid gland is enlarged and auscultates both lobes of the thyroid. For what is the nurse practitioner listening? a. Rush b. Gurgle c. Murmur d. Bruit

d. Bruit If the thyroid is enlarged, either unilaterally or bilaterally, the nurse uses the bell of the stethoscope to auscultate over each lobe for a bruit. Bruits are most often found with a toxic goiter, hyperthyroidism, or thyrotoxicosis. Rush and gurgle are distracters for this question. A murmur is assessed during a cardiac assessment.

A nurse is assessing an adult client's neck. Which of the following would be most appropriate when auscultating the client's thyroid gland for bruits? a. Turn the client's head to the right. b. Hyperextend the client's neck. c. Have the client swallow water. d. Have the client hold his or her breath.

d. Have the client hold his or her breath. When auscultating the thyroid, the client should hold the breath to obscure any tracheal breath sounds during auscultation. The neck should be slightly extended, without being turned to any side. The client swallows water during inspection, and palpation of the thyroid gland but not during auscultation.

Which of the following would the nurse document as an abnormal finding with lymph node assessment? a. Discrete b. Diameter: 0.75 cm c. Mobile d. Tender

d. Tender

A client describes her frequent headaches as being sever and lasting for days. The client's positive response to what question would most clearly suggest to the nurse that these headaches are migraines?

Do you have any visual changes before the headache?

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

During the health interview of the head and neck, the patient tells the nurse about having a lump in the neck. Which question would the nurse ask to assess manifestations associated with this lump?

"Do you have difficulty swallowing?

A community health nurse is planning a health promotion campaign that will focus on cancer prevention. Which educational intervention should the nurse select in order to most influence participants' risks of head and neck cancers?

A smoking cessation program

A client's recent weight loss and diarrhea has been attributed to hyperthyroidism. When auscultating the client's thyroid gland, what assessment finding is most consistent with this diagnosis?

A sound of turbulent blood flow in the thyroid

A nurse palpates an enlarged, hard, and nontender left-sided supraclavicular lymph node in a client. Where should the nurse focus the physical assessment to obtain more data about this finding?

Abdomen and thoracic area for changes associated with malignancy 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.

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)

A nurse is palpating the head and neck of a newly referred client. Which of the following would the nurse suspect if assessment reveals that the client's skull and facial bones are larger and thicker than normal?

Acromegaly

The nurse is assessing the head and neck of a 51 year old male client. Following inspection and palpation of the client's thyroid gland, the nurse determines that the gland is enlarged. What is the next action that the nurse should perform?

Auscultate the client's thyroid

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

A nurse is preparing to palpate a client's submental lymph nodes. At what anatomic location should the nurse position his or her hands?

Behind the tip of the client's mandible

A nurse is preparing a presentation for a local community group about preventing traumatic brain injury. The nurse would discuss which measure as prevention of the leading cause?

Falls prevention

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 male college student presents to the student health clinic with reports of night-time headaches for the past 2 weeks. He denies nausea or photosensitivity but states that 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

A nurse is preparing to assess an adult client's carotid pulses. Which of the following actions would be contraindicated?

Compressing the arteries bilaterally

When preparing to assess a client's thyroid gland, the nurse should ensure that which piece of equipment is readily available?

Cup of water

When examining a client's thyroid gland, the nurse ensures that which equipment is readily available? Centimeter-scale ruler Penlight Cup of water Tongue depressor

Cup of water When examining the thyroid gland, the client is asked to swallow so that each side of the gland can be felt. A cup of water would aid in swallowing. A penlight, tongue depressor, or ruler is not needed.

A nurse has completed the assessment of an older adult client's head and neck and is now analyzing the assessment findings. Which of the following findings should the nurse attribute to age-related physiological changes?

Decreased strength of temporal artery pulsations

A nurse needs to examine a client's thyroid as part of the head and neck assessment. How should the nurse instruct the client to position his head to best facilitate this exam?

Flex the head toward the side being examined To correctly examine the thyroid, the nurse should stand behind the client and ask him to lower the chin and turn the head toward the side being examined. This action helps to relax the client's neck muscles.

What is the most common type of hyperthyroidism?

Graves' disease

A nurse is assessing an adult client's neck. Which of the following would be most appropriate when auscultating the client's thyroid gland for bruits?

Have the client hold his or her breath

When talking to a client before starting the physical exam, the nurse notes that the client consistently tilts her head to one side. Which of the following should the nurse examine first?

Hearing Acuity

A nurse is performing a head and neck assessment of a client who is newly admitted to hospital unit. When preparing to assess the client's thyroid gland, what landmarks should the nurse first identify? Select all that apply.

Hyoid bone and Cricoid cartilage

A nurse is working with a client who has a history of headaches. When preparing to assess the client's temporomandibular joint (TMJ) , the nurse should provide what instruction?

I'm going to put my fingers in front of your ears and ask you to open your mouth wide.

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

When conduction a generalized assessment of a new client, for what would the nurse inspect the neck?

Limitations in movement

Which of the following findings should the nurse document after assessing the thyroid gland of an older adult without abnormalities?

Nodularity

A nurse is conducting a focused head and neck assessment of a client. When preparing to assess the client's thyroid gland, the nurse should be aware of which of the following principles?

Many clients have an additional (third) thyroid lobe.

The nurse is assessing the face of a client with a diagnosis of Parkinson's disease. Which of the following would the nurse most likely assess?

Masklike expression

A nurse is caring for a patient admitted with neck pain. The patient is febrile. What is the most likely medical diagnosis for this patient?

Meningitis

During the physical examination the head and neck, the nurse palpates several nodules on the patient's thyroid gland. What would this finding suggest to the nurse?

Metabolic process An enlarged thyroid gland with two or more nodules suggests a metabolic rather than a neoplastic disease process. Diffuse enlargement of the thyroid gland is seen in Graves' disease and endemic goiter. A single nodule palpated on the thyroid gland is suspicious for a malignancy.

Which risk factor for traumatic brain injury should a nurse include in a discussion about prevention for a group of adolescents?

Modes of transportation are the leading cause

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

During a health history, a client reports complaints of headaches. Which of the following would lead the nurse to suspect that the client is experiencing cluster headaches?

Pain radiating from eye to temporal region

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

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

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 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

Which factor, if present in a client's lifestyle and health practices assessment, would alert the nurse to the need for performing a more thorough head and neck assessment?

Smokeless tobacco use

When assessing a patient with Graves disease, how would you expect the thyroid gland to be?

Soft

A nurse is palpating the position of the client's trachea. At which anatomic site would the nurse first position a finger for palpation?

Sternal notch

The nurse can best palpate the superficial cervical nodes, the deep cervical chain, and the supraclavicular nodes by first locating which muscle?

Sternomastoid

A nurse has completed an assessment of a client's lymph nodes. Which of the following data would the nurse document as an abnormal finding?

Tender

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.

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

There is an infection in the area that these nodes drain. Whenever a lymph node is enlarged or tender, the nurse should assess for infection in the area that the particular nodes drain. Thyroid or muscular involvement is less likely, and infection does not likely underlie the nodes directly.

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

This could be a sign of cancer Lymphatics larger than 1 cm, fixed, irregular, or hard or rubbery require emergency investigation

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

Vision

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? a. Female gender b. Firearm violence c. Contact sports d. Transportation accidents

a. Female gender Risk factors for traumatic brain injury include transportation accidents, violence (often firearms related), falls, male gender, failure to use protective equipment, and participation in contact sports.

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 a. Paget disease b. Acromegaly

b. Acromegaly (abnormal growth of hands, feet, and face) The skull and facial bones are larger and thicker in acromegaly.

The nurse can best palpate the superficial cervical nodes, the deep cervical chain, and the supraclavicular nodes by first locating which muscle? a. Infraspinous b. Platysma c. Sternomastoid d. Trapezius

c. Sternomastoid

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. Bell's palsy b. Temporal arteritis c. Tension headache d. Migraine headache

d. Migraine headache *Migraine headaches* are usually located around the eyes, temples, cheeks, and forehead. They are often accompanied by nausea and vomiting. Bell's palsy is a one sided facial paralysis caused by inflammation of the facial nerve. A tension headache usually presents with stress, anxiety, or tension and is located in the frontal, temporal, or occipital region. Temporal arteritis produces pain around the temple but no nausea or vomiting.

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? a. RC: Thyroid crisis b. RC: Acromegaly c. RC: Cerebrovascular accident d. RC: Cushing's syndrome

d. RC: Cushing's syndrome 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.

Primary headaches are more worrisome than secondary headaches.

false

The nurse does a health history. The patient states he has lost 30 pounds in the last couple months without really trying. The patient also states he feels warm all the time and sometimes feels like he has heart palpitations. The nurse would anticipate orders to evaluate the patient for

hyperthyroidism

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 emergency room reporting "the worst headache I have ever had." What are critical nursing behaviors for this client? (Select all that apply.)

• Physical examination for neurologic changes • Focused history

The nurse would expect to assess which symptoms in a patient complaining of migraine headaches? Select all the apply.

• photophobia • throbbing • recurrent