HHA PrepU: Chapter 15 Head and Neck

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 -This could be a sign of pneumothorax -This could be a sign of an embolus -This could be a sign of a parotid stone

-This could be a sign of cancer Lymphatics larger than 1 cm, fixed, irregular, or hard or rubbery require emergency investigation. Such signs raise the possibility of cancer. The signs and symptoms cited in the scenario do not indicate pneumothorax, embolus, or parotid stone.

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 -tonsillitis -nasopharyngitis -a goiter

-a metastasis

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 -Bacterial thyroiditis -Cranial damage -Muscle tension

-Arthritic changes of the cervical spine Arthritic changes in cervical spine may may present in the older adults as neck pain, decreased strength and sensation of the upper extremities. Bacterial thyroiditis has neck swelling and cranial damage may manifest as headaches or tension of the muscles

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

-Attempting to roll the structure up and down and side to side While lymph nodes may be rolled both up and down and side to side, muscles will not move in this manner. The other cited techniques do not differentiate between lymph nodes and muscles.

An adult client comes to the ED with a new onset of pain in his neck and jaw. What system requires emergency assessment? -Cardiovascular -Integumentary -Respiratory -Nervous

-Cardiovascular

A nurse performs palpation of a client's lymph nodes. Which finding should be reported to the health care provider? -Mobile from side to side -Soft in consistency -Fixed to underlying tissue -Round and 8 mm in size-Round and 8 mm in size

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

A client with a cervical spine injury has chronic pain. What would be the most appropriate initial nursing intervention for this client? -Work with medical team to evaluate possible surgery -Discuss pharmacologic interventions -Chronic pain related to cervical spine injury -Assess characteristics

-Assess characteristics 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. Option C represents a nursing diagnosis, not an intervention.

Primary headaches are more worrisome than secondary headaches. -True -False

-False

A normal assessment of the neck would include palpation of the thyroid isthmus. Where would the nurse find the isthmus? -Just above the thyroid cartilage -Between the thyroid and the cricoid cartilages -Just below the cricoid cartilage -In front of the sternocleidomastoid muscle

-Just below the cricoid cartilage Just below the cricoid cartilage, the isthmus of the thyroid should be palpable as a smooth rubbery band that rises and falls with swallowing. the other three options are distracters for the question.

A patient with hypothyroidism is admitted to the medical unit. The nurse would expect to assess which signs/symptoms? Select all that apply. -lethargy -constipation -cool skin -lower systolic blood pressure -weight loss

-lethargy -constipation -cool skin -lower systolic blood pressure

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? -Meningeal inflammation -Stress -Injury to the sternomastoid -Arthritis

-Arthritis 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.

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. -Provide medication for pain relief. -Inquire about family history of headaches. -Review the client's medical record.

-Assess the client's blood pressure. Onset of headache after the age of 50 paired with the statement the client has made here is considered a "red flag." The nurse should suspect this is a secondary headache or arising from another condition. Markedly elevated blood pressure could be indicative of imminent danger to the client's life. Assessment of the blood pressure should be the nurse's first action.

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? -Endocarditis -Bronchitis -Atelectasis -Tuberculosis

-Atelectasis 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.

A nurse palpates an elderly client's thyroid and detects an enlargement over the right lateral lobe. What action should the nurse take first? -Immediately notify the health care provider -Document the findings in the nurse notes -Auscultate with the bell over the lateral lobes -Ask the client about past history of hypothyroidism

-Auscultate with the bell over the lateral lobes 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.

An adult client comes to the ED with a new onset of pain in his neck and jaw. What system requires emergency assessment? -Cardiovascular -Integumentary -Respiratory -Nervous

-Cardiovascular Acute situations that need emergency assessment and intervention include head or neck injuries, neck pain (may be cardiac), enlarged hard nodes (which may indicate cancer), and thyrotoxicosis. The other options are, therefore, incorrect.

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? -Migraine -Cluster -Tension -Stress

-Cluster 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 and are localized to the eyes, 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.

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 V -Cranial nerve VI -Cranial nerve VII -Cranial nerve VIII

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

What activity is known to aggravate a tension headache? -Listening to music -Exercise -Driving -Prolonged sleep

-Driving

What activity is known to aggravate a tension headache? -Listening to music -Exercise -Driving -Prolonged sleep

-Driving Factors that aggravate or provoke: sustained muscle tension, as in driving or typing.

What structure is found midline in the tracheal area just beneath the mandible? -Cricoid cartilage -Hyoid bone -Thyroid cartilage -Adam's apple

-Hyoid bone 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.

When identifying the midline structures of the neck from the mandible to the sternal notch, the nurse notes the structures in what order? -Cricoid cartilage, hyoid bone, tracheal rings, thyroid isthmus -Thyroid cartilage, thyroid isthmus, cricoid cartilage, hyoid bone -Hyoid bone, thyroid cartilage, cricoid cartilage, isthmus of the thyroid -Hyoid bone, tracheal rings, cricoid cartilage, lobes of the thyroid gland

-Hyoid bone, thyroid cartilage, cricoid cartilage, isthmus of the thyroid 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 client diagnosed with goiter has undergone a thyroidectomy. Which statement from the client indicates understanding of post-operative care teaching? -I must take thyroid hormone replacement medication for the rest of my life. -I will complete the entire course of thyroid hormone replacement over six weeks. -I must keep my follow up appointments to receive my thyroid hormone injections. -I will take my thyroid hormone replacement medication once every week.

-I must take thyroid hormone replacement medication for the rest of my life. After thyroidectomy, clients must be treated with exogenous thyroid hormone for the rest of their lives. Thyroid hormones are usually taken by mouth on a daily basis.

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 skin integrity related to bed rest -Impaired range of motion related to injury -Immobility related to bed rest -Impaired comfort related to possible neck injury

-Impaired comfort related to possible neck injury Diagnosis of a cervical spine injury is challenging and, in many cases, goes undiagnosed, especially in those lacking adequate health insurance. Clients at risk include those following a fall or collision and those with osteoporosis, advanced arthritis, cancer, or degenerative bone disease. The scenario does not indicate that the client is on bed rest or that the client has a limited range of motion.

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? -Diabetes -Brain tumor -Impending stroke -Hyperthyroidism

-Impending stroke 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.

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? -Increased heart rate -Increased blood pressure -Laboratory tests -Feeling anxious

-Laboratory tests In order to determine the presence of hypothyroidism, laboratory tests to determine blood levels of the TSH, FT4 and FT1 are needed to ensure correct diagnosis of this condition. The presence of tachycardia, increased blood pressure and anxiety are signs associated with hypothyroidism.

When conducting a generalized assessment of a new client, for what would the nurse inspect the neck? -Strain -Vertebral injury -Lymph node enlargement -Limitations in movement

-Limitations in movement During inspection of the neck, the nurse observes for lesions and limitations in movement. The nurse cannot assess strain, vertebral injury, or lymph node enlargement by inspection. Therefore, the other options are incorrect.

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. -Administer intravenous pain medication. -Palpate the carotid pulses bilaterally at the same time. -Prepare the client for a temporal artery biopsy.

-Notify the healthcare provider immediately. 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.

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? -Bell's palsy -Acute pharyngitis -Thyroid enlargement -Parotid enlargement

-Parotid enlargement 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.

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 -Headache -Shortness of breath -Range of motion of the arms and shoulders

-Range of motion of the neck Musculoskeletal injury or disease can be confirmed with an X-ray, CT, or MRI. If test results are negative, the nurse should assess for complete range of motion of the neck, looking for any muscle tension, loss of mobility, or pain. According to the scenario, the nurse would not assess for headache, shortness of breath, or ROM of the arms and shoulders next.

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 -Migraine -Cluster -Analgesic rebound

-Tension

A client comes to the trauma unit in respiratory distress following a motor vehicle accident. On examination, the nurse notices that the trachea is deviated from the midline. What does this finding indicate? -Tension pneumothorax -Cardiac tamponade -Flail chest -Severe neck fracture

-Tension pneumothorax Palpation of the thyroid gland reveals important landmarks of the trachea. Such landmarks are noted when assessing for tracheal deviation, which accompanies a potentially life-threatening condition called tension pneumothorax. A deviation of the trachea does not indicate cardiac tamponade, flail chest, or a severe neck fracture.

The nursing instructor is discussing assessment of the head and neck with the class. What identifying characteristic would the instructor use for the thyroid cartilage? -Its position just below the mandible -The curve on its inferior edge -Its relation to the cricoid cartilage -The notch on its superior edge

-The notch on its superior edge The thyroid cartilage is readily identified by the notch on its superior edge.

When examining the head, the nurse remembers that the anatomic regions of the cranium take their names from which of the following sources? -Noted anatomists -The underlying bones -Their anatomical positions -The underlying vascular network

-The underlying bones Regions of the head take their names from the underlying bones of the skull, not from the names of anatomists, anatomical positions, or vasculature.

A female client visits the clinic and tells the nurse that she wants to "stay healthy." The nurse observes that the client has diffuse neck enlargement, is perspiring, and is quite fidgety. The client tells the nurse that she is "hungry all the time, but I have lost weight." A priority nursing diagnosis for the client is -imbalanced nutrition: less than body requirements related to excessive energy level and nervousness. -ineffective health maintenance related to increased metabolism, diaphoresis, and hunger. -health-seeking behaviors related to verbalization of wanting to stay healthy and concerns over weight loss. -thyroid dysfunction related to neck swelling, perspiration, and fidgeting and concern over weight loss.

-health-seeking behaviors related to verbalization of wanting to stay healthy and concerns over weight loss. The client is concerned about weight loss. An appropriate health promotion diagnosis for this client would be health-seeking behaviors related to verbalization of wanting to stay healthy and concerns over weight loss.

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 -inflammation -enlargement -hypothyroidism

-malignancy Hard or fixed nodes, particularly in the supra-clavicular region of the neck, suggest a malignancy. This could even be a possible metastasis of a thoracic or abdominal malignancy. Although inflamed or enlarged nodes may be tender on palpation, the node should still be mobile. In hypothyroidism, the thyroid gland may be enlarged, but discovering hard or fixed nodes warrants further assessment for malignancy.

The nurse is planning to assess a client's lymph nodes. Which set of nodes should the nurse assess first? -submental -preauricular -supraclavicular -superficial cervical

-preauricular The lymph nodes in front of the ear, or preauricular, are usually palpated first. The submental nodes are under the chin. The supraclavicular nodes are located near the clavicle and sternocleidomastoid muscle. The superficial cervical nodes are located superficial to the sternocleidomastoid muscle.

The nurse suspects that a client has Cushing's syndrome. What assessment finding did the nurse use to make this clinical determination? -red cheeks -mask-like face -swelling around the eyes -elongated prominent forehead

-red cheeks The increased adrenal cortisol production of Cushing syndrome produces a round or "moon" face with red cheeks. A mask-like face is associated with Parkinson's disease. Swelling around the eyes is associated with nephrotic syndrome. An elongated prominent forehead is associated with acromegaly.

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 -cluster headaches. -tumor-related headaches. -migraine headaches. -tension headaches.

-tension headaches.

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 -migraine headache. -cluster headache. -tension headache. -tumor-related headache.

-tumor-related headache. Tumor-related headaches have no prodromal stage; may be aggravated by coughing, sneezing, or sudden movements of the head.