prep U 12 Head and Neck, Including Lymph Nodes and Vessels

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.

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?

Cushing syndrome

Puffy moon face and buffalo hump found during a comprehensive (palpation) physical exam can represent what?

sit in an upright position. Have the client remain seated upright. Then palpate the lymph nodes with your fingerpads in a slow walking, gentle, circular motion.

The nurse is preparing to assess the lymph nodes of an adult client. The nurse should instruct the client to

muscle tension, spasm

neck pain usually includes

parotid, submandibular and sublingual glands

what are the three pairs of salivary glands?

fever and headache

whats a key for meningitis

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

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?

lethargy constipation cool skin lower systolic blood pressure

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

neck swelling and cranial damage may manifest as headaches or tension of the muscles

Bacterial thyroiditis has (AND MANIFEST AS)

the elderly with hypothyroidism the more common condition, affecting 10% to 16% of adults ages 65 to 74 years

Both hypothyroidism and hyperthyroidism occur more frequently in what population?

Bruits

During auscultation in a comprehensive physical exam when you find an enlarged thyroid only listen for what?

swallow a small sip of water. Observe the movement of the thyroid cartilage, thyroid gland.

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

Arthritic changes of the cervical spine

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 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

A 82 year old female presents with neck pain, decreased strength and sensation of the upper extremities. The nurse identifies that this could be related to what? A. Arthritic changes of the cervical spine B. Bacterial thyroiditis C. Cranial damage D. Muscle tension

both motor and sensory innervations to the forehead, cheeks, and chin.

Cranial nerve (CN) V—the trigeminal nerve—supplies

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 and 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.

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 nuchal rigidity. The nurse recognizes these findings as most likely to be caused by what condition?

Previous injuries to the head and neck Previous head or neck injuries may cause limitations in movement and chronic pain. Change in sleeping habits is too vague to be correct. The other two options may produce pain but not necessarily limit functioning.

A client reports severe pain in the posterior region of the neck and difficulty turning the head to the right. What additional information should the nurse collect? Previous injuries to the head and neck Difficulty with swallowing Changes in sleeping habits Stiffness in the right shoulder

Tender

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?

C7 The vertebra prominens is C7, which can easily be palpated when the neck is flexed. Using C7 as a landmark helps the nurse to locate other vertebrae.

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? C3 C5 C7 T2

2. The thyroid gland consists of two lateral lobes connected by an isthmus. Approximately one-third of the population has a third lobe that extends upward from the isthmus or from one of the two lobes.

A nurse is examining a client's neck and is preparing to palpate the thyroid gland. The nurse would most likely expect to palpate how many lobes? 1 2 3 4

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.

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? Firearm violence Female gender Contact sports Transportation accidents

Look for a source such as infection in the area that it drains Knowledge of the lymphatic system is important to a sound clinical habit: whenever a malignant or inflammatory lesion is observed, look for involvement of the regional lymph nodes that drain it; whenever a node is enlarged or tender, look for a source such as infection in the area that it drains.

During your physical examination of the patient you note an enlarged tender tonsillar lymph node. What would you do? A. Assess for meningitis B. Look for involvement of other regions of the body C. Look for a source such as infection in the area that it drains D. Assess for dietary changes

False Rationale: Lymphatics larger than 1 cm, fixed, irregular, or hard or rubbery require emergency investigation. Such signs raise the possibility of cancer.

Is the following statement true or false? An expected finding with neck palpation is lymph nodes larger than 1 cm in size.

hypothyroidism

Periorbital edema found during a comprehensive physical exam (palpation) can represent what?

hyperthyroidism The low, soft, rushing sound is a systolic or continuous bruit commonly heard in hyperthyroidism. A bruit is not commonly auscultated in Hashimoto thyroiditis. Identifying characteristics of this condition include enlarged, firm, and rubbery thyroid glands with no bruit. Thyroid cysts and benign malignancies would not have a low, soft, rushing sound that can be auscultated.

The nurses assesses the thyroid gland of a client with recent weight loss. On auscultation, a low, soft, rushing sound is heard over the lateral lobes. Which condition is most likely?

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.

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?

Above the cheek bone near the scalp line

Where is the temporal artery palpated?

Hard, rubbery, irregular, fixed, and nontender lymph nodes

what are possible sign of lymphoma?

in the cheek anterior to the bottom half of the ear.

where is the parotid salivary gland located?

Tension

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 headaches. Tension headaches are dull, tight, and diffuse.

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

Parkinson's disease.

A mask-like face is associated with what disease?

Approximately one-third

How much of the population has a third lobe that extends upward from the isthmus or from one of the two lobes?

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 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?

Pregnant Women

need teaching regarding regular thyroid assessments to ensure thyroid levels remain normal to ensure the health of the mother and fetus.

Any history of radiation therapy may be linked to thyroid cancer.

subjective data collection when assessing the head and neck for personal history includes

glands are in the mouth and under the tongue.

where is the sublingual salivary gland located?

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.

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

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

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

Cushing syndrome- due to increase adrenal cortisol production

Which syndrome causes "moon" face?

ACROMEGALY The skull and facial bones are larger and thicker in acromegaly.

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. parotid gland enlargement. B. acromegaly. C. Paget disease. D. Cushing syndrome.

Assess the woman for hypothyroidism. 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. 295

A 66-year-old woman has come to the clinic with complaints of increasing fatigue over the last several months. She claims to frequently feel lethargic and listless and states that, "I can never seem to get warm, no matter what the thermostat is set at." How should the nurse proceed with assessment? A. Order tests to rule out an overactive thyroid gland. B. Assess for other signs and symptoms of Cushing's syndrome. C. Palpate the woman's parotid gland for enlargement. D. Assess the woman for hypothyroidism.

Periorbital edema Thin lateral eyebrows Dry, coarse, and sparse hair Puffy dull face with dry skin Manifestations of hypothyroidism include periorbital edema, thin lateral eyebrows, dry, coarse and sparse hair, and a puffy dull face with dry skin. The trachea is not displaced in hypothyroidism.

A client is admitted for treatment of hypothyroidism. What should the nurse expect to assess in this client? Select all that apply. Periorbital edema Thin lateral eyebrows Trachea pulled to the left Dry, coarse, and sparse hair Puffy dull face with dry skin

Relieving factors Relieving factors includes anything the client subjectively reports they have tried to make the migraine go away. Onset refers to when the migraine started. Location helps determine what part of the client's head the pain is localized within or where it radiates. Treatment refers to any assessment, support, or care the client has received from various health care providers.

A client reports using pain medication and sitting in a dark room on the onset of a migraine headache. In which part of the subjective section of the physical examination should the nurse document this information?

Correct answer: Tachycardia Correct answer: Diarrhea Correct answer: Anxiety .The most common sign is tachycardia, but other possibilities include diarrhea, anxiety, fever, weakness, and even psychosis, coma, or death. Headache is not a classic sign.

A nurse is caring for an adult client who has just undergone surgery to remove a thyroid tumor. The nurse is assessing for symptoms of hyperthyroidism. What are some of the symptoms of hypermetabolism? Select all that apply. Bradycardia Headache Tachycardia Diarrhea Anxiety

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.

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

In the midline, a few centimeters behind the tip of the mandible The submental lymph nodes are located near the midline, a few centimeters behind the tip of the mandible. Superficial cervical lymph nodes are located superficial to the sternomastoid. The preauricular lymph nodes are located in front of the ear. The tonsillar lymph nodes are located near the mandible. 291.

The nurse assesses a client's submental lymph nodes. In which area of the client's head should the nurse palpate these lymph nodes? A. Superficial to the sternomastoid B. In front of the ear C. In the midline, a few centimeters behind the tip of the mandible D. At the angle of the mandible

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.

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?

Always use seat belts. 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.

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

Mobile phones should only be used if there is a hands-free option available. Only hands-free mobile phones can be used when driving, and text messaging is prohibited due to the risk for distraction. Small children should only sit in the back of the motor vehicle, especially if there is a passenger side airbag. Only medications with side effects such as fainting or dizziness should be avoided. Helmets should always be worn when riding motorcycles, all-terrain vehicles, motorized scooters, bicycles, horses, and snowmobiles.

When preparing to provide education regarding the prevention of head injuries from motor vehicle accidents, the nurse should be sure to include which point? Mobile phones should only be used if there is a hands-free option available. A car seat should only be installed in the front if there are passenger airbags available. Refrain from taking any medication prior to operating a motor vehicle. Helmets can obscure vision when riding all-terrain vehicles and should be avoided.

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.

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?

Smokeless tobacco use 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.

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?

Lymphatic Lymphatic vessels filter potential pathogens from the body. They also drain the fluid that has moved outside of the circulation back into the vessels. Arteries carry oxygenated blood from the heart to the body. Veins carry unoxygenated blood from the body to the lungs. Aortic is an adjective for aorta, which is the large vessel carrying oxygenated blood away from the heart.

Which type of vessels filter pathogens from the body and drain the fluid that has moved outside of the circulation back into the vessels?

Ambient lighting Penlight or flashlight for tangential lighting Gloves, if any lesions of the scalp or skin of head and neck are suspected Small cup of water

what equipment to you obtain data for neck assessment?

Two pairs of parathyroid glands

what glands are are embedded in the thyroid lobes and produce the hormone calcitonin, which helps move calcium into bones; usually these glands are usually not palpable.

pregnant women

what group should you review the need for regular examinations that include thyroid assessment. Such prenatal care helps to ensure that thyroid levels remain within normal limits, protecting both mother and fetus?

butterfly shaped, produces thyroid hormones. Sits just below the cricoid cartilage. consists of a band (the isthmus) that crosses the trachea and two symmetrical 3- to 4-cm lobes that lie on each side of the trachea.

what is the thyroid gland? where is it located?

are at the angle of the jaw below the mandible

where is the submandibular salivary gland located?

neck pain

which pain with fever and headache (possible meningitis) needs a focused neurologoical assessment

This is a typical description for a client with Parkinson's disease. Facial mobility is decreased, which results in a blunt expression or a "masked" appearance. The client also has decreased blinking and a characteristic stare with an upward gaze. Combined with the findings of slow movements and a shuffling gait, the diagnosis of Parkinson's is highly likely.

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? Cushing's syndrome Nephrotic syndrome Myxedema Parkinson's disease

Do you have any visual changes before the headache?"

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?

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.

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?

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

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?

This could be a sign of dehydration. A depressed fontanel may indicate dehydration. This is not a normal finding and does need further assessment. A depressed fontanel does not indicate increased intracranial pressure, possible neurological disorder, or a sign of physical abuse.

A woman brings her 1-month-old infant to the ED. She says the baby is not eating or drinking well. The nurse finds the fontanels are depressed slightly. Why does this require further assessment? A. This could be a sign of dehydration B. This is a sign of a possible neurological disorder C.This could be a sign of increased intracranial pressure D. This could be a sign of physical abuse

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 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?

acromegaly.

An elongated prominent forehead is associated with

hypothyroidism symptoms

Fatigue, weakness, and cold sensitivity and periorbital edema are symptoms of

nephrotic syndrome

Swelling around the eyes is associated with?

Sternomastoid The superficial cervical nodes are in the area superficial to the sternomastoid muscle, whereas the deep cervical chain is deeply within and around it. The supraclavicular nodes lie deeply between the clavicles and sternomastoid muscle.

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. Sternomastoid C. Trapezius D. Platysma

C7 The cervical vertebrae (C1 through C7) are located in the posterior neck and support the cranium. The vertebra prominens is C7, which can easily be palpated when the neck is flexed. Using C7 as a landmark will help you to locate other vertebrae.

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?

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.

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

Parameters of lymph node assessment include size, shape, delinitation, mobility, consistency, and tenderness.

When palpating the lymph nodes of the neck, the nurse assesses for which of the following characteristics?

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. 295

When preparing to assess a client's thyroid gland, the nurse should ensure that which piece of equipment is readily available? A. Penlight B. Tongue depressor C. Centimeter-scale ruler D. Cup of water

refer the client to a physician for further evaluation. The trachea may be pulled to the affected side in cases of large atelectasis, fibrosis or pleural adhesions. The trachea is pushed to the unaffected side in cases of a tumor, enlarged thyroid lobe, pneumothorax, or with an aortic aneurysm.

While assessing an older adult client's neck, the nurse observes that the client's trachea is pulled to the left side. The nurse should ask the client to flex his neck to the left side. observe whether the client has difficulty swallowing water. refer the client to a physician for further evaluation. palpate the cricoid cartilage for smoothness.

a stroke

facial asymmetry found during a comprehensive physical exam (palpation) can represent what?