Prep U Ch 15

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

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.

The nurse practitioner auscultates both lobes of a client's enlarged thyroid gland. Identification of what sound would tend to confirm a diagnosis of a toxic goiter

Bruit

An adult client visits the clinic and tells the nurse that she has had headaches recently that are intense and stabbing and often occur in the late evening. The nurse should suspect the presence of

Cluster headaches. signs to look for, intense and stabbing.

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 VII

A nurse has performed a head and neck assessment of an adult patient and noted that the thyroid gland is not palpable. What is the nurse's most appropriate action

Document this as an expected assessment finding

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

Headache Impact Test

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.

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

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.

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.

A client reports right-sided temporal headache accompanied by nausea and vomiting. A nurse recognizes that which condition is likely to produce these symptoms

Migraine headache

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.

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

Nurses encourage use of appropriate safety equipment to reduce risk of head or neck trauma.

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

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

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

Sit in an upright position

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

A nurse asks the client to describe the pain associated with a headache by rating the pain on a scale from 1 to 10. This subjective data should be documented in which section of the assessment

characteristic symptoms.

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

hyperthyroidism

The nurse is planning to assess a client's lymph nodes. Which set of nodes should the nurse assess firs

preauricular

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

relieving factors

The nurse is preparing to assess the neck of an adult client. To inspect movement of the client's thyroid gland, the nurse should ask the client to

swallow a small sip of water

A client complains of a headache over both temporal areas. What type of headache should the nurse suspect the client is experiencing

tension

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

Arthritis

The nurse is preparing to perform a head and neck assessment of an adult client who has immigrated to the United States from Cambodia. The nurse should first

Ask the client if touching the head is permissible.

The nurse suspects an enlarged thyroid in a patient during the physical examination of the head and neck. What should the nurse first

Ask the patient to sip and swallow water.

A client with a cervical spine injury reports chronic pain. What would be the most appropriate initial nursing intervention for this client

Assess the client regarding characteristics of the pain.

A 57-year-old client reports, "I am having the worst headache I have ever experienced." Which action should the nurse perform next

Assessment of the blood pressure should be the nurse's first action. 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.

When palpating the neck, performing which of the following techniques will help differentiate lymph nodes from a band of muscles

Attempting to roll the structure up and down and side to side

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

Primary headaches are more worrisome than secondary headaches

False

What structure is found midline in the tracheal area just beneath the mandible

Hyoid bone

When identifying the midline structures of the neck from the mandible to the sternal notch, the nurse notes the structures in what order

Hyoid bone, thyroid cartilage, cricoid cartilage, isthmus of the thyroid

The nurse assesses a client's submental lymph nodes. In which area of the client's head should the nurse palpate these lymph nodes

In the midline, a few centimeters behind the tip of the mandible

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

Laboratory tests

Which instruction to the client will help facilitate examination of the temporomandibular joint by the nurse

Open the mouth

A community health nurse is attending a seminar on headaches. What would this nurse learn is a red flag for headaches

Stiff neck. Limitation of neck mobility may be from muscle tension/strain or cervical vertebral joint dysfunction.

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

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

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

The underlying bones

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. The fact that it is fixed and hard is a cancerous sign.

While assessing the head and neck of an adult client, the client tells the nurse that she has been experiencing sharp shooting facial pains that last from 10 to 20 seconds but are occurring more frequently. The nurse should refer the client for possible

Trigeminal neuralgia. A chronic pain condition affecting the trigeminal nerve in the face.

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

acromegaly.

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

parotid enlargement

While assessing an adult client's head and neck, the nurse observes asymmetry in front of the client's ear lobes. The nurse refers the client to the physician because the nurse suspects the client is most likely experiencing a/an

parotid gland enlargement.

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. 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.

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

Atelectasis.

The nurse is palpating a client's neck as part of a physical assessment. Which of the following blood vessels should the nurse be especially careful to avoid bilaterally compressing during the assessment

Carotid artery Explanation: It is important to avoid bilaterally compressing the carotid arteries when assessing the neck, as bilateral compression can reduce the blood supply to the brain.

Teenagers doing community service following arrest for driving under the influence are working at the rehabilitation hospital with clients who have paraplegia. These clients have been paralyzed by drunk drivers. How would the nurses who care for these clients best use the time spent with these teenagers

Education for high-risk groups about not driving while under the influence or sleepy is critical. The nurses working with these clients would not spend time with the teenagers teaching them how to turn the patients, fulfilling court requirements, or keeping the shelves restocked.

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 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.

During your physical examination of the patient you note an enlarged tender tonsillar lymph node. What would you do

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.

A nurse performs palpation of a client's lymph nodes. Which finding should be reported to the health care provider

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 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

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

Ask permission before palpating the head and neck

The nurse is planning to assess an adult client's thyroid gland. The nurse should plan to

Approach the client posteriorly

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 performing a head and neck assessment on a client. Which area should the nurse inspect for facial symmetry

Nasolabial folds Explanation: The nasolabial folds are ideal places to check facial features for symmetry.

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 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.

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. Neck pain and fever combo could indicate meningitis.

A client complains of recurring headaches that are worse when first waking in the morning and with coughing or sneezing. What would be the nurse's most appropriate action

Perform a focused assessment.

The nurse assesses an adult client's head and neck. While examining the carotid arteries, the nurse assesses each artery individually to prevent

Reduction of the blood supply to the brain

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.

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

tumor-related headache.

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

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.

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

Tachycardia Diarrhea Anxiety Hyperthyroidism may present as an emergency, with symptoms of hypermetabolism in all systems. The most common sign is tachycardia, but other possibilities include diarrhea, anxiety, fever, weakness, and even psychosis, coma, or death. Nurses should recognize clients at greatest risk for this emergency state. Such clients include those with thyroid tumors and those who have undergone thyroid surgery. Signs of hypermetabolism do not include bradycardia or 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

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.

The nurse is performing an assessment of the neck and identifies tracheal deviation. What is the most appropriate response of the nurse

Tracheal deviation is an emergency and the health care provider should be notified immediately. The client should be provided nursing care and further head and neck assessment along documentation can occur once emergency has subsided.